Deakin University Honours Project #3
The development of minimally invasive colorectal surgery techniques and its impact on regional Australia
Prof Glenn Guest, AProf Douglas Stupart, Mr Sonal Nagra
Department of Surgery, Deakin University; University Hospital Geelong, Barwon Health.
Transanal Endoscopic Microsurgery (TEMS), Laparoscopic Surgery, Microsurgery Surgery and Endoscopic Surgery are minimally invasive surgical techniques that are at the cutting edge of surgery in Australia. Long-term outcomes of the introduction of these techniques to regional centers has not been studied to date, but has formed an ongoing interest. A prospective database and electronic information systems will be used to assess the safety and efficacy of these techniques at University Hospital Geelong.
The first reports of laparoscopic interventions date to the 1930s but it would not be until the mid-1980s when modern laparoscopes complete with optics would first be popularized through their use in cholecystectomy. Robotic surgery and robot-assisted surgery has a wide range of applications in many areas, and the use of these techniques is advancing especially in the areas of general surgery, gynaecology, and head and neck surgery. At the forefront of this technology is the da Vinci Surgical System, first introduced in 1998 and comprises a high definition 3D vision system, and a robotic cart that enables the surgeon to operate four robotic arms which move a camera and surgical instruments. This invention has been touted as “one of the biggest breakthroughs in surgery since the introduction of anaesthesia” and was popularized for its successes in urology, particularly in prostate surgeries. However, studies of the efficacy of robot-assisted surgical systems have consistently reported no improvement in surgical outcomes except for in cases of total mesorectum excision (TME) to treat rectal cancer.
During the latter studies, robot-assisted surgery was associated with reduced length of hospital stay and shorter recovery time for erectile function when compared to conventional laparoscopic procedure. These differences have been subscribed to the use of magnified vision, and manipulation of surgical instruments with greater precision during robot-assisted surgery than during conventional laparoscopy. The use of robot-assisted laparoscopy during colorectal surgery has been reported to be safe and feasible[9-10] but contributes to increased costs and operation length of time, and does not appear to improve post-operative outcomes for cases not involving TME surgeries.
Therefore conventional laparoscopic techniques remain the standard of care at University Hospital Geelong; and are associated with lower overall morbidity rate, lower infection rate, and reduced length of hospital stay when compared to open surgery. In a study of 337 surgical patients seen for nephrectomies over a 10 year period, laparoscopy was associated with increased duration of surgery (by one hour) but reduction in post-operative complications and length of hospital stay. With the exception of one case-report of life-threatening massive pericardial effusion as a complication of an infected Lap-Band, the experience at University Hospital Geelong with laparoscopy techniques largely reflects positive literature reports that laparoscopy techniques are at least as effective as open surgery in the short term, and are safer with regard to complications and result in reduced length of hospital stay. In the context of rapidly advancing techniques involving robot-assisted surgeries, benchmarking standard of care practices will become increasingly important to ensure patient care and surgical outcomes continue to improve.
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