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The SAGES Manual of Robotic Surgery pp 151–174Cite as

Masters Program Colon Pathway: Robotic Low Anterior Resection

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Abstract

Minimally invasive colorectal surgery offers many advantages to the patient as well as the surgeon. Despite this, its acceptance and use for low anterior resection (LAR) has been quite limited. Since 2010, much has been published regarding the safety and feasibility of robotic-assisted low anterior resection (RobLAR), including comparisons to open low anterior resection (OpenLAR) and laparoscopic-assisted low anterior resection (LapLAR). This chapter will review current data regarding LapLAR and RobLAR and compare outcomes using the two technologies. The surgeon’s learning curve for RobLAR will be discussed and guidance provided to safely and efficiently develop expertise in this procedure. Preoperative planning, operating room logistics, patient positioning, and port placement will be described in detail. Also provided are helpful information regarding instrumentation, intraoperative techniques, alternative approaches, and troubleshooting. Finally, the author’s own experience will be presented, including postoperative complications and oncologic outcomes.

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Abbreviations

A#:

Assistant port number

ACOSOG:

American College of Surgeons Oncology Group trial

ALaCaRT:

Australasian Laparoscopic Cancer of the Rectum trial

CO2 :

Carbon dioxide

COLOR:

Colon carcinoma laparoscopic or open resection trial

COREAN:

Comparison of open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy trial

CRM:

Circumferential resection margin

CUSUM:

Cumulative sum analysis

DRM:

Distal resection margin

EBL:

Estimated blood loss

EEA:

End-to-end anastomosis

ICG:

Indocyanine green

IMA:

Inferior mesenteric artery

IMV:

Inferior mesenteric vein

LapLAR:

Laparoscopic low anterior resection

LAR:

Low anterior resection

LLQ:

Left lower quadrant

LMQ:

Left middle quadrant

LOS:

Length of stay

LUQ:

Left upper quadrant

MRC-CLASICC II:

Medical Research Council Conventional versus laparoscopic-assisted surgery in colorectal cancer trial

NIR:

Near-infrared

OpenLAR:

Open low anterior resection

P#:

Port number

PILLAR II:

Perfusion assessment in laparoscopic left-sided/anterior resection trial

R#:

Robotic arm number

RA-CUSUM:

Risk-adjusted cumulative sum analysis

RLQ:

Right lower quadrant

RobLAR:

Robotic low anterior resection

ROLARR:

Robotic-assisted versus laparoscopic resection for rectal cancer trial

RUQ:

Right upper quadrant

TME:

Total mesorectal excision

References

  1. Jacobs M, Verdeja JC, Goldstein HS. Minimally invasive colon resection (laparoscopic colectomy). Surg Laparosc Endosc. 1991;1(3):144–50.

    CAS  PubMed  Google Scholar 

  2. Speicher PJ, Englum BR, Ganapathi AM, Nussbaum DP, Mantyh CR, Migaly J. Robotic low anterior resection for rectal cancer: a national perspective on short-term oncologic outcomes. Ann Surg. 2015;262(6):1040–5.

    Article  PubMed  Google Scholar 

  3. Bege T, Lelong B, Esterni B, Turrini O, Guiramand J, Francon D, et al. The learning curve for the laparoscopic approach to conservative mesorectal excision for rectal cancer: lessons drawn from a single institution's experience. Ann Surg. 2010;251(2):249–53.

    Article  PubMed  Google Scholar 

  4. Dincler S, Koller MT, Steurer J, Bachmann LM, Christen D, Buchmann P. Multidimensional analysis of learning curves in laparoscopic sigmoid resection: eight-year results. Dis Colon Rectum. 2003;46(10):1371–8. discussion 8-9

    Article  PubMed  Google Scholar 

  5. Ito M, Sugito M, Kobayashi A, Nishizawa Y, Tsunoda Y, Saito N. Influence of learning curve on short-term results after laparoscopic resection for rectal cancer. Surg Endosc. 2009;23(2):403–8.

    Article  PubMed  Google Scholar 

  6. Kayano H, Okuda J, Tanaka K, Kondo K, Tanigawa N. Evaluation of the learning curve in laparoscopic low anterior resection for rectal cancer. Surg Endosc. 2011;25(9):2972–9.

    Article  PubMed  Google Scholar 

  7. Park IJ, Choi GS, Lim KH, Kang BM, Jun SH. Multidimensional analysis of the learning curve for laparoscopic resection in rectal cancer. J Gastrointest Surg. 2009;13(2):275–81.

    Article  PubMed  Google Scholar 

  8. Schlachta CM, Mamazza J, Seshadri PA, Cadeddu M, Gregoire R, Poulin EC. Defining a learning curve for laparoscopic colorectal resections. Dis Colon Rectum. 2001;44(2):217–22.

    Article  CAS  PubMed  Google Scholar 

  9. Son GM, Kim JG, Lee JC, Suh YJ, Cho HM, Lee YS, et al. Multidimensional analysis of the learning curve for laparoscopic rectal cancer surgery. J Laparoendosc Adv Surg Tech A. 2010;20(7):609–17.

    Article  PubMed  Google Scholar 

  10. deSouza AL, Prasad LM, Ricci J, Park JJ, Marecik SJ, Zimmern A, et al. A comparison of open and robotic total mesorectal excision for rectal adenocarcinoma. Dis Colon Rectum. 2011;54(3):275–82.

    Article  PubMed  Google Scholar 

  11. Krane MK, Fichera A. Laparoscopic rectal cancer surgery: where do we stand? World J Gastroenterol. 2012;18(46):6747–55.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Toda S, Kuroyanagi H. Laparoscopic surgery for rectal cancer: current status and future perspective. Asian J Endosc Surg. 2014;7(1):2–10.

    Article  PubMed  Google Scholar 

  13. deSouza AL, Prasad LM, Marecik SJ, Blumetti J, Park JJ, Zimmern A, et al. Total mesorectal excision for rectal cancer: the potential advantage of robotic assistance. Dis Colon Rectum. 2010;53(12):1611–7.

    Article  PubMed  Google Scholar 

  14. Miller K, Benden M, Pickens A, Shipp E, Zheng Q. Ergonomics principles associated with laparoscopic surgeon injury/illness. Hum Factors. 2012;54(6):1087–92.

    Article  PubMed  Google Scholar 

  15. Bonjer HJ, Deijen CL, Haglind E. A Randomized Trial of Laparoscopic versus Open Surgery for Rectal Cancer. N Engl J Med. 2015;373(2):194.

    PubMed  Google Scholar 

  16. Fleshman J, Branda M, Sargent DJ, Boller AM, George V, Abbas M, et al. Effect of laparoscopic-assisted resection vs open resection of stage II or III rectal cancer on pathologic outcomes: the ACOSOG Z6051 randomized clinical trial. JAMA. 2015;314(13):1346–55.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Green BL, Marshall HC, Collinson F, Quirke P, Guillou P, Jayne DG, et al. Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer. Br J Surg. 2013;100(1):75–82.

    Article  CAS  PubMed  Google Scholar 

  18. Jeong SY, Park JW, Nam BH, Kim S, Kang SB, Lim SB, et al. Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial. Lancet Oncol. 2014;15(7):767–74.

    Article  PubMed  Google Scholar 

  19. Stevenson AR, Solomon MJ, Lumley JW, Hewett P, Clouston AD, Gebski VJ, et al. Effect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer: the ALaCaRT randomized clinical trial. JAMA. 2015;314(13):1356–63.

    Article  CAS  PubMed  Google Scholar 

  20. Formisano G, Marano A, Bianchi PP, Spinoglio G. Challenges with robotic low anterior resection. Minerva Chir. 2015;70(5):341–54.

    CAS  PubMed  Google Scholar 

  21. Agha A, Furst A, Iesalnieks I, Fichtner-Feigl S, Ghali N, Krenz D, et al. Conversion rate in 300 laparoscopic rectal resections and its influence on morbidity and oncological outcome. Int J Color Dis. 2008;23(4):409–17.

    Article  CAS  Google Scholar 

  22. Law WL, Lee YM, Choi HK, Seto CL, Ho JW. Laparoscopic and open anterior resection for upper and mid rectal cancer: an evaluation of outcomes. Dis Colon Rectum. 2006;49(8):1108–15.

    Article  PubMed  Google Scholar 

  23. Pugliese R, Di Lernia S, Sansonna F, Scandroglio I, Maggioni D, Ferrari GC, et al. Results of laparoscopic anterior resection for rectal adenocarcinoma: retrospective analysis of 157 cases. Am J Surg. 2008;195(2):233–8.

    Article  PubMed  Google Scholar 

  24. Rottoli M, Bona S, Rosati R, Elmore U, Bianchi PP, Spinelli A, et al. Laparoscopic rectal resection for cancer: effects of conversion on short-term outcome and survival. Ann Surg Oncol. 2009;16(5):1279–86.

    Article  PubMed  Google Scholar 

  25. Slim K, Pezet D, Riff Y, Clark E, Chipponi J. High morbidity rate after converted laparoscopic colorectal surgery. Br J Surg. 1995;82(10):1406–8.

    Article  CAS  PubMed  Google Scholar 

  26. Yamamoto S, Fukunaga M, Miyajima N, Okuda J, Konishi F, Watanabe M. Impact of conversion on surgical outcomes after laparoscopic operation for rectal carcinoma: a retrospective study of 1,073 patients. J Am Coll Surg. 2009;208(3):383–9.

    Article  PubMed  Google Scholar 

  27. Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM, et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet. 2005;365(9472):1718–26.

    Article  PubMed  Google Scholar 

  28. Jayne DG, Guillou PJ, Thorpe H, Quirke P, Copeland J, Smith AM, et al. Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. J Clin Oncol. 2007;25(21):3061–8.

    Article  PubMed  Google Scholar 

  29. Scheidbach H, Rose J, Huegel O, Yildirim C, Kockerling F. Results of laparoscopic treatment of rectal cancer: analysis of 520 patients. Tech Coloproctol. 2004;8(Suppl 1):s22–4.

    Article  PubMed  Google Scholar 

  30. daVinci Rectal Resections in US 2015: Quarterly Procedure Evolution [Graph]2015.

    Google Scholar 

  31. Mak TW, Lee JF, Futaba K, Hon SS, Ngo DK, Ng SS. Robotic surgery for rectal cancer: a systematic review of current practice. World J Gastrointest Oncol. 2014;6(6):184–93.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Papanikolaou IG. Robotic surgery for colorectal cancer: systematic review of the literature. Surg Laparosc Endosc Percutan Tech. 2014;24(6):478–83.

    Article  PubMed  Google Scholar 

  33. Ortiz-Oshiro E, Sanchez-Egido I, Moreno-Sierra J, Perez CF, Diaz JS, Fernandez-Represa JA. Robotic assistance may reduce conversion to open in rectal carcinoma laparoscopic surgery: systematic review and meta-analysis. Int J Med Robot. 2012;8(3):360–70.

    Article  PubMed  Google Scholar 

  34. Trastulli S, Farinella E, Cirocchi R, Cavaliere D, Avenia N, Sciannameo F, et al. Robotic resection compared with laparoscopic rectal resection for cancer: systematic review and meta-analysis of short-term outcome. Color Dis. 2012;14(4):e134–56.

    Article  CAS  Google Scholar 

  35. Xiong B, Ma L, Huang W, Zhao Q, Cheng Y, Liu J. Robotic versus laparoscopic total mesorectal excision for rectal cancer: a meta-analysis of eight studies. J Gastrointest Surg. 2015;19(3):516–26.

    Article  PubMed  Google Scholar 

  36. Baek SJ, Al-Asari S, Jeong DH, Hur H, Min BS, Baik SH, et al. Robotic versus laparoscopic coloanal anastomosis with or without intersphincteric resection for rectal cancer. Surg Endosc. 2013;27(11):4157–63.

    Article  PubMed  Google Scholar 

  37. Alecu L, Stanciulea O, Poesina D, Tomulescu V, Vasilescu C, Popescu I. Robotically performed total mesorectal excision for rectal cancer. Chirurgia (Bucur). 2015;110(2):137–43.

    CAS  Google Scholar 

  38. Biffi R, Luca F, Pozzi S, Cenciarelli S, Valvo M, Sonzogni A, et al. Operative blood loss and use of blood products after full robotic and conventional low anterior resection with total mesorectal excision for treatment of rectal cancer. J Robot Surg. 2011;5(2):101–7.

    Article  PubMed  Google Scholar 

  39. Park EJ, Cho MS, Baek SJ, Hur H, Min BS, Baik SH, et al. Long-term oncologic outcomes of robotic low anterior resection for rectal cancer: a comparative study with laparoscopic surgery. Ann Surg. 2015;261(1):129–37.

    Article  PubMed  Google Scholar 

  40. Sun Y, Xu H, Li Z, Han J, Song W, Wang J, et al. Robotic versus laparoscopic low anterior resection for rectal cancer: a meta-analysis. World J Surg Oncol. 2016;14(1):61.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Erguner I, Aytac E, Boler DE, Atalar B, Baca B, Karahasanoglu T, et al. What have we gained by performing robotic rectal resection? Evaluation of 64 consecutive patients who underwent laparoscopic or robotic low anterior resection for rectal adenocarcinoma. Surg Laparosc Endosc Percutan Tech. 2013;23(3):316–9.

    Article  PubMed  Google Scholar 

  42. Shin JY. Comparison of short-term surgical outcomes between a robotic colectomy and a laparoscopic colectomy during early experience. J Korean Soc Coloproctol. 2012;28(1):19–26.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Baik SH, Kwon HY, Kim JS, Hur H, Sohn SK, Cho CH, et al. Robotic versus laparoscopic low anterior resection of rectal cancer: short-term outcome of a prospective comparative study. Ann Surg Oncol. 2009;16(6):1480–7.

    Article  PubMed  Google Scholar 

  44. Kim YW, Lee HM, Kim NK, Min BS, Lee KY. The learning curve for robot-assisted total mesorectal excision for rectal cancer. Surg Laparosc Endosc Percutan Tech. 2012;22(5):400–5.

    Article  PubMed  Google Scholar 

  45. Ghezzi TL, Luca F, Valvo M, Corleta OC, Zuccaro M, Cenciarelli S, et al. Robotic versus open total mesorectal excision for rectal cancer: comparative study of short and long-term outcomes. Eur J Surg Oncol. 2014;40(9):1072–9.

    Article  CAS  PubMed  Google Scholar 

  46. Memon S, Heriot AG, Murphy DG, Bressel M, Lynch AC. Robotic versus laparoscopic proctectomy for rectal cancer: a meta-analysis. Ann Surg Oncol. 2012;19(7):2095–101.

    Article  PubMed  Google Scholar 

  47. Bokhari MB, Patel CB, Ramos-Valadez DI, Ragupathi M, Haas EM. Learning curve for robotic-assisted laparoscopic colorectal surgery. Surg Endosc. 2011;25(3):855–60.

    Article  PubMed  Google Scholar 

  48. Foo CC, Law WL. The learning curve of robotic-assisted low rectal resection of a novice rectal surgeon. World J Surg. 2016;40(2):456–62.

    Article  PubMed  Google Scholar 

  49. Park EJ, Kim CW, Cho MS, Baik SH, Kim DW, Min BS, et al. Multidimensional analyses of the learning curve of robotic low anterior resection for rectal cancer: 3-phase learning process comparison. Surg Endosc. 2014;28(10):2821–31.

    Article  PubMed  Google Scholar 

  50. Park EJ, Kim CW, Cho MS, Kim DW, Min BS, Baik SH, et al. Is the learning curve of robotic low anterior resection shorter than laparoscopic low anterior resection for rectal cancer?: a comparative analysis of clinicopathologic outcomes between robotic and laparoscopic surgeries. Medicine (Baltimore). 2014;93(25):e109.

    Article  Google Scholar 

  51. Byrn JC, Hrabe JE, Charlton ME. An initial experience with 85 consecutive robotic-assisted rectal dissections: improved operating times and lower costs with experience. Surg Endosc. 2014;28(11):3101–7.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Choi DJ, Kim SH, Lee PJ, Kim J, Woo SU. Single-stage totally robotic dissection for rectal cancer surgery: technique and short-term outcome in 50 consecutive patients. Dis Colon Rectum. 2009;52(11):1824–30.

    Article  PubMed  Google Scholar 

  53. Obias V, Sanchez C, Nam A, Montenegro G, Makhoul R. Totally robotic single-position ‘flip’ arm technique for splenic flexure mobilizations and low anterior resections. Int J Med Robot. 2011;7(2):123–6.

    Article  PubMed  Google Scholar 

  54. EndoWrist One Vessel Sealer. In: Surgical I, editor. p. 1–2.

    Google Scholar 

  55. New da Vinci EndoWrist Stapler Takes Robotic-Assisted Surgery to the Next Level. [Intuitive Internal White Paper]. In press.

    Google Scholar 

  56. Kawada K, Hasegawa S, Hida K, Hirai K, Okoshi K, Nomura A, et al. Risk factors for anastomotic leakage after laparoscopic low anterior resection with DST anastomosis. Surg Endosc. 2014;28(10):2988–95.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Choi GS, Park IJ, Kang BM, Lim KH, Jun SH. A novel approach of robotic-assisted anterior resection with transanal or transvaginal retrieval of the specimen for colorectal cancer. Surg Endosc. 2009;23(12):2831–5.

    Article  PubMed  Google Scholar 

  58. Prasad LM. deSouza AL, Marecik SJ, Park JJ, Abcarian H. Robotic pursestring technique in low anterior resection. Dis Colon Rectum. 2010;53(2):230–4.

    Article  PubMed  Google Scholar 

  59. [This page was last modified on 1 November 2015, at 23:31.]. Available from https://en.wikipedia.org/wiki/Indocyanine_green.

  60. Asari SA, Cho MS, Kim NK. Safe anastomosis in laparoscopic and robotic low anterior resection for rectal cancer: a narrative review and outcomes study from an expert tertiary center. Eur J Surg Oncol. 2015;41(2):175–85.

    Article  CAS  PubMed  Google Scholar 

  61. Jafari MD, Lee KH, Halabi WJ, Mills SD, Carmichael JC, Stamos MJ, et al. The use of indocyanine green fluorescence to assess anastomotic perfusion during robotic assisted laparoscopic rectal surgery. Surg Endosc. 2013;27(8):3003–8.

    Article  PubMed  Google Scholar 

  62. Jafari MD, Wexner SD, Martz JE, McLemore EC, Margolin DA, Sherwinter DA, et al. Perfusion assessment in laparoscopic left-sided/anterior resection (PILLAR II): a multi-institutional study. J Am Coll Surg. 2015;220(1):82–92. e1

    Article  PubMed  Google Scholar 

  63. https://www.fascrs.org/video/results-robotic-vs-laparoscopic-resection-rectal-cancer-rolarr-study-2015.

    Google Scholar 

  64. Baek SJ, Kim CH, Cho MS, Bae SU, Hur H, Min BS, et al. Robotic surgery for rectal cancer can overcome difficulties associated with pelvic anatomy. Surg Endosc. 2015;29(6):1419–24.

    Article  PubMed  Google Scholar 

  65. Buchs NC. Robotic technology: optimizing the outcomes in rectal cancer? World J Clin Oncol. 2015;6(3):22–4.

    Article  PubMed  PubMed Central  Google Scholar 

  66. Cho MS, Baek SJ, Hur H, Min BS, Baik SH, Lee KY, et al. Short and long-term outcomes of robotic versus laparoscopic total mesorectal excision for rectal cancer: a case-matched retrospective study. Medicine (Baltimore). 2015;94(11):e522.

    Article  Google Scholar 

  67. Kim CN, Bae SU, Lee SG, Yang SH, Hyun IG, Jang JH, et al. Clinical and oncologic outcomes of totally robotic total mesorectal excision for rectal cancer: initial results in a center for minimally invasive surgery. Int J Color Dis. 2016;31(4):843–52.

    Article  Google Scholar 

  68. Kwak JM, Kim SH. Robotic surgery for rectal cancer: an update in 2015. Cancer Res Treat. 2016;48(2):427–35.

    Article  PubMed  PubMed Central  Google Scholar 

  69. Ng KH, Lim YK, Ho KS, Ooi BS, Eu KW. Robotic-assisted surgery for low rectal dissection: from better views to better outcome. Singap Med J. 2009;50(8):763–7.

    CAS  Google Scholar 

  70. Pai A, Marecik SJ, Park JJ, Melich G, Sulo S, Prasad LM. Oncologic and clinicopathologic outcomes of robot-assisted total mesorectal excision for rectal cancer. Dis Colon Rectum. 2015;58(7):659–67.

    Article  PubMed  Google Scholar 

  71. Brown SR, Mathew R, Keding A, Marshall HC, Brown JM, Jayne DG. The impact of postoperative complications on long-term quality of life after curative colorectal cancer surgery. Ann Surg. 2014;259(5):916–23.

    Article  PubMed  Google Scholar 

  72. Jayne DG, Brown JM, Thorpe H, Walker J, Quirke P, Guillou PJ. Bladder and sexual function following resection for rectal cancer in a randomized clinical trial of laparoscopic versus open technique. Br J Surg. 2005;92(9):1124–32.

    Article  CAS  PubMed  Google Scholar 

  73. Kim JY, Kim NK, Lee KY, Hur H, Min BS, Kim JH. A comparative study of voiding and sexual function after total mesorectal excision with autonomic nerve preservation for rectal cancer: laparoscopic versus robotic surgery. Ann Surg Oncol. 2012;19(8):2485–93.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Colorectal Surgery, Emory University, 6335 Hospital Parkway, Suite 112, Johns Creek, GA, 30097, USA

    Seth Alan Rosen M.D.

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  1. Seth Alan Rosen M.D.
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Correspondence to Seth Alan Rosen M.D. .

Editor information

Editors and Affiliations

  1. Department of General and Gastrointestinal Surgery, Emory Endosurgery, Emory University School of Medicine, Atlanta, GA, USA

    Ankit D. Patel

  2. Gastrointestinal, Minimally Invasive and Bariatric Surgery, The Center for Advanced Surgical Technology, University of Nebraska Medical Center, Omaha, NE, USA

    Dmitry Oleynikov

Electronic Supplementary Material Robotic-assisted low anterior resection (RobLAR) electronic supplementary mnaterial

Robotic-assisted low anterior resection—Pelvic dissection (MP4 140333 kb)

Robotic-assisted low anterior resection—Inferior mesenteric artery dissection (MP4 104958 kb)

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Rosen, S.A. (2018). Masters Program Colon Pathway: Robotic Low Anterior Resection. In: Patel, A.D., Oleynikov, D. (eds) The SAGES Manual of Robotic Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-51362-1_12

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