The Use of Robotics in Colorectal Surgery

Minimally invasive techniques have gained popularity in colorectal surgery due to their numerous benefits: shorter length of stay, lower complications, and high-definition visualization. However, increased adoption of laparoscopy in the challenging confines of the narrow pelvis and the need to operate in multiple quadrants was met with steep learning curves and increased conversion rates. Furthermore, recent multicenter randomized controlled trials have cast doubt on the ability of laparoscopic total mesorectal excision to achieve pathologic outcome noninferiority compared to open resection in locally advanced rectal cancers. Robotics mitigates these shortcomings using three-dimensional optics, wrist-like motion, tremor filtering, motion scaling, better ergonomics, and less fatigue. This translates into a lower conversion rate, easier learning curve, and the ability to operate in constricted spaces and in multiple quadrants. We have found these advantages when performing robotic partial colectomy, low anterior resection, total colectomy, abdominoperineal resection, and rectopexy. Robotic-assisted intracorporeal anastomoses are noticeably easier to perform compared to laparoscopic, limiting excessive handing of bowel that leads to ileus and possibly improper orientation. Extraction sites no longer need to be in the midline, which decreases incisional hernia occurrence and patient morbidity. Improved visualization, particularly in the narrow pelvis, helps attain completeness of the mesorectal envelope and decreases the conversion rate. Surgeries are performed using either the da Vinci Xi or Si (Intuitive Surgical Inc., Sunnyvale, California, United States) iterations of the robotic system. The advantages of the newly introduced Xi Surgical System overcome the robotic arm restrictions and difficulty operating in multiple quadrants common with its predecessor. Critics of robotics cite cost as the major deterrent to adopting new technology. However, this can be offset with increased case volume, instrument use optimization, and previously mentioned clinical benefits.