The Robotic Approach in Rectal Cancer

*Ciprian Duta, Stelu Pantea, Dan Brebu, Amadeus Dobrescu, Caius Lazar, Kitty Botoca, Cristi Tarta and Fulger Lazar*

## **Abstract**

Since a robotic surgical system was developed in the early 1990s and the first robotic-assisted radical prostatectomy was reported in 2001, robotic surgery has spread in many surgical specialties, changing surgical management. Currently, compared to other colorectal procedures, robotic surgery appears to offer great benefits for total mesorectal excision for rectal cancer. Abdominal cavity other procedures such as right hemicolectomy and high anterior resection are relatively uncomplicated and can be performed easily by laparoscopic surgery. First reports have focused on the clinical benefits of robotic rectal cancer surgery compared with laparoscopic surgery. The indications for robotic and laparoscopic rectal cancer surgery are not different. The recently published results of the ROLARR trial, comparing robotassisted TME to laparoscopic TME, show no advantages of robot assistance in terms of intraoperative complications, postoperative complications, plane of surgery, 30-day mortality, bladder dysfunction, and sexual dysfunction. A drawback of the study is the variability in experience of the participating surgeons in robotic surgery. After correction of this confounder, an advantage for robotic assistance was suggested in terms of risk of conversion to open surgery. For robotic rectal cancer surgery to become the preferred minimally invasive option, it must demonstrate that it does not have the technical difficulties and steep learning curve of laparoscopic surgery. Robotic surgery has several technical advantages over open and laparoscopic surgery. The system provides a stable operating platform, three-dimensional imaging, articulating instruments and a stable surgeon controlled camera which is mainly beneficial in areas where space and maneuverability is limited such as the pelvis.

**Keywords:** robotic treatment, rectal cancer, total mesorectal excision (TME), robotic surgery, laparoscopy

#### **1. Introduction**

Oncological surgery as it is known does not mean organ surgery, but it means the correct lymphadenectomy so that the oncological long-terms results are as expected. Rectal cancer surgery is a touchstone for any surgeon. The surgical technique has continuously progressed over the years and has been standardized with proven oncological results. After Richard Heald's contribution to the need to perform a complete excision of the mesorectum to have excellent control of locoregional spread of disease, surgeons quickly adopted the technique resulting in a significant improvement in local recurrence [1]. Then followed the revolution represented by the appearance of laparoscopy. Robotic surgery has brought a new lease of life to minimally invasive surgery due to its proven advantages. A shorter learning curve than laparoscopy, a lower conversion rate that has allowed an increasing number of patients to benefit from minimally invasive surgery [2, 3].

#### **2. The minimally invasive approach to rectal cancer**

Laparoscopy was a real revolution in surgery in the early 1990s. There are few examples in the history of surgery in which an innovative method has such a rapid and widespread spread throughout the world [4]. Of course, colorectal surgery has also faced the first attempts at laparoscopic surgery since the early 1990s, when the first published series of cases appeared [5–9].

The minimally invasive approach for colorectal neoplastic pathology had ups and downs. If initially laparoscopy began to be used especially for benign pathology, in the late 1990s it began to be approached more and more and neoplastic pathology. There have also been controversies related to this approach related to the quality of the specimens and the lymphadenectomy performed. There were also fears related to tumor dissemination at the level of the incision to extract the resection piece and the "chimney effect" with the possibility of metastases at the level of insertion of the trocars [10]. In the late 1990s, the first prospective studies appeared that showed the benefits of the laproscopic approach compared to the open approach, without repercussions related to the percentage of R0 resections or the increase in the number of parietal metastases [11–13].

Only in 2004 with the appearance of the COST study [14] and in 2005 of the CLASICC study [15] it was demonstrated that there are no differences between the laparoscopic and open approach in terms of 3-year recurrence rate, overall survival, number of excised lymph nodes and R0 resection percentage. But if we look to these studies carefully we can comment that most of the cases were related to the middle and upper locations and very few cases were related to low or ultra-low locations.

After that two other multicentric trials, aimed to specifically compare laparoscopic and open surgery in patients with rectal cancer, were the COLOR II trial [16] and the COREAN trial [17], enrolling respectively 1103 and 340 patients. In the COLOR II trial a complete or nearly complete TME was obtained in 92% of laparoscopic and 94% of open procedures; CRM positivity was 10% in both groups; distal margins were negative in 100% of both procedures. In the COREAN trial TME was complete/nearly complete in 92% (laparoscopic) and 88% (open) of patients; CRM was positive in 3% of laparoscopic and in 4% of open procedures; distal margins were negative in all patients in both procedures. In both COLOR and COREAN trials no significant differences were found regarding oncological outcomes, confirming the safety and feasibility of the laparoscopic approach for rectal cancer.

Even so, the global spread of the laparoscopic approach has been extremely slow. With a few exceptions, such as in the United Kingdom, South Korea, etc., the adoption rate has seen an upward but slow trend. In most countries, in centers with a high volume of colorectal interventions, the laparoscopic approach reaching in the period 2008–2015 a percentage that varied between 20 and 50%. If, however, we are talking about medium or low volume centers, the adoption rate was much lower. Another important element of increasing the number of cases was determined by the introduction in more and more centers of the ERAS program in colorectal surgery [18].

A study published on trends in the implementation of the minimally invasive approach in Canada and in the world in general showed that, except for South Korea and the United Kingdom where the percentage of minimally invasive approach in colorectal surgery exceeded 60%, otherwise the percentage varies between 20 and 40%. Finally, a series of strategies are issued to increase the use of the minimally invasive approach in colorectal surgery: increasing exposure to minimally invasive

#### *The Robotic Approach in Rectal Cancer DOI: http://dx.doi.org/10.5772/intechopen.100026*

advanced surgery procedures, increasing the number of fellowship programs in minimally invasive surgery, intensive hands-on courses for young surgeons and programs of subsequent mentorship [19].

Despite the many benefits of the laparoscopic approach, there have been elements of slowing the spread on a large scale: the need for staff with expertise in both open surgery and laparoscopic surgery, relatively long learning curve, prolonged operation time, difficult positions for the surgeon maintained for a long time, the difficulty of performing an adequate dissection in case of a narrow pelvis, the need to change the operating device depending on the quadrant in which the operation is performed, etc.

The emergence of the AlaCaRT [20] and ACOSOGZ6051 [21] studies was a step backwards in terms of the ability of the laparoscopic approach to obtain oncological results at least comparable to the open approach. Even some of the lead authors of these studies have pointed out that the robotic approach may be an asset for minimally invasive rectal cancer surgery.
