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Laparoscopic & Robotic surgery


Robotic Esophagectomy


Esophageal cancer is the eighth most common cancer worldwide, with an estimated 456,000 new cases in 2012 (3.2% of the total), and the sixth most common cause of death from cancer with an estimated 400,000 deaths (4.9% of the total). These figures include both adenocarcinoma and squamous cell carcinoma sub-types. Around 80% of the cases worldwide occur in less developed regions (1). Carcinoma of esophagus is an aggressive disease with poor outcomes if not adequately treated (overall ratio of mortality to incidence of 0.88) (1). The overall 5-year survival rate for esophageal cancer remains poor, despite the modest improvement from 5% between 1975 and 1977 to 19% between 2002 and 2008 (2). Show More


Radical esophagectomy with adequate lymphadenectomy remains the cornerstone treatment for early-stage esophageal carcinoma; however surgery alone is rarely curative for tumors invading beyond the muscularis propria or involving locoregional lymph nodes. As a result, many trials have addressed the role of chemotherapy and radiation in the neoadjuvant or adjuvant setting. Accumulating evidence suggests that patients whose tumors have invaded beyond the submucosa (T2 or above) and who are surgical candidates should undergo some form of neoadjuvant therapy including chemotherapy, radiation or both prior to surgical resection. The recent meta-analysis by Sjoquist et al (3) included 12 RTCs of neoadjuvant chemoradiotherapy vs surgery alone. The HR for all-cause mortality with neoadjuvant chemoradiotherapy was 0.78 (95% CI: 0.70-0.88; P < 0.0001); the HR for SCC was 0.80 (95% CI: 0.68-0.93; P = 0.004) and for adenocarcinoma was 0.75 (95% CI: 0.59-0.95; P = 0.02). 

Multiple surgical approaches have been described for esophagectomy which are broadly grouped under two categories i.e. transthoracic or transhiatal approach. Transthoracic esophagectomy is performed more commonly by means of combined laparotomy and right thoracotomy (Ivor Lewis procedure) or a three-incision resection with a cervical anastomosis (McKeown procedure). It is the preferred surgical approach at many centers allowing for en-bloc resection of the tumor with the surrounding para-tracheal, subcarinal and para-esophageal lymph nodes. The studies which have compared transhiatal and transthoracic approaches had mixed results. The  randomized trial, published in 2002 by Hulscher et al (4), has provided level I evidence regarding this controversial issue. Two hundred and twenty patients were assigned to either transhiatal or transthoracic esophagectomy. Transhiatal esophagectomy had a shorter operative duration than transthoracic esophagectomy (3.5 h vs 6 h), with lower blood loss (1 L vs 1.9 L). Perioperative morbidity rate was also lower in the transhiatal group (pulmonary complications, 57% vs 27%; chylous leakage, 10% vs 2%). Duration of mechanical ventilation, ICU stay and hospital stay were all shorter in the transhiatal group. However, there was no significant difference in hospital mortality (transthoracic: 4%; transhiatal: 2%). Although initially a trend toward a survival benefit with transthoracic approach was seen, after longer follow-up, no difference in 5-year overall survival was found (transthoracic: 36%; transhiatal 34%). Notably, the transthoracic approach was of benefit in some subgroups; patients with 1-8 positive lymph nodes had better disease-free survival rate (64% vs 23%), and patients with tumors arising from the distal esophagus (rather than gastric cardia) tended towards a survival benefit (51% vs 37%, not statistically significant)(4). At present, there is some evidence which suggest that, in a fit patient with lymph nodal disease there is survival advantage of transthoracic approach.
 Minimal invasive approach
Minimally invasive esophagectomy (MIE) was designed to reduce surgical trauma, resulting in lower morbidity and mortality rates without compromising the oncological outcomes. The initial publications involving minimally invasive esophagectomy were mostly institutional series. Outcomes from these institutional series included anastomotic leak rates of 4% to 11.7%, pneumonia rates of 7.7% to 16.7%, major morbidity rates of 12.5% to 23%, and operative mortality rates of 0.9% to 6%.(5). Luketich, one of the earlier pioneers of MIE, reported his extensive experience from 1996 to 2002 on 222 patients who underwent MIE for either high-grade dysplasia (n = 47) or invasive cancer (n = 175). MIE was successfully completed in 206 (92.8%) patients with operative mortality of 1.4% (6). The median length of ICU and hospital stay, intraoperative blood loss and amount of intravenous fluids infused intraoperatively were  significantly decreased with MIE. With enough evidence to support the fact that MIE is associated with significantly lower blood loss, less postoperative cardio-pulmonary complications, and with comparable oncological outcomes, it seemed to be a better alternative to traditional TTE. 
The steep learning curve associated with MIE has always been a challenge. The conventional MIE methods are limited by the technical difficulties. Mainly, the use of long instruments with limited degree of freedom and two-dimensional view can become hindrance for optimal dissection. In the UK, for instance, only 15,6% of all esophagectomies are performed by minimally invasive methods. Some centers even stopped their MIE programs because of safety issues. Whereas the thoracoscopic approach has obvious advantages for the patients, surgeons choose for an open thoracic approach because of their concern of the high technical complexity of a minimally invasive procedure and therefore MIE is not routinely applied around the world as a standard approach for esophageal cancer.  
Robotic Esphagectomy - merits
The first robotic system became available in 1998, and the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA, USA) was approved by the United States Food and Drug Administration in 2000. The first case of robot-assisted esophagectomy for esophageal carcinoma reported in the literature was carried out by Horgan et al. in September 2001 at the University of Illinois, Chicago. Horgan’s procedure was a transhiatal esophagectomy (THE). Robotic transthoracic radical esophagolymphadenectomy (a type of TTE) was first done in November 2002 at the University of Iowa Hospital, Iowa City, and reported by Kernstine et al.  
Since its introduction, Robotic surgery has generated considerable excitement and interest in various oncological surgeries including esophageal surgery. Robot-assisted surgery can accelerate the learning curve of MIE with the help of magnified three-dimensional view, improved articulation of instruments with seven degree of freedom, improved dexterity and enhanced ergonomics.  The dexterity and articulated instruments permit seven degrees of motion including in/out; rotation; pitch at wrist; yaw at wrist; pitch at fulcrum; yaw at fulcrum and grip strength. The improved tremor free motion stability can add to fine movements and facilitate a precise dissection and suturing in a confined operating space. Robotic assisted surgery can help the surgeon in precise dissection of the structures in the mediastinum which otherwise would have been challenging via conventional MIE. Magnified view helps in better clearance of lymphnodes especially in subcarinal and para tracheal region. The steady ten times magnified field of view is especially helpful when operating on moving structures in the mediastinum, caused by breathing, and pulsatile movements of the heart and aorta. 
In open surgery, the ribcage hampers a direct look at the operative field in the upper mediastinum. Obtaining good exposure, with a clear illumination of the operative field is often difficult. A thoracoscopic approach might overcome this disadvantage, but by working in the upper thoracic aperture, the instruments have to reach deep into the thorax, imposing problems in manipulation, through the fulcrum effect at the ribs.  Also, in the thoracic inlet, instruments tend to approach the operative field in a parallel way, therefore compromising maneuverability. The advantages the robotic system offers eliminate these problems in manipulation, visualization and ergonomics and enable surgeons to do a dissection along the border of the superior vena cava and along the recurrent laryngeal nerves, up to the level of the clavicle, and down to the aortic arch. Improved dexterity and control over tremors helps in performing Ivor Lewis esophaectomy with hand sewn anastomosis. 
Another modification being used by surgeons is that they have started performing thoracic part by robotic approach and abdominal part by laparoscopic approach (robot assisted minimally invasive esophagectomy – RAMIE). Benefits of RAMIE are there especially for upper thoracic tumors or where para tracheal lymphnode dissection is to be done. Contraindications to RAMIE are similar to MIE that is previous right side thoracic surgery.  
Another modification is robot assisted transhiatal esophagectomy (RATE). In this robot is placed in the abdomen only and complete mobilization is done via transhiatal approach. There is limited data to this but the post operative outcomes have been impressive.
Oncological results
After more than 15 years  robotic esophageal surgeries, several groups have mentioned their long term oncological outcomes. The Utrecht group, reported  their radical resection (R0) rate of 95%,  5-year overall survival (OS) of 42%, and locoregional recurrence of 6% in case series of 108 patients (7). The Yonsei group, another pioneer, also reported R0 and 3-year OS rates of 95.7% and 85%, respectively (8). Both groups concluded that robotic TTE is oncologically effective and acceptable with a high R0 rate and adequate lymphadenectomy. 
Our experience
We at Rajiv Gandhi Cancer institute have being doing MIE for esophageal cancers. Off late, we have successfully introduced Robotics in management of carcinoma esophagus. Till date, we have performed >50 cases of carcinoma esophagus with robot assisted esophagectomy. The complication rate has been minimal.
GLOBACON 2012: Estimated cancer incidence, mortality and prevalence worldwide in 2012. http://globocan.iarc.fr/old/FactSheets/cancers/oesophagus-new.asp.
 Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin 2013;63:11-30.
 Sjoquist KM, Burmeister BH, Smithers BM, Zalcberg JR, Simes RJ, Barbour A, Gebski V. Survival after neoadjuvant chemotherapy or chemoradiotherapy for resectable oesophageal carcinoma: an updated meta-analysis. Lancet Oncol. 2011;12:681–692.
 Omloo JM, Lagarde SM, Hulscher JB, Reitsma JB, Fockens P, van Dekken H, Ten Kate FJ, Obertop H, Tilanus HW, van Lanschot JJ. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the mid/distal esophagus: five-year survival of a randomized clinical trial. Ann Surg. 2007;246:992–1000; discussion 1000-1001.
Kim T, Hochwald SN, Sarosi GA, Caban AM, Rossidis G, Ben-David K. Review of minimally invasive esophagectomy and current controversies. Gastroenterol Res Pract. 2012;2012:683213.
Luketich JD, Alvelo-Rivera M, Buenaventura PO, et al. Minimally invasive esophagectomy: outcomes in 222 patients. Annals of Surgery. 2003;238(4):486–495.
Van der Sluis PC, Ruurda JP, Verhage RJ, et al. Oncologic long-term results of robot-assisted minimally invasive thoraco-laparoscopic esophagectomy with two-field lymphadenectomy for esophageal cancer. Ann Surg Oncol. 2015;22(Suppl 3):S1350–6.
Park SY, Kim DJ, Do YW, Suh J, Lee S. The oncologic outcome of esophageal squamous cell carcinoma patients afterrobot- assisted thoracoscopic esophagectomy with total mediastinal lymphadenectomy. Ann Thorac Surg. 2017;103:1151–7.  Show Less

Current status of robotic colorectal surgery



Worldwide, more than 1 million individuals will develop colorectal cancer (CRC) annually, with a disease-specific mortality rate of nearly 33%. In the developed world, CRC is the third most common cancer in men and the second in women. Although the highest incidence rates are found in Western countries, CRC has been gradually increasing in other parts of the world over the past 20-30 years. On the other hand, substantial progress has been made in CRC management in recent decades with minimal invasive surgery rapidly gaining acceptance among colorectal surgeons worldwide. Several prospective, randomized trials have demonstrated that there are no differences in oncologic outcomes between laparoscopic and open surgery approaches for treating CRC. However, laparoscopic resection of rectal cancer is technically demanding and has a steep learning curve. There are several technical drawbacks to conventional laparoscopic surgery, including limited motion of instruments in a narrow pelvic cavity, relative loss of dexterity, inadequate visual field associated with unstable camera view, and assistant’s traction which is not under the surgeon’s control .Therefore, the emergence of the robotic surgical system which has several advantages, such as superior three-dimensional vision, seven degrees of freedom of movement truly mimicking the movements made by surgeon’s hands, lack of tremor, and far superior ergonomics compared to conventional laparoscopy, was extremely fortunate. Since the first robotic-assisted radical prostatectomy was successfully performed by Binder and Kramer in Germany in 2001, robotic surgery has dramatically changed the surgical management of clinically localized prostate cancer. In the short period, robotic-assisted radical prostatectomy has become standard of care.  Robotic surgery was naturally introduced to the field of general surgery, particularly rectal cancer resection, because its technological advantages can be maximized when the operation is performed in the narrow pelvis.Show More


 Application in clinical practice

The first robotic-assisted colectomies were reported in 2002 by Weber et al. who performed successful robotic-assisted laparoscopic sigmoidectomies and right hemicolectomies for diverticulitis. Since then, a wide range of colorectal operations have been performed, including right and left hemicolectomies, sigmoid resections, rectopexies with/without resection, anterior resections, abdominoperineal resections, and total colectomies. At present, application of the robotic surgical system for total mesorectal excision (TME) seems to have the greatest potential benefit, as it is expected to prove its ability when the operation is performed within a confined pelvis. The majority of recent studies have been focusing on robotic TME for rectal cancer. Other procedures like right hemicolectomy or sigmoid resection are relatively straightforward procedures for the colorectal surgeon, and can be effectively and safely performed using conventional laparoscopy. Furthermore, after considering the higher medical cost and longer operating time, it is less attractive to implement robotic colorectal surgery except for TME in rectal cancer. Some authors suggest alternative roles for the robot in the field of colon surgery, such as intracorporeal anastomosis, easier taking down of the splenic flexure, natural orifice specimen extraction, or as a training tool.


Safety and feasibility

In general, longer operating time is widely considered to be one of the disadvantages of robotic surgery, along with higher cost and lack of tactile sense, compared with conventional laparoscopic procedure. The robotic surgical system is still complex and bulky, and therefore a large operating room is needed and it takes significantly longer to prepare the device. . The most frequent cause of conversions include difficulty in pelvic dissection, which can cause bleeding from the lateral pelvic wall, rectal perforation, and unintended injury to an adjacent organ. The most important technological advantage of the robotic surgical system is the ability to perform a fine dissection in a narrow pelvic cavity due to a stable, three-dimensional image and a freely articulating EndoWrist (Intuitive Surgical, Sunnyvale, A, USA). Similar outcomes of postoperative recovery between robotic and laparoscopic colorectal surgery were reported in most of the available publications comparing postoperative course in their case matched analysis, and showed no differences in first flatus passage, time to resume diet and postoperative hospital stay. Robotic colorectal surgery seems to be equivalent to laparoscopic surgery in terms of overall operative complications. To the best of our knowledge, there is no report of postoperative mortality from robot-related complications. As most studies are based on data from highly experienced laparoscopic colorectal surgeons, there is a definitive difference in the surgeon’s expertise between the two operative techniques. We hypothesize that this difference may attenuate the benefits of robotic surgery, resulting in similar clinical outcomes rather than superior results due to its technological advantages. In view of the results achieved so far, robotic colorectal surgery can be performed safely and feasibly by the skillful laparoscopic surgeon. 


Oncologic outcomes 

There is increasing evidence that the number of harvested lymph nodes has an important impact on survival. A pooled analysis including more than 60,000 patients demonstrated that the number of harvested lymph nodes is associated with survival in colon cancer. Therefore, it is one of the most important outcomes to be evaluated in any surgical treatment proposed for colorectal cancer. Also, other parameters such as distal resection margin length or circumferential resection margin (CRM) involvement rate, which can be an index of surgical quality, were no different between the two groups in rectal cancer surgery. The widespread acceptance of TME surgery as the gold standard operative procedure for patients with rectal cancer promises to be one of the most important factors in reducing local recurrence. Nevertheless, the CRM may still be positive if the tumor extends up to or through themes rectal fascia. Also, as more sphincter-saving surgeries are performed even in very low rectal cancer, the risk of CRM involvement may be increasing, regardless of perfect TME performance. We believe that macroscopic evaluation of TME completeness should be an additional parameter in cases with CRM involvement in order to ensure the oncologic safety of the procedure. Evidence of the oncologic outcomes of robotic rectal cancer surgery is also limited. In multicenter study of robotic TME by Pigazzi et al. , the3-year overall survival rate was 97% in 143 consecutive patients with rectal cancer undergoing robotic surgery and no isolated local recurrences were found during the mean follow-up period of 17.4 months. In that study, the absence of a control group, relatively short follow-up period, and extensive use of neoadjuvant chemo radiation could have been barriers to reaching definitive conclusions. Nevertheless, their excellent results suggest that a robotic surgical system is likely to improve local disease control. Prospective controlled trials should be conducted to verify whether robotic surgery for rectal cancer could improve local disease control and disease free-survival, as well as reduce postoperative morbidity. .Only prospective clinical trials with long-term follow-up can clearly determine whether the technological advantages of the robotic surgical system can translate into favorable surgical or oncologic outcomes. Currently, an international, multicenter, randomized controlled trial of robotic-assisted versus laparoscopic resection for rectal cancer (ROLARR) is proposed. 

Bladder and sexual function 

Bladder and sexual dysfunction are well-known complications and are closely related to avulsion or direct injury to pelvic autonomic nerves following rectal resection. As normal bladder and sexual function is controlled by sympathetic input from the superior hypogastric plexus and parasympathetic input from the pelvic splanchnic nerves, inadvertent damage to these nerves will result in postoperative bladder and sexual dysfunction, the severity of which will depend on the extent of the injury and the relative components of the autonomic supply affected. Hypo gastric nerve injury results in the failure of complete bladder filling and loss of ejaculation in men, whereas injury to the sacral parasympathetic nerves results in poor depressor contraction and erectile dysfunction. Before the introduction of TME, the incidence of postoperative bladder and sexual dysfunction was high, with reported rates of 10–30% and 40–60% .Even with incorporation of autonomic nerve-preserving techniques in TME, bladder and sexual dysfunction is reported to be in the range of 0–12% and 10–35% of patients, respectively . There are two contrary hypotheses about the impact of laparoscopic TME with pelvic autonomic nerve preservation on postoperative bladder and sexual function: one is that the magnified view of the pelvis afforded by the laparoscope may facilitate identification of the autonomic nerves and thus prevent inadvertent injury, while the other is that several technical pitfalls of laparoscopic surgery may predispose to nerve injury. However, Jayne et al. showed that laparoscopic rectal resection did not adversely affect bladder function, but there was a trend towards worse male sexual function from the CLASICC trial’s patients. They also found that conversion to open surgery was independent predictor of postoperative male sexual dysfunction .Whether accurate pelvic dissection by robot with three-dimensional vision can improve bladder and sexual function compared with laparoscopic surgery is not clear. Several studies have reported low conversion rates of robotic resection for rectal cancer and we can expect this to translate into better preservation of bladder and sexual function. However, to the best of our knowledge, there is no high level of evidence evaluating bladder and sexual function after robotic TME. 


Current evidence establishes the safety and feasibility of robotic colorectal surgery. Robotic surgery achieves equivalent clinical short-term outcomes except for longer operating times and lower conversion rates compared with laparoscopic surgery. Limited preliminary studies appear to report short- or mid-term oncologic outcomes with comparable or better results as compared to laparoscopic surgery. 


Robotic Surgery

Robotic surgery, or robot-assisted surgery, allows doctors to perform many types of complex procedures with more precision, flexibility and control than is possible with conventional techniques. Robotic surgery is usually associated with minimally invasive surgery — procedures performed through tiny incisions. It is also sometimes used in certain traditional open surgical procedures.

About robotic surgery

Robotic surgery with the da Vinci Surgical System was approved by the Food and Drug Administration in 2000. The technique has been rapidly adopted by hospitals in the United States and Europe for use in the treatment of a wide range of conditions.

The most widely used clinical robotic surgical system includes a camera arm and mechanical arms with surgical instruments attached to them. The surgeon controls the arms while seated at a computer console near the operating table. The console gives the surgeon a high-definition, magnified, 3-D view of the surgical site. The surgeon leads other team members who assist during the operation.


Surgeons who use the robotic system find that for many procedures it enhances precision, flexibility and control during the operation and allows them to better see the site, compared with traditional techniques. Using robotic surgery, surgeons can perform delicate and complex procedures that may have been difficult or impossible with other methods.

Often, robotic surgery makes minimally invasive surgery possible. The benefits of minimally invasive surgery include:

  • Fewer complications, such as surgical site infection
  • Less pain and blood loss
  • Quicker recovery
  • Smaller, less noticeable scars


Robotic surgery involves risk, some of which may be similar to those of conventional open surgery, such as a small risk of infection and other complications.

Robotic Surgery Experience-

We have da Vinci Si system at our institute. We have been doing robotic surgeries since 2011 with special focus on robotic colorectal surgeries and robotic esophagectomies . Show Less

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