Rachel Cunningham talks to Conor Shields about the new techniques with robotic assisted surgery that is being undertaken at the Mater Hospital in Dublin
The colorectal field has been relatively slow to venture into the world of robotic surgery in Ireland. According to Conor Shields, consultant colorectal and general surgeon at the Mater Hospital, the reason for this is easy to understand.
“With colorectal you’re working in a number of different quadrants within the abdomen, unlike prostate surgery where there is a single target, a single organ. As a result, it took a while longer to develop a fitting operation with the robot”. Mr Shields explained that the colorectal robotic programme in the Mater is really only starting. “It is very much in its infancy, particularly when compared to urology, for instance. That’s been much more established as an approach for a variety of technical reasons”.
He and his colleague, Professor Ronan Cahill have performed 10 robotic operations between them to date. Mr Shields outlined the two main benefits of robotic surgery that they’ve noted so far: “One is that the impact of surgery seems to be less, the patients feel better the next day and don’t look as if they have just undergone major surgery. “The other benefit is that in some patients where a laparoscopic approach would not have been possible, we may have opted for open surgery. But actually, we have been able to use robotic surgery on these patients, meaning they were able to undergo a minimally invasive option.
“An open operation would have you out of action for up to six weeks whereas with the robotic procedure, it would be significantly less. So far, the first 10 have gone well; the patients have been happy and, looking at the results, we’ve been happy too,” he stressed. Mr Shields claimed that the obese patient was a “particularly suitable candidate for robotic surgery but mainly for us it is an advantage when operating on the male patient. The specific difficulty in colorectal laparoscopic surgery is in male patients who have narrower pelvises.
“A male with a rectal tumour and a narrow pelvis is classically known as a difficult case laparoscopically, whereas robotically, it is more feasible. Those patients are more likely to have a minimally invasive operation, and would hopefully avoid an open operation.
“What we have treated so far are rectal cancers and symptomatic diverticular disease. This is a benign disease, so it’s nice when the patient feels less of an impact from their surgery. With cancer surgery, because it is such shocking news for a patient, their focus is on getting rid of it. Whereas with benign surgery, you always have to weigh up the long-term quality of life and if the operation is less of an impact, it actually swings the cost benefit ratio towards surgery. For benign disease, there is a greater expectation that it will be uncomplicated.
“Hand-eye coordination and even the manner in which you’re interpreting the screen is quite different from laparoscopic surgery. Certainly, the optics are better, it’s more of a virtual reality environment, you’re enveloped in it rather than simply looking at a 2D screen, which makes it easier to envision what you’re doing,” he pointed out
However he remains unconvinced that robotic surgery would become the standard surgical approach in this field in the future. “I don’t think this method will ever become the norm in this area, the operations take too long and they’re expensive. From a logistic and economic point of view, I don’t think it makes sense for robotic surgery to become the routine approach in the colorectal field. “Operating on rectal cancers in general, perhaps yes. As with all these things, the technology will evolve and I suppose that instrumentation will always grow. We’re never looking at the end of the road, we’re simply looking at one further step along the path to 21st century instrumentation where perhaps ultimately we will be using controls on all instruments, that is possibly where we will end up in 10/20 years time. Robotics is just another step in this development, it isn’t the end product.
“It all comes down to the economics, it takes a long time and is expensive which is why I don’t think it will ever replace open surgery completely. A recent trial failed to show a specific advantage of robotic surgery over standard surgery, but then we’d have to bear in mind that the original laparoscopic colorectal surgery trials back in the mid-00s also failed to show an advantage before being adopted.
“It’s an exciting technique, very enjoyable operating, and it makes minimally invasive surgery an option for those who wouldn’t otherwise have been able to have it. Still, I don’t see it replacing standard colorectal surgery just yet.
“The feeling with the use of robotics for prostatectomy was that complications were lowered, and we’d ultimately hope to see something similar in colorectal surgery as the data grows. Impotence, certainly, can be one complication of rectal surgery; the hope is that complications would be less because the optics are better, you can see the structures much better, you can see nerves much more easily than in an open surgery. The data doesn’t exist right now, as we are very much in our infancy and the trial stage of this procedure.
“I would say that it makes minimally invasive surgery possible that would otherwise not be available with open surgery. Can we say at this point that it is a better surgery? Not yet. But there are some patients who can’t have laparoscopic surgery because they are obese, their pelvis is too small etc. and it’s great to have that other option available for them.
“The next step for us is to make colorectal robotic surgery part of a routine, something more commonly being offered to the patient. Not necessarily to every patient but at least one operation per week. Our plan would also be to start a robotic programme in the Mater public hospital.
“We’d hope that the Mater hospital will invest, which would make this operation more widely available and it would also make it more possible for us to reach these targets. At that stage then training would improve and we’d have two robots on the same street which would be a big advantage; one robot could be used for training as well. It’s simply down to investment, a hospital needs to see the data before it can justify such an expense.
“Arguably, within robotic rectal surgery, there is one less surgeon required. In open rectal surgery, two assistants are commonly required but with the robotic approach, you only need one, who has some robotic training as well. So we have one less medical staff, which could make a case in terms of the economics for it. Hospital-wise, my feeling is that every cancer centre will ultimately end up with a robot.
“I was a bit sceptical coming into this originally but I must admit that I am now a convert. I think overall it will help make people better surgeons, as we will become more aware of surgical planes, we will improve accuracy, the instruments are much more precise than open or laparoscopic surgery. There is minimal blood loss; you’re looking at 50 – 100 ml per case, which is a fraction of what would be expected using other surgical methods.
“Within rectal surgery, I don’t think that it’s something that patients are yet particularly aware of. It may grow in appeal as patients realise the operation requires less fluid replacement, less pain relief, no blood transfusion, and leaves the patient feeling comparably better the next day. It will be interesting to see, as the research develops, whether they will begin to request it”.