Journal of the Egyptian National Cancer Institute (2016) 28, 169–174

Cairo University

Journal of the Egyptian National Cancer Institute

www.elsevier.com/locate/jnciwww.sciencedirect.com

Full Length Article

Preliminary results of robotic colorectal surgery

at the National Cancer Institute, Cairo University

* Corresponding author. Mobile: +20 01001729571.

E-mail address: drbarbary@yahoo.com (A.M. Mahmoud).

Peer review under responsibility of The National Cancer Institute,

Cairo University.

http://dx.doi.org/10.1016/j.jnci.2016.05.0031110-0362 � 2016 National Cancer Institute, Cairo University. Production and hosting by Elsevier B.V.This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Ashraf Saad Zaghloul, Ahmed Mostafa Mahmoud *

Surgical Oncology Department, National Cancer Institute, Cairo University, Egypt

Received 16 January 2016; revised 8 May 2016; accepted 21 May 2016

Available online 13 June 2016

KEYWORDS

Minimally invasive surgery;

Robotic-assisted;

Colorectal cancer;

Egypt

Abstract Background: The available literature on minimally invasive colorectal cancer demon-

strates that laparoscopic approach is feasible and associated with better short term outcomes than

open surgery while maintaining equivalent oncologic safety. Reports have shown that robotic sur-

gery may overcome some of the pitfalls of laparoscopic intervention.

Objective of the work: To evaluate early results of robotic colorectal surgery, in a cohort of Egyp-

tian patients, regarding operative time, operative and early post-operative complications, hospital

stay and pathological results.

Patients and methods: A case series study which was carried out in surgical department at National

Cancer Institute, Cairo University. Ten Egyptian cases of colorectal cancer (age ranged from 30 to

67, 5 males and 5 females) were recruited from the period of April 2013 to April 2014. Robotic sur-

gery was performed to all cases.

Results: Three patients had low anterior resection, three anterior resection, one total proctectomy,

one abdominoperineal resection, one left hemicolectomy and one colostomy. The study reported no

mortalities and two morbidities. The mean operative time was 333 min. The conversion to open was

done in only one patient. A total mesorectal excision with negative circumferential margin was

accomplished in all patients, distal margin was positive in one patient. Mean lymph nodes removed

was 10.7. Mean hospital stay was 7.4 days.

Conclusion: To the best of our knowledge, this is the first study reporting the outcomes of robotic

colorectal cancer intervention in Egyptian patients. Our preliminary results suggest that robotic-

assisted surgery for colorectal cancer can be carried out safely and according to oncological prin-

ciples.� 2016 National Cancer Institute, Cairo University. Production and hosting by Elsevier B.V. This is an

open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

The most important advance in rectal surgery over the last30 years was development of total mesorectal excision(TME). TME is associated with reduction of local recurrencerate to less than 10% and improve survival [1].

170 A.S. Zaghloul, A.M. Mahmoud

The development of minimally invasive approach in col-orectal disease began with first report of laparoscopic assistedcolectomy in 1991 [2]. The available literature on minimally

invasive TME for rectal cancer demonstrates that laparoscopicTME is feasible and associated with better short termoutcomes than open surgery while maintaining equivalent

oncologic safety [3]. The proposed advantages of minimallyinvasive colorectal surgeries (MIC) over open colectomiesinclude improved intra operative visualization of pelvis, less

stress on patient, less post-operative pain, improved cosmoses,shorter duration of ileus and briefer hospitalization [4].

More recently, robotic assisted laparoscopic colorectalsurgery has become an intriguing technique most beneficial

for procedures requiring rectal resection. This technologyprovides visualization and reach for these complex pelvicprocedures [5]. The 1st robotic assisted colorectal resection

was reported in Japan by Hashizume et al. in 2002 [6].The use of robotics for the treatment of rectal cancer has

recently been shown to be feasible [7–10]. The general advan-

tages of the Da Vinci robotic system are a three-dimensionalview, hand-tremor filtering, fine dexterity, and motion scaling,providing an absolute benefit when the operative field is

narrow and fixed and sharp dissection is necessary [11].There are no available data on the outcome of robotic inter-

vention in cancer surgery in developing countries and the onlydata available are those of American, European and Asian

experiences.Within this context, the present study aims to report our

initial experience with robotic colorectal surgery in a series

of 10 consecutive Egyptian patients, regarding operative time,operative & early post-operative complications, hospital stayand pathological results.

Patients and methods

A case series study included 10 cases of colorectal cancer.

Patients were recruited from the surgical department of theNational Cancer Institute, Cairo University and operated byRobot da Vinci Si Surgical System (Intuitive Surgical, USA)

over a period of one year. Their age ranged from 30 to67 years. They were 5 males and 5 females. The patientsprovided informed consent. Patients with previous laparo-tomy, patients presented with intestinal obstruction, patients

with severe cardiac or pulmonary disease were excluded fromrobotic surgery. The study was approved by local ethicscommittee.

All rectal cancer patients with T3d, T3c, T4, N2, obturator,internal iliac, presacral lymph nodes and extensive intravascu-lar mural invasion were subjected to long course preoperative

neoadjuvant chemo-irradiation. Accordingly five patientsreceived preoperative neoadjuvant treatment.

Patient demographics, pathological, operative andperioperative outcomes were recorded prospectively into our

departmental database and analyzed.

Surgical technique

For tumors of the upper rectum, a partial mesorectal excision(PMSE) is done and for tumors of the mid and low rectum,total mesorectal resection was done (TME). In cases of very

low tumors without invasion to the rectal sphincters, inter-

sphincteric or total proctectomy resection with specimenextraction through the anus and hand sewn coloanal anasto-mosis was performed. Abdominoperineal resection (APR)

was proposed to patients with sphincter invading lesions orwith very low tumors.

Full robotic technique was done in all cases. The operation

was carried out with the aid of the four-arm Da Vinci roboticsystem. The patient was placed in a modified lithotomy posi-tion and then tilted into a steep Trendelenburg position with

the left side maximally elevated. The Da Vinci system isdocked (Fig. 1) coming in over the patient’s left hip at an acuteangle of about 30� in relation to the operating table. The twoworking ports were placed 12–14 cm from symphysis pubis in

midclavicular line (Fig. 2). The two working arms usuallycarry a grasper on the left connected to bipolar cautery andhook with monopolar cautery on the right. The third robotic

arm on the patient left side carries another grasper and is usedfor additional retraction. Medial to lateral mobilization withhigh ligation of inferior mesenteric artery (IMA) and vein

(IMV) was carried out with clips (Figs. 3 and 4), then dissec-tion continue in retroperitoneal space dropping the left ureterand left gonadal vessels. Mobilization of splenic flexure is done

if needed. After completion of colon mobilization, dividing theperitoneum in front of sacral promontory going in the retrorectal space, then dissection continues circumferentially alongthe mesorectal fascia down to the planned rectal section line.

Arms two and three, under control of the surgeon‘s lefthand are used for dissection and retraction of the bladder orrectum as needed (Figs. 5 and 6).

Once the distal transection cut is prepared the assistantdivides the distal rectum using articulating linear staplerthrough a 12 mm laparoscopic port inserted in the right lower

quadrant (Fig. 7).Delivery of the specimen through Pfannenstiel incision,

dividing the proximal sigmoid at the proper distance, then

introduction of the anvil of EEA (end to end anastomosiscircular stapler), then purse string suture is done at the cutend (Fig. 8). Creating pneumoperitoneum again and end toend anastomosis was done using a EEA (Fig. 9).

Results

A total of 10 patients underwent robotic colorectal resections.

patient clinical data are listed in Table 1. Mean age for patientswas 47.4 years (range 30–67), equal number of male andfemale patients were involved. The patient BMI ranges from

24.8 to 39.5 with median 29.21. All patients presented withbleeding per rectum, 6 patients (60%) presented with rectalmass and 3 cases (30%) presented with change in bowel habits.

Regarding tumor location, most patients (60%) had tumors inthe lower rectum (<7 cm), upper rectum tumors were in 3patients (30%) and one patient (10%) presented with tumorin the descending colon.

The histopathologic data are presented in Table 2. Distalmargin was positive in one patient (10%), circumferential mar-gin was negative in all cases. Half of patients (50%) were stage

II, 3 cases were stage I (30%), while 2 patients were stage III.Mean distal margin was 4.6 cm (range 0–15) and mean numberof lymph nodes removed was 10.7 (range 5–23).

Regarding operative data; one patient (10%) was estimatedto be inoperable, 3 patients (30%) underwent low anterior

Figure 1 Port placement.

Figure 2 Docking.

Figure 3 IMA is skeletonized at its origin.

Results of robotic colorectal surgery at the National Cancer Institute 171

resection (LAR) and the same number underwent anteriorresection (30%). One patient (10%) had total proctocolectomyand coloanal anastomosis, and one (10%) had Lt hemicolec-

tomy and abdominoperineal resection. The remaining one case(10%) underwent colostomy for locally advanced rectal cancer(T4) post neoadjuvant RTH and CTH, the tumor was fixed tothe sacrum. Means for docking and robotic times were

39.5 min (range 30–50) and 4.9 h (range 3–7) respectively.The mean total operative time was 333 min (range 215–465).Estimated blood loss ranged from 200 to 500 cc (mean340 cc). The mean hospital stay was 7.4 days (range 5–16)

(Table 3).Considering morbidity and mortality, the study showed no

mortalities or intraoperative bleeding (>1000 cc blood loss).

Only one case (10%) needs reoperation and 2 cases (20%)had prolonged post-operative ileus (Table 4).

Discussion

Proponents of the robotic technique claim that endowristedrobotic instruments allow a surgeon to approach the rectum

from different directions and angles, thus permitting preciseretraction and sharp dissection [12].

Figure 4 IMV is ligated with clips.

Figure 5 Posterior dissection.

Figure 6 Anterior dissection.

Figure 7 Rectal transection using articulating linear stapler.

172 A.S. Zaghloul, A.M. Mahmoud

This current study describes the short term outcomes of 10consecutive Egyptian rectal cancer cases performed at theNational Cancer Institute, Cairo University. Prolonged opera-tive time is often described as one of the major drawbacks of

robotic surgery. Our study reported a mean operative timeof 333 min, this time compared favorably to previous studiesdone by Spinoglio et al. and Sawada et al. [13,14] which

reported a mean operative time of 383.3 min, and 417 minrespectively. However other studies reported a shorter timeof operation [9,14]. This difference is mainly due to the less

experience attributed to the novelty of the procedure in ourcountry.

Most authors reported a very low conversion rate for

robotic colorectal operations [15–17]. This goes in accordancewith our study which reported only one case (10%) which wasconverted to open. The reason behind this conversion in ourcase was mainly due to that the tumor was locally advanced

and when converted to open procedure, the tumor was irre-sectable and only colostomy was done.

Owing to the precise dissection and to the significant mag-

nification, the blood loss in our study ranged between 200 and500 cc. All studies reported the same results of blood loss notexceeding the 500 cc [9,18]. This indicates that the blood loss

was significantly lower for robotic surgeries than laparoscopicsurgeries and thus may reduce the probability of transfusion.

There was no occurrence of anastomotic leak in our study;

however Pigazzi et al. reported a 10.5% leak [19]. We can referthis discrepancy to the fact that we always perform protectiveileostomy in low anastomosis. Only one case needed reopera-tion (10%) which goes in agreement with percentage (10.4%)

of a study done by Hellan et al. [16]. Two patients (20%)had prolonged postoperative ileus. This stands in contrast tostudies done by Pigazzi et al. [19] and Hellan et al. [16], which

reported lower percentage of prolonged ileus >6 days. Thismay be explained by many factors as the prolonged operativetime in our cases and lack of routinely epidural analgesia.

Figure 8 Extracorporeal anvil insertion and purse string

suturing.

Figure 9 End to end anastomosis using a circular stapler.

Table 1 Clinical presentation of patients.

Variable Number of patients (%)

Bleeding per rectum 10 (100%)

Rectal mass 6 (60%)

Change in bowel habits 3 (30%)

Tumor location

Upper rectum (>11 cm) 3 (30%)

Left colon 1 (10%)

Lower rectum (<7 cm) 6 (60%)

Table 2 Histopathological data.

Variable Percentage/range

Stage I 3 (30%)

Stage II 5 (50%)

Stage III 2 (20%)

Number of removed LN 10.7 (5–23)

Distal margin (cm) 4.6 (0–15)

Positive circumferential margin 0

Positive distal margin 1 (10%)

Table 3 Operative data.

Variable Percentage/range

Type of operation

Low anterior resection 3 (30%)

Total proctectomy & colo-anal anastomosis 1 (10%)

APR 1 (10%)

Anterior resection 3 (30%)

Lt hemicoloctomy 1 (10%)

Colostomy 1 (10%)

Docking time (minutes) 39.5 (30–50)

Robotic time (hours) 4.9 (3–7)

Total operative time (min) 333 (215–480)

Blood loss (cc) 340 (300–500)

Hospital stay (days) 7.4 (5–16)

Conversion to open 1 (10%)

Table 4 Morbidity and mortality.

Variable Number of

patients (%)

Intraoperative bleeding (more than 1000 cc) 0

Re-operation 1 (10%)

Postoperative ileus 2 (20%)

Mortality 0

Results of robotic colorectal surgery at the National Cancer Institute 173

In our study, the mean hospital stay was 7 days, which iscomparable to that of the Pigazzi et al. study (8.3 days) [19].

In terms of oncologic outcome, the distal margin clearancewas obtained in all our cases except for one patient. The meannumber of harvested lymph nodes was 10.7 in our study which

was to some extent less than that of open and laparoscopic ser-ies [18] and other robotic studies. The Pigazzi et al. study [19]

reported mean lymph nodes of 14.1, and in Hellan et al. andLuca et al. studies, the mean harvest was 13 and 18.5 respec-

tively [16,17].As observed by other authors, we agree that Da Vinci sys-

tem facilitates nerve sparing TME [20,21]. Robotic TME seems

to enhance microdissection accuracy, leading to better, saferand more comfortable mesorectal dissection with a lower riskof positive CRM.

The disadvantage of the use of Robotics in colorectal sur-gery has been paid to the high cost that is associated with thistechnique. Several studies have reported that the cost ofrobotic colorectal surgery is higher than that of laparoscopic

surgery [22,23]. This fact stand behind the limitation of itswidespread application in many countries [24]. Comparinglaparoscopic colorectal surgery to robotic colorectal surgery

is beyond the scope of this study, however laparoscopic sur-gery has a steep learning curve especially for rectal cancer,where the integrity of total mesorectal excision (TME) influ-

ences outcomes, one of potential benefits of robotic surgeryis to facilitate less experienced surgeons to perform minimalaxis surgery [25–27].

174 A.S. Zaghloul, A.M. Mahmoud

Hence, future studies should assess the cost-effectiveness ofrobotic colorectal surgeries based on long term oncologicoutcomes and functional results.

Our impression in the studied group is that the maximumbenefit of robotic colorectal surgery is in lower rectal tumors,that is to overcome the constrains of narrow pelvic space for

adequate total mesorectal excision, and to precisely dissectand protect autonomic pelvic nerves for preservation ofpotency and continence.

On the other hand, we cannot ignore the great advantagesof the technique itself where a console operator can use threeworking arms with articulated instruments and stable control-lable camera plate form, in addition to a skilled assistant with

two assistant trocars, that is to say five working trocars or fivehands with unlimited advantage of accurate and magnifiedoncologically safe dissection.

Conclusion

Robotic colorectal surgery is safe and applicable approach in

our patients. Colorectal cancer surgeons who lack extensivelaparoscopic experience and wish to perform a transition fromopen to minimally invasive surgery may benefit from this

modality. Future studies are necessary to assess the long termoncological outcomes of the robotic colorectal surgery in com-parison with open and laparoscopic procedures and thereafter

determine the feasibility of its widespread application.

Conflict of interest

None declared.

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