Single-stage totally robotic dissection for rectal cancer surgery: technique and short-term outcome in 50 consecutive patients

Robotic splenic flexure cancer resection: technique and short-term outcomes

BACKGROUND

Surgical approach for splenic flexure cancer is demanding due to the complex regional anatomy and the variety of vascular and lymphatic reticula. Minimally invasive approach is recommended to reduce morbidity and postoperative stay, however, laparoscopic SFC resection may results challenging due to vascular and lymphatic dissection. Robotic assistance may help in performing such a procedure thanks to its enhanced dexterity, increased range of motion, enhanced precision and visualization.

METHODS

From a database of 287 colorectal procedures, data of twelve consecutive patients who underwent elective splenic flexure resection for SFC with curative intent from 2018 to 2024 at our institution were included in this retrospective cohort study. Parameters considered for statistical analysis were operative time, time to bowel canalization, length of postoperative stay, and 30-day postoperative complications. Kaplan-Meier method was used for univariate survival analysis.

RESULTS

All patients underwent robotic left splenic flexure resections for cancer using the da Vinci Si surgical system in the first 9 and the Vinci Xi surgical system in the last 3 procedures. Median operative time was 267 minutes. Median operative time in the three procedures carried out by Xi system was 200 minutes. All procedures were R0. One postoperative complication occurred. Three conversions were needed, one for pulmonary failure and two for technical difficulties in severe locally advanced tumor.

CONCLUSIONS

Robotic splenic flexure resection for SFC seems to be safe and feasible, Xi system is promising in reducing time and ameliorate a fast postoperative recovery. Further studies are needed to confirm the role of robotic in splenic flexure resection for SFC.

Propensity matched analysis of robotic and laparoscopic operations for mid-low rectal cancer: short-term comparison of anal function and oncological outcomes

Laparoscopic surgery for rectal cancer, while in some respects equivalent or even preferable to open surgery, is challenged in specific conditions where the tumor is located in the middle and lower third of the rectum. Robotic surgery equipped with a superior arm of machinery and gained better visualization can compensate for the deficiency of the laparoscopic approach. This study adopted a propensity matched analysis to compare the functional and oncological short-term outcomes of laparoscopic and robotic surgery. All patients who underwent proctectomy have been collected prospectively between December 2019 and November 2022. After censoring for inclusion criteria, we performed a propensity matching analysis. A detailed collection of post-operative examination indicators was performed, while the K-M survival curves were plotted to analyze post-operative oncology outcomes. The LARS scale was designed to evaluate the anal function of patients in the form of questionnaires. Totally, 215 patients underwent robotic operations while 1011 patients selected laparoscopic operations. Patients matched 1∶1 by propensity score were divided into the robotic and laparoscopic groups, 210 cases were included in each group. All patients underwent a follow-up for a median period of 18.3 months. Robotic surgery was connected with an enhanced recovery including the earlier time to first flatus passage without ileostomy (P = 0.050), the earlier time to liquid diet without ileostomy (P = 0.040), lower incidence of urinary retention (P = 0.043), better anal function 1 month after LAR without ileostomy (P < 0.001), longer operative time (\P = 0.042), compared with laparoscopic operations. The oncological outcomes and occurrence of other complications were comparable between the two approaches. For mid-low rectal cancer, robotic surgery could be recognized as an effective technique with identical short-term outcomes of oncology and better anal function in comparison to laparoscopic surgery. However, multi-center studies with larger samples are expected to validate the long-term outcomes of robotic surgery.

Early outcomes from the Minimally Invasive Right Colectomy Anastomosis study (MIRCAST)

BACKGROUND

The impact of method of anastomosis and minimally invasive surgical technique on surgical and clinical outcomes after right hemicolectomy is uncertain. The aim of the MIRCAST study was to compare intracorporeal and extracorporeal anastomosis (ICA and ECA respectively), each using either a laparoscopic approach or robot-assisted surgery during right hemicolectomies for benign or malignant tumours.

METHODS

This was an international, multicentre, prospective, observational, monitored, non-randomized, parallel, four-cohort study (laparoscopic ECA; laparoscopic ICA; robot-assisted ECA; robot-assisted ICA). High-volume surgeons (at least 30 minimally invasive right colectomy procedures/year) from 59 hospitals across 12 European countries treated patients over a 3-year interval The primary composite endpoint was 30-day success, defined by two measures of efficacy-absence of surgical wound infection and of any major complication within the first 30 days after surgery. Secondary outcomes were: overall complications, conversion rate, duration of operation, and number of lymph nodes harvested. Propensity score analysis was used for comparison of ICA with ECA, and robot-assisted surgery with laparoscopy.

RESULTS

Some 1320 patients were included in an intention-to-treat analysis (laparoscopic ECA, 555; laparoscopic ICA, 356; robot-assisted ECA, 88; robot-assisted ICA, 321). No differences in the co-primary endpoint at 30 days after surgery were observed between cohorts (7.2 and 7.6 per cent in ECA and ICA groups respectively; 7.8 and 6.6 per cent in laparoscopic and robot-assisted groups). Lower overall complication rates were observed after ICA, specifically less ileus, and nausea and vomiting after robot-assisted procedures.

CONCLUSION

No difference in the composite outcome of surgical wound infections and severe postoperative complications was found between intracorporeal versus extracorporeal anastomosis or laparoscopy versus robot-assisted surgery.

The double bipolar method for robotic total mesorectal excision in patients with rectal cancer

Although meta-analyses and systematic reviews have clarified the benefits of robotic surgery, few studies have focused on robotic rectal surgery (RRS) and the use of Endowrist® instruments. Therefore, we evaluated RRS using the double bipolar method (DBM) and compared its short-term outcomes with those of RRS using the single bipolar method (SBM). This study enrolled 157 consecutive patients and all procedures were performed by the same surgeon and recorded through short video clips. We analyzed the patient demographics and short-term clinical outcomes. Although this observational study has several limitations, the console time for total mesorectal excision using the DBM was significantly shorter than that using the SBM. Although the DBM did not demonstrate a specific learning curve, it was a safe and feasible procedure even for patients with advanced disease. Further studies are needed to evaluate the cost-effectiveness of the DBM.

A comparison of robotic-assisted splenectomy and laparoscopic splenectomy for children with hematologic disorders

INTRODUCTION

Laparoscopic splenectomy (LS) is the standard of care for hematologic disorders requiring splenectomy. Less is known about the outcomes following robotic-assisted splenectomy (RS) for this indication. Our aim was to describe outcomes of RS to LS in pediatric patients with hematologic disorders in our institution.

METHODS

A single institution retrospective review was performed of pediatric patients undergoing LS vs. RS from 2014 to 2019. Patient demographics, diagnosis, spleen size, hospital length of stay (LOS), operative time, post-operative opioid use, and hospital charges were evaluated. Standard univariate analyses were performed.

RESULTS

Twenty-four patients were included in the study (14 LS, 10 RS). The mean spleen size at the time of surgery was larger in the RS group compared to LS (14.5 cm vs. 12.2 cm, p = 0.03). Operative time between the two cohorts was comparable (RS 140.5 vs LS 154.9 min). Median LOS for RS was shorter than LS (2.1 vs. 3.2 days, p = 0.02). Cumulative postoperative opioid analgesic requirements were not significantly different between the groups (17.4 mg vs. 30.5 mg). The median hospital charges, including the surgical procedure and hospital stay were higher in the RS group ($44,724 RS vs $30,255 LS, p = 0.01).

CONCLUSION

Robotic splenectomy is a safe and feasible option for pediatric patients with hematologic disorders, and was associated with decreased LOS but higher charges compared to laparoscopic splenectomy. Further studies are required to delineate the optimal use and potential benefits of robot-assisted surgical techniques in children.

LEVEL OF EVIDENCE

II.

Minimally invasive right colectomy anastomosis study (MIRCAST): protocol for an observational cohort study of surgical complications using four surgical techniques for anastomosis in patients with a right colon tumor

BACKGROUND

Right colectomy is the standard surgical treatment for tumors in the right colon and surgical complications are reduced with minimally-invasive laparoscopy compared with open surgery, with potential further benefits achieved with robotic assistance. The anastomotic technique used can also have an impact on patient outcomes. However, there are no large, prospective studies that have compared all techniques.

METHODS/DESIGN

MIRCAST is the Minimally-Invasive Right Colectomy Anastomosis Study that will compare laparoscopy with robot-assisted surgery, using either intracorporeal or extracorporeal anastomosis, in a large prospective, observational, multicenter, parallel, four-cohort study in patients with a benign or malignant, non-metastatic tumor of the right colon. Over 2 years of follow-up, the study will prospectively evaluate peri- and postoperative complications, postoperative recovery, hospital stay, and mid-term results including survival, local recurrence, metastases rate, and conversion rate. The primary composite endpoint will be the efficacy of the surgical method regarding surgical wound infections and postoperative complications (Clavien-Dindo grade III-IV complications at 30 days post-surgery). Secondary endpoints include long-term oncologic results, conversion rate, operative time, length of stay, and quality of life.

DISCUSSION

This will be the first large, international study to prospectively evaluate the use of minimally-invasive laparoscopy or robot-assisted surgery during right hemicolectomy and to control for the impact of the anastomotic technique. The research will contribute to current knowledge regarding the medical care of patients with malignant or benign tumors of the right colon, and enable physicians to determine which technique may be the most appropriate for their patients.

TRIAL REGISTRATION

This study was registered on Clinicaltrials.gov (clinicaltrials.gov identifier: NCT03650517 ) on August 28th 2018 (study protocol version CI18/02 revision A, 21 February 2018).

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.

A prospective randomized controlled trial comparing conventional Intuitive® procedure card recommended port placement with the modified Indian (Manipal) technique

Introduction

The da Vinci^® X hybrid systems (Intuitive Surgical^®, Sunnyvale CA) provides standard sites recommendations for port placement during robotic surgery; including that for colorectal procedures. The author's encountered challenges while adhering to the provided instructions, such as clash of instruments and arms and need for additional ports, and hence to overcome these challenges attempted a few innovative technical modifications. The surgical results as well as merits of the revised Indian (Manipal) port placement with single docking technique are presented here.

Methods

Twenty patients underwent robotic rectal resection at the Department of Surgical Oncology and Robotic Surgery, Manipal Comprehensive Cancer Centre, Bengaluru, India, between December 2017 and June 2018. A randomised controlled study was conducted to compare the two techniques. Ten patients were operated using hybrid da Vinci^® 'X' system using the manufacturer's recommendations and 10 by the modified Indian (Manipal) port placement with a single docking technique.

Result and Conclusions

The Indian (Manipal) modifications of port placements are optimal for colorectal procedures such as low anterior resection as well as for ultralow anterior resections. The intraoperative parameters compared between the recommendations of the Intuitive^® (da Vinci^® systems) and attempted modifications demonstrated statistically significant advantages with the use of the revised techniques. The improvements offered by this modification include no additional requirements of ports or staplers, lesser clash amongst instruments as well as arms, better mobilisation of splenic flexure amongst others.

Robotic surgery for colorectal disease: review of current port placement and future perspectives

Purpose

As robotic surgery is increasingly performed in patients with colorectal diseases, understanding proper port placement for robotic colorectal surgery is necessary. This review summarizes current port placement during robotic surgery for colorectal diseases and provides future perspective on port placements.

Methods

PubMed were searched from January 2009 to December 2018 using a combination of the search terms “robotic” [MeSH], “colon” [MeSH], “rectum” [MeSH], “colorectal” [MeSH], and “colorectal surgery” [MeSH]. Studies related to port placement were identified and included in the current study if they used the da Vinci S, Si, or Xi robotic system and if they described port placement.

Results

This review included 77 studies including a total of 3,145 operations. Fifty studies described port placement for left-sided and mesorectal excision; 17, 3, and 7 studies assessed port placement for right-sided colectomy, rectopexy, transanal surgery, respectively; and one study assessed surgery with reduced port placement. Recent literatures show that the single-docking technique included mobilization of the second and third robotic arms for the different parts without movement of patient cart and similar to previous dual or triple-docking technique. Besides, use of the da Vinci Xi system allowed a more simplified port configuration.

Conclusion

Robot-assisted colorectal surgery can be efficiently achieved with successful port placement without movement of patient cart dependent on the type of surgery and the robotic system.

Robotic Surgery for Rectal Cancer and Cost-Effectiveness

Robotic surgery is considered as one of the advanced treatment modality of minimally invasive surgery for rectal cancer. Robotic rectal surgery has been performed for three decades and its application is gradually expanding along with technology development. It has several technical advantages which include magnified three-dimensional vision, better ergonomics, multiple articulated robotic instruments, and the opportunity to perform remote surgery. The technical benefits of robotic system can help to manipulate more meticulously during technical challenging procedures including total mesorectal excision in narrow pelvis, lateral pelvic node dissection, and intersphincteric resection. It is also reported that robotic rectal surgery have been shown more favorable postoperative functional outcomes. Despite its technical benefits, a majority of studies have been reported that there is rarely clinical or oncologic superiority of robotic surgery for rectal cancer compared to conventional laparoscopic surgery. In addition, robotic rectal surgery showed significantly higher costs than the standard method. Hence, the cost-effectiveness of robotic rectal surgery is still questionable. In order for robotic rectal surgery to further develop in the field of minimally invasive surgery, there should be an obvious cost-effective advantages over laparoscopic surgery, and it is crucial that large-scale prospective randomized trials are required. Positive competition of industries in correlation with technological development may gradually reduce the price of the robotic system, and it will be helpful to increase the cost-effectiveness of robotic rectal surgery.

[Standardized access options for colorectal surgery with the da Vinci Xi system]

BACKGROUND

Performing colorectal surgery with previous da Vinci system generations presented some limitations that caused uncertainty for surgeons as they began to apply robotic technologies. The da Vinci Xi system is designed to overcome these limitations and to enable multiquadrant colorectal surgery.

OBJECTIVE

The design concept of the da Vinci Xi system and the standardized access for colorectal surgery are explained.

MATERIAL AND METHODS

The da Vinci Xi system applies an overhead boom that maximizes the arm workspace, minimizes interference and makes the port placement universal for standardized access. Colorectal approaches have been validated in numerous cadaver models confirming the reproducibility of the standardized access.

RESULTS

Standardized access with a straight-line port placement is possible in all colorectal applications. For right-sided hemicolectomy, a transverse abdominal approach as well as a suprapubic port placement are possible. Utilizing the same principles, left-sided colectomy, sigmoid colectomy and low anterior resections can be performed. Proctocolectomy is enabled through boom rotation and a second docking. Only minor arm-to-arm interferences occurred and were easily manageable by the bedside assistant. None of the approaches required rearrangement of the patient cart or swapping arms to different port locations.

CONCLUSION

The da Vinci Xi system enables a standardized access for colorectal surgery through a universal straight-line port placement. Learning this standard principle once enables the surgeon to apply it to all colorectal surgeries and shorten the learning curve as well as minimizing stress for both novices and experienced robotic surgeons learning a new surgical robotic platform.

Open versus minimally invasive surgery for rectal cancer: a single-center cohort study on 237 consecutive patients

Minimally invasive surgery (MIS) is gaining popularity in rectal tumor treatment. However, contrasting data are available regarding its safety and efficacy. Our aim is to compare the open and MIS approaches for rectal cancer treatment. Two-hundred-thirty-seven patients were included: 113 open and 124 MIS rectal resections. After the propensity score matching analysis (PS), the cases were matched into 42 open and 42 MIS. Short- and long-term outcomes, and pathological findings were analyzed before and after PS. A further comparison of the same outcomes and costs was conducted between the laparoscopic and the robotic approaches. As a whole, a sphincter-preserving procedure was more frequently performed in the MIS group (110 vs 75 cases; p < 0.0001). The estimated blood loss during MIS was significantly lower than during open surgery [127 (± 92) vs 242 (± 122) mL; p < 0.0001], with clear advantages for the robotic approach over laparoscopy [113 (± 87) vs 147 (± 93) mL; p 0.01]. Complication rate was comparable between the two groups. A higher rate of CRM positivity was evidenced after open surgery (12.4% vs 1.7%; p 0.004). A higher number of lymph nodes was harvested in the MIS group [12.5 (± 6.4) vs 11 (± 5.6); p 0.04]. After PS, no difference in terms of perioperative outcomes was noted, with the only exception of a higher blood loss in the open approach [242 (± 122) vs 127 (± 92) mL; p < 0.0001]. For the matched cases, no difference in 5-year overall and disease-free survival was evidenced (p 0.50 and 0.88, respectively). Mean costs were higher for robotics as compared to laparoscopy [9812 (±1974)€ vs 9045 (± 1893)€; p 0.02]. MIS could be considered as a treatment option for rectal cancer. The PS study evidenced clear advantages in terms of estimated blood loss over the open surgery. Costs still remain the main limit for robotics.

Comparison of Short-Term Outcomes Between Robotic-Assisted and Laparoscopic Surgery in Colorectal Cancer

Aim. The robotic technique has been established as an alternative approach to laparoscopy in colorectal surgery. The aim of this study was to compare short-term outcomes of robot-assisted and laparoscopic surgery in colorectal cancer. Methods. The cases of robot-assisted or laparoscopic colorectal resection were collected retrospectively between July 2015 and October 2017. We evaluated patient demographics, perioperative characteristics, and pathologic examination. A multivariable linear regression model was used to assess short-term outcomes between robot-assisted and laparoscopic surgery. Short-term outcomes included time to passage of flatus and postoperative hospital stay. Results. A total of 284 patients were included in the study. There were 104 patients in the robotic colorectal surgery (RCS) group and 180 in the laparoscopic colorectal surgery (LCS) group. The mean age was 60.5 ± 10.8 years, and 62.0% of the patients were male. We controlled for confounding factors, and then the multiple linear model regression indicated that the time to passage of flatus in the RCS group was 3.45 days shorter than the LCS group (coefficient = −3.45, 95% confidence interval [CI] = −5.19 to −1.71; P < .001). Additionally, the drainage of tube duration (coefficient = 0.59, 95% CI = 0.3 to 0.87; P < .001) and transfers to the intensive care unit (coefficient = 7.34, 95% CI = 3.17 to 11.5; P = .001) influenced the postoperative hospital stay. The total costs increased by 15501.48 CNY in the RCS group compared with the LCS group ( P = .008). Conclusions. The present study suggests that colorectal cancer robotic surgery was more beneficial to patients because of shorter postoperative recovery time of bowel function and shorter hospital stays.

Port positioning and docking for single-stage totally robotic dissection for rectal cancer surgery with the Si and Xi Da Vinci Surgical System

We have previously reported our technique of single-docking totally robotic dissection for rectal cancer surgery using the Da Vinci^® Si Surgical System in 2009. However, we have since optimised our port placement for the Si system and have developed a novel configuration of port placement and docking for the Da Vinci^® Xi Surgical System. We have performed over 700 cases using this technique with the Si system and have used our Xi technique since 2016 for totally robotic dissection for rectal cancer. We have kept the configuration of port placements for both the Xi and Si system as similar as possible, with the priorities to avoid arm collisions as well as to provide a workable port configuration of two left-handed instruments and one right-handed instrument. To date, there have had no major complications or arm collisions related to this technique of docking, port positioning and instrument placement.

Robotic proctectomy for rectal cancer: analysis of 71 patients from a single institution

BACKGROUND

Despite increasing use of robotic surgery for rectal cancer, few series have been published from the practice of generalizable US surgeons.

METHODS

A retrospective chart review was performed for 71 consecutive patients who underwent robotic low anterior resection (LAR) or abdominoperineal resection (APR) for rectal adenocarcinoma between 2010 and 2014.

RESULTS

46 LARs (65%) and 25 APRs (35%) were identified. Median procedure time was 219 minutes (IQR 184-275) and mean blood loss 164.9 cc (SD 155.9 cc). Radial margin was negative in 70/71 (99%) patients. Total mesorectal excision integrity was complete/near complete in 38/39 (97%) of graded specimens. A mean of 16.8 (SD+/- 8.9) lymph nodes were retrieved. At median follow-up of 21.9 months, there were no local recurrences.

CONCLUSIONS

Robotic proctectomy for rectal cancer was introduced into typical colorectal surgery practice by a single surgeon, with a low conversion rate, low complication rate, and satisfactory oncologic outcomes.

Robotic Rectal Resection With a Single-docking Technique Thanks to the Rotation of the R3 Arm

BACKGROUND

Robotic surgery for rectal resection presents some advantages compared with the traditional technique; however, it also presents some limitations, especially due to the multiple changes of surgical fields. We describe a new technique to perform low-anterior resection using single docking with the rotation of the third arm and our perioperative results.

MATERIALS AND METHODS

A total of 31 patients who underwent low-anterior rectal robotic resection with single-docking technique using robotic daVinci SI (Surgical Intuitive System) were included in the study.

RESULTS

The mean operative time was 338 minutes. The conversion rate was 3%. The mean time of refeeding was 1.4 days and the mean time of hospital stay was 6 days.

CONCLUSIONS

Our technique allowed to use the robot for all surgical steps with a single docking, thereby reducing the cost of the hybrid technique and facilitating the operative team in the management of the robotic cart.

Robotic Resection is a Good Prognostic Factor in Rectal Cancer Compared with Laparoscopic Resection: Long-term Survival Analysis Using Propensity Score Matching

BACKGROUND

Robotic total mesorectal excision for rectal cancer has rapidly increased and has shown short-term outcomes comparable to conventional laparoscopic total mesorectal excision. However, data for long-term oncologic outcomes are limited.

OBJECTIVE

The aim of this study is to evaluate long-term oncologic outcomes of robotic total mesorectal excision compared with laparoscopic total mesorectal excision.

DESIGN

This was a retrospective study.

SETTINGS

This study was conducted in a tertiary referral hospital.

PATIENTS

A total of 732 patients who underwent totally robotic (n = 272) and laparoscopic (n = 460) total mesorectal excision for rectal cancer were included in this study.

MAIN OUTCOME MEASURES

We compared clinicopathologic outcomes of patients. In addition, short- and long-term outcomes and prognostic factors for survival were evaluated in the matched robotic and laparoscopic total mesorectal excision groups (224 matched pairs by propensity score).

RESULTS

Before case matching, patients in the robotic group were younger, more likely to have undergone preoperative chemoradiation, and had a lower tumor location than those in the laparoscopic group. After case matching most clinicopathologic outcomes were similar between the groups, but operative time was longer and postoperative ileus was more frequent in the robotic group. In the matched patients excluding stage IV, the overall survival, cancer-specific survival, and disease-free survival were better in the robotic group, but did not reach statistical significance. The 5-year survival rates for robotic and laparoscopic total mesorectal excision were 90.5% and 78.0% for overall survival, 90.5% and 79.5% for cancer-specific survival, and 72.6% and 68.0% for disease-free survival. In multivariate analysis, robotic surgery was a significant prognostic factor for overall survival and cancer-specific survival (p = 0.0040, HR = 0.333; p = 0.0161, HR = 0.367).

LIMITATIONS

This study has the potential for selection bias and limited generalizability.

CONCLUSIONS

Robotic total mesorectal excision for rectal cancer showed long-term survival comparable to laparoscopic total mesorectal excision in this study. Robotic surgery was a good prognostic factor for overall survival and cancer-specific survival, suggesting potential oncologic benefits.

Total robotic radical rectal resection with da Vinci Xi system: single docking, single phase technique

OBJECTIVE

This study aims to assess the advantages of Da Vinci Xi system in rectal cancer surgery. It also assesses the initial oncological outcomes after rectal resection with this system from a tertiary cancer center in India.

INTRODUCTION

Robotic rectal surgery has distinct advantages over laparoscopy. Total robotic resection is increasing following the evolution of hybrid technology. The latest Da Vinci Xi system (Intuitive Surgical, Sunnyvale, USA) is enabled with newer features to make total robotic resection possible with single docking and single phase.

METHODS AND RESULTS

Thirty-six patients underwent total robotic resection in a single phase and single docking. We used newer port positions in a straight line. Median distance from the anal verge was 4.5 cm. Median robotic docking time and robotic procedure time were 9 and 280 min, respectively. Median blood loss was 100 mL. One patient needed conversion to an open approach due to advanced disease. Circumferential resection margin and longitudinal resection margins were uninvolved in all other patients. Median lymph node yield was 10. Median post-operative stay was 7 days. There were no intra-operative adverse events.

CONCLUSION

The latest Da Vinci Xi system has made total robotic rectal surgery feasible in single docking and single phase. With the new system, four arm total robotic rectal surgery may replace the hybrid technique of laparoscopic and robotic surgery for rectal malignancies. The learning curve for the new system appears to be shorter than anticipated. Early perioperative and oncological outcomes of total robotic rectal surgery with the new system are promising. Copyright © 2016 John Wiley & Sons, Ltd.

Robotic rectal surgery: State of the art

Laparoscopic rectal surgery has demonstrated its superiority over the open approach, however it still has some technical limitations that lead to the development of robotic platforms. Nevertheless the literature on this topic is rapidly expanding there is still no consensus about benefits of robotic rectal cancer surgery over the laparoscopic one. For this reason a review of all the literature examining robotic surgery for rectal cancer was performed. Two reviewers independently conducted a search of electronic databases (PubMed and EMBASE) using the key words “rectum”, “rectal”, “cancer”, “laparoscopy”, “robot”. After the initial screen of 266 articles, 43 papers were selected for review. A total of 3013 patients were included in the review. The most commonly performed intervention was low anterior resection (1450 patients, 48.1%), followed by anterior resections (997 patients, 33%), ultra-low anterior resections (393 patients, 13%) and abdominoperineal resections (173 patients, 5.7%). Robotic rectal surgery seems to offer potential advantages especially in low anterior resections with lower conversions rates and better preservation of the autonomic function. Quality of mesorectum and status of and circumferential resection margins are similar to those obtained with conventional laparoscopy even if robotic rectal surgery is undoubtedly associated with longer operative times. This review demonstrated that robotic rectal surgery is both safe and feasible but there is no evidence of its superiority over laparoscopy in terms of postoperative, clinical outcomes and incidence of complications. In conclusion robotic rectal surgery seems to overcome some of technical limitations of conventional laparoscopic surgery especially for tumors requiring low and ultra-low anterior resections but this technical improvement seems not to provide, until now, any significant clinical advantages to the patients.

Robotic Surgery for Colon and Rectal Cancer

Robotic surgery, used generally for colorectal cancer, has the advantages of a three-dimensional surgical view, steadiness, and seven degrees of robotic arms. However, there are disadvantages, such as a decreased sense of touch, extra time needed to dock the robotic cart, and high cost. Robotic surgery is performed using various techniques, with or without laparoscopic surgery. Because the results of this approach are reported to be similar to or less favorable than those of laparoscopic surgery, the learning curve for robotic colorectal surgery remains controversial. However, according to short- and long-term oncologic outcomes, robotic colorectal surgery is feasible and safe compared with conventional surgery. Advanced technologies in robotic surgery have resulted in favorable intraoperative and perioperative clinical outcomes as well as functional outcomes. As the technical advances in robotic surgery improve surgical performance as well as outcomes, it increasingly is being regarded as a treatment option for colorectal surgery. However, a multicenter, randomized clinical trial is needed to validate this approach.

Robotic Versus Laparoscopic Resection for Mid and Low Rectal Cancers

BACKGROUND AND OBJECTIVES

The current study was conducted to determine whether robotic low anterior resection (RLAR) has real benefit over laparoscopic low anterior resection (LLAR) in terms of surgical and early oncologic outcomes.

METHODS

We retrospectively analyzed data from 35 RLARs and 28 LLARs, performed for mid and low rectal cancers, from January 2013 through June 2015.

RESULTS

A total of 63 patients were included in the study. All surgeries were performed successfully. The clinicopathologic characteristics were similar between the 2 groups. Compared with the laparoscopic group, the robotic group had less intraoperative blood loss (165 vs. 120 mL; P < .05) and higher mean operative time (252 vs. 208 min; P < .05). No significant differences were observed in the time to flatus passage, length of hospital stay, and postoperative morbidity. Pathological examination of total mesorectal excision (TME) specimens showed that both circumferential resection margin and transverse (proximal and distal) margins were negative in the RLAR group. However, 1 patient each had positive circumferential resection margin and positive distal transverse margin in the LLAR group. The mean number of harvested lymph nodes was 27 in the RLAR group and 23 in the LLAR group.

CONCLUSIONS

In our study, short-term outcomes of robotic surgery for mid and low rectal cancers were similar to those of laparoscopic surgery. The quality of TME specimens was better in the patients who underwent robotic surgery. However, the longer operative time was a limitation of robotic surgery.

Case-matched Comparison of Robotic Versus Laparoscopic Colorectal Surgery: Initial Institutional Experience

Robotic colorectal surgery is an emerging technique. In this study, we aimed to compare outcomes of robotic colorectal operations to laparoscopy. Patients undergoing robotic colorectal surgery between November 2010 and July 2013 were case matched to laparoscopic counterparts based on diagnosis and operation type. Perioperative and short-term postoperative outcomes were compared. There were 57 patients who underwent robotic colorectal surgery. American Society of Anaesthesiologists score was higher in patients who underwent robotic surgery (2 vs. 3, P=0.01). Blood loss (200 vs. 300 mL, P=0.27) and conversion rate to open surgery (6 vs. 5, P=0.75) were similar between the groups. Operating time was longer in robotic surgery (172 vs. 267 min, P<0.0001). Time to first bowel movement (3 vs. 3 d, P=0.38), hospital stay (5 vs. 6 d, P=0.22), and postoperative complications were comparable between the groups. In the early learning curve period, robotic colorectal surgery shows similar short-term outcomes with longer operating time compared with conventional laparoscopy.

Comparison of robotic and laparoscopic colorectal resections with respect to 30-day perioperative morbidity

BACKGROUND

Robotic surgery has emerged as a minimally invasive alternative to traditional laparoscopy. Robotic surgery addresses many of the technical and ergonomic limitations of laparoscopic surgery, but the literature regarding clinical outcomes in colorectal surgery is limited. We sought to compare robotic and laparoscopic colorectal resections with respect to 30-day perioperative outcomes.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was used to identify all patients who underwent robotic or laparoscopic colorectal surgery in 2013. We performed a logistic regression analysis to compare intraoperative variables and 30-day outcomes.

RESULTS

There were 8392 patients who underwent laparoscopic colorectal surgery and 472 patients who underwent robotic colorectal surgery. The robotic cohort had a lower incidence of unplanned intraoperative conversion (9.5% v. 13.7%, p = 0.008). There were no significant differences between robotic and laparoscopic surgery with respect to other intraoperative and postoperative outcomes, such as operative duration, length of stay, postoperative ileus, anastomotic leak, venous thromboembolism, wound infection, cardiac complications and pulmonary complications. On multivariable analysis, robotic surgery was protective for unplanned conversion, while male sex, malignancy, Crohn disease and diverticular disease were all associated with open conversion.

CONCLUSION

Robotic colorectal surgery has comparable 30-day perioperative morbidity to laparoscopic surgery and may decrease the rate of intraoperative conversion in select patients.

Comparison of perioperative and short-term outcomes between robotic and conventional laparoscopic surgery for colonic cancer: a systematic review and meta-analysis

Purpose

Reports from several case series have described the feasibility and safety of robotic surgery (RS) for colonic cancer. Experience is still limited in robotic colonic surgery, and a few meta-analysis has been conducted to integrate the results for colon cancer specifically. We conducted a systematic review of the available evidence comparing the surgical safety and efficacy of RS with that of conventional laparoscopic surgery (CLS) for colonic cancer.

Methods

We searched English databases (MEDLINE, Embase, and Cochrane Library), and Korean databases (KoreaMed, KMbase, KISS, RISS, and KisTi). Dichotomous variables were pooled using the risk ratio, and continuous variables were pooled using the mean difference (MD).

Results

The present study found that the RS group had a shorter time to resumption of a regular diet (MD, –0.62 days; 95% CI, –0.97 to –0.28), first passage of flatus (MD, –0.44 days; 95% CI, –0.66 to –0.23) and defecation (MD, –0.62 days; 95% CI, –0.77 to –0.47). Also, RS was associated with a shorter hospital stay (MD, –0.69 days; 95% CI, –1.12 to –0.26), a lower estimated blood loss (MD, –19.49 mL; 95% CI, –27.10 to –11.89) and a longer proximal margin (MD, 2.29 cm; 95% CI, 1.11-3.47). However, RS was associated with a longer surgery time (MD, 51.00 minutes; 95% CI, 39.38–62.62).

Conclusion

We found that the potential benefits of perioperative and short-term outcomes for RS than for CLS. For a more accurate understanding of RS for colonic cancer patients, robust comparative studies and randomized clinical trials are required.

Minimally invasive surgery of rectal cancer: current evidence and options

Minimally invasive surgery (MIS) of colorectal cancer has become more popular in the past two decades. Laparoscopic colectomy has been accepted as an alternative standard approach in colon cancer, with comparable oncologic outcomes and several better short-term outcomes compared to open surgery. Unlike the treatment for colon cancer, however, the minimally invasive approach in rectal cancer has not been established. In this article, we summarize the current status of MIS for rectal cancer and explore the various technical options.

Total mesorectal excision for mid and low rectal cancer: Laparoscopic vs robotic surgery

AIM: To compare the short- and long-term outcomes of laparoscopic and robotic surgery for middle and low rectal cancer.

METHODS: This is a retrospective study on a prospectively collected database containing 111 patients who underwent minimally invasive rectal resection with total mesorectal excision (TME) with curative intent between January 2008 and December 2014 (robot, n = 53; laparoscopy, n = 58). The patients all had a diagnosis of middle and low rectal adenocarcinoma with stage I-III disease. The median follow-up period was 37.4 mo. Perioperative results, morbidity a pathological data were evaluated and compared. The 3-year overall survival and disease-free survival rates were calculated and compared.

RESULTS: Patients were comparable in terms of preoperative and demographic parameters. The median surgery time was 192 min for laparoscopic TME (L-TME) and 342 min for robotic TME (R-TME) (P < 0.001). There were no differences found in the rates of conversion to open surgery and morbidity. The patients who underwent laparoscopic surgery stayed in the hospital two days longer than the robotic group patients (8 d for L-TME and 6 d for R-TME, P < 0.001). The pathologic evaluation showed a higher number of harvested lymph nodes in the robotic group (18 for R-TME, 11 for L-TME, P < 0.001) and a shorter distal resection margin for laparoscopic patients (1.5 cm for L-TME, 2.5 cm for R-TME, P < 0.001). The three-year overall survival and disease-free survival rates were similar between groups.

CONCLUSION: Both L-TME and R-TME achieved acceptable clinical and oncologic outcomes. The robotic technique showed some advantages in rectal surgery that should be validated by further studies.

Clinical and oncologic outcomes of totally robotic total mesorectal excision for rectal cancer: initial results in a center for minimally invasive surgery

PURPOSE

A robotic system was mainly designed to allow precise dissection in deep and narrow spaces. We report the clinical and oncologic outcomes of totally robotic total mesorectal excision for rectal cancer.

METHODS

Between July 2009 and January 2012, 60 consecutive patients undergoing robotic surgery for rectal cancer at the Eulji University Hospital were included.

RESULTS

The mean total operation time, docking time, and surgeon console time were 466.8 ± 115.6, 7.5 ± 6.7, and 261 ± 87.5 min, respectively. Oral intake of diet was started at 3.3 ± 0.9 days and the mean hospital stay was 8.6 ± 2.4 days. All 60 procedures were technically successful without the need for conversion to open or laparoscopic surgery. Complications included anastomotic leakage, anastomotic stricture, postoperative bleeding, ileus, and perineal wound infection in 3 (5 %), 1 (1.7 %), 2 (3.3 %), 2 (3.3 %), and 1 (1.7 %) patient, respectively. The mean distal resection margin and total number of lymph nodes harvested was 3.1 ± 1.7 cm and 20.1 ± 11.5, respectively. During the mean follow-up period of 48.5 months (range, 7-75), the 4-year overall and disease-free survival rates were 87.7 and 72.8 %, respectively.

CONCLUSIONS

A totally robotic approach for rectal cancer operations was a time-consuming procedure, although we already had a lot experience in laparoscopic colorectal surgery. However, the dexterity of the robotic surgery could enable the surgeon to expand the choice of surgical methods according to the condition of the rectal cancer without the need for conversion.

A review on robotic surgery in rectal cancer

Robotic surgery has the upper hand when compared to the laparoscopic approach in terms of superior visualisation, flexibility in movement, steadiness and accessibility to confined anatomical spaces. Nevertheless, limitations still exist with regards to cost, reduced tactile sensation, time-consuming setup and a significant learning curve to achieve. Although studies have shown better or at least comparable outcomes between the robotic and laparoscopic approach, the limitations mentioned result in poor penetrance among centres and surgeons. Advancements in robotic surgery technology and attaining the acquired skillset will translate into better clinical outcomes for patients.

Robotic versus laparoscopic low anterior resection for rectal cancer: a meta-analysis

BACKGROUND

The objective of this meta-analysis was to compare the clinical and oncologic outcomes of robotic low anterior resection (R-LAR) with conventional laparoscopic low anterior resection (L-LAR).

METHODS

A search in the MEDLINE, Embase, and Ovid databases was performed for studies published before July 2014 that compared the clinical and oncologic outcomes of R-LAR and L-LAR. The methodological quality of the selected studies was assessed. Depending on statistical heterogeneity, a fixed or random effects model was used for the meta-analysis. The clinical and oncologic outcomes evaluated included operative time, estimated blood loss, length of hospital stay, rate of conversion to open surgery, post-operative complications, circumferential margin status, and number of lymph nodes collected.

RESULTS

Eight studies, including 324 R-LAR cases and 268 conventional L-LAR cases, were analyzed. The meta-analysis showed that R-LAR was associated with a shorter hospital stay (mean difference (MD) = -1.03; 95% confidence interval (CI) = -1.78, -0.28; P = 0.007), lower conversion rate (odds ratio (OR) = 0.08; 95% CI = 0.02, 0.31; P = 0.0002), lower rate of circumferential margin involvement (OR = 0.5; 95% CI = 0.25, 1.01; P = 0.05), and lower overall complication rate (MD = 0.65; 95% CI = 0.43, 0.99; P = 0.04) compared with L-LAR. There was no difference in operative time (MD = 28.4; 95% CI = -3.48, 60.27; P = 0.08), the number of lymph nodes removed (MD = -0.63; 95% CI = -0.78, 2.05; P = 0.38), and days to return of bowel function (MD = -0.15; 95% CI = -0.37, 0.06; P = 0.17).

CONCLUSIONS

R-LAR was shown to be associated with a shorter hospital stay, lower conversion rate, lower rate of circumferential margin involvement, and lower overall complication rate compared with L-LAR. There were no differences in operative time, the number of lymph nodes removed, and days to return of bowel function.

Robotic-laparoscopic rectal cancer excision versus traditional laparoscopy

BACKGROUND AND OBJECTIVES

Robotic surgery has been advocated for the radical excision of rectal cancer. Most data supporting its use have been reported from European and Asian centers, with a paucity of data from the United States documenting clear advantages of the robotic technique. This study compares the short-term outcome of robotic versus laparoscopic surgery.

METHODS

Consecutive patients who underwent laparoscopic (group 1) or robotic (group 2) rectal cancer excision at a single institution over a 2-year period were retrospectively reviewed. The main outcome measures were operative time, blood loss, conversion rates, number of lymph nodes, margin positivity, length of hospital stay, complications, and readmission rates.

RESULTS

Forty-two patients were analyzed. The median operative time was shorter in group 1 than that in group 2 (240 minutes vs 260 minutes, P=.04). No difference was noted in blood loss, transfusion rates, intraoperative complications, or conversion rates. There was no difference in circumferential or distal margin positivity. The median length of stay was shorter in group 1 (5 days vs 6 days, P=.05). The 90-day complication rate was similar in both groups (33% vs 43%, P=.75), but there was a trend toward more anastomotic leaks in group 1 (14% vs 0%, P=.23). Similarly, a non-statistically significant trend toward a higher readmission rate was noted in group 1 (24% vs 5%, P=.18).

CONCLUSION

Robotic rectal cancer excision yielded a longer operative time and hospital length of stay, although immediate oncologic results were comparable. The need for randomized data is critical to determine whether the added resource utilization in robotic surgery is justifiable.

Open, Laparoscopic, and Robotic Surgery for Rectal Cancer: Medium-Term Comparative Outcomes from a Multicenter Study

Purpose

Several studies have demonstrated the oncologic equivalence of laparoscopic (LS) and open (OS) rectal cancer surgeries and have shown how challenging LS may become. Robotic surgery (RS) has emerged as a practical alternative, offering interesting advantages in comparison to both LS and OS. The aim of this study is to resolve the clinicopathologic outcome advantages of RS with respect to OS and LS techniques.

Methods

Patients with rectal cancer undergoing OS, RS, or LS were evaluated within the period from April 2009 to August 2011. The evaluations were carried out in 4 Italian hospitals. Perioperative clinicopathologic data, postoperative complications, and 3-year overall and disease-free survival (DFS) rates were analyzed.

Results

A total of 160 patients (94 male, 66 female) were included. A total of 105 patients underwent mini-invasive procedure (40 LS; 65 RS), whereas OS was performed in 55 patients. Anterior resection of rectal cancer was the most performed surgical procedure (139; 87%). Median operation time was significantly longer in the RS group (p<0.01). Regarding complication rates and quality of the surgical specimen evaluation, no statistical difference was found among the 3 groups. The shortest hospital stay (p<0.01) was obtained from the LS and RS groups. The median follow-up was 33 months without any significant difference in overall and DFS rates.

Conclusions

Although RS for rectal cancer requires more time to be performed than LS and OS techniques, the analysis shows comparatively the feasibility and safety of RS in terms of perioperative clinicopathologic and medium-term outcomes.

Dealing with robot-assisted surgery for rectal cancer: Current status and perspectives

The laparoscopic approach for treatment of rectal cancer has been proven feasible and oncologically safe, and is able to offer better short-term outcomes than traditional open procedures, mainly in terms of reduced length of hospital stay and time to return to working activity. In spite of this, the laparoscopic technique is usually practised only in high-volume experienced centres, mainly because it requires a prolonged and demanding learning curve. It has been estimated that over 50 operations are required for an experienced colorectal surgeon to achieve proficiency with this technique. Robotic surgery enables the surgeon to perform minimally invasive operations with better vision and more intuitive and precise control of the operating instruments, thus promising to overcome some of the technical difficulties associated with standard laparoscopy. It has high-definition three-dimensional vision, it translates the surgeon’s hand movements into precise movements of the instruments inside the patient, the camera is held and moved by the first surgeon, and a fourth robotic arm is available as a fixed retractor. The aim of this review is to summarise the current data on clinical and oncologic outcomes of robot-assisted surgery in rectal cancer, focusing on short- and long-term results, and providing original data from the authors’ centre.

Male urinary and sexual function after robotic pelvic autonomic nerve-preserving surgery for rectal cancer

BACKGROUND

Urinary and sexual dysfunction is the potential complication of rectal cancer surgery. The aim of this study was to evaluate the urinary and sexual function in male patients with robotic surgery for rectal cancer.

METHODS

This prospective study included 137 of the 336 male patients who underwent surgery for rectal cancer. Urinary and male sexual function was studied by means of a questionnaire based on the International Prostatic Symptom Score and International Index of Erectile Function. All data were collected before surgery and 12 months after surgery.

RESULTS

Patients who underwent robotic surgery had significantly decreased incidence of partial or complete erectile dysfunction and sexual dysfunction than patients with laparoscopic surgery. The pre- and post-operative total IPSS scores in patients with robotic surgery were significantly less than that with laparoscopic surgeries.

CONCLUSIONS

Robotic surgery shows distinct advantages in protecting the pelvic autonomic nerves and relieving post-operative sexual dysfunction.

Totally robotic vs 3D laparoscopic colectomy: A single centers preliminary experience

AIM: To compare robotic and three-dimensional (3D) laparoscopic colectomy based on the literature and our preliminary experience.

METHODS: This retrospective observational study compared operative measures and postoperative outcomes between laparoscopic 3D and robotic colectomy for cancer. From September 2013 to September 2014, 24 robotic colectomies and 23 3D laparoscopic colectomy were performed at our Department. Data were analyzed and reported both by approach and by colectomy side. Robotic left colectomy (RL) vs laparoscopic 3D left colectomy (LL 3D) and Robotic right colectomy (RR) vs laparoscopic 3D (LR 3D). Rectal cancer procedures were not included.

RESULTS: There were 18 RR and 11 LR 3D, 6 RL and 12 LL 3D. As regards LR 3D, extracorporeal anastomosis (EA) was performed in 7 patients and intracorporeal anastomosis (IA) in 4; the RR group included 14 IA and 4 EA. There was no mortality. Median operative time was higher for the robotic group while conversion rate (12.5% vs 13%) and lymph nodes removed (14 vs 13) were similar for both. First flatus time was 1 d for RR and 2 d the other patient groups. Oral intake was resumed in 1 d by LR and in 2 d by the other patients (P = 0.012). Overall cost was €4950 and €1950 for RL and LL 3D, and €4450 and €1450 for RR and LR 3D, respectively.

CONCLUSION: There were no differences between RR and LR 3D, except that IA was easier with RR, and probably contributed with the learning curve to the longer operative time recorded. Both techniques offer similar advantages for the patient with significantly different costs. In left colectomies robotic colectomy provided better outcomes, especially in resections approaching the rectum.

Single stage robotic total mesorectal excision-a stepwise approach

Background

The totally robotic procedure was traditionally described as a two-stage technique or a three-stage technique. The number of stages corresponds to the number of movements of the robotic cart. In this video article, we develop a stepwise approach video of robotic total mesorectal excision (TME) for mid rectal cancer (the surgery was performed by SHK) using a da Vinci^® Si HD Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) at Korea University Anam Hospital, Seoul.

Methods

After the induction of general anesthesia, the patient is placed in a modified lithotomy position. Six ports are used, including one 12-mm camera port, four 8-mm robotic working ports, and one 5-mm port for the assistant. The patient is tilted to the right side and placed in the Trendelenburg position. The small-bowel loops retracted out from the pelvic cavity to the right upper quadrant (RUQ) to expose the inferior mesenteric artery (IMA). The surgery is divided into three phases: (I) abdominal phase: vascular ligation, and sigmoid colon to splenic flexure mobilization; (II) pelvic dissection phase; and (III) rectal reconstruction phase. Mesorectal clearing was done at the level of rectal transection line (1-2 cm from distal tumor margin), then the rectum was transected with robotic stapler. Once this step is finished, the robotic arms are undocked and the cart is moved away from the patient. The remaining steps are performed in a conventional laparoscopic method.

Results

Robotic TME was performed in a 56-year-old man with an endoscopically define rectal mass. The lesion was moderately differentiated adenocarcinoma, 8 cm from the anal verge (AV). The rectal mass was managed with single stage robotic TME. The operative time was 160 minutes and the patient was discharge on post operative day 10. Final pathology revealed moderately differentiated adenocarcinoma.

Conclusions

Single stage robotic TME was efficient and feasible technique for mid rectal cancer resection.

Standardized single docking, four arms and fully robotic proctectomy for rectal cancer: the key points are the ports and arms placement

Rectal cancer continues to be a surgical challenge. As more technology is developed, the surgeon must both incorporate this new technology into his practice and, at the same time, keep improving oncologic surgery and overall outcomes. We describe a standardized approach and fully robotic proctectomy, using four arms and one single docking (SI system). Patient cart and ports placement, as well as arms position to avoid collision, are key points to perform the entire procedure with one single docking. Although the place of robotic surgery might still need to be defined, standardizing the procedures is a step towards its evaluation. We propose with this report a solution to perform a single docking four arms robotic proctectomy.

Robotic surgery for colorectal cancer: systematic review of the literature

INTRODUCTION

Surgical practice has been changed since the introduction of robotic techniques and robotic colorectal surgery is an emerging field. Innovative robotic technologies have helped surgeons overcome many technical difficulties of conventional laparoscopic surgery. Herein, we review the clinical studies regarding the application of surgical robots in resections for colorectal cancer.

METHODS

A systematic review of the literature was conducted for articles published up to September 9, 2012, using the MEDLINE database. The keywords that were used in various combinations were: "surgical robotics," "robotic surgery," "computer-assisted surgery," "colectomy," "sigmoid resection," "sigmoidectomy," and "rectal resection."

RESULTS

Fifty-nine articles reporting on robot-assisted resections of colon and/or rectum were identified and 41 studies were finally included in the analysis. A total of 1635 colorectal procedures were performed: 254 right colectomies, 185 left colectomies/sigmoid resections, 969 anterior resections, 182 abdominoperineal or intersphincteric resections, 34 colectomies (without being specified as right or left), and 11 total/subtotal colectomies. In general, blood loss, conversion rates, and complications were low but the operative time was longer than the open procedures, whereas the duration of hospitalization was shorter. The number of harvested lymph nodes was also quite satisfactory.

CONCLUSIONS

Robotic colorectal operations provide favorable results, with acceptable operative times and low conversion rates and morbidity. Surgical robots may provide additional benefits treating challenging pathologies, such as rectal cancer. Further clinical studies and long-term follow-up are required to better evaluate the outcomes of robotic colorectal surgery.

A comparison of laparoscopic and robotic colorectal surgery outcomes using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database

BACKGROUND

Until randomized trials mature, large database analyses assist in determining the role of robotics in colorectal surgery. ACS NSQIP database coding now allows differentiation between laparoscopic (LC) and robotic (RC) colorectal procedures. The purpose of this study was to compare LC and RC outcomes by analyzing the ACS NSQIP database.

METHODS

The ACS NSQIP database was queried to identify patients who had undergone RC and LC during 2013. Demographic characteristics, intraoperative data, and postoperative outcomes were identified. Using propensity score matching, abdominal and pelvic colorectal operative and postoperative outcomes were analyzed.

RESULTS

A total of 11,477 cases were identified. In the abdomen, 7790 LC and 299 RC cases were identified, and 2057 LC and 331 RC cases were identified in the pelvis. There were significant differences in operative time, conversion to an open procedure in the pelvis, and hospital length of stay. RC operative times were significantly longer in both abdominal and pelvic cases. Conversion rates in the pelvis were less for RC when compared to LC--10.0 and 13.7%, respectively (p = 0.01). Hospital length of stay was significantly shorter for RC abdominal cases than for LC abdominal cases (4.3 vs. 5.3 days, p < 0.001) and for RC pelvic cases when compared to LC pelvic cases (4.5 vs. 5.3 days, p < 0.001). There were no significant differences in surgical site infection (SSI), organ/space SSI, wound complications, anastomotic leak, sepsis/shock, or need for reoperation within 30 days.

CONCLUSION

As the robotic platform continues to grow in colorectal surgery and as technical upgrades continue to advance, comparison of outcomes requires continuous reevaluation. This study demonstrated that robotic operations have longer operative times, decreased hospital length of stay, and decreased rates of conversion to open in the pelvis. These findings warrant continued evaluation of the role of minimally invasive technical upgrades in colorectal surgery.

Robotic left colon cancer resection: a dual docking technique that maximizes splenic flexure mobilization

BACKGROUND

Techniques for robotic resection of the left colon are not well defined and have not been widely adopted due to limited range of motion of the robotic arms. We have developed a dual docking technique for both the splenic flexure and the pelvis. We report our initial experience of robotic left colectomy using this technique for left-sided colon cancer.

METHODS

The study group comprised 61 patients who underwent robotic left colon cancer resection using our dual docking technique between July 2008 and January 2013. Operations comprised two stages: colon mobilization (stage 1) followed by pelvic dissection (stage 2). After completion of stage 1, the robot arms were undocked and the operating table was rotated 60° counterclockwise until a 45° angle was created between the patient cart and the operating table.

RESULTS

All 61 procedures were technically successful without the need for conversion to laparoscopic or open surgery. Median total operation, 1st docking, and 2nd docking times were 227 min (range, 137-653 min), 4 min (range, 3-8 min), and 3 min (range, 3-9 min), respectively. Estimated blood loss was 20 ml (range, 20-2,000 ml). Median time to soft diet was 2 days (range, 2-12 days) and median length of hospital stay was 7 days (range, 4-20 days). Median total number of lymph nodes harvested was 17 (range, 3-61). According to the Clavien-Dindo classification, the numbers of complications for grades 1, 2, 3a, 3b, and 4 were 10, 2, 3, 3, and 1. There was no mortality within 30 days.

CONCLUSIONS

Robotic left colon cancer resection using our dual docking technique is safe and feasible. This procedure can maximize splenic mobilization in robotic colorectal surgery.