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Background Pelvic exenteration surgery for locally advanced and recurrent rectal cancer has developed significantly. Rates of complete resection have improved with high volume units achieving rates of up to 85%. The challenge is to maintain these R0 rates and reduce morbidity. One way to improve quality is to drive standardisation of care. Such standardisation allows more seamless training. Robotic pelvic exenteration is also a potentially attractive way to improve outcome. The pelvic sidewall is one of the technically complex areas to operate in within the pelvis. This study aimed to examine the challenges of introducing a robotic pelvic exenteration program and to standardise the key critical views and surgical steps for a pelvic sidewall clearance to allow this to be more widely introduced into robotic exenteration practice.
Methods This qualitative work was carried out in two parts. An interview study examined the challenges of introducing robotics into advanced rectal cancer surgery. An advanced resection was considered as a resection for recurrent rectal cancer or a locally advanced rectal cancer requiring an extended resection beyond a standard total mesorectal excision. Structured interviews were carried out with experienced robotic and advanced cancer surgeons until saturation was achieved. A key area of interest identified was pelvic sidewall resection. A pelvic sidewall clearance was defined as removal of the lymph node package with the resection of the internal iliac vessels. Experienced advanced cancer surgeons were interviewed about the key steps of the technique. Iterative consensus meetings identified the technical steps and views of the procedure.
Results In total 14 expert surgeons were interviewed concerning the challenges of introducing robotics. The main barriers identified were classified into infrastructure, technical and training issues. The infrastructure barriers identified were lack of robotic access, governance concerns, paucity of evidence of the feasibility and safety of robotic advanced cancer resection, lack of financial incentives and challenges developing the robotic multi-disciplinary team to support such procedures. Technical concerns were multi-quadrant operating with robotic platforms, loss of hepatic feedback and intra-operative navigation. Operative considerations were the ability to control bleeding, the bespoke nature of procedures with the lack of standardisation and size of extraction sites. Training concerns focussed on the ability to develop training programs that combine robotic surgery and open exenteration techniques as well as the long learning curve associated with robotic advanced rectal cancer surgery. Four expert advanced cancer surgeons took part in a consensus study to identify the critical views and key steps of a pelvic sidewall resection. Each surgeon was interviewed on their approach to the procedure. Following these interviews in two consensus meetings, consensus was reached on the key steps and ‘critical views’. This was translated into a procedural flow chart complete with photographs of the ‘critical views’ of pelvic sidewall resection.
Conclusion Robotic advanced rectal cancer surgery is a key area of increasing interest, but significant barriers exist to the more widespread adoption. Standardisation of procedures such as pelvic sidewall resection will allow the development of focused training programs.
