16/11/2017 1 Robotic Surgery: the US Perspective Meagan Costedio MD FACS FASCRS November 10 th , 2017 Disclosures • None
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16/11/2017
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Robotic Surgery: the US Perspective
Meagan Costedio MD FACS FASCRS
November 10th, 2017
Disclosures
• None
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Advantages
• Actual
– Enhanced dexterity and precision
– 3-dimensional vision
– Intuitive instrument manipulation
– Enhanced primary surgeon control
– Tremor elimination
– Ergonomics for the surgeon
• Theoretical
– Decreased conversion rate
– Improved hemostasis
– Improved Accuracy of TME
– Improved sexual/urinary function
Disadvantages
• $ COST $
• Increased operative time
• Loss of tactile feedback
• Inability to reposition table
• Inadequate data
??Safety??
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Real Benefit
Ergonomic Outcomes
Surgeon wore EMG electrodes during 13 laparoscopic and 5 robotic
procedures
• Mean maximum voluntary contraction measured in bilateral deltoid, biceps, triceps and the trapezius• B/L deltoid, biceps, triceps significantly elevated activation in laparoscopic
procedures
Unsure of clinical significance to surgeon
Sihni AM, et al. Ergonomic Analysis of Robot-Assisted and Traditional Laparoscopic Procedures. Surg Endosc. 2014 Dec;28(12):3379-84
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Survival
Lim DR, Bae SU, Hur H, Min BS, Baik, Lee KY, Kim NK. Long-term oncological outcomes of robotic versus laparoscopic total mesorectal excision of mid–low rectal cancer following neoadjuvant chemoradiation therapy. Surg
Endo. April 2017, 31(4). 1728–1737.
Rashid L, Neighorn C, Bastawrous A. Outcome comparisons between high-volume robotic and laparoscopic surgeons in a large healthcare system. Am J Surg 2017 May; 213(5):901-5.
Conversion
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Valverde A, Boawquen N, Oberlin O, Svrech M, Flejou J, Sezeur A, Mosnier H, Houdart R, Lupinacci, R. Robotic versus laparoscopic rectal resection for sphincter-saving surgery: pathological and short-term outcomes in a single-center analysis of 130 consecutive patients. Surg Endosc. 2017 Mar 7.
Gorgun E, Ozben V, Costedio M, Stocchi L, Kalady M, Remzi F. Robotic vs. Conventional Laparoscopy in Rectal Cancer Surgery in Obese Patients. Colo Dis. 2016. 18, 1063–1071.
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Conversion
Gorgun E, Ozben V, Costedio M, Stocchi L, Kalady M, Remzi F. Robotic vs. Conventional Laparoscopy in Rectal Cancer Surgery in Obese Patients. ColoDis. 2016. 18, 1063–1071.
Conversion
Conversion
Jayne D, Pigazzi A, Marshall J, et al. Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoes resection for rectal cancer: The ROLARR Randomized Clinical Trial. JAMA 2017 Oct 24;318 (16):1569-80.
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Functional Outcomes
Paneleimonitis S, Ahmed J, Ramachandra M, Faroog M, Harper M, Parvaiz A. Urogenital function in robotic vs laparoscopic rectal cancer surgery: a comparative study. Int J Colorectal Dis. 2017 Feb;32(2):241-248
Cost
Rashid L, Neighorn C, Bastawrous A. Outcome comparisons between high-volume robotic and laparoscopic surgeons in a large healthcare system. Am J Surg 2017 May; 213(5):901-5.
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COST
Silva-Velazco J, Dietz DW, Stocchi L, Costedio M, Gorgun E, Kalady MF, Kessler H, Lavery IC, Remzi FH. Considering Value in Rectal Cancer Surgery: An Analysis of Costs and Outcomes Based on the Open, Laparoscopic, and Robotic Approach for Proctectomy. Ann Surg. 2017 May;265(5):960-968.
COST
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Robotic Trends
Damle A, Damle RN, Flahive JM, et al. Diffusion of technology: Trends in robotic-
assisted colorectal surgery. Am J Surg. 2017 Mar 21. epub.
Marketing
Wright JD, Tergas AI, Hou JY. Effect of Regional Hospital Competition and Hospital Financial Status on the Use of
Robotic-Assisted Surgery. JAMA Surg. 2016: 151(7):612-20.
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Innovations
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Conclusions
• Robotics have significant surgeon benefits
• There are no proven significant PATIENT benefits
– ? decreased conversion rate in obese males
• Hospital benefits – Innovation and Marketing
• WE NEED COMPETITION IN THIS INDUSTRY TO OFFSET COST!!
• The right operation is the technique that the operating surgeon feels most comfortable with
Questions
?
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SI Robotic LAR Techniques:IMA/IMV, Splenic flexure
8mm -#3
12mm -Camera
8mm -#1
8mm -#2
5mm –Asst port
#1 – Scissors w/ monopolar
#2 – Cadiere Forceps
#3 – Fenestrated bipolar
Asst – Bowel grasper / suction
SI Robotic LAR Techniques:Side Dock
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SI Robotic LAR Techniques:Side Dock
SI Robotic LAR Techniques:IMA/IMV, Splenic flexure
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SI Robotic LAR Techniques:Pelvis
8mm –Asst -Lt
12mm -Camera
8mm - #1
8mm - #3
5mm –Asst Rt
8mm - #2
#1 – Scissors w/ monopolar
#2 – Fenestrated Bipolar
#3 – Cadiere
Asst Lt – Bowel grasper / Needle driver
Asst Rt - Suction
SI Robotic LAR Techniques:Pelvis
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XI Robotic LAR
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XI Port PlacementXI Port Placement
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XI Docked
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