La TME robotica

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La TME robotica a. coratti – m. di marino UO Chirurgia Generale, Grosseto

description

Il trattamento multidisciplinare del cancro del retto Ferrara, 9 ottobre 2012. La TME robotica. a. coratti – m. di marino. UO Chirurgia Generale, Grosseto. Laparoscopic surgery. DRAWBACKS Unnatural movements Poor ergonomics for the surgeon Reduced degrees of freedom - PowerPoint PPT Presentation

Transcript of La TME robotica

Page 1: La TME robotica

La TME robotica

a. coratti – m. di marino

UO Chirurgia Generale, Grosseto

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Laparoscopic surgeryLaparoscopic surgery

ADVANTAGES

•Pain control

•Blood losses negligible

• Immunitary system

•Shorter ileus

•Abdominal wall

•Morbidity

•Post-op stay

DRAWBACKS

• Unnatural movements

• Poor ergonomics for the

surgeon

• Reduced degrees of freedom

• Dissociated visual-

mechanical control

• Bidimensional vision

• Limited sutures

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Robotic surgery

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OVERCOMES LAPAROSCOPIC

PITFALLS

3D / HD vision

Fine dissection

Deep, small operating fields

High precision suturing

Easier setup

Tutoring

Robotic surgeryRobotic surgery

The new system “da Vinci SI HD”

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Robotic surgery

ENDO-WRIST ™ SYSTEM

6 degrees of freedom Tremor elimination

Motion scaling

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Robotic surgery in Grosseto

General Surgery First period 2000 – 2007 732

General Surgery Second period 2007 – 2012 393

Urology/gynecologist

- 2007 – 2012 298

TOTAL2000 – 2012

1423

October 2000 – September 2012

Total series

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Robotic rectal resection Robotic rectal resection

Reported series

Author Year Refer. Pts. Op. time (min)

Conversion

Morbidity Mortality

D’Annibale* 2004 Dis Colon Rectum

53 240 9.4% 15% 0

Hellan 2007 Ann Surg Oncol

39 285 2.6% 12.1% 0

Baik 2008 Surg Endosc

9 220.8 0 0 0

Spinoglio* 2008 Dis Colon Rectum

50 338.8 4% 14% 0

Choi 2009 Surg Endosc

13 260.8 0 23% 0

Luca* 2009 Ann Surg Oncol

55 290 0 12.7% 0

* Including colonic resections

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Casciola (JSLS 2009)

Short- and medium-term outcome of robot-assisted and traditional laparoscopic rectal resection.

Robotic rectal resection Robotic rectal resection

No randomized prospective study – 66 pts

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Intraoperative and pathologic data

Robotic rectal resection Robotic rectal resection

Casciola (JSLS 2009)

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Early and long-term outcomes

Robotic rectal resection Robotic rectal resection

Casciola (JSLS 2009)

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Oncological results

Robotic rectal resection Robotic rectal resection

Casciola (JSLS 2009)

Conclusions

Robot-assisted rectal surgery is a safe and feasible procedure that facilitates

laparoscopic total mesorectal excision.

Local recurrence

ROB: 0LAP: 5.4%(NS)

(NS)

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Pigazzi et Al (Ann Surg Oncol 2010)

Multicentric Study on Robotic Tumor-Specific Mesorectal Excision

for the Treatment of Rectal Cancer.

Robotic rectal resection Robotic rectal resection

Retrospective multicentric study – 143 pts

Procedure 112 RAR, 31APR

Conversion (%) 4.9%

Mean blood loss 283ml

Mean op time 297min

N. harvested nodes 14.1 (± 6.5)

Distal margin 2.9cm (± 1.8)

Negative radial margin 142/143 (99.3%)

3Y survival 97%

Local recurrence 0 (mean follow-up 17.4 months)

Conclusions

Robot-assisted rectal surgery is a safe and feasible procedure that may facilitate

mesorectal excision.

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Perioperative results: 58 pts. (2001-2012)

Procedures LARAPR

Hybrid techniqueFull robotic

4414

3325

Pathology Rectal carcinomaLarge rectal adenomaAnal carcinomaAnal melanoma

51322

Preop CHT/RT 46/58 (79,3%)

Open conversions 1/58 (1.7%)

Operative time 288min (range: 120-420)

Blood loss Negligible NO intraoperative blood transfusions

Ileostomy (LAR) 41/44(93.3%)

Morbidity 9/58 (15,5%)

Redo surgery 5/58 (8,6%) Anastomotic leakage 2, pelvic abscess 1, bowel occlusion 1, postoperative bleeding 1 (VLS redo)

Mortality 0

Mean hospital stay

7.9 days (range: 4-40)

Experience in GrossetoExperience in Grosseto

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Oncological outcomes - Rectal carcinoma

TNM of rectal carcinomas (51 cases)

yT0N0Stage IStage IIStage IIIStage IV

52510101

Retrieved lymph nodes

11.3 (range: 5-30)

Resection margins

R0 in all cases

Mean follow-up 44.2 months (range: <1-118)

Recurrence Local: 0

Port site: 0

Distant MTS: 6/51 (11,7%)

Liver 2, peritoneum 3, inguinal nodes 1

Related cancer mortality

3,9% (2/51)

Experience in GrossetoExperience in Grosseto

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3-Years overall survival (OS)

3-Years disease free survival (DFS)

Long term survival (DFS, OS) - Rectal carcinoma

Experience in GrossetoExperience in Grosseto

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Functional outcomes: 58 pts. (2001-2012)

Urinary dysfunction 1.7% (1/58)

Sexual dysfunction Males: 6.9% (2/29)Total: 5,1% (3/58)

Faecal incontinence(LAR)

5.8% (2/34; 8 pts. are waiting for closure of ileostomy)

Soiling(LAR)

8.8% (3/34; 8 pts. are waiting for closure of ileostomy)

Experience in GrossetoExperience in Grosseto

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Rectal robotic surgery Rectal robotic surgery

Surgical steps Patient positioning

Robotic cartPorts

Full robotic technique

SURGICAL STRATEGY

Hybrid (lap/rob) technique

■ LAPAROSCOPY■ ROBOTIC

■ ROBOTIC

Technical aspects

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Docking 1

. Paziente supino

. Posizione ginecologica

. Arti super. Addotti

. Anti-trendelenburg 30 °

. Ruotato sul fianco destro di 15 °. Carello robotico dalla spalla sinistra

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Docking 2

. Paziente supino

. Posizione ginecologica

. Arti super. Addotti

. Trendelenburg 25 °

. Ruotato sul fianco destro di 15 °. Carello robotico dalla gamba sinistra

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Posizionamento dei trocars

ottica

R 1

R 2

R 3

Ass

Ass

I step II step

ottica

R 2

Ass

R 3

Ass

R 1

minilaparomia

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Posizionamento dei trocars

ottica

R 1

R 2

R 3

Ass

Ass

I step II step

ottica

R 2

Ass

R 3

Ass

R 1

Minilaparotomia

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Personal experiencePersonal experience

Very difficult at the

beginning

Ports positioning

Cart docking

Pelvic exposure

Time consuming

Laparoscopy it’s better?

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Personal experiencePersonal experience

Intermediate experience

Switch from hybrid to full robotic

Changing in port and cart setup

Very difficult at the

beginning

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Personal experiencePersonal experience

Very difficult at the

beginning

Intermediate experience

Advanced experience

Full robotic technique

Starting by pelvic dissection

Ultralow intersphyncteric

dissection

No return to laparoscopy!

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Robot-assisted LAR - I stepRobot-assisted LAR - I step

video

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Robot-assisted LAR – II stepRobot-assisted LAR – II step

video

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ADVANTAGES

Technical aspects

3D/HD vision - Endowrist

TME

Nerves sparing

Intersphynteric dissection

Pelvic dissection (deep, narrow)

Obese patients

Reduction of conversions (?)

Rectal robotic surgery Rectal robotic surgery

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Technical aspects DRAWBACKS

Large operating field

Change of cart/patients positioning

Bowel retraction

Expert assistant surgeon

High cost procedure

Rectal robotic surgery Rectal robotic surgery

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Conclusions Conclusions

Robot-assisted rectal resection are feasible and safe.

The robotic technique may improve TME, nerves sparing and

intersphynteric dissection in ultralow rectal resection.

Major advantages can be appreciated in males, in narrow and

deep pelvis, and in obese patients.

The long-term functional and oncological results are very

interesting.

We are waiting the ROLARR trial.

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Scuola ACOI di Chirurgia RoboticaScuola ACOI di Chirurgia Roboticawww.roboticschool.itwww.roboticschool.it

COURSES 2012

BASICMay, 21-25

1st ADVANCED(Upper GI, HPB, Endocrine)June, 25-29

2nd ADVANCED(Colorectal, HPB, Endocrine)November, 26-30