An investigation into the feasibility of learning, effectiveness and outcomes of robotic rectal surgery

  • Sofoklis Panteleimonitis

Student thesis: Doctoral Thesis

Abstract

Background
The advantages of laparoscopic colorectal surgery, such as shorter hospital stay and reduced post-operative pain, have led to it becoming the standard of care for colorectal diseases in much of the Western world. However, the limitations of laparoscopic instrumentation such as 2-dimensional imaging, poor ergonomics and straight fixed tip instruments have limited its application in rectal surgery, where accurate dissection in narrow deep cavities is required. Robotic systems were designed to overcome these limitations and are increasingly adopted for rectal resections. Although the feasibility and safety of robotic rectal surgery has been established, it is debated whether the technological advances of robotic surgery offer superior clinical and oncological outcomes. Considering the high costs associated with robotic rectal surgery, its clinical effectiveness needs to be demonstrated. In addition, for colorectal surgeons to adopt robotic rectal surgery it needs to have an acceptable learning curve and there is a need for a training pathway that ensures patient safety. Finally, considering the development of the most advanced robotic platform – the da Vinci Xi – its clinical outcomes for rectal resections require further investigation to establish efficacy.

Aims
The aim of this programme of research is to explore the gaps in the literature regarding the use of robotic surgical systems for rectal surgery and investigate its clinical effectiveness. In particular, the presented research aims to add to the knowledge base by investigating the following topics in robotic rectal surgery: 1) urogenital function, 2) high-risk patient outcomes, 3) learning curves, 4) da Vinci Xi training pathway and new technology assessment. This will be achieved by performing several studies, each specifically designed to address a specific research question.

Methods
Five retrospective observational studies (2.1, 2.2, 3, 4.1, 4.2) were conducted in order to investigate the subjects of research presented in this thesis. In addition, a randomised controlled trial (study 1) has been designed to provide level 1 evidence for the urogenital functional outcomes of robotic versus laparoscopic rectal surgery in male patients.

Results
Six studies investigating the four topics listed in the aims above are included in this programme of research. Study 1 is a randomised control trial investigating the urogenital function of robotic vs laparoscopic rectal surgery patients. This trial, which is in the process of entering the recruitment phase, aims to provide level 1 evidence and establish the urogenital benefits offered by robotic rectal surgery. Studies 2.1 and 2.2 present data that supports the hypothesis that robotic rectal surgery could potentially lead to improved post-operative clinical outcomes compared to laparoscopy when applied in patients that are considered technically challenging. Study 3 found that experienced laparoscopic colorectal surgeons may undergo a short learning process when changing from laparoscopic to robotic rectal surgery and skills attained during laparoscopic rectal resections are transferable to robotic surgery. The final two studies are specific to the da Vinci Xi operating platform. Study 4.1 demonstrated that a structured training programme for robotic rectal resection surgery is feasible, safe and effective. Finally, study 4.2 showed the Xi system can lead to improved clinical and oncological short-term outcomes such as length of stay, lymph node yield and R0 clearance.

Conclusions
The above studies conclude that robotic rectal surgery is a mode of surgery that in the hands of appropriately trained colorectal surgeons may lead to clinical benefits to its patients and is easier to learn than laparoscopic surgery, with previous laparoscopic surgery training shortening the learning process. In addition, with the application of a structured training programme robotic rectal surgery can be taught safely and effectively in a timely manner and the da Vinci Xi offers certain technological advances that might help further improve patient outcomes. The results of this programme of research add to the current evidence base and offer evidence-based recommendations for further research
Date of AwardOct 2018
Original languageEnglish
Awarding Institution
  • University of Portsmouth
SupervisorAmjad Parvaiz (Supervisor) & Mick Harper (Supervisor)

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