The Short-Term Results of Da Vinci Robotic Rectal Resection for Malignant and Benign Tumors

The history of rectal surgery is about 300 years, since 1739 y. when Jean Faget performed the first extirpation of the rectum; in 1899 the English surgeon William Ernest Miles developed a method of rectum extirpation, which almost unchanged by nowadays [1]. Theodor Kocher performed the first trans sacral rectal resection in 1874. This method was called «posterior rectal resection». Carl Gussenuer performed the first anterior rectal resection by trans abdominal access in 1879. The first colon anastomosis performed in 1910 by the Donald Balfour [1]. The first description about fascial way of rectum mobilization was published in monograph of the famous Russian surgeon Semen Abramovich Holdin: Malignant neoplasms of the rectum, published in 1955. Later this technic was widely replicated and patented by the English surgeon R.B. Heald as a method of rectal removing with total mesorectal exscision (TME) in 1982y [2-5]. The standardization of fascial plane rectal mobilization technic with TME has opened a new page in surgical treatment of the rectal cancer and allowed significantly reduce the number of local reсurrence and increase the disease-free survival.


Introduction
The history of rectal surgery is about 300 years, since 1739 y. when Jean Faget performed the first extirpation of the rectum; in 1899 the English surgeon William Ernest Miles developed a method of rectum extirpation, which almost unchanged by nowadays [1]. Theodor Kocher performed the first trans sacral rectal resection in 1874. This method was called «posterior rectal resection». Carl Gussenuer performed the first anterior rectal resection by trans abdominal access in 1879. The first colon anastomosis performed in 1910 by the Donald Balfour [1]. The first description about fascial way of rectum mobilization was published in monograph of the famous Russian surgeon -Semen Abramovich Holdin: Malignant neoplasms of the rectum, published in 1955. Later this technic was widely replicated and patented by the English surgeon R.B. Heald as a method of rectal removing with total mesorectal exscision (TME) in 1982y [2][3][4][5]. The standardization of fascial plane rectal mobilization technic with TME has opened a new page in surgical treatment of the rectal cancer and allowed significantly reduce the number of local reсurrence and increase the disease-free survival.
The period between 1990-2000 yy., characterized the introduction of minimally invasive laparoscopic procedures in colorectal surgery [6,7]. The first laparoscopic rectal resection performed in 1990y. by Patrick Leahy [6][7][8]. In 2006 y. the Italian surgeon Pigazzi performed the World's first rectal resection with TME, using by Da Vinci robotic system [9,10]. The technological progress opens a new era of colorectal surgery with ultraprecision technic. Surgical technic for rectal surgery has several special features: a limited narrow field of the small pelvic cavity, closest of important autonomic nervous system at surgical plane, the importance of the rectal fascia preserving during rectal mobilization as the main oncological principle of ablastics [6,7,9]. The emergence of robotic surgical technologies allowed improving the quality of visualization and surgery convenience, deprived of intentional jitter manipulators -that could increase accuracy during rectal mobilization and autonomic nervous system preservation [9,[11][12][13].
The analysis of the results for Da Vinci robotic rectal surgery is the most actual topic of modern surgery and introduction of the robotic surgery for complex surgical cases -one of the perspective tasks. The aim of the study is to improve the surgical treatment results for benign and malignant rectal tumors due to introduction of the ultra -precision robotic technic.

Material and Methods
Since 2014 -2016 yy we analyzed the results of 26 robotic rectal resections performed with Da Vinci system (Intuitive Surgical, Inc., Sunnyvale, CA, USA). All patients had a standard scheme of the preoperative investigation: MRI, CT-scan and colonoscopy with biopsy, morphological verification, CEA, CA19.9. General patient's condition estimated by ASA scale, clinical and biochemical blood tests. The pelvic organs function estimated by Wexner Scale, rectal manometry, sphincterometry; IPSS score, residual urine level for urinary function survey. The postoperative pain estimated by "Visual-analogue pain intensity scale" and "brief pain scale". The quality of life estimated by QOLscale. The first 10 procedures we performed by the hybrid technic: first, we mobilized left side of the colon laparoscopicaly, then we docked the Da Vinci system and mobilized the rectum in embryonic lay according TME technic, performed 002 lymphadenectomy with robotic system. Other 16 procedures we've done almost by the robotic technic without laparoscopy assistance. At the Figure 1 showed the patient position on surgical table with Trendelenburg position, slightly knee fold and legs divided. At the Figure 2 showed the robotic and assistant trocars position.  First, at the start of surgery we do the "vascular isolation of the tumor" -as main oncological principals. Initially, the peritoneum was opened above the right iliac artery and further over the abdominal part of the aorta up to the inferior mesenteric artery (IMA) not reaching 1-1.5 cm to the visible part of the lower horizontal branch of the duodenum. With the correct implementation of this stage, after the dissection of the peritoneum, a loose interfascial space opened -an embryonic layer separating the fibrous tissue of the mesentery of the sigmoid colon from the para aortic adipose tissue, and below the mesorectal tissue from the presacral fascia. Further mobilization was carried out in the embryonic layer. This method is important, because removed adipose tissue with the lymphatic collectors "en-block"-the main oncological principles of ablastics.   After IMA mobilization at base, lymphadenectomy is performed along this trunk to the site and distally to the left colic artery (a. colica sinistra). In this place we are clipping and crossing the IMA. Thus, a. colica sinistra have preserved and the adipose tissues from the base of IMA have removed. Then the lower mesenteric vein clipped and intersected. This stage of the surgery does not actually differ from that laparoscopic technique and illustrated below (Figures 3-6). Further mobilization continued along the back wall and the left semicircle and then along the front wall (Figures 7-10). Depending on the tumor location we performed total or partial mobilization of the mesorectal adipose tissue. Mobilization of the rectum with mesorectal adipose tissue was carried out in compliance with the principle of facial removal of the organ (Figures 7-10). When the mobilization of the rectum performed, it transected by the Echelon flex linear stapler (yellow or blue cassettes, 60 or 40 mm) or Endo -Gia Universal Roticulator linear stapler (purple cassettes 45 and 60 mm) ( Figure 11). Intracorporeal anastomosis perfomed with circular stapler (Figure 12). Then, after finishing the operation, surgeon cheked the quolity of mesorecum exscision and tumor localization, proximal, distal and lateral bordies ( Figure 13).
In assessing pain, the mean value for the visual-analogue pain intensity scale was 2.1 points out of 10 possible. A qualitative assessment of the brief pain inventory showed the following results: an average score of 1.5 out of 10 possible, with a maximum value of 6.5 points recorded in only 2 patients ( Table  5). The estimation of pain influence for quality of life (human ability to walk, life activity, sleep, work) -only 1 patient noticed that the pain level is considerable influent for life activity (Table  6 & Figure 16). The average duration of painkillers intake was 2.7 days. In 1 patient we must prescribe the narcotic analgetics, 9 (34,6%) patients didn't take the painkillers after surgery. The average time for urination restoration was -2 days. According the IPS Score the mean value was 4, after 10 days -6.8, after 6 month -3 (Table 7 & Figure 17).