Laporoskopik ve robotik rektum kanser cerrahisi sonrası yakın dönem onkolojik ve postoperatif sonuçların retrospektif olarak değerlendirilmesi /
Yazar: VAGIF GURBANOV
Danışman: PROF. DR. MUSTAFA ALİ KORKUT
Ege Üniversitesi / Tıp Fakültesi / Genel Cerrahi Ana Bilim Dalı
Derece: Tıpta Uzmanlık, 2023
Konu: Genel Cerrahi = General Surgery

Özet:
AMAÇ: Bu çalışmamızda amacımız rektum kanseri sebebiyle opere ettiğimiz
hastalarda laparoskopik ve robotik cerrahide elde edilen onkolojik cerrahi başarıyı,
total mezokolon eksizyon skorlamasını, operasyon sonrasında cinsel fonksiyonlarda
kayıp ve aktivite değişimini ve lenf nodu sayısını da hesaplayarak laparoskopik ve
robotik cerrahi tekniklerin sonuçlarını karşılaştırmaktır. Mevcut literatürün kapsamlı
bir incelemesi yoluyla, bu çalışma her bir yöntemin faydalarına ve sınırlamalarına
genel bir bakış sunacak ve ikisi arasındaki seçimi etkileyen faktörleri belirleyecektir.
Birincil amac, cerrahiye odaklanarak her cerrahi tekniğin yararlarını ve
sınırlamalarını,ameliyat sonrası iyileşme ve hasta memnuniyetini belirlemektir.
MATERYAL VE METOD: Çalışmaya Ege Üniversitesi Eğitim ve Araştırma
Hastanesi Genel Cerrahi Kliniği'nde mart 2017-2021 tarihleri arasında rektum
kanseri nedeniyle ameliyat edilen 100 hasta (53 laparoskopik 47 robotik) dahil edildi.
Hastaların dosyaları retrospektif olarak incelendi. Hastalar laparoskopik ve robotik
cerrahi olarak 2 gruba ayrıldı. Gruplar demografik olarak yaş, cinsiyet, ek hastalıklar,
tümörün yerleşim yeri, ameliyat tipi (Low anterior rezeksiyon (LAR) ,Ultra Low
anterior rezeksiyon (Ultra LAR) ve Abdominoperineal Rezeksiyon (APR))
postoperatif hastanede yatış morbidite (clavien-dindo skorlaması) ve mortalite oranı
tümörün cerrahi sınırdan uzaklığı, çıkarılan lenf nodu sayısı, tümör evresi.
Postoperatif adjuvan tedavi lokal nüks, uzak metastaz, reoperasyon gerekliliği, tekrar
hastaneye kabul, üriner,inkontinans ve cinsel fonksiyonlar açısından karşılaştırıldı.
Hastalar polikliniğe çağrılarak Low anterior rezeksiyon sendromu (LARS), Wexner
skoru, Uluslararası Prostat Semptom Skoru (İPSS skoru), Uluslararası Erektil
Fonksiyon İndeksi (İİEF skoru), Kadın cinsel işlev ölçeği (FSFİ skoru) yapılan anket
çalışmasıyla değerlendirildi. Tüm verileri toparlayıp laparoskopik ve robotik rektum
cerrahisi geçiren hastaların yakın dönem postoperatif onkolojik ve cinsel
fonksiyonlarını karşılaştırdık.

Abstract:
INTRODUCTION: In this study, our aim is to compare the results of laparoscopic
and robotic surgical techniques by calculating the success of oncological surgery,
total mesocolon excision scoring, loss of sexual function and activity after the
operation, and the number of lymph nodes in patients operated on for rectal cancer in
laparoscopic and robotic surgery. Through a comprehensive review of the available
literature, this study will provide an overview of the benefits and limitations of each
method and identify factors that influence the choice between the two. The primary
goal is to identify the benefits and limitations of each surgical technique, with a focus
on surgery, post-operative recovery, and patient satisfaction.
MATERIAL AND METHOD: 100 patients (53 laparoscopic 47 robotic) who were
operated for rectal cancer in Ege University Training and Research Hospital General
Surgery Clinic between March 2017-2021 were included in the study. The files of the
patients were reviewed retrospectively. The patients were divided into 2 groups as
laparoscopic and robotic surgery. Groups were demographically determined by age,
gender, comorbidities, tumor location, type of surgery (Low anterior resection
(LAR), Ultra Low anterior resection (Ultra LAR) and Abdominoperineal Resection
(APR)), postoperative hospitalization morbidity (clavien-dindo scoring), and
mortality rate, distance of the tumor from the surgical margin, number of lymph
nodes removed, tumor stage. Postoperative adjuvant therapy was compared in terms
of local recurrence, distant metastasis, need for reoperation, readmission to hospital,
urinary incontinence and sexual functions. The patients were called to the outpatient
clinic and evaluated with a questionnaire; low anterior resection syndrome findings
(LARS), using Wexner-International Prostate Symptom Score (IPSS score)-
International Erectile Function Index (IIEF score)-Female sexual function scale
(FSFI score). We gathered all the data and compared the recent postoperative
oncological and sexual functions of patients who had undergone laparoscopic and
robotic rectal surgery.
RESULTS: When the patients were evaluated in terms of age, BMI, tumor size, and
ASA scores, no significant difference was found in the laparoscopic and robotic
surgery groups. The length of hospital stay and follow-up period in robotic cases
were found to be statistically significantly shorter than in laparoscopic cases
(p<0.001). In preoperative imaging, there were positive lymph nodes in 44.7% in the
robotic group and 73.6% in the laparoscopic group, and this difference was
statistically significant (p<0.001). While no converting to open technique was made
in robotic cases, it was observed that 28,3% of laparoscopic cases were converted to
open technique (p<0.001). There was no difference between the two groups in terms
of postoperative complications. While there was no positivity of circumferential
margin in the robotic group, a positivity of 35.8% of the circumferential margin was
found in the laparoscopic group, the difference was found to be significant
(p<0.001). There was no difference in terms of lymphatic and perineural invasion. In
the postoperative period, recurrence was observed in 4 patients who underwent
robotic surgery and 6 patients who underwent laparoscopic surgery. When the factors
affecting the recurrence are examined; it was observed that age, additional disease,
ASA score, family history, BMI, tumor size, lymph node positivity, operation time
and type, stoma type, converting open technique, complications, and circumferential
margin positivity had no effect on recurrence. It was determined that the pathological
stage, length of hospital stay, adjuvant and neoadjuvant treatment had an effect on
recurrence. Mean Wexner score was 7.69 ± 2.16, FSFI score was 10.19 ± 8.64 in
women, IPSS score was 6.18 ± 1.50 in men, and IIEF score was 14.95 ± 5.33 in men.
It was found that incontinence and sexual dysfunction were less common in robotic
cases.
CONCLUSION: Robotic surgery is a safe and effective surgical technique at least
as much as laparoscopic surgery. With an effective patient selection, the length of
hospital stay is shorter in robotic cases, but the transition to open technique is clearly
less common. In terms of patient and surgeon comfort, the superiority of robotic
surgery has been demonstrated both in the literature and in our study. In this aspect,
robotic surgery should be preferred in suitable patients. Although robotic surgery is
superior in the literature in terms of urinary dysfunction, sexual dysfunction, erectile
dysfunction and incontinence. Robotic surgery is recommended in this aspect, since
the findings in our study are also in this direction.