Release date: 2017-08-21 Surgery is the only way to cure colorectal cancer and is the core of colorectal cancer treatment. Minimally invasive technology, as the mainstream of contemporary surgery, has considerable applications in the field of colorectal cancer. Laparoscopic radical resection of colorectal cancer has been recognized as a routine procedure for colorectal cancer surgery. A large number of retrospective studies and large multicenter randomized controlled clinical trials such as COLOR and COLOR II have shown that laparoscopic surgery can not only achieve radical tumor resection, but also reduce surgical trauma and promote postoperative recovery. However, laparoscopic surgery is difficult and the learning period is long. It requires experienced surgeons, which restricts the standardized promotion and quality improvement of laparoscopic surgery. In addition, with the advancement of the minimally invasive concept, minimally invasive surgery is not satisfied with the "small incision" of the body surface, but further pursues the reduction of wounds by "inside and inside", and as much as possible to ensure anal sphincter preservation under the premise of ensuring radical cure And better preserve the nerves and protect the function of the abdominal pelvic organs. These have brought enormous challenges to laparoscopic surgery. With the application of surgical robot technology, robotic colorectal cancer radical surgery is characterized by its precise and stable operation, easy to learn, easy to use, and is gradually replacing ordinary laparoscopy, which is expected to lead the new trend of colorectal cancer surgery. The development of surgical robots The earliest surgical robots can be traced back to the ROBODOC orthopedic surgery robotic system introduced in 1992. The AESOP robot, introduced in 1994, replaces the hand-held lens with a mechanical arm, providing a more stable view of the laparoscopic procedure. The universal "surgical robot" in the true sense began with the ZEUS system introduced in 1996. The ZEUS system adds two 7-DOF manipulators to the AESOP system for surgical procedures, replacing the surgeon's hands. At the same time, the ZEUS system separates the surgical operating platform from the physician control platform, enabling remote surgery with master-slave remote control technology. The famous "Lindbergh" remote cholecystectomy is a milestone clinical application of the ZEUS robotic surgery system. Subsequently, the DaVinci system introduced in 2000 made a lot of improvements on the basis of the ZEUS system, introduced a three-dimensional field of view technology, and added a third mechanical arm, which made the robot extremely accurate in terms of motion accuracy and stability. A big improvement can replace the role of a help to a certain extent. Currently in the field of surgical robots, the Da Vinci system is in a monopoly position. Technical characteristics of Da Vinci robot The technical advantages of Da Vinci robots are more precise surgical operations: 3D immersive field of view and high-definition magnified images facilitate accurate recognition; lens movement is controlled by the surgeon, vision adjustment is more convenient; simulation robot can be 540 in 7 directions ° Free movement, especially the universal joint design at the head end of the robot arm, the flexibility even exceeds the hands of the doctor; the computer system intelligently filters out the involuntary vibration in the operator's movement to ensure the stability of the operation. These technical advantages allow the robot to operate accurately and quickly even in a small space, even if it is difficult to suture the laparoscopic surgery, especially in the interstitial space, pelvic floor and other parts, the convenience Even more than open surgery. Studies have shown that [1], Da Vinci robot can significantly reduce the actual operating time (34% ~ 46%), reduce the operating error rate (44% ~ 66%), reduce unnecessary tissue damage, and truly achieve "by the table Mini-invasive surgery. Therefore, the Da Vinci system learning curve has a platform period of about 20 operations, which is significantly earlier than ordinary laparoscopic surgery, and its ease of learning also provides considerable support for promotion. Application status of Da Vinci robot At present, surgical robots have been widely used abroad: as of the end of June 2017, the total installed capacity of Da Vinci robots in the world has reached 4,023; in 2016 alone, the total number of robots in Da Vinci worldwide exceeded 700,000. For example, the global growth rate was 15% in 2015. In China, robotic surgery is still in its infancy, but it is developing rapidly: as of the end of June 2017, there are 65 installed machines in mainland China. In 2016, only 19 new installations were installed, an increase of 47.5%. In 2016, the total number of robotic operations in 2016 was 17979. For example, 1857 cases of colorectal cancer surgery, accounting for 10.3% of all robotic surgery, an increase of 52.7% compared with 2015. In view of the technical characteristics of robotic surgery, Da Vinci robot is currently used for radical resection of rectal/sigmoid colon cancer, including abdominal perineal resection (APR), levator ani muscle and perineal resection combined with rectal cancer resection (ELAPE), low/anterior resection Surgery (AR/LAR), resection of the rectal cancer (ISR) between the sphincters, and removal of the anastomosis, etc., the effect is good. A number of meta-analyses [2-4] showed that robotic surgery significantly reduced the rate of conversion to open surgery, reduced intraoperative bleeding, accelerated postoperative gastrointestinal function recovery, and protected urinary function and sexual function; some studies also showed that robotic surgery Can reduce the positive rate of circumferential margin and the incidence of postoperative complications. In terms of long-term outcomes [5,6], robotic and open surgery, laparoscopic surgery did not differ significantly in local recurrence, disease-free survival, and overall survival. Compared with rectal/sigmoid colon cancer surgery, robots have performed less in the radical resection of right colon cancer. The main reason is that the Da Vinci robot's robotic arm has a limited range of motion, while the right colon cancer has an anatomy and lymph nodes. The cleaning range is large, which brings more difficulties to the application of the robot. However, with the update of equipment and the development of surgical techniques, some clinical centers have also summarized the right-sided colon cancer radical surgery for robots. Related reports also show that robotic right colon cancer radical surgery can also reduce trauma and promote postoperative recovery. Liver metastasis is very common in the course of colorectal cancer and is also a major factor affecting the prognosis of colorectal cancer. Synchronous resection of the intestines has been a hot and difficult point in colorectal cancer surgery. The robot is also an alternative surgical procedure for simultaneous resection of the intestines. In the case of liver tumors, robotic surgery is relatively mature. Studies have shown that robotic surgery is similar to the complications of conventional laparoscopic surgery, significantly less than open surgery, and there is no significant difference in long-term survival. However, for the simultaneous resection of liver metastases from intestinal cancer, there are few reports on the current research, and its safety and effectiveness have yet to be further verified. Experience sharing of robotic surgery Writing consensus The Colorectal Cancer Center of Zhongshan Hospital affiliated to Fudan University is the earliest unit for robotic surgery in the country. From 2010 to the end of June 2017, a total of 1300 cases of robotic colorectal cancer radical surgery have been carried out. In 2016, 376 cases were carried out, accounting for the same period. National robotic colorectal cancer surgery volume of 20%. In 2015, the Center for Colorectal Cancer of Zhongshan Hospital took the lead in formulating the world's first "Consensus of Robotic Colorectal Cancer Surgery Experts", which filled the gap in this field and effectively promoted the promotion of robots and the standardization of surgical operations. Technological innovation 1. The Department of Colorectal Surgery of Zhongshan Hospital affiliated to Fudan University pays attention to technological innovation. It is the first to carry out robotic transabdominal perineal resection (APR) at home and abroad. More than 200 cases were carried out from 2013 to June 2017. Randomized controlled clinical trials have shown that robotic APR surgery significantly reduces intraoperative bleeding (100 ml versus 130 ml, P < 0.001) and accelerates postoperative gastrointestinal function recovery while ensuring radical tumor resection ( First exhaust time: 1.0 days vs. 2.0 days, P < 0.001), protected pelvic autonomic function (first spontaneous urination time: 2.0 days vs 3.0 days, P < 0.001), reducing the incidence of postoperative complications (10.4%) For 18.8%, P=0.027). The procedure was presented at the 2015 Minimally Invasive Surgery Week/SLS Annual Meeting of the United States, and was discussed in the 2017 ESMO Conference Poster, and received extensive attention at international conferences such as the China-Japan-Korea Colorectal Cancer Symposium, and was included in Robotic Colorectal Cancer. Surgical Expert Consensus. 2, in the low position anal sphincter surgery, Zhongshan Hospital is the first in the country to carry out robotic pull-out resection and anastomosis, directly through the anus directly to the tumor specimens under direct vision, not only to ensure that the margin is negative, while eliminating the abdominal incision, reducing the incision Complications, incisional hernias and other complications, both aesthetics. From 2013 to April 2017, 47 cases were performed: no infection and dysuria and dysfunction; 3 cases (6.4%) occurred after anastomotic leakage, 2 cases (4.3%) were treated with conservative treatment; average postoperative hospital stay 9 days; no recurrence or metastasis was observed during the follow-up for 2 years. 3, Zhongshan Hospital colorectal surgery will also combine robotic surgery and perioperative "fast track" management, with the advantage of robots to protect the function of the gastrointestinal tract, combined with perioperative oral nutritional support, control fluid replacement, postoperative promotion of gastrointestinal motility Recovery, early bed-out activities, etc., significantly reduced postoperative hospital stay (5.0 days vs. 6.0 days, P < 0.001), improved efficiency. 4. In the joint resection of multiple organs, the Department of Colorectal Surgery of Zhongshan Hospital is also in the forefront of the world. Combined with hepatic surgery, robotic simultaneous enterohepectomy is performed. From 2013 to June 2017, 60 cases were performed, which is more than traditional open surgery. Significantly reduced intraoperative bleeding (99 ml vs 205 ml, P < 0.001), accelerated postoperative gastrointestinal function recovery (first exhaust time: 2.6 days vs 3.9 days, P < 0.001), reduced hospital stay (8 days to 10 days) , P < 0.001). On this basis, in March 2014, Zhongshan Hospital, Department of Colorectal Surgery, Department of Hepatic Surgery and Thoracic Surgery completed the world's first simultaneous resection of liver and lung metastases for robotic rectal cancer, and successfully explored the field of robotic multiple organ resection. . The development direction of robotic surgery Although the surgical robot system has been launched for more than ten years, its technical advantages have yet to be further explored. Taking single-hole surgery as an example: ordinary laparoscopic operation is difficult, largely due to left-right backhand operation, while robotic surgery can avoid this problem through the special design of the software system; at the same time, the mechanical arm can also pass similar stomach/ The curved and movable design of the colonoscope expands the scope of the operation, so that the single-hole surgery and the general surgery are close in operation or even the same; there is a corresponding robot single-hole device. In addition, the robot can also install a variety of new equipment, such as micro-camera, spectral analysis, fluorescence imaging, etc. [7], to obtain some "specific functions", such as intraoperative histopathological analysis, identification of deep vascular lymph nodes. We should realize that robots are not static, but an open platform that can play a greater role by combining with other technologies. The advantages of robotic surgery are basically recognized by the outside world. However, the main difficulty in its promotion is its high cost. The Da Vinci robot is currently in a monopoly position, and its equipment and consumables are all dependent on imports. Not only the equipment price reaches 10 million yuan, but also the price of consumables remains high. In addition, Da Vinci robots require routine inspection and maintenance every year, which is an expense that cannot be ignored. A retrospective study reported by Silva-Velazco J et al. [8] in 2017 showed that the cost of direct surgery for robotic rectal cancer surgery was significantly higher than that of laparoscopic and open surgery, about 1.3 times, mainly for robotic equipment and consumables. . In order to solve this problem, in 2017, Zhongshan Hospital affiliated to Fudan University, together with three medical device manufacturers, jointly prepared to construct the Shanghai Minimally Invasive Engineering Technology Research Center for Colorectal Cancer, to study the minimally invasive surgery technology suitable for the Chinese population, and to develop independent knowledge. Domestically produced surgical robots, laparoscopes and other minimally invasive devices have attempted to break the monopoly of foreign products and lower prices, thus promoting the promotion of robotic surgery, enabling more patients to enjoy the benefits of minimally invasive surgery such as robots and laparoscopy. beneficial. Professor Xu Jianmin Since its inception, robotic surgical equipment has continued to advance, and surgical concepts and techniques have been continuously updated, and it has flourished in the field of colorectal cancer. With the development and application of domestic robot equipment, robotic surgery will be widely carried out, leading the new trend of surgery. Source: China Medical Tribune Today Tumor (Micro Signal CMToncology) Shanghai J.Shine Co.,Ltd , https://www.jshinechem.com