Robotic tumor-specific mesorectal excision of rectal cancer: short-term outcome of a pilot randomized trial

The role of the robotic technique in minimally invasive surgery in rectal cancer

Laparoscopic rectal surgery is feasible, oncologically safe, and offers better short-term outcomes than traditional open procedures in terms of pain control, recovery of bowel function, length of hospital stay, and time until return to working activity. Nevertheless, laparoscopic techniques are not widely used in rectal surgery, mainly because they require a prolonged and demanding learning curve that is available only in high-volume and rectal cancer surgery centres experienced in minimally invasive surgery. Robotic surgery is a new technology that enables the surgeon to perform minimally invasive operations with better vision and more intuitive and precise control of the operating instruments, promising to overcome some of the technical difficulties associated with standard laparoscopy. The aim of this review is to summarise the current data on clinical and oncological outcomes of minimally invasive surgery in rectal cancer, focusing on robotic surgery, and providing original data from the authors’ centre.

Robotic surgery: colon and rectum

Although robotic technology aims to obviate some of the limitations of conventional laparoscopic surgery, the role of robotics in colorectal surgery is still largely undefined and different with respect to its application in abdominal versus pelvic surgery. This review aims to elucidate current developments in colorectal robotic surgery.In colon surgery, robotic techniques are associated with longer operative times and higher costs compared with laparoscopic surgery. However, robotics provides a stable camera platform and articulated instruments that are not subject to human tremors. Because of these advantages, robotic systems can play a role in complex procedures such as the dissection of lymph nodes around major vessels. In addition robot-assisted hand-sewn intracorporeal anastomoses can be easily performed by the surgeon, without a substantial need for a competent assistant. At present, although the short-term outcomes and oncological adequacy of robotic colon resection have been observed to be acceptable, the long-term outcomes of robotic colon resection remain unknown.In rectal surgery, robotic-assisted surgery for rectal cancer can be carried out safely and in accordance with current oncological principles. However, to date, the impact of robotic rectal surgery on the long-term oncological outcomes of minimally invasive total mesorectal excision remains undetermined. Robotic total mesorectal excision may allow for better preservation of urinary and sexual functions, and robotic surgery may attenuate the learning curve for laparoscopic rectal resection. However, a major drawback to robotic rectal surgery is the high cost involved.Large-scale prospective randomized clinical trials such as the international randomized trial ROLARR are required to establish the benefits of robotic rectal surgery.

Robotic-assisted total mesorectal excision with the aid of a single-port device

INTRODUCTION AND INDICATIONS: Robotic surgery has numerous advantages in rectal cancer surgery. Studies have reported the advantages associated with single-port approaches, such as eliminating the need for additional incisions, as well as the difficulties inherent in this technique. The authors present a hybrid technique that they performed using a robotic total mesorectal excision with the aid of a single port-device. Materials and methods. The authors performed the technique on 2 patients using a single-port device through an umbilical incision and 3 accessory ports for the robotic arms. There was no need to place ports for the assistant's equipment or for an assistant incision.

RESULTS AND COMPLICATIONS

The operation time was 177.5 minutes, and there were no intraoperative or postoperative complications. Both patients were discharged 7 days after the operation.

CONCLUSIONS

This technical variation is an additional step forward for oncological surgery with minimal damage to the abdominal wall.

Robotic surgery for gynaecologic cancer: an overview

After decades of reluctance to change surgical approaches, new technologies have created new perspectives for surgery. Initially, the laparoscopic approach was considered to be only one useful for relatively simple procedures as the design of the instruments and the limited access hampered free movements to perform complicated surgery. Robotic systems overcame this problem and boosted the use of minimally invasive techniques also for radical gynaecological surgery. Robot-assisted laparoscopy can now routinely be used for the surgical treatment of early or downstaged cervical carcinoma, endometrial carcinoma and staging of early ovarian carcinoma. Robot-assisted laparoscopy has proven to be feasible, although the benefits for the patient are less clear than those for the surgeon. The main advantage of robot-assisted laparoscopy over conventional laparoscopy is probably not that it is safer or better, but that it allows more types of radical surgery to be performed and that it prevents the surgeon from developing complaints and muscular conditions that interfere with the ability to perform surgery. New applications have emerged with the introduction of new devices to be used in conjunction with the robotic system as well as with totally new robotic systems. Training in these new tools should be more systematic and structured to allow their safe introduction and use.

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

OBJECTIVE

The objective of this study was to clarify the impact of robotic surgery (RS) in the management of mid and low rectal cancer in comparison with open surgery (OS) and laparoscopic surgery (LS).

BACKGROUND

The benefits of RS in the treatment of rectal cancer have not yet been clearly described.

METHODS

Using propensity scores for adjustment of sex, age, body mass index, tumor stage, and tumor height, a well-balanced cohort with 165 patients in each group, was created by matching each patient who underwent RS as the study group with one who underwent OS or LS as the control group (RS:OS = 1:1, RS:LS = 1:1 match). Pathological results, morbidity, perioperative recovery, and short-term oncological results were compared between the 3 groups.

RESULTS

In RS and LS, the time to first flatus and resumed soft diet and length of hospital stay were significantly shortened compared with OS. Robotic surgery showed better recovery outcomes than LS with regard to time to resumed soft diet and length of hospital stay. The visual analog scale was significantly lower in the RS than in the OS and LS from postoperative days 1 to 5. The voiding problem and circumferential resection margin involvement rate were significantly lower in the RS group than in the OS group. No significant difference in 2-year disease-free survival was observed among the 3 groups.

CONCLUSIONS

Robotic surgery may be an effective tool in the effort to maximize the advantages of minimally invasive surgery in the management of mid to low rectal cancer.

Advances in gynaecological oncology surgery

Latest surgical advances in the field of gynaecological oncology, a sub-specialty of gynaecology, are reviewed in this chapter. The surgery is mainly practised in cancer centres by board-certified gynaecologists, and requires a 2-3 year period of additional training in gynaecological oncology. Surgical treatment of gynaecological malignancies has progressed in two directions: reduction of the invasiveness of the surgery and expansion of the number and type of procedures performed. Gynaecological oncology focuses on the pelvis to the upper abdomen and the thorax to target (all visible disease) the last cancer cell in women with advanced ovarian cancer. Minimal-access surgery has evolved to include any operation by laparoscopy. It uses fewer ports (single-port surgery), and robotic assistance improves the comfort of the surgeon. The concept of fertility-sparing surgery for women with cervical cancer is now supported by mature data. The indication and the aggressiveness of the exenterative surgery are also broader than originally recommended. The ideal timing of surgery is under investigation in several areas, mainly in women with ovarian and cervical cancer. The aim is to reduce morbidity and mortality of surgical procedures while maintaining the survival outcome.

The da Vinci robotic surgical assisted anterior lumbar interbody fusion: technical development and case report

STUDY DESIGN

Technique development to use the da Vince Robotic Surgical System for anterior lumbar interbody fusion at L5-S1 is detailed. A case report is also presented.

OBJECTIVE

To evaluate and develop the da Vinci robotic assisted laparoscopic anterior lumbar stand-alone interbody fusion procedure.

SUMMARY OF BACKGROUND DATA

Anterior lumbar interbody fusion is a common procedure associated with potential morbidity related to the surgical approach. The da Vinci robot provides intra-abdominal dissection and visualization advantages compared with the traditional open and laparoscopic approach.

METHODS

The surgical techniques for approach to the anterior lumbar spine using the da Vinci robot were developed and modified progressively beginning with operative models followed by placement of an interbody fusion cage in the living porcine model. Development continued to progress with placement of fusion cage in a human cadaver, completed first in the laboratory setting and then in the operating room. Finally, the first patient with fusion completed using the da Vinci robot-assisted approach is presented.

RESULTS

The anterior transperitoneal approach to the lumbar spine is accomplished with enhanced visualization and dissection capability, with maintenance of pneumoperitoneum using the da Vinci robot. Blood loss is minimal. The visualization inside the disc space and surrounding structures was considered better than current open and laparoscopic techniques.

CONCLUSION

The da Vinci robot Surgical System technique continues to develop and is now described for the transperitoneal approach to the anterior lumbar spine.

LEVEL OF EVIDENCE

4.

Does robotic rectal cancer surgery offer improved early postoperative outcomes?

BACKGROUND

Laparoscopic rectal surgery continues to be challenging, especially in low rectal cancers, because the technique has several limitations. Robotic rectal surgery could potentially address these limitations. However, it still remains unclear whether robotic surgery should be accepted as the new standard treatment in rectal cancer surgery.

OBJECTIVE

The aim of this study is to provide a comprehensive and critical analysis of the available literature to assess if robotic rectal surgery offers improved early postoperative outcomes in comparison with standard laparoscopic rectal surgery.

DATA SOURCES

A systematic review was conducted following the search of electronic databases (PubMed, Science Direct, Google Scholar) for the period 2007 to 2011 by using the key words "rectal surgery," "laparoscopic," "robotic."

STUDY SELECTION

All studies reporting outcomes on laparoscopic and robotic resection for extraperitoneal and intraperitoneal rectal cancer were included in the review process; all studies on colonic cancer and benign disease were excluded.

INTERVENTIONS

A comparison was conducted of robotic vs standard laparoscopic rectal cancer surgery.

MAIN OUTCOME MEASURES

The primary outcome measured was the assessment of whether robotic rectal cancer surgery provides improved short-term outcomes in comparison with standard laparoscopic rectal surgery.

RESULTS

Robotic rectal surgery was associated with increased cost and operating time, but lower conversion rates, even in obese individuals, distal rectal tumors, and patients who had preoperative chemoradiotherapy regardless of the experience of the surgeon. There is also marginally better outcome in anastomotic leak rates, circumferential resection margin positivity, and perseveration of autonomic function, but this did not reach statistical significance.

LIMITATIONS

This review has some limitations because it relies on the analysis of data collected from various nonrandomized controlled trials with variable quality and different methodology.

CONCLUSION

The current evidence suggests that robotic rectal surgery could potentially offer better short-term outcomes especially when applied in selected patients. Obesity, male sex, preoperative radiotherapy, and tumors in the lower two-thirds of the rectum may represent selection criteria for robotic surgery to justify its increased cost.

Robotic versus laparoscopic total mesorectal excision for rectal cancer: A Meta-analysis

AIM: To compare the efficacy of robotic versus laparoscopic total mesorectal excision for rectal cancer.

METHODS: Controlled trials comparing the efficacy of robotic versus laparoscopic total mesorectal excision for rectal cancer were electronically searched from MEDLINE (PubMed), EMBASE, OVID, CNKI, and WANFANG databases. Relevant published and unpublished data and their references were also searched manually. The data were extracted and the methodological quality of the incorporated research was evaluated by two reviewers independently, and the RevMan 5.1 software was used for Meta-analysis.

RESULTS: Six studies including 414 patients were included in the analysis. A meta-analysis showed that there were no significant differences in operative time [MD = 23.77, 95% CI (-1.80, 49.34), P = 0.07], length of hospital stay [MD = -0.59, 95% CI (-1.62, 0.43), P = 0.26], number of cleared lymph nodes [MD = 0.97, 95% CI (-0.69, 2.64), P = 0.25], overall complications [RR = 0.82, 95% CI (0.49, 1.36), P = 0.44] and individual complications between the study group and control group.

CONCLUSION: Current evidence demonstrates that robotic and laparoscopic techniques have similar curative effect in total mesorectal excision for rectal cancer. The above conclusion is still validated by carrying out more multi-center randomized controlled trials.

Current status of robotic rectal cancer surgery

SUMMARY After the introduction of robotic surgery for rectal cancer, the safety and feasibility of robotic rectal cancer surgery was demonstrated. However, early comparative studies between laparoscopic and robotic surgery did not show a significant postoperative benefit. Recently, it was reported that robotic rectal surgery showed better postoperative outcomes than laparoscopic surgery with regard to postoperative recovery, pain and function preservation. In addition, robotic transanal specimen extraction was safely performed while maintaining a lower level of postoperative pain and recovery time. All of these findings should be validated with well-designed comparative studies. As robotic technology advances and continues to be studied, the use of robotic surgical systems will become more common among colorectal surgeons.

Robot versus laparoscopic gastrectomy for cancer by an experienced surgeon: comparisons of surgery, complications, and surgical stress

BACKGROUND

No previous robotic studies present an equivalent surgical quality comparison in an experienced setting for gastric cancer. In addition, a reliable postoperative complication assessment is needed to accurately evaluate surgical outcomes.

METHODS

After 20 cases of robotic-assisted gastrectomy (RAG), a total of 121 consecutive gastric cancer patients underwent gastrectomy (38 RAG vs 83 laparoscopic-assisted gastrectomy [LAG]) from February 2009 to November 2010 at the Department of Surgery, Korea University Anam Hospital, Seoul, Korea. The Clavien-Dindo (C-D) classification was used to classify surgical complications. The granulocyte-to-lymphocyte (G:L) ratio was analyzed to evaluate surgical stress.

RESULTS

The baseline characteristics, with the exception of age, were similar. The mean total operation time for RAG (234.4 ± 48.0 min) was not significantly different than that for LAG (220.0 ± 60.6 min; P = 0.198). However, in obese patients, fewer lymph nodes were harvested by RAG (23.4 ± 7.0) than by LAG (32.2 ± 12.5, P = 0.006). Overall C-D complications were more common for RAG (47.3 vs 38.5 %), but the difference was not significant (P = 0.361). The mean hospital stay was similar for the 2 groups. Surgical stress as estimated by the G:L ratio was comparable between the 2 groups.

CONCLUSIONS

RAG performed by an experienced surgeon resulted in similar postoperative outcomes and complications to those of LAG. Assessment of operation time, C-D complication grade, and G:L ratio revealed that RAG is a practical and feasible alternative to LAG, with the possible exception of obese patients.

Robot-assisted low anterior resection in fifty-three consecutive patients: an Indian experience

From December 2005 to December 2009, we performed 150 laparoscopic colorectal procedures. Based on this experience, we started offering robot-assisted colorectal surgery from December 2009. This study is a prospective evaluation of consecutive patients in order to study the technical feasibility and oncological outcome of robot-assisted low anterior resection. This investigation was conducted at a single minimal access surgery institute. Between December 2009 and December 2011, 53 consecutive patients with rectal adenocarcinoma underwent a robot-assisted low anterior resection (LAR) or ultralow anterior resection (ULAR) with total mesorectal excision (TME), using the standard da Vinci 'S' model. Patient demographics, mean operative time, mean postoperative hospital stay, blood loss, days to first flatus, resumption of oral feeds, urinary incontinence, and sexual dysfunction were studied. Surgical and pathological outcomes such as quality of TME, free circumferential margins, and number of lymph nodes dissected were also evaluated. Robot docking and undocking times were noted. Of the 53 patients, 41 were men and 12 were women. Their mean age was 66.7 years (range 37-90 years). The ASA grades were distributed as follows: ASA I 15 (28.3 %), ASA II 25 (47.16 %), ASA III 12 (22.64 %), ASA IV 1 (1.88 %). The mean operative time was 180 min (150-230 min) and the mean blood loss was 101.6 ml (50-300 ml). The robot docking time was 10 min (15-25 min) and the undocking time was 5 min (3-10 min). The mean hospital stay was 8 days (7-15 days). None of the patients was converted to either laparoscopic or open procedure. The longitudinal and circumferential margins were negative in all patients. Histopathological reports of 45 patients showed complete TME while 8 patients showed nearly complete TME. No repositioning of the robot was needed for splenic flexure mobilization, thus decreasing the operative time. Along with TME, even the splenic flexure mobilization was achieved through the same robotic ports without undocking the robot. Robot-assisted LAR and ULAR is technically feasible, and a complete TME is possible.

Current state of the art in laparoscopic colorectal surgery for cancer: Update on the multi-centric international trials

Laparoscopic colectomy is now widely applied to cases of malignancy, supported by early data from several large randomized controlled trials. Long-term follow-up is now available from those trials, supporting equivalency of cancer-free and overall survival for open and laparoscopic resections. This promising data has inspired further exploration of other applications of laparoscopic techniques, including use of single incision laparoscopy. This article reviews recent reports of long-term data for colorectal cancer resection from four randomized, prospective international trials.

Robotic versus laparoscopic gastrectomy for gastric cancer: a meta-analysis of short outcomes

BACKGROUND

Robotic gastrectomy (RG) for gastric cancer remains controversial. The main aim of this meta-analysis was to compare the safety and efficacy of robotic gastrectomy (RG) and conventional laparoscopic gastrectomy (LG) for gastric cancer.

METHODS

Literature searches of electronic databases (PubMed, Embase, Cochrane Library Ovid, and Web of Science databases) and manual searches up to December 30, 2011 were performed. Comparative clinical trials were eligible if they reported perioperative outcomes for RG and LG for gastric cancer. Fixed and random effects models were used. The RevMan 5.1 was used for pooled estimates.

RESULTS

Three NRCTs enrolling 918 patients (268 in the RG group and 650 in the LG group) were included in the meta-analysis. RG for gastric cancer was associated with a significantly longer operative time (WMD: 68.77, 95% CI: 35.09-102.45; P < 0.0001), but significantly less intraoperative blood loss (WMD: -41.88, 95% CI: -71.62 to -12.14; P = 0.006). We found no significant differences in the number of lymph nodes (WMD: -0.71, 95% CI: -6.78 to 5.36; P = 0.82), overall morbidity (WMD: 0.74, 95% CI: 0.47 to 1.16; P = 0.19), perioperative mortality rates (WMD: 1.80, 95% CI: 0.30 to 10.89; P = 0.52) and length of hospital stay (WMD: 0.42, 95% CI: -1.87 to 0.79; P = 0.42) between the two groups.

CONCLUSIONS

It may be concluded that RG is a safe and effective alternative to LG and is justifiable under the setting of clinical trials. Additional RCTs that compare RG and LG and investigate the long-term oncological outcomes are required to determine potential advantages or disadvantages of RG.

Current status of robotic surgery

Surgery has increasingly become a technology-driven specialty. Robotic assistance is considered one innovation within abdominal surgery over the past decade that has the potential to compensate for the drawbacks of conventional laparoscopy. The dramatic evolution of robotic surgery over the past 10 years is likely to be eclipsed by even greater advances over the next decade. We review the current status of robotic technology in surgery. The Medline database was searched for the terms "robotic surgery, telesurgery, and laparoscopy." A total of 2,496 references were found. All references were considered for information on robotic surgery in advanced laparoscopy. Further references were obtained through cross-referencing the bibliography cited in each work. There is a paucity of control studies on a sufficient number of subjects in robot-assisted surgeries in all fields. Studies that meet more stringent clinical trials criteria show that robot-assisted surgery appears comparable to traditional surgery in terms of feasibility and outcomes but that costs associated with robot-assisted surgery are higher because of longer operating times and expense of equipment. While a limited number of studies on the da Vinci robotic system have proven the benefit of this approach in regard to patient outcomes, including significantly reduced blood loss, lower percentage of postoperative complications, and shorter hospital stays, there are mechanical and institutional risks that must be more fully addressed. Robotic assistance will remain an intensively discussed subject since clinical benefits for most procedures have not yet been proven. While the benefit still remains open to discussion, robotic systems are spreading and are available worldwide in tertiary centers.

Robot-assisted versus conventional laparoscopic surgery for colorectal disease, focusing on rectal cancer: a meta-analysis

BACKGROUND

Robotic colorectal surgery may solve some of the problems inherent to conventional laparoscopic surgery (CLS). We sought to evaluate the advantages of robot-assisted laparoscopic surgery (RALS) using the da Vinci Surgical System over CLS in patients with benign and malignant colorectal diseases.

METHODS

PubMed and Embase databases were searched for relevant studies published before July 2011. Studies clearly documenting a comparison of RALS with CLS for benign and malignant colorectal diseases were selected. Operative and postoperative measures, resection margins, complications, and related outcomes were evaluated. Weighted mean differences, relative risks, and hazard ratios were calculated using a random-effects model.

RESULTS

The meta-analysis included 16 studies comparing RALS and CLS in patients with colorectal diseases and 7 studies in rectal cancer. RALS was associated with lower estimated blood loss in colorectal diseases (P = 0.04) and rectal cancer (P < 0.001) and lower rates of intraoperative conversion in colorectal diseases (P = 0.03) and rectal cancer (P < 0.001) than CLS. In patients with colorectal diseases, however, operating time (P < 0.001) and total hospitalization cost (P = 0.06) were higher for RALS than for CLS.

CONCLUSIONS

RALS was associated with reduced estimated blood loss and a lower intraoperative conversion rate than CLS, with no differences in complication rates and surrogate markers of successful surgery. Robotic colorectal surgery is a promising tool, especially for patients with rectal cancer.

Robotic-assisted total mesorectal excision: should it be considered as the technique of choice in the management of rectal cancer?

The feasibility of robotic surgery has been extensively explored over the past decade with a more recent shift towards defining focused clinical applications for which quantifiable patient benefits can be directly attributed to its use. The aim of this article is to review the current literature on the use of daVinci robotic surgery for the management of rectal cancer and identify the potential benefits, if any, that robotic-assisted total mesorectal excision (RTME) may provide over the current conventional approach. A comprehensive search strategy was used to identify relevant evidence in order to explore the oncological, operative and functional outcome measures for the RTME in addition to quantifying the level of evidence which describes the clinical effectiveness of the daVinci robot in oncological surgery. Both robotic assisted techniques and the primary outcomes are discussed. In total, 23 studies were reviewed across 11 institutions, including one pilot randomised control trial. When data repetition is disregarded, a total of 452 robotic assisted laparoscopic anterior resections and 60 robotic-assisted laparoscopic abdomino-perineal excision of the rectum have been published since the introduction of the daVinci into clinical practice. Feasibility of the daVinci robotic assisted total mesorectal excision is demonstrated, with comparable oncological outcomes presented for rectal cancer excision. A demonstration of a reduced open conversion rate as well as of reduced hospital stay with the use of the robot is highlighted, although further trials are required to confirm both these findings. No functional benefit in using the daVinci could be confirmed due to the lack of focused trials in this area.

Robotic colorectal surgery: a systematic review

Aim. Robotic colorectal surgery may be a way to overcome the limitations of laparoscopic surgery. It is an emerging field; so, we aim in this paper to provide a comprehensive and data analysis of the available literature on the use of robotic technology in colorectal surgery. Method. A comprehensive systematic search of electronic databases was completed for the period from 2000 to 2011. Studies reporting outcomes of robotic colorectal surgery were identified and analyzed. Results. 41 studies (21 case series, 2 case controls, 13 comparative studies 1 prospective comparative, 1 randomized trial, 3 retrospective analyses) were reviewed. A total of 1681 patients are included in this paper; all of them use Da Vinci except 2 who use Zeus. Short-term outcome has been evaluated with 0 mortality and191 total major and minor complications. Pathological results were not analyzed in all studies and only 20 out of 41 provide data about the pathological results. Conclusion. Robotic surgery is safe and feasible option in colorectal surgery and a promising field; however, further prospective randomized studies are required to better define its role.

Robot-assisted laparoscopic abdominoperineal resection for low rectal cancer

BACKGROUND

This article reports on patients with low rectal cancer treated with robot-assisted laparoscopic abdominoperineal resection.

METHODS

Robot-assisted laparoscopic abdominoperineal resection was performed on seven patients in the General Surgery Clinic of Umraniye Training and Research Hospital between 2010 and 2011 by performing abdominal and perineal skin incisions using the same technique. Gender, age of the patients, intraoperative and postoperative complications, morbidity and mortality were evaluated.

RESULTS

Five of the patients were male and two of them were female. Mean age was 59.2 years. All of the procedures were completed robotically. No intraoperative complication occurred, whereas urinary bladder dysfunction (n = 1) and chylous ascites (n = 1), treated conservatively, developed in the postoperative period. On histopathological examination, surgical and circumferential margins were found to be negative in all specimens. Early recurrence was not found on postoperative follow-up.

CONCLUSION

Robot-assisted laparoscopic surgery can be performed safely in narrow and deep anatomical areas, such as the pelvis.

Robotic resection compared with laparoscopic rectal resection for cancer: systematic review and meta-analysis of short-term outcome

AIM

The study aimed to compare robotic rectal resection with laparoscopic rectal resection for cancer. Robotic surgery has been used successfully in many branches of surgery but there is little evidence in the literature on its use in rectal cancer.

METHODS

  We performed a systematic review of the available literature in order to evaluate the feasibility, safety and effectiveness of robotic versus laparoscopic surgery for rectal cancer. We compared robotic and laparoscopic surgery with respect to twelve end-points including operative and recovery outcomes, early postoperative mortality and morbidity, and oncological parameters. A subgroup analysis of patients undergoing full-robotic or robot-assisted rectal resection and robotic total mesorectal excision was carried out. All aspects of Cochrane Handbook for systematic reviews and Preferred Reporting Items for Systematic Reviews and Metanalysis (PRISMA) statement were followed to conduct this systematic review. Comprehensive electronic search strategies were developed using the following electronic databases: PubMed, EMBASE, OVID, Medline, Cochrane Database of Systematic Reviews, EBM reviews and CINAHL. Randomized and nonrandomized clinical trials comparing robotic and laparoscopic resection for rectal cancer were included. No language or publication status restrictions were imposed. A data-extraction sheet was developed based on the data extraction template of the Cochrane Group. The statistical analysis was performed using the odd ratio (OR) for categorical variables and the weighted mean difference (WMD) for continuous variables.

RESULTS

Eight non randomized studies were identified that included 854 patients in total, 344 (40.2%) in the robotic group and 510 (59.7%) in the laparoscopic group. Meta-analysis suggested that the conversion rate to open surgery in the robotic group was significantly lower than that with laparoscopic surgery (OR = 0.26, 95% CI: 0.12-0.57, P = 0.0007). There were no significant differences in operation time, length of hospital stay, time to resume regular diet, postoperative morbidity and mortality, and the oncological accuracy of resection.

CONCLUSION

Robotic surgery for rectal cancer has a lower conversion rate and a similar operative time compared with laparoscopic surgery, with no difference in recovery, oncological and postoperative outcomes.

Hospital discharge criteria following colorectal surgery: a systematic review

AIM

The aim of this study was to identify and synthesize the hospital discharge criteria that have been used in the colorectal surgery literature.

METHODS

A systematic literature search was conducted using eight bibliographic databases. Searches were limited to English language journal articles published between January 1996 and October 2009. Primary research applying hospital discharge criteria following colorectal surgery was included. Study selection was made independently by two reviewers. Discharge criteria were extracted from each included study.

RESULTS

The 156 studies identified by the search strategy described 70 different sets of criteria to indicate readiness for discharge. The majority of studies applied a combination of three or four criteria; those most frequently cited were tolerance of oral intake (80%), return of bowel function (70%), adequate pain control (44%) and adequate mobility (35%). End-points employed to determine the achievement of criteria were generally poorly defined.

CONCLUSION

A variety of hospital discharge criteria were applied in the colorectal surgery literature. Development of standardized criteria will allow more accurate comparison of results between studies assessing hospital length of stay or other discharge-related outcome measures.

Comparison of Short-term Surgical Outcomes between a Robotic Colectomy and a Laparoscopic Colectomy during Early Experience

Purpose

Although robotic surgery was invented to overcome the technical limitations of laparoscopic surgery, the role of a robotic (procto)colectomy (RC) for the treatment of colorectal cancer compared to that of a laparoscopic (procto)colectomy (LC) was not well defined during the initial adoption periods of both procedures. This study aimed to evaluate the efficacy and the safety of a RC for the treatment of colorectal cancer by comparing the authors' initial experiences with both a RC and a LC.

Methods

The first 30 patients treated by using a RC for colorectal cancer from July 2010 to March 2011 were compared with the first 30 patients treated by using a LC for colorectal cancer from December 2006 to June 2007 by the same surgeon. Perioperative variables and short-term outcomes were analyzed. In addition, the 30 RC and the 30 LC cases involved were divided into rectal cancer (n = 17 and n = 12, respectively), left-sided colon cancer (n = 7 and n = 12, respectively) and right-sided colon cancer (n = 6 and n = 6, respectively) for subgroup analyses.

Results

The mean operating times for RC and LC were significantly different at 371.8 and 275.5 minutes, respectively, but other perioperative parameters (rates of open conversion, numbers of retrieved lymph node, estimated blood losses, times to first flatus, maximal pain scores before discharge and postoperative hospital stays) were not significantly different in the two groups. Subgroup analyses showed that the mean operative times for a robotic proctectomy and a laparoscopic proctectomy were 396.5 and 298.8 minutes, respectively (P < 0.000). Postoperative complications occurred in five patients in the RC group and in six patients in the LC group (P = 0.739).

Conclusion

Although the short-term outcomes of a RC during its initial use were better than those of a LC (with the exception of operating time), differences were not found to be significantly different. On the other hand, the longer operation time of a robotic proctectomy compared to that of a laparoscopic proctectomy during the early period may be problematic.

An international, multicentre, prospective, randomised, controlled, unblinded, parallel-group trial of robotic-assisted versus standard laparoscopic surgery for the curative treatment of rectal cancer

PURPOSE

There is growing enthusiasm for robotic-assisted laparoscopic operations across many surgical specialities, including colorectal surgery, often not supported by robust clinical or cost-effectiveness data. A proper assessment of this new technology is required, prior to widespread recommendation or implementation.

METHODS/DESIGN

The ROLARR trial is a pan-world, prospective, randomised, controlled, unblinded, superiority trial of robotic-assisted versus standard laparoscopic surgery for the curative treatment of rectal cancer. It will investigate differences in terms of the rate of conversion to open operation, rate of pathological involvement of circumferential resection margin, 3-year local recurrence, disease-free and overall survival rates and also operative morbidity and mortality, quality of life and cost-effectiveness. The primary outcome measure is the rate of conversion to open operation. For 80% power at the 5% (two-sided) significance level, to identify a relative 50% reduction in open conversion rate (25% to 12.5%), 336 patients will be required. The target recruitment is 400 patients overall to allow loss to follow-up. Patients will be followed up at 30 days and 6 months post-operatively and then annually until 3 years after the last patient has been randomised.

DISCUSSION

In many centres, robotic-assisted surgery is being implemented on the basis of theoretical advantages, which have yet to be confirmed in practice. Robotic surgery is an expensive health care provision and merits robust evaluation. The ROLARR trial is a pragmatic trial aiming to provide a comprehensive evaluation of both robotic-assisted and standard laparoscopic surgery for the curative resection of rectal cancer.

Robotic surgery for rectal cancer: initial experience from 30 consecutive patients

BACKGROUND

Robotic surgery offers 3D visualization and the advantage of the usage of multi-articulated instruments with superior dexterity. Theoretically, it can overcome many limitations of laparoscopic rectal surgery in the narrow pelvis.

MATERIALS AND METHODS

Between January 2010 and January 2011, the patients who underwent robotic rectal resection for cancer were retrospectively evaluated in terms of demographics, operative data, complications, the duration of hospital stay, and histopathological data.

RESULTS

Thirty consecutive patients made up of 13 female and 17 male patients underwent robotic rectal resection. Sphincter-saving mesorectal excision was performed in 27 patients. Of these, there were 19 total and 8 partial mesorectal excisions. The mean operative time was 270 min (175-480 min). The median postoperative hospital stay was 4 days (4-20 days). No operation was converted. The complication rate was 13.3%. One patient died due to colonic necrosis caused by Drummond artery deficiency (3.3%). The median number of harvested lymph nodes was 15 (3-38), and the distal resection margin was 4 cm (2-8). Histopathological evaluation revealed that the mesorectum resection was complete in all patients.

CONCLUSION

Robotic rectal surgery (hybrid or totally robotic) is a safe and feasible procedure when performed by experienced laparoscopic surgeons.

Meta-analysis of robotic and laparoscopic surgery for treatment of rectal cancer

AIM: To conduct a meta-analysis to determine the relative merits of robotic surgery (RS) and laparoscopic surgery (LS) for rectal cancer.

METHODS: A literature search was performed to identify comparative studies reporting perioperative outcomes for RS and LS for rectal cancer. Pooled odds ratios and weighted mean differences (WMDs) with 95% confidence intervals (95% CIs) were calculated using either the fixed effects model or random effects model.

RESULTS: Eight studies matched the selection criteria and reported on 661 subjects, of whom 268 underwent RS and 393 underwent LS for rectal cancer. Compared the perioperative outcomes of RS with LS, reports of RS indicated favorable outcomes considering conversion (WMD: 0.25; 95% CI: 0.11-0.58; P = 0.001). Meanwhile, operative time (WMD: 27.92, 95% CI: -13.43 to 69.27; P = 0.19); blood loss (WMD: -32.35, 95% CI: -86.19 to 21.50; P = 0.24); days to passing flatus (WMD: -0.18, 95% CI: -0.96 to 0.60; P = 0.65); length of stay (WMD: -0.04; 95% CI: -2.28 to 2.20; P = 0.97); complications (WMD: 1.05; 95% CI: 0.71-1.55; P = 0.82) and pathological details, including lymph nodes harvested (WMD: 0.41, 95% CI: -0.67 to 1.50; P = 0.46), distal resection margin (WMD: -0.35, 95% CI: -1.27 to 0.58; P = 0.46), and positive circumferential resection margin (WMD: 0.54, 95% CI: 0.12-2.39; P = 0.42) were similar between RS and LS.

CONCLUSION: RS for rectal cancer is superior to LS in terms of conversion. RS may be an alternative treatment for rectal cancer. Further studies are required.

Surgical treatment for colorectal cancer

The rapid in development of surgical technology has had a major effect in surgical treatment of colorectal cancer. Laparoscopic colon cancer surgery has been proven to provide better short-term clinical and oncologic outcomes. However this quickly accepted surgical approach is still performed by a minority of colorectal surgeons. The more technically challenging procedure of laparoscopic rectal cancer surgery is also on its way to demonstrating perhaps similar short-term benefits. This article reviews current evidences of both short-term and long-term outcomes of laparoscopic colorectal cancer surgery, including the overall costs comparison between laparoscopic surgery and conventional open surgery. In addition, different surgical techniques for laparoscopic colon and rectal cancer are compared. Also the relevant future challenge of colorectal cancer robotic surgery is reviewed.

The role of minimally invasive surgery and outcomes in colorectal cancer

For some time now, there has been significant interest in understanding and defining the role of minimally invasive surgery in colorectal cancer. Laparoscopic surgery has been shown to have similar or better outcomes compared with open surgery. Recently, prospective randomized trials have demonstrated oncologic outcomes of laparoscopic colon surgery equivalent to those for open surgery. However, the technical challenges of performing laparoscopic resection of rectal cancers and the uncertainty of the oncologic quality of the surgical resection have hindered the growth of minimally invasive rectal surgery. Robotic rectal surgery has recently emerged as an attractive alternative to laparoscopic surgery because it allows for superior visualization within a narrow pelvic field and more precise dissection. Studies of robotic rectal resection have suggested similar or potentially improved short-term oncologic outcomes when compared with laparoscopic rectal resection. Ongoing randomized studies will provide additional insight into the role of laparoscopic and minimally invasive robotic surgery for rectal cancer.

Status of robotic assistance--a less traumatic and more accurate minimally invasive surgery?

PURPOSE

Robotic assistance is considered one innovation within abdominal surgery over the past decade that has the potential to compensate for the drawbacks of conventional laparoscopy, such as limited degree of freedom, 2D vision, fulcrum, and pivoting effect. Robotic systems provide corresponding solutions as 3D view, intuitive motion and enable additional degrees of freedom. This review provides an overview of the history of medical robotics, experimental studies, clinical state-of-the-art and economic impact.

METHODS

The Medline database was searched for the terms "robot, telemanipulat, and laparoscop." A total of 2,573 references were found. All references were considered for information on robotic assistance in advanced laparoscopy. Further references were obtained through cross-referencing the bibliography cited in each work.

RESULTS

In experimental studies, current robotic systems showed superior handling and ergonomics compared to conventional laparoscopic techniques. In gynecology especially for hysterectomy and in urology especially for prostatectomy, two procedures formerly performed via an open approach, the robot enables a laparoscopic approach. This results in reduced need for pain medication, less blood loss, and shorter hospital stay. Within abdominal surgery, clinical studies were generally unable to prove a benefit of the robot. While the benefit still remains open to discussion, robotic systems are spreading and are available worldwide in tertiary centers.

CONCLUSION

Robotic assistance will remain an intensively discussed subject since clinical benefits for most procedures have not yet been proven. The most promising procedures are those in which the robot enables a laparoscopic approach where open surgery is usually required.

Robot-Assisted Rectal Surgery for Malignancy: A Review of Current Literature

Laparoscopic colorectal surgery is rapidly gaining acceptance for the management of colorectal cancer. However, laparoscopic colorectal surgery is technically more challenging than conventional surgery. This challenge is more profound for laparoscopic rectal cancer, where there is a need to perform a total mesorectal excision (TME), in the confines of the pelvis, with the limitations of the laparoscopic system. The Da Vinci robotic surgical system was designed to overcome the pitfalls of laparoscopic surgery, hence the use of this novel system in colorectal surgery seems logical, in particular with regards to rectal cancer surgery. Recently, there have been an increasing number of reports in the literature on robotic colorectal surgery. The advantages of the robotic surgical system include; 7 degrees of movement, 3 dimensional views, tremor filtration, motion scaling and superior ergonomics. These advantages when applied to robotic TME for rectal cancer surgery may potentially translate to better outcomes. The aim of this review is to summarise the current evidence on clinical and oncological outcomes of robotic rectal cancer surgery. Key words: Malignancy, Rectal, Robot

Robotic-assisted colon and rectal surgery: a systematic review

BACKGROUND

Colorectal surgery is one of the most common procedures performed by general surgeons, with an increasing number being performed laparoscopically. Robotic technology is emerging in the ongoing evolution in minimally invasive surgery. This study systematically reviews the literature regarding the safety and feasibility of robotic-assisted colorectal surgery.

METHODS

A comprehensive search of electronic databases was completed for the period 2000 to 2010. Two independent reviewers assessed the studies for relevance and inclusion, and extracted data.

RESULTS

After an initial screen of 347 titles, 20 studies met the inclusion criteria. A total of 854 patients were included with a mean age of 61 years and a body mass index of 25.5 kg/m(2) . Major complications included 27 anastamotic leaks (27/766 = 3.5%), 10 post-operative bleeds (1.1%) and 14 post-operative infections (1.6%). There were no mortalities reported.

CONCLUSIONS

This systematic review demonstrates that robotic-assisted colorectal surgery is emerging as a safe and feasible option in colorectal surgery.

Minimally invasive ventral mesh rectopexy for complex rectocoele: impact on anorectal and sexual function

AIM

Minimally invasive surgery for pelvic floor prolapse has recently been shown to be feasible and safe. This study presents the results of robotic-assisted and laparoscopic rectopexy for complex rectocoele, focusing on less frequently reported outcomes of bowel and sexual function.

METHOD

We prospectively assessed 41 consecutive patients who underwent ventral mesh rectopexy (robotic-assisted or laparoscopic) for a symptomatic complex rectocoele from January 2009 to January 2010. Complex rectocoele was defined as having one or more of the following features: larger than 3 cm, an enterocoele or internal rectal prolapse. Patients with cystocoele underwent bladder suspension concurrently. Both groups were assessed for anatomical recurrence and function, comparing preoperative and postoperative faecal incontinence, obstructive defaecation syndrome and Gastrointestinal Quality-of-life Index scores, as well as vaginal discomfort and sexual function.

RESULTS

Forty-one women underwent the procedure (16 robotic-assisted), with four (10.5%) having minor complications and two developing anatomical recurrence. There was significant relief of the commonest predominant symptoms of vaginal bulge/fullness (P<0.0001) and sexual dysfunction (P=0.02). There were three conversions to laparotomy (one robotic-assisted) and five patients declined postoperative functional assessment. In the remaining 33 patients [follow-up median 12 (8-21) months], analysis revealed no significant difference in overall functional score (P>0.740) or between patients with one or two meshes inserted (P>0.486). Only patients with a preoperative obstructive defaecation syndrome score >6 had a significant improvement postoperatively (P=0.030).

CONCLUSION

Minimally invasive ventral mesh rectopexy for complex rectocoele offers satisfactory anatomical correction and functional results, with the potential for alleviating symptoms of outlet obstruction and improving vaginal comfort and sexual dysfunction.

An international, multicentre, prospective, randomised, controlled, unblinded, parallel-group trial of robotic-assisted versus standard laparoscopic surgery for the curative treatment of rectal cancer

PURPOSE

There is growing enthusiasm for robotic-assisted laparoscopic operations across many surgical specialities, including colorectal surgery, often not supported by robust clinical or cost-effectiveness data. A proper assessment of this new technology is required, prior to widespread recommendation or implementation.

METHODS/DESIGN

The ROLARR trial is a pan-world, prospective, randomised, controlled, unblinded, superiority trial of robotic-assisted versus standard laparoscopic surgery for the curative treatment of rectal cancer. It will investigate differences in terms of the rate of conversion to open operation, rate of pathological involvement of circumferential resection margin, 3-year local recurrence, disease-free and overall survival rates and also operative morbidity and mortality, quality of life and cost-effectiveness. The primary outcome measure is the rate of conversion to open operation. For 80% power at the 5% (two-sided) significance level, to identify a relative 50% reduction in open conversion rate (25% to 12.5%), 336 patients will be required. The target recruitment is 400 patients overall to allow loss to follow-up. Patients will be followed up at 30 days and 6 months post-operatively and then annually until 3 years after the last patient has been randomised.

DISCUSSION

In many centres, robotic-assisted surgery is being implemented on the basis of theoretical advantages, which have yet to be confirmed in practice. Robotic surgery is an expensive health care provision and merits robust evaluation. The ROLARR trial is a pragmatic trial aiming to provide a comprehensive evaluation of both robotic-assisted and standard laparoscopic surgery for the curative resection of rectal cancer.

Laparoscopy for colon and rectal cancer

Laparoscopy has emerged as a useful tool in the surgical treatment of diseases of the colon and rectum. Specifically, in the application of colon cancer, a laparoscopic-assisted approach offers short-term benefits to patients while maintaining a long-term oncologic outcome. Hand-assisted laparoscopic surgery may help decrease operative times while preserving the benefits of laparoscopy. The literature on the use of laparoscopy for rectal cancer is still in its early stages. Limited data suggest short-term benefits without compromising oncologic outcome; however, data from large multicenter trials will clarify the role of laparoscopy in the treatment of rectal cancer. Robotic proctectomy is a novel technique that may offer considerable advantage and overcome some limitations laparoscopy creates while working in the confines of the pelvis. The improved magnification and visualization offered with the robot may also assist in preserving bladder and sexual function. Transanal endoscopic microsurgery (TEM) for the treatment of T1 rectal cancers with low-risk features appears to be safe. However, TEM has a significantly higher recurrence rate when used to treat invasive cancer. Endoluminal techniques and equipment are under development and could offer more minimally invasive approaches to the treatment of colon and rectal cancer. Credentialing and training of surgeons and teams involved in the use of laparoscopy is important prior to making these techniques ubiquitous.

One hundred and two consecutive robotic-assisted minimally invasive colectomies--an outcome and technical update

BACKGROUND

The objective of this study was to review 102 consecutive robotic colectomies at our institution. We evaluated the 8-year experience of one surgeon (DLC) in Peoria, IL using the da Vinci system.

METHODS

An IRB-approved retrospective review was performed. Results were compared with the literature. Changes in technique over the years were evaluated.

RESULTS

One hundred and two robotic colectomies, right (59) and sigmoid (43), were performed. Mean age is 63.5 years and mean BMI 27.4 kg/m². Preoperative indications are polyps (53), diverticular disease (27), cancer (19), and carcinoid (3). Mean total case time (TCT) for all cases is 219.6 ± 45.1 (50-380) min, and mean robot operating time (ROT) is 126.6 ± 41.6 (12-306) min. Operative times for Right: Port setup time (PST) 32.4 ± 10.5 (20-64) min, ROT 145.2 ± 39.6 (53-306) min, TCT 212.3 ± 46.4 (50-380) min; times for sigmoid: PST 31.2 ± 9.6 (10-57) min, ROT 101.2 ± 29.2 (12-165) min, TCT 229.7 ± 41.6 (147-323) min. Median length of stay for all patients is 3 (2-27) days. The overall complication rate is 18.6%, the overall conversion rate 8.8%, and the anastomotic leak rate is 0.98%. Residents PGY 1-5 participated in 61 cases (59.8%).

CONCLUSION

We report our updated procedural sequence and technical alterations. Experience has allowed residents to evolve to be primary surgeons. We add our results to the current robotic literature.

Laparoscopic extraperitoneal rectal cancer surgery: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

BACKGROUND

The laparoscopic approach is increasingly applied in colorectal surgery. Although laparoscopic surgery in colon cancer has been proved to be safe and feasible with equivalent long-term oncological outcome compared to open surgery, safety and long-term oncological outcome of laparoscopic surgery for rectal cancer remain controversial. Laparoscopic rectal cancer surgery might be efficacious, but indications and limitations are not clearly defined. Therefore, the European Association for Endoscopic Surgery (EAES) has developed this clinical practice guideline.

METHODS

An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. The expert panel constituted for a consensus development conference in May 2010. Thereafter, the recommendations were presented at the annual congress of the EAES in Geneva in June 2010 in a plenary session. A second consensus process (Delphi process) of the recommendations with the explanatory text was necessary due to the changes after the consensus conference.

RESULTS

Laparoscopic surgery for extraperitoneal (mid- and low-) rectal cancer is feasible and widely accepted. The laparoscopic approach must offer the same quality of surgical specimen as in open surgery. Short-term outcomes such as bowel function, surgical-site infections, pain and hospital stay are slightly improved with the laparoscopic approach. Laparoscopic resection of rectal cancer is not inferior to the open in terms of disease-free survival, overall survival or local recurrence. Laparoscopic pelvic dissection may impair genitourinary and sexual function after rectal resection, like in open surgery.

CONCLUSIONS

Laparoscopic surgery for mid- and low-rectal cancer can be recommended under optimal conditions. Still, most level 1 evidence is for colon cancer surgery rather than rectal cancer. Upcoming results from large randomised trials are awaited to strengthen the evidence for improved short-term results and equal long-term results in comparison with the open approach.

Robotic surgery claims on United States hospital websites

To examine the prevalence and content of robotic surgery information presented on websites of U.S. hospitals. We completed a systematic analysis of 400 randomly selected U.S. hospital websites in June of 2010. Data were collected on the presence and location of robotic surgery information on a hospital's website; use of images or text provided by the manufacturer; use of direct link to manufacturer website; statements of clinical superiority; statements of improved cancer outcome; mention of a comparison group for a statement; citation of supporting data and mention of specific risks. Forty-one percent of hospital websites described robotic surgery. Among these, 37% percent presented robotic surgery on their homepage, 73% used manufacturer-provided stock images or text, and 33% linked to a manufacturer website. Statements of clinical superiority were made on 86% of websites, with 32% describing improved cancer control, and 2% described a reference group. No hospital website mentioned risks. Materials provided by hospitals regarding the surgical robot overestimate benefits, largely ignore risks and are strongly influenced by the manufacturer.

Robotic-assisted minimally invasive surgery; a useful tool in resident training--the Peoria experience, 2002-2009

BACKGROUND

The purpose of this study was to review the use of robotic-assisted general surgery at our institution. We evaluated the 8 year experience of one minimally invasive surgery (MIS) fellowship-trained surgeon in Peoria, IL, performing 240 cases of foregut, colon, solid organ and biliary surgery using the da Vinci system, with resident assistance. Foregut and colon procedures are the fifth and sixth most commonly performed procedures of the senior author annually.

METHODS

An IRB-approved retrospective review of prospectively collected data representing 124 foregut and 102 colon operations was performed. Data analysed were procedure performed and indications for surgery, gender, age, body mass index (BMI), estimated blood loss (EBL), port set-up time (PST), robot operating time (ROT), total case time (TCT), length of stay (LOS), complications, conversions and resident involvement were recorded. Fourteen cases were excluded from the data review. Statistical analysis using the ANOVA test was applied. A specific review of resident participation was performed.

RESULTS

Times for 226 foregut and colon cases were: PST 31.2 ± 9.4 (range 10-64) min, ROT 119.3 ± 41.5 (range 12-306) min, and TCT 194.8 ± 50.3 (range 50-380) min. The EBL was 48.6 ± 55.0 (range 5-500) ml, BMI 28.5 ± 4.7 (range 15.4-46.8) kg/m(2) , and median LOS 2.0 (range 0-27) days. The overall complication rate was 13.3%. No deaths occurred. Over the 8 year study period the number of cases participated in by residents was 0, 16, 22, 15, 29, 26, 28 and 10 (as of June 2009), respectively.

CONCLUSION

This series demonstrates the technical feasibility and safety of robotic surgery for the foregut and colon in a clinical setting where the surgeon does far more of other types of MIS. This series compares favorably with the literature. Incorporation of robotic training in the curriculum has allowed residents to learn robotic techniques in an effective manner.

Robotic-assisted laparoscopic surgery for restorative proctocolectomy with ileal J pouch-anal anastomosis

Restorative proctocolectomy (RP) with ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice for chronic ulcerative colitis (CUC). Robotic-assisted laparoscopic surgery (RALS) has been shown to have its greatest merits in colorectal procedures involving the pelvis. The aim of this study was to evaluate the safety and feasibility of RP with IPAA using an innovative robotic technique. A total of five consecutive patients underwent RALS RP with IPAA between August 2008 and February 2010. Patient demographics, intraoperative parameters, and postoperative outcomes were tabulated and assessed. Surgery was indicated for medically intractable CUC in three patients (60%), CUC-related dysplasia in one patient (20%) and CUC-related adenocarcinoma in one patient (20%). An ileal pouch-anal anastomosis was successful in all five cases. The mean operative time was 330 min and estimated blood loss was 200 cc. There were no intraoperative complications or conversions. The mean length of hospital stay was 5.6 days and no patients developed major postoperative complications. RALS is an innovative technique offering technical and visual advantages to the colorectal surgeon and can be offered for those who are seeking restorative proctolectomy for chronic ulcerative colitis.

Robotic versus laparoscopic rectopexy for complex rectocele: a prospective comparison of short-term outcomes

PURPOSE

The role of robotic assistance in pelvic floor prolapse surgery is debatable. This study aims to report our early experience of robotic-assisted ventral mesh rectopexy in the treatment of complex rectocele and to compare this with the laparoscopic approach in terms of safety and short-term postoperative outcomes.

METHODS

We analyzed a cohort of 63 consecutive patients operated on for complex rectocele from March 2008 to December 2009. A complex rectocele was defined as a rectocele that had one or more of the following features: larger than 3 cm in diameter, associated with an enterocele or internal rectal prolapse. The patients underwent either the robotic procedure or laparoscopic procedure, based only on the availability of the robotic system. Procedures involved either a single-mesh fixation for posterior-compartment prolapse (concurrent rectocele and enterocele) or a double-mesh fixation for a concurrent anterior compartment prolapse (with cystocele). A transvaginal tape was inserted at the same surgery in patients with urinary incontinence.

RESULTS

All patients were female; 40 underwent the laparoscopic procedure and 23 underwent the robotic procedure. Both groups were similar in age (mean, 59 ± 13 vs 61 ± 11; P = .440), ASA status, and previous abdominal surgery, respectively. Patients undergoing the robotic procedure had a significantly higher body mass index (mean, 27 ± 4 vs 24 ± 4; P = .03), more frequent double-mesh implantation (17/23 vs 14/40; P = .003), and longer operative time (mean, 221 ± 39 min vs 162 ± 60 min; P = .0001). Patients undergoing a laparoscopic procedure had slightly more blood loss (mean, 45 ± 91mL vs 6 ± 23 mL, P = .05). The number of transvaginal-tape procedures performed (6/40 vs 3/23, P > .999), conversion rate (10% vs 5%; P = .747), and duration of hospitalization were similar (mean, 5 ± 2 d vs 5 ± 1.6 d; P = .872). There were no mortalities or recurrences at the 6-month postoperative review.

CONCLUSION

In our experience, the robotic approach for the treatment of complex rectocele is as safe as the laparoscopic approach, with favorable short-term results.

Robotic rectal cancer surgery: technique of abdomino-perineal resection

Rectal cancer surgery using a minimally invasive technique has been regarded as a challenging procedure. Since the introduction of the robotic surgical system into the operating theater, totally robotic rectal surgery has been attempted with several techniques. Abdomino-perineal resection might be a more reliable indication for totally robotic surgery than low anterior resection. Because the range of dissection is confined to the pelvic cavity and mobilization of the sigmoid colon, problems during totally robotic surgery can be minimized. With our technique, totally robotic surgery can be performed successfully. Technical advantages of the current robotic system can be reflected in patient benefits after totally robotic abdomino-perineal resection.

A comparison of open and robotic total mesorectal excision for rectal adenocarcinoma

PURPOSE

This retrospective study was designed to compare open with robot-assisted total mesorectal excision for rectal adenocarcinoma.

METHODS

With use of predefined exclusion criteria, all consecutive laparoscopic-assisted (51 patients) and robot-assisted (36 patients) rectal resections for adenocarcinoma from August 2005 to November 2009 at a single institution were considered. Hand-assisted laparoscopy was used for splenic flexure mobilization in all cases. Patients were assigned into robotic and open groups on the basis of the technique used for total mesorectal excision. All 36 robot-assisted resections had the total mesorectal excision performed with robotic assistance and were included in the robotic group. Forty-six of the 51 patients who received a laparoscopic-assisted procedure had the total mesorectal excision performed through the hand port using open surgical technique and were included in the open group. Both groups were compared with respect to patient demographics, perioperative outcomes, and pathology.

RESULTS

The robotic and open groups were comparable in age, sex, body mass index, history of prior abdominal surgery, ASA class, number of patients receiving neoadjuvant chemoradiation, and tumor stage. There were more abdominoperineal resections (P = .019) and more low and mid rectal tumors (P = .007) in the robotic group. Total procedure time was longer in the robotic group (P = .003), but blood loss was less (P = .036). Lymph node yield, intraoperative and postoperative complications, and length of stay were all comparable. There were 3 positive circumferential margins in the open group vs none in the robotic group, but this did not reach statistical significance.

CONCLUSIONS

Robotic total mesorectal excision is feasible and safe, and is comparable to open total mesorectal excision in terms of perioperative and pathological outcomes. The longer operative time associated with robotic total mesorectal excision could decrease as experience with this relatively new technique increases. Large randomized trials are necessary to validate the potential benefits of less blood loss and lower margin positivity rates observed in this study.