Up until now, the removal of bowel tumors in the lesser pelvis (rectal cancers) involved a major, generally invasive operation. This operation can now be done in a much gentler way using an innovative procedure, robotic surgery. Thanks to a better three-dimensional view of the operating area and robotic instruments that allow highly accurate surgery to be performed in the anatomically constricted space of the lesser pelvis, surgical trauma and incisions for the operation can be kept to a minimum, while, at the same time, achieving excellent surgical results. The robotic colorectal surgery programme at the Comprehensive Cancer Center (CCC) of MedUni Vienna and Vienna General Hospital has been certified by the European Academy of Robotic Colorectal Surgery (EARCS) since the beginning of the year. This makes the CCC in Vienna General Hospital the first centre for robotic colorectal surgery in Austria.
Every year, around 1,100 people in Austria develop rectal cancer, one third of these being diagnosed with a low-lying tumor, that is to say a tumor situated right at the end of the colon. This location represents a particular challenge for surgeons, since the tumors are technically difficult to access and, because of the anatomically constricted space in the lesser pelvis, the view of the operating area is restricted. On top of this, the surrounding neuroplexus in this region is very dense and very sensitive and any nerve damage can easily result in incontinence or loss of sexual function.
Up until now, rectal tumors were mostly removed using open surgery, that is to say by performing a major operation. This is very onerous for patients because of the size of the wound. For a few years now, it has also been possible to perform the operation via keyhole surgery (laparoscopy). However, since this procedure is very difficult in view of the anatomical situation, it is only used to operate on less than 30% of all rectal cancer patients. In addition, the conversion rate, that is to say the need to switch from keyhole surgery to open surgery during the operation, is very high for the laparoscopic technique. In turn, this conversion is associated with a higher complication rate.
The latest step in the development of minimally invasive colorectal surgery is the robot-assisted method. In the robotic method, the surgeon controls a 4-armed surgical robot from a console, while receiving an enlarged, 3D image of the operating area. The optimal visibility conditions and mobility of the robotic arms in 7 different degrees of freedom provide a highly accurate and nerve-conserving operating technique, which entails even less blood loss than laparoscopy. Moreover, studies show that the method is easier to learn than the conventional laparoscopic procedure and also has ergonomic advantages for surgeons. Robotic surgery offers clear advantages over open or laparoscopic surgery, especially in constricted spaces such as the lesser pelvis and is already being successfully used in urology for removing the prostate gland. It is also being increasingly used in the field of gynaecology.
The two experts in robotic colorectal surgery at the CCC, Thomas Bachleitner-Hofmann and Michael Bergmann (Department of Surgery of MedUni Vienna/Vienna General Hospital, Head: Michael Gnant), estimate that it will be used to perform around 90% of all rectal surgeries in future.
Quality Assurance via surgeon certification
In order to ensure uniform standards of treatment and hence to further improve patient safety, the European Academy of Robotic Colorectal Surgery (EARCS, Homepage: www.earcs.pt) is providing special training courses to comprehensively train surgeons in the use of the new method. So far only around 25 doctors in Europe are trained and certified. Bachleitner-Hofmann and Bergmann are the first two Austrian surgeons to be certified. Says Bachleitner-Hofmann: “Especially in specialist centres, robotic surgery should be the standard procedure for removing a colorectal tumor, since it has clear advantages over the other methods, particularly for low-lying rectal cancers. We are proud to be to the first centre in Austria to have obtained certification to perform robotic colorectal surgery.”
CCC will continue to monitor and evaluate the procedure. It therefore plans to conduct a study (fatigue study) to evaluate the benefits of robotic surgery over the two conventional procedures in terms of surgeon fatigue. Certain parameters will be used to compare physical fitness and the ability to concentrate before and after the different operating procedures. Says Bergmann: “As an academic institution, comprehensive scientific validation of the new method is important to us. Our impression is that the fatigue factor is significantly less for the surgeon when he/she uses the robot. This is presumably due to the better ergonomics of the robotic method. We also want to establish this scientifically. It has already been demonstrated on many occasions that adequately rested doctors contribute to increased patient safety. That would then be an added advantage of this technique.”