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ROBOTIC SURGERY

Robotic surgery builds on the innovations of laparoscopy, which has been increasingly adopted for colon and rectal cancer surgery over the past 2 decades, with numerous well-designed trials demonstrating short-term advantages in terms of recovery and complication rates, along with long-term oncologic outcomes at least equivalent to those of open surgery. These advantages likely result from the fact that laparoscopic approaches provide improved visualization of the surgical field, which translates into greater operative exposure, exploiting one of surgery’s most fundamental tenets.

As the technical challenges of laparoscopy have limited its adoption for colorectal cancer treatment, robotic systems, which resolve many of the mechanical and optical limitations of laparoscopy, are a promising technologic advance. In place of the rigid nonarticulating instruments and suboptimal visualization employed in manual minimally invasive procedures, robotic surgical equipment provides flexible instrumentation and wristed movement capabilities. Reliance on a secondary expert surgeon is reduced due to a third robotic arm for self-assistance, and perspective is enhanced by high-definition 3-dimensional views from a mounted, stabilized, surgeon-controlled camera.1,2 The superior ergonomics and surgical dexterity provided by the robot result from the instruments’ 7 degrees of freedom and 90-degree articulation, permitting manipulation within small spaces, a capability particularly relevant in the narrow, bony pelvis.3,4

Compared to laparoscopy, robotic technology has been shown to enhance dexterity by 65%, reduce skill-based errors by 93%, and shorten the time needed to complete a task by 40%.5 Robotic technology also provides motion scaling and tremor filtering, facilitating precise dissection and suturing, which is particularly valuable in dissecting along the origins of the mesenteric vessels during complete mesocolic excision or in performing total mesorectal excision (TME) within the pelvis.6 In addition, the robotic platform enables an integrated and supervised teaching environment without compromising operative or long-term outcomes.4

There are no absolute contraindications to robotic colon and rectal cancer surgery, and its application is limited primarily by the surgeon’s experience and expertise. Relative contraindications, depending on the surgeon’s judgment, are locally invasive tumors and recurrent disease, which often obscure normal anatomic planes. In addition, consideration should be given to whether a patient can tolerate pneumoperitoneum and steep positioning.

Another advantage of robotic systems is that they simplify complex surgical maneuvers such as intracorporeal suturing and creation of intracorporeal anastomoses. Creation of the bowel anastomosis intracorporeally after colon resection may cause less visceral trauma and tissue stretching and might therefore contribute to faster recovery of bowel function and, consequently, reduced length of hospital stay.7-9 In addition, after completion of an intracorporeal anastomosis, the specimen can be removed through a smaller or alternate site, which may reduce the risk of surgical site infections and incisional hernias.4,10

The Robotic Versus Laparoscopic Resection for Rectal Cancer (ROLARR) trial was the first multicenter, prospective, randomized controlled trial examining robotic surgery versus conventional laparoscopic surgery ...

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