At the 2021 virtual American College of Surgeons Clinical Congress, a panel of experts discussed the benefits of robotic surgery in oncology. All panelists said more research was needed in comparing robotic approaches with open approaches.

Abhineet Uppal, MD, an assistant professor at The University of Texas MD Anderson Cancer Center, in Houston, pointed out that 86% of patients are operated on at hospitals that don’t have robots. He said surgical complications for colorectal diseases are low regardless of the surgical approach that is used: open, laparoscopic or robotic. “Robotic surgery offers ergonomic and visualization advantages in confined spaces,” Dr. Uppal said. The learning curve for robotic surgery is significant, especially for surgeons without laparoscopic experience, he added.

Dr. Uppal said randomized data on the advantages of robotic surgery in colorectal diseases are limited. The results of a meta-analysis revealed that robotic-assisted ventral mesh rectopexy is effective and feasible in the treatment of rectal prolapse (Int J Colorectal Dis 2021;36[8]:1685-1694). A few studies have examined robotics for total proctocolectomy, and found longer operation times, shorter hospital stays and nonsignificant trends for fewer complications with robotic surgery (J Colorectal Dis 2021;36[7]:1345-1356; Dis Colon Rectum 2016;59:201-207). Studies have shown that oncologic outcomes are similar between robotic and laparoscopic total mesorectal excision (Int J Colorectal Dis 2019;34[6]:983-991). “As the footprint of robots decreases, ease of use will increase,” Dr. Uppal said.

Vivian Strong, MD, an attending surgeon at Memorial Sloan Kettering Cancer Center, and a professor of surgery at Weill Cornell Medical College, both in New York City, spoke about the role of robotics for gastric cancer. She said oncologic outcomes were equivalent with robotic and open approaches and there were advantages with a minimally invasive approach. In fact, robotic approaches have distinct advantages for selected patients, she noted. She said not all cases are appropriate for robotic approaches, and surgeons should use caution with diffuse-type tumors where margins are not well visualized and for large/bulky tumors. However, neoadjuvant chemotherapy is not a contraindication if margins can be visualized.

Adam Yopp, MD, the Occidental Chemical Chair in Cancer Research and chief of the Division of Surgical Oncology at UT Southwestern Medical Center, in Dallas, spoke about the role of robotic surgery in metastatic colorectal cancer. He said robotic-assisted partial hepatectomy for colorectal liver metastases is safe and oncologically sound in limited series. “Concomitant robotic-assisted colectomy and hepatectomy is efficacious and can avoid second surgical procedures,” he said. Robotic-assisted insertion of a hepatic artery infusion pump in high-volume robotic hepato-pancreato-biliary centers is feasible, with similar complication rates as seen in open procedures (HPB 2017;19[5]:429-435; J Surg Oncol 2016;114[3]:342-347). “Further registry trials capturing prospective data on robotic-assisted liver surgery [are] needed.”

Karim Halazun, MD, an associate professor of surgery with the liver transplantation, hepatobiliary and pancreatic surgery program at Weill Cornell Medicine, in New York City, spoke about robotic surgery for hepatocellular carcinoma (HCC). “Robotic surgery for HCC is safe. Robotic surgery for HCC is oncologically feasible and at least equivalent to open and laparoscopic surgery. There is limited literature specifically examining HCC outcomes, and therefore more data is required,” Dr. Halazun said. He noted that robotic surgery has some technical advantages over laparoscopic surgery, and better transection technology is required. He said the advantages of robotic surgery were visualization with bifocal 3D vision and Firefly; articulating instruments that improve fine hilar dissection; and easier dissection of hepatic veins due to visualization and instrumentation. Disadvantages of robotic surgery, said Dr. Halazun, included no Cavitron ultrasonic surgical aspirator, a variable setup that impedes the learning curve, and operating at a distance from the patient can induce anxiety.

According to Melissa Hogg, MD, MS, a surgeon with Northshore University HealthSystem, in Evanston, Ill., surgery has a learning curve, and this concept is revisited with each technique, including robotics. She said formal robotic training can diminish the learning curve for robotic-assisted surgery. In addition, she said, surgeons with laparoscopic experience may be able to overcome the robotic learning curve faster.