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La TME robotica

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

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La TME robotica

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  1. Il trattamento multidisciplinare del cancro del retto Ferrara, 9 ottobre 2012 La TME robotica a. coratti – m. di marino UO Chirurgia Generale, Grosseto

  2. Laparoscopic surgery • DRAWBACKS • Unnatural movements • Poor ergonomics for the surgeon • Reduced degrees of freedom • Dissociated visual-mechanical • control • Bidimensional vision • Limited sutures • ADVANTAGES • Pain control • Blood losses negligible • Immunitary system • Shorter ileus • Abdominal wall • Morbidity • Post-op stay

  3. Robotic surgery

  4. Robotic surgery The new system “da Vinci SI HD” OVERCOMES LAPAROSCOPIC PITFALLS • 3D / HD vision • Fine dissection • Deep, small operating fields • High precision suturing • Easier setup • Tutoring

  5. Robotic surgery • ENDO-WRIST ™ SYSTEM • 6 degrees of freedom • Tremor elimination • Motion scaling

  6. Robotic surgery in Grosseto October 2000 – September 2012 Total series

  7. Robotic rectal resection Reported series * Includingcolonicresections

  8. Robotic rectal resection No randomized prospective study – 66 pts Casciola (JSLS 2009) Short- and medium-term outcome of robot-assisted and traditional laparoscopic rectal resection.

  9. Robotic rectal resection Casciola (JSLS 2009) Intraoperative and pathologic data

  10. Robotic rectal resection Casciola (JSLS 2009) Early and long-term outcomes

  11. Robotic rectal resection Casciola (JSLS 2009) Oncological results Local recurrence ROB: 0 LAP: 5.4% (NS) (NS) Conclusions Robot-assistedrectalsurgeryis a safe and feasible procedure thatfacilitateslaparoscopictotalmesorectalexcision.

  12. Robotic rectal resection Retrospective multicentric study – 143 pts Pigazzi et Al (Ann Surg Oncol 2010) Multicentric Study on Robotic Tumor-Specific Mesorectal Excision for the Treatment of Rectal Cancer. Conclusions Robot-assisted rectal surgery is a safe and feasible procedure that may facilitate mesorectal excision.

  13. Experience in Grosseto Perioperativeresults: 58 pts. (2001-2012)

  14. Experience in Grosseto Oncologicaloutcomes - Rectal carcinoma

  15. Experience in Grosseto Long termsurvival (DFS, OS) -Rectal carcinoma 3-Years overall survival (OS) 3-Years disease free survival (DFS)

  16. Experience in Grosseto Functionaloutcomes: 58 pts. (2001-2012)

  17. Rectal robotic surgery Technical aspects SURGICAL STRATEGY Full robotic technique Hybrid (lap/rob) technique Surgical steps Patient positioning Robotic cart Ports ■ ROBOTIC ■ LAPAROSCOPY ■ ROBOTIC

  18. Docking 1 . Paziente supino . Posizione ginecologica . Arti super. Addotti . Anti-trendelenburg 30 ° . Ruotato sul fianco destro di 15 ° . Carello robotico dalla spalla sinistra

  19. Docking 2 . Paziente supino . Posizione ginecologica . Arti super. Addotti . Trendelenburg 25 ° . Ruotato sul fianco destro di 15 ° . Carello robotico dalla gamba sinistra

  20. Posizionamento dei trocars I step II step ottica ottica R 1 R 2 Ass R 2 R 3 R 3 Ass Ass Ass R 1 minilaparomia

  21. Posizionamento dei trocars I step II step ottica ottica R 1 R 2 Ass R 2 R 3 R 3 Ass Ass Ass R 1 Minilaparotomia

  22. Personal experience Very difficult at the beginning • Ports positioning • Cart docking • Pelvic exposure • Time consuming • Laparoscopy it’s better?

  23. Personal experience Very difficult at the beginning Intermediate experience • Switch from hybrid to full robotic • Changing in port and cart setup

  24. Personal experience Very difficult at the beginning Intermediate experience Advanced experience • Full robotic technique • Starting by pelvic dissection • Ultralow intersphyncteric dissection • No return to laparoscopy!

  25. Robot-assisted LAR - I step video

  26. Robot-assisted LAR – II step video

  27. Rectalroboticsurgery Technical aspects ADVANTAGES • 3D/HD vision - Endowrist • TME • Nervessparing • Intersphyntericdissection • Pelvicdissection (deep, narrow) • Obese patients • Reduction of conversions (?)

  28. Rectalroboticsurgery Technical aspects DRAWBACKS • Large operating field • Change of cart/patients positioning • Bowel retraction • Expert assistant surgeon • High cost procedure

  29. Conclusions • Robot-assistedrectalresection are feasible and safe. • The robotictechniquemayimprove TME, nervessparing and intersphyntericdissection in ultralowrectalresection. • Major advantages can be appreciated in males, in narrow and deeppelvis, and in obese patients. • The long-termfunctional and oncologicalresults are veryinteresting. • We are waiting the ROLARR trial.

  30. Scuola ACOI di Chirurgia Robotica www.roboticschool.it COURSES 2012 BASIC May, 21-25 1st ADVANCED (Upper GI, HPB, Endocrine) June, 25-29 2nd ADVANCED (Colorectal, HPB, Endocrine) November, 26-30

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