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Which one to choose ? Robotic TME or Transanal TME

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The key steps of transanal TME ... increased risk of prostatic ... sexual dysfunction assessment Future Advancement in robotic system Lower cost in robotic ... – PowerPoint PPT presentation

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Title: Which one to choose ? Robotic TME or Transanal TME


1
Which one to choose ? Robotic TME or Transanal
TME
Presenter Dr, Yan Tze Wah,
Princess Margaret Hospital
2
Background
3
The better approach?
4
1. Robotic (assisted) TME
5
Laparoscopic TME - Advantages
Less post-operative pain
Less blood loss
Shorter hospital stay
Earlier Return of Bowel Function
6
Laparoscopic TME - Advantages
7
Laparoscopic TME - shortcomings
Two-Dimensional view
Misalignment of hands and instruments
Fixed instrument tips
Steep learning curve 150 cases
Dexterity of instruments
8
  • Developed to overcome limitations of Minimally
    Invasive Surgery and to enhance capability of
    open surgery

9
The robotic assisted surgery - Advantages
Three-Dimensional view
Articulating instruments with 7 degree of freedom
Motion scaling and tremor free
Shorter learning curve
Stable Camera and operating platform
10
Clinical Question

gt
Robotic TME
Laparoscopic TME
11
Literature Review
  • 8 studies included 1 RCT and 7 NRCTs
  • 1229 patients 554 RTME vs 675 LTME
  • Studies from Italy, Romania, US, Korea
  • From 2009 to 2013
  • Follow up period 10 to 29.2 months

12
Results
  • Intraoperative
  • No difference in
  • Operative time
  • Blood loss
  • Postoperative
  • No difference in
  • Bowel Function
  • Resume of oral diet
  • Hospital Stay
  • Complications
  • Histopathological
  • No difference in
  • 1. Lymph nodes harvest
  • 2. Distal resection margin
  • 3. Proximal resection margin

13
Results
  • Long term outcome
  • No difference in
  • Local recurrence rate
  • 2. Overall survival
  • 3. Disease free survival
  • Lower in
  • 1. Sexual dysfunction (OR 0.09)
  • Others
  • Higher in
  • 1. Cost

14
  • Conclusion
  • Robotic TME performs at least similarly well or
    even better as laparoscopic TME does

15
Future
  • 1ST OUTCOME Rate of conversion to open surgery
  • 2ND OUTCOME Oncological efficacy
  • OTHER OUTCOMES intraoperative and postoperative
    complications, 30-day post-operative mortality, 3
    years disease free survival, sexual dysfunction
    assessment

16
Future
  • Advancement in robotic system
  • Lower cost in robotic surgery
  • More experiences of robotic technique
  • It is likely that Robotic TME will do better
    than laparoscopic TME, as a matter of time.

17
2. Transanal TME
18
Concepts
  • Problems of transabdominal /up-to-down
    approach
  • Visualization
  • Bony landmarks
  • Applications of instruments (eg. stapler)
  • Leading to
  • Involved CRM
  • Poor quality TME
  • Unnecessary APR

19
Development


  • Transanal Endoscopic Microsurgery(TEM)
  • By Prof Buess in 1983
  • Transabdominal-transanal operation(TATA) by John
    Marks in 1984

Total Mesorectal Excision(TME) by Heald in 1982
Transanal Natural Orifice Transluminal
Endoscopic Surgery  (NOTES) 
the very culmination of 30 years of progress
20
Key steps (in hybrid approach)
1. IMA ligation and left side colon mobilization
2 Creation of PENUMORECTUM and TME from bottom
to up
3. Withdrawal of specimen transanally if possible
4. Coloanal anastomosis
21
Transanal TME POTENTIAL BENEFITS
Obviate the need of stapling device
Unobstructed views of Holy plane
Easier coloanal anastomosis
Ensure distal tumour margin
Allow two team approach
Avoid abdominal wound for specimen retrieval
22
Transanal TME POTENTIAL Problems
Deep learning curve
Damaging sphincter muscle
Risk of urethral injury
Difficult to deal with intraabdominal condition
(e.g. adhesion)
23
Literature Review
  • No large scale studies
  • Most are unpaired/ cases series

24
Literature Review
  • Total 36 studies with 627 patients (510 of
    Transanal TME)
  • 8 case reports, 24 case series, 4 comparative
    studies
  • Papers from 2010 - 2015

25
Literature Review
Post-operative 1. Length of stay 2-29 days 2.
No 30 days mortality 3. Anastomotic leak rate
6.1
  • Intra-operative
  • 1. Operative time 76 to 495 mins
  • 2. Conversion rate 12/510 (4.1)

Histopathological 1. Lymph nodes 5 to 81 2.
TME excision adequate in 88, incomplete in
6 3. Positive CRM margin 22 cases (5) 4.
Positive DRM (0.3)
Long term outcomes 1. Locoregional recurrence
12 cases 2. Overall survival rates 96.6(12
months) and 80.5 (24 months) 3. Recurrence free
survival 93.3 (12 months) and 88.9 (24
months)
26
Literature Review
  • When only looking into the 4 comparative studies
  • Shorter operating time
  • Lower conversion rate
  • Shorter hospital stay
  • Lower early hospital readmission rate
  • Longer DRM
  • Higher mesorectum completeness ( 96 vs 72)

27
Literature Review
  • Reasons for conversion
  • Posteriorly fixed tumour
  • Intra-abdominal adhesion
  • Bulky high tumour
  • Urethral injury
  • Obese
  • Post-op complications
  • Anastomotic leak
  • Abscess formation
  • Urinary retention
  • Paralytic ileus
  • Anastomotic stenosis
  • Bowel obstruction
  • Pelvic hematoma
  • Intra-op complication
  • Rectal perforation
  • Pelvic bleeding
  • Urethral injury
  • Pneumatosis of retroperitoneum
  • Air embolism

28
  • Conclusion
  • From the limited availavle literatures,
    transanal TME shows promising early results when
    compared to laparoscopic TME

29
Future
1ST OUTCOME involvement of CRM 2ND OUTCOME
Completeness of mesorectum, residual mesorectum,
morbidity and mortality, local recurrence,
disease free survival and overall survival,
percentage of sphincter saving procedure,
functional outcome and quality of life
30
To maximize the benefit/ Future
  1. Adequate training, better experience
  2. Standardisation of technique
  3. Newer technique/ equipment eg Robotic trananal
    TME, Newer Transanal platform

31
Summary
Transanal TME
Robotic TME
When compare to Laparoscopic TME
  1. Lower positive resection margin rate
  2. Quicker resume in oral intake
  3. Lower sexual dysfunction
  4. Longer Disease free survival/ overall survival
  1. Shorter operating time
  2. Higher mesorectum completeness
  3. Longer DRM
  4. Lower early hospital readmission rate
  1. Lower conversion rate
  2. Shorter hospital stay

32
Which one to choose ? Robotic TME or Transanal
TME YET TO BE DETERMINED
33
Credits and References
  • Seniors in Princess of Margaret Hospital
  • Journals/ Literatures/ Books
  • Harold Ellis. A History of Surgery Pages
    111-112.
  • Xiong, Binghong, et al. "Robotic versus
    laparoscopic total mesorectal excision for rectal
    cancer a meta-analysis of eight
    studies." Journal of Gastrointestinal
    Surgery 19.3 (2015) 516-526.
  • Simillis, C., et al. "A systematic review of
    transanal total mesorectal excision is this the
    future of rectal cancer surgery?." Colorectal
    Disease 18.1 (2016) 19-36.
  • deAngelis, Nicola, et al. "Transanal total
    mesorectal excision for rectal cancer a single
    center experience and systematic review of the
    literature."Langenbeck's Archives of
    Surgery (2015) 1-15.
  • Wolthuis, Albert M., et al. "Transanal total
    mesorectal excision Towards standardization of
    technique." World journal of gastroenterology 21.4
    4 (2015) 12686.
  • Deijen, Charlotte L., et al. "COLOR III a
    multicentre randomised clinical trial comparing
    transanal TME versus laparoscopic TME for mid and
    low rectal cancer." Surgical endoscopy (2015)
    1-6.
  • Bjørn, Maya Xania, and Sharaf Karim Perdawood.
    "Transanal total mesorectal excisiona systematic
    review." Dan Med J 62 (2015) A5105.
  • Pai, Ajit, et al. "Current status of robotic
    surgery for rectal cancer A bird's eye
    view." Journal of minimal access surgery 11.1
    (2015) 29.
  • Serra-Aracil, Xavier, et al. "Hybrid NOTES TEO
    for transanal total mesorectal excision
    intracorporeal resection and anastomosis." Surgica
    l endoscopy 30.1 (2016) 346-354.
  • Bendl, Ryan, and Roberto Bergamaschi. "Transanal
    TME a bum rap?."Colorectal Disease 18.1 (2016)
    7-8.

34
Credits and References
  • Pictures/ Graphs
  • Timeline
  • en.wikipedia.org
  • quotesgram.com
  • ramb.elsevier.es
  • bulletin.facs.org
  • Transanal TME
  • www.wjgnet.com
  • www.scielo.br
  • www.oapublishinglondon.com
  • laparoscopyhospital.com
  • Robotic TME
  • www.emaze.com
  • www.youtube.com

35
Thanks!
  • Any questions?
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