Comparative Evaluation of the Short-Term Treatment Outcomes Between Open, Laparoscopic- and Robotic-Assisted Surgical Approaches for Rectal Cancer Treatment.

The open surgeries and more recently minimal invasive surgeries aided by laparoscopic or robotic approaches are employed for rectal cancer treatment procedures. The open approach is the most commonly opted technique, but recent studies have also shown that laparoscopic total mesorectal excision (TME) has become the standard of care. There are certain shortcomings of laparoscopic surgery such as long learning curve, inadequate counter traction, limited dexterity, lack of tactile feedback and limited two-dimensional visions. Robotic surgery also offers several benefits to overcome the drawbacks of laparoscopic procedures, such as providing better dexterity and a more stable visualization. This study aims to analyse the surgical results in terms of completion of TME, short-term surgical outcomes and hospital stay in after open, laparoscopic- and robotic-assisted rectal resections respectively. A retrospective review of prospectively maintained database of patients operated for carcinoma rectum between January 2013 and August 2018 at Manipal Comprehensive Cancer Centre, Manipal-Vattikuti Institute of Robotic Surgery, Bangalore, was analysed in this study. The surgical parameters like completion of total mesorectal excision; proximal, distal and circumferential resection margins; number of nodes retrieved; and total post operative hospital stay were analysed in the open, laparoscopic-assisted and robotic-assisted groups. A total of 100 patients were included in the study consisting of 25, 25 and 50 patients each in the open, laparoscopic and robotic arms respectively. In case the desired results were not obtained using the advanced technique the procedure was converted and open technique was adopted. The conversion rate to open procedure was 8% (2of 25) in the laparoscopic-assisted group and 2% (1/50) in the robotic-assisted group. The average post operative hospital stay was 7.4, 7.36 and 6 days in the open, laparoscopic- and robotic-assisted group (p = 0.01) respectively. Robotic rectal resections show a trend towards better surgical results in the form of improved circumferential resection margins, completeness of TME and lower conversion rates.

A prospective randomized controlled trial comparing conventional Intuitive® procedure card recommended port placement with the modified Indian (Manipal) technique.

INTRODUCTION: The da Vinci® X hybrid systems (Intuitive Surgical®, Sunnyvale CA) provides standard sites recommendations for port placement during robotic surgery; including that for colorectal procedures. The author's encountered challenges while adhering to the provided instructions, such as clash of instruments and arms and need for additional ports, and hence to overcome these challenges attempted a few innovative technical modifications. The surgical results as well as merits of the revised Indian (Manipal) port placement with single docking technique are presented here. METHODS: Twenty patients underwent robotic rectal resection at the Department of Surgical Oncology and Robotic Surgery, Manipal Comprehensive Cancer Centre, Bengaluru, India, between December 2017 and June 2018. A randomised controlled study was conducted to compare the two techniques. Ten patients were operated using hybrid da Vinci® 'X' system using the manufacturer's recommendations and 10 by the modified Indian (Manipal) port placement with a single docking technique. RESULT AND CONCLUSIONS: The Indian (Manipal) modifications of port placements are optimal for colorectal procedures such as low anterior resection as well as for ultralow anterior resections. The intraoperative parameters compared between the recommendations of the Intuitive® (da Vinci® systems) and attempted modifications demonstrated statistically significant advantages with the use of the revised techniques. The improvements offered by this modification include no additional requirements of ports or staplers, lesser clash amongst instruments as well as arms, better mobilisation of splenic flexure amongst others.

Toxicity profile of chemotherapy agents used in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancies.

INTRODUCTION: Morbidity associated with cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is due to the synergistic effect of cytoreduction, effect hyperthermia and the cytotoxic agents used for HIPEC. This study was done to analyse the postoperative morbidity in relation to the chemotherapy agent used in patients undergoing CRS-HIPEC for peritoneal surface malignancy (PSM) in Indian set up. MATERIALS AND METHODS: Patient with PSM, underwent CRS-HIPEC as per the institutional protocol. Patients were stratified as per the chemotherapy drug used during HIPEC & perioperative outcome were documented. RESULTS: 163 patients underwent CRS-HIPEC for PSM: 67.4% were of ovarian primary. Others were colorectal, appendicular, gastric primary and rare tumors.Cisplatin was the most common drug used: as alone (57.05%) or in combination with Adriamycin (12.88%). Mitomycin-C (MMC) was used in 20% and oxaliplatin in 10%.Grade 3-5 morbidity in the whole cohort was 44.8% and grade 1-2 was 74%.Grade 1-2 electrolyte abnormality was the most common morbidity overall and grade 3-4 hematological toxicity was the most common severe morbidity. Frequency of grade 3-5 morbidity were 38.7%, 48.5%,50% and 61.9% for Cisplatin alone, MMC, oxaliplatin and Adriamycin + cisplatin respectively. None of the patients had grade 3-4 nephrotoxicity as sole complication. All major complications were highest in the group who received Adriamycin. Cisplatin was associated with higher rate of electrolyte imbalance, oxaliplatin with post-operative bleeding. Rates of other complications did not differ significantly. CONCLUSION: Cisplatin followed by MMC were the well tolerated drugs during HIPEC and tolerance to Adriamycin combination regimen in Indian patients was poor.