Robotic
Venkatesh Munikrishanan
Manish Chand
The use of robotic platforms for colorectal resectional surgery has significantly increased in the past decade. As surgeons have become more familiar with and proficient at robotic surgery, a greater number and variety of procedures have been added to the repertoire. Historically, robotic colorectal surgery has focused on the pelvis, where some surgeons have found laparoscopy to be challenging. The pelvis can prove to be difficult for some laparoscopic surgeons because the limited space combined with the close proximity to important structures can impose problems with rigid “straight” laparoscopic instruments. The theoretical technical advantages of “wristed” instruments and 3D binocular vision have been most commonly used for rectal cancer surgery, but we describe the robotic approach to total colectomy (TC) with ileorectal anastomosis.
INDICATIONS AND CONTRAINDICATIONS
Indications
In general terms, the indications and contraindications for robotic TC are the same as those for laparoscopy. These attributes are determined by both clinical and technical factors related to the disease and patient, respectively. While the disease-related factors have not changed over many years, the evolution of laparoscopy has meant that the number and variety of indications from a technical standpoint have increased. Consequently, the contraindications that may have been historically considered “absolute” are now “relative” contraindications. This divide is often a function of individual surgeons and unit expertise rather than strict parameters.
Table 25-1 shows the common indications for TC, which can be broadly divided into malignant and benign conditions. However, as surgeon experience increases, one may also consider emergent indications.
An important consideration, regardless of indication, must be the anticipated functional consequences. The traditional measures include normal resting sphincter tone, absence of perianal disease, and sufficient rectal capacity and compliance. If these conditions are not met, the patient is at high risk of developing significant quality of life deterioration. The objective measure of anorectal physiology testing may be necessary for some patients.
TABLE 25-1 Indications for Robotic Total Colectomy | ||||||||||||||||||
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Malignant Conditions
The technical approach to resection of malignant disease often differs from that for benign disease in TC as one considers the oncologic aspects of the procedure. However, synchronous tumors and dysplasia are potential problems.
As with laparoscopy, the malignant conditions are often less challenging because the anatomy is less distorted than it might be in the presence of inflammation. There is commonly more non-diseased bowel that can be manipulated with greater confidence, and often there are fewer adhesions. This combination of factors can affect the procedure and often cannot be fully assessed until first inspection of the abdominopelvic cavity following induction of pneumoperitoneum.
Familial adenomatous polyposis and hereditary non-polyposis colorectal cancer provide indications for prophylactic colectomy, but one must consider surveillance strategies if required. The discussion of risk of colorectal cancer (CRC) and alternative surveillance strategies must be had in detail, often in conjunction with a clinical geneticist. These patients require significant counseling and support before undertaking the surgery. Functional consequences and fecundity must be discussed in detail because these may well be young patients.
Benign Conditions
The indications for TC in benign disease are commonly colitis with rectal sparing, but may occasionally be ischemic with colitis or pancolonic diverticulitis.
Patients with significant colonic inertia may request or be offered a TC as a last resort. These patients have often had a long relationship with the clinical team and failed a variety of treatments before reaching the point of surgery. Because there is no immediate urgency for surgery, appropriate counseling in a multidisciplinary setting in conjunction with a gastroenterologist, psychologist, stoma nurses, and other allied health professionals is necessary to achieve patient satisfaction. The technique differs from the conditions mentioned and there is usually no concern with pathologic anatomy, but it can often be colonic redundancy with which the surgeon must contend. The redundant bowel can lead to challenges in manipulating and positioning.
The level of distal transection and subsequent restoration of gastrointestinal continuity is based on individual cases and should be discussed with the patient before the procedure. The distal transection will be commonly influenced by the distal extent of disease, future surveillance strategy, and risk of recurrence of the disease and desire to restore continuity. The distal margin should be to the rectum in patients in whom the surgical indication is diverticulitis.
There are currently little data supporting the use of a robotic platform in the emergent setting. Again, many of the same general arguments for the use of minimally invasive surgery apply. However, there may be additional concerns surrounding costs, setup time, and access, which have largely been addressed by laparoscopy in this setting. Additional indications in this setting are colonic hemorrhage, inflammatory bowel disease, pseudomembranous colitis, and ischemic colitis.
Contraindications
Table 25-2 shows the common contraindications. The majority of these factors are deemed “relative” contraindications, and often it is the experience of the surgeon following detailed patient consultation that makes the final decision. The evolution of these relative contraindications mimics that of laparoscopy. As surgeons become more experienced, they are able to consider an increasing number of such cases for robotic TC. The contraindications can be broadly divided into patient comorbidities that may restrict patient positioning and pneumoperitoneum and patient technical factors causing restricted access and vision.
The most important considerations in Table 25-2 are the anesthetic and perioperative factors. Robotic TC involves considerable investment from the theatre team, surgeon, and institution. A patient not suitable for a prolonged surgical procedure with a pneumoperitoneum is an inappropriate candidate for robotics. There must be a detailed discussion with the anesthesia and intensive care teams in this regard, not only about the surgery but also about the postoperative care setting.
From a technical standpoint, the key to successful surgery is the ability to access and visualize the entire abdomen-pelvic cavity. Adhesions, ascites, and bowel distension can restrict access and vision, and the severity of these will dictate whether the procedure is possible. The surgeon will be best placed to determine whether with appropriate adhesiolysis and manipulation/positioning of the bowel the procedure can be safely undertaken on the basis of prior experience.
TABLE 25-2 Contraindications for Robotic Total Colectomy | ||||||||||||||||||||||||||
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Obesity can affect the procedure from an anesthesia and technical perspective. If the size of the patient impairs cardiorespiratory function during pneumoperitoneum, it may not be possible to complete the procedure. This problem is usually apparent early in the procedure, particularly when patient positioning is performed in reverse Trendelenburg. An increase in intra-abdominal fat can impair vision, make positioning of the bowel challenging and reduce access to the pelvic cavity where space is at a premium.
PREOPERATIVE PLANNING
Multidisciplinary Team Meeting
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