What are the guidelines for robotic cancer surgery?

Guidelines for Robotic Cancer Surgery

Robotic-assisted surgery is an acceptable minimally invasive approach for cancer surgery with comparable oncologic outcomes to traditional laparoscopy, and should be preferentially considered for obese patients, those with complex anatomy, or higher anesthetic risk, though it remains under evaluation for rectal cancer and requires experienced centers. 1

Gynecologic Malignancies

Endometrial Cancer

• Minimally invasive surgery (including robotic) is the preferred approach when technically feasible and is considered a quality measure by the Society of Gynecologic Oncology and the American College of Surgeons. 1, 2
• Robotic approaches perform similarly to laparoscopy with comparable or improved perioperative outcomes for surgical staging of early-stage endometrial carcinoma. 1, 2
• Oncologic outcomes (disease-free survival and overall survival) appear comparable to other surgical approaches, though longer-term outcomes are still being investigated. 1
• Robotic surgery results in less frequent conversion to laparotomy compared to laparoscopic approaches, especially in heavier patients. 1, 2
• The procedure is safe and feasible in patients at higher anesthesiologic risk. 1, 2
• Standard surgical procedure includes total hysterectomy with bilateral salpingo-oophorectomy and surgical staging with lymph node assessment when indicated. 1
• Intraperitoneal morcellation must be avoided to optimize oncologic outcomes—endometrial carcinoma should be removed en bloc. 1, 2

Technical Advantages in Gynecologic Surgery

• Robotic surgery offers improved dexterity through wristed instruments, which may improve complex dissection techniques such as para-aortic lymphadenectomy. 2
• The technology provides three-dimensional camera vision, superior precision, elimination of operator tremor, and decreased surgeon fatigue. 3

Colorectal Cancer

Rectal Cancer

• Laparoscopic/robot-assisted radical rectal cancer surgery offers advantages of minimally invasive and anus-preserving procedures, but long-term oncological efficacy still needs further evaluation and is recommended to be performed in experienced centers only. 1
• Robotic-assisted rectal cancer surgery provides some technical advantages for surgeons compared with conventional laparoscopy, but is still under evaluation. 1
• The standard of care remains total mesorectal excision (TME), implying meticulous excision of all mesorectal fat including all lymph nodes. 1
• For low rectal tumors, transanal TME may facilitate pelvic and distal mesorectal dissection, but standardization and assessment of the technique are necessary. 1
• Surgeons should consider their experience with the technique, stage and location of cancer, and patient factors such as obesity and previous abdominal surgery when selecting robotic versus open surgery. 1

Surgical Staging Principles

• Mid-low rectal cancer should undergo TME, while upper rectal cancer should undergo wide mesorectal excision (removal of at least 5 cm of the rectal mesentery). 1
• Prophylactic dissection of lateral lymph nodes without confirmed imaging diagnosis is not recommended. 1

Patient Selection Criteria

Ideal Candidates

• Obese patients are particularly good candidates for robotic surgery due to reduced conversion rates to laparotomy. 1, 2
• Patients with complex pathology or large uteri may benefit from robotic approaches. 2
• Select premenopausal women with stage I endometrioid cancer may safely undergo ovarian preservation. 1

Contraindications and Limitations

• Laparotomy may still be required for elderly patients, those with very large uterus, or certain metastatic presentations. 1
• Approximately 26% of patients may need conversion to laparotomy due to poor visibility, metastatic cancer, bleeding, increased age, or increased body mass index. 1

Preoperative Considerations

Patient Preparation

• Discussion with the patient regarding benefits, potential risks, complications, and alternative treatments is mandatory, followed by informed consent. 3
• Appropriate preoperative evaluation including laboratory and imaging tests should be performed depending on the procedure type. 3
• Bowel cleansing should be considered for appropriate procedures. 3

Facility Requirements

• Robotic surgery requires an appropriate surgical suite to accommodate the patient side cart, vision system, and surgeon's console. 3
• Surgical personnel must be properly trained with robotics technology. 3
• The procedure is equipment-intensive and requires proper port placement configuration and appropriate instrumentation. 3

Cost Considerations

• Costs for robotic equipment and maintenance remain high, which is a significant disadvantage. 1, 2
• This may be partially offset by shorter hospital stays and fewer complications. 2
• The Society of Gynecologic Oncology, American Association of Gynecologic Laparoscopists, and American Congress of Obstetricians and Gynecologists have published guidelines addressing cost issues. 1

Common Pitfalls to Avoid

• Do not perform robotic rectal cancer surgery outside of experienced centers given the ongoing evaluation of long-term oncologic outcomes. 1
• Avoid intraperitoneal morcellation in all cases to optimize oncologic outcomes. 1, 2
• Do not assume robotic surgery is appropriate for all patients—consider conversion risk factors including age, obesity, and surgical complexity. 1
• Ensure adequate training and facility resources before implementing robotic surgery programs. 3