The use of robotics in colorectal surgery is gaining momentum of late. Technical advances, such as three-dimensional imaging, a stable camera platform, excellent ergonomics, tremor elimination, ambidextrous capability, motion scaling and instruments with multiple degrees of freedom, have helped many surgeons adapt to it easily. There is a shorter learning curve compared to the standard laparoscopic surgery. This article helps to give an outline as to how robotic colorectal surgery can go a long way in the future of colorectal surgery.

1. Robotic colorectal surgery: Technique, advantages,
disadvantages and its impact in today's era of minimal
access surgery

2. Review Article
Robotic colorectal surgery: Technique, advantages,
disadvantages and its impact in today's era of
minimal access surgery
Vachan Subhash Hukkeri a,
*, Deepak Govil b
a
DNB GI Surgery, Resident, Indraprastha Apollo Hospital, GI Surgery, Sarita Vihar, Mathura Road, Delhi 110076,
India
b
Consultant, GI Surgery, Indraprastha Apollo Hospital, India
1. Introduction
Robot-assistedminimalaccesssurgeryisgainingacceptancefor
use in colorectal surgery, and it has specially gained interest in
cases involving rectal surgery. The first robot for clinical use in
general surgery was the automated endoscopic system for
optimal positioning (AESOP) (Computer Motion, Santa Barbara,
CA, USA). In 1994, the Food and Drug Administration (FDA)
approvedAESOPforclinicaluseasaroboticcameraholder.After
that, Computer Motion has invented the Zeus surgical system
but that is approved by FDA for use only as a surgical assistant
but not as an operating surgeon. The da Vinci®
robotic system
(Intuitive Surgical Inc., Sunnyvale, CA, USA) is the first
telerobotic manipulation system approved by the FDA for
intraabdominal surgery in the United States. The da Vinci®
robotic system was designed to overcome the limitations of
open conventional surgery and laparoscopy.
a p o l l o m e d i c i n e 1 2 ( 2 0 1 5 ) 7 7 – 8 1
a r t i c l e i n f o
Article history:
Received 27 April 2015
Accepted 1 May 2015
Available online 15 June 2015
Keywords:
Robotic surgery
Colorectal surgery
Laparoscopic surgery
da Vinci®
robotic system
Docking
a b s t r a c t
The use of robotics in colorectal surgery is gaining momentum of late. Technical advances,
such as three-dimensional imaging, a stable camera platform, excellent ergonomics, tremor
elimination, ambidextrous capability, motion scaling and instruments with multiple
degrees of freedom, have helped many surgeons adapt to it easily. There is a shorter
learning curve compared to the standard laparoscopic surgery. This article helps to give
an outline as to how robotic colorectal surgery can go a long way in the future of colorectal
surgery.
# 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights
reserved.
* Corresponding author. Tel.: +91 9910369502; mobile: +91 9036360278.
E-mail addresses: vachan_sh@rediffmail.com, gourihukkeri@gmail.com (V.S. Hukkeri).
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevier.com/locate/apme
http://dx.doi.org/10.1016/j.apme.2015.05.002
0976-0016/# 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights reserved.

3. 2. da Vinci®
robot
It has three components (Fig. 1).
(1) Surgeon's console or master manipulator.
(2) Surgical cart or slave manipulator which has four robotic
arms.
(3) Third unit for holding camera and insufflation instru-
ments.
Surgeon performs the surgery by manipulating the robotic
control in console. A binocular camera system is attached for
insertion through the laparoscopic port and provides three-
dimensional images to the surgeon.
The Robotic system has several advantages over laparos-
copy. It provides three-dimensional imaging system. Robotic
interface can downscale movements (5:1–2:1), filter physiolog-
ic tremor and perform intuitive movement between the
surgeon's hand and four robotic arms. The central robotic
arm holds the camera and other arms hold the surgical
instruments. The key technology of the da Vinci®
system is the
endowrist function at the tip of robotic arms, which provide 7
degrees of freedom, 1808 of articulation and 5408 of rotation.
This provides the most important technological advantage for
precise dissection and intracorporeal suturing.
The general concern that we need to know advanced
laparoscopy, before we can venture into robotic surgery is
really a myth, as we only have to be well versed with basic
laparoscopy like placing ports and pneumo-insufflation,
before we go for robotic surgery.
Surprisingly the learning curve for robotic procedure is not
as steep as advanced laparoscopy. Suturing with robotics is
also much simpler than laparoscopy.
There are certain drawbacks associated with robotic
system. The biggest drawback is the lack of tactile and tensile
feedback which can cause tissue damage. This can be
minimised by visual experience. Another important drawback
is docking, and undocking of robotic cart from the patient is a
time consuming procedure. This can be serious if emergency
conversion is required in case of bleeding. Although all these
things take much less time with experience of the OT staff, one
of the major drawbacks cited is the cost of robotic system and
the cost of the consumables and disposables for the patient.
During robotic surgery, the surgeon is seated at a console,
using minimal force controllers, while viewing the procedure
through an ideally positioned three-dimensional (3D) imaging
system. While no direct comparisons for surgeon strain exist
between robotics and either laparoscopic or open surgery, few
experts would argue that the robotic system is less physically
taxing. In this way, robotics may allow surgeons to have
longer, more productive and injury-free careers.1
3. Technical aspects
The use of robotics in colorectal surgery has simplified certain
key and complicated steps. With its three-dimensional vision
and magnification, difficult areas, such as the pelvis, can be
operated on with relative ease. It is especially helpful in cases
having a deep and narrow pelvis (including male pelvis), where
the reach of robotic instruments is much easier than laparos-
copy. Even in bulky tumours, the handling of tumours and
dissection can be done with relative ease. The magnification
and access also allow to perform more number of intersphinc-
teric resections, thus improving chances of sphincter preserva-
tion. Almost all colorectal procedures can be done robotically. In
surgeries, such as LAR, APR, total proctocolectomy and
[(Fig._1)TD$FIG]
Fig. 1 – da Vinci®
robotic system: (A) surgical console, (B) operating arms and (C) monitor cart.
a p o l l o m e d i c i n e 1 2 ( 2 0 1 5 ) 7 7 – 8 178

4. rectopexy, the pelvic dissection can be done with better
visualisation and reach. The superior tissue handling also
helps in keeping the dissection in the right plane and avoids
unwanted tissue damage. Intracorporeal anastomosis is also
being done after surgeries, such as right hemicolectomy. Bowel
preparation needs to be done in these cases to prevent
intraperitoneal spillage of enteric contents.
The left sided colorectal surgeries can be done completely
robotically or in a hybrid fashion. Hybrid procedure means a
part of the procedure being done laparoscopically and partly by
the robot. Usually robotic parts include pelvic dissection or
TME, and laparoscopic parts include left colon mobilisation
from splenic flexure to distal sigmoid colon. The advantages of
hybrid approach may be valid, only if the surgeon is already an
expert in standard laparoscopic technique.
The ‘‘totally robotic’’ colorectal procedures are described in
three ways. The single docking method as suggested by Hellan
et al., involves literally single docking for the entire procedure
from colon mobilisation to pelvic dissection (Fig. 2). Recently
introduced ‘‘flip arm technique’’ is a modified version of this
technique.2
The second one involves 2 dockings, but in a fixed position
of robotic cart. This technique is probably the most popular
‘‘totally robotic’’ technique. There are a few subtypes, among
which the most well known are one from Choi et al.3
and the
other from Lee et al.4
Those two have similar setting in terms
of the position of robotic cart but different trocars of
placement. One of the major drawbacks of those approaches
is the difficulty in splenic flexure mobilisation, which is
mandatory in Western patients. Eastern Asian patients such
as Korean and Japanese ones have long sigmoid colon, so that
mobilisation of splenic flexure of left colon is not a routine
procedure in most cases, which is a routine in most of western
countries where the patients have relatively short sigmoid
colon and the incidence of sigmoid diverticulitis is high. The
third one (called ‘‘dual-docking technique’’), which uses both
redocking and reorientation during the procedure, is sug-
gested for more facilitated mobilisation of splenic flexure,
while sacrificing the convenience of preparation.5
This
technique is also recommended especially for initial experi-
ence or as a transition from hybrid to either single docking or
double docking with fixed position.
4. Evidence so far
The first robotic colorectal surgery was performed in 2011.6
Since the first report from Weber et al. who performed a right
hemicolectomy and sigmoid colectomy for benign disease in
2002, more and more surgeons are getting interested in robotic
surgery.7
Recent investigations of laparoscopic colorectal resection
for the treatment of cancer have revealed superior short-term
operative outcomes and non-inferior oncologic outcomes
compared with open surgery, the classic standard treat-
ment.8,9
MIRA-SAGES Consensus stated that the surgical
robotic system is an enabling technology that enables
surgeons to participate in advanced minimally invasive
surgery with less effort compared to a standard laparoscopic
surgery.10
The learning curve to operate in remote places, such
as the rectum, has been reduced with the help of robotics.
The concept of robotic total mesorectal excision for rectal
cancer was first reported by Pigazzi et al. in 2006. They
compared short-term outcomes between robotic total mesor-
ectal excision and laparoscopic total mesorectal excision. They
concluded that robotic low anterior resection with total
mesorectal excision and autonomic nerve preservation was
feasible. One year later since Pigazzi et al. reported their first
six robotic total mesorectal cases compared to conventional
laparoscopic surgeries, they concluded that robotic-assisted
surgery for rectal cancer could be carried out safely.11,12
ThefirstAsianexperienceofrobotictotalmesorectalexcision
for rectal cancer patients was reported by Baik et al. in 2007.13
It
was performed in June 2006. Since then, they have also reported
simultaneous robotic total mesorectal excision, total abdominal
hysterectomy for rectal cancer and uterine myoma in 2007.14
In
that case report, they reported that simultaneous robotic
surgeries were feasible and safe using the da Vinci®
system.
The first robotic abdominoperineal resection in Asia was
performed in Hong Kong in August 2006 and also other types
of robotic general surgeries began to be reported.15–17
In 2008, Spinoglio et al. reported their initial first fifty cases
of robotic colorectal surgeries. They compared the fifty cases of
robotic resection with one hundred and sixty one cases of
laparoscopic resections. They concluded that robotic colon
surgery was feasible and safe but a longer operating time was
needed.18
The first prospective randomised trial comparing robotic
low anterior resection and laparoscopic low anterior resection
was launched by Baik et al. in 2006.19
They reported the short-
term outcome of a pilot study in 2008. Eighteen cases of robotic
low anterior resection were compared with eighteen cases of
laparoscopic low anterior resection. The results showed the
feasibility and safety of robotic low anterior resection and
better mesorectal grade in the robotic low anterior resection
group, even though they could not find statistical differences
between the groups.
In a systemic review of thirty-nine case series, the clinical
application of the da Vinci®
robotic system in right and left/
sigmoid colectomies yielded satisfactory results in terms of
open conversion (1.1% and 3.8%, respectively) and operative
morbidity (13.4% and 15.1%, respectively). Robot-assisted
anterior resection was accompanied by a considerably low
[(Fig._2)TD$FIG]
Fig. 2 – Docking for a pelvic surgery.
a p o l l o m e d i c i n e 1 2 ( 2 0 1 5 ) 7 7 – 8 1 79

5. conversion rate (0.4%), morbidity (9.7%) and adequate number
of harvested lymph nodes (14.3, mean).20
In another systematic review, authors compared robotic
and laparoscopic surgery with respect to twelve end-points
including operative and recovery outcomes, early postopera-
tive mortality and morbidity, and oncological parameters. A
subgroup analysis of patients undergoing full-robotic or robot-
assisted rectal resection and robotic total mesorectal excision
was carried out. Randomised and non-randomised clinical
trials comparing robotic and laparoscopic resection for rectal
cancer were included. Meta-analysis suggested that the
conversion rate to open surgery in the robotic group was
significantly lower than that with laparoscopic surgery
(OR = 0.26, 95% CI: 0.12–0.57, P = 0.0007). There were no
significant differences in operation time, length of hospital
stay, time to resume regular diet, postoperative morbidity and
mortality, and the oncological accuracy of resection. Robotic
surgery for rectal cancer has a lower conversion rate and a
similar operative time compared with laparoscopic surgery,
with no difference in recovery, oncological and postoperative
outcomes.21
Another systematic review presenting a summary of the
current evidence on the role of robotic colorectal surgery found
that robotic colorectal surgery is both safe and feasible.
However, it has no clear advantages over standard laparo-
scopic colorectal surgery in terms of early postoperative
outcomes or complications profile. It has shorter learning
curve but increased operative time and cost. It could offer
potential advantage in resection of rectal cancer as it has a
lower conversion rates even in obese individuals, distal rectal
tumours and patients who had preoperative chemoradiother-
apy. There is also a trend towards better outcome in
anastomotic leak rates, circumferential margin positivity
and preservation of autonomic function, but there was no
clear statistical significance to support this from the currently
available data. The use of robotic approach seems to be
capable of addressing most of the shortcomings of the
standard laparoscopic surgery. The technique has proved its
safety profile in both colonic and rectal surgery. However, the
cost involved may restrict its use to patients with challenging
rectal cancer and in specialist centres.22
5. Conclusion
Even though minimally invasive approach to colorectal
surgery has been around for some time, its growth has been
hindered by many limitations. Laparoscopic surgery in
colorectal cases presents with certain challenges including
limited magnification, limited range of motion, limited access
in pelvis, operator fatigue, etc. Robotic surgery has come as a
welcome relief for surgeons in these circumstances. With its
better magnification, a three-dimensional field view, better
manoeuvrability, stability, no fatigability and better reach into
confined spaces such as pelvis, it offers an easy novel surgical
approach for these cases. The ease of operating in confined
spaces, such as the narrow pelvis of males allows the surgeons
to perform sprinter saving procedures like intersphincteric
resections robotically. With recent evidences showing it is
non-inferiority in terms of surgical outcome, robotic surgery is
likely to gain an upper hand in time in colorectal cases
especially considering its shorter learning curve. Despite its
many advantages, it is hindered by certain shortcomings,
including the high cost of the surgical system and the overall
cost of surgery. The process of docking the robot takes longer
time in the initial few cases. Overall robotic colorectal surgery
is in its infancy, and appears to have a bright future ahead.
Conflicts of interest
The authors have none to declare.
r e f e r e n c e s
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