1. Robotic Total Mesorectal Excision
Oscar I. Moreno Ponte MD

2. Objectives
1. Discuss overview of robotic surgery. 2. Describe evolution of robotic surgery 3. Discuss applicability of robotic surgery in colorectal surgery. 4. Review oncological and clinical outcomes of laparoscopic mesorectal excision. 5. Review oncological and clinical outcomes of robotic mesorectal excision.

3. Robotic Surgery
…”Developed to overcome the limitations of minimally Invasive Surgery and to enhance the capability of open surgery”…

4. Chronological Events First Remote Cholecystectomy.
The Lindbergh Operation
Dr. Jacques Marescaux and Dr. Michel Gagner
New York, September 2001.

5. History of Robotic Surgery
In 1985, PUMA 560 CT guided brain biopsy
A robot with improved absolute positioning accuracy for CT guided stereotactic brain surgery.
Kwoh, Y. Et all. Engng, Feb 1988, 35(2), 153–161.

6. History of Robotic Surgery
In 1988, The PROBOT
PROBOT-A Computer Integrated Prostatectomy System
Mei, Q. Et all. LNCS, 1996, Volume 1131/1996,

7. History of Robotic Surgery
In 1992, The ROBODOC
The ROBODOC Clinical Trial: A Robotic Assistant for Total Hip Arthroplasty.
Spencer. E.H. Et all Ort Nur, 1996, VOL 15; NUMBER 1,Pag 9-14

8. History of Robotic Surgery
In 1994, ZEUS Robotic Surgical System Robots Helping Surgeons: The da Vinci and ZEUS System By FDA

9. History of Robotic Surgery
In 2000, The da Vinci Surgical System Robots Helping Surgeons: The da Vinci and ZEUS System By FDA

10. Chronological Events
- 1997, Dr Tommaso Falcone, Cleveland Clinic; Successfully reconnection of fallopian tubes using ZEUS surgical system , Dr Friedrich Wilhelm, Leipzig Heart Center; First Robotic Assisted heart bypass using da Vinci surgical System , Dr. Randall Wolf and Dr. Robert Michler, The Ohio state university; First Robotic Assisted heart bypass in USA , Dr. Jacques Marescaux and Dr. Michel Gagner; first remote cholecystectomy , Dr. Mohan S. Gundeti, University of Chicago; First robotic pediatric neurogenic bladder reconstruction , Dr. Stuart Geffner, Santa Barbara Medical Center, Ney Jersey; the first all-robotic-assisted Kidney transplant , Dr. Borut Gersak, University Medical Centre Ljubljana; first robotic operation at the femoral vasculature

11. Chronological Events
First Fallopian Tube Reconstruction. Successful pregnancy 2 years after reconstruction. Dr Tommaso Falcone; Cleveland Clinic, July 1997.

12. Chronological Events
First Robotic Assisted heart bypass using da Vinci surgical System. Dr Friedrich Wilhelm; Leipzig Heart Center, Germany 1998

13. Chronological Events
First Robotic Assisted heart bypass in USA. Dr. Randall Wolf and Dr. Robert Michler The Ohio State University 1999

14. Chronological Events
1999….World's first surgical robotics beating heart coronary artery bypass graft (CABG) was performed in Canada by Dr. Douglas Boyd and Dr. Reiza Rayman using the ZEUS surgical robot…. Same year…. the first closed-chest beating heart cardiac hybrid revascularization procedure is performed at the London Health Sciences Centre (London, Ontario)

15. Chronological Events
Robotic assisted Aortobifemoral bypass Dr Willem Wisselink, Vrije Universiteit Medical Center. Amsterdam, The Netherlands 2002

16. Chronological Events
First robotic pediatric neurogenic bladder reconstruction. Dr. Mohan S. Gundeti, University of Chicago 2008

17. Chronological Events First all-robotic-assisted Kidney transplant.
Dr. Stuart Geffner, Santa Barbara Medical Center, New Jersey 2009

18. Robotic Surgery Application
Otolaryngology—Head & Neck Surgery Gastrointestinal Surgery Cardiothoracic Surgery Cardiology and Electrophysiology Urology Gynecology Neurosurgery Orthopedic Pediatric

19. Laparoscopic Surgery
Standard of care for most benign and malignant colorectal disease.
Less post-operative pain
Better Cosmesis
Early return of bowel function
Shorter hospital stay
Without sacrificing oncological clearance.

20. Laparoscopic Surgery - Shortcomings of laparoscopic surgery
Two dimensional view
Dexterity of instruments within the abdominal space
Fixed instruments tips with 4 degree of freedom
Possible misalignment of hands and instruments

21. Robotic Surgery
The da Vinci Surgical system was developed to overcome shortcomings of laparoscopy…..
Three dimensional imaging
Stable camera and operating platform
Articulating instruments with 7 degree of freedom
Motion scaling and and tremor free movements
Ergonomic Comfort

22. Open Versus Laparoscopic Colorectal Surgery
Cancer Treatment Reviews 2008 Vol 34, 498– 504

23. Open versus Laparoscopic Colorectal Surgery

24. Open versus Laparoscopic Colorectal Surgery
Twelve trials More than 3346 patients No difference in recurrence rate No difference in Cancer related mortality

25. Open versus Laparoscopic Colorectal Surgery

26. Open versus Laparoscopic Colorectal Surgery
….” For any stage, 3 year survival and disease free interval are not worse in patients undergoing laparoscopic versus conventional open resection”……

27. Laparoscopic Vs Open Surgery for rectal Cancer.
COLOR II. A randomized clinical trial comparing laparoscopic and open surgery for rectal cancer.
- International Clinical Trial
- Primary end point: Loco-regional recurrence rate
- Secondary end point: Disease free survival, post operative morbidity, quality of life and health economy analysis.
“The results and safety of Laparoscopic Surgery in the treatment of rectal cancer remains unknown”

28. Laparoscopic Rectal Surgery
….”Technical Complexity and long Learning curve can compromise oncologic Outcomes”…..

29. Laparoscopic Rectal Surgery
…”Ninety operation required to achieve oncological safety”….

30. Robotic Rectal Surgery
…” Stable view and precise movements make the Robot specially appropriate for manipulation of tissue in a closed and fixed space”… …” We believe that robotics could be relevant in the treatment of rectal cancer”….

31. Robotic Colorectal Surgery
Relatively new approach….
SURG ENDOSC 2002 Vol. 16, Number 8,

32. Robotic Colorectal Surgery

33. Robotic Colorectal Surgery
Relatively new approach….
DIS COLON RECTUM 2002 Vol. 45, Number 12,

34. Robotic Colorectal Surgery
- Robotic Assisted Technique for the mobilization of the bowel - Three arm da Vinci System - Three-trocar Technique - Division of the Mesentery and Anastomosis performed with standard laparoscopic assisted technique. - Operative time (180) - No Complication - Expected postoperative course

35. Robotic Colorectal Surgery

36. Robotic Rectal Surgery

37. Robotic Rectal Surgery

38. Robotic Rectal Surgery
Operative Technique
Hybrid Technique: Laparoscopic mobilization of the colon and Robotic TME
Totally Robotic Anterior Resection
A. Pagazzi et all; Surg Endosc 2006 Vol 20,
M. Hellam et all; Ann of Surg Onc 2007 Vol 14,

39. Robotic Rectal Surgery

40. Robotic Rectal Surgery
LAR 80 (55.9%) CA 32 (22.4%) APR 31 (21.7%)
Sphincter preservation achieve in 78.3 %
Diverting Ileostomy 63%
Operative time 297 min
EBL 283 ml ( ml)
Conversion to open 4.9%
Ann Surg Oncol 2010 Vol 17:1614–1620

41. Robotic Rectal Surgery
Overall anastomotic leak 10.5% - Tumor Location >7 cm from the anal verge 9.3% - Lower tumors 16.4% Overall Pelvic Septic Complications abscess and leakages 16%

42. Robotic Rectal Surgery
Oncologic Outcomes
Negative distal and circumferential margins 99.3%
Mean number of harvested lymph nodes 14.1
Complete pathologic response 19.3%
No Port site recurrence
Total Recurrence 13 patients; Distant-only Mets 7.7% Local combined with distal Mets 1.5% No Local-only recurrence
Disease free Survival at 3 years 76.6%
Three year overall Survival rate 77%
Ann Surg Oncol 2010 Vol 17:1614–1620

43. Robotic Rectal Surgery
“All circumferential and Distal resection margins were negative The medial number of harvested lymph nodes was 14.5”

44. Robotic Rectal Surgery

45. Robotic Vs Laparoscopic TME

46. Robotic Vs Laparoscopic TME
Ann Surg Oncol 2009 Vol 16:1480–1487

47. Robotic Vs Laparoscopic TME
Ann Surg Oncol 2009 Vol 16:1480–1487

48. Robotic Vs Laparoscopic TME
Ann Surg Oncol 2009 Vol 16:1480–1487

49. Robotic Vs Laparoscopic TME
Ann Surg Oncol 2009 Vol 16:1480–1487

50. Robotic Vs Laparoscopic TME

51. Robotic Vs Laparoscopic TME
Surg Endosc 2010 Vol 24:2888–2894

52. Robotic Vs Laparoscopic TME
Surg Endosc 2010 Vol 24:2888–2894

53. Robotic Vs Laparoscopic TME
Surg Endosc 2010 Vol 24:2888–2894

54. Robotic Vs Laparoscopic TME

55. Robotic Vs Laparoscopic TME

56. Robotic Vs Laparoscopic TME

57. Robotic Vs Laparoscopic TME

58. Robotic Vs Laparoscopic TME

59. Conclusion
The evolution of Robotic Surgery is limited due to small numbers of high volume centers The Robotic Technology will radically change general surgery and the fractionated subspecialties

60. Conclusion
The Robotic assisted surgery for benign and malignant disease of colon and rectum is safe and feasible Total Mesorectal Excision can be performed safely and effectively using the robotic system The clinical and oncological outcomes of the Robotic Total Mesorectal Excision can be compared with standard and open approach.