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advances in surgical treatment of colon and rectal cancers

S l awomir Marecik, MD, FACS Advocate Lutheran General Hospital, Park Ridge, IL Clinical Assistant Professor University of Illinois, Chicago, USA. advances in surgical treatment of colon and rectal cancers. The advantages of robotic low anterior resection. Robots. Are here to stay

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advances in surgical treatment of colon and rectal cancers

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  1. Slawomir Marecik, MD, FACS Advocate Lutheran General Hospital, Park Ridge, IL Clinical Assistant Professor University of Illinois, Chicago, USA advances in surgical treatment of colon and rectal cancers

  2. The advantages of robotic low anteriorresection

  3. Robots • Are here to stay • One oftheavailable toolsin our armamentarium • Powerful tool • Massive potential

  4. Laparoscopic TME • Technically challenging • Tumor location • Anatomic structures • Difficult retraction • Unstable camera • Poor ergonomics for surgeon UK MRC CLASICC

  5. Advanced lesion Obese, low (male) APR LAPAROSCOPY OPEN

  6. Major Robotic Advantages 1 2 3 Quality Of Dissection Minimally Invasive Comfort For Surgeon

  7. Quality Of Dissection

  8. Laparoscopic n=57 Robotic n=56 Mesorectal Grade Complete 43 Nearly complete 12 Incomplete 2 Mesorectal grade Complete 52 Nearly complete 4 Incomplete 0 Robotic vs. Lap Rectal Dissection Quality Of Dissection p=0.033 Baik SH. Robotic versus laparoscopic low anterior resection of rectal cancer: short-term outcome of prospective comparative study. Ann SurgOncol. 2009

  9. Quality Of Dissection Randomized Studies To Compare Laparoscopic vs. Robotic Resection • Pigazzi, Baek O.7 % CRM 143 pts • Kim 1.6 % CRM 59 pts • Prasad, Marecik 1 % CRM 82 pts • ROLLAR • ACOSOG • Can we reduce preoperative radiation? • Improved urogenital function?

  10. Minimally Invasive Aspect A HybridApproach Is The Most Practical Solution At This Time • The robot is more useful in certain areas • Laparoscopy is more useful in other areas

  11. Comfort For The Surgeon • Laparoscopic TME challenging • Difficulties with advanced disease • An increase in obese patient population

  12. Obesity Trends* Among U.S. AdultsBRFSS,1990, 2000, 2010 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 2000 1990 2010 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

  13. Robotic LAR • randomized data is lacking • ACOSOG, ROLARR pending • difficulties in adoption of Korean experience • BMI • height • splenic flexure mobilization • radiation

  14. DCR 2010

  15. Comparison Robotic vs. Open TME deSouza AL, Prasad LM , Marecik SJ et al. Comparison of Open and Robotic Total Mesorectal Excision for Rectal Adenocarcinoma; Dis Colon Rectum, 2011

  16. Robotic TME Laparoscopy for rectal cancer – conversion rates MRC CLASSIC trial conversion rate – 34% (2005)

  17. Colorectal Dis 2011

  18. APR (abdomino-perineal resections) cylindrical intraabdominallevator transection RILT Robotic CylindricalAbdominoperineal Resection with Intraabdominal LevatorTransection Marecik SJ, Zawadzki M, deSouza AL, Park JJ, Abcarian H, Prasad L Dis Colon Rectum, Oct 2011

  19. Distal pursestring Prasad LM, deSouza AL, Marecik SJ, Park JJ, Abcarian H. Robotic pursestring technique in low anterior resection. Dis Colon Rectum. 2010 Feb;53(2):230-4.

  20. Natural orifice extraction

  21. Robotic LAR ???

  22. Conclusion • Robotic assistance in low anterior resection decreases conversion rates when compared to laparoscopy • Mesorectal quality grade is higher in robotic technique, which may translate into better oncological outcomes • Robotic system allows for a very precise work in deep pelvis making intersphincteric dissection easier, distal pursestring application possible and transanal specimen extraction more common

  23. Conclusion • Robotic assistance has potential to improve outcomes in obese patients and in patients with advanced disease

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