Robotic Colorectal Surgery

백승혁 연세대학교의과대학 2008 Yonsei medical journal Vol.49 No.6

Robotic colorectal surgery has gradually been performed more with the help of the technological advantages of the da Vinci(R) system. Advanced technological advantages of the da Vinci(R) system compared with standard laparoscopic colorectal surgery have been reported. These are a stable camera platform, three-dimensional imaging, excellent ergonomics, tremor elimination, ambidextrous capability, motion scaling, and instruments with multiple degrees of freedom. However, despite these technological advantages, most studies did not report the clinical advantages of robotic colorectal surgery compared to standard laparoscopic colorectal surgery. Only one study recently implies the real benefits of robotic rectal cancer surgery. The purpose of this review article is to outline the early concerns of robotic colorectal surgery using the da Vinci(R) system, to present early clinical outcomes from the most current series, and to discuss not only the safety and the feasibility but also the real benefits of robotic colorectal surgery. Moreover, this article will comment on the possible future clinical advantages and limitations of the da Vinci(R) system in robotic colorectal surgery.

정규 결직장 수술 전 기계적 장세척은 과연 필요한가?

김익용 대한소화기학회 2020 대한소화기학회지 Vol.75 No.2

The presence of bowel contents during colorectal surgery has been related to surgical site infections (SSI), anastomotic leakage (AL) and postoperative complications theologically. Mechanical bowel preparation (MBP) for elective colorectal surgery aims to reduce fecal materials and bacterial count with the objective to decrease SSI rate, including AL. Based on many observational data, meta-analysis and multicenter randomized control trials (RTC), non-MBP did not increase AL rates or SSI and other complications in colon and even rectal surgery. In 2011 Cochrane review, there is no significant benefit MBP compared with non-MBP in colon surgery and also no better benefit MBP compared with rectal enemas in rectal surgery. However, in surgeon’s perspectives, MBP is still in widespread surgical practice, despite the discomfort caused in patients, and general targeting of the colon microflora with antibiotics continues to gain popularity despite the lack of understanding of the role of the microbiome in anastomotic healing. Recently, there are many evidence suggesting that MBP+oral antibiotics (OA) should be the growing gold standard for colorectal surgery. However, there are rare RCT studies and still no solid evidences in OA preparation, so further studies need results in both MBP and OA and only OA for colorectal surgery. Also, MBP studies in patients with having minimally invasive surgery (MIS; laparoscopic or robotics) colorectal surgery are still warranted. Further RCT on patients having elective left side colon and rectal surgery with primary anastomosis in whom sphincter saving surgery without MBP in these MIS and microbiome era.

정규 결장수술 후 예방적 항생제로 2제 병용요법과 3제 병용요법의 비교

김윤석,이승현,안병권,백승언 대한대장항문학회 2009 Annals of Coloproctolgy Vol.25 No.1

Purpose: The use of prophylactic antibiotics is the current standard of care after elective colorectal surgery. The aim of this study was to compare the efficacy of antibiotic prophylaxis with dual antibiotic therapy and triple antibiotic therapy after elective colorectal surgery. Methods: We studied consecutive patients underwent elective colorectal surgery from January to June, 2007. Patients of triple-therapy group were administered second cephalosporin, metronidazole, and aminoglycoside for early 3 mo and dualtherapy group were administered second cephalosporin and metronidazole for next 3 mo. The prophylactic antibiotics were administered 2-3 doses for 24 hr after surgery. The surgery for diverticulitis, inflammatory bowel disease, and colon obstruction were excluded. Wound conditions were checked on alternate days during the hospital stay and follow up at least for 30 days after discharge. Results: Over 6 mo, 110 patients were enrolled (59 dual-therapy group, 51 triple-therapy group). In two group, sex, age, American Society of Anesthesiology score, body mass index, combined diseases, and location of disease were similar. Wound infection rate were 1.7% in dual-therapy group and 2.0% in triple-therapy group (P=1.0). Anastomotic leakage rate were 5.1% in dual-therapy group and 2.0% in triple-therapy group (P=0.622). Conclusion: The addition of aminoglycoside to dual antibiotic therapy, second cephalosporin-metronidazole showed on advantage in prevention of postoperative wound complications. Further studies are required to establish appropriate guideline of antibiotic prophylaxis after elective colorectal surgery. Purpose: The use of prophylactic antibiotics is the current standard of care after elective colorectal surgery. The aim of this study was to compare the efficacy of antibiotic prophylaxis with dual antibiotic therapy and triple antibiotic therapy after elective colorectal surgery. Methods: We studied consecutive patients underwent elective colorectal surgery from January to June, 2007. Patients of triple-therapy group were administered second cephalosporin, metronidazole, and aminoglycoside for early 3 mo and dualtherapy group were administered second cephalosporin and metronidazole for next 3 mo. The prophylactic antibiotics were administered 2-3 doses for 24 hr after surgery. The surgery for diverticulitis, inflammatory bowel disease, and colon obstruction were excluded. Wound conditions were checked on alternate days during the hospital stay and follow up at least for 30 days after discharge. Results: Over 6 mo, 110 patients were enrolled (59 dual-therapy group, 51 triple-therapy group). In two group, sex, age, American Society of Anesthesiology score, body mass index, combined diseases, and location of disease were similar. Wound infection rate were 1.7% in dual-therapy group and 2.0% in triple-therapy group (P=1.0). Anastomotic leakage rate were 5.1% in dual-therapy group and 2.0% in triple-therapy group (P=0.622). Conclusion: The addition of aminoglycoside to dual antibiotic therapy, second cephalosporin-metronidazole showed on advantage in prevention of postoperative wound complications. Further studies are required to establish appropriate guideline of antibiotic prophylaxis after elective colorectal surgery.

복강경 대장직장수술에서 수술방법에 따른 습득 곡선

박광국,이승훈,이승현,안병권,백승언 대한내시경복강경외과학회 2012 Journal of Minimally Invasive Surgery Vol.15 No.2

Purpose: This study aimed at evaluation of the learning curve for laparoscopic colorectal surgery with varied operative procedures. Methods: From June 2004 to May 2010, 269 consecutive patients underwent laparoscopic colorectal surgery. Patients were divided into four groups according to operative methods: right-side colectomy, left-side colectomy, rectal resection, and total colectomy group. Each group was divided into threeearly, middle, and late-groups according to operation numbers. Learning curves were generated for each group using moving average methods. Prospective collection and retrospective review of data on operative outcomes, including open conversion, operation time, intra-operative blood loss, postoperative hospital stay, and postoperative complication were performed. Results: Operations included 75 right-side colectomies, 12 left-side colectomies, 178 rectal resections, four total colectomies, and seven open conversions (2.6%). The mean operative time for right-side colectomy and rectal resection showed a significant decline from the early group to the middle and late groups, while the left-side colectomy group showed no significant difference. Operation time was platitude after 50 cases of whole laparoscopic colorectal surgery, 11 cases in the right-side colectomy group, eight cases in the left-side colectomy group, and 34 cases in the recto-sigmoid resection group. Conclusion: For the surgeon, laparoscopic colorectal surgery can be performed more independently after 50 cases. The learning curve may be determined according to the general skill of laparoscopic colorectal surgery. The question of whether the learning curve is determined by varied operative procedures has not yet been resolved.

복강경 대장 절제술 경험이 없는 술자에 의하여 시행된 대장암 복강경 절제술: 초기 50예와 후기 51예 단기성적 비교

선장원,허정욱,조상혁,주재균,김형록,김영진 대한대장항문학회 2009 Annals of Coloproctolgy Vol.25 No.4

Purpose: The present study aimed to investigate the safety and the feasibility of laparoscopic colorectal surgery performed by a surgeon during a learning period. Methods: Between April and December 2008, 101 consecutive patients with colorectal cancers underwent laparoscopic surgery by one colorectal surgeon who previously had no experience with laparoscopic colorectal surgery. Standard laparoscopy with a lymphadenectomy using a 5-port technique was performed according to the tumor location. The patients were divided into two chronological groups: 50 cases early in learning period (early cases) and 51 cases later in the learning period (late cases). Results: The operations were 29 right hemicolectomies, 9 left hemicolectomies, 18 anterior resections, 35 low anterior resections, 6 intersphincteric resections, 2 abdominoperineal resections, and 2 Hartmann’s operation. There were 7 conversions (6.9%). The median operating time was 205 (range, 95-385) min, and the median blood loss was 258 (50-800) mL. The median times to flatus per anus and to feeding of soft diet were 2 (1-5) and 4 (2-13) days, respectively. The median hospital stay was 9 (6-27) days. There were 21 postoperative complications, including 7 anastomotic complications (3 leakages, 3 abscesses, and 1 stenosis). The median number of lymph nodes harvested was 20 (4-65). The operating time, blood loss, and complication rates were significantly decreased in the late group. Conclusion: Our initial experience with laparoscopic colorectal surgery appears to have acceptable perioperative results and short-term oncologic outcomes, which improved with the experience of the surgeon. Purpose: The present study aimed to investigate the safety and the feasibility of laparoscopic colorectal surgery performed by a surgeon during a learning period. Methods: Between April and December 2008, 101 consecutive patients with colorectal cancers underwent laparoscopic surgery by one colorectal surgeon who previously had no experience with laparoscopic colorectal surgery. Standard laparoscopy with a lymphadenectomy using a 5-port technique was performed according to the tumor location. The patients were divided into two chronological groups: 50 cases early in learning period (early cases) and 51 cases later in the learning period (late cases). Results: The operations were 29 right hemicolectomies, 9 left hemicolectomies, 18 anterior resections, 35 low anterior resections, 6 intersphincteric resections, 2 abdominoperineal resections, and 2 Hartmann’s operation. There were 7 conversions (6.9%). The median operating time was 205 (range, 95-385) min, and the median blood loss was 258 (50-800) mL. The median times to flatus per anus and to feeding of soft diet were 2 (1-5) and 4 (2-13) days, respectively. The median hospital stay was 9 (6-27) days. There were 21 postoperative complications, including 7 anastomotic complications (3 leakages, 3 abscesses, and 1 stenosis). The median number of lymph nodes harvested was 20 (4-65). The operating time, blood loss, and complication rates were significantly decreased in the late group. Conclusion: Our initial experience with laparoscopic colorectal surgery appears to have acceptable perioperative results and short-term oncologic outcomes, which improved with the experience of the surgeon.

대장직장암절제술에서 로봇수술과 복강경수술의 비교

신재원,김선한 대한의사협회 2012 대한의사협회지 Vol.55 No.7

Laparoscopic surgery is an acceptable option for colorectal cancer. Robotic surgery is an emerging methodology and may be a solution to some difficulties inherent to conventional laparoscopic surgery. The aims of this study are to review the outcomes of laparoscopic and robotic surgery, and to discuss robotic surgery from the perspective of treating colorectal cancer. In rectal cancer, robotic surgery takes a longer operative time and has a higher cost, but decreases conversion to open surgery and shortens the learning curve. It has a great potential for preserving bladder and sexual function after total mesorectal excision (TME). The TME quality may also be better. Robotic surgery can also modify the current standard anastomosis following rectal resection, which is a double-stapling technique. Using a robot enables transanal specimen retrieval then a single-circular stapled anastomosis, which is associated with low pain and fast recovery. More solid answers including the long-term oncologic safety will be provided by ongoing randomized trials. In colon cancer, the ease of performing intracorporeal suture anastomosis may be a benefit. Since complete mesocolic excision with wide lymphadenectomy is becoming more and more acceptable to achieve better oncologic outcomes,the role of robotic surgery in providing a stable environment for radically dissecting lymph nodes should be evaluated. Recently developed new technologies such as fluorescent imaging and a robotic stapler seem promising potentially providing further benefits such as a decrease in anastomotic leakage. Single port robotic surgery is also an interesting concept requiring clinical evaluation. Robotic surgery is a developing field and may provide further functional and oncological benefits to colorectal cancer patients. Large scale randomized trials are timely important.

Effect of prehabilitation on patients with frailty undergoing colorectal cancer surgery: a systematic review and meta-analysis

Min Cheol Chang,Yoo Jin Choo,Sohyun Kim 대한외과학회 2023 Annals of Surgical Treatment and Research(ASRT) Vol.104 No.6

Purpose: The effect of prehabilitation in patients with frailty undergoing colorectal cancer surgery remains controversial. This meta-analysis aimed to assess the impact of prehabilitation before colorectal surgery on the functional outcomes and postoperative complications in patients with frailty undergoing colorectal cancer surgery. Methods: PubMed, EMBASE, Cochrane Library, and Scopus databases were searched for articles published up to November 9, 2022. We included randomized and non-randomized trials in which the effects of prehabilitation in patients with frailty undergoing colorectal cancer surgery were investigated against a control group. Data extracted for our meta- analysis included the 6-minute walk test (6MWT), postoperative incidence of complications (Clavien-Dindo classification ≥IIIa), comprehensive complication index (CCI), and length of stay (LOS) in the hospital. Results: Compared with the control group, we found a significant improvement in the incidence of postoperative complications and shorter LOS in the hospital in the prehabilitation group. However, the 6MWT and CCI results showed no significant differences between the 2 groups. Conclusion: Prehabilitation in patients with frailty who underwent colorectal cancer surgery improved the incidence of postoperative complications and LOS in the hospital. Hence, clinicians should consider conducting or recommending prehabilitation exercises prior to colorectal cancer surgery in patients with frailty.

The additional analgesic effects of transverse abdominis plane block in patients receiving low-dose intrathecal morphine for minimally invasive colorectal surgery: a randomized, single-blinded study

Seung-Rim Han,Chul Seung Lee,Jung Hoon Bae,Hyo Jin Lee,Mi Ran Yoon,Do Sang Lee,Yoon Suk Lee,Abdullah Al-Sawat,Jung-Woo Shim,Sang-Hyun Hong,In Kyu Lee 대한외과학회 2021 Annals of Surgical Treatment and Research(ASRT) Vol.101 No.4

Purpose: Intrathecal analgesia (ITA) and transverse abdominis plane block (TAPB) are effective pain control methods in abdominal surgery. However, there is still no gold standard for postoperative pain control in minimally invasive colorectal surgery. This study aimed to investigate whether the analgesic effect could be increased when TAPB, which can further reduce wound somatic pain, was administered in low-dose morphine ITA patients. Methods: Patients undergoing elective colorectal surgery were randomized into an ITA with TAPB group or an ITA group. Patients were evaluated for pain 0, 8, 16, 24, and 48 hours after surgery. The primary outcome was the total morphine milligram equivalents administered 24 hours after surgery. The secondary outcomes were pain scores, ambulatory variables, inflammation markers, hospital stay duration, and complications within 48 hours after surgery. Results: A total of 64 patients were recruited, and 55 were compared. There was no significant difference in morphine use over the 24 hours after surgery in the 2 groups (ITA with TAPB, 15.3 mg vs. ITA, 10.2 mg; P = 0.270). Also, there was no significant difference in pain scores. In both groups, the average pain score at 24 and 48 hours was 2 points or less, showing effective pain control. Conclusion: ITA for pain control in patients with colorectal surgery is an effective pain method, and additional TAPB was not effective.

외과 영역에서 로봇 수술의 적용

김진경,양승윤,김성현,김형일 대한의사협회 2021 대한의사협회지 Vol.64 No.10

Background: Application of robotic surgery in the field of general surgery has been increasing. This paper is an overview of the current uses and future perspectives of robotic surgery in four major divisions—endocrine, upper gastrointestinal, hepato-biliary-pancreatic (HBP), and colorectal surgery. Current Concepts: In endocrine surgery, cosmetic advantage is the highest priority when selecting a surgical approach for thyroidectomy. Currently, the transaxillary route is the most common approach. The introduction of the single-port system could maximize the advantages of this technique. In upper gastrointestinal surgery, the use of robots has the advantage of better retrieval of lymph nodes, less bleeding, earlier discharge, and less complications than the laparoscopic approach. However, a more prospective comparative trial is required to confirm those findings. In the HBP field, the indications of robotic surgery have expanded, starting with cholecystectomy to more challenging procedures, such as donor hepatectomy and pancreaticoduodenectomy. Meticulous dissection using robots could provide benefits to patients. In colorectal surgery, robotic surgery is an excellent technical tool for minimally invasive surgeries for rectal cancers, especially in male patients with narrow, deep pelvises. However, further studies are required to confirm the impact of robotic surgery on rectal cancers. Discussion and Conclusion: Robots are used to provide optimal surgical outcomes. Investigating new technologies and innovative surgical procedures is the highly important for a surgeon in the era of minimally invasive surgery.

결직장암의 복강경수술

김준기 ( Jun Gi Kim ) 대한소화기학회 2007 대한소화기학회지 Vol.50 No.4

Laparoscopic surgery for colorectal cancer was first adopted 16 years ago. There are various limitations in performing laparoscopic surgery including the technical complexity and question of positive impact on the long-term oncologic outcome. The purpose of this review is to outline the important issues surrounding the laparoscopic surgery for colorectal cancer based on the most recently published articles. The laparoscopic approach provides the advantages of an illuminated and magnified view, which may be superior to open surgery. There was no significant difference on the oncologic clearance, especially its proportion of positive radial margins to the number of harvested lymph nodes. In addition, laparoscopic surgery for colorectal cancer was associated with earlier recovery of bowel function, need for fewer analgesics, and with a shorter hospital stay compared to open surgery. Long-term oncologic outcome does not appear to be impaired by laparoscopic resection and local recurrence and disease specific survival has been reported to be similar for both laparoscopic and open surgery for colorectal cancer. Laparoscopic surgery for colorectal cancer is feasible and safe when performed by experienced surgeons. The oncologic results of many ongoing prospective randomized controlled trials are eagerly awaited. (Korean J Gastroenterol 2007;50:249-255)