Can Robotics be useful to a General Surgeon Performing Colorectal Surgery? Curtis L. Peery MD April 27 th 2018 Throckmorton Surgical Society

Transcription

1 Can Robotics be useful to a General Surgeon Performing Colorectal Surgery? Curtis L. Peery MD April 27 th 2018 Throckmorton Surgical Society

2 1.Intuitive Surgical 2.C-Sats 3.Virtual Incision

3 Study comparing expert(experienced surgeons)vs novice(med. students and junior residents) in robotic vs laparoscopic skills using a validated surgical simulator(promis). Chandra, V. et al: Surg 2010 Jun; Vol. 147 (6), pp

4 Urology

5 da Vinci Xi Multi-quadrant access Crystal clear 3D HD vision Platform for future technologies da Vinci Si Dual Console option Enhanced HD Vision (1080i) Upgradable architecture da Vinci Eliminates lap compromises Introduction of 4 th arm (2003) Simple instruments da Vinci S 3D HD Vision (720p) Cross-quadrant access Streamlined set-up Advanced technologies: - Firefly - Simulation -Single-site - Wristed vessel sealer & stapler - Integrated table motion Future Innovation: Single-port

6 Core Door Warmer Walkway Walkway Walkway Main Door Circulation Desk

7 1. Platform Rotates on a Boom Easier docking Shorter turnover Better access to patient 2. Camera flip Ability to move camera to different port 3. Longer instruments Wider operative field 4. Incorporates newest technology Firefly fluorescent imaging Stapler Vessel sealer On Table Motion

8 Over 900 cases to date Other 12% Bariatric 46% Hernia 42% Xi Case Volume 150 Bypass Other: Upper GI Colorectal-47 cases(5.1%)

9 38 14% Robotic Laparoscopic 86% 239

10 6 4 ROBOTIC LOS(Days) LAPAROSCOPIC Source: Sanford Health

11 1. Improved dissection Improved TMR excision Improved bladder and sexual function 2. Integrated technology Stapler Firefly Vessel Sealer 3. Fewer conversions to Open 4. Intracorporeal Anastomosis!!!

12 25,998 Laparoscopic to 1,484 Robotic colectomies ( ) -Mortality- Similar -morbidity- Similar -Operative Times(+40 min) -Decreased LOS(0.5 days) Robotic LAR: -Conversion Rate(OR 0.49) -Postop Sepsis(0.49) Robotic Right Hemicolectomies: - Conversion Rate(0.58)

13 TOTAL MESORECTAL EXCISION Gold standard technique for the surgical treatment of rectal cancer Technically demanding procedure. Conversion rate of ( Robotic 8.1% vs Laparoscopic 12.2%) + Circumferential Resection Margin (6.2%) laparoscopic group vs. (5.1%) in the robotic group Both L TME and R TME saw early decrease in bladder and sexual function R TME patients recovered faster with a statistic difference at 3 months (CLASICC (Green et al. 2013) and COLOR II (van der Pas et al. 2013)). The ROLARR Randomized Clinical Trial JAMA. 2017;318(16): doi: /jama Kim et al. 2012;Annals of Surg Onc:19(8):

14 FIREFLY FLUORESCENT IMAGING TILE PRO

15 5 Studies 1,302 total patients Colorectal surgery fluorescent imaging resulted in decreased anastomotic leak rate(or 0.34;p=0.006) Rectal cancer ICG 1.1% vs non ICG 6.1% No randomized controls but 3 currently on going.

16 Fewer Incisional Hernias Fewer Surgical complications Shorter LOS Less reliance on surgical staplers Fewer Anastomotic strictures

17 Meta analysis 16 observational studies 1 RCT Follow up was months Midline 10.6% Transverse 3.7%(OR=3.0) Pfannenstiel 0.9%(OR=8.6) Lee,L., et al. Surg Endosc (2017)

18 Laparoscopic right hemicolectomy with intracorporeal anastomosis: shortand long term benefits in comparison with extracorporeal anastomosis Intracorporeal Extracorporeal p value Number Operative time(min) Postop complications 18.7% 35% Surgical site infections 4.4% 14% Postop interventions 0% 7% LOS(days) Incisional Hernia 2.2% 17% Shapiro,R et al. Surgical Endoscopy Dec

19 Incisional Type Hernia Rate No. of cases Muscle splitting 0.68% 146 Midline 12.4% 113 Harr,JN, etal. Surg. Endosc(2016) 30:

20 13 Studies included Dis Colon Rectum:1998;41: Conclusion: PERSONAL EXPERIENCE 300 Gastrojejunal Anastomoses(GJA): 1 leak (POD#28) No GJA bleeds 18 Hand Sewn Colorectal Anastomoses: No Leaks No Bleeds

21 Robotic Hand Sewn Anastomosis I feel is a game changer! George Angelos MD

22 U.S. Hernia Projections for Open 80% Lap 60% Robotic 40% 20% 0% 19% 6% 1% 2% Based on 2014 Premiere data for Inguinal and Ventral Hernia using ICD 9 codes transferrable to ICD 10, but no actual analysis is performed.

23 Robotic Descending Colon HPI: 64 year old male who underwent screening coloscopy and found to have unresectable polyp in the distal traverse colon. BMI of 28. PMH: No relevant past medical history. PSH: Robotic left inguinal hernia repair. Resection

24 Port Placement.

25 Robotic Descending Colon Hospital course was uneventful, the patient was discharged home on POD 1 in stable condition. Post operative follow up the patient endorsed he was doing very well. Resection Pathology: Well Differentiated Adeno CA pt1an0mo with 0/29 LNs Positive Two Weeks Post Op

26 1. Improved dissection 2. Integrated technology Stapler Firefly Vessel Sealer 3. Fewer conversions to Open 4. Intracorporeal Anastomosis!!!

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