Annals of Surgery Journal Club

Interactive resource for surgery residents and surgeons to discuss and critically evaluate articles published in Annals of Surgery selected by a monthly guest expert who will review an article each month, offer questions and respond to reader's comments.

Sunday, May 5, 2013

May, 2013 Journal Club
Moderator: Dr. John R. T. Monson
Article: The Impact of Robotic Surgery for Mid and Low Rectal Cancer: A Case-Matched Analysis of a 3-Arm Comparison—Open, Laparoscopic, and Robotic Surgery

Jeonghyun Kang, MD, Kyu Jong Yoon, MD, Byung Soh Min, MD, Hyuk Hur, MD, Seung Hyuk Baik, MD, PhD, Nam Kyu Kim, MD, PhD, and Kang Young Lee, MD, PhD

Ann Surg 2013;257:95-101



This paper addresses a subject that is currently highly topical – the use of robotic surgery in rectal resection.  This paper presents a retrospective case matched comparison between patients undergoing open surgery (OS), laparoscopic surgery (LS) and robotic surgery (RS) for cancers within 10cm of the anal verge.  The authors searched their own prospectively collected database and used a propensity score methodology to produce three patient groups that were as well matched as possible.  Short-term clinical outcomes were recorded including operative events, post-operative recovery and the incidence of complications.  The results as presented suggest that both of the minimally invasive approaches were associated with better outcomes than open surgery and for the most part RS was better than LS when it came to pain scores, restoration of GI function and hospital stay.  The authors conclude therefore that RS may be an effective tool in efforts to maximize the benefits of a minimally invasive approach to rectal cancer.


While interesting at first glance it is clear that these results should be interpreted with caution for several reasons.  First the patients groups do not appear to be that well matched for rates of chemoradiotherapy, tumor location and the rate of APER.  In addition, 22% of RS patients avoided a mini-laparotomy for specimen extraction by using trans-anal delivery.  Finally, these authors are true experts in the use of both LS and RS for rectal cancer and in addition may have some advantages due to the Asian population in this study.


By their own admission, the authors recognize that some of their outcomes are counter-intuitive and might well be influenced by selection bias – operative choice was determined by individual surgeon choice.  Clearly the role of RS in rectal cancer surgery will need to be further studied before it achieves wider application.



1.      Should studies such as this be used by surgeons or institutions to drive decision-making about introducing new technologies to practice?

2.      How easily transferrable is this technology to your practice?  How well does this experience reflect your own in terms of equipment availability and patient population?

3.      Do you believe either LS or RS represent the new standard of care for rectal cancer surgery and if not why not?


Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers.