Robotics in IBD surgery – hype or revolution?

Use of robotic approaches is currently spreading rapidly in visceral surgery, including IBD surgery, and the number of studies showing the feasibility of robotically performing complex colorectal procedures such as colectomies and ileoanal pouch operations is increasing steadily. Undoubtedly most IBD operations can be done perfectly well with a robot – indeed, just as well as with conventional or laparoscopic approaches. However, there is still a paucity of randomised controlled studies demonstrating any measurable or clinically relevant advantages. Whereas the data regarding especially the short-term advantages of minimally invasive surgery compared to open surgery in IBD are clear, the differences between robotic surgery and modern 3D laparoscopic surgery remain modest and often seem clinically debatable. On the other hand, lower conversion rates are consistently found for robotic surgery and this may indeed make a difference for the patient.

The potential, currently still moderate advantages of robotic surgery need to be weighed against its considerably higher costs. Apart from the purchase costs, currently amounting to well over a million euros, at least for the established systems, the procedural costs for every operation are also much higher than with conventional laparoscopy. Even when taking into account a potentially shorter postoperative stay, as commonly postulated in low-evidence level studies, robotic surgery remains far more expensive at this point in time.

A further aspect to consider in IBD surgery is the inflamed, fibrotic nature of the tissue in IBD patients, especially those with Crohn’s Disease, which is challenging to manage, even with the tender touch of the human hand. Robotic technology still generally lacks adequate tactile sense and therefore may not be as atraumatic as required. This in turn may result in more morbidity in IBD surgery, where the friable tissue tends to crack up and tear more easily.

Nevertheless, the currently available robotic technology does offers clear-cut advantages: Compared to standard laparoscopy, the learning curve for complex procedures is shorter. Moreover, the ergonomic advantages for the surgeon are obvious, especially when performing difficult procedures deep down in confined spaces in patients with challenging anatomies. The higher degree of freedom of wrist movement with angulated instruments increases the accessibility of narrow spaces and facilitates suturing. Moreover, robotics is often able to filter out hand tremor and thereby potentially increase accuracy of dissection. It generally allows autonomous control of camera movement by the surgeon, thereby reducing the need for assisting surgical personnel. A further benefit is that the magnified 3D view enhances identification of delicate structures such as nerves. Although some of these aspects are also available without a robotic system per se (e.g. 3D view, angulated instruments, select camera arm), the combination of all of them in a robotic platform may sometimes provide the edge.

There is also a need to consider the impact of the further rapid technological advancement that will undoubtedly occur in the coming years. At the moment, robotic surgery is still very much in its infancy as it predominantly merely aids the surgeon in performing procedures: hitherto it is basically more telemanipulation than actual robotics. The latter will be continuously optimised taking into account the growth in available data as a result of the increasing distribution of robotic systems worldwide. In the future, robots, in conjunction with AI and navigational abilities, will increasingly learn to perform parts of procedures autonomously. Furthermore, new approaches are emerging. For example, improved single port access with a single robotic base incorporating different working arms is further reducing the access trauma and may revive single port or NOTES approaches, for which enthusiasm has wavered over the past decade due to being perceived as too tedious in conjunction with conventional laparoscopy.

Many new robotics systems have come onto the market in the last couple of years and most of them have tried to adopt an approach with trocar settings similar to conventional laparoscopic surgery, which may enhance the adoption of robotics also by experienced laparoscopic surgeons. As robotics often does not seem beneficial for an entire procedure, some of the systems focus on those segments of minimally invasive procedures where the greatest advantage is to be expected compared to standard laparoscopic surgery, e.g. suturing in confined spaces, and this will also contribute to cost reduction. More competition will hopefully bring prices down and aid in getting more robots into practice. The growing number of systems will make appropriate training even more important in the future, but this is probably well manageable through the use of simulator training models.

Despite the fascination in this topic, the scientific community will have to bear in mind that robotics also needs to prove itself in the context of evidence-based medicine. A robotic platform does not make sense for every procedure, and the potential advantages always need to be ethically weighed against the costs, especially in a world of restricted resources.

In conclusion, robotics is here to stay and has shown its feasibility, including for IBD surgery. Further controlled studies will be required to identify those robotic procedures that offer clear and relevant advantages compared to laparoscopic surgery, and these procedures should then preferably be performed robotically. As surgeons wanting to improve surgical techniques for the benefit of our patients, we will have to hop on this train of progress, “as neither a wise man nor a brave man lies down on the tracks of history to wait for the train of the future to run over him” (Dwight D. Eisenhower).

However, this data-driven model requires integration of data reporting and collection. Can ECCO lead the way through its international database, UR-CARE?

Relevant literature

Zaman S, Mohamedahmed AYY, Abdelrahman W, et al. Minimally invasive surgery for inflammatory bowel disease: a systematic review and meta-analysis of robotic versus laparoscopic surgical techniques. J Crohns Colitis 2024;18:1342–55. doi: 10.1093/ecco-jcc/jjae037.

Rathod S, Kumar N, Matiz GD, et al. The role of minimally invasive surgery in the management of inflammatory bowel disease: current trends and future directions. Cureus 2024;16:e65868. doi: 10.7759/cureus.65868.

Violante T, Ferrari D, Novelli M, et al. Evaluating the impact of robotic IPAA: a case-matched analysis from a high-volume center. Ann Surg 2024 Sep 5. doi: 10.1097/SLA.0000000000006524. Online ahead of print.

Kienle P, Magdeburg R. Minimal-invasive und roboterassistierte Chirurgie bei chronisch entzündlicher Darmerkrankung: Aktueller Stand und Evidenzlage [Minimally invasive and robot-assisted surgery for chronic inflammatory bowel disease: Current status and evidence situation]. Chirurg 2021;92:21–9. [German]. doi: 10.1007/s00104-020-01306-4.

Seeliger B, Pavone M, Schröder W, et al. Skill progress during a dedicated societal robotic surgery training curriculum including several robotic surgery platforms. Surg Endosc 2024;38:5405–12. doi: 10.1007/s00464-024-11128-8.

The Surgibots Podcast, Spotify. Don’t believe the hype – we need more clinical evidence 21.11.2024