Page 9 - Read Online

Sebastián-Tomás et al. Mini-invasive Surg 2019;3:30 I http://dx.doi.org/10.20517/2574-1225.2019.29 Page 3 of 10

The latest release to date, the Xi version, appeared in 2014. It offers the possibility of adjusting the operating
table without undocking the system, shortening the procedure length and allowing multi-quadrant single-
docking procedures. Augmented-reality software allows the assessment of intestinal perfusion or real-time
three-dimensional (3D) anatomical simulation of abdominal structures [39-41] . Senhance® Surgical Robotic
System and the REVO-I® Robot Platform are the two other systems commercially available nowadays.
Competitive industry players like Medtronic and Verb surgical (powered by GOOGLE® and Johnson &
[42]
Johnson®) platforms are expected soon .

LEARNING CURVE OF ROBOTIC TME
The learning curve for robotic TME, from the beginning to the higher expertise, should include at least 20-23
cases, which is faster than for conventional laparoscopy [43,44] . Contrasting results have been reported
regarding the impact of the previous proficiency on laparoscopy on the duration of the period [45,46] . Most
of the publications evaluated the expertise with variables as “operative time”, “bleeding” or “conversion”
[47]
which may not be the most critical outcomes . There is a wide agreement on the fact that operative times
are longer during a learning curve, but a recent study on robotic rectal resection showed no relationship
[48]
between extended operative time and morbidity . The evaluation of the experience in oncologic surgery
should also focus on the quality of the resected specimen, especially for rectal cancer resection. Only
a recent meta-analysis showed no significant differences in CRM involvement between learning and
competent surgeons. The authors did not found significant differences in the other clinic and pathologic
[49]
variables, without evaluating the quality of the TME .
A learning curve is unavoidable, and robotic surgery requires special training and the development of
new skills. The companies responsible for robotic systems are compelled by the Food and Drug Agency
to develop technical training for the surgeons. The European Association of Endoscopic Surgeons (EAES)
[50]
recommended a training officially-certified and based on a formal curriculum for skills and procedures .
The lack of standardization in robotic rectal surgery was specifically noted, this is critical to assure the
safety and success of training surgeons in their future practice. Recent resources aim to provide an
objective assessment of the acquired surgical skills to produce future standards for robotic surgeons on
[50]
basic knowledge and procedural safety . If any superiority favouring robotic TME is proven soon, the
learning curve should not be an obstacle, but a necessary step for novel surgeons to reach the standards
of quality. Noteworthy, there is an underlying and not despicable risk if surgeons abandon conventional
laparoscopic surgery learning in favour of robotics. We may have soon a generation of surgeon incapable of
performing laparoscopic surgery, with unclear but potentially serious consequences.

BENEFITS AND LIMITATIONS OF ROBOTIC RECTAL SURGERY
Technical advantages
Current robotic platforms display a 3D image, enhancing the visualization of the anatomical structures
by improving the surgeon’s depth perception and image quality. Compared to conventional laparoscopy,
[47]
robotic surgery also allows to control a stable camera . The system has recently incorporated the
EndoWrist® technology, which improves dexterity and eliminates physiological tremor reducing the
[51]
challenge of laparoscopic intra-corporeal suturing . These technical advantages are expected to allow a
better mesorectal dissection, preserving the integrity of the fascia and decreasing the odds of autonomic
[38]
nerve injury resulting in sexual dysfunction, anterior resection syndrome, or urinary retention .
The use of robotic platforms is associated with better surgeon’s ergonomics than those provided by
conventional laparoscopy. Robotic assistance results in lesser activation of the upper-body mussels
[52]
[53]
reducing musculoskeletal discomfort . Berguer et al. reported that robotic help makes less stressful
performing complex tasks. Previous laparoscopic experience has a complex influence on the adaptation to