Preliminary results of robotic approach in rectal cancer surgery

To evaluate the preliminary outcomes of robotic surgery and present our experience in 41 rectal cancer cases. Subjects and methods: This is a prospective case series study on 41 patients who underwent robotic surgery (the da Vinci Si version) from November 2016 to July 2018 at Binh Dan Hospital. Results: There were 2 cases of anterior resection, 23 cases of low anterior resection, 6 cases of ultra-low anterior resection, 10 cases of abdominal perineal resection. Mean operation time was 213.7 mins. There was no recording of intra-operative complications. Mean harvested lymph node was 11.9 nodes.

Journal of military pharmaco-medicine n02-2019 PRELIMINARY RESULTS OF ROBOTIC APPROACH IN RECTAL CANCER SURGERY Nguyen Phu Huu1; Hoang Vinh Chuc1; Vu Khuong An1 Nguyen Phuc Minh1; Tran Vinh Hung1 SUMMARY Objectives: To evaluate the preliminary outcomes of robotic surgery and present our experience in 41 rectal cancer cases Subjects and methods: This is a prospective case series study on 41 patients who underwent robotic surgery (the da Vinci Si version) from November 2016 to July 2018 at Binh Dan Hospital Results: There were cases of anterior resection, 23 cases of low anterior resection, cases of ultra-low anterior resection, 10 cases of abdominal perineal resection Mean operation time was 213.7 mins There was no recording of intra-operative complications Mean harvested lymph node was 11.9 nodes Post-operative pathology staging included stage I, stage IIA, stage IIB, stage IIIB, stage IIIC and stage IVA had 2, 5, 24, 6, 3, cases, respectively Distal margin was negative in all patients Post-operative complications were cases of wound infection, case of urine retention, case of ileus and case of anastomotic leak with conservative treatment Mean length of stay was 8.2 days Conclusions: The use of robotic approach for rectal cancer treatment is a safe and feasible procedure in Vietnam Further studies are required to determine long-term oncology and compare perioperative outcomes between open surgery, laparoscopic surgery and robotic surgery for rectal cancer management * Keywords: Rectal cancer; Robotic rectal surgery; Rectal surgery INTRODUCTION Colorectal cancer is a very common malignancy of the gastrointestinal tract Currently, the incidence of colorectal cancer is the third largest in men and the second in women In 2012, the world had approximately 1,361,000 new cases and 694,000 deaths [1] Surgery is the primary treatment of this disease Surgical methods have evolved from open surgery to minimally invasive methods Since the first endoscopic resection of the rectum was reported in the 1990s, it has gradually been performed in many centers around the world because this method has been shown to be beneficial to patients with more outstanding short-term and long-term oncologic outcomes than open surgery [2, 3, 4] However, laparoscopic colorectal surgery has a certain difficulty in the narrow space of the pelvic bone due to straight laparoscopic tools, the tremor of the surgeon, two-dimensional camera (2D) and need professional assistants Today, robotic surgery is a new option for treating colorectal cancer The da Vinci® Robot System used in this study has a three-dimensional (3D) view, the magnification is magnified 10x, the EndoWrist® system Binh Dan Hospital Corresponding author: Nguyen Phu Huu (bsphuhuu2012@gmail.com) Date received: 20/12/2018 Date accepted: 24/01/2019 235 Journal of military pharmaco-medicine n02-2019 (figure 3) provides the surgeon with manual manipulation and a series of more flexible moves than the human hands Pigazzi et al first performed total mesorectal excision (TME) in the treatment of low rectal cancer with robots in 2006 [5] After that, many centers around the world reported that the results were favorable In Vietnam, studies on the safety and feasibility of robotic surgery for colorectal cancer are not available because this is a new treatment Our studies ams: To understand the safety of using robots to treat colorectal cancer and had surgical anesthesia before surgery Laparoscopy was performed using The da Vinci® Robot System at Binh Dan Hospital from November 2016 to July 2018 We use the clinical standards of the American Cancer Society (AJCC) 8th edition [6] Methods A prospective case series study Some attentions to consider when using colostomy for the da Vinci® Robot System versus traditional laparoscopic surgery: - The operating room layout (figure 1) SUBJECTS AND METHODS Subjects All patients were diagnosed with rectal cancer through gastrointestinal endoscopy - The location of the trocar must follow certain guidelines (figure 2) - Patient posture will not be changed after docking robot Figure 1: Da Vinci Robot System and the operating theater layout in rectal cancer operation 236 Journal of military pharmaco-medicine n02-2019 Figure 2: Trocars position in rectal cancer operation (C: Trocar d = 12 mm for robot camera; A: trocar d = 12 m for assistant’s instruments; 1, 2, 3: Trocar d = mm for three robot arms) Figure 3: EndoWrist® system and movements of robot arms 237 Journal of military pharmaco-medicine n02-2019 RESULTS The ratio of male/female was 2.15 Average age 62 ± 12.07 (the youngest was 23 and the oldest was 85) Surgical methods: In 41 cases of rectal cancer treated, we had: - Anterior resection: cases - Low anterior resection: 23 cases - Ultra-low anterior resection: cases - Abdominal perineal resection: 10 cases Average number of lymph nodes: 11.93 ± 6.74 (at least nodes and at most 23 nodes) Average number of nodal metastases: 0.76 ± 1.61 nodes (at most nodal metastases and at least no nodes) Percentage of positive nodal metastases was 9.06% Docking time (the time between the onset of the locating of the trocar and commencement of surgery on the console): 19.51 ± 8.05 minutes (the fastest was minutes and the slowest was 40 minutes) Time of surgery on the robot (the time of surgical operation on the console): 194.15 ± 51.42 minutes (the fastest was 120 minutes and the slowest was 330 minutes) Total surgery time (from the moment the patient underwent anesthesia until the completion of the surgery): 213.66 ± 62.36 minutes (the fastest was 135 minutes and the slowest was 360 minutes) There were no complications in robotrelated surgery Average blood loss: 83.41 ± 43.22 mL (at least 30 mL and at most 200 mL) Mean duration for the patient with flatus: 2.68 ± 0.89 days (the fastest was day and the slowest was days) 238 Time for re-ingest patients: 2.48 ± 1.04 days (the fastest was day and the slowest was days) After the surgery, there were cases of wound infection (the place where the specimens were collected, local dressings changed), case of prolonged ileus (re-operation on the 4th postoperative day to assessment of intestinal obstruction), case of urinary retention (patient treated with benign prostatic hyperplasia accompanied by medical treatment) Average postoperative hospital stay: ± 2.11 days (at least days and at most 16 days) Table 1: Postoperative staging (AJCC 8th edition) pTMN Number of cases Percentage I T2N0M0 4.88% IIA T3N0M0 12.2% IIB T4aN0M0 24 58.54% IIIB T4aN1M0 14.63% IIIC T4aN2aM0 7.32% IVA T3N1M1 2.44% Stage DISCUSSION The role of laparoscopic surgery has been demonstrated through numerous studies in the literature However, this method still has its own limitations, especially when the pelvic surgery by the majority of endoscopic instruments straight, difficult to turn in the narrow space The surgeon does not feel the depth of the 2D screen, the long-arm may be shaking and they need professional surgeon assistants Journal of military pharmaco-medicine n02-2019 Robotic surgery helps to avoid the above limitations Through the robot, doctors are more favorable because: The details in the surgery are shown sharper, deeper through the 3D screen; the operator adjusts the camera itself; flexible surgical instruments in a narrow space for better surgery and surgical procedures Therefore, robotic surgery can be applied to many specialties such as urinary, gastrointestinal and gynecological surgery In particular, robotic surgery has its merits in patients with narrow pelvis, obese patients or patients who have been treated with neoadjuvant chemotherapy for colorectal cancer [7] Studies in the world have shown that short-term cancer outcomes are similar to laparoscopic surgery [8, 9] For long-term cancer outcomes, many studies are currently underway In recent years, the number of studies on robotic surgery has increased steadily and mainly in colorectal cancer [7, 8, 9,10] Ferrara's experience showed that compared to laparoscopic surgery, robotic surgery is more profitable, especially in lymphadenectomy [10] Total number of resected lymph nodes is required at least 12 nodes, in accordance with the guidelines of the National Comprehensive Cancer Network (NCCN) [11] Table 2: Studies of robotic surgery in rectal cancer Authors Year of researching Nation Number of patients Ng et al [12] 2009 Singapore Nozawa et al [7] 2014 Japan 63 Huang et al 2015 Taiwan 40 Our study 2016 Vietnam 41 Table 3: Comparison of treatment outcome in some studies Author Huang et al Ng et al Our study Number of patients 40 41 Men/women ratio 1/1 5/3 28/13 60 (32 - 89) 55 (42 - 80) 62 (28 - 85) Total time of operation (mins) 264 (109 - 527) 192 (145 - 250) 213.66 (135 - 360) Average blood loss (mL) 150 (20 - 500) N/A 83.41 (30 - 200) 35% 12.5% 21.95% Total number of resected lymph nodes (0 - 22) 17 (2 - 26) 11.93 (2 - 23) Total number of metastatic nodes 1.3 (0 - 6) 0.3 (0 - 2) 0.76 (0 - 7) Postoperative length of stay (days) (5 - 32) (4 - 30) (6 - 16) Age Percentages of complications 239 Journal of military pharmaco-medicine n02-2019 Figure 4: Rectal cancer specimen (source: Binh Dan Hospital, 2017) Figure 5: Rectal cancer specimen and lymph nodes (source: Binh Dan Hospital, 2017) 240 Journal of military pharmaco-medicine n02-2019 Through robotic camera, the surgeon views the surgical organs more clearly than the operation by laparoscopy, manipulate the robot instruments same as the human hands via the EndoWrist® system As a result, the surgeon can avoid damage to the hypogastric nerves, ureters, and can resect corrected Thus, postoperative urinary and sexual function of the patient is preserved, helping patients with better quality of life after surgery The duration of robotic surgery is usually longer than laparoscopic surgery The reason is that the surgeon needs time to locate the position of the trocars, dock robots into the patient and prepare the robotic instruments When the surgeon is familiar with these steps, the surgery time decreases markedly In our study, the first docking time of the robot usually lasted about 30 - 40 minutes because of the unfamiliarity with the instruments and the location of the trocars However, after about 10 first cases, this time is significantly shortened to about 10 - 15 minutes We did not report any complications in the surgery Patients hospitalized after surgery from - 16 days, the majority of patients discharged from surgery after days Of these, cases of wound infection (the place to get specimen), case of long-term ileus (recurrent surgery excluded bowel obstruction on the 4th postoperative day), case of urinary retention (after healing with benign prostatic hyperplasia accompanied by medical treatment, patient was discharged after 10 days) Ng’s studies operated cases of patients with middle and low rectal cancer with discharge time about - days after the operation; there is a case of patients with pneumonia due to chronic obstructive pulmonary disease accompanied and discharged after 10 days Huang reported 40 cases of colorectal cancer had postoperative length of stay about - 32 days, with 14 of 40 cases had complications during and after surgery, including: Postoperative hemorrhage, prolonged abscess, leaking of anastomosis, urethral injury, urinary tract infection and pneumonia Nowadays, the incidence of anastomotic leakage is one of the criteria for safety assessment of colorectal surgery in particular and of gastrointestinal surgery with anastomosis in general Many studies reported the leakage rate in robotic surgery on rectal cancer management In 2010, Baek reported an incidence of anastomotic leaks was 7.7% in robotic TME In 2011, this author conducted a case-matched study between laparoscopic surgery and robotic surgery in TME, the leakage incidence was 2.9% and 8.6%, respectively This research concluded there was no difference of the leakage rate between two groups In our study, a case of suspected anastomotic leaks (2.4%) was successfully treated without reoperation This proves that robotic surgery is a safe method for treating rectal cancer Our average number of lymph nodes was 11, less than Ng’s studies and more than Huang’s studies, but our number of metastatic lymph nodes was higher than Ng’s studies (table 3), because our patients came to hospital with advanced cancer All of our cases had safe upper and lower tumor sections Currently, we have no report of recurrence or metastases cancer 241 Journal of military pharmaco-medicine n02-2019 As we used robotic systems, we found that the position of trocars is very important and needs to be located accurately, so that when the docking is complete, the robot arms can be operated easily without collisions, which is dangerous for patients and instruments In addition, the patient's posture will not be altered after docking the robot, so accurately calculating the position of the trocar will save time changing the position of the robot, thereby shortening the overall operating time CONCLUSION Surgery of rectal cancer by robot shows the safety, feasibility and initially good results for patients with the ability to perform operation better in the narrow space In the future, we will continue to research with larger sample size and compared with laparoscopic surgery for safety, lymph node dissection and short-term as well as long-term oncologic outcomes outcomes of a randomized, phase trial Lancet Oncol 2013, 14 (3), pp.210-218 doi:10.1016/S1470-2045(13)70016-0 Rubino F, Mutter D, Marescaux J et al Laparoscopic total mesorectal excision (TME) for rectal cancer surgery: Long-term outcomes Surg Endosc 2004, 18 (2), pp.281-289 doi:10.1007/s00464-002-8877-8 Pigazzi A, Ellenhorn JDI, Ballantyne G.H, Paz I.B Robotic-assisted laparoscopic low anterior resection with total mesorectal excision for rectal cancer Surg Endosc 2006, 20 (10), pp.1521-1525 doi:10.1007/s00464005-0855-5 Amin M.B, Edge S.B, Greene F.L et al AJCC Cancer Staging Manual 8th a.b Cham: Springer International Publishing 2017 doi:10.1007/978-3-319-40618-3 Nozawa H, Watanabe T Robotic surgery for rectal cancer Asian J Endosc Surg 2017, 10 (4), pp.364-371 doi:10.1111/ases.12427 REFERENCES Park E.J, Cho M.S, Baek S.J et al Long-term oncologic outcomes of robotic low anterior resection for rectal cancer Ann Surg 2015, 261 (1), pp.129-137 doi:10.1097/ SLA.0000000000000613 Ferlay J, Soerjomataram I, Dikshit R et al Cancer incidence and mortality worldwide: Sources, methods and major patterns in GLOBOCAN 2012 J Cancer 2015, 136 (5), pp.359-386 doi:10.1002/ijc.29210 Xiong B, Ma L, Zhang C, Cheng Y Robotic versus laparoscopic total mesorectal excision for rectal cancer: A meta-analysis J Surg Res 2014, 188 (2), pp.404-414 doi:10.1016/j.jss.2014.01.027 Bozzetti F, Braga M, Gianotti L, Gavazzi C, Mariani L Postoperative enteral versus parenteral nutrition in malnourished patients with gastrointestinal cancer: A randomized multicentre trial Lancet 2001, 358 (9292), pp.1487-1492 doi:10.1016/S0140-6736(01) 06578-3 Van der Pas MHGM, Haglind E, Cuesta MA et al Laparoscopic versus open surgery for rectal cancer (COLOR II): Short-term 242 10 Ferrara F, Piagnerelli R, Scheiterle M et al Laparoscopy versus robotic surgery for colorectal cancer Surg Innov 2016, 23 (4), pp.374-380 doi:10.1177/1553350615624789 11 NCCN Rectal Cancer 2017 12 Ng K.H, Lim Y.K, Ho K.S, Ooi B.S, Eu K.W Robotic-assisted surgery for low rectal dissection: From better views to better outcome Singapore Med J 2009, 50 (8), pp.763-767 http://www.ncbi.nlm.nih.gov/pubmed/1971097  ... particular and of gastrointestinal surgery with anastomosis in general Many studies reported the leakage rate in robotic surgery on rectal cancer management In 2010, Baek reported an incidence of anastomotic... leaking of anastomosis, urethral injury, urinary tract infection and pneumonia Nowadays, the incidence of anastomotic leakage is one of the criteria for safety assessment of colorectal surgery in. .. the number of studies on robotic surgery has increased steadily and mainly in colorectal cancer [7, 8, 9,10] Ferrara's experience showed that compared to laparoscopic surgery, robotic surgery is