la tme robotica
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La TME robotica
a. coratti – m. di marino
UO Chirurgia Generale, Grosseto
Laparoscopic surgeryLaparoscopic surgery
ADVANTAGES
•Pain control
•Blood losses negligible
• Immunitary system
•Shorter ileus
•Abdominal wall
•Morbidity
•Post-op stay
DRAWBACKS
• Unnatural movements
• Poor ergonomics for the
surgeon
• Reduced degrees of freedom
• Dissociated visual-
mechanical control
• Bidimensional vision
• Limited sutures
Robotic surgery
OVERCOMES LAPAROSCOPIC
PITFALLS
3D / HD vision
Fine dissection
Deep, small operating fields
High precision suturing
Easier setup
Tutoring
Robotic surgeryRobotic surgery
The new system “da Vinci SI HD”
Robotic surgery
ENDO-WRIST ™ SYSTEM
6 degrees of freedom Tremor elimination
Motion scaling
Robotic surgery in Grosseto
General Surgery First period 2000 – 2007 732
General Surgery Second period 2007 – 2012 393
Urology/gynecologist
- 2007 – 2012 298
TOTAL2000 – 2012
1423
October 2000 – September 2012
Total series
Robotic rectal resection Robotic rectal resection
Reported series
Author Year Refer. Pts. Op. time (min)
Conversion
Morbidity Mortality
D’Annibale* 2004 Dis Colon Rectum
53 240 9.4% 15% 0
Hellan 2007 Ann Surg Oncol
39 285 2.6% 12.1% 0
Baik 2008 Surg Endosc
9 220.8 0 0 0
Spinoglio* 2008 Dis Colon Rectum
50 338.8 4% 14% 0
Choi 2009 Surg Endosc
13 260.8 0 23% 0
Luca* 2009 Ann Surg Oncol
55 290 0 12.7% 0
* Including colonic resections
Casciola (JSLS 2009)
Short- and medium-term outcome of robot-assisted and traditional laparoscopic rectal resection.
Robotic rectal resection Robotic rectal resection
No randomized prospective study – 66 pts
Intraoperative and pathologic data
Robotic rectal resection Robotic rectal resection
Casciola (JSLS 2009)
Early and long-term outcomes
Robotic rectal resection Robotic rectal resection
Casciola (JSLS 2009)
Oncological results
Robotic rectal resection Robotic rectal resection
Casciola (JSLS 2009)
Conclusions
Robot-assisted rectal surgery is a safe and feasible procedure that facilitates
laparoscopic total mesorectal excision.
Local recurrence
ROB: 0LAP: 5.4%(NS)
(NS)
Pigazzi et Al (Ann Surg Oncol 2010)
Multicentric Study on Robotic Tumor-Specific Mesorectal Excision
for the Treatment of Rectal Cancer.
Robotic rectal resection Robotic rectal resection
Retrospective multicentric study – 143 pts
Procedure 112 RAR, 31APR
Conversion (%) 4.9%
Mean blood loss 283ml
Mean op time 297min
N. harvested nodes 14.1 (± 6.5)
Distal margin 2.9cm (± 1.8)
Negative radial margin 142/143 (99.3%)
3Y survival 97%
Local recurrence 0 (mean follow-up 17.4 months)
Conclusions
Robot-assisted rectal surgery is a safe and feasible procedure that may facilitate
mesorectal excision.
Perioperative results: 58 pts. (2001-2012)
Procedures LARAPR
Hybrid techniqueFull robotic
4414
3325
Pathology Rectal carcinomaLarge rectal adenomaAnal carcinomaAnal melanoma
51322
Preop CHT/RT 46/58 (79,3%)
Open conversions 1/58 (1.7%)
Operative time 288min (range: 120-420)
Blood loss Negligible NO intraoperative blood transfusions
Ileostomy (LAR) 41/44(93.3%)
Morbidity 9/58 (15,5%)
Redo surgery 5/58 (8,6%) Anastomotic leakage 2, pelvic abscess 1, bowel occlusion 1, postoperative bleeding 1 (VLS redo)
Mortality 0
Mean hospital stay
7.9 days (range: 4-40)
Experience in GrossetoExperience in Grosseto
Oncological outcomes - Rectal carcinoma
TNM of rectal carcinomas (51 cases)
yT0N0Stage IStage IIStage IIIStage IV
52510101
Retrieved lymph nodes
11.3 (range: 5-30)
Resection margins
R0 in all cases
Mean follow-up 44.2 months (range: <1-118)
Recurrence Local: 0
Port site: 0
Distant MTS: 6/51 (11,7%)
Liver 2, peritoneum 3, inguinal nodes 1
Related cancer mortality
3,9% (2/51)
Experience in GrossetoExperience in Grosseto
3-Years overall survival (OS)
3-Years disease free survival (DFS)
Long term survival (DFS, OS) - Rectal carcinoma
Experience in GrossetoExperience in Grosseto
Functional outcomes: 58 pts. (2001-2012)
Urinary dysfunction 1.7% (1/58)
Sexual dysfunction Males: 6.9% (2/29)Total: 5,1% (3/58)
Faecal incontinence(LAR)
5.8% (2/34; 8 pts. are waiting for closure of ileostomy)
Soiling(LAR)
8.8% (3/34; 8 pts. are waiting for closure of ileostomy)
Experience in GrossetoExperience in Grosseto
Rectal robotic surgery Rectal robotic surgery
Surgical steps Patient positioning
Robotic cartPorts
Full robotic technique
SURGICAL STRATEGY
Hybrid (lap/rob) technique
■ LAPAROSCOPY■ ROBOTIC
■ ROBOTIC
Technical aspects
Docking 1
. Paziente supino
. Posizione ginecologica
. Arti super. Addotti
. Anti-trendelenburg 30 °
. Ruotato sul fianco destro di 15 °. Carello robotico dalla spalla sinistra
Docking 2
. Paziente supino
. Posizione ginecologica
. Arti super. Addotti
. Trendelenburg 25 °
. Ruotato sul fianco destro di 15 °. Carello robotico dalla gamba sinistra
Posizionamento dei trocars
ottica
R 1
R 2
R 3
Ass
Ass
I step II step
ottica
R 2
Ass
R 3
Ass
R 1
minilaparomia
Posizionamento dei trocars
ottica
R 1
R 2
R 3
Ass
Ass
I step II step
ottica
R 2
Ass
R 3
Ass
R 1
Minilaparotomia
Personal experiencePersonal experience
Very difficult at the
beginning
Ports positioning
Cart docking
Pelvic exposure
Time consuming
Laparoscopy it’s better?
Personal experiencePersonal experience
Intermediate experience
Switch from hybrid to full robotic
Changing in port and cart setup
Very difficult at the
beginning
Personal experiencePersonal experience
Very difficult at the
beginning
Intermediate experience
Advanced experience
Full robotic technique
Starting by pelvic dissection
Ultralow intersphyncteric
dissection
No return to laparoscopy!
Robot-assisted LAR - I stepRobot-assisted LAR - I step
video
Robot-assisted LAR – II stepRobot-assisted LAR – II step
video
ADVANTAGES
Technical aspects
3D/HD vision - Endowrist
TME
Nerves sparing
Intersphynteric dissection
Pelvic dissection (deep, narrow)
Obese patients
Reduction of conversions (?)
Rectal robotic surgery Rectal robotic surgery
Technical aspects DRAWBACKS
Large operating field
Change of cart/patients positioning
Bowel retraction
Expert assistant surgeon
High cost procedure
Rectal robotic surgery Rectal robotic surgery
Conclusions Conclusions
Robot-assisted rectal resection are feasible and safe.
The robotic technique may improve TME, nerves sparing and
intersphynteric dissection in ultralow rectal resection.
Major advantages can be appreciated in males, in narrow and
deep pelvis, and in obese patients.
The long-term functional and oncological results are very
interesting.
We are waiting the ROLARR trial.
Scuola ACOI di Chirurgia RoboticaScuola ACOI di Chirurgia Roboticawww.roboticschool.itwww.roboticschool.it
COURSES 2012
BASICMay, 21-25
1st ADVANCED(Upper GI, HPB, Endocrine)June, 25-29
2nd ADVANCED(Colorectal, HPB, Endocrine)November, 26-30
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