![Page 1: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/1.jpg)
ADVANCES IN SURGICAL TREATMENT OF COLON AND RECTAL CANCERS
Slawomir Marecik, MD, FACSAdvocate Lutheran General Hospital, Park Ridge, ILClinical Assistant ProfessorUniversity of Illinois, Chicago, USA
![Page 2: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/2.jpg)
THE ADVANTAGES OF ROBOTIC LOW ANTERIOR
RESECTION
![Page 3: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/3.jpg)
Robots Are here to stay One of the available tools in our
armamentarium Powerful tool Massive potential
![Page 4: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/4.jpg)
Laparoscopic TME Technically challenging
Tumor location Anatomic structures Difficult retraction Unstable camera Poor ergonomics for surgeon
UK MRC CLASICC
![Page 5: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/5.jpg)
Advanced lesion
Obese, low (male)
APROPEN
LAPAROSCOP
Y
![Page 6: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/6.jpg)
Major Robotic Advantages
1 Quality Of Dissection
2 Minimally Invasive
3 Comfort For Surgeon
![Page 7: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/7.jpg)
Quality Of Dissection
![Page 8: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/8.jpg)
Robotic n=56
Mesorectal grade
Complete 52
Nearly complete 4
Incomplete 0
Laparoscopic n=57
Mesorectal Grade
Complete 43
Nearly complete 12
Incomplete 2
p=0.033
Baik SH. Robotic versus laparoscopic low anterior resection of rectal cancer: short-term outcome of prospective comparative study.
Ann Surg Oncol. 2009
Quality Of Dissection
Robotic vs. Lap Rectal Dissection
![Page 9: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/9.jpg)
Quality Of Dissection Pigazzi, Baek O.7 % CRM 143 pts Kim 1.6 % CRM 59 pts Prasad, Marecik 1 % CRM 82 pts
ROLLAR ACOSOG
Can we reduce preoperative radiation? Improved urogenital function?
Randomized Studies To Compare Laparoscopic vs.
Robotic Resection
![Page 10: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/10.jpg)
Minimally Invasive Aspect The robot is more useful in certain areas
Laparoscopy is more useful in other
areasA Hybrid Approach Is
The Most Practical Solution At This Time
![Page 11: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/11.jpg)
Comfort For The Surgeon Laparoscopic TME challenging Difficulties with advanced disease An increase in obese patient population
![Page 12: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/12.jpg)
Source: Behavioral Risk Factor Surveillance System, CDC.
2000
Obesity Trends* Among U.S. AdultsBRFSS, 1990, 2000, 2010
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
2010
1990
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
![Page 13: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/13.jpg)
Robotic LAR randomized data is lacking
ACOSOG, ROLARR pending
difficulties in adoption of Korean experience BMI height splenic flexure mobilization radiation
![Page 14: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/14.jpg)
DCR 2010
![Page 15: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/15.jpg)
Comparison Robotic vs. Open TME
Open/HALS (=46) Robotic (n= 36) P valueMid and low rectal tumors
47.8% 80.5% .006
OR time (min) 273.8 337.9 .003EBL (mL) 273.8 187.5 .036Postoperativecomplications, n (%)
15 (32.6) 11 (30.6) .84
Length of stay (days)
7.3 7.0 .74
Distal margin positive, n (%)
0 (0) 1 (2.8) .44
Radial margin positive, n (%)
3 (6.5) 0 NS
Lymph nodes 16.8 15 .26deSouza AL, Prasad LM , Marecik SJ et al. Comparison of Open and Robotic Total Mesorectal Excision for Rectal Adenocarcinoma; Dis Colon Rectum, 2011
![Page 16: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/16.jpg)
![Page 17: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/17.jpg)
Author No. of Pts Conversion rate
Mean BMI Laparoscopic
Mean BMI Converted
P value
Yamamoto SJapan (2009)
1073(Lap)
7.3% 22.7(13.7-36.7)
24.6(16.6-34.8)
<0.0001
Agha AGermany (2008)
300(Lap)
8.6% 26.2(16.7-37.5)
29.0(22.6-43.9)
0.002
Rottoli MItaly (2009)
173(Lap)
15% 24.9 ±3.2 27.3±2.9 <0.001
deSouza2010*
44(Robotic)
4.5% 28.2(17.6-43)
41.5 -
Laparoscopy for rectal cancer – conversion rates
Robotic TME
MRC CLASSIC trial conversion rate – 34% (2005)
![Page 18: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/18.jpg)
![Page 19: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/19.jpg)
Colorectal Dis 2011
![Page 20: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/20.jpg)
APR (abdomino-perineal resections)cylindrical intraabdominal levator transection
Robotic Cylindrical Abdominoperineal Resection with Intraabdominal Levator Transection Marecik SJ, Zawadzki M, deSouza AL, Park JJ, Abcarian H, Prasad L
Dis Colon Rectum, Oct 2011
RILT
![Page 21: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/21.jpg)
![Page 22: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/22.jpg)
Distal pursestring
Prasad LM, deSouza AL, Marecik SJ, Park JJ, Abcarian H. Robotic pursestring technique in low anterior resection. Dis Colon Rectum. 2010 Feb;53(2):230-4.
![Page 23: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/23.jpg)
Natural orifice extraction
![Page 24: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/24.jpg)
Robotic LAR
upper rectumeasy, thin patient
Laparoscopic TMEMini-laparotomy
lower rectumdifficult, obese
patientRobotic
???
![Page 25: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/25.jpg)
Conclusion Robotic assistance in low anterior resection
decreases conversion rates when compared to laparoscopy
Mesorectal quality grade is higher in robotic technique, which may translate into better oncological outcomes
Robotic system allows for a very precise work in deep pelvis making intersphincteric dissection easier, distal pursestring application possible and transanal specimen extraction more common
![Page 26: advances in surgical treatment of colon and rectal cancers](https://reader036.vdocuments.us/reader036/viewer/2022062521/56816624550346895dd97dba/html5/thumbnails/26.jpg)
Conclusion Robotic assistance has potential to
improve outcomes in obese patients and in patients with advanced disease