Robotic Surgery for Ulcerative Colitis

Abstract

Subtotal colectomy (STC) or total proctocolectomy (TPC) and ileal pouch–anal anastomosis (IPAA) performed in two or three stages remain the procedure of choice for patients with ulcerative colitis (UC). Minimally invasive laparoscopic approaches for STC and IPAA have been established for over a decade, having been shown to reduce postoperative pain, length of stay, and improve fertility. However “straight-stick” laparoscopy has ergonomic and visual disadvantages in the pelvis, which may contribute to IPAA failure. The robotic platform was developed to overcome these limitations. Robotic STC is associated with lower conversion rates and earlier return of bowel function with acceptably longer operative time (mean, 28 minutes) than laparoscopic STC. The robotic approach has also been shown in case series to be safe in urgent settings. Robotic IPAA is associated with lower blood loss and length of stay than laparoscopic IPAA. Robotic TPC/IPAA has been shown in small case series to be safe and feasible despite longer operating times.

Overall, 20 to 30% of ulcerative colitis (UC) patients will undergo operative intervention in their lifetimes. Also, 10% of UC patients will need urgent surgery within a year of diagnosis for toxic colitis, severe bleeding, or medical refractory disease and steroid dependency. ¹ The standard of care is a restorative proctocolectomy with pelvic pouch formation in staged procedures. Ileal pouch–anal anastomosis (IPAA) provides a desirable alternative to permanent stoma following total proctocolectomy (TPC). It was first described in 1978 by Parks and Nicholls ² and has a definitive positive effect on global quality of life (QOL) including body and sexual image, work, and social function. ^{2 3 4} In urgent situations, a three-stage intervention with a subtotal colectomy (STC), followed by completion proctectomy with IPAA, then ileostomy reversal limits the operative morbidity and prepares a patient for IPAA. In elective situations, such as dysplasia or contraindication to medical therapy, a two-stage approach (TPC and ileostomy reversal) is utilized. A one-stage approach is possible in selected patients; however, it is generally avoided due the higher risk of anastomotic leak and long-term sequalae of leak including poor pouch function.

Despite low, early adoption to perform urgent laparoscopic resection for inflammatory bowel disease, it has been well established over the last decade that patients undergoing STC for UC benefit from minimally invasive approach with less blood loss and postoperative pain, earlier return to activity, and better fertility preservation despite the longer operating times associated with laparoscopic surgery when compared with open technique. ^{5 6 7} However “straight-stick” laparoscopy performed with two-dimensional view and straight instruments is ergonomically limited deep in the pelvis, overcoming the sacral promontory with limited space and views, particularly in the long narrow male pelvis and the obese patient. ⁸ The robotic platform offers technical advantages over laparoscopy such as endowristed instruments with 270 degrees of freedom, magnified three-dimensional visualization on a stable camera platform, tremor abolition, and simultaneous use of energy devices. ^{9 10} The robot initially had its niche in the pelvis with early adaptation by urologists and gynecologic surgeons. It was later adapted by colon and rectal surgeons, finding improved ergonomics and the possibility of better pelvic nerve preservation and sexual function in proctectomy. ¹¹ The newer DaVinci Xi (Intuitive Surgical Inc., Sunnyvale, CA) platform has allowed colorectal robotic surgery to expand into the abdomen. Long instrument shafts, patient clearance, camera port hopping ability, table motion technology, and nearly 360-degree boom rotation offer improved maneuverability for multiquadrant work. Its advantages have translated into fewer conversions to open, earlier return of bowel function, and shorter length of stay when compared with laparoscopic surgery. ^{12 13 14}

Robotic surgery for UC is challenging, as curative procedures are often performed in a staged fashion. The initial total abdominal colonic resection is often completed in an urgent setting on acutely ill patients, while construction of a neorectum with an ultra-low anastomosis is usually done in an elective setting in optimized patients. Multiple case series have examined the short- and intermediate-term outcomes of robotic STC, TPC/IPAA, and completion proctectomy/IPAA for UC, demonstrating that these approaches are safe and feasible, with shorter length of stay, earlier stoma function, less blood loss, low-leak rates, and equal morbidity and mortality to their laparoscopic counterpart operations. ¹⁵ The following pages describe our technique and experience with robotic STC and end ileostomy in the urgent setting, as well as robotic IPAA creation (stage 2 of the three-stage procedure), as well as the robotic experience with TPC for UC.

Robotic Subtotal Colectomy and End Ileostomy

Performing emergency procedures with robotic technology has traditionally been discouraged due to longer operating times, case reports, and series describing urgent robotic colon, and bariatric operations have been published, demonstrating proof of concept that the robot is safe to use in emergencies and may offer advantages over laparoscopy such as improved visualization and standardization of the procedure by utilizing the third robotic arm, therefore, lessen the need for skilled assistants. ^{16 17} Existing retrospective data demonstrate that elective robotic STC is safe and feasible with lower conversion rates than laparoscopy. ¹⁸

Operative Technique for Robotic Subtotal Colectomy

Robotic STC is performed using a double-dock/boom rotation technique with the DaVinci Xi system (Intuitive Surgical Inc.). The patient is placed in low lithotomy or supine position. Varying degrees of the Trendelenburg and reverse Trendelenburg positions can be used to maximize visualization based on the redundancy of the transverse colon and omental fat. A 12-mm Hasson's balloon port is placed at the umbilicus which is double cannulated with a robotic port. Our practice is to position the robot on the patient's left side; however, right-sided positioning can be used with a 180-degree boom rotation.

Left-Sided Dissection

The first dock is targeted at the left colon. A 12-mm robotic port is placed in the right lower quadrant. If possible, this can be placed at the ileostomy marking; however, with larger body habitus, more lateral placement 2-cm above and medial to the anterior superior iliac spine will facilitate the left-sided dissection. A 5-mm AirSeal device (ConMed, Utica, NY) is placed in the right upper quadrant that functions as a laparoscopic assist port. An additional 8-mm working port is placed in the left lower quadrant. Our practice is to start with monopolar scissors (switching as needed to the vessel sealer) in the right lower quadrant port and the fenestrated bipolar forceps in the left lower quadrant port ( Fig. 1 ). Mobilization is commenced at the sigmoid colon and continued to the transverse colon as far proximal as possible. The proximal rectum is transacted using the robotic stapler via the 12-mm port (60 mm Sureform green load). The mesentery is the divided using the vessel sealer device.

Fig. 1.

Setup for left-sided dissection of robotic subtotal colectomy. The left colon is targeted. A = AirSeal, laparoscopic assist port. 1 = arm 1, 8-mm port docked with fenestrated bipolar scissors. 2 = arm 2, 8-mm port docked with camera. 3 = arm 3* = 12-mm robotic stapler port. X = ileostomy site (can be used for arm 3).

Right-Sided Dissection

The boom is then rotated 180 degrees and the robot redocked with the addition of a left upper quadrant 5-mm assist port for right colon mobilization. The hepatic flexure is targeted. For this docking, the scissors (vessel sealer) are used in the right hand and the fenestrated bipolar in the left hand ( Fig. 2 ). The right colon is mobilized to the terminal ileum. A muscle-splitting incision is then created at the stoma marking and specimen extraction performed through this site. The end ileostomy is matured. Overall port placement is depicted in Fig. 3 .

Fig. 2.

Setup for right-sided dissection of robotic subtotal colectomy. The boom is rotated 180 degrees and the hepatic flexure is targeted. A = AirSeal. AP = a 5-mm laparoscopic-assisted port is added. 1* = fenestrated bipolar (a left lower quadrant or suprapubic port can be added for arm 1* if working space is limited). 2 = camera. 3 = monopolar scissors.

Fig. 3.

Overview of port placement for robotic subtotal colectomy. (All reprinted with permission from Anderson et al ¹⁹ ). A= Air-Seal. AP=a 5-mm laparoscopic-assisted port is added. 1=fenestrated bipolar (a left lower quadrant or suprapubic port can be added for arm 1* if working space is limited). 2=camera. 3=monopolar scissors.

Operative Technique for Robotic Ileal Pouch–Anal Anastomosis

Video 1 Robotic completion proctectomy and ileal pouch–anal anastomosis.

Download video file ^{(36.5MB, mp4)}

Our technique for robotic-assisted proctectomy and IPAA using the DaVinci Xi platform is described. Prophylactic antibiotics are administered per institutional protocol. Following establishment of general anesthesia, the patient is placed in the low lithotomy position with Trendelenburg. The end ileostomy is taken down and surrounding adhesions are carefully lysed. An Applied GelPOINT (Applied Medical, Rancho Santa Margarita, CA) is placed in the ileostomy aperture and the abdomen insufflated (Applied Medical, Rancho Santa Margarita, CA). Additional robotic trocars are placed including a SurgiQuest (Orange, CT) AirSeal. The small bowel mesentery is mobilized for adequate reach. The patient is then placed in the Trendelenburg position and the robot is docked, targeting the pelvis. A combination of monopolar scissors, vessel sealer, fenestrated bipolar grasper, and robotic stapler were used to carry out the completion proctectomy. A robotic stapler is used to transect the rectum approximately 2-cm above the sphincter complex. The rectum is retrieved and the terminal ileum is delivered via the ileostomy aperture. A 15-cm ileal J pouch is created using 2 to 3 firings of a linear stapler in similar fashion to open pouch creation. A betadine leak test is performed. The J pouch can also be performed intracorporeally if desired. A 29-mm circular stapler anvil is secured at the turn of the J pouch and the pouch placed into the abdomen. The abdomen is reinsufflated and the IPAA is created. Care is taken to ensure that the pouch and mesentery are not twisted and are under no tension. Inspection and digital palpation are used to confirm that the vagina is not included in the IPAA in female patients. An air leak test is performed. The stapler port fascia is closed with a transfascial suture, diverting loop ileostomy is created 20- to 30-cm proximal to the pouch, and a pelvic drain is placed ( Video 1 ; available in the online version). ¹⁹

Discussion of Robotic Ileal Pouch–Anal Anastomosis

The first case series demonstrating the feasibility of proctocolectomy with J pouch creation utilizing a robotic platform was published in 2011. ²⁰ That initial account, based on five patients with chronic and complicated UC, reported acceptable short-term outcomes, no conversions to open surgery, and technical and visual advantages over laparoscopic approach alone. Ensuing small-series studies ( n  = 3.6) related successful robotic and hybrid iterations of the IPAA procedure for UC and FAP patients with minimal complications. ^{21 22} An observational study in 2016 comparing robotic-assisted surgery ( n  = 81) to open ( n  = 170), IPAA found the former to be associated with longer operative times and a greater number of readmissions but shorter length of hospital stay and no difference in short-term complications. ²³

Earlier case-matched studies of robotic versus laparoscopic proctectomy with IPAA for inflammatory bowel disease (including UC, Crohn's Disease and indeterminant colitis) found the two techniques to be comparable with regard to efficacy, length of hospital stay, return of bowel function, postoperative complications and short-term pouch function. Robotic operating time exceeded that for laparoscopy which may be partially accounted for by docking time and surgeon learning curve. ^{24 25} A more recent study published in 2019, retrospectively compared 30-day outcomes in 132 patients who underwent laparoscopic ( n  = 58) versus robotic ( N  = 74) IPAA. ²⁶ The robotic group was associated with significantly longer operative times but also smaller estimated blood loss and lower rate of prolonged length of stay (median, 4 vs. 5 days). They found no difference in other short-term complications. Of note, there was a significant difference in diagnosis, with more UC patients (91.9 vs. 62.1%) and fewer FAP patients (8.1 vs. 37.9%) in the robotic group.

Total Proctocolectomy

In 2019, Hamzaoglu et al reported their experience with totally robotic restorative proctocolectomy with IPAA in a series of 10 patients with UC. They described a double-docking technique using the intuitive DaVinci Xi platform. They concluded that the procedure was safe and feasible with acceptable operating time (median, 380 minutes), no leaks, and three superficial wound infections. They also advocated specifically for the use of robotic stapler which allows the surgeon to control the rectal transection and may reduce the risk of anastomotic leak and rectal cuff problems. ¹⁵

Conclusion

The robotic technique has a shorter learning curve than laparoscopic and improves complex task performance while decreasing operator workload. ²⁷ Several reports have demonstrated the noninferiority of robotics compared with laparoscopy, in terms of short- and long-term outcomes. ²⁸ These advantages shine in low pelvic operations, particularly in male and obese patients, with some evidence for better sexual and urologic functional outcomes. Despite these advantages, this approach is burdened by some drawbacks, such as higher costs and increased operative time respect to conventional laparoscopy. ^{11 29 30} However, the preponderance of current data suggests that robotic STC, proctectomy/IPAA, and TPC are safe and feasible in experienced hands, particularly in the context of newer robotic technology. There is a need for larger patient series and longer term data, particularly for robotic STC and TPC.

Funding Statement

Funding No financial support was received for the work being published.