Table Of ContentVincent Obias Editor
Robotic Colon and
Rectal Surgery
Principles and Practice
123
Robotic Colon and Rectal Surgery
Vincent Obias
Editor
Robotic Colon and Rectal
Surgery
Principles and Practice
Editor
Vincent Obias
Department of Surgery Division of Colon
and Rectal Surgery
George Washington University
Washington, DC, USA
ISBN 978-3-319-43254-0 ISBN 978-3-319-43256-4 (eBook)
DOI 10.1007/978-3-319-43256-4
Library of Congress Control Number: 2016962016
© Springer International Publishing Switzerland 2017
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This book is dedicated to all of the surgeons
who are courageous enough to thoughtfully
utilize a new technology or technique to
improve the outcomes of their patients, to
question these advancements, to critically
review and publish their results, and, once
these surgeons are comfortable with their
mastery, to continue to innovate and try new
ideas.
Foreword
Issac Asimov’s Three Laws of Robotics
1. A robot may not injure a human being or, through inaction, allow a human being
to come to harm.
2. A robot must obey the orders given it by human beings except where such orders
would conflict with the First Law.
3. A robot must protect its own existence as long as such protection does not con-
flict with the First or Second Laws.1
Robotics, in its current form, is not the robot from fiction and movies. Rather, it is
a mechanized computer interface that augments a surgeon’s innate abilities. Robotic
surgery is a natural continuation of minimally invasive surgery that was pioneered by
laparoscopists and endoscopists. As has been the case in many instances in science
and industry, the advent of robotics has disrupted the status quo and has helped move
the field of surgery forward. At its base, robotics is a mechanized computer interface
between the surgeon and the patient. However, instead of separating the patient from
the surgeon, robotic draws the surgeon closer with incredible 3D views and fine
wristed instruments. As technology continues its exponential pace, future iterations
of robotic platforms will look radically different from what we have used as pio-
neers, but the basic surgeon-computer-patient paradigm will always be there.
It is with great pleasure that I introduce the reader to the first edition of this text-
book. The genesis of this textbook was rooted in the realization that current robotic
colorectal textbooks were being written and edited by surgeons who did not do
robotics. All of the main authors in this textbook have done over 100 robotic
colorectal procedures and are experts in the field. They truly support and endorse
robotics in colorectal surgery and their enthusiasm shines through in the chapters
they have written.
Thank you for reading this textbook. I hope you enjoy this labor of love.
Vincent J. Obias, MD, MS, FASCRS, FACS
1 Asimov, Issac, I, Robot. 1950.
vii
Contents
1 Introduction: The Evolution of Minimally Invasive Surgery ............. 1
Jeremy L. Holzmacher and Samir Agarwal
2 The Learning Curve of Robotic Assisted Laparoscopic
Colorectal Surgery and How to Start Applying Robotic
Technology in Colorectal Surgery ......................................................... 11
M. Nicole Lamb and Ovunc Bardakcioglu
3 Training and Credentialing in Robotics ................................................ 17
Ryan Broderick, Simone Langness, and Sonia Ramamoorthy
4 Robotic Right Hemicolectomy ............................................................... 23
Henry J. Lujan, Brian X. Rivera, and Diego Holguin
5 Robotic Abdominoperineal Resection ................................................... 49
Grace S. Hwang, John Gahagan, and Alessio Pigazzi
6 Robotic Low Anterior Resection of Rectal Cancer .............................. 59
Se-Jin Baek and Seon-Hahn Kim
7 Robotic Total Colectomy ........................................................................ 79
Cesar Santiago and Sean Satey
8 Robotic-Assisted Transanal Microscopic Surgery ............................... 93
Borja Villanueva Figueredo, Federico Perez Quirante,
Carlos Martinez Parra, Jorge A. Lagares-Garcia, and Anthony Firilas
9 Surgical Immunofluorescence and Firefly Technology
in Colon and Rectal Surgery .................................................................. 105
Elizabeth R. Raskin
10 Surgery on Obese Patients ..................................................................... 115
Eduardo Parra Davila and Carlos Hartmann Otero
11 Robotics and Pelvic Floor ....................................................................... 129
Nell Maloney-Patel, Juana Hutchinson-Colas, and Ashley Tsang
ix
x Contents
12 Robotic Surgery for the Treatment of Inflammatory
Bowel Disease .......................................................................................... 153
Michelle DeLeon and Craig Rezac
13 Ergonomics in Robotic Colorectal Surgery .......................................... 169
John G. Armstrong and John C. Byrn
14 Nerve Preservation in Robotic Rectal Surgery .................................... 183
Fabrizio Luca and Manuela Valvo
15 Completed and Ongoing Trials in Robotic Colorectal Surgery .......... 195
Robert K. Cleary
16 Robotic Costs ........................................................................................... 229
Deborah S. Keller and Eric M. Haas
17 The Robotic-Assisted Treatment of Endometriosis:
A Colorectal Surgical Perspective ......................................................... 243
Maria Victoria Vargas, Gaby Moawad, Vincent Obias,
and Madiha Aziz
18 Anesthesia in Robotic Colon and Rectal Surgery ................................ 259
Christopher Schroff and Jason Sankar
19 Single-Incision Robotic Colon Resection (SIRC) ................................. 271
Yen-Yi Juo and Vincent Obias
20 Intraoperative Conversions in Robotic Colorectal Surgery ............... 285
Matthew Skancke and Vincent Obias
21 Current and Future Platforms for Robotic Colorectal Surgery ......... 295
Jeffrey N. Harr and Deborah Nagle
Acknowledgements ......................................................................................... 311
Index ................................................................................................................. 313
Chapter 1
Introduction: The Evolution of Minimally
Invasive Surgery
Jeremy L. Holzmacher and Samir Agarwal
Perhaps the most invigorating and daunting challenge to the modern day surgeon is
the continual drive to push the envelope of what is innovative, fast, and cost effec-
tive. Likewise, surgeons must at all times maintain patient safety and provide treat-
ments that are as efficacious as the current standard of care. As surgery began
forming into a cogent specialty in the late nineteenth and early twentieth century,
foundational strides were made in advancing antisepsis and sterility along with
updating the current body of anatomic knowledge. Around this same time, the
developing interest in the basic sciences lead to the birth of the surgeon scientist
who formally set to define the pathological basis for surgical disease. William
Stewart Halsted was one of the key figures in removing the general surgeon from the
paradigm of the surgeon barber of the 1800s into the surgeon scientist of the twen-
tieth century. This was part and parcel to his pursuit of the scientific of surgical
diseases, and in many respects set the tone of translational research from the labora-
tory to the operating room. Of course, his achievements were built upon meticulous
and often tireless efforts of the great surgeons that came before him. Physicians who
explored nearly every cavity, crevice, and orifice of the human body and for whom
so many eponyms exist.
As the century progressed, a wave of new technologies began surfacing which
would come to empower both diagnostic and therapeutic medicine. Henry Dakin
and Nobel laureate Alexis Carrel did extensive research into wound management
during World War I, leading to major advancements in wound healing by experi-
menting with antisepsis solutions and the evolving practice of debridement and
irrigation. By World War II, most of the foundations for basic operative procedures
had been established and the subsequent growth of surgical procedures from the
J.L. Holzmacher, M.D. • S. Agarwal, M.D. (*)
School of Medicine and Health Sciences, Department of Surgery, George Washington
University, 2150 Pennsylvania Ave. NW, Suite 6B,
Washington 20037, DISTRICT OF COLUMBIA, USA
e-mail: [email protected]
© Springer International Publishing Switzerland 2017 1
V. Obias (ed.), Robotic Colon and Rectal Surgery,
DOI 10.1007/978-3-319-43256-4_1
2 J.L. Holzmacher and S. Agarwal
1940s onward became nearly exponential. Diseases, which were lethal only
decades earlier, could now be treated in a precise and nuanced fashion. The mod-
ern era of major open surgery had come, it was radical in breadth and scope, and
the evolution of surgery as a field had only begun.
The Dawn of Endoscopy
While open surgery dominated as the sole intervention for surgical disease for the
majority of the twentieth century, concurrent advances in catheter-based and endo-
scopic technology set the foundation for what would become minimally invasive
surgery. In their infancy, however, minimally invasive approaches were largely
regarded as ineffective for interventional means. Indeed, the adoption of minimally
invasive procedures like endoscopy by thoracic and abdominal surgeons was
delayed largely by two key factors: (1) endoscopy was deemed inferior to the gold
standard of open surgery, especially when dealing with enclosed intracorporeal
cavities; and (2) the technology of endoscopes was limited by their lack of video-
imaging capabilities, high definition visualizations, and insufficient lighting for
the operating surgeon and their assistants to perform meaningful maneuvers.
Consequently, surgeons sparingly performed endoscopy leaving a vacuum through
which other specialties would advance the field. The toils and triumphs of these
pioneers are as expansive as the achievements of the great major operative sur-
geons of the time.
Kurt Semm, a gynecologist, succeeded in developing an electronic insufflator
with trocar systems that allowed introduction and removal of instruments without
losing intra-abdominal pressure, and his performance of the first laparoscopic
appendectomies (Figs. 1.1 and 1.2). The radiologist Benjamin Orndoff began exper-
imenting with “peritoneoscopy” and was able to establish pneumoperitoneum using
an intraspinal needle by insufflating oxygen. Similarly, Janos Veress developed a
modified intraspinal needle to instill pneumothorax for the treatment of tuberculo-
sis, later to be adopted for introduction of pneumoperitoneum (Fig. 1.3). George
Kelling, a gastroenterologist, experimented feverishly with methods of insufflation
and insufflating gases, as well as conceptualizing and describing the beginnings of
what would ultimately become modern day laparoscopic instruments (Fig. 1.4). A
true endoscopist, George Berci of Austria led advances in miniaturizing video-
imaging technology within endoscopes and improving endoscopic illumination,
setting the stage for high definition televised laparoscopes for visualizing intracavi-
tary anatomy (Figs. 1.5 and 1.6).
Surgery via laparoscopy, however, was not first successfully performed until the
early 1980s by European surgeons using their own personal techniques for chole-
cystectomy. The legitimacy of endoscopy became solidified in 1987 when the
French physician P. Mouret who performed a four trocar laparoscopic cholecystec-
tomy successfully in a young woman.
