|Year : 2019 | Volume
| Issue : 2 | Page : 44-46
Current status of robotic colorectal surgery in Australasia: A questionnaire survey of consultant members of the colorectal surgical society of Australia and New Zealand
Kenneth N Buxey1, Francis F Lam2, Graham L Newstead1
1 Department of Colorectal Surgery, Prince of Wales Hospital, NSW, Australia
2 Department of Colorectal Surgery, Prince of Wales Hospital Group (Prince of Wales Public and Private Hospital), NSW, Australia
|Date of Web Publication||27-Jun-2019|
Dr. Kenneth N Buxey
Prince of Wales Hospital, Barker Street, Randwick, Sydney, NSW 2031
Source of Support: None, Conflict of Interest: None
Background: There has been considerable interest worldwide in the application of a robotic operating platform in the practice of colorectal surgery. Objective: The aim of this study was to evaluate the current uptake of robotic colorectal surgery in Australia and New Zealand. Design: Survey data were obtained from the Colorectal Surgical Society of Australia and New Zealand (CSSANZ) registry of all specialist colorectal surgeons in Australia and New Zealand. Setting: Specialist colorectal surgeons responded to the survey through e-mail contact via an official e-mail from the CSSANZ. Materials and Methods: A questionnaire was distributed to members of the CSSANZ regarding their current robotic surgical practice. Main Outcome Measures: Volume of and nature of robotic surgery being currently undertaken in Australia and New Zealand, with an emphasis on seeking to understand the surgeon and patient factors that would promote robotic practice and also any factors or barriers in the implementation of robotic colorectal surgery being performed. Sample Size: The sample size was 77. Results: Seventy-seven replies were received from a total of 227 surveys. The response rate is similar to other comparable surveys published when the laparoscopic colorectal era was introduced. Most surgeons performed minimally invasive (laparoscopic) surgery; however, only 29% performed any robotic surgery and 50% of these performed <5 cases in the preceding 12 months. Low rectal cancer and rectopexy surgeries were the most frequently performed robotic operations. About 48% of surgeons believed that the robotic platform offers specific patient benefits, and 75% believed that it offers specific benefits to the surgeon. The main reason for consultants not performing robotic procedures was largely related to cost, with training also cited as a barrier. Conclusion: Robotic colorectal surgery is being performed by 29% of colorectal consultants in Australasia, although only a minority of these surgeons have a substantial volume. In the future, a substantial reduction in costs is envisaged, as more companies enter the robotic surgery marketplace and competition drives reduction in costs. This in many ways mirrors the introduction of laparoscopy and we believe as cost comes down, training pathways need to be established to train the next generation of colorectal surgeons robotically. Limitations: Our study is limited by inherent limitations of survey data and the response rate.
Keywords: Australasia, colorectal surgery, robotic surgery
|How to cite this article:|
Buxey KN, Lam FF, Newstead GL. Current status of robotic colorectal surgery in Australasia: A questionnaire survey of consultant members of the colorectal surgical society of Australia and New Zealand. World J Colorectal Surg 2019;8:44-6
|How to cite this URL:|
Buxey KN, Lam FF, Newstead GL. Current status of robotic colorectal surgery in Australasia: A questionnaire survey of consultant members of the colorectal surgical society of Australia and New Zealand. World J Colorectal Surg [serial online] 2019 [cited 2019 Aug 18];8:44-6. Available from: http://www.wjcs.us.com/text.asp?2019/8/2/44/261544
| Introduction|| |
Internationally, the application of robotic surgery has gained popularity within the colorectal sphere, most notably for rectal surgery. The Society of American Gastrointestinal and Endoscopic Surgeons has produced a consensus statement on robotic gastrointestinal surgery stating that a robotic platform has the following advantages over a traditional laparoscopic platform:
- Superior visualization, including three-dimensional imaging of the operating platform
- Stabilization of instruments within the surgical field
- Mechanical advantage over traditional laparoscopy
- Improved ergonomics for the operating surgeon.
The position statement indicates that the greatest potential benefit of the application lies in single-quadrant surgery where there is a complex reconstructive component with a need for complex suturing and fine dissection. It also acknowledges that a technically exceptional laparoscopic surgeon may derive minimal benefit from such a platform and that a robotic platform might rather serve as an enabling technology allowing surgeons to bring complex minimally invasive procedures to a greater number of patients.
Although robotic colorectal surgery was first described in 2001, the uptake and establishment of the technique in Australasia has taken considerable time. Cited factors include cost, availability of the platform, and availability of a suitable training pathway.,
Only limited information about robotic surgery is available from trial data and the ROLARR (Robotic-Assisted vs Conventional Laparoscopic Surgery on Risk of Conversion to Open Laparotomy Among Patients Undergoing Resection for Rectal Cancer) trial, which compared robotic surgery to laparoscopy and concluded that the robotic approach was not cost-effective due to increased operating times and costs associated with robotic instrumentation. The robotic group achieved marginal improvements in quality of life indices, resulting in a high incremental cost-effectiveness ratio for the robotic technique and an overall conclusion that robotic surgery is not cost-effective when compared with laparoscopy.
Nonetheless, there remains considerable interest in the technique, and many believe that it is very valuable particularly in specific operations such as ventral mesh rectopexy and ultralow rectal cancer surgery.
Given the ongoing interest, despite the lack of current high-quality evidence and the aforementioned barriers, we aimed to evaluate the current practice of robotic colorectal surgery among specialist colorectal surgeons in Australasia.
| Materials and Methods|| |
A questionnaire was e-mailed to consultant members of the Colorectal Surgical Society of Australia and New Zealand, the number of which is 227. Participation was voluntary. The questionnaire requested information from members on the practice of robotic colorectal surgery. Each invitation was accompanied by a three-digit random number, which was recorded with the response so as to avoid the potential for duplication. Questions were asked about the types of surgery being performed robotically and the number of such surgeries. Information was also sought around training, proctorship, scope of nonrobotic minimally invasive colorectal surgery being performed, access to robotics, involvement of trainees, perception of strengths, disadvantages of robotic techniques, and perceived needs and pressures to perform this type of surgery. Responses were then collated, analyzed, and presented as descriptive statistics.
| Results|| |
Seventy-seven replies were received from a total of 227 surveys. The response rate is similar to other comparable surveys published when the laparoscopic era was introduced, and represents a greater response rate than in published surveys on robotic practice in other specialties. Of the respondents, 29% currently perform robotic colorectal surgery. However, 50% of those who responded acknowledged the performance of <5 cases in the last 12 months. Only 11 surgeons (30% of the robotically active group) performed 10 or more cases in the preceding 12 months, and only 2 surgeons performed in excess of 50 cases during this time. The most commonly performed robotic operations were rectal surgeries (90.9% of robotic surgeons performed rectal surgery on the robot), ventral rectopexy (77.3%), ultralow (72.7%), and low anterior resections (72.7%). Overall, the respondents surveyed were minimally invasive surgeons performing MIS colorectal surgery. 81% were performing laparoscopic surgery and of those, 98% indicating that they perform right colectomy laparoscopically and 97% indicating that they perform high anterior resection laparoscopically. Nearly 74% perform ultralow anterior resection laparoscopically, and 37% perform transanal total mesorectal excisions. Almost 68% of respondents perform minimally invasive transanal surgery (either transanal endoscopic microsurgery, transanal minimally invasive surgery, or both).
About 48% of robotic surgeons indicated that they had received their initial training in robotic surgery overseas; 75% indicated that they received proctoring on the commencement of independent practice. Nearly 48% of surgeons indicated that they were proctored for three cases, and 32% were proctored for between four and ten cases. Most surgeons only had access to robotic surgery in the private sector (77% of surgeons with access to a robot). Overall 48% of total respondents did work in at least one institution where there was access to robotics. Nearly 69% of those with robotic facilities had access to the latest da Vinci Xi robotic platform.
Only nine robotic surgeons acknowledged the involvement of a fellow in their robotic practice. Nearly 22% of the total respondents indicated that they identified external pressure to perform robotic surgery and cited it as coming from the following sources: colleagues (76.5%), industry (47.1%), and patients (17.6%). The questionnaire also asked about barriers to performing robotic surgery and whether, in the presence of better access and training opportunities, surgeons would be willing to adopt robotics, and finally, what perceived benefits robotics offered, divided into patient benefits and surgeon benefits.
Fifty-three respondents formally commented on such barriers and the most commonly cited being cost (85%) with other barriers cited including concerns about whether the technique provided any benefits to patients (28%), access to the robot (23%), and access to appropriate training (10%).
Overall 82.9% of respondents, when directly asked if cost was a barrier to them recommending a robotic approach, felt that this was the case. Indeed, 77.2% believed that cost made it difficult for their patients to agree to robotic surgery.
Nonetheless, 72% of respondents either used robotics or indicated that they would use robotics if these barriers could be eliminated.
About 69% of surgeons not using robotics indicated that they would require additional training to be able to utilize it in their practice if it were to become available. Of those, 35% believed that they would require some training overseas to achieve competency, and 32% believed that they would have difficulty accessing a proctor.
Nearly 48% of respondents believed that at least some patients do derive specific benefits from robotic surgery. The most common among them are cases requiring suturing (81.4%) followed by low pelvic pathology (65%), obese patients (61%), and male patients (58%).
As distinct from patient specific benefits, many surgeons (75%) believed that robotics offer specific benefits to the operating surgeon when comparing this to performing the same technique using laparoscopy. The most commonly cited surgeon-specific benefits were improved comfort and ergonomics (74%), improved instrumentation, specifically articulation (35%), and improved vision (33%).
| Discussion|| |
Despite the growing popularity of robotic surgery and the wide implementation of robotic operating platforms in private hospitals in Australasia, little has been published on the actual numbers of surgeons doing these surgeries and their case volume. Nor have the factors looking at why one would or would not perform such surgery and some of the barriers involved in robotic practice have been described. Results from our study provide insight into the current robotic colorectal practices in Australasia. Our survey suggests that, while minimally invasive surgery is widely performed by Australasian colorectal surgeons, robotic surgery is performed by relatively few surgeons; the majority of these perform minimal case numbers, with a select few performing moderate or high volumes of cases. This appears to be despite the fact that most surgeons believe robotic surgery to be of benefit to the surgeon. Cost remains the overwhelming barrier to implementation of this technique in Australasia at present. Access to appropriate training and subsequent mentorship and proctorship also remain as issues. The lack of evidence and belief that patients experience a benefit from robotic surgery also remain barriers, although, given that most surgeons believe they benefit from an enhanced operating environment, such factors are obviously closely related to the increase in costs, and in particular patient costs, associated with the procedure.
In the future, a substantial reduction in costs is envisaged, as more companies enter the robotic surgery marketplace and competition drives reduction in costs. In 2009, a similar survey regarding laparoscopic surgery was undertaken in the UK which identified, at the time, only 25% of surgeons performed laparoscopic colorectal resections and those who did only performed these laparoscopically 30% of the time. Principal barriers cited were cost and training.
| Conclusion|| |
Only 9 years subsequent to this study, laparoscopy is now clearly the standard of care. This current study serves as a “snapshot” of the current Australasian uptake of robotic colorectal surgery, and similar data gathered in 10 years' time will be interesting to assess the status of the robotic platform. In order for Australasian surgeons to be ready for the potential uptake of robotic surgery, there need to be clear pathways for gaining appropriate training and experience. These need to be factored into the training of the next generation of colorectal surgeons.
Our study is limited by inherent limitations of survey data and the response rate. The response rate is, however, comparable with similar literature published both in the colorectal literature when laparoscopic surgery was being established in the United Kingdom and when transoral robotic surgery was first being performed in North America.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ballantyne GH, Merola P, Weber A, Wasielewski A. Robotic solutions to the pitfalls of laparoscopic colectomy. Osp Ital Chir 2001;7:405-12.
Jayne D, Pigazzi A, Marshall H, Croft J, Corrigan N, Copeland J, et al.
Effect of robotic-assisted vs. conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: The ROLARR randomized clinical trial. JAMA 2017;318:1569-80.
Weaver A, Steele S. Robotics in colorectal surgery. F1000Res 2016;5. pii: F1000 Faculty Rev-2373.
Harinath G, Shah PR, Haray PN, Foster ME. Laparoscopic colorectal surgery in great Britain and Ireland – where are we now? Colorectal Dis 2005;7:86-9.
Schwab KE, Dowson HM, Van Dellen J, Marks CG, Rockall TA. The uptake of laparoscopic colorectal surgery in great Britain and Ireland: A questionnaire survey of consultant members of the ACPGBI. Colorectal Dis 2009;11:318-22.
Chia SH, Gross ND, Richmon JD. Surgeon experience and complications with transoral robotic surgery (TORS). Otolaryngol Head Neck Surg 2013;149:885-92.