1. La TME robotica a. coratti – m. di marino UO Chirurgia Generale, Grosseto

2. Laparoscopic 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

3. Robotic surgery

4. OVERCOMES LAPAROSCOPIC PITFALLS  3D / HD vision  Fine dissection  Deep, small operating fields  High precision suturing  Easier setup  Tutoring Robotic surgery The new system “da Vinci SI HD”

5. Robotic surgery ENDO-WRIST ™ SYSTEM  6 degrees of freedom  Tremor elimination  Motion scaling

6. Robotic surgery in Grosseto General SurgeryFirst period2000 – 2007732 General SurgerySecond period2007 – 2012393 Urology/gynecologist-2007 – 2012298 TOTAL2000 – 20121423 October 2000 – September 2012 Total series

7. Robotic rectal resection Reported series AuthorYearRefer.Pts. Op. time (min) ConversionMorbidityMortality D’Annibale*2004Dis Colon Rectum 532409.4%15%0 Hellan2007 Ann Surg Oncol 392852.6%12.1%0 Baik2008 Surg Endosc 9220.8000 Spinoglio*2008 Dis Colon Rectum 50338.84%14%0 Choi2009 Surg Endosc 13260.8023%0 Luca*2009Ann Surg Oncol 55290012.7%0 * Including colonic resections

8. Casciola (JSLS 2009) Short- and medium-term outcome of robot-assisted and traditional laparoscopic rectal resection. Robotic rectal resection No randomized prospective study – 66 pts

9. Intraoperative and pathologic data Robotic rectal resection Casciola (JSLS 2009)

10. Early and long-term outcomes Robotic rectal resection Casciola (JSLS 2009)

11. Oncological results 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: 0 LAP: 5.4% (NS)

12. Pigazzi et Al (Ann Surg Oncol 2010) Multicentric Study on Robotic Tumor-Specific Mesorectal Excision for the Treatment of Rectal Cancer. Robotic rectal resection Retrospective multicentric study – 143 pts Procedure112 RAR, 31APR Conversion (%)4.9% Mean blood loss283ml Mean op time297min N. harvested nodes14.1 (± 6.5) Distal margin2.9cm (± 1.8) Negative radial margin142/143 (99.3%) 3Y survival97% Local recurrence0 (mean follow-up 17.4 months) Conclusions Robot-assisted rectal surgery is a safe and feasible procedure that may facilitate mesorectal excision.

13. Perioperative results: 58 pts. (2001-2012) ProceduresLAR APR Hybrid technique Full robotic 44 14 33 25 PathologyRectal carcinoma Large rectal adenoma Anal carcinoma Anal melanoma 51 3 2 Preop CHT/RT46/58 (79,3%) Open conversions1/58 (1.7%) Operative time288min (range: 120-420) Blood lossNegligible NO intraoperative blood transfusions Ileostomy (LAR)41/44(93.3%) Morbidity9/58 (15,5%) Redo surgery5/58 (8,6%) Anastomotic leakage 2, pelvic abscess 1, bowel occlusion 1, postoperative bleeding 1 (VLS redo) Mortality0 Mean hospital stay7.9 days (range: 4-40) Experience in Grosseto

14. Oncological outcomes - Rectal carcinoma TNM of rectal carcinomas (51 cases) yT0N0 Stage I Stage II Stage III Stage IV 5 25 10 1 Retrieved lymph nodes 11.3 (range: 5-30) Resection marginsR0 in all cases Mean follow-up44.2 months (range: <1-118) RecurrenceLocal: 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 Grosseto

15. 3-Years overall survival (OS) 3-Years disease free survival (DFS) Long term survival (DFS, OS) - Rectal carcinoma Experience in Grosseto

16. Functional outcomes: 58 pts. (2001-2012) Urinary dysfunction1.7% (1/58) Sexual dysfunctionMales: 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 Grosseto

17. Rectal robotic surgery Surgical steps Patient positioning Robotic cart Ports Full robotic technique SURGICAL STRATEGY Hybrid (lap/rob) technique ■ LAPAROSCOPY ■ ROBOTIC Technical aspects

18. Docking 1. Paziente supino. Posizione ginecologica. Arti super. Addotti. Anti-trendelenburg 30 °. Ruotato sul fianco destro di 15 °. Carello robotico dalla spalla sinistra

19. Docking 2. Paziente supino. Posizione ginecologica. Arti super. Addotti. Trendelenburg 25 °. Ruotato sul fianco destro di 15 °. Carello robotico dalla gamba sinistra

20. Posizionamento dei trocars ottica R 1 R 2 R 3 Ass I step II step ottica R 2 Ass R 3 Ass R 1 minilaparomia

21. Posizionamento dei trocars ottica R 1 R 2 R 3 Ass I step II step ottica R 2 Ass R 3 Ass R 1 Minilaparotomia

22. Personal experience Very difficult at the beginning  Ports positioning  Cart docking  Pelvic exposure  Time consuming  Laparoscopy it’s better?

23. Personal experience Intermediate experience  Switch from hybrid to full robotic  Changing in port and cart setup Very difficult at the beginning

24. Personal experience Very difficult at the beginning Intermediate experience Advanced experience  Full robotic technique  Starting by pelvic dissection  Ultralow intersphyncteric dissection  No return to laparoscopy!

25. Robot-assisted LAR - I step Robot-assisted LAR - I step video

26. Robot-assisted LAR – II step Robot-assisted LAR – II step video

27. ADVANTAGES Technical aspects  3D/HD vision - Endowrist  TME  Nerves sparing  Intersphynteric dissection  Pelvic dissection (deep, narrow)  Obese patients  Reduction of conversions (?) Rectal robotic surgery

28. Technical aspects DRAWBACKS  Large operating field  Change of cart/patients positioning  Bowel retraction  Expert assistant surgeon  High cost procedure Rectal robotic surgery

29. 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.

30. Scuola ACOI di Chirurgia Robotica www.roboticschool.it COURSES 2012 BASIC May, 21-25 1 st ADVANCED (Upper GI, HPB, Endocrine) June, 25-29 2 nd ADVANCED (Colorectal, HPB, Endocrine) November, 26-30