The American Journal of Surgery 187 (2004) 88 –92
Scientific paper
Robotic assisted rectopexy Yaron Munz, M.D.a,b,*, Krishna Moorthy, M.D.a, Rishma Kudchadkar, M.D.a, Juan David Hernandez, M.D.a, Shirley Martin, R.N.a, Ara Darzi, M.D.a, Timothy Rockall, M.D.a a
Department of Surgical Oncology and Technology, Imperial College School of Science, Technology and Medicine, St. Mary’s Campus, London, United Kingdom b Department of Surgical Oncology and Technology, St. Mary’s Hospital, 10th Floor, QEQM Wing, Pread St., London W2 1NY, United Kingdom Manuscript received June 17, 2002; revised manuscript November 21, 2002
Abstract Background: During the last 3 years, robotic surgery has had a considerable impact on minimally invasive surgery in a wide range of specialties. This study describes the surgical technique and preliminary results of our first 6 cases of robotic assisted suture rectopexy. Methods: During a period of 13 months 6 patients with full thickness rectal prolapse were operated on with the da Vinci surgical system. All patients were considered suitable for a suture rectopexy. Setting-up time, procedure time, patient recovery, and hospital stay were recorded and compared with the current literature. Results: All operations were completed successfully using the robotic system. There were no major complications and no deaths. Mean setting-up time was 28 minutes, mean operation time was 127 minutes, and mean hospital stay was 6 days. At 3 to 6 months of follow-up all patients are in good health, with no signs of recurrence and no reports of constipation. Conclusions: Robotic assisted suture rectopexy is feasible and safe and apparently meets accepted standards of laparoscopic surgery. © 2004 Excerpta Medica, Inc. All rights reserved. Keywords: Suture rectopexy; Laparoscopic; Robotic
Since the introduction of surgical robots almost 4 years ago, this new technology is redefining standards in minimal access surgery, similar to the way minimal access surgery revolutionized open surgery. Surgical robots, ie, telemanipulator systems, now are widely applied in a variety of procedures across all surgical specialties. Though pioneered for cardiothoracic procedures the well-recognized advantages of the system have led to its greater use in general surgery as well as other subspecialties [1– 4]. Features such as tremor elimination, motion scaling and working tips with 7 degrees of freedom together with threedimensional visualization and powerful magnification (⫻10) provide the surgeon both enhanced visual quality and improved dexterity which are unsurpassed in endoscopic surgery. These qualities lead to greatly enhanced dexterity
* Corresponding author. Tel.: ⫹44-2078861310; fax: ⫹44-2074130470. E-mail address:
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especially within confined spaces such as the thoraces and the pelvis [5,6]. Over the years abdominal rectopexy has emerged as a procedure of choice for full thickness rectal prolapse especially where constipation is not the chief complaint [7,8]. The role of abdominal rectopexy has broadened even more with the advent of minimally invasive techniques [9,10]. Even though laparoscopic surgery has been established for over a decade, laparoscopic colorectal procedures have taken longer to evolve as skills required are more advanced and take more time to master. Several studies have shown the benefits of laparoscopic rectopexy over equivalent open procedures in terms of operative time, postoperative pain control, procedure-related complications, hospital stay, and return to daily routine [11]. It is only natural that the advantages offered by the robotic system be integrated with current techniques of laparoscopic surgery.
0002-9610/04/$ – see front matter © 2004 Excerpta Medica, Inc. All rights reserved. doi:10.1016/j.amjsurg.2002.11.001
Y. Munz et al. / The American Journal of Surgery 187 (2004) 88 –92
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Fig. 1. Robotic operating theater. Fig. 3. Fixation of uterus to abdominal wall.
Fig. 5. Dissection, mobilization and fixation. A. Identification of the right ureter. B. Dissection and mobilization on the right side of the rectum. C. Complete dissection of the left side of the rectum. D. Fixation of rectum to sacral promontory.
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Fig. 2. Layout of the robotic system and staff. Fig. 4. Port positioning, laparoscopic and robotic.
With that intent we have applied robotic surgery to patients suffering from full thickness rectal prolapse and describe the surgical technique of nonresection suture rectopexy using the da Vinci robotic system and detail the outcome results of our first 6 patients.
Patients and methods Between February 2001 and February 2002, 6 patients underwent robotic assisted laparoscopic suture rectopexy using the da Vinci surgical system (Intuitive Surgical, Mountain View, California). There were 5 women and 1 man. Mean age was 65 years (range 37 to 87). All patients had a symptomatic full thickness rectal prolapse requiring surgery. Duration of symptoms was in the range of 2 to 12 months prior to the operation. It should be stressed that in this group constipation was not considered a major symptom, thus all patients included in the study were suitable for a suture rectopexy. Informed consent for laparoscopic rectopexy using the da Vinci system was obtained. Preoperational work-up included full colonoscopy (2 patients), barium enema (3 patients), and anal-sphincter manometry (1 patient). Patients received bowel preparation with Kleenprep (Norgine Ltd., Oxford, UK) and deep vein thrombosis prophylaxis with TED stockings and subcutaneous low molecular weight heparin, 20 mg daily. A single dose of broadspectrum antibiotics was administered perioperatively. A urinary catheter and an orogastric tube were sited once patients were anesthetized The robotic system used was the da Vinci surgical system (Fig. 1). It consists of a master unit with the surgeons’ operating console and a slave unit, mounted on a cart, with three arms of which one is used for holding the camera and the other two are manipulator arms with a variety of interchangeable instruments.
Surgical technique The patient is positioned in a modified Lloyd-Davis position, with the legs widely abducted and with minimal hip flexion to accommodate the surgical cart (Fig. 2). Pneumoperitoneum is established using an open technique at the umbilicus and a standard disposable 12-mm port is introduced. A 30-degree scope is used and after initial laparoscopy, the patient is tilted to about a 40-degree head down position. Two assistant ports, 10 mm and 12 mm, are inserted bilaterally half way the distance between the umbilicus and the anterior superior iliac spine, through which standard laparoscopic instruments are introduced for lysis of adhesions, extraction of bowel from the pelvis, and fixation of the uterus to the anterior abdominal wall and sigmoid colon to the left lateral wall (Fig. 3). The surgical cart is then positioned between the patient’s legs and the robotic arms together with the attached 8 mm ports are placed under direct vision bilaterally further down along the umbilicus-anterior superior iliac spine line, to allow free maneuvering of the instruments within the pelvic space (Fig. 4). Using a “Cadiere” type grasper on the left and a hook diathermy on the right, dissection begins on the right side of the rectum. After the ureter is identified (Fig. 5A), the peritoneum is opened allowing the positive CO2 pressure to infiltrate into the retrorectal space. The dissection is continued down to the level of the pelvic floor, all from the right side (Fig. 5B). The pelvic nerves are easily identified during the dissection. The left ureter is identified and the peritoneum is incised medially from the left to enter the dissected space (Fig. 5C). Once the rectum is fully mobilized down to the pelvic floor posterior and laterally the assistant holds the rectum under traction using endo-Babcock graspers through the left assistant port. The right robotic instrument is replaced with a needle holder and the rectum is then fixed to the sacral promontory with 2 nonabsorbable 0 sutures (Surgidac; US Surgical Corps, Norwalk, Connecticut; Fig. 5D).
Y. Munz et al. / The American Journal of Surgery 187 (2004) 88 –92
Once the procedure is completed, the instruments are removed and the port sites are closed in the usual manner.
Results All 6 operations were completed robotically assisted and with no significant blood loss. Mean setting-up time was 28 minutes (range 17 to 41) and mean procedure time (starting as soon as pneumoperitoneum is established and terminating once procedure is completed) was 127 minutes (range 110 to 142). All patients resumed oral feeding within 24 hours and urinary catheters were removed 48 hours (5 patients) to 72 hours (1 patient) postoperatively. First bowel movement was recorded 2 to 4 days postoperatively, and mean hospital-stay was 6 days (range 4 to 8). No major complications were recorded and there was no mortality. At follow-up, 3 to 6 months postoperatively, 5 of the patients were found to be in good health and without any clinical evidence of recurrence of rectal prolapse. Further more, there were no cases of significant postoperative constipation necessitating the use of laxatives. One patient is still suffering from fecal soiling, but is much improved compared with his preoperative state (no postoperative manometry data).
Comments Since November 2000 the da Vinci surgical system has been used in our department for more than 40 procedures including cholecystectomy, Nissen fundoplication, Heller’s cardiomyotomy, internal mammary artery take-down, adrenalectomy, inguinal hernia repair, radical prostatectomy, rectal resection, and suture rectopexy. Inherent features of the da Vinci system including threedimensional visualization system, articulated instrument tips with 7 degrees of freedom, motion scaling, and tremor elimination provide enhanced surgical dexterity. Time needed for skills acquisition is reduced compared with that needed to achieve equivalent laparoscopic skills. However, a learning curve does exist in performing with the system [12]. Once a surgeon has reached the plateau of the learning curve, performing with the system is simple and intuitive, thus enabling the surgeon to carry out more complex procedures in shorter periods of time. Operating this system is not without any difficulties. The first is the preprocedural setting-up process, which is both time consuming and complicated. In this study mean setting-up time was 28 minutes, which is far from ideal and approximately double the setting-up time for conventional laparoscopy. The second disadvantage is intraoperative trouble shooting. Owing to the huge size of the system any surgical or technical difficulty is more complicated to han-
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dle. However, once these issues are addressed by the provision of team training and education it is likely that the system will become efficient and cost effective. It has been already demonstrated that with proper training, set-up time can be significantly reduced to no more then 10 minutes and difficulties encountered during the operation can be dealt with efficiently by skilled team members, ie, surgical residents and operating room nurses thus, increasing overall efficiency [13]. It is clear that at present and in the near future, cost effectiveness issues will be the major factor limiting the wider use of robotic systems. In view of this it is essential to decide which procedures are most likely to benefit from robotically enhanced performance. We believe it is justified to use this system in operations that are carried out within confined spaces where the advantages of the system are clearly appreciable to the surgeon, specifically dexterity enhancement and accuracy. From that perspective suitable procedures may be Nissen’s fundoplication, Heller’s cardiomyotomy, hepatobilliary surgery, and pelvic operations, ie, rectopexy, rectal resection, prostatectomy, and certain gynecological procedures. Thoracoscopic surgery probably has the most to gain, as most common cardiac procedures are not possible using standard thoracoscopic techniques [14,15]. Rectopexy may include sigmoid resection and rectal fixation or just mobilization of the rectum from the pelvis and fixation. There is some evidence that postoperative constipation is more severe in the nonresection group especially where preoperative constipation exists as a major symptom [16,17]. However, where there is no significant preoperative constipation there is a debate as to whether resection improves the outcome [18,19]. This is an important issue as it may dictate the type of approach the surgeon will use. Combining robotic rectal dissection with sigmoid resection and anastomosis requires either a hybrid procedure (standard laparoscopy and robotically enhanced surgery) or repositioning of the robot mid procedure. This is potentially time consuming and adds to the complexity of the procedure. Future developments in robotic technology are likely to resolve this problem. In most studies involving laparoscopic suture rectopexy, mean time taken for the procedure was around 150 minutes, mean hospital stay was usually about 6 or 7 days, and morbidity was in range of 10% to 25%. This was mainly related to continued colonic dysfunction or iatrogenic injury. Mortality was zero in all published series (Table 1). From long-term follow-up it is suggested that constipation is relieved in more than 70% of patients operated on [20 –22]. In this study group morbidity was zero and at 3 to 6 months postoperative follow-up there was no clinical evidence of recurrence and all the patients had a significant improvement in symptoms. When current literature is used to compare the results of our robotic assisted rectopexy study with laparoscopic rectopexy it is clear that standards
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Table 1 Comparison between robotic and laparoscopic suture rectopexy Procedure
Study (author)
Operative time (minutes)
Hospital stay (days)
Morbidity (%)
Mortality (%)
Lap rectopexy Lap rectopexy Lap rectopexy Lap rectopexy Lap rectopexy Robotic rectopexy
Milsom Monson Scheinin Darzi Roberts Rockall
150 (90–300) 96 (50–150) 150 (90–295) 106.5 153 (95–215) 127 (110–142)
5 (2–20) 7 (3–23) 5 (3–15) 5.7 4 (3–6) 6 (4–8)
9 24 24 19 18 0
0 0 0 0 0 0
Lap ⫽ laparoscopic.
were fully achieved in terms of procedure time (mean of 127 minutes), hospital stay, morbidity, and mortality. It should be emphasized that in spite of the small number of patients operated on using the da Vinci system, procedure time was within accepted limits, implying that skills acquisition is facilitated owing to the system’s inherent features. Therefore we conclude that robotic assisted rectopexy is feasible and safe and may be advantageous compared with current techniques. However, patient selection should follow current guidelines used for open surgery in deciding type of procedure to be used. It is essential to add that these are preliminary results and any definitive conclusions would be premature. At present the variety of instruments available for use by the system is still quite limited but the future holds much promise as technology rapidly develops and it is only a matter of time until more improvements are added. These may include additional arms and force feedback mechanisms adding tactile sensation, thus providing full immersion. The systems are also likely to become more compact and less cumbersome. The advantages to the surgeon and potentially to the patient of such a system are great and in the future the surgical community is likely to witness an expansion in the availability and use of robotically enhanced surgery [23,24].
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