Minimally Invasive and Robotic Colorectal Surgery Updates

My supervisor from the O.R. called me up last week to tell me two good news. One I'd like to keep for myself awhile longer, the other was about a seminar on Minimally Invasive and Robotic Colorectal Surgery which will be held in Diamond Hotel in Manila. I was still in shock when she called me up that I'm not sure if I heard the title of the seminar correctly. I think all I heard were the terms... Robotic, surgery and seminar. She encouraged me to attend in preparation for the first news I got from her. :) 

I already attended a seminar of similar nature which involved basic instrumentation when it comes to laparoscopic surgeries. That was when I first met Maryland, the 9 million worth Tower, trochars of different sizes, grasper and metz. Back at work, I've managed to assist in several Laparoscopic cholecystectomies. I've learned to appreciate the wonders of Minimally Invasive surgeries having spent most of my time assisting in open surgeries. In Lap Chole, the patient is still put under General Anesthesia but a large difference was in the incisions made and the estimated recovery period of the patient. Undeniably, the trend in surgeries have shifted drastically through the years from the traditional open surgery to Laparoscopic surgery and now Robotic Surgery.

LAPAROSCOPIC COLORECTAL SURGERY

Let me talk about Laparoscopic Colorectal surgeries first because it's relatively new here in the Philippines. It's not yet done in USTH because we've managed to assist mostly in Lap Chole Cases and I've heard that they also do Lap Appendectomies in the Pay division, however Lap Colorectal surgery is all together new and in my opinion amazing. It is already done in the Philippine General Hospital with surgeons trained outside of the country. Most are Laparoscopic assisted cases but they've also done total Lap surgeries. Fascinating. MIS techniques have definitely been incorporated even in rectal cancer management. 

I must admit that the open surgical management of Colorectal cancers are tedious and usually subjects the patient to a longer recovery period. I will only talk about the role O.R. nurses like myself have on the surgery. I vaguely remember assisting in surgical procedures like extended hemicolectomies, right, transverse or left. And there are times when almost majority of the Bowel is removed. Tedious because the surgeons take great care in preserving the marginal arteries. That's where your fine tip kellies, silk ties and scissors play hand in hand. Wait for the resection of the affected Colon and prepare you ochsners and angulated clamps and the most tedious part of it all... the anastomosis if possible. No to mention preparing a double set up for surgeries like APRs. 

The Beauty of Minimally Invasive Surgeries is that large incisions are minimalized to a few darting holes. instead of sporting large battle wounds, you can now get away with just a few scratches, minimal stitches and probably some band aids. In the said seminar the organizers allowed us to familiarize ourselves with different instruments used in the procedure. I've met Endo GIA used in complete Laparoscopic procedures, Circular Staplers for rectal anastomosis used for mid and low rectal tumors, linear staplers for Lap assisted cases and the TA 45 cutter that cuts ands staples at the same time again for Lap assisted cases. Goodbye suture entanglements! :)

What are the advantages of Minimally Invasive (Laparoscopic/Robotic) Surgeries?

• smaller surgical incisions
• a fairly acceptable cosmetic result
• earlier return of bowel function for Laparoscopic colectomies
• reduced postoperative adhesions ( the less manipulation done, the lesser the inflammation that comes with it)
• Better operative exposure
• Preoperative Bowell Preparations usually not required
• Less operative pain
• reduced hospital stay
• quick recovery and return to full activity
• fewer wound infections

Convinced? How do you know then if you are fit to undergo MIS? the patient must not:

• previous abdominal surgeries done
• suffer from coagulation problems
• suffer from Congestive heart failure and
• Cardiac diseases or COPD's

Every Surgery entails risks, with MIS...

• there is always a possibility to convert to open surgery. That's why a set is always on stand by for possible open.
• Peritonitis from Carbon Toxicity, the peritoneum is insuflated with Carbon Dioxide to expand the working space.
• Incisional Hernias

Just a quick reminder for OR nurses, Lap Collorectal surgeries are a little bit different from Lap Chole's. Sometimes the tumor cannot be located through the cameras and an intra-op scope may be required. Most of the time though the location of the tumor is tattooed during colonoscopies. Another reminder emphasized by Dr. Paul Lopez from PGH is the need to always ready a major set because sometime in the operation they will need to make an incision in order to extract the specimen. There are new techniques though where an incision is not made anymore and the extraction is done transanal.  

Recent advances in surgery include single port access (scarless) surgeries where specimens can be extracted through the umbillicus which is a natural orifice thus the scarless effect used in simple Laparoscopic surgeries like Lap Appendectomys and Cholecystectomys. In Colon Surgeries, surgeons have adapted a "Hybrid" Technique where the specimen is extracted through the rectum oviating the need to extend the incision. 

ROBOTIC SURGERY

Now that we're done with Lap and Lap assisted cases I'd like to talk about my favorite part of the seminar.

Let's talk about Da Vinci!

I've encountered Da Vinci in one of my favorite medical Dramas: Greys Anatomy, he's the robot Dr. Baily's inlove with! The good news is there are already two Da Vinci's here i the Philippines! Yey! We have one in The Medical City and in St. Lukes Global City! 

In a Robotic Asssited Surgery, the surgeon performs the procedure via a special viewing and control console. The console controls the Robotic arms with all the endowrist instruments (precise instrumentation and comparable to wrist motion of the human hand) attached with it. The robotic arms are inserted into the body through small incisions similar to laparoscopic surgeries. The instruments are smaller, more precise and easily movable for easy disection and suturing. The surgeon's view of the operation is in 3D through the console.

What are the common applications of Robotic Surgery? According to the seminar, the most common applications are:

• Prostate cancers
• Kidney cancers
• Urinary bladder cancers
• Colorectal cancers
• Gynecologic tumors and
• Thyroid conditions

Advantages of Robot Assisted Surgery:

• limited damage to muscles, blood vessels, nerves and other surrounding tissue
• minimal blood loss
• relatively less operative pain thus less pain medications
• minimal infection risk
• minimal scarring
• relatively shorter hospital confinement
• faster recovery and return to normal body function

Amazing isn't it? The times are changing indeed. :)

I am open to corrections, a girl can do so much note taking, I might be wrong in some parts of the article feel free to correct me. 

credits go to the Operating Room Nurses Association of the Philippines, Surgeons at the Philippine General Hospital