1Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
*Corresponding author: Young Il Kim,
Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical
Center, University of Ulsan College of Medicine, Seoul 05505, Korea, Tel:
82-2-3010-1206, E-mail: illie@amc.seoul.kr
• Received: September 30, 2022 • Accepted: October 4, 2022
This is an Open-Access article distributed under the terms of the
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Minimally invasive surgery for colorectal disease has now become the standard
treatment in Republic of Korea. However, there are limitations to the
laparoscopic approach, such as an unstable camera support, a limited range of
motion, and poor ergonomics. Recent advances in technology have led to the
introduction of robotic surgical systems in colorectal surgery to overcome these
shortcomings. Robot-assisted colorectal surgery has clear advantages in many
aspects. Surgery involving the rectum benefits the most among colorectal
diseases owing to technical difficulties in rectum dissection. The concept of
robotic surgery is not different from laparoscopic surgery in that it is a
minimally invasive surgery, and abundant research demonstrates comparable
results from both modalities for postoperative complications, oncological
outcomes, and functional outcomes. However, the cost of robot-assisted surgery
limits surgeons to performing robotic surgeries in only selected cases.
Improvements regarding cost-effectiveness and more convincing studies that
support benefits of robotic surgery are needed to popularize robot-assisted
colorectal surgery.
Since the introduction of laparoscopic colorectal surgery in the early 1990s,
minimally invasive surgery (MIS) for colorectal disease has now become the standard
treatment in Republic of Korea (Korea). While the MIS approach was applied for less
than 50% of colorectal cancer patients in 2008, it increased to nearly 80% in 2018
[1]. Important randomized controlled
trials (RCTs) have presented evidence that laparoscopic surgery is feasible
oncologically and technically [2–4]. MIS provides a faster recovery, less
postoperative pain, and a reduced risk of surgical site infection compared to open
surgery with comparable survival outcomes [5–7]. However, there are
limitations to the laparoscopic approach, such as an unstable camera support, a
limited range of motion owing to the rigid straight surgical equipment, and poor
ergonomics. Constant efforts are ongoing to overcome these problems, and recent
advances in technology have led to the introduction of robotic surgical systems in
colorectal surgery.
The concept of modern robots first appeared in 1921 where the word
“robot” was used in the play R.U.R.: Rossum’s Universal Robots
by a Czech novelist Karel Capek. Robot means forced labor in the Czech language
[8]. This nomenclature seems well defined
in that one of the key advantages of robotic surgery is to aid surgeons during
physically demanding procedures. Robotic assistance provides an immersive
3-dimensional view that the operator can control without any additional human
assistance, while manipulating articulated surgical instruments for a much more
versatile movement. The first robot-assisted surgery performed for colorectal
disease was in 2001 with the Da Vinci telerobotic surgical system. The feasibility
of robotic colorectal surgery has been validated by many studies since then and it
is now practiced worldwide for various colorectal diseases; malignancies, benign
lesions and inflammatory bowel diseases (IBD). This article reviews the clinical
impacts of applying robotic surgical systems to treating colorectal diseases.
Current Evidence for Robotic Surgery in Colorectal Diseases
Specific features of robot-assisted surgery led to variations in the extent of
application of the robotic system according to the target organ. Even though the
colon and rectum are both a continuation of the large bowel, each organ has a
distinct anatomy and thus benefits from robot-assisted surgery differently. Also,
the diverse spectrum of colorectal diseases (malignant, benign, IBD, etc.) presents
dissimilar practices and indications for adapting robotic surgery.
1. Rectal cancer
The most widely appreciated site for the application of robotic systems is the
rectum. This is due to the anatomical characteristics of the rectum. The rectum
is located in a confined compartment constituted by the sacral promontory
posteriorly, genitourinary organs anteriorly, and pelvic floor muscles
laterally. The bony structure of the pelvis forms a narrow canal, and this
feature is particularly prominent in male patients. Operating in such
environment is challenging and surgeons often experience limitations of their
rigid laparoscopic instruments. Manipulating the rectum in such a narrow pelvis
for traction, especially with a bulky tumor, is time consuming and causes
surgeons to become exhausted. There are several studies that demonstrated a
longer operation time, a worse quality of total mesorectal excision, and a
higher rate of postoperative morbidities in patients with a narrow pelvis or a
bulky tumor when operated on laparoscopically [9–12].
Robot-assisted surgery provides a comfortable environment for surgeons. The fully
wristed robot instruments and stable 3-dimensional camera vision that can be
controlled by the operator enables a much more versatile movement in narrow
spaces [13]. The difficulty of the pelvic
anatomy does not result in an overtly prolonged operation time, and Baek et al.
reported a shorter operation time even in patients with a narrow pelvis when
using a robotic system [14]. This
advantage of robotic surgery for rectal cancer also leads to better preservation
of urinary and sexual functions. Identifying pelvic autonomic nerves and not
damaging the nerves is extremely important during total mesorectal excision for
rectal cancer [15]. The nerves are at
risk of transection or thermal injury during the ligation of the inferior
mesenteric artery, dissection of the mesorectum at the level of the sacral
promontory, and dissection of the antero-lateral planes of the
rectoprostatic/rectovaginal (Denonvilliers’) fascia. Although a
laparoscopic camera provides a more magnified vision compared to open surgery,
the robotic system is equipped with an immersive 3-dimensional camera, which
allows for identification and direct observation of these important structures
in greater detail. Previous studies have shown higher rates of preserved
physiological functions after robot-assisted rectal surgery compared to
laparoscopic surgery [16].
All of these benefits of robotic systems would not be acceptable without
oncological safety. A series of RCTs from various centers worldwide, along with
numerous retrospective studies over the past 20 years of clinical practice, have
presented unified results of comparable survival outcomes of robot-assisted
rectal cancer surgery with laparoscopic surgery (Table 1) [17–21]. Confidence from accumulated experience
has led to the adaption of robotic surgery to even more complicated and advanced
cases of rectal cancer [22–26].
Table 1.
Studies validating robot-assisted surgery for rectal cancer
Surgery for colon cancer is not fundamentally different from rectal cancer in
that the principle concept is to excise the mesocolon along with the draining
vessels and lymphatics from the primary tumor, defined as complete mesocolic
excision. This surgical objective is equivalent to TME for rectal cancer and is
known to be essential for an optimal survival outcome [27,28]. However, the
anatomical distinction between the colon and rectum makes surgery on the colon
less challenging; nevertheless, it requires additional caution during
dissection. The colon is not confined within a limited compartment, and the
surgical field is much broader and more open. Basically, the whole
intraperitoneal space can be used to manipulate the instruments. Therefore, the
advantages of robotic surgery may not be as prominent during colon
resection.
This is supported by a RCT from Park et al., which compared robotic-assisted
colectomy with traditional laparoscopic-assisted colectomy in right-sided colon
cancer [29]. The length of hospital-stay,
postoperative morbidity, and the number of harvested lymph nodes were comparable
between the two groups, but the operation time was significantly longer in the
robot-assisted colectomy group (195 min versus 130 min, P<0.001). The
overall medical cost was also significantly higher in the robot-assisted surgery
group and there were no benefits in the long-term survival outcomes [30]. Choi et al. concluded that there were
no clinical benefits of robot surgery in right-sided colon cancer that outweighs
the high costs [1]. However, to date,
there are not enough studies with a large sample size and statistical power to
strongly contraindicate robot-assisted colectomy.
Recent technological advances in robotic systems have led to the development of
single-platform robot systems since 2018 (da Vinci SP) (Fig. 1). The operator can perform reduced port surgeries
more comfortably with fully wristed robotic instruments through a single-port
compared to the conventional single-incision laparoscopic surgery.
Single-incision laparoscopic surgery is known to be beneficial in terms of
cosmetic aspects but it is usually only used for highly selected patients due to
technical difficulties [31]. The utility
of a robotic system for single-port surgery may become a safer and more
practical approach for surgeons to perform colon cancer resection [32–34].
Fig. 1.
Da Vinci robot surgical systems, (A) X system, (B) Xi system, and (C)
SP system. Constant improvement of the technology has expanded the use
of robot-assisted surgery in colorectal diseases.
3. Ventral rectopexy
The perineal or a transabdominal approach are both available treatment modalities
for pelvic organ prolapses. In particular, abdominal ventral mesh rectopexy is
an effective approach for treating rectal prolapse and MIS has shown benefits of
a low complication rate and recurrence rate, with improved symptoms of fecal
incontinence and obstructed defecation syndrome [35–37]. The key
procedures of ventral mesh rectopexy are similar to rectum resection in that the
dissection of the rectum down to the rectovaginal or rectoprostatic septum is
essential. Therefore, patients indicated for ventral mesh rectopexy can also
benefit from robot-assisted surgery, similar to patients with rectal cancer.
Theoretically, suturing the mesh to the anterior wall of the lower rectum can be
performed readily with the fully wristed robotic instruments.
A RCT comparing robot-assisted ventral mesh rectopexy (RVMR) to laparoscopic
ventral mesh rectopexy demonstrated no difference in operation time or
postoperative complications. The RVMR group showed a trend of less residual
rectocele postoperatively in terms of amount and size [38]. However, there are mixed results regarding the
operation time in retrospective studies and RVMR should be applied to selected
patients depending on the cost-effectiveness and surgeon compatibility [39,40].
4. Inflammatory bowel disease
Extensive studies still need to be conducted to prove the feasibility of robotic
surgery in IBD patients. A retrospective study analyzed the perioperative
outcomes of 108 patients with Crohn’s disease who received
robotic-assisted ileocolic resection and compared the results to open cases. The
robot-assisted cases had a significantly shorter hospital stay by 2 days
(P<0.0001) with a lower 30-day complication rate (24% versus 38%,
P=0.039), but they required a mean of 60 min additional operation time
(P<0.0001) [41].
Two case-matched comparison studies of robotic versus laparoscopic proctectomy
for IBD patients presented similar complication rates, short-term functional
results, conversion rate, and length of stay for both groups, but the robotic
group had a longer operative time [42,43]. Robot-assisted
surgery can have advantages in pelvic nerve preservation during proctectomy, but
further research is warranted as surgeons adapt to robotic surgery for IBDs
[44].
Cost-Effectiveness of Robot-Assisted Surgery
The biggest obstacle to the nationwide adaption of robot-assisted colorectal surgery
in Korea is the cost benefit ratio. Since the first approval of robot-assisted
surgery in the year 2005 by the Ministry of Food and Drug Safety of Korea, robot
surgery has been classified as non-reimbursable. All citizens of Korea are obligated
to obtain national health insurance and essential medical services are generally
covered by this national health insurance system. While robot-assisted surgery has
been praised for its minimally invasive approach and shortened hospital stay, its
cost-effectiveness has been considered unclear for coverage by the national health
insurance system. This results in a roughly 2- to 4-fold higher operative cost for
patients receiving robot-assisted surgery compared to laparoscopic surgery in Korea
[45,46]. The national insurance policy differs in each country but robotic
surgery is universally accepted to be more expensive compared to laparoscopic
surgery (Table 2) [19,30,45–48]. This is the core issue why robot-assisted surgery, while presenting
comparable postoperative outcomes and survival outcomes to laparoscopic surgery,
still cannot be the standard treatment for colorectal diseases.
Table 2.
Studies analyzing cost of robot-assisted surgery for colorectal
disease
Robot-assisted colorectal surgery has clear advantages in many aspects. Surgery
involving the rectum benefits the most among colorectal diseases owing to technical
difficulties in rectum dissection. The fundamental concept of robotic surgery is not
that different from laparoscopic surgery in that it is a minimally invasive
approach, and abundant research demonstrates comparable results from both modalities
for postoperative complications, oncological outcomes, and functional outcomes.
However, the cost of robot-assisted surgery limits surgeons to performing robotic
surgeries in only selected cases. Currently, few patients meet the indications to
justify the high costs of robot-assisted surgery. Further advances in robotic
surgical systems may improve the cost-effectiveness of robotic surgery and influence
national insurance policies to provide a more comprehensive indication criterion for
applying robot-assisted surgery in colorectal diseases.
Acknowledgements
Not applicable.
Conflict of Interest
No potential conflict of interest relevant to this article was reported.
Author Contribution
The article is prepared by a single author.
Ethics Approval and Consent to Participate
Not applicable.
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Fig. 1.
Da Vinci robot surgical systems, (A) X system, (B) Xi system, and (C)
SP system. Constant improvement of the technology has expanded the use
of robot-assisted surgery in colorectal diseases.
Fig. 1.
Robot-Assisted Colorectal Surgery
Studies validating robot-assisted surgery for rectal cancer
