Robotic Versus Laparoscopic Stapler Use for Rectal Transection in Robotic Surgery for Cancer

Abstract

Background:

This study was designed to compare the operative and short-term postoperative outcomes of the robotic and laparoscopic staplers in patients undergoing rectal surgery for cancer.

Materials and Methods:

Between December 2014 and April 2017, patients consecutively undergoing robotic rectal surgery for cancer were included in this study. Patients were grouped into two according to the type of staplers for rectal transection [Robotic (45-mm) versus Laparoscopic (60-mm) linear staplers]. Patient demographics, pathologic data, perioperative outcomes, and short-term results were compared.

Results:

One hundred seven patients met our inclusion criteria. The number of male patients were higher in robotic stapler group than in the laparoscopic stapler group (55% versus 76%, P = .03). Age (59 versus 63 years, P = .40), body mass index (27 versus 27 kg/m², P = .60), American Society of Anesthesiologists score (2 versus 2, P = .20), number of prior abdominal operations (31% versus 20%, P = .22) and number of patients having neoadjuvant chemoradiotherapy (34% versus 36%, P = .86) were comparable between the groups. The numbers of cartridges used were similar regardless of the type of staplers (2 versus 2, P = .58). The overall complication was similar between the groups (24% versus 31%, P = .32). Leak rates were 5% (n = 2) and 3% (n = 2) in the robotic and laparoscopic stapler groups, respectively (p = 1). There was no mortality.

Conclusions:

This is the first study evaluating the role of robotic stapler specifically for rectal transection in comparative manner. The use of robotic stapler for rectal transection was safe and feasible in rectal surgery for cancer.

Introduction

Distal transection of the rectum is one of the key steps in surgery for sigmoid or rectal cancer. There is no standardized approach for rectal stump closure in laparoscopic or robotic surgery. Several methods are described for laparoscopic rectal transections such as hand-assisted,¹ open,² and intracorporeal transections with roticulating^3,4 or linear staplers.^3,5,6 Before the introduction of the robotic stapler, rectal transections were performed with relatively hybrid methods, including laparoscopic double^7,8 and single-stapling techniques.^9,10 Recent introduction of the robotic stapler (EndoWrist 45, Intuitive Surgical, Inc.) has enabled surgeons to perform totally robotic approach for rectal cancer. However, data regarding the role of robotic staple use on the outcomes of robotic surgery are limited.¹¹

In this study, we aimed to compare the operative and short-term postoperative outcomes of the robotic and laparoscopic staplers in patients undergoing rectal surgery for cancer.

Materials and Methods

This study was approved by the Institutional Review Board. Between December 2014 and February 2017, the medical records of patients consecutively undergoing robotic anterior/low anterior resection for rectosigmoid and rectal cancer were reviewed. All cases were performed with the da Vinci Xi surgical platform (Intuitive Surgical, Inc., Sunnyvale, CA). Patients with benign diseases and having concurrent operations and abdominoperineal resections were excluded. Data were obtained from our prospectively maintained database.¹² Demographics, American Society of Anesthesiologists (ASA) physical status classification, body mass index (BMI), history of abdominal operations, reasons for conversion, duration of operation, estimated blood loss, postoperative morbidity and mortality during the same hospital stay or within 30-days (short-term) after surgery, histopathological results, time to first flatus, and length of hospital stay were recorded.

Rectal transections were performed with either robotic (EndoWrist 45-mm, stapler, Intuitive Surgical, Inc.) or laparoscopic (60 mm Endopath Echelon, Ethicon or 60 mm Endo GIA Roticulator, Covidien) linear staplers. Whether robotic or laparoscopic, we utilized only “green” cartridges. The stapler height of the robotic “green” cartridge is 4.3 mm. On the contrary, laparoscopic “green” cartridges have 4.1 and 4.8 mm heights, respectively. Patients were grouped into two according to the type of stapler used for rectal transection (Robotic stapler versus laparoscopic stapler). The decision for stapler type was usually made at the discretion of the individual surgeon.

Definitions, patient preparation, and follow-up

The overall morbidity rate was calculated by considering the number of patients who had at least one postoperative complication. The definition of conversion to open surgery was the use of any incision performed for anything other than either specimen extraction or port placement. Undocking the robotic platform and continuing surgery with laparoscopic instruments was considered as conversion to laparoscopy.

Anastomotic leak was defined as the occurrence of a break in the integrity of the anastomosis as documented by the combination of clinical, radiologic, and operative means.¹³

Postoperative ileus was defined as no return of bowel function within 7 days of operation.¹⁴

Patients who had cT3 to T4 or any cN1 cancer were treated by neoadjuvant chemoradiotherapy. Patients received a mechanical bowel preparation, venous thrombosis, and antibiotic prophylaxis preoperatively. Patients were asked to ambulate and to perform breathing exercises since the evening of the surgery day and offered oral liquid intake. Discharge criteria were tolerance of food with documented bowel or stoma function without nausea and vomiting, good pain control with oral analgesia, and autonomous ambulation.

Surgical technique

The patient was placed in Lloyd-Davies position. After insertion of four 8-mm robotic trocars and one 5-mm assistant trocar, abdominal cavity was explored. Then, a Trendelenburg position with slight right tilt was given to the patient. Following, the peritoneum was incised at the sacral promontorium and preserving the ureters, gonadal vessels, and autonomic nerves dissection continued in the embryological plane in a medial-to-lateral manner. After identification of the inferior mesenteric artery, ligation was performed at its origin. Then, high division of the inferior mesenteric vein at the lower edge of the pancreas followed. While staying in the mesofascial plane, left mesocolon was dissected off the Toldt's fascia. Next, dissection of the splenocolic and gastrocolic ligaments mobilized the splenic flexure. A total or partial mesorectal excision was performed accordingly, depending on the location of the cancer.

Our technique for mesorectal excision was described previously.¹⁵ For transection of the rectum, the third 8-mm robotic trocar was replaced with a 12-mm robotic or a laparoscopic trocar providing entrance for the linear stapler. The rectal transection was performed intracorporeally with either a 45-mm robotic or a 60-mm laparoscopic linear stapler. Specimen was extracted through a 6–8-cm suprapubic incision. Following extracorporeal division of the colon proximally, anvil of a circular stapler was placed to the proximal end of the colon and secured with a purse-string suture. A colorectal anastomosis was completed with a transanally inserted circular stapler. A diverting ileostomy and drains were utilized based on surgeon's decision during surgery.

Histopathological examination of the mesorectal fascia was evaluated according to a standardized procedure described by Quirke et al.¹⁶

Statistical analysis

Continuous variables were described as mean ± standard deviation except otherwise mentioned. Categorical variables were described as n (%). Categorical variables were compared using the Pearson chi-square test or Fisher's exact test, and continuous variables were compared with Mann-Whitney U test. A “P” value of <.05 was considered as significant. Statistical analyses were performed using Epi Info™ software.

Results

In total, 107 patients met our inclusion criteria (Table 1). Robotic stapler was utilized in 45 and laparoscopic stapler in 62 patients. The only statistical difference observed between the groups was gender distribution (P = .03). Males were predominant in the robotic stapler group (76% versus 55%). There was no statistically significant difference in age (P = .63), BMI (P = .55), or ASA score (P = .20). Regarding prior abdominal surgeries (P = .22) and proportion of the patients with neoadjuvant chemoradiotherapy (P = .86) the groups were comparable. The groups were similar regarding the number of stapler fires per patient (P = .58).

Table 1.

Comparison of Patient Characteristics, Operative Outcomes

	Robotic stapler group (n = 45)	Laparoscopic stapler group (n = 62)	P
Gender, Female, n (%)	11 (24)	28 (45)	.03
Age (year), mean ± SD	63 ± 9	59 ± 11	.40
BMI, (kg/m²), mean ± SD	27 ± 4	27 ± 4	.60
ASA score, median (range)	2 (1–3)	2 (1–4)	.20
Prior abdominal operation, n (%)	9 (20)	19 (31)	.22
NCRT, n (%)	16 (36)	21 (34)	.86
Operative time (minutes), mean ± SD	307 ± 106	320 ± 128	.90
Blood loss (mL), mean ± SD	90 ± 50	130 ± 80	.50
Stapler firings, n, mean ± SD	2 ± 1	2 ± 1	.58
Anastomosis level (cm), mean ± SD	7 ± 6	9 ± 7	.19
Conversion, n (%)	0	2 (3)	.51
Flatus (day), mean ± SD	2 ± 1	2 ± 1	.42
LOS (day), mean ± SD	6 ± 3	6 ± 3	.53
Stoma, n (%)	20 (44)	29 (47)	.81

Continuous variables are described as mean ± SD (standard deviation); categorical variables are described as n (%).

Statistical significance is emphasized in bold.

BMI, body mass index; ASA, American Society of Anesthesiologists; NCRT, neoadjuvant chemoradiotherapy; LOS, length of hospital stay; SD, standard deviation.

A total of 63 patients (31 robotic and 32 laparoscopic stapler patients) with mid and low rectal tumors had total mesorectal excision (TME). Among those, only one patient in the laparoscopic stapler group had incomplete TME.

While two (3%) patients in the laparoscopic stapler group were converted to open, there were no conversions in the robotic stapler group (P = .52). The reason for conversion was an aortic injury and tumor invasion of the bladder in 2 patients. The aortic injury was suture repaired. For bladder invasion, the suprapubic incision was extended and resection was completed with partial bladder resection.

In laparoscopic stapler group, two patients had positive distal resection margins in the frozen examination. In these patients, the resection was advanced distally and the colorectal anastomosis was constructed after achievement of negative distal margins. Before anastomosis, for low lying rectal tumors, we routinely perform a frozen section for assessment of the distal resection margin.

There was no difference in the length of hospital stay (P = .48) between the groups.

The overall and intraoperative complications were similar between the groups (Table 2). In the robotic stapler group, one bladder injury occurred during creation of the suprapubic incision and was repaired primarily.

Table 2.

Complications

	Robotic stapler group (n = 45)	Laparoscopic stapler group (n = 62)	P
Overall complications, n (%)	14 (31)	14 (24)	.32
Intraoperative complications, n (%)	1 (2)	1 (2)	1
Pulmonary embolism	1 (2)	1 (2)	1
Superficial SSI (wound infection)	1 (2)	3 (5)	.64
Deep SSI (pelvic abscess)	2 (5)	2 (3)	1
Acute renal failure	1 (2)	1 (2)	1
Anastomotic leak	2 (5)	2 (3)	1
Enterocutaneous fistula	1 (2)	0	.42
Ileus	10 (24)	7 (11)	.13
Urinary infection	0	1	1

Categorical variables are described as n (%).

SSI, surgical site infection.

Both groups had two leaks each (P = 1). Two of the patients with anastomotic leak underwent laparoscopic loop ileostomy: one at postoperative day four and the other at postoperative day 12. The other two anastomotic leaks were treated nonoperatively.

No statistically significant difference was found between the groups in terms of pathologic outcomes (Table 3). When a subanalysis was performed for T stages, the distribution of T3–T4 tumors was still comparable between the groups.

Table 3.

Pathologic Results

	Robotic stapler group (n = 45)	Laparoscopic stapler group (n = 62)	P
Distal resection margin (cm), mean ± SD	3.8 ± 2.2	3.4 ± 1.9	.28
Tumor size (cm), mean ± SD	4.2 ± 2.1	4.5 ± 1.8	.53
≤1-mm radial margin involvement, n (%)	2 (5)	5 (8)	.70
LN harvested, mean ± SD	26.5 ± 12.3	28 ± 13.4	1
Incomplete mesorectal excision^a, n	0	1	1
pT stage			.81
0–2	17	22
3–4	28	40
pTNM stage, n (%)			.26
0/I	11 (24)	17 (27)
II	20 (44)	20 (32)
III	13 (29)	24 (39)
IV	1 (2)	1 (2)

Continuous variables are described as mean ± SD; categorical variables are described as n (%).

Assessed according to Quirke's criteria.¹⁶

LN, lymph node; SD, standard deviation.

There was no mortality in either of the groups.

Discussion

This is the first study evaluating the role of robotic stapler specifically for rectal transection in a comparative manner. Creation of a durable rectal stump is an important component of a double-stapling colorectal anastomosis. Due to its potential short- and long-term unfavorable effects, anastomotic leakage is one of the most feared complications in rectal surgery. Despite the improved surgical technology and experience of operating surgeons the incidence of anastomotic leakage after robotic rectal cancer surgery was reported up to 12%.⁷ Risk of local recurrence can be high in patients who had an anastomotic leakage.^17,18 Jung et al.¹⁹ reported poor overall survival in patients with a history of anastomotic leakage after curative surgery for cancer. Major risk factors associated with colorectal anastomotic leakage are increased age, male sex, low-lying anastomosis, neoadjuvant chemoradiation, perioperative transfusion, and use of more than three cartridges.^{3,5,8,17,19,20}

The results of this study revealed that the robotic stapler provided comparable outcomes with its laparoscopic counterpart, despite greater number of male patients in the robotic stapler group. The inherent morphologic obstacles of the male pelvis could complicate the laparoscopic rectal transection due to a narrow space and limited traction manipulation. Furthermore, rectal transection in patients with low-lying rectal tumors could be extra challenging.²¹ These factors might cause oblique positioning of the stapler and subsequent requirement of multiple stapler firings.²⁰

Elongating the stapling line, most probably due to inadequate cutting angle within narrow pelvic cavity was found to be associated with anastomotic leak.^5,8 Since the level of anastomosis was comparable between the groups, the greater number of male patients in the robotic stapler group can be considered as a potential adversity. Since the robot provides precise control and stable retraction, use of robotic stapler in the same setting may facilitate safer and more precise transection at any rectal level.

Robotic stapler has some potential advantages. These are console surgeon initiated control, wider range of motion of the stapler arm, and SmartClamp feedback. Console surgeon can easily place the stapler with the help of high-definition 3D view. Due to limited angling capability of the laparoscopic linear staplers, rectal transection can be difficult, especially in patients with low-lying rectal tumors.²² In addition, due to its wider range of motion (up to 90°), a more perpendicular line of transection across the distal rectum could be achieved with the robotic arm and this may, in turn, require fewer stapler firings.

In this study, the numbers of cartridges used were similar between the study groups, although the sizes of the staplers were different. This observation may favor the use of robotic stapler for rectal transection.

The rationale to use a 60-mm laparoscopic stapler for rectal transection was based on our early experience. We had used 45-mm staplers in our initial laparoscopy practice dating back to early 2000s. However, we had needed to use more than three cartridges in some cases to complete the rectal transection. Our observation was also supported by prior studies reporting the need for three or more cartridges for rectal transection with 30- or 45-mm linear laparoscopic staplers.²³ The use of ≥3 cartridges for rectal transection was reported to be associated with anastomotic leakage after laparoscopic low anterior resection.^3,8,20,22 Since multiple stapling was also associated with an irregular staple line, we changed our stapler length to 60-mm. Furthermore, the higher number of stapler firings seems to result from the tissue slippage between the laparoscopic stapler jaws.²⁴ This issue can be overcome by the robotic stapler, which has a security mechanism (SmartClamp feedback). Robotic stapler could not be fired when there is an incomplete clamping.²⁵

The pathologic outcomes, including resection margins, harvested lymph nodes and disease stages were comparable between the study groups. This shows that we could apply the basic principles of oncologic surgery regardless of the type of stapling instruments.

Our study had some inherent limitations due to its retrospective nature. In addition, another limitation might be the difference in the lengths of the laparoscopic and robotic staplers. The first study on robotic stapler use in the field of colorectal surgery was published by Holzmacher et al.¹¹ In their study, the patient population was heterogeneous in terms of types of colorectal diseases and operations performed. Corresponding to this, we aimed to assess the role of the robotic stapler in a relatively homogenous patient cohort.

In conclusion, the use of robotic stapler for rectal transection seems to be safe and feasible in the setting of rectal surgery for cancer and is a further step to achieve a pure robotic rectal surgery.

Footnotes

Disclosure Statement

No competing financial interests exist.

References

Pietrabissa

, Moretto

, Carobbi

, et al. Hand-assisted laparoscopic low anterior resection: Initial experience with a new procedure. Surg Endosc, 2002; 16:431–435.

Kuroyanagi

, Oya

, Ueno

, et al. Standardized technique of laparoscopic intracorporeal rectal transection and anastomosis for low anterior resection. Surg Endosc, 2008; 22:557–561.

Ito

, Sugito

, Kobayashi

, et al. Relationship between multiple numbers of stapler firings during rectal division and anastomotic leakage after laparoscopic rectal resection. Int J Colorectal Dis, 2008; 23:703–707.

Ishii

, Hasegawa

, Nishibori

, et al. The application of a new stapling device for open surgery (Contour Curved Cutter Stapler) in the laparoscopic resection of rectal cancer. Surg Endosc, 2006; 20:1329–1331.

Leroy

, Jamali

, Forbes

, et al. Laparoscopic total mesorectal excision (TME) for rectal cancer surgery: Long-term outcomes. Surg Endosc, 2004; 18:281–289.

Fukunaga

, Higashino

, Tanimura

, et al. New technique for rectal division in laparoscopic anterior resection—with video. World J Surg, 2008; 32:2095–2100.

Bertani

, Chiappa

, Biffi

, et al. Assessing appropriateness for elective colorectal cancer surgery: Clinical, oncological, and quality-of-life short-term outcomes employing different treatment approaches. Int J Colorectal Dis, 2011; 26:1317–1327.

Kim

, Cho

, Min

, et al. Risk factors for anastomotic leakage after laparoscopic intracorporeal colorectal anastomosis with a double stapling technique. J Am Coll Surg, 2009; 209:694–701.

Zimmern

, Prasad

, Desouza

, et al. Robotic colon and rectal surgery: A series of 131 cases. World J Surg, 2010; 34:1954–1958.

10.

Prasad

, deSouza

, Marecik

, et al. Robotic pursestring technique in low anterior resection. Dis Colon Rectum, 2010; 53:230–234.

11.

Holzmacher

, Luka

, Aziz

, et al. The use of robotic and laparoscopic surgical stapling devices during minimally invasive colon and rectal surgery: A comparison. J Laparoendosc Adv Surg Tech A, 2017; 27:151–155.

12.

Harris

, Taylor

, Thielke

, et al. Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform, 2009; 42:377–381.

13.

Eberhardt

, Kiran

, Lavery

. The impact of anastomotic leak and intra-abdominal abscess on cancer-related outcomes after resection for colorectal cancer: A case control study. Dis Colon Rectum, 2009; 52:380–386.

14.

Moghadamyeghaneh

, Hwang

, Hanna

, et al. Risk factors for prolonged ileus following colon surgery. Surg Endosc, 2016; 30:603–609.

15.

Karahasanoglu

, Hamzaoglu

, Baca

, et al. Robotic surgery for rectal cancer: Initial experience from 30 consecutive patients. J Gastrointest Surg, 2012; 16:401–407.

16.

Quirke

, Durdey

, Dixon

, et al. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision. Lancet, 1986; 2:996–999.

17.

Bell

, Walker

, Rickard

, et al. Anastomotic leakage after curative anterior resection results in a higher prevalence of local recurrence. Br J Surg, 2003; 90:1261–1266.

18.

Petersen

, Freitag

, Hellmich

, et al. Anastomotic leakage: Impact on local recurrence and survival in surgery of colorectal cancer. Int J Colorectal Dis, 1998; 13:160–163.

19.

Jung

, Yu

, Choi

, et al. Risk factors and oncologic impact of anastomotic leakage after rectal cancer surgery. Dis Colon Rectum, 2008; 51:902–908.

20.

Park

, Choi

, Kim

, et al. Multicenter analysis of risk factors for anastomotic leakage after laparoscopic rectal cancer excision: The Korean laparoscopic colorectal surgery study group. Ann Surg, 2013; 257:665–671.

21.

Akiyoshi

, Kuroyanagi

, Oya

, et al. Factors affecting the difficulty of laparoscopic total mesorectal excision with double stapling technique anastomosis for low rectal cancer. Surgery, 2009; 146:483–489.

22.

Kawada

, Hasegawa

, Hida

, et al. Risk factors for anastomotic leakage after laparoscopic low anterior resection with DST anastomosis. Surg Endosc, 2014; 28:2988–2995.

23.

Pigazzi

, Luca

, Patriti

, et al. Multicentric study on robotic tumor-specific mesorectal excision for the treatment of rectal cancer. Ann Surg Oncol, 2010; 17:1614–1620.

24.

Park

, Choi

, Lee

, et al. Endo-satinsky clamp for rectal transection during laparoscopic total mesorectal excision. Dis Colon Rectum, 2010; 53:355–359.

25.

Kwak

, Kim

. Robotic surgery for rectal cancer: An update in 2015. Cancer Res Treat, 2016; 48:427–435.