2. Objectives
1. To review the anatomy in question in order to better understand the
need for robotics in colorectal surgery.
2. To review the advantages of robotics in colorectal surgery.
3. To review what is needed to implement robotics in colorectal surgery
at the JGH.
4. To contextualize robotics within a Canadian system and to review
costs.
3. Rectal
anatomy
• The rectum is a fixed organ which lies in the
confines of a bony compartment
• Surgical field limited visually & spatially
during rectal dissection
• Rectal cancer surgery must obey oncologic
principles while preserving autonomic nerves
and blood supply and requires precise
dissection especially when performing
sphincter saving procedures.
4. What are the advantages of robotics in
colorectal surgery?
5. Advantages of robotics in colorectal surgery:
access and operative time
Improved ergonomics
• Easier access to narrow male pelvis especially in obese patients
• Lower conversion rates to open compared to laparoscopic
• Shorter operative time
6. Decreased SSI (0% vs
7%)
Decreased
+Circumferential
resection margins
Better nerve
preservation resulting in
improved bladder and
sexual function
Advantageous in locally
advanced rectal cancer
with complete resection
of regrowth following
watch and wait
Ability to do combined
liver resections and
rectal resections AND
combined gyneonc cases
Advantages of robotics in colorectal surgery:
improved surgical and oncologic outcomes
7. Disadvantages of robotic colorectal surgery
Steep learning curve Initial costs Increased OR time if
multiple docking required
11. WHY WE NEED IT
• Allows table to move without removal of instruments
• Enables patient repositioning without disruption of surgical workflow
• No need to undock/redock – single docking
• Saves time
• Simplifies work flow
• Enables access to different quadrants
• Optimizes gravity
• Decreases OR time
12. WHY WE NEED IT
• Especially useful in splenic flexure mobilization
required with low anterior resection
WITHOUT THE TABLE
- requires hybrid of laparoscopy in the
abdomen and robotics in the pelvis
OR
- repositioning of robot to complete the
necessary steps
more time consuming which increases OR time
13. How does the robot fit into our Canadian
system?
14. Adoption of robotic
colorectal surgery
in Canada
• Slow
• Poor access to robotic platform
• Lack of surgeon training
• Perceived increase in cost
15. The impact of robotic
surgery on a tertiary
care colorectal surgery
program, an assessment
of costs and short term
outcomes: A Canadian
Perspective
Patel et al Surgical endoscopy 2022
16. Outcomes by surgical approach
Patel et al. Surgical Endoscopy 2022
Outcome Robotic (N=129) Laparoscopic (N=105) Open (N=60)
Mean LOS (days) 4.6 6.6 10.3 p<0.001
Length of stay < 48 hrs 18 (14%) 8 (8%) 0 p=0.006
Length of stay < 7 days 116 (90%) 78 (75%) 37 (62%) p<0.001
Mean OR time (hours) 4.0 4.3 2.9 p< 0.001
17. Complications by surgical approach
Patel et al, Surgical Endoscopy 2022
complications Robotic (N=129) Laparoscopic (N=105) Open (N-60)
ER visit (30 days) 30 (2.1%) 32 (30%) 22 (37%) p= 0.14
Readmission (30 days) 21 (16%) 15 (14%) 12 (20%) p= 0.59
Anastomotic leak 5/103 (5%) 5/92 (5%) 4/49 (8%) p=0.71
Unplanned OR (30 days) 7 (5%) 4 (4%) 2(3%) p=0.74
No difference – robotics has been shown to be safe in rectal cancer surgery
18. Conversion rates to open
Patel et al, surgical Endoscopy 2022
Abdominal
perineal resection
82% vs 33%
(p=0.001)
Low anterior
resection
87% vs 50%
(p<0.001)
Sigmoid resection
81% vs 49%
(p<0.001
Robotic (N=129 Laparoscopic (N=105)
Conversion to open 9(7%) 29 (28%) p<0.001
19. Mean Total Costs
Patel et al, surgical Endoscopy 2022
Robotic (N=129) Laparoscopic (105) Open (60)
Total cost of care REF -$752 + $ 2174 p=0.17
Total surgical costs REF -$2549 - 4456 p<0.0001
Total cost excluding
surgical costs
REF +1797 + 6630 p=0.0001
21. Robotic Colorectal
Surgery at the JGH
• 1st year- January - September – 4
cases/month = 36 cases
• From October- December-8 cases
= 30 cases
• Cases would include all colorectal
procedures in the first part of the
year
• Only left-sided colorectal
procedures in the 2nd part
22. Cost
= (+) $ ~1400
Offset by shorter length of stay and decreased complications (readmission)
23. Conclusions
• Robotics is safe in colorectal surgery and provides important benefits with
regards to surgeon ergonomics and efficiency, as well as improved patient
outcomes.
• The cost of purchasing a robot is usually the rate limiting step for Canadian
hospitals, at the JGH, we are fortunate that this not an issue as we already
have 2 robots.
• The slight increased cost for the use of a robot in colorectal cases is
nominal for the advancement of surgical technology.
• These increased costs will be off-set by the advantages of robotics.
24. Conclusions
• As a tertiary centre of excellence in cancer care, this is our
opportunity to be at the forefront of technological advances so that
we do not fall further behind
• As an academic teaching centre, we need to be on the robot so that
our surgical residents can be competitive when they apply to their
colorectal fellowships in the US
Editor's Notes
SHOULD EMPHASIZE THE DIFFICULTY OF OPERATING IN THE PELVIS ESPECIALLY IN MEN. COULD EVEN QUOTE THE HIGHER LOCAL RECURRENCE IN LOW RECTAL CANCERS, WHICH IS PARTLY RELATED TO POOR ONCOLOGIC SPECIMENS.
Should mention that decreased CRM is important for DFS / local recurrence.
Gyne onc cases – could even explain what happened last week.
BUT I WILL ADDRESS THESE POINTS OVER THE NEXT FEW SLIDES ABOUT how WE CAN MITIGATE THESE DISADVANTAGES
Usually, the biggest hurdle for hospital in the advancement of technology is purchasing the product. However, our hospital is very fortunate as we already have the most recent model of the robot. So the question is what do the colorectal surgeons need and why in order to make use of this incredible opportunity and advance care of our cancer patients.
I think you’ll need to give a bit of context to this – ie. When we operate, we operate in steep inclinations which allows gravity to help expose the structures in the pelvis. Then when we have to mobilize splenic flexure, we switch the inclination 180degrees. This is an absolute necessity. To do this without the tilting table means docking and re-docking the robot throughout the case which adds on ___ minutes.
Or something to introduce the transition of your talk going into talking about Canadian data.
If we were to adopt robotic colorectal surgery at the Jewish General Surgery, the most important question is how would we proceed? How do we envision the adoption of this new technique.
THIS AMOUNT IF NOTHING WHEN CONSIDERING THE ADVANCEMENT OF SURGICAL TECHNOLOGY.
