Is Hybrid Robotic Laparoscopic Assistance the Ideal Approach for Rectal Dissection.

Marek Zawadzki, MD, Slawomir J Marecik, MD, Vamsi R Velchuru, FRCS, John J Park, MD, Leela M Prasad, MD. University of Illinois, Chicago, USA, Advocate Lutheran General Hospital, Park Ridge, USA

Background: The use of robotic assistance in the management of rectal cancer has gradually increased in popularity over the years but the optimal technique is still under debate. Typically, a low anterior resection (LAR) for carcinoma entails dissection in multiple abdominal quadrants. The current version of the da Vinci robot offers limited range of movement of the robotic arms. In order to compensate for these limitations, special techniques have been developed. These are the hybrid approach and the totally robotic approach. The authors’ preferred technique is a hybrid approach with laparoscopic hand-assisted mobilization of the left colon and robotic assistance for rectal dissection. The aim of this study was to establish the efficacy of hybrid robotic laparoscopic LAR in treatment of rectal cancer.
Methods: Between August 2005 and July 2011, consecutive patients undergoing rectal dissection for cancer via the hybrid technique were included in our study. Surgical technique involved three stages – firstly hand assisted laparoscopic mobilization of the left and sigmoid colon and vascular control (both IMA and IMV); secondly robotic rectal dissection; and lastly anastomosis. Demographics, margin positivity, intraoperative, and short-term outcomes were evaluated.
Results: The hybrid approach with laparoscopic hand-assisted mobilization of the left colon and robotic rectal dissection was performed in 77 patients with rectal adenocarcinoma. Of these, 68 underwent low anterior resection and 9 had a coloanal pull-through procedure. The robot was positioned between the patient’s legs in 73 cases and by the patient’s left hip in 4 cases. Most tumors were located in the mid or lower rectum (70%) and 62% of the patients received neo-adjuvant treatment. The average age was 60.1 years with an average BMI of 28.0. Mean operative time was 327 minutes and the conversion rate was 3.9% (n=3). Reasons for conversion included morbid obesity (BMI of 43), advanced T4 tumor invading the pelvic sidewall, and intraoperative bleeding. All but one specimen had negative circumferential margins. Two patients had distal margin positivity. The anastomotic leak rate was 6.4% (n=5). Two patients developed pelvic abscesses, without clinically or radiologically confirmed anastomotic failure. One patient developed a colovaginal fistula. Four patients had focal neuropathy in the immediate postoperative period. No robot specific complications were observed.
Conclusions: The hybrid approach involving hand-assisted left colon mobilization and robotic rectal dissection is a safe and feasible technique for minimally invasive low anterior resection. This combination maximizes the advantages of each method without compromising the benefits of a minimally invasive approach. This approach can be also considered an ideal technique for surgeons new to robotic rectal dissection.