LETTER TO EDITOR
|Year : 2015 | Volume
| Issue : 4 | Page : 285-286
Robotic surgery: A step forward in the wide spread of minimally invasive colorectal surgery
Nicola de'Angelis1, Luca Portigliotti2, Daniel Azoulay1, Francesco Brunetti1
1 Department of Digestive Surgery, and Liver Transplantation, Henri Mondor Hospital, AP-HP, Créteil, France
2 Department of General Surgery, University of Eastern Piedmont, Azienda Ospedaliero Universitaria Maggiore della Carità Hospital, Novara, Italy
|Date of Web Publication||1-Oct-2015|
51, Marechal de Lattre de Tassigny Street, 94010 Créteil
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
de'Angelis N, Portigliotti L, Azoulay D, Brunetti F. Robotic surgery: A step forward in the wide spread of minimally invasive colorectal surgery. J Min Access Surg 2015;11:285-6
|How to cite this URL:|
de'Angelis N, Portigliotti L, Azoulay D, Brunetti F. Robotic surgery: A step forward in the wide spread of minimally invasive colorectal surgery. J Min Access Surg [serial online] 2015 [cited 2019 Nov 17];11:285-6. Available from: http://www.journalofmas.com/text.asp?2015/11/4/285/166490
We are observing, in the last 2 years, a rising number of publications on robotic colorectal surgery that animate a vivid debate on the advantages and applications of robotics.
Before getting to an evidence-based response from the literature, we note the enthusiasm of many surgical teams in using robotic technology also in colorectal surgical procedures that are rarely performed by laparoscopy (i.e., robotic-assisted transanal total mesorectal excision).
No one can argue against the fact that minimally invasive surgery (MIS) scores over conventional open surgery in terms of less post-operative pain, reduced post-operative morbidity, shorter hospital stay while providing similar oncological outcomes. However, only a minority of the patients seems to benefit from the advantages of laparoscopy, which accounts for 4-6% of all colorectal resections in the USA,  and up to 29% in France.  These data should be attentively analysed in the light of the fact that after more than 20 years from its introduction, laparoscopy is still reserved to few surgical cases.
Various socioeconomic factors, technical limitations and a steep learning curve have been advocated as the causes that hampered the wide spread of laparoscopy. In this perspective, robotics was introduced to overcome the drawbacks of laparoscopy and change the face of MIS that should not be a luxury for few but a standard of care for many.
As known, robotics provides several technological improvements, such as a three-dimensional (3D) view of the operating field, a seven-degrees-of-freedom motion with wristed instruments, the absence of fulcrum effect and surgeon tremor and greater ergonomics. Moreover, two-headed robotic platforms represent an exceptional teaching tool whereby residents in training can achieve optimal anatomical knowledge and surgical skills, thanks to the mentoring console.
The current literature has most often focused on comparing the surgical and clinical advantages of robotics versus laparoscopy, but this may not be the clue of the problem. Indeed, we should be able to look further and analyse the advantages of robotic surgery in terms of advanced technology that could increase the currently small number of patients undergoing MIS also for complex procedures that might be too challenging for laparoscopy and are still approached by open surgery.
We recently read the results of an awaited randomised controlled trial (COLOR II) showing that laparoscopy is as safe and effective as open surgery for rectal cancer resections but this approach remains technically demanding and associated with high conversion rates (17%).  The available literature also shows that robotic surgery provides all advantages of the MIS approach and it may allow performing complex procedures, such as rectal resections, with greater ease, lower conversion rate, less pelvic autonomic nerve damage and a reduced learning curve. , Notwithstanding these promising results, the conclusion of many studies is that robotics is too expensive and probably not as cost-effective as laparoscopy.
The real benefits of robotics, however, are difficult to quantify by means of preliminary cost-effectiveness analyses performed on the early experience of a few specialised centres.  Before discouraging the implantation of robotic platforms, further clinical trials should be designed to answer a specific patient-oriented question: "What are the supplement benefits of robotics for those patients or procedures in which MIS still struggles to be applied?"
If robotic technology can target these patients, together with the progressive increase in surgical experience and training and an eventual market-driven competition, robotic-related costs will continue to decrease and it will become more affordable. It is just a matter of time.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
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