1. Slawomir Marecik, MD, FACS Advocate Lutheran General Hospital, Park Ridge, IL Clinical Assistant Professor University of Illinois, Chicago, USA

3.  Are here to stay  One of the available tools in our armamentarium  Powerful tool  Massive potential

4.  Technically challenging  Tumor location  Anatomic structures  Difficult retraction  Unstable camera  Poor ergonomics for surgeon UK MRC CLASICC

5. Advanced lesion Obese, low (male) APR

6. 1 Quality Of Dissection 2 Minimally Invasive 3 Comfort For Surgeon

7. Quality Of Dissection

8. Robotic n=56 Mesorectal grade Complete 52 Nearly complete 4 Incomplete 0 Laparoscopic n=57 Mesorectal Grade Complete 43 Nearly complete 12 Incomplete 2 p=0.033p=0.033 Baik SH. Robotic versus laparoscopic low anterior resection of rectal cancer: short-term outcome of prospective comparative study. Ann Surg Oncol. 2009 Quality Of Dissection

9.  Pigazzi, Baek O.7 % CRM143 pts  Kim 1.6 % CRM59 pts  Prasad, Marecik 1 % CRM82 pts  ROLLAR  ACOSOG  Can we reduce preoperative radiation?  Improved urogenital function? Randomized Studies To Compare Laparoscopic vs. Robotic Resection

10.  The robot is more useful in certain areas  Laparoscopy is more useful in other areas A Hybrid Approach Is The Most Practical Solution At This Time

11.  Laparoscopic TME challenging  Difficulties with advanced disease  An increase in obese patient population

12. Source: Behavioral Risk Factor Surveillance System, CDC. 2000 Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 2010 1990 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

13.  randomized data is lacking  ACOSOG, ROLARR pending  difficulties in adoption of Korean experience  BMI  height  splenic flexure mobilization  radiation

14. DCR 2010

15. Open/HALS (=46)Robotic (n= 36)P value Mid and low rectal tumors 47.8%80.5%.006 OR time (min)273.8337.9.003 EBL (mL)273.8187.5.036 Postoperative complications, n (%) 15 (32.6)11 (30.6).84 Length of stay (days)7.37.0.74 Distal margin positive, n (%) 0 (0)1 (2.8).44 Radial margin positive, n (%) 3 (6.5)0NS Lymph nodes16.815.26 deSouza AL, Prasad LM, Marecik SJ et al. Comparison of Open and Robotic Total Mesorectal Excision for Rectal Adenocarcinoma; Dis Colon Rectum, 2011

17. AuthorNo. of PtsConversion rate Mean BMI Laparoscopic Mean BMI Converted P value Yamamoto S Japan (2009) 1073 (Lap) 7.3%22.7 (13.7-36.7) 24.6 (16.6-34.8) <0.0001 Agha A Germany (2008) 300 (Lap) 8.6%26.2 (16.7-37.5) 29.0 (22.6-43.9) 0.002 Rottoli M Italy (2009) 173 (Lap) 15%24.9 ±3.227.3±2.9<0.001 deSouza 2010* 44 (Robotic) 4.5%28.2 (17.6-43) 41.5- Laparoscopy for rectal cancer – conversion rates Robotic TME MRC CLASSIC trial conversion rate – 34% (2005)

19. Colorectal Dis 2011

20. APR (abdomino-perineal resections) cylindrical intraabdominal levator transection Robotic Cylindrical Abdominoperineal Resection with Intraabdominal Levator Transection Marecik SJ, Zawadzki M, deSouza AL, Park JJ, Abcarian H, Prasad L Dis Colon Rectum, Oct 2011

22. Robotic pursestring technique in low anterior resection Prasad LM, deSouza AL, Marecik SJ, Park JJ, Abcarian H. Robotic pursestring technique in low anterior resection. Dis Colon Rectum. 2010 Feb;53(2):230-4.

24. upper rectum easy, thin patient Laparoscopic TME Mini-laparotomy lower rectum difficult, obese patient Robotic

25.  Robotic assistance in low anterior resection decreases conversion rates when compared to laparoscopy  Mesorectal quality grade is higher in robotic technique, which may translate into better oncological outcomes  Robotic system allows for a very precise work in deep pelvis making intersphincteric dissection easier, distal pursestring application possible and transanal specimen extraction more common

26.  Robotic assistance has potential to improve outcomes in obese patients and in patients with advanced disease