Vittoria Bellato interviews Mr Shahnawaz Rasheed, Consultant Surgeon at The Royal Marsden, London, about his experience of robotic-assisted pelvic exenteration.
Shahnawaz Rasheed was awarded his medical degree by St Bartholomew’s and The London Hospitals’ Medical School and PhD by Imperial College London for research on colorectal cancer undertaken at St Mark’s Hospital, London. He specialises in, primary, locally-advanced and recurrent colorectal cancer performed open, laparoscopic and robotic. He has published widely and delivered many lectures on various aspects of colorectal cancer.
He is the global Medical Director of the NGO Humanity First and is also a permanent council member for the G4 Alliance which advocates for surgery, anaesthesia, obstetrics and trauma in low and middle income countries. In addition, he is the lead for the Forum on International Crisis Management at the Institute for Global Health Innovation, Imperial College London and has an interest in improving delivery of care following international disasters. He is the executive director of the non-profit organisation Inspiral Health.
Vittoria Bellato: Thank you Mr Rasheed for sharing with us you expert view on this exciting subject: robotic pelvic exenteration.
The first use of robotic assisted surgery in pelvic exenteration is recent and was reported by Shin and colleagues in 2014 [1] and total published cases in literature are from case series and overall less than 100. When did you start to perform robotic pelvic exenteration at your centre?
Shahnawaz Rasheed: I started to do robotic surgery in 2013; in 2015 we started the robotic programme at the Royal Marsden; in 2017 we started to do beyond TME surgery (ELAPEs and multivisceral resections); the first total exenteration was in 2018.
VB: Are there any robotic courses/fellowships focused on this topic?
SR: Unfortunately there are not many. We do have here at Marsden a pelvic exenterative and robotic fellowship. The Fellow rotates between colorectal, gynaecology and urology units. This way their knowledge of the pelvis becomes excellent.
VB: The role of laparoscopy is specifically challenging for multivisceral pelvic resection. Operating deep in a narrow pelvis for a prolonged time, in anatomical planes extending beyond TME dissection, and involving multiorgan resection in areas that have been exposed to previous operations and/or radiation therapy provide challenges and obstacles for the laparoscopic surgeon. [2] These are just few of the main reasons why robotic approach could prove to be a game changer for pelvic exenterations. What’s your personal experience?
SR: I agree completely. We have done some laparoscopic exenterations but the mostly long, difficult, camera work is tiring. Here are just a few advantages of the robot:
- 3D Views
- Your wrist can move around much higher degrees of freedom than anything else
- We have three hands, so is very helpful to fix something in a place with one hand and operating with the other two.
- The ergonomic: The position of your body. If I am performing laparoscopic or open surgery as a right-handed surgeon on the left side of the patient I am forced to twist my lower back. And will stand in this position for a long time. With the robot I am sitting on a chair with my back straight and especially in complicated and long surgery I think this aspect is crucial to maintain focus and reduce stress.
- For ELAPE and total exenteration you can take all specimen from the perineal defect and finish with an inferior gluteal artery perforator Flap (IGAP) to fill that space. So you have zero proper incisions, just 8mm holes: this, to me, is game-changing for recovery and postoperative complications!
Because of all of those points your control is overall better and when I am operating deep in the pelvis it feels like I am walking in the actual pelvis. I see branches of epigastric nerves that you cannot even see in open or laparoscopic surgery and the all procedure result to be much more precise.
VB: On the other hand, what are the limits? When do you deem it impracticable to perform a robotic-assisted pelvic exenteration?
SR: So far the main one has been recurrent disease. While in primary locally-advanced disease we can operate with robotic exenterative procedures, or beyond TME procedures, where there are recurrent tumour adhesions and fibrosis this make it difficult to perform it. Therefore we usually prefer not to treat those patients with a robotic exenteration.
We used to exclude pelvic side wall dissection as well but recently we started to perform lateral lymph node dissection robotically.
VB: Do you advocate and usually perform the use of laparoscopy to initially assess the suitability of a minimally invasive surgery (MIS) exenteration?
SR: Yes, we routinely start with laparoscopic assessment before moving to robotic exenteration.
VB: Do you think that a trial to explore the role of robotic surgery in pelvic exenteration is feasible [3]?
SR: The only trial done so far has been the ROLARR trial [4] and the criticisms about that trial was that people on their learning curve were included on the trial as well. The study didn’t show a huge advantage in robotic compared to laparoscopic surgery. I do think that a trial is feasible but a problem could be that not many people perform laparoscopic pelvic exenteration. So which groups are we going to compare: laparoscopic plus robotic to open? Laparoscopic, robotic and open separately? And that is going to be the challenge on recruiting centres.
VB: To date, gynaecologists have been keen adopters of MIS pelvic exenteration as it is associated with smaller wounds, less blood loss, quicker recovery and reduced length of hospital stay and numbers of reported procedures by gynaecologists are slightly higher. [5-6] Which are the reasons of delay of change in practice by colorectal surgeons?
SR: I think, like everything, is going to take time! The first adopters of robotic surgery were the urologists, then gynaecologists and finally colorectal surgeons. We are a little behind but catching up quite fast.
VB: Widespread adoption of MIS exenteration is unlikely at present, as the number of patients deemed suitable for MIS exenteration is low, surgeon experience is limited and there remains a steep learning curve, in your opinion what can and should be done to implement this practice?
SR: I think you need a combination of things:
- We will need to publish data and papers on the benefits and the downside of robotic exenterative surgery.
- We need to run dedicated fellowships with this purpose as well.
- Using a fellowship model we will be in the position of training people and monitor their learning curves.
So a combination of publications, presentations, sharing ideas, inviting surgeons to come and experience and watch MIS robotic exenterative surgeries and a good numbers of structured fellowships.
VB: Thank you so much indeed Mr. Shahnawaz for your time and for sharing your experience in this brand new field in coloproctology!
References
- Shin JW, Kim J, Kwak JM, Hara M, Cheon J, Kang SH, Kang SG, Stevenson AR, Coughlin G, Kim SH. First report: Robotic pelvic exenteration for locally advanced rectal cancer. Colorectal Dis. 2014 Jan;16(1):O9-14. doi: 10.1111/codi.12446. PMID: 24330440.
- Smith N, Murphy DG, Lawrentschuk N, McCormick J, Heriot A, Warrier S, Lynch AC. Robotic multivisceral pelvic resection: experience from an exenteration unit. Tech Coloproctol. 2020 Nov;24(11):1145-1153. doi: 10.1007/s10151-020-02290-x. Epub 2020 Jul 13. PMID: 32662050.
- PelvEx Collaborative. Minimally invasive surgery techniques in pelvic exenteration: a systematic and meta-analysis review. Surg Endosc. 2018 Dec;32(12):4707-4715. doi: 10.1007/s00464-018-6299-5. Epub 2018 Jul 17. PMID: 30019221.
- Jayne D, Pigazzi A, Marshall H, Croft J, Corrigan N, Copeland J, Quirke P, West N, Rautio T, Thomassen N, Tilney H, Gudgeon M, Bianchi PP, Edlin R, Hulme C, Brown J. 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 Oct 24;318(16):1569-1580. doi: 10.1001/jama.2017.7219. PMID: 29067426; PMCID: PMC5818805.
- Matsuo K, Matsuzaki S, Mandelbaum RS, Kanao H, Chang EJ, Klar M, Roman LD, Wright JD. Utilization and perioperative outcome of minimally invasive pelvic exenteration in gynecologic malignancies: A national study in the United States. Gynecol Oncol. 2021 Apr;161(1):39-45. doi: 10.1016/j.ygyno.2020.12.036. Epub 2021 Jan 3. PMID: 33402282.
- Bizzarri N, Chiantera V, Ercoli A, Fagotti A, Tortorella L, Conte C, Cappuccio S, Di Donna MC, Gallotta V, Scambia G, Vizzielli G. Minimally Invasive Pelvic Exenteration for Gynecologic Malignancies: A Multi-Institutional Case Series and Review of the Literature. J Minim Invasive Gynecol. 2019 Nov-Dec;26(7):1316-1326. doi: 10.1016/j.jmig.2018.12.019. Epub 2019 Jan 4. PMID: 30611973.