By Jeffrey S. Cohen, MD FACS FASCRS
Over the last 20 years, minimally invasive colon and rectal surgery has become widely accepted as the optimal approach for both benign and malignant pathologies. Laparoscopy offers the proven benefit of a minimally invasive approach that results in excellent outcomes, shorter hospital stays, decreased patient discomfort and excellent cosmesis.
Though the benefits to a minimally invasive approach to colon and rectal surgery are well-documented, the majority of colon resections are still not performed in a minimally invasive manner. Laparoscopy is limited by two-dimensional visualization on a flat monitor, difficult ergonomics with rigid instrumentation and an unstable operative platform with both camera and instruments held by the surgical team. The technical and physical limitations of laparoscopy may have contributed to less than unanimous adoption. The innovation of robotic colon and rectal surgery has been developed to address all of the limitations of laparoscopic surgery and has given rise to a rapid increase in minimally invasive colon resections.
Since the first robotic colon resection was performed in 2001, there has been a boom in the number and complexity of robotic colon and rectal resections performed. Advantages of robotic surgery include a perfectly stable robotic camera controlled by the operating surgeon, three-dimensional visualization, magnified visualization, elimination of instrument tremor and positions of the operating surgeon in an ergonomic-preferred seated position to minimize surgeon fatigue. Advanced technologies controlled at the surgeon console allow performance of even the most complex surgical procedures in a minimally invasive manner.
Robotic colon and rectal surgery performed on the Intuitive Surgical DaVinci robotic platform is achieved via 8mm ports placed by the operating surgeon at the bedside. Once the camera is instilled in the abdominal cavity, the optimal position of the four operating robotic arms is determined by the robotic computer based on the planned procedure. It is at this point when the operating surgeon moves to the operating console with an assistant remaining at the patient bedside.
It is from the operating console that the overwhelming benefits of robotic surgery are immediately apparent. First, the operating surgeon can now discern the anatomy in a perfect, high-definition 3-D image, which allows superior visualization compared to laparoscopy, resulting in more precise dissection with resultant improvement in oncologic results and preservation of sexual and urinary function.
Compared to rigid laparoscopic instruments, the robotic instrumentation uses Endowrist technology. This allows the operating surgeon to maneuver the instruments as if his hand and wrists were actually in the abdominal cavity. No longer is the surgeon limited by rigid instruments that force the surgeon to modify operations due to the limitations of the laparoscopic instruments.
Advanced robotic technologies now allow the surgeon to control the entire operation form the operating console. No longer is the surgeon dependent on the bedside assistant to control the camera or even the stapling devices. Advanced technologies include the da Vinci Vessel Sealer, which enables the surgeon to cut and seal even the major colic vessels safely and with precise wristed control.
The robotic stapler is another fully wristed instrument that allows the precise stapling of the bowel with much greater articulation and precision than previously encountered with laparoscopy. The da Vinci robotic stapler also uses SmartClamp technology, which assures the surgeon that there is adequate closure of the stapling device prior to firing the stapler.
The most exciting advance in minimally invasive robotic surgery is the ability to perform intracorporeal anastomosis. In order to minimize the incisions, the surgeon is now able to perform not just the bowel resection within the abdominal cavity, but the anastomosis as well.
Firefly Technology has made intracorporeal anastomosis both safe and simple. It uses intravenous administration of indocyanin green (IcG) to verify adequate blood flow using fluorescence to both ends for the bowel prior to anastomosis. Without the ability to confirm adequate blood flow intracorporeally, it was previously necessary to make a large enough incision to visually inspect the bowel outside the abdominal cavity prior to anastomosis.
The combination of Vessel Sealer, Robotic Stapler with Smartclamp and Firefly allows the entire procedure to be performed within the confines of the abdominal cavity, allowing for significantly less trauma, smaller incisions and faster recovery for the patient.
Robotic colon and rectal surgery has shown documented benefits when compared to laparoscopic surgery on many fronts. Patients with diverticulitis, colon and rectal cancer, Crohn’s disease and ulcerative colitis all benefit from a robotic approach to their pathology. More recent prospective studies have demonstrated benefit in return of bowel function, length of hospital stay, blood loss, fewer open conversions, improved oncologic resection, lymph node clearance and urinary function as well as sexual function.
It is important to note that these benefits have been demonstrated when robotic colon and rectal surgery is performed by experienced robotic colon and rectal surgeons that have completed their learning curve and are committed to performing many, if not most, of their colon resections robotically.