Roboterassistierte Rektumkarzinomchirurgie

 

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Zusammenfassung

Hintergrund: Die onkologischen Ergebnisse in der Therapie des Rektumkarzinoms konnten in den letzten Jahrzehnten deutlich verbessert werden. Gründe sind hier vor allem die Einführung des chirurgischen Konzepts der totalen mesorektalen Exzision (TME) und die Implementierung multimodaler Therapiestrategien. Zudem konnte gezeigt werden, dass die onkologischen Ergebnisse der offenen und laparoskopischen TME vergleichbar sind. Seit geraumer Zeit wird nun kontrovers über den möglichen Stellenwert robotergestützter Assistenzsysteme in der Viszeralchirurgie diskutiert. Ziel dieser Arbeit war es daher, die operativen und perioperativen Ergebnisse von Patienten zu erfassen, die aufgrund eines Rektumkarzinoms bzw. Karzinoms im rektosigmoidalen Übergang mithilfe des Da-Vinci®-Systems operiert wurden. Patienten und Ergebnisse: Retrospektiv wurden die Ergebnisse von 202 konsekutiven Patienten ausgewertet, die zwischen September 2010 und November 2015 in 3 viszeralchirurgischen Zentren behandelt wurden. Das Kollektiv bestand aus 136 Männern und 66 Frauen mit einem durchschnittlichen BMI von 28. Hierbei wurden folgende chirurgische Eingriffe durchgeführt: 49 anteriore Rektumresektionen, 119 tiefe anteriore Rektumresektionen und 34 abdominoperineale Rektumexstirpationen. Bei 13 Patienten war eine Konversion auf ein offenes Vorgehen notwendig. Insgesamt traten bei 62 Patienten (31 %) chirurgische Komplikationen (n = 67) und bei 24 Patienten (12 %) nicht chirurgische Komplikationen (n = 27) auf. Führend waren hier abdominelle bzw. sakrale Wundheilungsstörungen (n = 25) und Anastomoseninsuffizienzen (n = 18). Die Mortalität innerhalb von 30 Tagen lag bei 2 %. Die R0-Resektionsrate betrug 95 %, wobei die zirkumferenzielle Absetzung in 98 % der Fälle negativ war. Die TME-Qualität wurde histopathologisch in 91 % der Fälle als gut bewertet. Schlussfolgerung: Das Da-Vinci®-System kann in der Rektumkarzinomchirurgie komplikationsarm und zuverlässig eingesetzt werden. Auch wenn die aktuelle Datenlage darauf hindeutet, dass die Ergebnisse mit der offenen und laparoskopischen Chirurgie vergleichbar sind, wird eine endgültige Bewertung erst nach Veröffentlichung der Ergebnisse der prospektiv-randomisierten ROLARR-Studie möglich sein. Vorteilhaft ist das System vor allem durch die hohen Freiheitsgrade seiner abwinkelbaren Instrumente und die verbesserte Visualisierung (3D, stabile Kameraführung durch den Operateur). Positiv ist zudem der deutliche ergonomische Vorteil für den Chirurgen selbst.

Abstract

Background: The oncological outcome of patients with rectal cancer has improved considerably over the past few decades. This is mainly due to the introduction of the surgical concept of total mesorectal excision (TME) and the implementation of multimodal treatment strategies. Additionally, it has recently been demonstrated that the oncological results of open and laparoscopic TME are comparable. For some time there has been an ongoing debate on the potential relevance of robotic assistance systems in visceral surgery. The aim of this study was to evaluate the operative and perioperative outcomes of patients with rectal or rectosigmoid cancer, who were operated on using the Da Vinci® Surgical System. Patients and Results: We retrospectively analysed the outcomes of 202 consecutive patients, who were operated between September 2010 and November 2015 in three Surgical Centers. The cohort consisted of 136 men and 66 women with a mean BMI of 28. We performed the following procedures: 49 anterior rectal resections, 119 low anterior rectal resections, and 34 abdominoperineal excisions. Conversion to an open procedure was required in 13 patients. Non-surgical complications (n = 27) occurred in 24 patients (12 %) and surgical complications (n = 67) in 62 patients (31 %). Most complications were due to abdominal or sacral wound infections (n = 25) and anastomotic leaks (n = 18). The mortality rate within 30 days was 2 %. The rate of R0 resections was 95 %, with circumferential resection margins being negative in 98 % of the patients. The quality of the mesorectal resection was scored as good in 91 % of the patients. Conclusions: The Da Vinci® Surgical System can be used safely and with a low complication rate for surgical treatment of rectal cancer. While primary evidence suggests that the outcome of robotic-assisted surgery is comparable with open and laparoscopic surgery, its definitive value has to be determined upon publication of the prospective randomized ROLARR trial. The main advantages of the Da Vinci® system are its endowristed instruments with multiple degrees of freedom and its optimised visualisation (3D, stable camera platform controlled by the surgeon). Another positive feature is the significant ergonomic advantage for the surgeon.

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