Robotic proctectomy for rectal cancer yields acceptable outcomes

Much debate has centered around the best method of performing total mesorectal excision (TME). The vast majority of trials have found laparoscopy to be equivalent or superior to laparotomy. Within the realm of minimal access surgery, the ROLARR trial was a multicenter multinational randomized controlled trial in which robotic and laparoscopic TME were compared. This impressively designed and undertaken study showed the two procedures to be equivalent. More recently Sammour and coworkers from the MD Anderson Cancer Center assessed 276 patients who underwent robotic proctectomy. Their single national cancer institute accredited center study revealed very satisfactory outcomes including the circumferential resection margin of >1 mm in 95.7% of patients, the distal resection margin of >1 mm in 100% of patients, the mesorectum complete in 75.8%, and nearly complete in 23.7% of patients at a median number of nodes of 22. Eighty-three of the 276 patients were available for a minimum of 3 year follow-up. The authors noted a 2.4% local recurrence rate and a Kaplan-Meier disease free survival of 82% with an overall 5 year survival of 7%. Based upon these findings, the authors, led by my friend and colleague senior author George Chang, concluded that “robotic proctectomy for rectal cancer can be performed with good short and medium term oncologic outcomes in selected patients”. I concur with these findings with the caveat that, as is the case for open and also for laparoscopic surgery, that rectal cancer should be operated upon in a center focused upon caring for patients with rectal cancer. The fact that 1,391 patients underwent proctectomy for rectal cancer during the 7 year study period attests to this critically important criterion being fulfilled by this group. The question remains not as to which technique should be applied to perform TME, but in what setting should the operation be undertaken. Hopefully, as we have described, Wexner et al, all centers in which rectal cancer is a focus and/or in which high volumes of rectal cancer surgery are performed will seek American College of Surgeons Commission on Cancer accreditation by the new National Accreditation Program for Rectal Cancer.