MIAMI BEACH — Although most colorectal surgeons tend to prefer open surgery to laparoscopy, adding robotics to their repertoire could enhance the appeal of this technically demanding procedure, Emilio Morpurgo, M.D., said at a congress on laparoscopy and minimally invasive surgery.
“Robotics offers all the articulation of the human wrist”—something that is absent in the classic laparoscopic approach, said Dr. Morpurgo, of the Center for Minimally Invasive and Robotic Surgery, Hospital of Camposampiero, in Padova, Italy. “It is particularly useful in dissecting, anastomosis, and suturing.”
While the laparoscopic learning curve is quite steep, “robotics may be a bridge to that—as it was for urologists, many of whom went directly from open prostatectomy to robot-assisted laparoscopy, without passing through traditional laparoscopy,” he told this newspaper.
Dr. Morpurgo presented the results of 90 colorectal procedures (including 46 cancers) performed at his institution using robot-assisted laparoscopy, and compared them with 386 procedures (including 293 cancers) performed using traditional laparoscopy.
Among the procedures were right and left hernicolectomy, resection of transverse and sigmoid colon, low anterior resection, Miles' operation, total/subtotal colectomy, Hartmann's procedure, and rectopexis.
Robot-assisted surgery proved as safe and effective as laparoscopic techniques, he reported at the congress, sponsored by the Society of Laparoendoscopic Surgeons. There were no differences between the groups regarding duration of surgery, recovery of bowel function, length of postoperative stay, or amount of blood loss.
Among those undergoing the robotic procedure, complications required switching eight patients to another procedure: four were converted to hand-assisted surgery because of advanced cancer (three patients) or adhesions (one patient); three to laparoscopy because of technical difficulties, increased CO2, or bowel distension; and one to laparotomy because of injury to the spleen.
Among those in the laparoscopy group, 34 patients were switched to another procedure: 12 to hand-assisted surgery (5 due to advanced cancer, 3 due to difficulties resulting from obesity, 1 because of adhesions, and 3 nonspecified), and 22 to laparotomy (6 because of advanced cancer, 6 because of bowel distension, 2 because of adhesions, 2 because of splenic injuries, and 6 unspecified).
There were 10 major complications in the robot group (8.8%), including one death from electrolyte imbalance after a small bowel injury. A second case of small bowel injury also occurred. “This may be a new complication unique to this approach, in which it is difficult to see this injury,” said Dr. Morpurgo. “If the small bowel has to be manipulated during the procedure, it must be carefully inspected afterward.”
A higher percentage of patients in the laparoscopy group (13.2%) had complications, but there were no mortalities. Most complications were because of symptomatic anastomotic leaks in 19 patients, or 5% of the total, which is comparable with results seen with open surgery, Dr. Morpurgo said.
Other complications in this group included wound/perineal complications (seven patients), bleeding from trocars (six), abdominal bleeding (five), and stoma complications (four).
“Colorectal surgeons have to start doing more minimally invasive surgery,” said Dr. Morpurgo. “Since laparoscopy is not usually performed by colorectal surgeons, the robot can render an operation more like an open surgery, with all the benefits of laparoscopy.”
William Kelley, M.D., a general surgeon who practices in Richmond, Va., agreed that robotic surgery can make the laparoscopic approach less intimidating for colorectal surgeons. A fair number of U.S. colorectal surgeons have already familiarized themselves adequately with laparoscopic techniques, he said.
“Colon cancer is one of the hottest areas for robotic surgery,” said Dr. Kelley, who also is director of general surgery at the Minimally Invasive Surgery Center in Richmond, Va.