Transanal specimen extraction in robotic rectal cancer surgery

Single versus double stapled anastomosis in natural orifice specimen extraction (NOSE) laparoscopic anterior resection

BACKGROUND

Laparoscopic anterior resection (LAR) with Natural Orifice Specimen Extraction (NOSE) has shown benefits such as reduced pain, fewer wound complications, and improved cosmesis. In colorectal anastomosis during NOSE, double staple anastomosis (DSA) and triple stapled technique (TSA) are common. However, a novel single stapled anastomosis (SSA) technique, utilising two laparoscopically placed purse strings and only four 5 mm ports, has emerged. This study aims to compare the complications between single and double stapled anastomoses in NOSE LAR.

METHODS

A retrospective analysis of NOSE LAR data from 2011 to 2022 included patients. All patients received mechanical bowel preparation, colonoscopic instillation of betadine or chlorhexidine, and antibiotics. DSA was performed conventionally, while the SSA technique involved an additional rectal laparoscopic purse string. Fisher's exact test assessed anastomotic leak rates and the need for intraoperative revisions.

RESULTS

Analysis of 179 patients revealed 40 with SSA and 139 with DSA. Patient age ranged from 20 to 88 years, with a BMI between 22 and 46 kg/m2. Diverticulitis and malignant polyps, the most common indications. Operation duration was similar between groups (238 min in SSA, 234 min in DSA; P = 0.69). Intraoperative laparoscopic anastomotic redo was significantly higher in the SSA group (six patients) than the DSA group (five patients; P = <0.05). No anastomotic leaks occurred in the SSA group, while six occurred in the DSA group (P = 0.34). There was no significant difference in Length of Stay (LOS), (5 days in SSA versus 6 days in DSA group, P = 0.29).

CONCLUSIONS

Single stapled anastomosis in NOSE LAR appears safe for benign conditions but is more likely to necessitate intraoperative redo compared to double stapled anastomosis.

Meta-analysis of robotic-assisted NOSE versus traditional TWSR in colorectal cancer surgery: postoperative outcomes and efficacy

BACKGROUND

This meta-analysis aimed to assess the safety and efficacy of robotic-assisted natural orifice specimen extraction surgery (NOSE) compared to traditional robotic transabdominal wall specimen retrieval surgery (TWSR) for colorectal cancer.

METHODS

A systematic search was conducted in three electronic databases (PubMed, Web of Science and Embase) from inception to August 2023. Primary outcomes included postoperative complications, the number of lymph nodes harvested, overall survival and disease-free survival. Secondary outcomes included the postoperative visual analog scale (VAS) score, the additional use of analgesics, the restoration of gastrointestinal function, blood loss, the mean operation time, and length of postoperative hospital stay.

RESULTS

In this meta-analysis, a total of 717 patients from 6 observational studies met the inclusion criteria. Compared with the TWSR group, the NOSE group had greater benefits in terms of overall postoperative complications [odds ratios (OR) 0.55; 95% confidence intervals (CI) = 0.34 to 0.89; P = 0.01, I2 = 0%)], the number of lymph nodes harvested [weighted mean differences (WMD) = 1.18; 95% CI = 0.15 to 2.21; P = 0.02, I2 = 0%)], the rate of wound infection (OR 0.17; 95% CI = 0.04 to 0.80; P = 0.02, I2 = 0%), the passed flatus time (WMD =  - 0.35 days; 95% CI =  - 0.60 to - 0.10; P = 0.007, I2 = 73%), the additional use of analgesics (OR 0.25; 95% CI = 0.15 to 0.40; P < 0.001, I2 = 0%), the diet recovery time (WMD =  - 0.56; 95% CI =  - 1.00 to - 0.11; P = 0.01, I2 = 78%) and the postoperative VAS score (WMD =  - 1.23; 95% CI =  - 1.63 to - 0.83; P < 0.001, I2 = 65%). There were no significant differences in the blood loss (WMD =  - 5.78 ml; 95% CI =  - 17.57 to 6.00; P = 0.34, I2 = 90%), mean operation time (WMD = 14.10 min; 95% CI =  - 3.76 to 31.96; P = 0.12) (I2 = 93%), length of postoperative hospital stay (WMD =  - 0.47 day; 95% CI =  - 0.98 to 0.03; P = 0.07, I2 = 51%), incidences of postoperative ileus (OR 1.0; 95% CI = 0.22 to 4.46; P = 1.00, I2 = 0%), anastomotic leakage (OR 0.73; 95% CI = 0.33 to 1.60; P = 0.43, I2 = 0%), and intra-abdominal abscess (OR 1.59; 95% CI = 0.47 to 5.40; P = 0.46, I2 = 0%), or 3-year overall survival [hazard ratio (HR) = 1.07, 95% CI = 0.60 to 1.94; P = 0.81)] or disease-free survival (HR = 0.94, 95% CI = 0.54 to 1.63; P = 0.82, I2 = 0%).

CONCLUSION

This meta-analysis showed that the NOSE group had better postoperative outcomes than did the TWSR group and that NOSE was a safe and viable alternative to TWSR. More large-sample reviews and further randomized trials are warranted.

Intracorporeal versus extracorporeal anastomosis in minimally invasive right hemicolectomy: systematic review and meta-analysis of randomized controlled trials

Purpose

Compared with extracorporeal anastomosis (ECA), intracorporeal anastomosis (ICA) is expected to provide some benefits, including a shorter operation time and less intraoperative bleeding. Nevertheless, the benefits of ICA have mainly been evaluated in nonrandomized studies. Owing to the recent update of randomized controlled trials (RCTs) for minimally invasive surgery (MIS) of right hemicolectomy (RHC), the need to measure the actual effect by synthesizing the outcomes of these studies has emerged.

Methods

We performed a comprehensive search of the PubMed, Embase, and Cochrane databases (from inception to January 30, 2023) for studies that applied ICA and ECA for RHC with MIS. We included 7 RCTs. The operation time, intraoperative blood loss, conversion rate, length of incision, and postoperative outcomes such as ileus, anastomosis leakage, length of hospitalization, and postoperative pain were compared between ICA and ECA.

Results

A total of 740 patients were included in the study. Among them, 377 and 373 underwent ICA and ECA, respectively. There were significant differences in age (P = 0.003) and incision type (P < 0.001) between ICA and ECA. ICA was associated with a significantly longer operation time (P = 0.033). Although the postoperative pain associated with ICA was significantly lower than that associated with ECA on postoperative day 2 (POD 2) (P = 0.003), it was not different on POD 3 between the groups. Other perioperative outcomes were similar between the 2 groups.

Conclusion

In this meta-analysis, ICA did not significantly improve short-term outcomes compared to ECA; other advantages to overcome ICA's longer operation time are not clear.

Robotic sigmoidectomy for diverticulitis - Natural orifice extraction with stapleless hand-sewn intracorporeal anastomosis

AIM

A sigmoidectomy is the most definitive surgical treatment for recurrent diverticulitis. While it is usually accomplished via transabdominal specimen extraction and stapled anastomosis, the robotic platform can facilitate novel approaches and techniques. This is the first report of the initial experience using robotic sigmoidectomy with natural orifice specimen extraction and hand-sewn anastomosis (NOSHA).

METHOD

A prospectively maintained database of NOSHA procedures performed between 2018 and 2020 was retrospectively examined. The technique was described and variables across preoperative, intra-operative and postoperative timeframes were presented. The Clavien-Dindo classification system was used to describe postoperative complications.

RESULTS

Sixteen patients with recurrent diverticulitis treated with NOSHA were included in this study. Transanal specimen extraction and an intracorporeal hand-sewn anastomosis were achieved in all patients. However, two (12.8%) patients required specimen debulking prior to extraction. The mean operating time was 171.7 min, and patients had a return of bowel function within an average period of 35.2 h. The mean hospital length of stay was 2.9 days. In total, two (12.8%) complications were seen: one postoperative ileus managed conservatively and one readmission for abdominal pain which resolved without intervention. No anastomotic leaks or reoperations were observed.

CONCLUSION

Robotic NOSHA appears to be a viable technique for the surgical management of diverticulitis. Further studies are needed to establish its utility for various diseases and its reproducibility across clinical practices.

Comparative short- and long-term outcomes of three techniques of natural orifice specimen extraction surgery for rectal cancer

BACKGROUND

The aim of this study was to evaluate the safety of natural orifice specimen extraction surgery (NOSES) and to compare the short- and long-term outcomes of three techniques of NOSES for rectal cancer (RC).

MATERIALS AND METHODS

A consecutive series of RC patients in stage I-III who underwent laparoscopic NOSES were enrolled. Three main techniques of NOSES included specimen eversion and extra-abdominal resection (EVER), specimen extraction and extra-abdominal resection (EXER) and intra-abdominal resection and specimen extraction (IREX). The postoperative complications, 5-year disease free survival (DFS), 5-year local recurrence rate (LRR) and 5-year distant metastasis rate (DMR) were compared in three techniques.

RESULTS

268 RC patients met inclusion criteria, including 83 patients treated with EVER, 75 patients treated with EXER and 110 patients treated with IREX. Tumor location was the most critical factor associated with technique selection, with P < 0.001. Postoperative complication rate was 12.3% for all patients, and it was 18.1% for EVER, 13.3% for EXER and 7.3% for IREX. There were no significant differences for anastomotic leakage, anastomotic bleeding and intraabdominal abscess among three technique groups, with P > 0.05. For long-term outcomes, the 5-year DFS, 5-year LRR and 5-year DMR were 85.03%, 4.22% and 11.00% for all patients. Patients in advanced tumor stage have worse long-term survival compared with patients in early stage, but no significant survival differences were observed among three technique groups.

CONCLUSION

Three techniques of NOSES for RC had acceptable short- and long-term outcomes, and tumor location was a determinant of technique selection.

International consensus on natural orifice specimen extraction surgery (NOSES) for colorectal cancer

In recent years, natural orifice specimen extraction surgery (NOSES) in the treatment of colorectal cancer has attracted widespread attention. The potential benefits of NOSES including reduction in postoperative pain and wound complications, less use of postoperative analgesic, faster recovery of bowel function, shorter length of hospital stay, better cosmetic and psychological effect have been described in colorectal surgery. Despite significant decrease in surgical trauma of NOSES have been observed, the potential pitfalls of this technique have been demonstrated. Particularly, several issues including bacteriological concerns, oncological outcomes and patient selection are raised with this new technique. Therefore, it is urgent and necessary to reach a consensus as an industry guideline to standardize the implementation of NOSES in colorectal surgery. After three rounds of discussion by all members of the International Alliance of NOSES, the consensus is finally completed, which is also of great significance to the long-term progress of NOSES worldwide.

Robotic low anterior resection plus transanal natural orifice specimen extraction in a patient with situs inversus totalis

BACKGROUND

Situs inversus totalis (SIT) refers to an unusual condition involving reversal of abdominal and thoracic viscera, with an incidence rate of 1/5000-20,000 adults. Minimally invasive surgeries for SIT patients are technically challenging, while the surgical experience for SIT patients is quite limited.

CASE PRESENTATION

A 61-year-old man, previously diagnosed as SIT, came to our hospital for 6 months history of hematochezia and altered bowel habit. A diagnosis of rectal cancer was made in view of colonoscopic biopsy which confirmed an irregular circumferential lump of well differentiated adenocarcinoma at 10 cm from the anal verge. The computed tomography contrast-enhanced (thorax + abdomen + pelvis) scan revealed a total transposition of abdominal and thoracic organs and an enhanced eccentric mass of rectal but with no evidence of distant metastasis. Robotic low anterior resection (LAR) plus transanal natural orifice specimen extraction (NOSE) was performed after obtaining informed consent. The procedure was performed successfully and the patient convalesced nicely without any complications. The postoperative pathological diagnosis revealed a 4x4x0.6 cm³ moderately differentiated adenocarcinoma and circumferential clearance.

CONCLUSIONS

Robotic LAR plus transanal NOSE for rectal cancer patients with SIT can be performed safely and may be an effective approach in contrast to open or laparoscopic approach, despite the unconventional anatomy.

Transanal Endoscopic and Transabdominal Robotic Total Mesorectal Excision for Mid-to-Low Rectal Cancer: Comparison of Short-term Postoperative and Oncologic Outcomes by Using a Case-Matched Analysis

Purpose

This study aimed to compare short-term postoperative and oncologic outcomes of a transanal endoscopic total mesorectal excision (TME) to those of a transabdominal robotic TME.

Methods

A total of 62 patients with rectal cancer underwent transanal (n = 26) or robotic (n = 36) TME between June 2013 and December 2014. After case-matching by tumor location and TNM stage, 45 patients were included for analysis. The median follow-up period was 21.3 months. Operative, histopathologic and postoperative outcomes and recurrences were analyzed.

Results

Patients younger than 60 years of age were more frequently observed in the robotic TME group (75.0% vs. 47.6%, P = 0.059), but tumor location, cT and cN category, and preoperative chemoradiotherapy were not different between the 2 groups. Estimated blood loss was greater in the transanal group (283 mL vs. 155 mL, P = 0.061); however, the operation time and the rate of a diverting ileostomy and subsequent ileostomy repair were not different between the groups. The proximal resection margin was longer in the transanal TME group (20.8 cm ± 16.0 cm, P = 0.030), but the distal resection margins, involvements of the circumferential resection margin, TME quality, numbers of retrieved lymph nodes, postoperative complications, including anastomotic leak and voiding difficulty, and recurrence rates for the 2 groups were not statistically different.

Conclusion

Transanal endoscopic and transabdominal robotic TME showed similar histopathologic and postoperative outcomes with the exception of the estimated blood loss and the proximal resection margin for a select group of patients.

Meta-analysis of hybrid natural-orifice transluminal endoscopic surgery versus laparoscopic surgery

Background

Hybrid natural-orifice transluminal endoscopic surgery (NOTES), combining access through a natural orifice with small-sized abdominal trocars, aims to reduce pain and enhance recovery. The objective of this systematic review and meta-analysis was to compare pain and morbidity in hybrid NOTES and standard laparoscopy.

Methods

A systematic literature search was performed to identify RCTs and non- RCTs comparing hybrid NOTES and standard laparoscopy. The main outcome was pain on postoperative day (POD) 1. Secondary outcomes were pain during the further postsurgical course, rescue analgesia, complications, and satisfaction with the cosmetic result. The results of meta-analysis in a random-effects model were presented as odds ratio (ORs) or standard mean differences (MDs) with 95 per cent confidence intervals.

Results

Six RCTs and 21 non-randomized trials including 2186 patients were identified. In hybrid NOTES the score on the numerical pain scale was lower on POD 1 (−0·75, 95 per cent c.i. −1·09 to −0·42; P = 0·001) and on POD 2–4 (−0·58, −0·91 to −0·26; P &lt; 0·001) than that for standard laparoscopy. The need for rescue analgesia was reduced in hybrid NOTES (OR 0·36, 0·24 to 0·54; P &lt; 0·001). The reduction in complications found for hybrid NOTES compared with standard laparoscopy (OR 0·52, 0·38 to 0·71; P &lt; 0·001) was not significant when only RCTs were considered (OR 0·83, 0·43 to 1·60; P = 0·570). The score for cosmetic satisfaction was higher after NOTES (MD 1·14, 0·57 to 1·71; P &lt; 0·001).

Conclusion

Hybrid NOTES reduces postoperative pain and is associated with greater cosmetic satisfaction in selected patients.

A Comparison of Open, Laparoscopic, and Robotic Surgery in the Treatment of Right-sided Colon Cancer

INTRODUCTION

Multidimensional comparison between open, laparoscopy, and robotic surgery in the management of right-sided colon cancer are lacking. The aim of this study was to compare the early perioperative results and oncologic outcomes among the 3 different methods.

PATIENTS AND METHODS

Between June 2007 and 2011, a total of 96 patients who underwent right hemicolectomy in a single institution were classified into the open surgery (OS; n=33), the laparoscopy surgery (LS; n=43), and the robot surgery (RS; n=20) groups. Perioperative and oncologic outcomes were compared among the 3 groups.

RESULTS

Patient demographics were comparable. Operation time was significantly longer in the RS and LS than the OS (P<0.001). There was 1 OS conversion in LS. There was no difference of total retrieved lymph node numbers among the 3 groups. Postoperative recovery was faster and hospital stay was shorter in RS than OS. However, there was no difference between LS and RS. After the median 40 months' follow-up, 5-year disease-free survival was similar among the OS, LS, and RS (87.7%, 84%, and 89.5%, respectively). Total charge and total patient charge were significantly higher in RS than the others.

CONCLUSIONS

Our comparative study demonstrates that the RS have better short-term outcomes in reducing hospital stay compared with the OS, but similar to the LS. Although the oncologic outcomes are similar, the benefit of RS in right hemicolectomy is unclear considering a high cost of RS.

Laparoscopic natural orifice specimen extraction-colectomy: A systematic review

Over the last 20 years, laparoscopic colorectal surgery has shown equal efficacy for benign and malignant colorectal diseases when compared to open surgery. However, a laparoscopic approach reduces postoperative morbidity and shortens hospital stay. In the quest to optimize outcomes after laparoscopic colorectal surgery, reduction of access trauma could be a way to improve recovery. To date, one method to reduce access trauma is natural orifice specimen extraction (NOSE). NOSE aims to reduce access trauma in laparoscopic colorectal surgery. The specimen is delivered via a natural orifice and the anastomosis is created intracorporeally. Different methods are used to extract the specimen and to create a bowel anastomosis. Currently, specimens are delivered transcolonically, transrectally, transanally, or transvaginally. Each of these NOSE-procedures raises specific issues with regard to operative technique and application. The presumed benefits of NOSE-procedures are less pain, lower analgesia requirements, faster recovery, shorter hospital stay, better cosmetic results, and lower incisional hernia rates. Avoidance of extraction site laparotomy is the most important characteristic of NOSE. Concerns associated with the NOSE-technique include bacterial contamination of the peritoneal cavity, inflammatory response, and postoperative outcomes, including postoperative pain and the functional and oncologic outcomes. These issues need to be studied in prospective randomized controlled trials. The aim of this systematic review is to describe the role of NOSE in minimally invasive colorectal surgery.

Is prior laparoscopy experience required for adaptation to robotic rectal surgery?: Feasibility of one-step transition from open to robotic surgery

PURPOSE

The objective of this study is to ascertain the impact of laparoscopic colorectal surgery (LCS) experience on the learning curve of robotic rectal cancer surgery (RRS). Whether LCS experience is mandatory on overcoming the learning curve of RRS or not remains undetermined.

METHODS

Before starting the robotic procedure, surgeon A had a limited experience of less than 30 LCS cases, whereas surgeon B had performed more than 300 cases of LCS. From the beginning, 100 consecutive, unselected RRS cases performed by each of the two surgeons were retrospectively analyzed (groups A and B). Perioperative surgical and oncologic outcomes were compared between the two groups.

RESULTS

Clinicopathological characteristics between the two groups were similar. One case in group A was converted to open surgery. Mean operation time was shorter in group A than that of group B (272 vs. 344 min, p < 0.001). Overall perioperative morbidity rates were not different between the two groups (17.0 vs. 10.0 %, p = 0.214). There was no difference of circumferential resection margin positivity rate and retrieved lymph node numbers. In group A, the operation time decreased with a steep slope until 17 cases on the moving average curve. The slope in group B maintained a steady state and showed no remarkable changes throughout the study period.

CONCLUSIONS

A one-step transition from open to robotic rectal cancer surgery can be achieved without having extensive prior laparoscopic experience.

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.