EARLY EXPERIENCE OF FULLY ROBOTIC COMBINATION PROCEDURES WITH THE DA VINCI XI - COLORECTAL RESECTIONS FOR CANCER COMBINED WITH OTHER MAJOR SURGICAL PROCEDURES

PURPOSE The new da Vinci Xi® has been developed and released to overcome some of the limitations of the previous platform, therefore increasing the acceptance of its use in robotic multi-quadrant operations. The new characteristics could have an important role in colon-rectal surgery and particularly in attaining fully robotic colon-rectal resection combined with other major surgical procedures. The aim of this study is to evaluate the pre-operative results of totally robotic colorectal surgery for cancer in association with other major procedures with Da Vinci Xi. METHODS We reviewed the charts of all patients undergoing fully robotic combination procedures involving colon-rectal resections using the Da Vinci Xi, from January 2015 to October 2015. Variables that were examined included patient demographic characteristics, pre-operative data such as trocar position, technical aspects, operative time and robot dock/undocking times. Postoperative variables included the length of hospital stay, morbidity and mortality. Ten patients were included in this study, including 12 colorectal procedures: 5 right hemi-colectomy and 5 anterior rectal resections with TME were performed in combination with sigmoidectomy (1), right nephrectomy (2), hysterectomy (1), hepatic resection (3), enucleation of pancreatic tail lesion (2) and ileo-cecal resection (1). RESULTS All the operations were completed by a fully robotic approach, without conversion to hand assisted laparoscopy or laparotomy, and without hybrid approaches or need of changing of robotic cart position. Trocar positions respected the Universal Port Placement Guidelines provided by Intuitive Surgical for “left lower quadrant”. Simultaneous procedures in the same quadrant or left quadrant and pelvis, or left/right and upper, were performed with a single docking/single targeting approach; in cases of left/right quadrant or right quadrant/pelvis, we performed a dual-docking operation where we re-targeted using the camera to orient the system towards the new work space (an opposite facing quadrant) and re-docked the remaining arms. No external collisions or problems related to trocar positions were noted. Mean overall procedural time was 360 min (±128min). No patient experienced postoperative surgical complications and the mean hospital stay was 6 days (±3days). DISCUSSION In our early experience we were able to complete all procedures with a full robotic approach, without the necessity to associated or convert to a laparoscopic approach. Thanks to the targeting function of the Da Vinci Xi, the robot re-targeting could be enough in combined surgical operation of the same hemi-abdomen. This procedure allows us to obtain a new improved alignment of robotic arms. Instead, in the case of left/right quadrant, it was necessary to re-target using the camera to orient the system towards the new work space (an opposite facing quadrant) with 180°-boom rotation and then re-docked the remaining arms. However, this procedure is simple and not time consuming as it was only necessary to rotate the boom without changing cart’ position. These types of combined surgical procedures were not possible with the da Vinci Si. In fact with the previous system, it was mandatory to undock the robotic arms, disconnect and change the cart’ position in the opposite side of the operating table and finally re-docked the Da Vinci System. These maneuvers leads to both a substantial increase in operating time and difficulties in moving the bulky robotic cart. The limitations of Da Vinci Si were overcome by the new realized product Da Vinci Xi. We tried to suggest an initial proposal for standardized surgical procedures’, trying to define the best trocars’ position for combined surgical operations that would not requires an additional trocar position or problems with instruments collision. In our opinion the trocars’ position described in the this present experience allows us to perform operations in all abdominal quadrants without major movements thus only changing robotic arms’ position, rotating the boom or exploiting the targeting function. In fact, in all cases we were able to perform all surgical procedures without the need of additional robotic trocar, completing the surgical procedure with a full robotic approach and no robotic arms clashing or an excessive time needed for the re-docking was reported. CONCLUSIONS The herein presented high success rate of robotic colorectal resection combined with other surgical interventions for synchronous tumors, without conversion or excessive operating time, suggests the efficacy of the new released product Da Vinci Xi, in minimally invasive multi-quadrant combined surgery. A further possible advantage may be provided by da Vinci Xi Integrated Table Motion feature (available only in the EU), that allows patients to be repositioned without undocking the robot and without removing instruments inside the abdomen