Totally laparoscopic and totally robotic surgery in patients with left-sided colonic diverticulitis

Left colectomy for diverticular disease: systematic review and meta-analysis comparing robotic and laparoscopic resections

BACKGROUND

Around 50% of people aged 60 years and above are affected by diverticular disease, and 25% of these individuals will require surgical intervention. Our objective is to compare the results of left colonic resection for sigmoid diverticular disease using both robotic and laparoscopic approaches. Our primary aim is to conduct a meta-analysis while investigating the rates of conversion to open surgery, stoma and complications between the two methods.

METHODOLOGY

A systematic review was conducted following the PRISMA guidelines. A meta-analysis was performed using RevMan Version 5.4 software. The random-effect model was employed to pool dichotomous outcomes and estimate risk and odds ratios (OR).

RESULTS

Eight studies were thought to fulfil the eligibility criteria: 1892 patients (49.2%) had robotic surgery, and 1952 patients (50.84%) underwent a laparoscopic approach. There were fewer conversions to open surgery in the robotic group when compared to the laparoscopic group (P < 0.00001), a lower rate of postoperative ileus (P = 0.005), shorter length of stay (mean difference (MD) 0.18 P = 0.003) and fewer morbidities (P = 0.002). There were similar rates of stoma formation (4.7%, P = 1.00), anastomotic leak (2.6%, P = 0.85) and mortality (0.3% vs 0.2%, P = 0.59). The operative time was shorter in the robotic approach, although the difference was not significant (P = 0.47).

CONCLUSION

Robotic surgery is feasible for diverticular disease compared to laparoscopic left colectomy. Our study observed a reduction in the conversion to open rate, reduced morbidity, and less ileus while demonstrating similar rates of stoma formation, anastomotic leak, and mortality. However, more high-quality research needs to be conducted to investigate this further. The study is registered in Prospero (reg # CRD42023440509).

A retrospective comparison of 90-day outcomes, length of stay, and readmissions between robotic-assisted and laparoscopic colectomy

Investigations generally assess 30 days of perioperative outcomes with robotic-assisted and laparoscopic colectomy. Outcomes beyond 30 days serve as a quality metric of surgical services and an assessment of 90 days of outcomes may have greater clinical utility. The purpose of this study was to assess 90 days of outcomes, length of stay (LOS), and readmissions among patients who underwent a robotic-assisted versus laparoscopic colectomy using a national database. Patients undergoing either robotic-assisted or laparoscopic colectomy were identified using Current Procedural Terminology (CPT) codes within PearlDiver, a national, inpatient records database from 2010 to 2019. Outcomes were defined using the National Surgical Quality Improvement Program (NSQIP) risk calculator and identified using International Classification of Disease (ICD) diagnosis codes. Categorical variables were compared using chi-square tests, and continuous variables were compared using paired t tests. Covariate-adjusted regression models were also constructed to evaluate these associations while accounting for potential confounders. A total of 82,495 patients were assessed in this study. At 90 days, patients of the laparoscopic colectomy cohort experienced a higher rate of complications than patients who underwent robotic-assisted colectomy (9.5 vs. 6.6%, p < 0.001). There were no significant differences in LOS (6 vs. 6.5 days, p = 0.08) and readmissions (6.1 vs. 6.7%, p = 0.851) at 90 days. Patients undergoing robotic-assisted colectomy have a lower risk for morbidity at 90 days. Neither approach is superior for LOS nor 90 days of readmissions. Both techniques are effective minimally invasive procedures, yet patients may gain a greater risk benefit from robotic colectomy.

Should we encourage the use of robotic technologies in complicated diverticulitis? Results of systematic review and meta-analysis

Introduction: Complicated diverticulitis is a common abdominal emergency that often requires a surgical intervention. The systematic review and meta-analysis below compare the benefits and harms of robotic vs. laparoscopic surgery in patients with complicated colonic diverticular disease. Methods: The following databases were searched before 1 March 2023: Cochrane Library, PubMed, Embase, CINAHL, and ClinicalTrials.gov. The internal validity of the selected non-randomized studies was assessed using the ROBINS-I tool. The meta-analysis and trial sequential analysis were performed using RevMan 5.4 (Cochrane Collaboration, London, United Kingdom) and Copenhagen Trial Unit Trial Sequential Analysis (TSA) software (Copenhagen Trial Unit, Center for Clinical Intervention Research, Rigshospitalet, Copenhagen, Denmark), respectively. Results: We found no relevant randomized controlled trials in the searched databases. Therefore, we analyzed 5 non-randomized studies with satisfactory internal validity and similar designs comprising a total of 442 patients (184 (41.6%) robotic and 258 (58.4%) laparoscopic interventions). The analysis revealed that robotic surgery for complicated diverticulitis (CD) took longer than laparoscopy (MD = 42 min; 95% CI: [-16, 101]). No statistically significant differences were detected between the groups regarding intraoperative blood loss (MD = -9 mL; 95% CI: [-26, 8]) and the rate of conversion to open surgery (2.17% or 4/184 for robotic surgery vs. 6.59% or 17/258 for laparoscopy; RR = 0.63; 95% CI: [0.10, 4.00]). The type of surgery did not affect the length of in-hospital stay (MD = 0.18; 95% CI: [-0.60, 0.97]) or the rate of postoperative complications (14.1% or 26/184 for robotic surgery vs. 19.8% or 51/258 for laparoscopy; RR = 0.81; 95% CI: [0.52, 1.26]). No deaths were reported in either group. Discussion: The meta-analysis suggests that robotic surgery is an appropriate option for managing complicated diverticulitis. It is associated with a trend toward a lower rate of conversion to open surgery and fewer postoperative complications; however, this trend does not reach the level of statistical significance. Since no high quality RCTs were available, this meta-analysis isnot able to provide reliable conclusion, but only a remarkable lack of proper evidence supporting robotic technology. The need for further evidence-based trials is important.

The success rate of robotic natural orifice intracorporeal anastomosis and transrectal extraction (NICE procedure) in a large cohort of consecutive unselected patients

BACKGROUND

The Robotic NICE procedure is a total intracorporeal natural orifice approach in which specimen extraction and anastomosis is accomplished without an abdominal wall incision other than the port sites themselves. We aim to present the success rate of the NICE procedure in a large cohort of unselected consecutive patients presenting with colorectal disease using a stepwise and reproducible robotic approach.

METHODS

Consecutive patients who presented with benign or malignant disease requiring left-sided colorectal resection and anastomosis between May 2018 and June 2021 were evaluated. Data abstracted included demographic, clinical data, disease features, intervention data, and outcomes data. The main outcome was success rate of Intracorporeal anastomosis (ICA), transrectal extraction of specimen (TRSE), and conversion rate.

RESULTS

A total of 306 patients underwent NICE procedure. Diverticulitis was the main diagnosis (64%) followed by colorectal neoplasm (27%). Median operative time was 219 min, and the median estimated blood loss was 50 ml. ICA was achieved in all cases (100%). TRSE was successfully achieved in 95.4% of cases. In 14 patients (4.6%), an abdominal incision was required due to inability to extract a bulky specimen through the rectum. There overall postoperative complications rate was 12.4%. Eight patients (2.6%) experienced postoperative ileus. There were no superficial or deep surgical site infection (SSI). Eleven patients (3.6%) developed organ SSI space including 5 patients with intra-abdominal abscess and 4 patients with anastomotic leak. There was one mortality (0.3%) due to toxic megacolon from resistant Clostridium difficile. The 30-day reoperation rate was 2.9% (n = 9) including six patients presenting with organ space SSI and three patients with postoperative obstruction at the diverting loop ileostomy site.

CONCLUSION

The NICE procedure is associated with a very high success rate for both intracorporeal anastomosis and transrectal specimen extraction in a large cohort of unselected patients.

A systematic review and meta-analysis of robotic resections for diverticular disease

AIM

Resection of diverticular disease can be technically challenging. Tissue planes can be difficult to identify intraoperatively due to inflammation or fibrosis. Robotic surgery may improve identification of tissue planes and dissection which can facilitate difficult minimally invasive resections. This systematic review and meta-analysis evaluates the role of robotic surgery compared to laparoscopic surgery in diverticular resection.

METHODS

A systematic review and meta-analysis was performed in accordance with the PRISMA statement. The search was completed using PubMed, OVID MEDLINE and EMBASE. A total of 490 articles were retrieved, and studies reporting primary outcomes for robotic diverticular resection were included in the final analysis. A meta-analysis of studies comparing robotic and laparoscopic surgery was performed on rate of conversion to open surgery and complications.

RESULTS

Fifteen articles (8 cohort studies and 7 case series) reporting 3711 robotic diverticular resections were analysed. In comparison to laparoscopic, robotic surgery for diverticular disease was associated with a reduced conversion to open and a longer operating time. Meta-analysis showed robotic resection was associated with a lower conversion rate compared to laparoscopic surgery (OR: 0.57; 95% CI: 0.49-0.66, p < 0.001). There was no significant difference in grade III and above complications (OR: 0.74; 95% CI: 0.49-1.13, p = 0.17). Operating time was longer with a robotic approach (Hedge's G: 0.43; 95% CI: 0.04-0.81, p = 0.03).

CONCLUSION

Robotic resection is a feasible and safe option in diverticular disease. Although associated with a longer operating time, robotic surgery may render diverticular disease resectable with a minimally invasive approach that would have otherwise necessitated a laparotomy. Randomised controlled data is required to better define the role of robotic surgery for diverticular disease resections.

Safety of robotic surgical management of non-elective colectomies for diverticulitis compared to laparoscopic surgery

Non-elective minimally invasive surgery (MIS) remains controversial, with minimal focus on robotics. This study aims to evaluate the short-term outcomes for non-elective robotic colectomies for diverticulitis. All colectomies for diverticulitis in ACS-NSQIP between 2012 and 2019 were identified by CPT and diagnosis codes. Open and elective cases were excluded. Patients with disseminated cancer, ascites, and ventilator-dependence were excluded. Procedures were grouped by approach (laparoscopic and robotic). Demographics, operative variables, and postoperative outcomes were compared between groups. Covariates with p < .1 were entered into multivariable logistic regression models for 30 day mortality, postoperative septic shock and reoperation. 6880 colectomies were evaluated (Laparoscopic = 6583, Robotic = 297). The laparoscopic group included more preoperative sepsis (31.6% vs. 10.8%), emergency cases (32.3% vs. 6.7%), and grade 3/4 wound classifications (53.3% vs. 42.8%). There was no difference in mortality, anastomotic leak, SSI, reoperation, readmission, or length of stay. The laparoscopic group had more postoperative sepsis (p = 0.001) and the robotic group showed increased bleeding (p = 0.011). In a multivariate regression model, increased age (OR = 1.083, p < 0.001), COPD (OR = 2.667, p = 0.007), dependent functional status (OR = 2.657, p = 0.021), dialysis (OR = 4.074, p = 0.016), preoperative transfusions (OR = 3.182, p = 0.019), emergency status (OR = 2.241, p = 0.010), higher ASA classification (OR = 3.170, p = 0.035), abnormal WBC (OR = 1.883, p = 0.046) were independent predictors for mortality. When controlling for confounders, robotic approach was not statistically significantly associated with septic shock or reoperation. When controlling for confounders, robotic approach was not a predictor for mortality, reoperation or septic shock. Robotic surgery is a feasible option for the acute management of diverticulitis.

Robotic versus laparoscopic colorectal surgery in elderly patients in terms of recovery time: a monocentric experience

Colorectal cancer has a great socio-sanitary relevance. It represents the third cancer by incidence and mortality. Ageing plays a major role in the development of colorectal cancer and this tumour, in patients aged 65 and older, has gradually increased over the past decade. The robotic technique is considered the evolution of conventional laparoscopy. Few studies evaluate the effects of robotic surgery in elderly patient, and even fewer are those that compare it with laparoscopic surgery in this population. The aim of this study was to evaluate the perioperative outcomes of robotic colorectal surgery compared to laparoscopic colorectal surgery in patients older than 65 years. We conducted a retrospective study enrolling 83 elderly patients (age > 65) undergoing robotic and laparoscopic colectomy (32 and 51, respectively) between January 2019 and January 2021. For statistical analysis, p values were calculated using t test and chi-square test. p < 0.05 is the criterion for statistical significance. Statistical analyses were performed with the Number Cruncher Statistical System (NCSS) 2020 data analysis version 20.0.1 (Utah, USA). The operation time was higher in robotic left (p = 0.003, mean time 249.6 vs 211.7 min) and right (p = 0.004, mean time 238.5 vs 183.5 min) hemicolectomy and similar for procedures on rectosigmoid and rectum when compared to laparoscopic technique. In terms of length of hospital stay and recovery of bowel function, these values were significantly lower for robotic group in left hemicolectomy (p = 0.004), rectum (p = 0.003) and rectosigmoid (p = 0.003), while right hemicolectomy was similar in two groups (p = 0.26). There was no statistically significant difference between the groups regarding conversion rate, postoperative complications, length of specimen, number of lymph nodes encountered and oncological results. Colorectal robotic surgery in elderly patients appears as a feasible and safe surgical approach when compared to the laparoscopic one, showing a shorter recovery and a reduction of length of stay with similar oncological outcomes even if with an increase of operating times.

Robotic versus laparoscopic left colectomy: a systematic review and meta-analysis

BACKGROUND

This study aimed to review the new evidence to understand whether the robotic approach could find some clear indication also in left colectomy.

METHODS

A systematic review of studies published from 2004 to 2022 in the Web of Science, PubMed, and Scopus databases and comparing laparoscopic (LLC) and robotic left colectomy (RLC) was performed. All comparative studies evaluating robotic left colectomy (RLC) versus laparoscopic (LLC) left colectomy with at least 20 patients in the robotic arm were included. Abstract, editorials, and reviews were excluded. The Newcastle-Ottawa Scale for cohort studies was used to assess the methodological quality. The random-effect model was used to calculate pooled effect estimates.

RESULTS

Among the 139 articles identified, 11 were eligible, with a total of 52,589 patients (RLC, n = 13,506 versus LLC, n = 39,083). The rate of conversion to open surgery was lower for robotic procedures (RR 0.5, 0.5-0.6; p < 0.001). Operative time was longer for the robotic procedures in the pooled analysis (WMD 39.1, 17.3-60.9, p = 0.002). Overall complications (RR 0.9, 0.8-0.9, p < 0.001), anastomotic leaks (RR 0.7, 0.7-0.8; p < 0.001), and superficial wound infection (RR 3.1, 2.8-3.4; p < 0.001) were less common after RLC. There were no significant differences in mortality (RR 1.1; 0.8-1.6, p = 0.124). There were no differences between RLC and LLC with regards to postoperative variables in the subgroup analysis on malignancies.

CONCLUSIONS

Robotic left colectomy requires less conversion to open surgery than the standard laparoscopic approach. Postoperative morbidity rates seemed to be lower during RLC, but this was not confirmed in the procedures performed for malignancies.

The Role of Robotic Visceral Surgery in Patients with Adhesions: A Systematic Review and Meta-Analysis

Abdominal adhesions are a risk factor for conversion to open surgery. An advantage of robotic surgery is the lower rate of unplanned conversions. A systematic review was conducted using the terms "laparoscopic" and "robotic". Inclusion criteria were: comparative studies evaluating patients undergoing laparoscopic and robotic surgery; reporting data on conversion to open surgery for each group due to adhesions and studies including at least five patients in each group. The main outcomes were the conversion rates due to adhesions and surgeons' expertise (novice vs. expert). The meta-analysis included 70 studies from different surgical specialities with 14,329 procedures (6472 robotic and 7857 laparoscopic). The robotic approach was associated with a reduced risk of conversion (OR 1.53, 95% CI 1.12-2.10, p = 0.007). The analysis of the procedures performed by "expert surgeons" showed a statistically significant difference in favour of robotic surgery (OR 1.48, 95% CI 1.03-2.12, p = 0.03). A reduced conversion rate due to adhesions with the robotic approach was observed in patients undergoing colorectal cancer surgery (OR 2.62, 95% CI 1.20-5.72, p = 0.02). The robotic approach could be a valid option in patients with abdominal adhesions, especially in the subgroup of those undergoing colorectal cancer resection performed by expert surgeons.

Laparoscopic versus robotic-assisted, left-sided colectomies: intra- and postoperative outcomes of 683 patients

Background

Robotic-assisted colorectal surgery has gained more and more popularity over the last years. It seems to be advantageous to laparoscopic surgery in selected situations, especially in confined regions like a narrow male pelvis in rectal surgery. Whether robotic-assisted, left-sided colectomies can serve as safe training operations for less frequent, low anterior resections for rectal cancer is still under debate. Therefore, the aim of this study was to evaluate intra- and postoperative results of robotic-assisted laparoscopy (RAL) compared to laparoscopic (LSC) surgery in left-sided colectomies.

Methods

Between June 2015 and December 2019, 683 patients undergoing minimally invasive left-sided colectomies in two Swiss, high-volume colorectal centers were included. Intra- and postoperative outcome parameters were collected and analyzed.

Results

A total of 179 patients undergoing RAL and 504 patients undergoing LSC were analyzed. Baseline characteristics showed similar results. Intraoperative complications occurred in 0.6% of RAL and 2.0% of LSC patients (p = 0.193). Differences in postoperative complications graded Dindo ≥ 3 were not statistically significant (RAL 3.9% vs. LSC 6.3%, p = 0.227). Occurrence of anastomotic leakages showed no statistically significant difference [RAL n = 2 (1.1%), LSC n = 8 (1.6%), p = 0.653]. Length of hospital stay was similar in both groups. Conversions to open surgery were significantly higher in the LSC group (6.2% vs.1.7%, p = 0.018), while stoma formation was similar in both groups [RAL n = 1 (0.6%), LSC n = 5 (1.0%), p = 0.594]. Operative time was longer in the RAL group (300 vs. 210.0 min, p < 0.001).

Conclusion

Robotic-assisted, left-sided colectomies are safe and feasible compared to laparoscopic resections. Intra- and postoperative complications are similar in both groups. Most notably, the rate of anastomotic leakages is similar. Compared to laparoscopic resections, the analyzed robotic-assisted resections have longer operative times but less conversion rates. Further prospective studies are needed to confirm the safety of robotic-assisted, left-sided colectomies as training procedures for low anterior resections.

Robotic versus conventional laparoscopic technique for the treatment of left-sided colonic diverticular disease: a systematic review with meta-analysis

PURPOSE

Minimally invasive surgery has been universally accepted as a valid option for the treatment of diverticular disease, provided specific expertise is available. Over the last decade, there has been a growing interest in the application of robotic approaches for diverticular disease. We aimed at evaluating whether robotic colectomy may offer some advantages over the laparoscopic approach for surgical treatment of diverticular disease by meta-analyzing the available data from the medical literature.

METHODS

The PubMed/Medline, EMBASE, and Web Of Sciences electronic databases were searched for literature up to December 2020. Inclusion criteria considered all comparative studies evaluating robotic versus laparoscopic colectomy for diverticulitis eligible. The conversion rate to the open approach was evaluated as the primary outcome.

RESULTS

The data of 4177 patients from nine studies were included in the analysis. There were no significant differences in the baseline characteristics. Patients undergoing laparoscopic colectomy compared to those who underwent surgery with a robotic approach had a significantly higher risk of conversion into an open procedure (12.5% vs. 7.4%, p < 0.00001) and abbreviated hospital stay (p < 0.0001) at the price of a longer operating time (p < 0.00001).

CONCLUSION

Compared with conventional laparoscopic surgery, the robotic approach offers significant advantages in terms of conversion rate and shortened hospital stay for the treatment of diverticular disease. However, because of the lack of available evidence, it is impossible to draw definitive conclusions.

Predictors and Consequences of Unplanned Conversion to Open During Robotic Colectomy: An ACS-NSQIP Database Analysis

Robotic-assisted surgery has become a desired modality for performing colectomy; however, unplanned conversion to an open procedure may be associated with worse outcomes. The purpose of this study is to examine predictors and consequences of unplanned conversion to open in a large, high fidelity data set. A retrospective analysis of 11 061 robotic colectomies was conducted using the American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) 2012-2017 database. Predictors of conversion and the effect of conversion on outcomes were analyzed by multivariate logistic regression resulting in risk-adjusted odds ratios of conversion and morbidity/mortality. Overall, 10 372 (93.8%) patients underwent successful robotic colectomy, and 689 (6.2%) had an unplanned conversion. Predictors of conversion included age ≥ 65 years, male gender, obesity, functional status not independent, American Society of Anesthesia (ASA) classification IV-V, non-oncologic indication, emergency case, smoking, recent weight loss, bleeding disorder, and preoperative organ space infection. Conversion is an independent risk factor for mortality, overall morbidity, cardiac morbidity, pulmonary morbidity, renal morbidity, venous thromboembolism morbidity, wound morbidity, sepsis, bleeding, readmission, return to the operating room, and extended length of stay (LOS). Unplanned conversion to open during robotic colectomy is an independent predictor of morbidity and mortality.

Robotic-Assisted Laparoscopic Resection of Tailgut Cysts

Introduction:

Tailgut cysts are rare remnants of the embryological hindgut. Resections are difficult to perform due to the narrow and delicate presacral space where they are usually located. Many different approaches have been described, but to date, no studies have been performed concerning robotic assisted surgery for this entity. Therefore, we conducted a retrospective analysis to evaluate the feasibility and outcome parameters of the robotic anterior approach for resection of tailgut cysts and to compare our results with available literature.

Material and Methods:

Data was retrospectively obtained from hospital records of all patients who underwent robotic assisted resection of tailgut cysts between January 1, 2017 and June 30, 2020. Outcomes include baseline characteristics, pre-operative radiological workup, operative time, intra- and postoperative complications, and histopathological results.

Results:

Between January 1, 2017 and June 30, 2020, five patients underwent robotic resection of tailgut cysts. All patients were female and mean age was 47.2 years (range 31.6–63.1 years). Only one patient reported to have local symptoms that could be attributed to the tailgut cyst. Median tumor size was 42 mm (range 30–64 mm). There was no conversion and median operating time was 235 minutes (range 184–331 minutes). Four patients had additional procedures. Intra- and postoperative complications included one intra-operative injury of the rectal wall, which was immediately oversewn, and one postoperative presacral hematoseroma with mild neurological symptoms. None of the specimens showed signs of malignant transformation in histopathological workup.

Conclusion:

This retrospective analysis shows that robotic resections of tailgut cysts are feasible and safe. Regarding the localization of tailgut cysts in the presacral space, the robotic assisted anterior approach is excellently suited, especially if the cysts are localized above the levator muscle. Longer operative times and higher material costs are outweighed by precise and safe preparation with a robotic platform in this delicate region and confined space. We recommend the robotic assisted anterior approach for the resection of tailgut cysts and retrorectal lesions in general.