Minimal Access Surgery

Educational Objectives

The goal of this program is to improve surgical outcomes through advances in laparoscopic, robotic, and robot-assisted techniques. After hearing and assimilating this program, the clinician will be better able to:

1.   Identify situations in which outcomes may be improved by a minimally invasive approach to surgery.

2.   Establish proper preparation and technique before beginning laparoscopic or robotic colorectal surgery.

3.   Explain techniques for localizing and documenting disease before and during colorectal procedures.

4.   Recognize challenges associated with robotic surgery (eg, loss of haptic feedback).

5.   Discuss appropriate applications of hybrid laparoscopic and robotic surgical techniques.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose. In his lecture, Dr. Perez presents information that is related to the off-label or investigational use of a therapy, product, or device.  

Acknowledgments

Dr. Ramamoorthy was recorded at 32nd Annual San Diego Postgraduate Assembly in Surgery, held March 2-6, 2009, in San Diego, CA, and sponsored by the University of California, San Diego, School of Medicine. Dr. Perez was recorded at Cur­rent Concepts in General Surgery, held September 2-4, 2009, in Albuquerque, NM, and sponsored by the University of New Mexico School of Medicine. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Laparoscopic vs Robotic Colorectal Surgery: When, Why, and How?

Sonia L. Ramamoorthy, MD, Assistant Clinical Professor, Department of Surgery, University of California San Diego (UCSD), School of Medicine, and Colorectal Surgeon, Moores UCSD Cancer Center, La Jolla, CA

Indications for minimally invasive procedures: always preferable  —  diagnostic laparoscopy; straightforward oper­ations for benign or malignant colorectal disease; sometimes preferable  —  bowel obstruction (depends on patient status); surgery for colorectal inflammatory bowel disease (IBD; data show favorable results [possibly due to rela­tive youth of patients]); diverticulitis (dependent on complexity of disease and skill level of laparoscopic surgeon [eg, proficiency in taking down fistulas and operating in inflamed areas]); T4 lesions; colostomy takedowns (poten­tially challenging procedure, particularly if surgeon attempting laparoscopic takedown did not perform colostomy)

Contraindications for minimally invasive procedures: hostile abdomen (eg, history of multiple surgeries, multiple scars, bowel adhesion to anterior abdomen); colorectal cancer with large masses (require large incisions for re­moval); critically ill patients (shortened operating times preferred); history of postoperative complications

Benefits of minimally invasive surgery: reduced pain (due to smaller incision); reduced rates of complications (eg, bowel obstruction, incisional hernia); data show patients experience less physiologic trauma and immunosuppres­sion (particularly with stage 3 disease); costs  —  higher initial costs; however, initial costs offset by faster return to work and shorter hospital stays

Technical issues: loss of palpation  —  uncomfortable for surgeons (particularly with large fields involved in some procedures); hand-assist devices  —  not shown to effect outcomes significantly (compared to pure laparoscopic pro­cedures); conversion of laparoscopic procedures to hand-assisted procedures may substitute for conversion to open surgery; improvements  —  improved optics reduced issues with loss of proprioception, motion reversal, and motion amplification; instrumentation, exposure, and operative time also improved

Technique: 30° camera  —  reduced need for hand-assist procedures (skilled camera operator required); allows viewing area “around corners” (advantageous in colorectal procedures); surgeon’s level of comfort  —  determined by familiarity with relevant anatomy and ability to handle potential complications (eg, ileocolic bleeding); supplies necessary to treat complications should be kept readily available (eg, stitches for accidental burn of bowel, clip applier for bleeding at ileocolic staple; speaker uses laparoscopic cigarette sponge to assist in dissection and drying of operating area); high volume surgeons vs low volume surgeons  —  procedures performed by low volume surgeons showed higher rates of postoperative and intraoperative complications; Cleveland Clinic study  —  center treats large volumes of colorectal disease; with disease in right colon, 100 to 120 laparo­scopic procedures performed before reaching conversion to open surgery rate of 0; left-sided disease  —  more procedures needed to reach conversion rate of 0; more likely to require conversion (often associated with diver­ticular disease and upper rectal disease misidentified as sigmoid disease); other factors predicting conversion to open surgery  —  higher American Society of Anesthesiologists (ASA) score; fistulas; surgeon’s experience; body mass index (BMI; significant factor); learning process  —  specific number of procedures necessary for profi­ciency not established; laparoscopic vs hand-assist procedures  —  laparoscopic colorectal procedures require in­cision for extraction (removal through natural orifices via intracorporeal anastomosis remains unfeasible); studies showed hand-assist procedures did not require conversion to open procedures; conversion from pure lap­aroscopic procedure to hand-assist procedure shows favorable outcomes and preserves most benefits associated with minimally invasive surgery

Preparation: establish consistent systems for operating room setup, port placement, and surgical approach; port placement dependent on patient’s body habitus; establish general placement of ports based on location of disease and patient’s anatomy; surgeons should work with committed teams of familiar staff and skilled camera operator; begin training surgical team with straightforward cases; tumor localization  —  especially important with laparo­scopic procedures; barium enema helpful; colonoscopy 86% accurate (most reliable with photographic documenta­tion of relevant anatomy inside colon); operating site should be tattooed when photographic evidence of disease not available; speaker recommends tattoos in 3 locations; establish consistent system for tattooing (eg, decide to always have tattoos placed distal to lesions); room setup  —  leave space between monitors to allow movement of slave mon­itors; electric bed critical (laparoscopic procedures require movement of bed); bean bag or similar device should be available to secure patient in position (speaker recommends having anesthesiologist place patient in steepest re­quired position before surgery to avoid intraoperative problems); padding for neck and shoulders and silk placed around chest also helps secure patient in position; left-side or lower-anterior procedures  —  keeping patient level prevents legs from interfering with procedure and allows ample excursion in both laparoscopic and robotic surger­ies

Speaker’s port site technique: allows access to nearly all quadrants of abdomen; right-side only procedures  —  5-up subcostal incision; avoid umbilicus unless needed for extraction port; “rule of 2s” for locating ports  —  from ante­rior iliac spine, move over 2 fingerbreadths, up 2 fingerbreadths, then over another 2 fingerbreadths; adjust accord­ing to patient’s body habitus; lithotomy position  —preferred for disease near hepatic flexure or for lesions of transverse colon; standing between patient’s legs allows mobilization of transverse colon (facilitates greater access when dissecting colon); abdominoperineal excision (APE) position  —  preferred for cecal masses; supine position; cameras  —  30° cameras always preferred during procedure; 0° camera with visiport sometimes utilized when en­tering abdomen; bowel grasper  —  longer instruments acceptable; excessive grasp may pinch bowel and create small cuts; running the bowel  —  grasping at mesenteric junction (instead of bowel) recommended

Robotic surgery: compensates for high level of difficulty associated with laparoscopic rectal surgery; advantages of robotic colorectal or pelvic surgery  —  allows 3-dimensional imaging with stable camera platform; surgeon controls camera; allows reduced distance between camera and area requiring visualization; enables visualization of blood vessels (reduces blood loss); wristed motion allows articulation around blood vessels (eg, allows camera to visual­ize levator ani at pelvic floor during mesorectal excision while leaving both hands free to operate); 4-armed robots  —allow surgeons full control of articulated instruments, lack of motion reversal, favorable motion scaling, and tremor filtration

Data: European colorectal disease study  —  laparoscopic anterior resections showed significant increases in circum­ferential resection margins compared to open procedures (associated with high likelihood of local recurrence); ab­dominoperineal resection (APR) study  —  findings similar to European colorectal disease study; conversion study  —higher rate of conversion with laparoscopic cases compared to colon cases (possibly due to lack of comfort with laparoscopic rectal dissection); higher conversion rate attributed to tumor fixity and uncertainty of negative margins in obese patients; strictureplasty for Crohn’s disease  —  robotic surgery shows significant advantages (eg, eliminates need for isolation and extracorporealization of small bowel); City of Hope data  —  no difference in oncologic out­comes (eg, distal margins, circumferential margins, lymph node harvests) when comparing robotic surgery to open procedures; similar results nationwide

Challenges of robotic surgery: initial learning often time-consuming; speaker recommends consulting urologic sur­gical team if general surgical team lacks experience; learning curve shorter with robotic surgery (compared to laparoscopic surgery); requires learning to substitute visual for haptic feedback (eg, when determining amount of pressure to apply while grasping); may create visual disorientation when working deep within pelvis; cost can be prohibitive

Speaker’s set-up: robotic arms positioned in left lower quadrant and right lower quadrant near umbilicus (allows straight-down viewpoint and monitoring of inferior mesenteric artery [IMA] during ligation); majority of opera­tion possible through left upper quadrant robot port and right lower quadrant robot port; allows reaching pelvic floor (impossible with laparoscopic procedures)

Robotic Applications in General Surgery

Timothy Perez, MD, Assistant Professor of Surgery, University of New Mexico Hospitals, Albuquerque

Background on robotics: not all robots self-powered or autonomous (eg, passive robots designed for holding cam­eras require human guidence); orthopedic robots capable of moving or mapping entire knee; neurosurgical robots also map under own power; current systems classified as “telemanipulators” (eg, da Vinci robotic surgery system)

Background on da Vinci robotic surgery system: only robot in clinical use (as of 2009); cleared but not approved by Food and Drug Administration (ie, accepted because of similarity to previously approved instruments); consists of surgeon’s console, patient cart (contains robotic arms), optical cart, and instruments (changed out on robot); tele­presence technology of surgeon’s console allows remote surgery (distance irrelevant); patient cart  —  contains 4 dif­ferent arms (including camera arm in center); camera has 2 lenses for 3-dimensional imaging; arms positioned before procedure; vision cart  —  contains standard instruments such as insufflator and light source; surgeon able to turn over and view operating field from remote position; disadvantages  —  distance from operating field sometimes disconcerting (surgeon dependent on assistants and technicians to provide feedback and warnings); many proce­dures (particularly colorectal) begin with laparoscopic surgical approach (requires preparation of entire separate set of instruments; da Vinci system lacks instruments expected in laparoscopic setting); connection between instru­ments and da Vinci system limits range of motion (less flexible than laparoscope); imaging  —  speaker praises high-quality flexible visualization presented by 12 mm camera with dual lenses; additional features  —  tremor reduction; 6 degrees of range of motion; hand-movement scaling (eg, 5 cm of movement on console translated to 1 cm of ro­botic movement; ratio can be adjusted); seated ergonomic operating posture; disadvantages  —  limited instrument selection (eg, linear stapler and suture must be introduced through separate port; clips not available); isolation from surgical field; additional ports with differently sized opening must be added for assistants; lack of tactile feedback (manufacturers suggest visualizing tissue and assessing for blanching; sutures may be easily torn); indications in general surgery  —  robotic surgery viable in most procedures amenable to laparoscopic approach

Data on robotic surgery: robotic cholecystectomy vs cholecystectomy without assistance  —  no difference in conver­sation rates, length of hospitalization, or conversion time; robotic surgery associated with significantly higher costs; robotic Nissen fundoplication studies  —  robotic surgery ideal for procedures localized to single quadrant (eg, fore­gut); operating time with robotic assistance longer than with standard laparoscopic procedure; however, no signifi­cant difference in complications found, and 2 studies found no difference in functional outcomes; robotic procedures associated with higher costs; Heller myotomy  —  procedure of choice for treatment of achalasia (uncom­mon condition); evaluated by several series, but no randomized trials; no perforations occurred during case studies of robot-assisted procedures (series showed rates of £16%); robot excels at delicately dissecting muscle while spar­ing mucosa; rectal resection  —  visualization capabilities helpful in narrow (eg, male) pelvises; robots difficult to re­position into different quadrants during surgery; gastrointestinal (GI) stapler not currently available for robot; in prospective nonrandomized study of robot-assisted rectal resection (single surgeon with 113 patients), no differ­ence in operating times associated with robotic surgery; robotic procedures had fewer complications and more complete mesorectal excision; standard laparoscope utilized for initial stages of dissection (mobilization of left co­lon and take-down of splenic flexure); robot utilized in pelvic portion of procedure (mesorectal excision), but stan­dard stapler introduced through assistance port; case series of robotic lower anterior resections (LARs)  —  hybrid laparoscopic and robotic technique; 60 out of 285 min of total operating time devoted to robot; 12% leakage rate; no positive circumferential margins; 13 lymph nodes removed; interdisciplinary consensus conference  —  found laparoscopic LAR with total mesorectal excision (TME) feasible and safe; expressed concern over added costs and loss of haptic feedback; robot-assisted thyroidectomy study  —transaxillary approach (gasless); single surgeon and 200 thyroidectomies; low rate of laryngeal nerve palsy; transient hypoglycemia and calcemia eventually normal­ized; relatively short operating time for robot-assisted procedure; custom-designed retractors allowed access to an­terior neck through axilla; robot docked for thyroid lobectomy after opening (repeated on opposite side in bilateral procedures); other applications of robotic surgery  —  surgeries for morbid obesity; adrenalectomy; gastrectomy for cancer; esophagectomy (transhyoidal or transthoracic); pancreatectomy (better preservation of spleen with distal procedure); natural orifice translumenal endoscopic surgery (NOTES); single incision procedures (speaker recom­mends specifically designed robot)

Minibots: intra-abdominal robots  —  self-propelled camera capable of moving through abdomen to capture images; ro­bots with cautery tools and graspers also under development

Suggested Reading

Albassam AA et al: Nissen fundoplication, robotic-assisted versus laparoscopic procedure: a comparative study in children. Eur J Pediatr Surg 19:316, 2009; Breitenstein S et al: Robotic-assisted versus laparoscopic cholecystectomy: outcome and cost anal­yses of a case-matched control study. Ann Surg 247:987, 2008; Gurusamy KS et al: Robot assistant for laparoscopic cholecys­tectomy. Cochrane Database Syst Rev CD006578, 2009; Hellan M et al: Totally robotic low anterior resection with total mesorectal excision and splenic flexure mobilization. Surg Endosc 23:447, 2009; Hida K et al: Risk factors for complications af­ter laparoscopic surgery in colorectal cancer patients: experience of 401 cases at a single institution. World J Surg 33:1733, 2009; Huffmanm LC et al: Robotic Heller myotomy: a safe operation with higher postoperative quality-of-life indices. Surgery 142:613, 2007; Pigazzi A et al: Robotic-assisted laparoscopic low anterior resection with total mesorectal excision for rectal can­cer. Surg Endosc 20:1521, 2006; Rotholtz NA et al: Predictive factors for conversion in laparoscopic colorectal surgery. Tech Co­loproctol 12:27, 2008; Tan PY et al: Laparoscopically assisted colectomy: a study of risk factors and predictors of open conversion. Surg Endosc 22:1708, 2008; Tjandra JJ et al: Laparoscopic- vs. hand-assisted ultralow anterior resection: a prospec­tive study. Dis Colon Rectum 51:26, 2008; Yamamoto S et al: Impact of conversion on surgical outcomes after laparoscopic op­eration for rectal carcinoma. J Am Coll Surg 208:383, 2009.