S. WEXNER minimally invasive colorectal surgery The early days

Buongiorno professor Weiner, benvenuti al nostro congresso in Roma.

Per il prof. Palazzini vi saluto e vi divertiremo della vostra lezione.

Ok, mille grazie, buongiorno a tutti.

Grazie a lei.

Ok, prego. Questa lettura sarà in inglese, ok?

Sì, sì, sì, assolutamente, in inglese.

Ok, ma dopo i domande in italiano, ebbene, ok?

Ok.

Quindi, l'evoluzione della colorectalia laparoscopica.

Nella prossima mezz'ora parleremo dell'evoluzione della colorectalia laparoscopica

e poi possiamo rispondere a alcune domande.

Sto parlando di una posizione preferita per molti chirurghi italiani durante il febbraio,

We hope to see many of you at our upcoming 25th annual course.

We started laparoscopic colorectal surgery at the end of 1990, so just close to 23 years ago.

David Jagelman and I and a few other American surgeons embarked upon learning this technology.

At that time there were a few small publications coming out.

This one from the Mayo Clinic in Scottsdale, Arizona, showing that the right colon could

be mobilized and then using some instruments available at the time with six ports, an extracorporeal

anastomosis could be performed.

Near here in Miami, Florida, around the same time, Moses Jacobs from the University of

Miami and Baptist Hospital showed a little bit larger series, a cohort series, and showed

Grazie a tutti.

on total proctocolectomy.

Now it's interesting when people

talk about no conversion in the early

1990s. The intent

was sometimes just to do a

laparoscopic mobilization and then

make a rather generous fan and steel

incision through which

vessels were divided and the

bowel was resected and anastomosis

was created. So it's

a little bit hard to tell what no conversion

means in this group of patients.

L'abdominocollectomia totale è stata realizzata in un contesto più grande

l'anno scorso, quando David Jagelman e io abbiamo pubblicato il nostro primo gruppo di casi

in una studiata prospettiva, che si trattava di un'abdominocollectomia totale

che si trattava di un'opera laparoscopica contro un'opera aperta.

Here, or midline incision here, so we have a phantastial or midline, not like now, where we take things out through the umbilicus, the anus, the vagina.

This was a very different kind of surgery, but it was our starting point.

Even doing it that way, we still found that we were able to give patients a benefit, at least in terms of cosmesis.

It was better than a standard laparotomy.

early on within the first few years we made it clear that laparoscopic colorectal surgery was

feasible we were still not quite sure about the benefits but as we've progressed it became very

apparent that often through three ports we could perform a mobilization divide vessels resect

bowel perform an anastomosis and give the patient's quicker bowel function recovery

e quindi un'esperienza ospedale meno costosa,

tutto ciò che ha portato la laparoscopia ad una crescita dell'adopzione.

Se vediamo alcune altre malattie che abbiamo iniziato a curare,

questa è una studia che abbiamo pubblicato su diverticulitis 16 anni fa,

una studia comparativa che si tratta di pazienti con scopi di scopo adattati.

E si può vedere che il tempo di operazione era più lungo

nel gruppo laparoscopico,

group, but the length of stay was shorter, so despite a longer operative time we had

a shorter hospital stay and particularly in the HINCI-1 patient, so in the earlier diverticulitis

we had a pretty big benefit early on, we felt that laparoscopy was the way to go for diverticulitis

and clearly that's been borne out over the years.

We looked at Crohn's disease, particularly patients with fistulas and diverticulitis

patients with fistulas, and we've recently just updated that series for the 2014 American

Cytocon Rectal Surgeons, but these early series show that we did not give the patients any

adverse outcomes by doing this.

We had similar morbidity as compared to our simpler laparoscopic procedures.

Bemelman in Europe and the Netherlands looked at cosmesis, and I honestly think this is

This is one of the things that really kept us driving forward as we looked at reduced pain, reduced length of hospitalization, earlier oral intake, less cost.

These are all transient things.

The things that really are the take home for the patients, the smaller incision obviously, any long term reduction in hernia formation, obviously any reduction in disease recurrence.

So here in the Bemelman study they looked at patients with Crohn's disease who underwent either laparoscopic procedures or laparotomy and they assessed the patients with validated instruments as to their cosmetic results and found that there was significant superiority in favor of the laparoscopic group.

At the Mayo Clinic in Scottsdale, again, Tonya Young-Fadek looked at laparoscopic iliocolic resections,

finding the same thing again, better cosmesis in these patients,

but she also started to find some things that we hadn't seen before very clearly.

Operative time started to decrease.

Yes, it was still significantly increased, but it was no longer double what it used to be.

The length of stay was almost half, and very importantly, the cost was less.

So despite the fact that the OR times were still longer to some degree and we're maybe

using more disposable instruments, the cost to the system was less.

And she felt that laparoscopic ileocolic resection had significant advantages compared to open

procedures.

Resection rectopexy, another operation that might be very well suited to laparoscopy,

one of the earlier series showing that you could just mobilize the rectum and perform

essenzialmente qualsiasi cosa che voglia

puoi fare una resezione rectopexica

resezione con un'antioresezione

rectopexica sola

questa alternativa laterale è probabilmente

la migliore adattata alla laparoscopia

perché non stai adattando una specie

e quindi non hai bisogno di nessuna incisione

se guardi qui puoi vedere

ciò che è generalmente conosciuto

nella serie laparoscopica precedente

che i procedimenti laparoscopici

prendevano due volte il tempo

177 vs 86 minuti

quasi esattamente due

ma nonostante sia diventata doppia, la lunghezza di restazione è diventata mezza.

Quindi non è il tempo in cui si sta in OR, ma è il trauma al paziente

che ci ha attaccato come qualcosa di importante,

perché nonostante questo periodo di operazione più lungo,

i pazienti stanno mangiando prima di uscire dall'ospedale.

Peter Marcello ha studiato un caso simile

dell'opinione contro la proctocollectomia laparoscopica,

e, di nuovo, ha detto che non c'erano convergenze,

ma se si ritorna a leggere alcuni di questi paperi precedenti,

it's very hard to know what conversion meant

when the incisions are sometimes 15 centimeters in length

but nonetheless laparoscopy still was able to confer

early return of bowel function and a shorter length of stay

again despite the increased operative time

so again here Peter's added about 50% to the length of surgery

from 225 to 330 minutes

but halved the amount of time needed for bowel function return

hospital stay didn't change

now why is that?

Il stato ospedale non cambia in questi pazienti perché hanno le iliostomie,

spesso molto proxime le iliostomie, perché le stomache sono afferenti a una pacchetta ileale

e sono spesso stomache con un alto rischio di dehydrazione.

Questi pazienti devono essere ben idratati, dobbiamo monitorare benissimo le loro output

e, in aggiunta, devono imparare la cura del stomaco a casa prima di essere dischargati dall'ospedale.

Il gruppo della clinica di Lahey ha sentito che questo stato ospedale di un giorno più corto

hospital stay and significantly improved cosmesis was achieved with a prolonged operative time

and after a decade of working with the same team.

So this is why this particular operation probably took longer than others to really become popular.

But the real holy grail, if you will, for laparoscopic surgery is cancer, because this is the issue.

Can we do better for cancer or are we doing something detrimental to the patients?

I think the first trial that answered this was Anthony Lacey's trial in Barcelona,

the Soco Barcelona trial, and Tony looked at 217 patients, very well matched.

I'm sure you're all familiar with the trial, but I think every so often it's good to review

these things to see why we do what we do.

So if we look at tumor occurrence rates, we actually now see a trend towards a higher

rate of recurrence in the open versus the laparoscopic group this is putting aside all of

the other benefits which we know we've conferred such as decreased pain earlier return to diet

earlier ambulation earlier discharge from hospital less cost and better cosmesis but now we're

starting to look at something that's oncologically meaningful and if you look at the cancer related

So there's not a significant difference in survival in stage one or two,

but when we get to stage three we see a big divergence in these survival curves

suggesting that we can perhaps do a better operation laparoscopically than we can open,

at least when it's done by a single team in a high volume center.

It might be very, very different than what was found in some other trials.

However, that result was reproduced in Italy, Mario Marino in Torino, a professor of surgery

in Torino, Italy, looked at 191 consecutive patients, pretty well matched, and again found

a very large difference for rectal cancer.

Lacey's trial was not rectal, this is rectal cancer, and about a four-fold difference for

rectal cancer.

Now, he's a very modest guy, everybody there in Italy knows him, and he's not going to overstate the claim,

but I'll overstate it for him, that when a single surgeon with expertise and high volume repeatedly performs these procedures,

we can confer a significant benefit to the oncologic outcome when we perform these procedures in a minimally invasive way.

That is not true in the multi-center trials where people are putting in two or three or six patients each over five years,

versus putting in, as these two gentlemen have done,

roughly 200 patients in each of these two trials.

And here's the point of the multicenter trial.

We began this trial, began to design this trial in 1993.

Heidi Nelson, Bob Beer, Jim Fleshman, myself, Dave Beck,

a variety of others started to design this trial.

We had an idea that we were going to randomize 1,200 patients

in 20 institutions, operating on them over two years

and then following them up for another two years

and at the end of four years have data.

That would have been 1997.

As you can see, the result didn't come out until 2004,

seven years later.

In addition, we didn't have 20 institutions as planned.

We had 48 because we needed more people to accrue patients

because patients weren't being randomized.

We also had the statisticians go back

and recalculate our power analysis

e non avevamo 1.200 pazienti, avevamo 872

e non li seguivamo per 5 anni, li seguivamo per 4.4

il rischio di conversione era del 21%

che è arguabile perché tutti hanno una definizione diversa di conversione

ma nonostante questo, guardiamo il tempo di recurrenza

e si può vedere che per 4.4 anni non c'erano differenze in recurrenza

ora, questo era supposto essere un trattamento non inferiore

e si è provato non inferiore

That was the aim, not to show it was better, but just that it was not inferior.

And regardless of what stage you look at, these curves are very different than they were in Antonio Laci's trial.

No differences, no divergence, not for any stage for survival.

So, unlike Marino for rectal cancer, unlike Laci for colon cancer, we didn't see any differences in oncologic outcomes, similar, equivalents.

However, this presentation at the May meeting of the American Society of Colon and Rectal Surgeons

and then followed by the New England Journal publication that same week in May 2004

was the green light in the United States to begin performing laparoscopic resection for colon

without fear that it was doing some harm to the patient.

Over time we've reassessed the data and a few years later Jim Fleshman presented

La prima è la 5-year disease free survival for our patients and again no difference is laparoscopic and open at all regardless of stage.

The equivalent trial in the UK is the classic trial.

They used 27 institutions and had a roughly similar number of patients to us, 794 patients and a roughly similar conversion rate of 29%.

The one difference of their trial to ours is they included patients with rectal cancers.

So, they were able to look at what is important in rectal cancer, circumferential margins,

and found that the rate of margin positivity was identical in the two groups, 14 percent, 16 percent.

No difference at all in margin.

And a much more recent follow-up of five-year survival that David Jane recently published,

you can see as you start going down, the only difference is the converted group.

e penso che ci sia un messaggio importante lì, che siamo maturi in grado di conoscere le nostre abilità

e di conoscere il potenziale beneficio, o meno, di un paziente individuo.

E per qualcuno di partire dalla laparoscopia conoscendo che c'è una piccola probabilità di successo

e conoscendo che si convertiranno, non sta aiutando il paziente.

Questo paziente avrà una migliore sopravvivenza.

However, if you have good, appropriate laparoscopic skills and reasonable patient selection,

laparoscopy is no different than open surgery for oncology,

but of course still retains all the differences we spoke about earlier

for earlier recovery and less pain and shorter hospital stay and less cost and less morbidity.

This suggests that not everyone should be trying things laparoscopically.

It is better to do it open than to pretend to do it laparoscopically and early to convert.

So, again, that is the oncologic safety in this trial.

Now, some of the more measurable parameters, the objective parameters, like lymph nodes, for example,

you can see here in the recent study in Journal of Gastrointestinal Surgery, no differences at all,

open versus laparoscopic TME in either the number of nodes or node positivity

and no significant difference in circumferential margins,

although with a larger denominator one might surmise that 4% and 9%

are indeed statistically significantly different as we go from laparoscopic to open

and one can imagine how Mario Marino's result or Antonio Laci's result

When you start getting these differences in margin positivity for rectal cancer.

We recently published data from Marilise Boutros and Mariana Berro,

our head of pathology and lab medicine,

looking at patients who underwent open versus laparoscopic surgery for rectal cancer.

You can see fairly well matched groups of patients.

There are some differences in surgeon in each group, lap versus open,

but that's a bit hard to control for.

The completeness of TME

was not any different between the groups.

The little bit better margin, perhaps,

the numbers of lymph nodes harvested

was significantly better in the laparoscopic group.

So again, this points to the same issue

that we see from the SARA study,

that we seem to be doing perhaps a higher ligation,

perhaps a better total mesoerotic excision,

a wider excision of tissue.

e non è più fatto dove si può dire che una procedura successiva di laparoscopia

contiene una incisione di 7 centimetri.

E' tipico che la più grande incisione, in un paziente dopo colo-anilinastomosi

per il cancro, la più grande incisione finisce con la chiusura del stomaco

perché ci sono alcune adhesioni attorno al stomaco necessitando di questa incisione

di essere spingita, invece di la incisione per creare il colone J

per iniziare, e è spesso il caso.

La stoma non è ancora completamente curata,

e questo è il motivo per cui ho preso la foto,

ma questo è il risultato più grande dell'incisione.

Quindi, come spesso si fa la laparoscopica colorectale

negli Stati Uniti?

Questa è una domanda

proprio come punto di riferimento

che Constantino Mavrantonis ha messo fuori

quando era un collega qui.

Adesso è il vice-surgente

in Grecia, in Atene,

all'Hospital di Anri Dunan.

Ma Constantino ha messo fuori

questa domanda

and you can see the answer

at that point in time

only 8% of surgeons

in the US, these are SAGE's

and ASCR's members, would have had a rectal cancer

operated upon laparoscopically

if we look at the case log

so rather than asking opinion

of what people would do in a hypothetical setting

let's see what they actually did do

in a real setting

and these are data from Dave Schetz

our executive director of the American Board of Colonial Surgery

sharing the percent

of laparoscopic resections done by colorectal fellows case logs, and you can see back in

the mid-90s when we started to disseminate this, there were one or two programs besides

ours at which laparoscopic surgery is done, particularly low anterior resection, particularly

for rectal cancer, and remember Heidi Nelson's publication was here, 2004, so you see colon

cancer starting to creep up a little, but the real explosion both in colon and rectal

cancer because people extrapolated was after that presentation in 2004. The percent of

all abdominal operations performed laparoscopically by trainees in the North American colorectal

programs increased from 3.6% to 24.3% by 2005 and that number is now over half. Similar

questionnaire survey, now fast forward from the Mavrentonis survey to Hussein Malou's

study 2009, surgeons in Canada, and you can see that now that number is up from 18% colon

and 6% rectum to 76% laparoscopically.

More recent review in the Journal of the American College of Surgeons, 48 hospitals over this

time period, you can see a roughly doubling in the percent of cases performed laparoscopically.

the greatest increase in laparoscopic colorectal surgery

was at centers in which laparoscopy was more commonly used.

That may not make sense, I'll try and explain it,

which is if you're working in an environment

where you have someone like Raoul Rosenthal

doing bariatric surgery and all of his team

and you have people doing laparoscopic

or other minimally invasive urology and GYN,

you're far more likely to embrace laparoscopic colon surgery

versus if you're at a center where you have other surgeons like GYN and urology and general surgery performing open procedures.

This is a national database review of colorectal resections performed in 380 hospitals

and you can see the lines creeping up.

The percent of laparoscopic cases going from under 40% to a little bit over 40%

and a commensurate decrease, because of course the number has to add up to 100%, commensurate

decrease in the number of open cases, that trend has certainly continued.

Gynecology, it's been potentially a more dramatic increase, but when we look at the colorectal

operations and others, here's bariatrics, almost 100%, antireflux surgery, gastroesophageal

di reflux disease, nissen fundoplications and the like, appendicectomy, cholecystectomy,

but even in 2012, colectomy still roughly hovering at about half and rectal resection

still under 20%.

What might contribute to improved adoption?

Well, I like to think as a past president of SAGES that the units we created there,

FLS and now FES, help because these are skills validations and educational tools to ensure

Grazie a tutti.

consider putting a hand in as a conversion so this is a subject of debate single incision a way to

try to minimize incisions even more the robot and then notes natural orifice transluminal endoscopic

surgery really championed by dave ratner and and rob halls and a couple of others back about six

or seven years ago and hasn't really taken off as quickly as we'd like but let me touch on these two

This is a Newsweek article from eight years ago, which really makes it look very appealing.

If you're the patient and you look at this advertisement in the magazine, you think,

wow, if I have surgery, what a sophisticated way.

I'd love to get my surgery done with a robot.

And marketing was done absolutely all over the United States for robots.

How have those studies borne out?

Well, let's look at some of the more recent ones.

This is TME, again, TME specific, which is mostly where we're told it's good.

29 robotic, 37 laparoscopic, no advantages at all, and no longer owe our time.

Now remember, when we compare laparoscopic to open, we see less blood loss, we see less morbidity,

We see more lymph nodes being retrieved and we see better margins

and in the single surgeon high volume studies like Lacey and Marino

we see decreased recurrence rates.

So there are five variables for which laparoscopy is superior to open

but none for which robotic is superior to laparoscopic

and you'll remember that laparoscopic is already longer than open

and now we're adding even more time.

Baik, che credo sia sicuramente il padre di una chirurgia colorectale robotica,

i suoi pazienti tendono a avere una BMI di meno di 20,

molto a differenza dei pazienti che abbiamo qui in America del Nord

e di molti altri pazienti in Italia,

molti pazienti molto, molto piccoli, quindi dovrebbe essere facile.

Inoltre, ciò che è riuscito a trovare è che

che stava sfruttando meno nodi nel gruppo robotico,

una rata più alta di un leak anastomotico,

ma altrimenti, ancora una volta, non c'erano benefici qui.

Ricordate, open versus laparoscopico,

vi ho mostrato i dati,

un ritorno più veloce della funzione,

non è vero aggiungere il robot,

una ritorna più corta,

non è vero aggiungere il robot,

una ritorna più bassa,

non si trova nessuna vantaggia con il robot,

OR times equivalente,

quindi nessuna vantaggia in nessun parametro.

study out of Hong Kong, another place with very surgeon-friendly patient body habituses,

again adding another hour or so laparoscopically, sorry, robotically, and again no differences.

We saw in our own study, amongst others, better node yield laparoscopic to open, no addition

by adding the robot, no advantages in any of these things at all, certainly anastomotic

with a rate of leaks of 13.6%.

Another study, a three-way comparison,

looking at open laparoscopic and robotic operative times,

actually now have decreased,

but again these are Asian studies,

which is a very different patient population.

I've got to emphasize that.

I love operating in Asia

because it's always very easy to see all the planes

and the vessels and the nodes,

but a longer time open,

but robotically that advantage of laparoscopy

is lost the robot fails to shave off that operating room time also when we look at length

of stay there is no gain on laparoscopy morbidity there is no gain on laparoscopy hospital stay

there is no gain on laparoscopy everywhere we go down this list we don't see any added

advantage of the robot patel study looks at hand assisted so another way to look at it

and the hand was able to save a little bit of time

compared to laparoscopy

but the robot managed to consume far more time

than either of those procedures

and there were no differences in nodes

no differences in complications amongst the group

one of the most significant differences

which we can attribute to the robot is cost

and if you're in a system with infinite amounts of euros to spend

I suspect it's a good way to spend some quickly

because here you can see in Bertani's study that the open cost was about 8,000 euros laparoscopic

about 8,000 euros robotic about 10,000 euros so if you're in a frame of mind to add 20% cost

definitely go for it this is the update on bake series in in a finger huts journal and world

journal surgery looking at complications no difference an asthmatic leak no difference

No difference bleeding, no difference ileus, nothing, no difference anywhere down here.

Leading Bake to conclude that there are similar outcomes, much more expensive, much decreased

hospital profit and ultimate cost effectiveness still needing to be assessed.

The other thing we can say about the finances of the robot is while the hospitals may be

losing money, the manufacturer is definitely gaining money.

The robot system is up to 2.3 million in the US, the annual service fee almost $200,000

and the disposables about $2,200 per procedure.

So with that review of robotic I've prepared this slide to highlight all of the proven

benefits of the robot.

Hang on, there aren't any.

Well, that's true.

But I turn your attention back and this highlights why I showed the slides in the earlier part

During the first 10 years of laparoscopic colorectal surgery we had numerous proven benefits in cohort studies, case match studies, randomized control studies.

We knew we were conferring when we added laparoscopy or substituted laparoscopy for laparotomy,

we knew we were decreasing the amount of pain, decreasing the length of ileus, expediting hospital discharge, lessening morbidity, improving cosmesis.

Not one of those things is borne out with adding the robot.

Now there are some theoretical benefits, it might be nicer for us to sit on the side

of the room not scrubbed working on a console rather than having to stand over the patient

in sometimes some difficult positions with their hands, although the hospital will lose

money per procedure with the robot, they may overall make money by marketing that they

have a robot and have patients come in for other reasons and my disclosure here is I

I was a consultant for Computer Motion before they were acquired by Intuitive in 2003.

I have stock options in Intuitive.

This is an amazingly good procedure for me personally.

It's just not good for my patients, so I'm happy that other people are doing it

because there is a definite financial yield for those of us with stock in the company.

But for the patients, sadly to date, there is not a single proven benefit whatsoever.

How about notes? Can we do any better there?

Maybe not the robot, but maybe notes is the answer.

notes is an extension of the platform introduced by the late Gerhard Buis from Tübingen, Germany

30 years ago, an idea that he could get up through the rectum and access lesions even

full thickness and work with them and close the rectum, his initial platform using binocular

vision from the Richard Wolff company has been modified and Karl Storz has two different

models, one with an angled camera, the newer one where you can use any straight laparoscopic

And then there's a variety from Ethicon, from Coviti and from Applied, from everybody

who makes things to do these disposable trans-anal endoscopic surgery platforms.

I thought I'd start out with one of the Italian articles showing trans-anal endoscopic

microsurgery for fistulas, for flaps, for strictures.

This is not just tumors and polyps, treating anastomotic leaks, pelvic abscesses.

So where can you go from that?

Well, maybe we can take the mesorectum from below,

and maybe the total evolution of laparoscopic surgery will be a notes-type surgery.

Lee Swanstrom in Portland, Oregon, and at IRCAD in Strasbourg, France,

along with his colorectal team, has shown that in a cadaver model

you could go up from below and perform a notes-type of TME,

again usually laparoscopically guided

but not laparoscopically undertaken

Pat Silla

working with Dave Ratner

and Andy Warshaw at Mass General

went on to show in a porcine model

that she could get a beautiful

TME specimen

you can see this nice glistening envelope

you can see the amount of tissue at the end of it

and based upon that

went on to do this cadaver study

again showing that she could get

a good quality TME

This may be the next step forward.

I think everybody was so excited by laparoscopy

we were all looking for the next great leap forward

and first we thought that leap might have been

hand assisted or single port or the robot

but it may actually end up being notes.

Having said that, it's going to be hard to learn

and people have to do a high volume of cases

and at present the only way to even contemplate this

This is to be trained in animals, trained in cadavers,

and then conduct any human study under ethical committee or IRB auspices.

So, we've gone through these various areas.

You can see since 1991, when we embarked on these procedures,

the end of early 91,

we've gone from rudimentary instruments and fairly large incisions,

but because of the early post-op benefits and the cosmetic benefits,

we've adopted it to cancer,

We've adopted it to everything we do and we're now trying to find new ways to do it even better.

I'm at the end of my half hour, but I definitely am amenable to any questions that anybody from Rome might have

and certainly welcome all of you here to our upcoming 25th annual David G. Jagelman Symposium

combined with our 35th annual Turnbull Symposium.

potete vedere molti dei vostri colleghi di tutta l'Europa sulla nostra facoltà che saranno con noi a febbraio.

Grazie mille.

Grazie mille, professor Vecchini, abbiamo piaciuto il vostro parco e la vostra lezione.

Cosa più aggiungere?

Vi avete dato un'enorme quantità di dati e figure.

Una cosa che mi ha attaccato riguardo la laparoscopia è il tempo dell'operazione,

quale è l'importanza del corso di imparare

perché dal principio è stato doppio il tempo

e poi è stato alzato

quindi, specialmente per i più giovani

il trattamento, quale è l'importanza

quando pensi che sia il momento

per un nuovo residente

di iniziare a fare questa radioscopia colorectale

e avere buoni risultati in un corto tempo

Well, that's an excellent question and, you know, when we think about the learning curve early on, we started on this already on faculty, on staff, as practicing colorectal surgeons without any training during residency.

So the learning curve that used to be described was the real on-the-job learning curve, people who finished their formal training now having to learn a new technique.

I think that's a very different learning curve than we see now, where, as I showed you in the slide, we've now exceeded 50% of all abdominal cases being done laparoscopically by colorectal trainees.

That starts even earlier when they're general surgery residents.

So the general surgery residents, many of whom are here with me, will start getting exposed as interns to laparoscopic appendicectomy, laparoscopic cholecystectomy, laparoscopic inguinal hernia repair.

As time goes on they'll also start doing gastroesophageal reflux, bariatric surgery, liver, pancreas, others.

So for them learning colon is just another procedure they're learning with a laparoscope

and I don't think that learning curve will be so steep.

The bigger issue is learning the appropriate operations to perform for diseases of the colon, rectum and anus.

Le abilità tecniche della laparoscopia sono ora ben acquistate durante la pratica di generalizzazione e colorectal surgery.

Sì, grazie. Un altro punto è per il costo, specialmente per questo tempo di crisi globale,

per parlare di chirurgia robotica, ovviamente per un paziente è qualcosa di difficile da affrontare.

Qual è il vostro pensiero su questo?

No, lo concordo completamente e penso che siamo ora 10 anni avanti nella robottica e a causa della lunghezza della lezione non ho aggiunto tutti i dati, ma i pazienti hanno iniziato a pubblicare questi rapporti sulle robottiche per problemi colorectali nel 2003, quindi siamo ora 10 anni avanti.

We don't have a single study that shows a gain from laparoscopy to robotics.

There have been several meta-analyses and literature reviews, Cochrane reviews lately.

People suggest there's a lower conversion rate, but, I mean, who knows if that's really the case.

People say that you can see better, but that's a soft call.

There's not a single proven benefit.

So to say to a patient, you know, we're going to do this because it's better,

I think you've got to have a good justification.

I think hospital administrators really need to question why it's being used.

The American College of Obstetrics and Gynecology has issued a statement saying it has no benefit

and should not be used for hysterectomy.

They've shown that, that it doesn't have any advantage there.

We don't see an advantage.

I think for prostate it may be a different story because you're suturing under the pubis

at an angle and it may have some added value in that particular application.

ma per quello che facciamo come chirurgi colorectali, penso che il momento sia arrivato per essere onesti

e dire, guarda, prendi il tempo per imparare la laparoscopia.

E questa è la vera curva di imparazione, non imparare la colonsurgia laparoscopica.

La colonsurgia laparoscopica è semplice, è imparare come fare una buona TME laparoscopica

e finire all'ultimo giorno con margini circunferenziali appropriati,

una TME completa con un specimen TME intatto,

con un margini distal di 1 o 2 centimetri appropriati,

high ligation at the aorta and at the duodenum

and mobilization of the flexure

and create a colloidal anastomosis

that I think is where we need to focus our learning

not on skipping that part of learning

to instead sit off in the corner of the room

and say well I can do this easier with the robot

parenthetically there are now

and I was told this number by Alessio Pagese

the other day we were at a meeting together

he's one of the robotic gurus in the United States

ha lavorato con Mike Stamos all'Università California Irvine

e Alessio mi ha detto, preparando per la lezione l'altro giorno

c'erano 28 pagine, quando ha cercato Google

28 pagine di avvertimenti dai giudici

per le malattie durante la chirurgia robotica

e questo è un numero straordinario

e penso che le persone devono essere onestiche

la perdita di sensazione tattile

l'addizionale tempo sotto anestesia

in posizione di Steve Trendelenburg

position cannot be underestimated. Some of the instruments have been shown to short out and

cause injury to patients. They're off screen, you can't see them. These are not things that are

discussed. All that's discussed is you're going to have your procedure done by a robot, I can see

better and I can do a better dissection distally in the pelvis, neither of which have been proven

of course. And when Alessio showed me this printout of the number of cases, it's kind of

My favorite one was an ad for a phone number that was 1-800-BAD-ROBOT.

I like that one particularly.

Yes.

Prof, one more question.

Sounds like definitely that the present and the future is laparoscopic.

How do you, what's your feeling how to improve technically

and have a minimal problem with complications?

Talking about pure laparoscopic surgery.

Well, I think what we need to do is improve optics and perhaps one of the reasons for

better visualization is three-dimensional imagery and there are certainly companies

working in that direction to improve imagery and maybe give us the option of looking 3D

with standard laparoscopy, that might be helpful.

Smaller diameter instruments are out there, portless instruments, instruments which you

can use without ports, the idea of doing things transiently. I think we're going to keep

getting less and less invasive, but we need to keep doing it in a more and more cost effective

way. Having said that, there are other companies, Canadian, Israeli, Japanese and German are

the four I know that are working on alternative platforms for robots that are not as large

or expensive or cumbersome to move around. And perhaps that will offer us a better kind

di laparoscopia, non davvero robotica, ma penso che sia la direzione in cui stiamo andando.

E penso che, a differenza di quando siamo arrivati a questo nel 1990-1991, quando abbiamo dovuto

scoprire chi era un buon candidato e a chi dovremmo fare la laparoscopia, ora siamo arrivati

all'opposito del paradigma diametricamente opposito. Ora dobbiamo pensare a una ragione

per non fare qualcosa di laparoscopico. Cioè, siamo prestiti a dire, beh, a questo paziente

non lo faremo, perché quasi mai fa male mettere una camera e guardare, vedere cosa

potete fare, e in un scenario di peggioramento, mobilizzare le cose, dividerle, in un scenario di peggioramento

potete poi almeno dare una piccola incisione, anche se non siete sicuri che potete completare

il procedimento. Quindi penso che le migliorazioni sull'aparoscopia saranno un'investimento migliore

di cercare di saturare di più il mercato con i robot.

Sì, ci siamo. Prof, vorrei informarvi che, ascoltando voi, ci sono 1500 chirurgi

sono presenti in Roma, inoltre via internet ci sono stati 7.000 chirurghi che stanno ascoltando.

Quindi, a parte il professor Palazzini, vi ringraziamo davvero da dentro l'arte per questa

incredibile lezione, con la grande quantità di dati che ci avete dato. Grazie, grazie

molto, prof, da tutti noi.

Ok, felicitazioni a professore Palazzani e tanti grazie a tutti.

Grazie ancora e buona giornata e buon lavoro. Grazie ancora.

Ok, buongiorno.

Buongiorno, buongiorno, arrivederci.