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Robotic Surgery


Preface

Robotic surgery is arguably the most disruptive and perhaps the most enabling twenty-first century surgical innovation. Born of military technology, developed by industry, and championed by surgeon pioneers, robotic surgery is increasingly adopted as an alternative to laparoscopy to perform a wide breadth of surgical procedures for both benign and malignant diseases ( Box 16.1 ). Since the U.S. Food and Drug Administration (FDA) approval in 2000 of the da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA), the most utilized commercially available surgical robot, surgeons have performed over 5 million robotic surgical procedures worldwide with more than 10,000 peer-reviewed publications reporting its safety, feasibility, and efficacy compared to open and laparoscopic procedures ( Fig. 16.1 ).

Box 16.1
Selected list of the most commonly performed robotic abdominal operations

Foregut/Upper Abdominal Operations

  • Heller myotomy

  • Antireflux surgery

  • Bariatric surgery (Roux-en-Y gastric bypass, sleeves)

  • Esophagogastrectomy with gastric pull-up

  • Radical gastrectomy for gastric cancer (subtotal distal, total, D1+ and D2 lymphadenectomies)

  • Splenectomy

Hepatopancreaticobiliary Operations

  • Liver resection (left lateral segmentectomy, right lobectomy, right posterior segmentectomy)

  • Pancreatic resections (pancreaticoduodenectomy, central and distal pancreatectomies)

  • Cholecystectomy (simple, radical)

Colorectal Operations

  • Right colectomy

  • Left colectomy

  • Low anterior resection with total mesorectal excision

  • Abdominoperineal resection

Other General Surgical Procedures

  • Hernias (inguinal, ventral incisional, hiatal)

  • Thyroidectomy (transaxillary, retroauricular)

Fig. 16.1, Increase in peer-reviewed publications in robotic surgery (PubMed search for “robotic surgery, robot-assisted surgery”).

The field of robotic surgery has challenged our traditional concepts of laparoscopic surgery with novel perceptions of the surgical view, methods of operative exposure, tissue manipulation, and instrument use. Robotic surgery capitalizes on the “master-slave” concept to offer surgeons control over a system that provides enhanced visualization, augmented dexterity and precision, sophisticated articulating instruments, and improved ergonomics. This alternative minimally invasive surgical (MIS) approach offers the potential to overcome the limitations of laparoscopy and increase MIS benefits to a diverse surgical patient population.

As an evolution from traditional laparoscopic surgery, numerous studies have demonstrated that robotic assisted laparoscopic techniques are safe and feasible and provide MIS benefits of improved patient outcomes with smaller incisions, less pain, less blood loss, shorter length of hospital stay, quicker return of bowel function, and more rapid overall recovery when compared to open procedures. Moreover, studies evaluating intraoperative oncologic parameters support the reliable use of robotic surgery in the treatment of malignant diseases including gastric, colorectal, pancreatic, and liver cancers. The oncologic parameters evaluated include negative margin status, adequate number of nodes, and proper extent of lymph node dissection in cancer operations. On the other hand, the consistently longer operative time and higher cost of robotic surgery continue to challenge the field of robotic surgery. Comparative results of these studies for rectal resections, pancreaticoduodenectomies, distal pancreatectomies, and liver resections are summarized and presented in Tables 16.1 to 16.4 .

Table 16.1
Summary of recently comparative studies, randomized control trials, and meta analyses focusing on the key outcomes of laparoscopic versus robotic total mesorectal excision. ∗
Study characteristics Outcomes
Number of patients Operation time (minutes) Length of stay (days) Major complication rate (%)
Cd III–V
Study Study design laTME rTME laTME rTME P Value laTME rTME P Value laTME rTME P Value
Baik SH, Ko YT, Kang CM, et al. Robotic tumor-specific mesorectal excision of rectal cancer: short-term outcome of a pilot randomized trial. Surg Endosc . 2008;22:1601–1608. RT 18 18 204 217 NS 8.7 ± 1.3 6.9 ± 1.3 <0.001 0.0% 0.0%
Patriti A, Ceccarelli G, Bartoli A, et al. Short- and medium-term outcome of robot-assisted and traditional laparoscopic rectal resection. JSLS . 2009;13:176–183. CCS 37 29 208 202 NS 9.6 ± 6.9 11.9 ± 7.5 NS NR NR
Park JS, Choi GS, Lim KH, et al. Robotic-assisted versus laparoscopic surgery for low rectal cancer: case-matched analysis of short-term outcomes. Ann Surg Oncol . 2010;17:3195–3202. MCC 82 41 169 232 <0.001 9.4 ± 2.9 9.9 ± 4.2 NS 7.3% 9.8% 0.641
Bianchi PP, Ceriani C, Locatelli A, et al. Robotic versus laparoscopic total mesorectal excision for rectal cancer: a comparative analysis of oncological safety and short-term outcomes. Surg Endosc . 2010;24:2888–2894. CCS 25 25 237 240 NS 6 (4–20) 6.5 (4–15) NS 0.12 0.8%
Baek JH, Pastor C, Pigazzi A. Robotic and laparoscopic total mesorectal excision for rectal cancer: a case-matched study. Surg Endosc . 2011;25:521–525. MCC 41 41 315 296 NS 6.6 (3–20) 6.5 (2–33) NS NR NR
Kwak JM, Kim SH, Kim J, et al. Robotic vs laparoscopic resection of rectal cancer: short-term outcomes of a case-control study. Dis Colon Rectum . 2011;54:151–156. MCC 59 59 228 270 <0.001 NR NR NR NR
Park JS, Choi GS, Lim KH, et al. S052: a comparison of robot-assisted, laparoscopic, and open surgery in the treatment of rectal cancer. Surg Endosc . 2011;25:240–248. CCS 123 52 – – – 4.9% 7.7% 0.331
Kim JY, Kim NK, Lee KY, et al. A comparative study of voiding and sexual function after total mesorectal excision with autonomic nerve preservation for rectal cancer: laparoscopic versus robotic surgery. Ann Surg Oncol . 2012;19:2485–2493. CCS 39 30 – – – NR NR NR NR
Kang J, Yoon KJ, Min BS, et al. The impact of robotic surgery for mid and low rectal cancer: a case-matched analysis of a 3-arm comparison—open, laparoscopic, and robotic surgery. Ann Surg . 2013;257:95–101. MCC 165 165 277 309 <0.001 13.5 ± 9.2 10.8 ± 5.5 <0.001 NR NR
Park SY, Choi GS, Park JS, et al. Short-term clinical outcome of robot-assisted intersphincteric resection for low rectal cancer: a retrospective comparison with conventional laparoscopy. Surg Endosc . 2013;27:48–55. CCS 40 40 185 236 0.001 11.3 ± 3.6 10.6 ± 4.2 NS 2.5% 5.0% 1.0
D’Annibale A, Pernazza G, Monsellato I, et al. Total mesorectal excision: a comparison of oncological and functional outcomes between robotic and laparoscopic surgery for rectal cancer. Surg Endosc . 2013;27:1887–1895. CCS 50 50 280 270 <0.001 10 (8–14) 8 (7.11) 0.034 NR NR
Barnajian M, Pettet D, 3rd, Kazi E, et al. Quality of total mesorectal excision and depth of circumferential resection margin in rectal cancer: a matched comparison of the first 20 robotic cases. Colorectal Dis . 2014;16:603–609. MCC 20 20 180 240 0.066 7 (5–36) 6 (4–31) NS NR NR
Tam MS, Abbass M, Abbas MA. Robotic-laparoscopic rectal cancer excision versus traditional laparoscopy. JSLS . 2014;18:e2014.00020. CCS 21 21 240 260 0.04 5 (3–14) 6 (4–23) 0.05 NR NR
Cho MS, Baek SJ, Hur H, et al. Short and long-term outcomes of robotic versus laparoscopic total mesorectal excision for rectal cancer: a case-matched retrospective study. Medicine (Baltimore) . 2015;94:e522. MCC 278 278 272 362 <0.001 10.7 ± 6.6 10.4 ± 5.6 NS 12.2% 12.2% 1.0
Melich G, Hong YK, Kim J, et al. Simultaneous development of laparoscopy and robotics provides acceptable perioperative outcomes and shows robotics to have a faster learning curve and to be overall faster in rectal cancer surgery: analysis of novice MIS surgeon learning curves. Surg Endosc . 2015;29:558–568. CCS 106 92 262 285 9.9 (8.5–11.3) 9.6 (8.3–11.0) 4.7% 6.5%
Serin KR, Gultekin FA, Batman B, et al. Robotic versus laparoscopic surgery for mid or low rectal cancer in male patients after neoadjuvant chemoradiation therapy: comparison of short-term outcomes. J Robot Surg . 2015;9:187–194. CCS 65 14 140 182 5 (4–10) 6 (2–32) NS NR NR
Allemann P, Duvoisin C, Di Mare L, et al. Robotic-assisted surgery improves the quality of total mesorectal excision for rectal cancer compared to laparoscopy: results of a case-controlled analysis. World J Surg . 2016;40:1010–1016. MCC 40 20 313 291 <0.001 NR NR 22.5% 20.0% 0.38
Kim YS, Kim MJ, Park SC, et al. Robotic versus laparoscopic surgery for rectal cancer after preoperative chemoradiotherapy: case-matched study of short-term outcomes. Cancer Res Treat . 2016;48:225–231. MCC 66 33 277 441 13.1 ± 12.8 10.9 ± 6.2 NS NR NR
Kim JC, Yu CS, Lim SB, et al. Comparative analysis focusing on surgical and early oncological outcomes of open, laparoscopy-assisted, and robot-assisted approaches in rectal cancer patients. Int J Colorectal Dis . 2016;31:1179–1187. CCS 486 553 205 441 <0.001 10.9 ± 6.2 13.1 ± 12.8 3.0% 3.0%
Feroci F, Vannucchi A, Bianchi PP, et al. Total mesorectal excision for mid and low rectal cancer: laparoscopic vs robotic surgery. World J Gastroenterol . 2016;22:3602–3610. CCS 58 53 192 342 <0.001 8 (5–53) 6 (3–17) <0.001 17.2% 7.5% 0.297
Ramji KM, Cleghorn MC, Josse JM, et al. Comparison of clinical and economic outcomes between robotic, laparoscopic, and open rectal cancer surgery: early experience at a tertiary care center. Surg Endosc . 2016;30:1337–1343. CCS 27 26 240 407 NS 11.3 ± 13.7 7 ± 3.4 NS 0.0% 12.0% 0.11
Shiomi A, Kinugasa Y, Yamaguchi T, et al. Robot-assisted versus laparoscopic surgery for lower rectal cancer: the impact of visceral obesity on surgical outcomes. Int J Colorectal Dis . 2016;31:1701–1710. CCS 109 127 237 236 8.0 (6–44) 7.0 (6–29) <0.001 6.4% 3.1% 0.19
Yamaguchi T, Kinugasa Y, Shiomi A, et al. Robotic-assisted vs. conventional laparoscopic surgery for rectal cancer: short-term outcomes at a single center. Surg Today . 2016;46:957–962. CCS 239 203 227 233 NS 9.3 ± 6.7 7.3 ± 2.3 <0.001 NR NR
Colombo PE, Bertrand MM, Alline M, et al. Robotic versus laparoscopic total mesorectal excision (TME) for sphincter-saving surgery: is there any difference in the transanal TME rectal approach?: a single-center series of 120 consecutive patients. Ann Surg Oncol . 2016;23:1594–1600. CCS 60 60 228 274 0.005 11 (6–60) 12 (6–27) NS 20.0% 28.3% 0.246
Bedirli A, Salman B, Yuksel O. Robotic versus laparoscopic resection for mid and low rectal cancers. JSLS . 2016;20. CCS 28 35 208 252 0.027 5.1 ± 3.7 4.6 ± 2.8 >0.05 NR NR
Silva-Velazco J, Dietz DW, Stocchi L, et al. Considering value in rectal cancer surgery: an analysis of costs and outcomes based on the open, laparoscopic, and robotic approach for proctectomy. Ann Surg . 2017;265:960–968. CCS 118 66 239 288 <0.001 6 (3–33) 5 (2–28) NR NR
Lim DR, Bae SU, Hur H, et al. Long-term oncological outcomes of robotic versus laparoscopic total mesorectal excision of mid-low rectal cancer following neoadjuvant chemoradiation therapy. Surg Endosc . 2017;31:1728–1737. CCS 64 74 312 364 0.033 NR NR NR NR
Kim J, Baek SJ, Kang DW, et al. Robotic resection is a good prognostic factor in rectal cancer compared with laparoscopic resection: long-term survival analysis using propensity score matching. Dis Colon Rectum . 2017;60:266–273. CCS 460 272 234 288 <0.001 14.4 ± 19.2 13.2 ± 13.5 NS NR NR
MCC 224 224 250 285 <0.002 13.8 ± 10.9 13.5 ± 14.1 NS NR NR
Law WL, Foo DCC. Comparison of short-term and oncologic outcomes of robotic and laparoscopic resection for mid- and distal rectal cancer. Surg Endosc 2017;31:2798–2807. CCS 171 220 225 260 <0.003 6 (2–83) 6 (2–64) NS NR NR
Kim MJ, Park SC, Park JW, et al. Robot-assisted versus laparoscopic surgery for rectal cancer: a phase II open label prospective randomized controlled trial. Ann Surg . 2018;267:243–251. RCT 82 83 228 339 <0.001 10.8 (7.4) 10.3 (3.4) NS 5.4% 9.4% 0.227
Valverde A, Goasguen N, Oberlin O, et al. Robotic versus laparoscopic rectal resection for sphincter-saving surgery: pathological and short-term outcomes in a single-center analysis of 130 consecutive patients. Surg Endosc . 2017;31:4085–4091. CCS 65 65 226 215 NS 12 ± 10 11 ± 8 NS 15.0% 23.0% 0.26
Harslof S, Stouge A, Thomassen N, et al. Outcome one year after robot-assisted rectal cancer surgery: a consecutive cohort study. Int J Colorectal Dis . 2017;32:1749–1758. CCS 141 208 NR NR 7 (2–61) NR
Jayne D, Pigazzi A, Marshall H, et al. Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: the ROLARR Randomized Clinical Trial. JAMA . 2017;318:1569–1580. RCT 234 237 261 298 8.2 ± 6.0 8.0 ± 5.9 NR NR

Outcomes (Cont.)
Study Conversion rate (%) Completeness of TME (%) Positive circumferential margin (%) Harvested lymph nodes
laTME rTME P Value laTME rTME P Value laTME rTME P Value laTME rTME P Value
Baik SH, Ko YT, Kang CM, et al. Robotic tumor-specific mesorectal excision of rectal cancer: short-term outcome of a pilot randomized trial. Surg Endosc . 2008;22:1601–1608. 11.1% 0.0% NS 72.2% 94.4% NS NR NR 18 (6–49) 22 (9–42) NS
Patriti A, Ceccarelli G, Bartoli A, et al. Short- and medium-term outcome of robot-assisted and traditional laparoscopic rectal resection. JSLS . 2009;13:176–183. 18.9% 0.0% NS NR NR 0.0% 0.0% 10.3 ± 4 11.2 ± 5 >0.05
Park JS, Choi GS, Lim KH, et al. Robotic-assisted versus laparoscopic surgery for low rectal cancer: case-matched analysis of short-term outcomes. Ann Surg Oncol . 2010;17:3195–3202. 0.0% 0.0% NS 94.4% 76.5% NS NR NR 20.0 ± 9.1 17.4 ± 10.6 NS
Bianchi PP, Ceriani C, Locatelli A, et al. Robotic versus laparoscopic total mesorectal excision for rectal cancer: a comparative analysis of oncological safety and short-term outcomes. Surg Endosc . 2010;24:2888–2894. 4.0% 0.0% NR NR 4.0% 0.0% NS 18 17 NS
Baek JH, Pastor C, Pigazzi A. Robotic and laparoscopic total mesorectal excision for rectal cancer: a case-matched study. Surg Endosc . 2011;25:521–525. 22.0% 7.3% NS NR NR 4.9% 2.4% NS 13.1 (3–33) 16.2 (5–39) NS
Kwak JM, Kim SH, Kim J, et al. Robotic vs laparoscopic resection of rectal cancer: short-term outcomes of a case-control study. Dis Colon Rectum . 2011;54:151–156. 3.4% 0.0% NS NR NR 0.0% 1.7% NS 20 (12–27) 21 (14–28) NS
Park JS, Choi GS, Lim KH, et al. S052: a comparison of robot-assisted, laparoscopic, and open surgery in the treatment of rectal cancer. Surg Endosc . 2011;25:240–248. 0.0% 0.0% NR NR 2.4% 1.9% NS 19.4 ± 10.2 15.9 ± 10.1 NS
Kim JY, Kim NK, Lee KY, et al. A comparative study of voiding and sexual function after total mesorectal excision with autonomic nerve preservation for rectal cancer: laparoscopic versus robotic surgery. Ann Surg Oncol . 2012;19:2485–2493. NR NR 94.9% 96.5% NS 2.5% 6.0% NS –
Kang J, Yoon KJ, Min BS, et al. The impact of robotic surgery for mid and low rectal cancer: a case-matched analysis of a 3-arm comparison—open, laparoscopic, and robotic surgery. Ann Surg . 2013;257:95–101. 1.8% 0.6% NS NR NR 6.7% 4.2% NS 15.0 ± 9.4 15.6 ± 9.1 NS
Park SY, Choi GS, Park JS, et al. Short-term clinical outcome of robot-assisted intersphincteric resection for low rectal cancer: a retrospective comparison with conventional laparoscopy. Surg Endosc . 2013;27:48–55. 0.0% 0.0% NS NR NR 5.0% 7.5% NS 12.9 ± 7.5 13.3 ± 8.6 NS
D’Annibale A, Pernazza G, Monsellato I, et al. Total mesorectal excision: a comparison of oncological and functional outcomes between robotic and laparoscopic surgery for rectal cancer. Surg Endosc . 2013;27:1887–1895. 12.0% 0.0% 0.011 NR NR 12.0% 0.0% 0.022 16.5 ± 7.1 13.8 ± 6.7 NS
Barnajian M, Pettet D, 3rd, Kazi E, et al. Quality of total mesorectal excision and depth of circumferential resection margin in rectal cancer: a matched comparison of the first 20 robotic cases. Colorectal Dis . 2014;16:603–609. 10.0% 0.0% NS 95.0% 80.0% NS NR NR 14 (3–22) 11 (4–18) NS
Tam MS, Abbass M, Abbas MA. Robotic-laparoscopic rectal cancer excision versus traditional laparoscopy. JSLS . 2014;18:e2014.00020. 0.0% 5.0% NS NR NR 5.0% 0.0% NS 17 (8–40) 15 (8–21) 0.03
Cho MS, Baek SJ, Hur H, et al. Short and long-term outcomes of robotic versus laparoscopic total mesorectal excision for rectal cancer: a case-matched retrospective study. Medicine (Baltimore) . 2015;94:e522. 0.7% 0.4% NS NR NR 4.7% 5,0% NS 15 ± 8 16± 8 NS
Melich G, Hong YK, Kim J, et al. Simultaneous development of laparoscopy and robotics provides acceptable perioperative outcomes and shows robotics to have a faster learning curve and to be overall faster in rectal cancer surgery: analysis of novice MIS surgeon learning curves. Surg Endosc . 2015;29:558–568. 3.8% 1.1% NR NR 2.8% 3.3% 17 (15–20) 16 (14–18)
Serin KR, Gultekin FA, Batman B, et al. Robotic versus laparoscopic surgery for mid or low rectal cancer in male patients after neoadjuvant chemoradiation therapy: comparison of short-term outcomes. J Robot Surg . 2015;9:187–194. 3.0% 0.0% 80.0% 100.0% NS NR NR 32 (17–56) 23 (4–67) 0.008
Allemann P, Duvoisin C, Di Mare L, et al. Robotic-assisted surgery improves the quality of total mesorectal excision for rectal cancer compared to laparoscopy: results of a case-controlled analysis. World J Surg . 2016;40:1010–1016. 20.0% 5.0% NS 55.0% 95.0% 0.0003 25.0% 10.0% NS 24 ± 14 20 ± 7 NS
Kim YS, Kim MJ, Park SC, et al. Robotic versus laparoscopic surgery for rectal cancer after preoperative chemoradiotherapy: case-matched study of short-term outcomes. Cancer Res Treat . 2016;48:225–231. 0.0% 6.1% NS 91.0% 97.0% NS 6.7% 16.1% NS 22.3 ± 11.7 21.6 ± 11.0 NS
Kim JC, Yu CS, Lim SB, et al. Comparative analysis focusing on surgical and early oncological outcomes of open, laparoscopy-assisted, and robot-assisted approaches in rectal cancer patients. Int J Colorectal Dis . 2016;31:1179–1187. 0.0% 6.1% NR NR 1.1% 1.5% NS 23.2 ± 10 20.9 ± 8.5 <0.001
Feroci F, Vannucchi A, Bianchi PP, et al. Total mesorectal excision for mid and low rectal cancer: laparoscopic vs robotic surgery. World J Gastroenterol . 2016;22:3602–3610. 1.7% 3.8% NS NR NR 1.7% 1.9% NS 18 (4–49) 11 (3–27) <0.001
Ramji KM, Cleghorn MC, Josse JM, et al. Comparison of clinical and economic outcomes between robotic, laparoscopic, and open rectal cancer surgery: early experience at a tertiary care center. Surg Endosc . 2016;30:1337–1343. 37.0% 12.0% NS 44.0% 60.0% NS 0.0% 0.0% 16.7 ± 6.8 16.8 ± 7.7 NS
Shiomi A, Kinugasa Y, Yamaguchi T, et al. Robot-assisted versus laparoscopic surgery for lower rectal cancer: the impact of visceral obesity on surgical outcomes. Int J Colorectal Dis . 2016;31:1701–1710. 0.9% 0.0% NS NR NR 0.9% 0.0% NS 26.0 (11–60) 26.0 (7–63) NS
Yamaguchi T, Kinugasa Y, Shiomi A, et al. Robotic-assisted vs. conventional laparoscopic surgery for rectal cancer: short-term outcomes at a single center. Surg Today . 2016;46:957–962. 3.3% 0.0% 0.009 NR NR NR NR 30.0 ± 10.3 29.3 ± 11.8 NS
Colombo PE, Bertrand MM, Alline M, et al. Robotic versus laparoscopic total mesorectal excision (TME) for sphincter-saving surgery: is there any difference in the transanal TME rectal approach?: a single-center series of 120 consecutive patients. Ann Surg Oncol . 2016;23:1594–1600. 4.8% 3.2% NS 90.0% 93.3% NS 90.0% 93.3% NS 15 (6–71) 19 (6–68) NS
Bedirli A, Salman B, Yuksel O. Robotic versus laparoscopic resection for mid and low rectal cancers. JSLS. 2016;20. NR NR NR NR 3.6% 2.9% >0.05 27 ± 11 23 ± 8 NS
Silva-Velazco J, Dietz DW, Stocchi L, et al. Considering value in rectal cancer surgery: an analysis of costs and outcomes based on the open, laparoscopic, and robotic approach for proctectomy. Ann Surg . 2017;265:960–968. 15.4% 9.1% NS 90.4% 89.4% NS 3.4% 7.6% NS 22 (7–106) 24 (3–129) NS
Lim DR, Bae SU, Hur H, et al. Long-term oncological outcomes of robotic versus laparoscopic total mesorectal excision of mid-low rectal cancer following neoadjuvant chemoradiation therapy. Surg Endosc . 2017;31:1728–1737. 6.4% 1.4% NS 98.4% 95.9% NS 1.6% 4.0% NS 11.6 ± 6.9 14.7 ± 6.5 NS
Kim J, Baek SJ, Kang DW, et al. Robotic resection is a good prognostic factor in rectal cancer compared with laparoscopic resection: long-term survival analysis using propensity score matching. Dis Colon Rectum . 2017;60:266–273. 0.9% 0.0% NS NR NR 3.5% 5.5% NS 19.7 ± 12.3 21.7 ± 14.3 0.049
0.9% 0.0% NR NR 4.9% 4.0% NS 20.2 ± 12.1 21.0 ± 14.4 NS
Law WL, Foo DCC. Comparison of short-term and oncologic outcomes of robotic and laparoscopic resection for mid- and distal rectal cancer. Surg Endosc . 2017;31:2798–2807. 3.5% 0.8% NS NR NR 8.2% 4.1% NS 12 14 0.002
Kim MJ, Park SC, Park JW, et al. Robot-assisted versus laparoscopic surgery for rectal cancer: a phase II Open Label prospective randomized controlled trial. Ann Surg . 2018;267:243–251. 0.0% 1.5% NS 78.1% 80.3% NS 5.5% 6.1% NS 18 (7–59) 15 (4–40)
Valverde A, Goasguen N, Oberlin O, et al. Robotic versus laparoscopic rectal resection for sphincter-saving surgery: pathological and short-term outcomes in a single-center analysis of 130 consecutive patients. Surg Endosc . 2017;31:4085–4091. 17.0% 5.0% 0.044 82.0% 88.0% NS 89.0% 6.0% NS 17 ± 9 19 ± 10
Harslof S, Stouge A, Thomassen N, et al. Outcome one year after robot-assisted rectal cancer surgery: a consecutive cohort study. Int J Colorectal Dis . 2017;32:1749–1758. 21.0% 31.0% 0.06 NR NR 7.0% 20 (6–47)
Jayne D, Pigazzi A, Marshall H, et al. Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: the ROLARR Randomized Clinical Trial. JAMA . 2017;318:1569–1580. 12.2% 8.1% NS 77.6% 76.4% NS 6.3% 5.1% NS 24.1 ± 12.9 23.2 ± 12.0

CCS , Case control study; CD III–V , Clavien-Dindo III–V class surgical complications; laTME , laparoscopic total mesorectal excision; MCC , matched case control; NR , not reported; NS , nonsignificant; RCT , randomized controlled trial; RT , retrospective trial; rTME , robotic total mesorectal excision.

∗ No significant difference was observed between laTME and rTME regarding gender and body mass index.

Table 16.2
Selected results from studies comparing robotic versus open pancreaticoduodenectomy.
Study Study Design Approach Number Of Cases Operation Time (Min) Estimated blood loss (mL) length-of-stay (days) Complications (Major) Mortality
Baker EH, Ross SW, Seshadri R, et al. Robotic pancreaticoduodenectomy: comparison of complications and cost to the open approach. Int J Med Robot . 2016;12:554–560. Retrospective
Cohort		 RPD
OPD		 22
49		 454 (294–529)
364 (213–948)
P = 0.035		 425 (50–2200)
650 (150–6100)
P = 0.42		 7 (4–25)
9 (5–48)
NS		 40.7% (13.6%)
67.4% (20.4%)
P = 0.036 ∗
NS		 0
4.1%
NS
Zureikat AH, Postlewait LM, Liu Y, et al. A multi-institutional comparison of perioperative outcomes of robotic and open pancreaticoduodenectomy. Ann Surg . 2016;264:640–649. Retrospective
Comparative		 RPD
OPD		 211
817		 402 (257–685)
300 (107–840)
P < 0.001		 200 (30–4500)
300 (20–7350)
P < 0.001		 8 (4–58)
8 (4–148)
NS		 NA (23.7%) †
NA (23.9%)
NS		 1.9%
2.82%
NS
Boggi U, Napoli N, Costa F, et al. Robotic-assisted pancreatic resections. World J Surg . 2016;40:2497–2506. Retrospective RPD
OPD		 83
36		 527 ± 166
425.3 ± 93
P < 0.0001		 NA
NA		 17 (14–26)
14 (13–28)
P = 0.06		 74% (18.1%)
78% (11.2%)
NS		 1.2%
0
NS
Chen S, Chen JZ, Zhan Q, et al. Robot-assisted laparoscopic versus open pancreaticoduodenectomy: a prospective, matched, mid-term follow-up study. Surg Endosc . 2015;29:3698–3711. NR
Prospective		 2010–2012
RPD
OPD
2013
RPD
OPD		 40
80
20
40		 445 ± 88
322 ± 73
P < 0.001
340 ± 98
324 ± 92
NS		 500 (310–738)
500 (400–800)
NS
200 (100–450)
500 (300–700)
P = 0.002		 All RPD
20 ± 7.4
All OPD
25 ± 11.2
P = 0.002		 All RPD
35% (11.7%)
All OPD
40% (13.3%)
NS		 All RPD
1.7%
All OPD
2.5%
NS
Bao PQ, Mazirka PO, Watkins KT. Retrospective comparison of robot-assisted minimally invasive versus open pancreaticoduodenectomy for periampullary neoplasms. J Gastrointest Surg . 2014;18:682–689. Retrospective RPD
OPD		 28
28		 431 (340–628)
410 (190–621)
P = 0.038		 100 (50–300)
300 (100–800)
P = 0.0001		 7.4(5.5–17.1)
8.1 (6.5–15.3)
NS		 NS
Grade B/C PF
SSI		 7%
7%
NS
Lai EC, Yang GP, Tang CN. Robot-assisted laparoscopic pancreaticoduodenectomy versus open pancreaticoduodenectomy—a comparative study. Int J Surg. 2012;10:475–479. Retrospective RPD
OPD		 20
67		 719 ± 186
265 ± 64
P = 0.01		 247 (50–889)
774 (50–8000)
P = 0.03		 13.7 ± 6.1
25.8 ± 23
P = 0.02		 50%
49%
NS		 0
3%
NS
Chalikonda S, Aguilar-Saavedra JR, Walsh RM. Laparoscopic robotic-assisted pancreaticoduodenectomy: a case-matched comparison with open resection. Surg Endosc . 2012;26:2397–2402. Prospective RPD
OPD		 30
30		 476
366
P = 0.0005		 485
775
NS		 9.8
13.3
P = 0.043		 30%
43%
NS		 4%
0
NS
Zhou NX, Chen JZ, Liu Q, et al. Outcomes of pancreatoduodenectomy with robotic surgery versus open surgery. Int J Med Robot . 2011;7:131–137. Retrospective
Case-matched		 RPD
OPD		 8
8		 719 ± 187
420 ± 127
P = 0.011		 154 ± 43
210 ± 53
P = 0.045		 16.4 ± 4.1
24 ± 7
P = 0.04		 25%
75%
P = 0.05		 0
12.5%
P = 0.05
Buchs NC, Addeo P, Bianco FM, et al. Robotic versus open pancreaticoduodenectomy: a comparative study at a single institution. World J Surg . 2011;35:2739–2746. Retrospective
Comparative		 RPD
OPD		 44
39		 444 ± 93.5
559 ± 135
P = 0.0001		 387 ± 334
827 ± 439
P = 0.0001		 13 ± 17.5
14.6 ± 9.5
NS		 36.4%
48.7%
NS		 4.5%
2.6%
NS
NA , Not available; NR , not reported; NS , nonsignificant; OPD , open pancreaticoduodenectomy; PF , pancreatic fistula; RPD , robotic pancreaticoduodenectomy; SSI , surgical site infection.

∗ No difference in delayed gastric emptying, marginal ulcers, pancreatic fistula, anastomotic leak, urinary tract infection, deep vein thrombosis, pulmonary emboli, pneumonia, sepsis; difference seen mostly due to surgical site infections: 26.5% versus 0 ( P = 0.007). Study found statistical increase in Grade B/C pancreatic fistula rates in RPD: 13.7% versus 9.1% ( P = 0.04).

Table 16.3
Results of comparative studies on robotic versus laparoscopic and open distal pancreatectomy.
Study Study Design Number Of Patients Body Mass Index Indications % PDAC/PNET/IPMN/MC Operation Time (Min) estimated blood loss (ml) Spleen Preservation Conversion Rate Length-of-stay (days) Fistula (grade b–c) Major morbidity and mortality
Waters JA, Canal DF, Wiebke EA, et al. Robotic distal pancreatectomy: cost effective? Surgery. 2010;148:814–823. Retro
Robot
Lap
Open		 17
18
22		 NA 0/29/35/18
11/28/11/17
50/18/18/9		 298
224
234
P = 0.01		 279
667
681
P = 0.17		 65
28
14
P = 0.04		 12∗
11
–
NS		 4
6
8
P = 0.0.4		 NA 18/0
33/0
18/0
P = 0.4
Kang CM, Choi SH, Hwang HK, et al. Minimally invasive (laparoscopic and robot-assisted) approach for solid pseudopapillary tumor of the distal pancreas: a single-center experience. J Hepatobiliary Pancreat Sci . 2011;18:87–93. Retro 20
25		 24.2
23.4		 0/15/10/25
0/12/40/8		 349
258
P = 0.024		 372
420
NS		 95
64
P = 0.27		 NA 7.1
7.3
NS		 NA 18/0
16/0
NS
Daouadi M, Zureikat AH, Zenati MS, et al. Robot-assisted minimally invasive distal pancreatectomy is superior to the laparoscopic technique. Ann Surg . 2013;257:128–132. Retro 30
94		 27.9
29.0		 43/27/17/13
15/22/12/31		 293
372
P = 0.01		 150
150
NS		 0
16
P < 0.05		 6
7		 26
17
NS		 20
14
NS
Duran H, Ielpo B, Caruso R, et al. Does robotic distal pancreatectomy surgery offer similar results as laparoscopic and open approach? A comparative study from a single medical center. Int J Med Robot . 2014;10:280–285. Retro
Robot
Lap
Open		 16
18
13		 NA 56/25/12/0
44/27/0/0
46/30/15/0		 315
250
366
NS		 NA 13
12

NS

 13
27
–
NS		 8
19.1
20.4
P = 0.035		 0
11
15
NS		 0
44
8
P = 0.014
Butturini G, Damoli I, Crepaz L, et al. A prospective non-randomised single-center study comparing laparoscopic and robotic distal pancreatectomy. Surg Endosc. 2015;29:3163–3170. PNRCT 22
21		 25.3
24.2		 14/4/0/3
10/4/0/3		 265
195		 NA 27
19
P = 0.78		 4.5
4.9
P = 0.84		 7
7
P = 0.84		 3
4
P = 0.61
Lee SY, Allen PJ, Sadot E, et al. Distal pancreatectomy: a single institution’s experience in open, laparoscopic, and robotic approaches. J Am Coll Surg . 2015;220:18–27. Retro 37
131
637		 28.7
28.2
28.4		 11/21/11/16
15/31/14/12
39/23/6/4
P < 0.05		 213
193
185
P < 0.05		 193
262
596
P < 0.05		 8
22
14
P = 0.02		 38
31
–		 5
5
7
P = 0.16		 8
8
12
P = 0.45		 43/0
33/0
35/0.6
P = 0.26
Chen S, Zhan Q, Chen JZ, et al. Robotic approach improves spleen-preserving rate and shortens postoperative hospital stay of laparoscopic distal pancreatectomy: a matched cohort study. Surg Endosc . 2015;29:3507–3518. PNRCT 69
50		 24.6
24.6		 23 (Malignant)
23 (Malignant)		 200
150
P < 0.001		 100
290
P < 0.001		 45/47
13/33
P < 0.001		 0
6
P = 0.072		 14.7
12.9
P = 0.023		 32
24.6
P = 0.376		 10/0
9/0
P = 0.808
Lai EC, Tang CN. Robotic distal pancreatectomy versus conventional laparoscopic distal pancreatectomy: a comparative study for short-term outcomes. Front Med . 2015;9:356–360. Retro 17
18		 23.5
11.1		 65
78		 221.4
173.6
P = 0.026		 100.3
268.3
P = 0.290		 52.9
38.9
P = 0.505		 NA 14
11
P = 0.46		 35
28
P = 0.73		 39/0
47/0
P = 73
IPMN , Intraductal papillary mucinous neoplasm; Lap , laparoscopy; MCN , mucinous cystic neoplasm; NA , not available; NS , nonsignificant; PDAC , pancreas ductal adenocarcinoma; PNET , pancreatic neuro endocrine tumor; PNRCT , prospective nonrandomized clinical trial; Retro , retrospective.

Table 16.4
Results of the comparative studies evaluating robotic versus laparoscopic liver resections.
Variables presented with standard deviations are mean numbers; variables presented with ranges are median numbers.
Study Study Type Approach Resection type Number Of Cases Tumor Size (cm) Malignant/Benign Operation Time (Min) Estimated Blood Loss (ml) Length-of-stay (days) Complications (major) Conversion
Berber E, Akyildiz HY, Aucejo F, et al. Robotic versus laparoscopic resection of liver tumours. HPB (Oxford) . 2010;12:583–586. Retro
Comp		 RLR
LLR		 Minor 9
23		 3.2 ± 1.3
2.9 ± 1.3		 9/0
23/0		 259 ± 28
234 ± 16		 136 ± 61
155 ± 54		 NA
NA		 1 (NA)
4 (NA)		 1
0
Ji WB, Wang HG, Zhao ZM, et al. Robotic-assisted laparoscopic anatomic hepatectomy in China: initial experience. Ann Surg . 2011;253:342–348. Retro
CC		 RLR
LLR		 Major & minor 13
20		 6.4 (1.8–12)
NA		 8/5
NA		 338 ± 167
130 ± 43		 NA
NA		 NA 1 (0)
2 (0)		 0
2
Wu YM, Hu RH, Lai HS, et al. Robotic-assisted minimally invasive liver resection. Asian J Surg . 2014;37:53–57. Retro
Comp		 RLR
LLR		 Major & minor 38
41		 6.3 ± 1.7
2.5 ± 1.6		 38/0
41/0		 380 ± 166
227 ± 80		 325 ± 480
173 ± 165		 7.9 ± 4.7
7.2 ± 4.4		 3 (NA)
4 (NA)		 2
5
Yu YD, Kim KH, Jung DH, et al. Robotic versus laparoscopic liver resection: a comparative study from a single center. Langenbecks Arch Surg . 2014;399:1039–1045. Retro
Comp		 RLR
LLR		 Major & minor 13
17		 3.1 ± 1.6
3.5 ± 1.8		 10/3
5/12		 241 ± 69
292 ± 85		 389 ± 65
343 ± 85		 7.8 ± 2.3
9.5 ± 3.0		 0 (NA)
2 (NA)		 0
0
Tsung A, Geller DA, Sukato DC, et al. Robotic versus laparoscopic hepatectomy: a matched comparison. Ann Surg . 2014;259:549–555. Retro
CC		 RLR
LLR		 Major & minor 57
114		 3.2 (2.1–5.0)
3.5 (2.0–6.0)		 26/10
54/18		 253 ± 44
199 ± 21		 200 ± 77
100 ± 50		 4.1 ± 0.6
4.0 ± 0.3		 11 (1)
29 (1)		 4
10
Tranchart H, Ceribelli C, Ferretti S, et al. Traditional versus robot-assisted full laparoscopic liver resection: a matched-pair comparative study. World J Surg . 2014;38:2904–2909. Retro
Comp		 RLR
LLR		 Minor 28
28		 3.5 (0.6–11.5)
4.0 (0.6–13.0)		 13/15
11/17		 236 ± 109
197 ± 98		 562 ± 589
331 ± 323		 7.0 ± 3.5
15.5 ± 12.3		 5 (3)
6 (3)		 4
2
Spampinato MG, Coratti A, Bianco L, et al. Perioperative outcomes of laparoscopic and robot-assisted major hepatectomies: an Italian multi-institutional comparative study. Surg Endosc 28:2973–2979. Retro
Comp		 RLR
LLR		 Major 25
25		 NA
NA		 NA
NA		 456 ± 121
375 ± 105		 625 ± 450
513 ± 288		 10.5 ± 4.5
10.2 ± 4.3		 4 (1)
9 (3)		 1
1
Montalti R, Scuderi V, Patriti A, et al. Robotic versus laparoscopic resections of posterosuperior segments of the liver: a propensity score-matched comparison. Surg Endosc . 2016;30:1004–1013. Retro
CC		 RLR
LLR		 Minor 36
72		 4.4 ± 3.1
5.0 ± 3.5		 NA
NA		 306 ± 182
295 ± 107		 415 ± 414
437 ± 523		 6.0 ± 2.9
4.9 ± 3.0		 13 (4)
16 (5)		 6
7
Lee KF, Cheung YS, Chong CC, et al. Laparoscopic and robotic hepatectomy: experience from a single centre. ANZ J Surg . 2016;86:122–126. Retro
Comp		 RLR
LLR		 Major & minor 70
66		 2.5 (0.6–9.0)
2.5 (1.0–12.0)		 56/16
57/9		 305 ± 131
260 ± 78		 675 ± 625
453 ± 401		 8.5 ± 5.0
6.8 ± 3.3		 8 (NA)
3 (NA)		 4
8
Kim JK, Park JS, Han DH, et al. Robotic versus laparoscopic left lateral sectionectomy of liver. Surg Endosc. 2016;30:4756–4764. Retro
Comp		 RLR
LLR		 Minor 12
31		 2.3 (2.0–3.6)
2.4 (1.7–3.0)		 7/5
24/7		 404 ± 139
246 ± 101		 225 ± 43
150 ± 94		 7.3 ± 1.1
6.8 ± 0.8		 3 (2)
6 (3)		 NA
NA
Lai EC, Tang CN. Long-term survival analysis of robotic versus conventional laparoscopic hepatectomy for hepatocellular carcinoma: a comparative study. Surg Laparosc Endosc Percutan Tech . 2016;26:162–166. Retro
Comp		 RLR
LLR		 Major & minor 100
35		 3.3 ± 1.9
2.7 ± 1.3		 100/0
35/0		 207 ± 77
134 ± 42		 335 ± 583
335 ± 583		 7.3 ± 5.3
7.1 ± 2.6		 14 (NA)
7 (NA)		 4
2
Croner RS, Perrakis A, Hohenberger W, et al. Robotic liver surgery for minor hepatic resections: a comparison with laparoscopic and open standard procedures. Langenbecks Arch Surg. 2016;401:707–714. Retro
CC		 RLR
LLR		 Minor 10
19		 4.8 (2.9–10.5)
4.1 (1.8–8.5)		 10/0
15/4		 321 ± 93
242 ± 93		 NA
NA		 NA
NA		 5 (0)
6 (0)		 NA
NA
Magistri P, Tarantino G, Guidetti C, et al. Laparoscopic versus robotic surgery for hepatocellular carcinoma: the first 46 consecutive cases. J Surg Res . 2017;217:92–99. Retro
Comp		 RLR
LLR		 Major & minor 22
24		 3.4 ± 1.4
2.7 ± 1.1		 22/0
24/0		 318 ± 114
211 ± 78		 588 ± 432
464 ± 293		 5.1 ± 2.4
6.2 ± 2.6		 15 (2)
24 (3)		 0
4
Fruscione M, Pickens R, Baker EH, et al. Robotic-assisted versus laparoscopic major liver resection: analysis of outcomes from a single center. HPB (Oxford) . 2019;21:906–911. Retro
Comp		 RLR
LLR		 Major 57
116		 NA
NA		 37/22
54/62		 194 (152–255)
204 (149–280)
P = 0.189		 250 (125–255)
400 (150–750)
P = 0.129		 4 (3–5)
5 (3–6)
P = 0.136		 16 (4)
41 (11)
P = 0.339		 NA
NA
CC , Case control; LLR , laparoscopic liver resection; NA , not available; Retro Comp , retrospective comparative; RLR , robotic liver resection.

Not surprisingly, the perceived technical advantages of the robotic system experienced by the surgeon have yet to be fully documented by data. It is clear that the robotic approach for many operations produce equivalent results to laparoscopic procedures perfected over decades of surgical development. However, clear superiority for a robotic approach over laparoscopic techniques has been difficult to demonstrate by traditional parameters. In coming years, it is likely that the ease of adaption, the shorter learning curve, and the ergonomic superiority will emerge as the inducements for entering the robotic surgery field. It is also expected that cost of robotic surgery and laparoscopic surgery will become similar. This will result from both an increased cost of laparoscopic procedures as technologies are developed in advanced MIS and robotic surgery becomes adopted and a decrease in robotic surgery cost accompanying additional robotic entries into the surgical market. As the field of robotic surgery matures with optimization of surgeon integration of robotic technology into clinical practice and with evolution of the technology that continues to enhance the surgeon’s operative performance and the cost of robotic surgery decreases, the benefits of robotic surgery may be redefined.

In this textbook’s first robotic surgery chapter, we present an overview of robotic surgery by covering the history of robotics in surgery, familiarizing the reader with results of the studies describing the advantages and disadvantages of the robotic approach, offering insight into safe and effective methods of adopting robotic surgery in clinical practice. Who will adopt robotic surgery into their practice and how its adoption will impact the field of surgical robotics and transform MIS depend on how surgeons address these challenges and embrace the opportunities robotics offers to improve outcomes for surgical patients, including the elderly and the frail. ,

History

The concept of robotic surgery is based on teleoperated robots and emerged from its foundations in robotics research funded by the National Aeronautics and Space Administration (NASA) and the Defense Advanced Research Project Administration starting in the 1970s. The initial goal of surgical robotics was to develop a system that would enable remotely controlled surgical procedures and replace patient-side surgeons in dangerous or difficult-to-reach places, such as in the battlefield and in space aircrafts. Its commercial development over the last half century has integrated the advances in robotic engineering, computer programming, and concepts of MIS. Most notable developments in surgical robotics are chronologically represented in Fig. 16.2 .

Fig. 16.2, Important dates in robotic surgery development.

Notably, in 1992, Computer Motion Inc. (Goleta, CA), with a NASA-JPL grant, developed Automated Endoscopic System for Optimal Positioning (AESOP), the first FDA-approved commercial robot that enabled surgeons to command and manipulate a laparoscopic camera during surgical procedures. With the addition of three arms capable of being remotely controlled by the surgeon, the AESOP system was soon developed into the Zeus Robotic Surgical System. Using this new robotic system, a landmark telerobotic surgery was performed in 2002 by Dr. Jacques Marescaux and his team. They successfully performed the first robot-assisted transatlantic cholecystectomy with the surgeon seated at the robotic manipulator located in New York City with the “patient-side” robot-system in Strasburg, France.

The da Vinci Surgical Systems (Intuitive Surgical, Sunnyvale, CA) came to dominate the field in robotic-assisted laparoscopic abdominal operations when Zeus Robotic Surgical System was discontinued after a merger between Computer Motion and Intuitive Surgical in 2003. Since the FDA approved Intuitive Surgical’s da Vinci Standard System in the year 2000, three newer generations of da Vinci Surgical Systems, each with increasingly more sophisticated features, were developed: the S System (2003), the Si System (2009), and the Xi System (2014). Over 4500 da Vinci Robotic Surgical Systems have been installed as of March 2018 with more than 50% of the robotic operations being performed in the United States.

The initial system was intended for cardiac bypass surgery, but it failed to gain acceptance by cardiac surgeons. Urologists popularized the surgical application of the robotic system with robotic prostatectomies that eventually took over 90% of market share of prostatectomies. In urology and gynecology, use of robotics has become standard practice and part of routine practice and training. Recently, robotic surgery adoption in complex abdominal operations is moving at an increased rate with the Xi System, outpacing the rate of laparoscopic application.

The remainder of the chapter covers the understanding and mastery of the robotic surgical platform, namely da Vinci Si and Xi Robotic Systems. We review the clinical outcomes, indications for robotic surgery, selection of patients, and the procedural steps for the following selected robotic operations: robotic radical distal gastrectomy with D2 lymphadenectomy, robotic hepatic posterior segmentectomies, robotic low anterior resection with total mesorectal excision (TME), robotic distal pancreatectomy, and robotic ventral hernia repairs.

Preparing for Robotic Surgery

Preparation and training are key to adopting robotic surgery into clinical practice and becoming a successful robotic surgeon. Before starting any robotic operation, the surgeon should (1) understand the robotic surgical system, its features and function, and optimal instrument selection and their use; (2) establish a safe and efficient robotic operating room; (3) study the necessary steps of the procedure and the specific steps of the robotic approach; and (4) be knowledgeable about the available literature on robotic surgery.

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