Liza M. Capiendo, MD
Dr. Capiendo is a Physician at Cedars-Sinai Medical Center. She was the Clinical Chief of the Division of Colon and Rectal Surgery from 2014 to 2016 at Cedars-Sinai. Her main clinical and research interests focus on the laparoscopic treatment of colon and rectal disorders.
We have witnessed a long, and recently rapid advance from open surgical techniques to minimally invasive operative procedures. With these advances, we have improved the lives and postoperative courses for many patients. In urology, the growth of robotic surgical technology has done much to further out gains in patient care. Urological experiences have been associated with a better, more precise, urethral anastomosis, decreased postoperative pain, less blood loss, shorter hospital stays and quicker recovery when compared with open procedures. Is the improved urological surgical experience similar in colorectal surgery?
How Did We Arrive at the Present?
The confined space of the human pelvis can hamper visibility and maneuverability in the operative field. Both laparoscopic and robotic systems are touted as helping the surgeon overcome this space limitation. In turn, has spurred the explosive growth of minimally invasive technologies.
Robotic surgery was originally developed by the military for remote surgical use. Subsequently, its use was found to be more applicable as an on-site tool, and, the first robotic procedure, a prostate operation was performed in 1992. In 2000, the currently popular robotic system, the da Vinci, was approved by the FDA for use in intra-abdominal surgery. The initial popularity of robotic systems was in urologic and gynecologic procedures. To date, over 1.5 million robotic procedures have been performed worldwide.
Colorectal surgeons have been thoughtfully slow to adopt robotic technology. Robotic colorectal surgery was first performed in 2001. At that time, it appeared that robotic techniques could achieve the same operative and postoperative results when compared with conventional laparoscopic techniques. Current colorectal robotic techniques are focused on the treatment of rectal cancer, rectal prolapse, and distal diverticulitis.
We are now performing most colorectal procedures using either laparoscopic or robotic technology. In both laparoscopic and robotic systems, we love the technical aspects of the operation. We enjoy the beauty of the dissection and precision of our movements. Our view of the surgical field is unrivaled when compared with open surgery. However, is one technology better than the other? Are there challenges in colorectal procedures that can be overcome, or clinical outcomes that can be improved by using robotic techniques? Should we be using a robot in colorectal surgery? Is robotic colorectal technology an advance? Are we improving the results for our patients? Can the hospital and society afford the expensive robotic system? And, specifically, in colorectal surgery, are we on the cusp of another surgical revolution? Are we moving forward, sideways or backwards? Is robotic surgery a fancy gimmick and sales tool? Or is it a technology looking for another diseased organ system to repair? Many questions, few answers. Let’s look at the pros and cons of the new robotic love affair.
Similarities Between Laparoscopic and Robotic Systems
As in laparoscopic surgery, robotic surgery makes use of small incisions. In both techniques patients recover faster when compared with recovery times following open operations. Chemotherapy can begin sooner when laparoscopic or robotic surgery is used for rectal cancer. In surgery for very low rectal tumors, the increased visibility using modern optic systems and improved precision and access to the most distal surgical sites potentially can decrease the permanent colostomy rate. Additionally, postoperative pain is minimized by an incision of just 6 to 8 cm long, compared with an incision length of 15 to 20cm in open surgery. Large, comparative clinical trials are underway, and the results thus far indicate that robotic surgery is as effective as open surgery, and yields results “no worse” than the results in laparoscopic surgical procedures.
Some of the advertised benefits of robotic surgery include, enhanced, high definition viewing of the operative field, four “arms” to perform many operative tasks, a lower blood loss, a more rapid return of bowel function, a lower complication rate, a faster return to work and daily activities, preservation of sexual function, preservation of bladder control and continence, decreased postoperative pain, a lower conversion rate to open surgery, shorter hospital stays and a better cosmetic outcome. This also describes laparoscopic surgery. Is there a difference?
The Bells and Whistles of Robots
The robotic system has certain benefits for both the surgeon and the patient. These are:
1. 3-Dimensional high-definition vision. The robotic system has 2 high-definition cameras that provide the surgeon with a magnified stereoscopic view of the surgical site, combining accurate depth perception with a sharp image.
2. An additional arm. The additional arm, which can be used to hold a retractor or other surgical instruments, gives the surgeon 50% more operating capability.
3. Instant image referencing. This innovative feature lets the surgeon display up to two diagnostic ultrasound or CT images taken prior to surgery, inside the da Vinci console monitor, directly alongside the view of the real-time procedure, providing a critical extra reference when necessary.
4. Extra-mobile “wrist action”. The mechanical wrist, which can hold a wide array of specialized instruments, functions just like a human wrist, but with an even greater range of motion.
5. Scalability. This innovation allows the surgeon to calibrate the robot’s arm to move a fraction of an inch for every inch that the surgeon’s hand moves, simplifying the most complex movements, including delicate resection, suturing and knot-tying. With the robotic system movements are smooth and without any awkwardness.
Weaknesses and Drawbacks
The robotic system has a few drawbacks.
1. An important clinical drawback is the lack of both tactile sensation and tensile feedback to the surgeon. Thus, tissue damage can occur easily during traction by the robotic arm and during movement of the robotic instrument.
2. Learning robotic surgery is associated with a steep learning curve.
3. The robot is an expensive system to purchase and as in laparoscopic surgery, each operation can require the use of expensive, single-use equipment.
Is “No Worse” the same as “Better”?
There are studies showing that robotic procedures are “no worse” than laparoscopic procedures. However, there are no prospective, randomized, controlled trials demonstrating a clear cut advantage of this new technology when compared with the now “traditional” laparoscopic technology. Unlike a urethral anastomosis, the colorectal anastomosis is no different between laparoscopic and robotic techniques, negating an important potential advantage of the robotic system. The visualization in the robotic operative field is superior in many ways. Importantly, robotic technology seems to put the eyes of the surgeon closer to the operative field; a definite advantage.
A Tool, a Toy and an Advance
Ultimately, as in any new intervention, the decision to use a robotic system in colorectal operations will depend on clinical benefit analysis. Our results to date underscore the increasing acceptance and use of robotic techniques in many common operative interventions.