Advanced Colorectal Surgery with a Newly Approved Japanese Robotic Surgical Platform in Singapore.

Abstract

Robotic-assisted colorectal surgery has matured over the past two decades, driven predominantly by the well-known robotic technology developed in the United States. New evidence also demonstrates improved postoperative recovery, lower conversion rates, and improved oncological resection margins over laparoscopy. However, high acquisition and maintenance costs and a bulky infrastructure have limited global adoption. The recent expiry of a significant number of core foundational intellectual property patents related to USA technology marked a pivotal shift especially in 2019 and reduced barriers of entry for competitors. A Japanese robotic surgical platform was developed domestically in 2020 and received regulatory approval for use in colectomy in 2022. Its similar user interface and structural design to the USA system, comprising an operation unit with 4 integrated operation arms, a surgeon cockpit, and a vision unit allows for easy adaptability and a short learning curve for experienced users of USA robotic system. Its compact profile, unique ergonomic and cost-related advantages may broaden global access to robotic-assisted minimally invasive surgery. Besides its user interface and structural design being comparable to the USA robotic system, unique distinguishing features include a more compact overall system, flexible 3-dimensional viewer, robotic arms with joy stick-type 8 axes of motion and 520 o instrument tip rotation, and an adjustable arm base angle allowing for more arm motion flexibility. Slimmer arm profiles and a docking-free design where the "pivot" position is set by a software removes the need for docking the arm to the trocar, allowing for more working space around the port sites. These features reduce arm interference and make external manipulation easier. Other differences from the USA robotic technology include the absence of integrated indocyanine green fluorescence capability, integrated table motion, and dual-console functionality; it also lacks advanced energy devices and linear staplers. The Japanese Surgical Robot System obtained approval for use in colorectal cancer surgery in Singapore in October 2024. Two minimally invasive colorectal surgeries that were performed with the system are presented. In the first, a 70-year-old man with sigmoid cancer underwent a robotic-assisted anterior resection. Indocyanine-green overlay was utilized. Tumor pathology was pT3N0 stage with clear margins. In the second, a 75-year-old lady woman with rectal prolapse underwent a robotic-assisted ventral mesh rectopexy with Permacol mesh. In both cases, there were no intraoperative complications and the patients were discharged well. The usage of robot-assisted colorectal surgery with the Japanese Surgical Robot System has expanded across Japan in the last 3 years with clinical results now published demonstrating its safety and feasibility with similar short-term outcomes to the USA system. Its superior ergonomics as a robotic-platform over laparoscopy and cost-related advantages suggest potential to broaden access. Long-term follow up of results and a focus on expanding the system's instrument portfolio including integrated advanced energy devices and staplers will be useful for colorectal surgery. See New Technology video.