Česky
For rectal diseases, this applies in particular to operations on haemorrhoids and rectal fistulas. For example, for haemorrhoidal diseases, only about 30% of cases are treated with conventional haemorrhoidectomy in departments that have implemented minimally invasive techniques in their surgical portfolio. Haemorrhoids of stage II and partly also stage III can be treated as an outpatient with Barron's ligature - placing an elastic ring on the haemorrhoid, and in case of milder stages with thermal damage to the feeding haemorrhoidal artery with laser, Hemoron or other thermocoagulation method.
The aim of all outpatient interventions except ligation is to induce aseptic inflammation around the haemorrhoidal arteries with subsequent obliteration and fibrosis, thereby restricting the inflow to the haemorrhoidal node. Therefore, outpatient procedures are sometimes referred to as obliteration procedures. In more advanced stages, the procedure is performed under general anaesthesia, where the prolapsed haemorrhoid is not excised but is fixed in its original place in the rectal wall with absorbable sutures. In the case of circular haemorrhoids, a stapler operation is then performed, which also avoids injury in the sensitive zone of the rectum.
Similarly, in the case of rectal fistulas, the laser method can be used successfully, or the rectum can be filled with an absorbable material. The application of stem cells also holds promise for the future. The success rate of minimally invasive methods is so far lower than that of the conventional surgical method - 60% vs. 80% in favour of the conventional method - but minimally invasive methods have a significantly reduced recovery time, minimal or no pain and no risk of injury to the rectal sphincters. Of course, the procedure can be repeated, thus cumulatively increasing the success rate.
For functional pelvic floor and rectal disorders, the laparoscopic approach is already used in the vast majority of cases. Most often, laparoscopic rectopexy is performed, where the prolapsed rectum is fixed with a special mesh in the sacral area with tissue glue or absorbable screws. Here too, the recovery time is significantly reduced and there is minimal risk of injury to pelvic structures, especially the nerves in the pelvic area, which are important for urological and sexual functions. The cosmetic effect cannot be overlooked either, with only minor scarring remaining after the laparoscopic approach. Further advances in the treatment of functional pelvic floor disorders will certainly bring about an extension of the spectrum of robotic surgery for these diagnoses. The robotic approach can perform pelvic floor muscleplasty even more precisely than the laparoscopic approach.
In the treatment of non-specific intestinal inflammation, the laparoscopic approach is even directly recommended in Western countries. In addition to the advantages mentioned above, there is a lower risk of developing postoperative intestinal paralysis, the patient is mobile sooner and the length of postoperative hospital stay is reduced. The higher cost of consumables invested during surgery is then recouped by a shorter hospital stay and a shorter stay in the intensive care unit.
This is also the case for malignant diseases of the colon and rectum. The oncological success rate is quite comparable to the conventional open approach, but there is a lower postoperative morbidity. The robotic approach can even achieve better oncological results than conventional surgery.
It is a sad fact that the laparoscopic approach is used in only about 20% of operations for malignant tumours. For benign diseases it is even less - about 15% of operations. What is striking about this is that the pioneers of minimally invasive procedures are mainly smaller and private medical institutions. Mini-invasive methods are patient-friendly due to less pain and shorter groaning time, and ultimately more economically advantageous - for the patient, the healthcare facility, the healthcare payer and, due to shorter sick leave, the patient's employer.
Július Örhalmi, MD, FASCRS, Department of Surgery, Hořovice Hospital
