Robotic-assisted laparoscopic stage II restorative proctectomy for toxic ulcerative colitis

Robotic multiquadrant colorectal procedures: A single-center experience and a systematic review of the literature

Purpose

Robotic surgery has been progressively implemented for colorectal procedures but is still limited for multiquadrant abdominal resections. The present study aims to describe our experience in robotic multiquadrant colorectal surgeries and provide a systematic review and meta-analysis of the literature investigating the outcomes of robotic total proctocolectomy (TPC), total colectomy (TC), subtotal colectomy (STC), or completion proctectomy (CP) compared to laparoscopy.

Methods

At our institution 16 consecutive patients underwent a 2- or 3-stage totally robotic total proctocolectomy (TPC) with ileal pouch-anal anastomosis. A systematic review of the literature was performed to select studies on robotic and laparoscopic multiquadrant colorectal procedures. Meta-analyses were used to compare the two approaches.

Results

In our case series, 14/16 patients underwent a 2-stage robotic TPC for ulcerative colitis with a mean operative time of 271.42 (SD:37.95) minutes. No conversion occurred. Two patients developed postoperative complications. The mean hospital stay was 8.28 (SD:1.47) days with no readmissions. Mortality was nil. All patients underwent loop-ileostomy closure, and functional outcomes were satisfactory. The literature appraisal was based on 23 retrospective studies, including 736 robotic and 9,904 laparoscopic multiquadrant surgeries. In the robotic group, 36 patients underwent STC, 371 TC, 166 TPC, and 163 CP. Pooled data analysis showed that robotic TC and STC had a lower conversion rate (OR = 0.17;95% CI, 0.04–0.82; p = 0.03) than laparoscopic TC and STC. The robotic approach was associated with longer operative time for TC and STC (MD = 104.64;95% CI, 18.42–190.87; p = 0.02) and TPC and CP (MD = 38.8;95% CI, 18.7–59.06; p = 0.0002), with no differences for postoperative complications and hospital stay. Reports on urological outcomes, sexual dysfunction, and quality of life were missing.

Conclusions

Our experience and the literature suggest that robotic multiquadrant colorectal surgery is safe and effective, with low morbidity and mortality rates. Nevertheless, the overall level of evidence is low, and functional outcomes of robotic approach remain largely unknown.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022303016.

Robotic Surgery for Ulcerative Colitis

Subtotal colectomy (STC) or total proctocolectomy (TPC) and ileal pouch-anal anastomosis (IPAA) performed in two or three stages remain the procedure of choice for patients with ulcerative colitis (UC). Minimally invasive laparoscopic approaches for STC and IPAA have been established for over a decade, having been shown to reduce postoperative pain, length of stay, and improve fertility. However "straight-stick" laparoscopy has ergonomic and visual disadvantages in the pelvis, which may contribute to IPAA failure. The robotic platform was developed to overcome these limitations. Robotic STC is associated with lower conversion rates and earlier return of bowel function with acceptably longer operative time (mean, 28 minutes) than laparoscopic STC. The robotic approach has also been shown in case series to be safe in urgent settings. Robotic IPAA is associated with lower blood loss and length of stay than laparoscopic IPAA. Robotic TPC/IPAA has been shown in small case series to be safe and feasible despite longer operating times.

Robotic Surgery in Crohn's Disease

Surgery for Crohn's disease presents unique challenges secondary to the inflammatory nature of the disease. While a minimally invasive approach to colorectal surgery has consistently been associated with better patient outcomes, adoption of laparoscopy in Crohn's disease has been limited due to these challenges. Robotic assisted surgery has the potential to overcome these challenges and allow more complex patients to undergo a minimally invasive operation. Here we describe our approach to robotic assisted surgery for terminal ileal Crohn's disease.

Robotic Colorectal Surgery

The role of robotics in colon and rectal surgery has been established as an important and effective tool for the surgeon. Its inherent technologies have provided for increased visualization and ease of dissection in the minimally invasive approach to surgery. The value of the robot is apparent in the more challenging aspects of colon and rectal procedures, including the intracorporeal anastomosis for right colectomies and the low pelvic dissection for benign and malignant diseases.

The Role of Laparoscopic, Robotic, and Open Surgery in Uncomplicated and Complicated Inflammatory Bowel Disease

The incidence of inflammatory bowel disease is increasing and despite advances in medical therapy, patients continue to require operations for complications of their disease. Minimally invasive surgical options have impacted postoperative morbidity dramatically with reduction of pain, length of stay and adhesion formation, but additionally, this population of patients are not only concerned with successful operative therapy but also the ability to return to their lifestyle and cosmetics. Laparoscopic and robotic surgery for Crohn's disease has proven to benefit patients with ileocolic or colonic disease, however complicated disease with phlegmon, abscess or fistulae is best served with a hybrid approach. Ulcerative colitis treatment has seen advancements with laparoscopic and robotic platforms, however the benefits of minimally invasive surgery must be balanced with producible and durable outcomes.

Perioperative outcomes and adverse events of robotic colorectal resections for inflammatory bowel disease: a systematic literature review

The purpose of this study was to assess outcome measures and cost-effectiveness of robotic colorectal resections in adult patients with inflammatory bowel disease. The Cochrane Library, PubMed/Medline and Embase databases were reviewed, using the text "robotic(s)" AND ("inflammatory bowel disease" OR "Crohn's" OR "Ulcerative Colitis"). Two investigators screened abstracts for eligibility. All English language full-text articles were reviewed for specified outcomes. Data were presented in a summarised and aggregate form, since the lack of higher-level evidence studies precluded meta-analysis. Primary outcomes included mortality and postoperative complications. Secondary outcomes included readmission rate, length of stay, conversion rate, procedure time, estimated blood loss and functional outcome. The tertiary outcome was cost-effectiveness. Eight studies (3 case-matched observational studies, 4 case series and 1 case report) met the inclusion criteria. There was no reported mortality. Overall, complications occurred in 81 patients (54%) including 30 (20%) Clavien-Dindo III-IV complications. Mean length of stay was 8.6 days. Eleven cases (7.3%) were converted to open. The mean robotic operating time was 99 min out of a mean total operating time of 298.6 min. Thirty-two patients (24.7%) were readmitted. Functional outcomes were comparable among robotic, laparoscopic and open approaches. Case-matched observational studies comparing robotic to laparoscopic surgery revealed a significantly longer procedure time; however, conversion, complication, length of stay and readmission rates were similar. The case-matched observational study comparing robotic to open surgery also revealed a longer procedure time and a higher readmission rate; postoperative complication rates and length of stay were similar. No studies compared cost-effectiveness between robotic and traditional approaches. Although robotic resections for inflammatory bowel disease are technically feasible, outcomes must be interpreted with caution due to low-quality studies.

[The technique of restorative proctocolectomy with ileal J‑pouch : Standards and controversies]

BACKGROUND

Restorative proctocolectomy (RPC) is the standard of care in the case of medically refractory disease and in neoplasia in ulcerative colitis (UC).

OBJECTIVES

This review aims at providing an overview of the current evidence on standards, innovations, and controversies with regard to the surgical technique of RPC.

RESULTS

RPC is the standard of care in the surgical management of UC refractory to medical treatment and in neoplasia. Due to its simplicity and good functional outcomes, the J‑pouch is the most used pouch design. RPC is usually performed as a two-stage procedure. In the presence of risk factors, a three-stage procedure should be performed. The technically more demanding mucosectomy and hand sewn anastomosis does not seem to result in a better oncologic outcome than stapled anastomosis. Functional results appear marginally better after stapled anastomosis, but the rectal cuff should not exceed 2 cm in this reconstruction. The laparoscopic approach is at least as good as the open approach. For the new, innovative surgical approaches such as robotics and transanal surgery, only feasibility but no advantages have yet been demonstrated.

CONCLUSION

The evidence in regard to controversial points remains limited.

Recent surgical advances in colorectal cancer excision: toward optimal outcomes

Colorectal cancer is the third most common cancer affecting both males and females in the western world. Despite all the developments in the current treatment of colorectal cancer, it is still continuing to be an important factor of patient morbidity and mortality worldwide. Surgery is the mainstay of treatment for colorectal cancer. Over the last decade, there have been major changes and developments in the surgical treatment. Understanding the importance of the anatomy, technological advances in minimally invasive surgery and effects of chemoradiotherapy have changed the approaches to colorectal cancer treatment. Today, novel treatment strategies must be targeted not only minimally invasive approaches, but also aiming to increase patients’ quality of life without compromising the oncological principles.

Minimally invasive surgery for inflammatory bowel disease: Review of current developments and future perspectives

Patients with inflammatory bowel disease (IBD) comprise a population of patients that have a high likelihood of both surgical treatment at a young age and repetitive operative interventions. Therefore surgical procedures need to aim at minimizing operative trauma with best postoperative recovery. Minimally invasive techniques have been one of the major advancements in surgery in the last decades and are nowadays almost routinely performed in colorectal resections irrespective of underlying disease. However due to special disease related characteristics such as bowel stenosis, interenteric fistula, abscesses, malnutrition, repetitive surgeries, or immunosuppressive medications, patients with IBD represent a special cohort with specific needs for surgery. This review summarizes current evidence of minimally invasive surgery for patients with Crohn’s disease or ulcerative colitis and gives an outlook on the future perspective of technical advances in this highly moving field with its latest developments in single port surgery, robotics and trans-anal techniques.

Short-term Outcome of Robot-assisted and Open IPAA: An Observational Single-center Study

BACKGROUND

The potential advantages of robot-assisted laparoscopy are being increasingly investigated, although data on its efficacy in benign colorectal surgery are scarce.

OBJECTIVE

We compared the early postoperative outcome in robot-assisted IPAA with open surgery procedures.

DESIGN

This was an observational study based on prospectively collected data obtained from chart reviews.

SETTING

The single-center data set covers patients operated on from January 13, 2004, to September 16, 2014, at a specialist center.

PATIENTS

Patients with ulcerative colitis undergoing IPAA surgery were included.

MAIN OUTCOME MEASURES

Study end points included the duration of operation, admission length, complications (Clavien-Dindo), reoperations, and readmissions.

RESULTS

Eighty-one robot-assisted and 170 open IPAA procedures were performed. The duration of operation was significantly longer for robot-assisted laparoscopic procedures (mean difference, 154 minutes; CI, 140-170). During a mean follow-up of 102 days, no significant differences in the distribution of complications were found (Spearman p = 0.12; p = 0.07), and no postoperative deaths occurred in either group. Postoperative admission length was shorter following robot-assisted procedures (mean difference, -1.9; CI, -3.5 to -0.3), whereas 40% of patients were readmitted, compared with 26% of patients who had open surgery (OR, 1.9; CI, 1.1-3.4). Pouch failure occurred in 3 patients (1 following robot-assisted laparoscopy; 2 following open surgery). On multivariate regression analyses, robot-assisted laparoscopy was associated with a significantly longer duration of operation (mean difference, 159 minutes; CI, 144-174), and more readmissions for any cause (OR, 2; CI, 1.1-3.7).

LIMITATIONS

This was a nonrandomized, single-center observational study.

CONCLUSION

In this implementation phase, robot-assisted IPAA surgery offers acceptable short-term outcomes. The limitations of this observational study call for randomized controlled trials with long-term follow-up and exploration of functional results.

Hand-assisted hybrid laparoscopic-robotic total proctocolectomy with ileal pouch--anal anastomosis

PURPOSE

Few studies have reported minimally invasive total proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). We herein report a novel hand-assisted hybrid laparoscopic-robotic technique for patients with FAP and UC.

METHODS

Between February 2010 and March 2014, six patients underwent hand-assisted hybrid laparoscopic-robotic total proctocolectomy with IPAA. The abdominal colectomy was performed laparoscopically with hand assistance through a transverse suprapubic incision, also used to fashion the ileal pouch. The proctectomy was carried out with the da Vinci Surgical System. The IPAA was hand-sewn through a trans-anal approach. The procedure was complemented by a temporary diverting loop ileostomy.

RESULTS

The mean hand-assisted laparoscopic surgery (HALS) time was 154.6 (±12.8) min whereas the mean robotic time was 93.6 (±8.1) min. In all cases, a nerve-sparing proctectomy was performed, and no conversion to traditional laparotomy was required. The mean postoperative hospital stay was 13.2 (±7.4) days. No anastomotic leakage was observed. To date, no autonomic neurological disorders have been observed with a mean of 5.8 (±1.3) bowel movements per day.

CONCLUSIONS

The hand-assisted hybrid laparoscopic-robotic approach to total proctocolectomy with IPAA has not been previously described. Our report shows the feasibility of this hybrid approach, which surpasses most of the limitations of pure laparoscopic and robotic techniques. Further experience is necessary to refine the technique and fully assess its potential advantages.

Minimally invasive surgery for inflammatory bowel disease

Surgical management of inflammatory bowel disease is a challenging endeavor given infectious and inflammatory complications, such as fistula, and abscess, complex often postoperative anatomy, including adhesive disease from previous open operations. Patients with Crohn's disease and ulcerative colitis also bring to the table the burden of their chronic illness with anemia, malnutrition, and immunosuppression, all common and contributing independently as risk factors for increased surgical morbidity in this high-risk population. However, to reduce the physical trauma of surgery, technologic advances and worldwide experience with minimally invasive surgery have allowed laparoscopic management of patients to become standard of care, with significant short- and long-term patient benefits compared with the open approach. In this review, we will describe the current state-of the-art for minimally invasive surgery for inflammatory bowel disease and the caveats inherent with this practice in this complex patient population. Also, we will review the applicability of current and future trends in minimally invasive surgical technique, such as laparoscopic "incisionless," single-incision laparoscopic surgery (SILS), robotic-assisted, and other techniques for the patient with inflammatory bowel disease. There can be no doubt that minimally invasive surgery has been proven to decrease the short- and long-term burden of surgery of these chronic illnesses and represents high-value care for both patient and society.

Surgery in the age of biological treatment

Surgery for IBD is in constant evolution; it does not appear that the introduction of biologicals has had a major effect on the chance of a patient being operated on or not. Pouch surgery had its heydays in the 80s and 90s and has since then become less frequent, but the number of patients undergoing surgery still seem about the same from one year to the other. Likewise, there is no substantial evidence that surgery for Crohn's disease is diminishing. There have been fears that patients on biological treatment have an increased risk of postoperative complications. The issue is not completely settled but it is likely that patients on biological treatment who come to surgery are those who do not benefit from biologicals. Thus, they are compromised in that they have an ongoing inflammation, are in bad nutritional state, and might have several other known risk factors for a complicated postoperative course. These factors and perhaps not the biologicals per se is what surgeons should consider. During the recent years, we have seen several new developments in IBD surgery; the ileorectal anastomosis is being used for ulcerative colitis and laparoscopic surgery usually resulting in a shorter hospital stay, less pain, and better cosmetics. We have also seen the introduction of robotic surgery, single incision minimal invasive surgery, transanal minimal invasive surgery, and other approaches to minimize surgical trauma. Time will show which of these innovations patients will benefit from.

Laparoscopic surgery for ulcerative colitis: a review of the literature

Despite the development of new therapies, including anti-TNF alpha antibodies and immunosuppressants, a substantial proportion of patients with ulcerative colitis (UC) still require surgery. Restorative proctocolectomy with ileal-pouch anal anastomosis is the standard surgical treatment of choice for UC. With the advent of laparoscopic techniques for colorectal surgery, ileal-pouch anal anastomosis has also been performed laparoscopically. This paper reviews the history and current trends in laparoscopic surgery for UC. The accumulation of experience and improvement of laparoscopic devices have shifted the paradigm of UC surgery towards laparoscopic surgery over the past decade. Although laparoscopic surgery requires a longer operation, it provides significantly better short and long-term outcomes. The short-term benefits of laparoscopic surgery over open surgery include shorter hospital stays and fasting times, as well as better cosmesis. The long-term benefits of laparoscopy include better fecundity in young females. Some surgeons favor laparoscopic surgery even for severe acute colitis. More efforts are being made to develop newer laparoscopic methods, such as reduced port surgery, including single incision laparoscopic surgery and robotic surgery.

Robotic colorectal surgery

INTRODUCTION

Minimally invasive surgery has many potential benefits, and the application of recently developed robotic technology to patients with colorectal diseases is rapidly gaining popularity.

QUALITY AND OUTCOMES

However, the literature evaluating such techniques, including the outcomes, risks, and costs, is limited. In this review, we evaluate and summarize the existing information, calling attention to areas where future investigation should occur.