Laparoscopic and Robotic Surgery in Rectal Cancer

Introduction

Laparoscopy has been one of the most important innovations in the surgical field in recent years, but its use for the treatment of colorectal malignancies is still controversial due to:

1. early reports of port site implants;

2. concern about performing an oncologically prop- er resection with adequate margins and lymph node dissection;

3. concern about long-term survival;

4. a steep learning curve.

Port Site Implants

Port site implants were described in the early reports, so it was suggested that laparoscopic colorectal resection only be performed within controlled trials [1]. The reported port site metastases [2] occurred soon after the colorectal resection in patients with large tumours, and when the cancer was heavily manipulated during the procedure, thus suggesting the possibility of neoplastic cell exfoliation during the resection [ 3]. With growing experience, it is now clear that the incidence of port site metastases is no different from that of wound recurrence after con- ventional open surgery, as reported by several Authors [ 4–12]. Nevertheless, adequate manoeuvres are needed to prevent this complication, avoiding tumour manipulation, preventing air leakage through port sites (the so-called chimney effect) and desufflating the abdomen before removing the tro- cars. The use of proper sleeve wound protection for the mini-laparotomy is also recommended, to avoid contact between the colon and the wound during the exteriorisation of the specimen because cancer implants have been described at the extraction site.

Proper Oncological Resection

It is generally agreed that the definition of proper oncological resection is based on the adequacy of the

tumour-free margins, specimen length and number of lymph nodes retrieved. Many reports from uncon- trolled and randomised studies show that a proper oncological resection based on these principles can be done laparoscopically, following the principles of surgical oncology [5, 6, 13–15]. Adequate laparo- scopic resections have also been described specifical- ly for the rectum and formal total mesorectal exci- sions can be performed [ 16–19].

Long-Term Survival

Shorter hospital stays and faster recovery times have been described after laparoscopic colorectal resec- tion [ 5, 7, 9, 13, 14, 16, 18, 20] and now, with growing experience and longer follow-ups now becoming available, the literature suggests that long-term sur- vival after laparoscopy does not differ from that of open surgery [ 9, 13, 14, 21]. This has also been demonstrated in randomised studies [ 9, 14].

Steep Learning Curve

Laparoscopic colorectal resection is a technically demanding procedure with a steep learning curve [ 22]. New surgical skills need to be learned and many colorectal surgeons do not have such specific train- ing. Laparoscopic instruments are straight, with no articulation at their tips. In addition, the surgeon must learn to operate watching on a two-dimension- al monitor. These disadvantages may be overcome, however, by the recent introduction of robotic tech- nology in the operating room (OR). The robotic device is designed to transfer the movements direct- ly from the surgeon’s hand to articulated instruments driven by robotic arms and, at the same time, to allow a real three-dimensional view of the surgical field. It has been demonstrated that an equally valid oncological resection and comparable surgical results can be obtained by standard laparoscopy and using the robotic approach [ 23].

Annibale D’Annibale, Emilio Morpurgo, Nicola Menin

Equipment

Laparoscopic Cart

The laparoscopic cart components are:

• a carbon dioxide source and insufflator

• a light source

• a camera system

• video monitors

• recording media.

Carbon dioxide source and insufflator. Carbon dioxide is stored in containers at a pressure of about 50 bar, so the containers must be carefully secured to the cart to prevent accidents in the OR. They are con- nected to an insufflator, which can generate and con- trol the flow of CO

into the abdominal cavity, assuring a maximal flow of 30 l/min. The machine has auto- matic pressure and flow regulators that adjust the flow of CO

to maintain a stable intra-abdominal pressure of 12–14 mmHg. Acoustic and visual alarms can be preset and alert the surgeon in the event of any change in abdominal pressure. Flow per minute, abdominal pressure, gas volume used and insufflation pressure are constantly indicated on the machine.

Light source. The light source is normally a 300-W xenon lamp producing a light very similar to sunlight allowing for automatic or manual light intensity reg- ulation. It has a stand-by position that allows the power of the light to be reduced when it is not need- ed without turning the lamp off, thereby prolonging lamp life.

Camera system. The camera system is connected to the camera and the 30° laparoscope. It has a video input and three outputs with different resolutions.

The red, green and blue (RGB) output is the one with the best resolution power and must be connected to the primary video monitor. Colour must be calibrat- ed by white balancing before starting each procedure.

The remaining outputs can be used for a satellite monitor and the recording system.

open surgery and new, unnatural technical skills have to be learned to perform major operations such as col- orectal resections proficiently. In laparoscopy, there is a loss of manual dexterity because: ( 1) the instruments are straight and have a fulcrum at the port entry, so movements are reversed; ( 2) straight instruments completely lack the complex articulation characteris- ing a human hand; (3) there is no three-dimensional view as in direct binocular human vision.

A new generation of advanced robotic systems has recently been designed to overcome these drawbacks, however. The da Vinci robotic surgical system (Intu- itive Surgical Inc., Sunnyvale, CA, USA) offers a three-dimensional view, and it exactly translates the surgeon’s hand movements to the tips of the surgical instruments, which have a wrist-like articulation. In addition, it holds the camera in a stable position that can be adjusted directly by the surgeon to optimise the view of the surgical field.

The da Vinci® Robotic Surgical System

The da Vinci robotic surgical system (Intuitive Surgi- cal Inc., Sunnyvale, CA USA) has three components:

the vision cart, the master console and the surgical cart.

Vision cart. This component is roughly similar to a standard laparoscopic cart, but with some substan- tial differences. It holds the dual light source and the image processor for the two cameras that are installed on the single endoscope, which is conse- quently able to provide a 3D image for the surgeon. It also holds a standard laparoscopic CO

insufflator and a standard laparoscopic monitor for the assis- tants and the scrub technician.

Master console (Fig. 1). This is where the surgeon

sits. It contains the computers that process the com-

bined images to create a true 3D image. The surgeon

looks down into the viewer as if he were looking

straight at the surgical field. He places his hands on

the control handles located in the lower part of the console and, by moving the joysticks, he transfers his movements to the robotic arms. Foot pedals at the console provide control for the electrocautery, as well as a clutch.

Surgical cart (Fig. 2). This consists of the 3 robotic arms mounted on a movable chassis. The manipula- tors (which are covered with sterile drapes during the procedures) are mounted on a central column placed on the wheel-mounted surgical cart. Two arms are for holding the surgical tools and respond to the movements of the surgeon’s hands, while one is for holding the three-dimensional stereo-endoscope and camera. The arms have three degrees of freedom (pitch, yaw and insertion) and they hold specifically designed instruments that have a wrist-like move- ment at their tip.

Patient’s Position and Operating Room Setup

The patient lies supine on the OR table, with legs lying flat and initially closed. The terminal part of the OR table must allow for the patient’s legs to be opened to perform the anastomosis at the end of the operation. If a Miles procedure or a handsewn, pull- through anastomosis are planned, the legs are subse- quently positioned on Allen stirrups, but are initially laid flat to avoid any interference with the surgeon’s hands and instruments during the procedure, flexing the legs later, when the perineal part of the operation is over. Both arms are tucked.

During the procedure, patients are placed in a steep Trendelemburg position and rotated to the right, so they must be carefully secured to the bed with bilater- al shoulder braces, with one brace positioned on a level with the right deltoid to prevent them from slid- ing when the table is tilted. Braces are wrapped with

gel or foam cushions. To avoid nerve stretching, the position must be checked before anaesthesia is induced, with the patient still cooperative.

Laparoscopy

The surgeon stands at the patient’s right side and watches the monitor on the laparoscopic cart, which stands on the opposite side; the assistant stands on the contralateral side, or may move to the right dur- ing the procedure to hold the camera more comfort- ably. The scrub technician stands near the patient’s right leg. The remaining devices (bowie and harmon- ic scalpel carts, suction-irrigation pump) are posi- tioned according to OR custom.

Laparoscopic Instruments

Standard laparotomic instruments must be readily available in case the procedure has to be unexpected- ly converted. Specific laparoscopic instruments include graspers, cautery hook, scissors, harmonic scalpel, right angle, staple appliers, laparoscopic lin- ear staplers and circular stapler. Retractors and uter- ine manipulators may be used, if necessary, during pelvic dissection. The bipolar coagulator has proved very effective in controlling oozing bleeding.

Robotics

The da Vinci robotic system is a heavy, bulky instru- ment and needs a large OR. The proper positioning of its three components in the room is crucial to min- imise the need to move it around the room. As a gen- eral rule, the robotic arms are placed on the same

Fig. 1. Robotic console Fig. 2.Robotic arms

side of the patient as the lesion (Figs. 3, 4), so for sur- gery of the left colon and rectum the arms are placed on the patient’s left side. The vision cart is positioned at the patient’s feet so that the assistant and scrub nurse have an optimal view. The master console is at the patient’s side, about 10 feet away to allow enough space for the robotic arms, the scrub nurse and the assistant to move. With the console in this position, the surgeon also has complete visual control of the surgical field and robotic arms. All the instruments are prepared in the room before the patient’s arrival.

After anaesthesia has been induced the robotic arms are wrapped with sterile plastic sheets and moved up to the operating table. The assistant stands at the patient’s right side.

Robotic Instruments

Specifically designed robotic instruments driven by the da Vinci’s arms include graspers, a cautery hook, scissors, a needle holder and a harmonic scalpel. The assistant helps the surgeon using standard laparo- scopic instruments.

Surgical Technique

Specific Anatomical Considerations

During embryological life the mesentery of the primitive gut is oriented anteriorly. When the bowel re-enters the abdominal cavity, the mesentery of the

left colon rotates towards the left and the mesentery containing the vessels fuses with the fascia of Gerota and the retroperitoneum. The plane that originates from this fusion is virtually avascular. This plane must be followed and enables the left colon to be mobilised with its mesentery, vessels and lymph nodes. The inferior mesenteric vein (IMV) can be recognised at Treitz ligament level, where it enters underneath the pancreatic tail (Fig. 5). The inferior mesenteric artery originates from and forms an acute angle with the distal part of the aorta (Fig. 6);

it can be recognised by opening the pre-aortic plane, where the mesenteric nervous plexus surrounds the

tion

Fig. 5.Tr, ligament of Treitz; IMV, inferior mesenteric vein;

Pa, pancreas

origin of the inferior mesenteric artery. After vascu- lar ligation, if the avascular plane behind the mesen- tery of the left colon is followed properly, it leads down to the pelvis into the vascular plane behind the mesorectum, which is mobilised together with the rectum. Here, the hypogastric nerves must be identi- fied and spared.

Port Positioning and Surgical Field Setup

Ports are positioned as shown in Fig. 7 for laparo- scopic resections and in Figs. 8 and 9 for robotic resections. The umbilical camera port is created with an open technique and the remaining trocars are positioned under vision after pneumoperitoneum has been created. For laparoscopy, 10-mm ports are used for the camera, the right hypochondrium and

rior mesenteric vein. The dotted line indicates the site of peritoneum incision to isolate the artery

Fig. 7.Position of trocars for laparoscopic rectal cancer sur- gery

Fig. 8. Position of trocars for left colon dissection during robotic rectal surgery

Fig. 9.Position of trocars for robotic dissection of rectum C

I

C1

E

I

C1

E C

E - Endodissector C - Cadiére forceps C1- Camera I - Instrument port

E - Endodissector C - Cadiére forceps C1- Camera I - Instrument port 10 mm

10 mm

12 mm

5 mm

the left flank; a 12-mm port is created in the right iliac fossa to allow for the use of the endo-GIA.

Robotic ports are 8 mm and the camera port is 12 mm. The robot is first positioned on a level with the left flank, using the trocars in the right iliac fossa and right hypochondrium, and dissection of the left colon is performed. For dissection of the lower rectum, the position of the robot must be changed to left thigh level and works through the 2 ports in the iliac fossae.

If a Miles procedure is adopted, the trocar in the left iliac fossa is used for the colostomy. The patient lies in a Trendelemburg position, rotated to the right.

The small bowel is pulled out of the pelvis and posi- tioned in the right hypochondrium to expose the lig- ament of Treitz, with the origin of the IMV.

Identification of the Inferior Mesenteric Vein

The IMV is identified at Treitz ligament level (Fig. 10).

To facilitate the identification of the vein, the liga- ment of Treitz can be pulled carefully to the right.

Once the IMV has been identified, the avascular plane between the vein and the fascia of Gerota is opened by sharp dissection and the mesentery of the left colon is detached from the retroperitoneum forming a sort of tent. The vein is clipped but not yet divided because delicate traction on it facilitates the sharp dissection along this plane (Fig. 11).

Identification of the Artery

To enable proper identification of the artery, the Trendelemburg position may be further increased so

as to draw the loops of small bowel out of the pelvis.

The plane of the right iliac artery is identified and the pre-aortic plane is opened. The IMA is identified and cautiously isolated (Figs. 12, 13). The magnification of the laparoscope enables the identification of the nerve fibres that must be spared posteriorly (Fig. 14).

The artery is clipped and divided, and this portion of the mesentery of the left colon is sharply dissected from the retroperitoneum and the ureter is recog- nised (Fig. 15). This dissection of the mesentery of the left colon from the retroperitoneum must be completed as far as possible in the middle to lateral direction, so that little remains to perform from the left abdominal gutter.

Fig. 10a, b.Tr, Treitz; IMV, inferior mesenteric vein; IMA, inferior mesenteric artery. The IMV is identified at the ligament of Treitz; the peritoneum is opened underneath the vein

a

Fig. 11. The mesentery of the left colon is lifted from the fas- cia of Gerota underneath the inferior mesenteric vein

Splenic Flexure Take-Down

A hole is made in the distal part of the mesentery of the transverse colon, above the tail of the pancreas (Figs. 16, 17). This allows a flow of gas into the lesser sac and thus facilitates the separation of the omen- tum from the colon, which is taken down from the middle third of the transverse colon (Fig. 18). The assistant surgeon helps by pulling the transverse colon towards the pelvis with a grasper introduced in the left flank. The splenic flexure is then carefully detached from the spleen with the harmonic scalpel.

If the patient is particularly tall or obese, this opera- tion may be completed using the access in the left

flank. At this point, mobilisation of the left colon is completed by detaching the residual peritoneal attachments in the left abdominal gutter.

Isolation of the Rectum and Mesorectum

Following the avascular plane identified after divid- ing the IMA, the plane between the mesorectum and the presacral fascia is entered. It has a typical cotton candy appearance that indicates the proper plane of dissection (Fig. 19). The dissection is continued down to the plane of the levator ani, sparing the hypogastric nerves, and the typical bilobated appear-

Co, colon; Gv, gonadal vessels; Ur, ureler. The IMA is iden- tified and the peritoneum is opened just underneath it

Fig. 13.IMA, inferior mesenteric artery; Ao, aorta; IA, right iliac artery

Fig. 14.IMA, inferior mesenteric artery; Pl, nervous plexus Fig. 15. IMA, inferior mesenteric artery; Ur, ureter; Gv, gonadal vessels

ance of the mesorectum comes into view (Fig. 20).

The rectum is isolated by sharp dissection, pushing anteriorly on the rectum. Once the rectum has been isolated posteriorly, the anterior peritoneal reflection is opened and the anterior aspect of the rectum is iso- lated from the vagina or seminal vesicles and prostate. If the cancer is located in the upper third of the rectum, the mesorectum is divided with the har- monic scalpel below the cancer, and the rectum is stapled with a green endo-GIA (Fig. 21). If the tumour is in the lower two thirds of the rectum, a total mesorectal excision is performed and the rec- tum is divided just above the dentate line.

Fig. 16.To take down the splenic flexure, first a hole is made in the mesentery of the distal part of the transverse colon, just above the pancreatic tail (arrow1); then the omentum is separated from the transverse colon (arrow2)

Fig. 17.Hole in the mesentery of the transverse colon

Fig. 18. Take-down of the omentum from the transverse colon. Om, omentum; Co, colon, Sp, spleen

Fig. 19.The cotton candy avascular plane between the rec- tum and mesorectum and the presacral fascia are identi- fied. AP, avascular plane; R, rectum; Hyp, left hypogastric nerve

Exteriorisation of the Specimen

Once the rectum has been divided, a mini-laparoto- my is performed. The mini-laparotomy can be either a Pfannestiel incision or a supra-umbilical midline incision. The Pfannestiel incision has better cosmetic results but cannot be easily extended in case a wider access is needed for some reason, whereas midline laparotomy is very easy to extend, so we recommend the latter for those who are at the beginning of their experience. The laparotomy must be protected to prevent contamination or insemination by neoplastic cells during the extraction of the specimen (Fig. 22).

The proximal portion of the colon is resected extra- corporeally and the anvil for the circular stapler is

positioned. The laparotomy is closed, pneumoperi- toneum restored and an end-to-end straight anasto- mosis is performed (Fig. 23). The anastomotic rings are checked to make sure they are complete through 360°; a pneumatic test is performed, submerging the anastomosis in water and insufflating air through the anus. Two perianastomotic drains are positioned (Fig. 24). Before removing the trocars, it is important to check for bleeding from the insertion sites.

If a handsewn anastomosis is planned, a transanal standard mucosectomy is performed after position- ing a Lone Star retractor. The specimen is removed through the minilaparotomy and a pull-through handsewn anastomosis is performed. For Miles pro- cedures, a standard perineal dissection is performed

Fig. 21.The rectum is stapled

Fig. 22.Exteriorisation of the specimen; the mini-laparoto- my is protected

Fig. 23.Anastomosis

and the specimen is removed through the colostomy site or through the perineum.

References

1. Wexner SD, Latulippe JF (1998) Laparoscopic colorec- tal surgery and cancer. Dig Surg 15:117–123

2. Berends FJ, Kazemier G, Bonjer HJ, Lange JF (1994) Subcutaneous metastases after laparoscopic colecto- my. Lancet 344:58

3. Tseng LNL, Berends FJ, Wittich P et al (1998) Port-site metastases. Surg Endosc 12:1377–1380

4. Franklin ME, Kazantzev GB, Abrego D et al (2000) Laparoscopic surgery for stage III colon cancer. Surg Endosc14:612–616

5. Franklin ME, Rosenthal D, Abrego-Medina D et al (1996) Prospective comparison of open vs laparoscopic colon surgery for carcinoma. Dis Colon Rectum 39:S35–S46

6. Scheidbach H, Schneider C, Huegel O et al (2002) Laparoscopic sigmoid resection for cancer. Dis Colon Rectum45:1641–1647

7. Leung KL, Kwok SPY, Lam SCW et al (2004) Laparo- scopic resection of rectosigmoid carcinoma: prospec- tive randomised trial. Lancet 363:1187–1192

8. Huscher C, Silecchia G, Croce E et al (1996) Laparo- scopic colorectal resection. Surg Endosc 10:875–879 9. Lacy A, Garcia-Valdecasas JC, Delgado S et al (2002)

Laparoscopy-assisted colectomy versus open colecto- my for treatment of non-metastatic colon cancer: a randomised trial. Lancet 359:2224–2229

ed and open colectomy for colon cancer. N Engl J Med 350:2050–2059

15. Köckerling F, Reymond MA, Schneider C et al (1998) Prospective multicenter study of the quality of onco- logic resections in patients undergoing laparoscopic colorectal surgery for cancer. Dis Colon Rectum 41:963–970

16. Zhou ZG, Hu M, Li Y et al (2004) Laparoscopic vs open mesorectal excision with anal sphincter preservation for low rectal cancer. Surg Endosc 18:1211–1215 17. Yamamoto S, Watanabe M, Hasegawa H et al (2002)

Prospective evaluation of laparoscopic surgery for rec- tosigmoidal and rectal carcinoma. Dis Colon Rectum 45:1648–1654

18. Feliciotti F, Guerrieri M, Paganini AM et al (2003) Long-term results of laparoscopic vs open resections for rectal cancer for 124 unselected patients. Surg Endosc17:1530–1535

19. Leroy J, Jamali F, Forbes L et al (2004) Laparoscopic total mesorectal excision (TME) for rectal cancer sur- gery. Surg Endosc 18:281–289

20. Ramos JM, Beart RW, Goes R et al (1995) Role of laparoscopy in colorectal surgery. Dis Colon Rectum 38:494–501

21. Pantakar SK, Larach SW, Ferrara A et al (2003) Prospective comparison of laparoscopic vs open resec- tions for colorectal adenocarcinoma over a ten-year period. Dis Colon Rectum 46:601–611

22. Bennett CL, Stryker SJ, Ferreira R et al (1997) The learning curve for laparoscopic colorectal surgery.

Arch Surg 132:41–44

23. D’Annibale A, Morpurgo E, Fiscon V et al (2004) Robotic and laparoscopic surgery for the treatment of colorectal diseases. Dis Colon Rectum 47:2162–2168 Fig. 24.The abdomen after anterior resection