Available online 26 January 2023, 151259

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Robotic colorectal surgery allows adult and pediatric surgeons to overcome the technical limitations of laparoscopic surgery. It also provides improved ergonomics in the field of surgery. Robotic surgery has several advantages in colorectal operations that require complex minimally invasive skills including anorectal malformations, Hirschsprung disease, and inflammatory bowel disease. In this section, we discuss the key aspects of colorectal surgery where robotic instrumentation seems ideal.

Introduction

Case 1 – A previously healthy full-term baby girl presents to the emergency room for persistent abdominal distention at 6 months of age. Contrast enema shows a transition zone in the rectosigmoid colon, and rectal biopsy confirms the absence of ganglion cells, hypertrophic nerves establishing the diagnosis of Hirschsprung Disease.

Case 2 – A 14 years old female is diagnosed with ulcerative colitis at 12 years of age. She was initially maintained on medical therapy but has had worsening symptoms and endoscopic progression of her disease. She is referred by her gastroenterologist for surgical intervention.

Case 3 – A newborn baby boy undergoes colostomy and mucus fistula for imperforate anus. Baby is thriving; at 6 months of age the fluoroscopic contrast enema via mucus fistula confirms the diagnosis of rectobladderneck fistula.

All three patients above need surgical intervention; most centers will perform these operations with minimally invasive approach. Does the patient's size dictate whether the operation can be performed with robotic assistance? Are the surgical outcomes in patients who undergo laparoscopic vs robotic assisted surgery the same or perhaps even better? Should a surgeon's health/ergonomics be a consideration in making decision regarding the choice of operation? Does the long-term benefit of robotic surgery for both surgeons and patients justify its higher cost?

Section snippetsErgonomics of Robotic Surgery

Robotic surgery offers all the advantages of laparoscopic surgery with the additional benefit of navigating difficult anatomic conditions such as low rectal cancer, narrow pelvis, high body mass index. Recently, there has been an increased focus on surgeon's long-term health and ergonomics. Ergonomics is derived from two Greek words ergon (labor) and nomia (arrangement). The high technological environment of robotic surgery allows surgical working environment to be catered to fit the surgeon

Robotic Pediatric Colorectal Surgery

Several studies have shown the benefit of laparoscopic surgery with improved post-operative surgical outcomes, including decreased pain, length of stay and earlier return of bowel function.9,10 Laparoscopic colectomy is associated with earlier recovery of bowel function, need for fewer analgesics, and with a shorter hospital stay compared with open colectomy with no difference in 28 days morbidity and mortality and low conversion rate from laparoscopic to open surgery (17%).11

Robotic surgery

Anorectal malformations

Anorectal malformations (ARM) are complex, heterogeneous disorders ranging from perineal fistulas to more complex malformations such as cloaca. Rectourethral fistula is the most common malformation in males and imperforate anus with a rectovestibular fistula is the most common anomaly in females.15 In ARM patients, De Vries and Pena reported Posterior Sagittal Anorectoplasty (PSARP) in 1982; biggest challenges post operatively were constipation, overflow incontinence or fecal incontinence.16

Hirschsprung Disease

In patients with Hirschsprung Disease (HD) undergoing robotic pull-through, the results have been more promising. Hirschsprung disease is the most common neurocristopathy in children, resulting in the congenital loss of enteric ganglia.21,22 Surgery, which involves resecting the aganglionic segment and restoring bowel continuity, usually results in a good outcome; however, some patients suffer from multiple episodes of enterocolitis and other obstructive symptoms.23, 24, 25

The first reported

Inflammatory bowel disease

Robotic assisted restorative proctocolectomy for patients with ulcerative colitis has seen tremendous advantages and can potentially be performed as a single stage operation.37 The robot is docked from the patient's right side; seven ports are employed via a medial to lateral approach. The operation starts with the division of ileocolic vessels; the mesenteric dissection is taken up to the root of the middle colic vessels which are then divided. The terminal ileum is divided and the right colon

Limitations of Robotic surgery

Interestingly, though not unsurprising, in patients undergoing robotic proctectomy with IPAA, the healthcare costs, revenues and profit based on the case numbers of each individual patient did not show robotic surgery to be cost-saving.43 The higher cost of robotic cases is likely due to longer operative time and higher robotic instrument cost and not due to inpatient post-operative hospital cost. A detailed health economic analysis by Jayne,41 based on data provided by Intuitive Surgical in

Conclusion

It is clear that surgeons have not reaped the benefits of the advancements in technology. Robotic surgery is monumental, in that it is comparable, if not better than laparoscopic surgery. The added benefit of robotic surgery is the huge leap in surgeon's ergonomics, which has the potential to lessen chronic work related hand, shoulder and neck pain as well as cervical neuropathy. Even though it may not be cost effective right now, the advantage to both surgeon and patients cannot be discredited

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© 2023 Published by Elsevier Inc.