Robotic right colectomy for cancer with intracorporeal anastomosis: short-term outcomes from a single institution

How aging may impact the failure to rescue after colorectal laparoscopic surgery. Analysis of 1000 patients in a single high-volume center

This study aimed to evaluate the FTR after laparoscopic colorectal surgery in an Italian high-volume centre. A retrospective analysis was conducted in a consecutive series of patients who underwent elective laparoscopic colorectal surgery for neoplastic disease between January 2010 and December 2023 at the General Surgery Department of the San Eugenio Hospital, Rome, Italy. Patients were grouped by age in adult (vs. < 75 years) and elderly group (≥ 75 years). A multivariate analysis of the predictive factors of complications was performed. A total of 1,000 patients met the inclusion criteria, excluding those who underwent open or robotic surgery, either in emergency or elective settings. 53 patients (5.3%) experienced major complications. The mean age of patients with no or mild complications was 65.60 years (± 10.61), whereas patients with severe complications were older (69.94 years ± 12.02, p = 0.0041). Gender distribution and BMI do not represent a risk factor for major complications (p = 0.2555 and p = 0.2686, respectively), unlike the ASA score III or IV (p = 0.0001). The overall FTR rate for adult patients is 9%, while it is slightly higher at 10% for elderly patients. No statistical differences were found between the 2 groups. Elderly patients had more frequent FTR due to infective complications, while the FTR rate for cardiovascular disease was more frequent in the adult group. Minimally invasive approach, skilled team, well-established rapid response and standardized complication management protocols can positively impact FTR regardless of patients' age.

Robotic CME in 110 consecutive cases: feasibility and short-term technical and oncological outcomes

BACKGROUND

Complete mesocolic excision (CME) has been introduced from open surgery, to compare right colon cancer surgery to total mesorectal excision for rectal cancer and it is currently being applied by robotic approach. CME concept is based on the complete removal of right mesocolon and the dissection deep at the level of the central feeding vessels. Aside the CME, intracorporeal anastomosis completes a total minimally invasive approach to the treatment of right colon cancer. This study retrospectively analyzed the feasibility and efficacy of robotic CME and intracorporeal anastomosis in a cohort of consecutive patients affected with right colon cancer.

METHODS

The data of 110 patients undergone a robotic CME with IA anastomosis for right colon cancer from 2018 to 2023 were prospectively collected and retrospectively analyzed. Intraoperative, postoperative, and short-middle term outcomes were considered for analysis, as well as pathologic and oncologic outcomes. A time-to-event analysis was performed using the Kaplan-Meier method for OS and DFS.

RESULTS

All patients underwent a robotic right colectomy. Median operative time was 184 min, blood loss was negligible, no intraoperative complications occurred. Three conversions (2.7%) were experienced due to bulky lymph nodes and severe local advanced tumor. Mean postoperative stay was 6 days. Six postoperative complications occurred, 4 postoperative ileus, 1 late dehiscence of the colonic stump and an iatrogenic colonic perforation. The latter needed reintervention.

CONCLUSIONS

Robotic CME with central vessels ligation seems feasible and safe, with acceptable morbidity and adequate short-middle term outcomes.

Short-term Outcomes of Robot-assisted Colectomy Using the Overlap Method for Right-sided Colon Cancer

Background/Aim

The recent development of minimally invasive surgery has led to transition from laparoscopic right colectomy (LC) to robot-assisted right colectomy (RC) in Japan. However, it is unclear whether the introduction of RC in municipal hospitals could be as safe as that in high-volume centers in Japan. Therefore, this retrospective study aimed to compare the short-term operative outcomes of RC and LC for right colon cancer at a local municipal hospital in Japan.

Patients and Methods

Patients with stage I-IV right colon cancer who underwent elective RC or LC between January 2021 and July 2023 were retrospectively analyzed. Patients with double cancer and those who underwent delta anastomosis were excluded. Postoperative surveillance included patient interviews, physical examinations, tumor marker examinations, and whole-body computed tomography every six months.

Results

Forty patients were analyzed, and 24 (60%) and 16 (40%) patients assigned in the LC and RC groups, respectively, were compared. The operative time, bleeding, postoperative complications, and pathological examinations did not differ significantly between the LC and RC groups.

Conclusion

RC using overlapping anastomoses was comparable to LC in terms of short-term operative outcomes. The introduction of RC with overlapping anastomosis is a feasible surgical technique.

Robotic versus laparoscopic right hemicolectomy: a systematic review of the evidence

Robotics may facilitate the realization of fully minimally invasive right hemicolectomy, including intra-corporeal anastomosis and off-midline extraction, when compared to laparoscopy. Our aim was to compare laparoscopic right hemicolectomy with robotic right hemicolectomy in terms of peri-operative outcomes. MEDLINE was searched for original studies comparing laparoscopic right hemicolectomy with robotic right hemicolectomy in terms of peri-operative outcomes. The systematic review complied with the PRISMA 2020 recommendations. Variables related to patients' demographics, surgical procedures, post-operative recovery and pathological outcomes were collected and qualitatively assessed. Two-hundred and ninety-three publications were screened, 277 were excluded and 16 were retained for qualitative analysis. The majority of included studies were observational and of limited sample size. When the type of anastomosis was left at surgeon's discretion, intra-corporeal anastomosis was favoured in robotic right hemicolectomy (4/4 studies). When compared to laparoscopy, robotics allowed harvesting more lymph nodes (4/15 studies), a lower conversion rate to open surgery (5/14 studies), a shorter time to faeces (2/3 studies) and a shorter length of stay (5/14 studies), at the cost of a longer operative time (13/14 studies). Systematic review of existing studies, which are mostly non-randomized, suggests that robotic surgery may facilitate fully minimally invasive right hemicolectomy, including intra-corporeal anastomosis, and offer improved post-operative recovery.

Implementation of totally robotic right hemicolectomy: lessons learned from a prospective cohort

Robotics facilitates the realization of intra-corporeal anastomosis during right hemicolectomy and allows extracting the operative specimen through a C-section, offering potential benefits in terms of post-operative recovery and incidence of incisional hernia. Therefore, we progressively implemented robotic right hemicolectomy (robRHC) in our centre, and would like to report our initial experience with the technique. Consecutive patients who underwent robRHC within a single centre were prospectively included. Variables related to patients' demographics, surgical procedures, post-operative recovery and pathological outcomes were collected. Sixty patients underwent robRHC in our centre. Indications for robRHC were colon cancer in 58 patients (96.7%) and polyps not amenable to endoscopic resection in 2 patients (3.3%). Fifty-eight patients underwent robRHC with D2 lymphadenectomy and central vessel ligation (96.7%), and two patients (3.3%) had robRHC associated with another procedure. All patients had intra-corporeal anastomosis. The mean ± operative time was of 200.4 ± 114.9 min. Two conversions (3.3%) to open surgery were performed. The mean ± SD length of stay was of 5.4 ± 3.8 days. Seven patients (11.7%) experienced a post-operative complication with a Clavien-Dindo score ≥ 2. Two patients (3.5%) had an anastomotic leak. The mean ± SD number of harvested lymph nodes was of 22.4 ± 7.6. All patients had negative pathological margins (R0 resection). To conclude, robotic RHC is a safe procedure, which can be implemented with satisfying peri- and post-operative outcomes. The potential benefits of the technique remain to be demonstrated by randomized controlled trials.

A Systematic Review of Varying Definitions and the Clinical Significance of Fredet's Fascia in the Era of Complete Mesocolic Excision

BACKGROUND

Fredet's fascia represents a crucial landmark for vascular surgical anatomy, especially in minimally invasive complete mesocolic excision (CME) for right-sided colon adenocarcinoma. Fredet's fascia allows access to the gastrocolic trunk of Henle (GCTH), the most critical step in both open and minimally invasive right-sided CME techniques. Despite this, a recent workshop of expert surgeons on the standardization of the laparoscopic right hemicolectomy with CME did not recognize or include the term of Fredet's fascia or area. Hence, we undertook a systematic review of articles that include the terms "Fredet's fascia or area", or synonyms thereof, with special emphasis on the types of articles published, the nationality, and the relevance of this area to surgical treatments.

METHODS

We conducted a systematic review up to 15 July 2022 on PubMed, WOS, SCOPUS, and Google Scholar.

RESULTS

The results of the study revealed that the term "Fredet's fascia" is poorly used in the English language medical literature. In addition, the study found controversial and conflicting data among authors regarding the definition of "Fredet's fascia" and its topographical limits.

CONCLUSIONS

Knowledge of Fredet's fascia's surgical relevance is essential for colorectal surgeons to avoid accidental injuries to the superior mesenteric vascular pedicle during minimally invasive right hemicolectomies with CME. In order to avoid confusion and clarify this fascia for future use, we suggest moving beyond the use of the eponymous term by using a "descriptive term" instead, based on the fascia's anatomic structure. Fredet's fascia could, therefore, be more appropriately renamed "sub-mesocolic pre-duodenopancreatic fascia".

Robotic-assisted Surgery: Expanding Indication to Colon Cancer in Japan

In recent years, robotic-assisted surgery has demonstrated remarkable progress as a minimally invasive procedure for colorectal cancer. While there have been fewer studies investigating robotic-assisted surgery for the treatment of colon cancer than rectal cancer, evidence regarding robotic-assisted colectomy has been accumulating due to increasing use of the procedure. Robotic-assisted colectomy generally requires a long operative time and involves high costs. However, as evidence is increasingly supportive of its higher accuracy and less invasive nature compared to laparoscopic colectomy, the procedure is anticipated to improve the ratio of conversion to laparotomy and accelerate postoperative recovery. Robotic-assisted surgery has also been suggested for a specific level of effectiveness in manipulative procedures, such as intracorporeal anastomosis, and is increasingly indicated as a less problematic procedure compared to conventional laparoscopy and open surgery in terms of long-term oncological outcomes. Although robotic-assisted colectomy has been widely adopted abroad, only a limited number of institutions have been using this procedure in Japan. Further accumulation of experience and studies investigating surgical outcomes using this approach are required in Japan.

The Italian Consensus on minimally invasive simultaneous resections for synchronous liver metastasis and primary colorectal cancer: A Delphi methodology

At the time of diagnosis synchronous colorectal cancer, liver metastases (SCRLM) account for 15-25% of patients. If primary tumour and synchronous liver metastases are resectable, good results may be achieved performing surgical treatment incorporated into the chemotherapy regimen. So far, the possibility of simultaneous minimally invasive (MI) surgery for SCRLM has not been extensively investigated. The Italian surgical community has captured the need and undertaken the effort to establish a National Consensus on this topic. Four main areas of interest have been analysed: patients' selection, procedures, techniques, and implementations. To establish consensus, an adapted Delphi method was used through as many reiterative rounds were needed. Systematic literature reviews were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses instructions. The Consensus took place between February 2019 and July 2020. Twenty-six Italian centres participated. Eighteen clinically relevant items were identified. After a total of three Delphi rounds, 30-tree recommendations reached expert consensus establishing the herein presented guidelines. The Italian Consensus on MI surgery for SCRLM indicates possible pathways to optimise the treatment for these patients as consensus papers express a trend that is likely to become shortly a standard procedure for clinical pictures still on debate. As matter of fact, no RCT or relevant case series on simultaneous treatment of SCRLM are available in the literature to suggest guidelines. It remains to be investigated whether the MI technique for the simultaneous treatment of SCRLM maintain the already documented benefit of the two separate surgeries.

Updates on Robotic CME for Right Colon Cancer: A Qualitative Systematic Review

Background. Complete mesocolic excision (CME) is a surgical technique introduced with the aim of ameliorating the oncologic results of colectomy. Various experiences have demonstrated favorable oncologic results of CME in comparison with standard colectomy, in which the principles of CME are not respected. The majority of the literature refers to open or laparoscopic CME. This review analyses current evidence regarding robotic CME for right colectomy. Methods. An extensive Medline (Pub Med) search for relevant case series, restricted to papers published in English, was performed, censoring video vignettes and case reports. Results. Fourteen studies (ten retrospective, four comparative series of robotic versus laparoscopic CME) were included, with patient numbers ranging from 20 to 202. Four different approaches to CME are described, which also depend on the robotic platform utilized. Intraoperative and early clinical results were good, with a low conversion and anastomotic leak rate and a majority of Clavien–Dindo complications being Grades I and II. Oncologic adequacy of the surgical specimens was found to be good, although a homogeneous histopathologic evaluation was not provided. Conclusions. Further large studies are warranted to define long-term oncologic results of robotic right colectomy with CME and its eventual benefits in comparison to laparoscopy.

Ileo-colic intra-corporeal anastomosis during robotic right colectomy: a systematic literature review and meta-analysis of different techniques

PURPOSE

Robotic assistance could increase the rate of ileo-colic intra-corporeal anastomosis (ICA) during robotic right colectomy (RRC). However, although robotic ICA can be accomplished with several different technical variants, it is not clear whether some of these technical details should be preferred. An evaluation of the possible advantage of one respect to another would be useful.

METHODS

We conducted a systematic review of literature on technical details of robotic ileo-colic ICA, from which we performed a meta-analysis of clinical outcomes. The extracted data allowed a comparative analysis regarding the outcome of overall complication (OC), bleeding rate (BR) and leakage rate (LR), between (1) mechanical anastomosis with robotic stapler, versus laparoscopic stapler, versus totally hand-sewn anastomosis and (2) closure of enterocolotomy with manual double layer, versus single layer, versus stapled.

RESULTS

A total of 30 studies including 2066 patients were selected. Globally, the side-to-side, isoperistaltic anastomosis, realized with laparoscopic staplers, and double-layer closure for enterocolotomy, is the most common technique used. According to the meta-analysis, the use of robotic stapler was significantly associated with a reduction of the BR with respect to mechanical anastomosis with laparoscopic stapler or totally hand-sewn anastomosis. None of the other technical aspects significantly influenced the outcomes.

CONCLUSIONS

ICA fashioning during RRC can be accomplished with several technical variants without evidence of a clear superiority of anyone of these techniques. Although the use of robotic staplers could be associated with some benefits, further studies are necessary to draw conclusions.

What is the best surgical procedure of transverse colon cancer? An evidence map and minireview

Colorectal cancers comprise a large percentage of tumors worldwide, and transverse colon cancer (TCC) is defined as tumors located between hepatic and splenic flexures. Due to the anatomy and embryology complexity, and lack of large randomized controlled trials, it is a challenge to standardize TCC surgery. In this study, the current situation of transverse/extended colectomy, robotic/ laparoscopic/open surgery and complete mesocolic excision (CME) concept in TCC operations is discussed and a heatmap is conducted to show the evidence level and gap. In summary, transverse colectomy challenges the dogma of traditional extended colectomy, with similar oncological and prognostic outcomes. Compared with conventional open resection, laparoscopic and robotic surgery plays a more important role in both transverse colectomy and extended colectomy. The CME concept may contribute to the radical resection of TCC and adequate harvested lymph nodes. According to published studies, laparoscopic or robotic transverse colectomy based on the CME concept was the appropriate surgical procedure for TCC patients.

Robotic-assisted versus conventional laparoscopic surgery for colorectal cancer: Short-term outcomes at a single center

Background

The robotic technique has been established as an alternative approach to laparoscopy for colorectal surgery. The aim of this study was to compare the 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 September 2018. We evaluated patient demographics, perioperative characteristics, and pathologic examinations. Short-term outcomes included time to passage of flatus and length of postoperative hospital stay.

Results

A total of 580 patients were included in the study. There were 271 patients in the robotic colorectal surgery (RCS) group and 309 in the laparoscopic colorectal surgery (LCS) group. The time to passage of flatus in the RCS group was 3.62 days shorter than the LCS group. The total costs were increased by 2,258.8 USD in the RCS group compared to the LCS group (P < 0.001).

Conclusion

The present study suggests that colorectal cancer robotic surgery was more beneficial to patients because of a shorter postoperative recovery time of bowel function and shorter hospital stays.

Preliminary exploration of robotic complete mesocolic excision for colon cancer with the domestically produced Chinese minimally invasive Micro Hand S surgical robot system

OBJECTIVE

To summarize our initial experience with robot-assisted complete mesocolic excision (R-CME) using a domestically produced Chinese surgical robot by a short-term evaluation.

METHODS

From March 2018 to December 2018, 25 patients with colon cancer underwent Micro Hand S R-CME. The operative findings, morbidities and oncological findings were analysed.

RESULT

The median operative duration was 210 (range, 180-235) min, and the median estimated blood loss volume was 55 (range, 25-125) ml. The median number of lymph nodes harvested was 42 (range, 21-77), and the median length of hospital stay after the operation was 7 (range, 5-9) days. There were no severe complications except for seven cases of grade I complications and five cases of grade II complications. The conversion rate was 0%. There were no cases of 30-day readmission or 30-day mortality.

CONCLUSION

R-CME using a domestically produced surgical robot for selected colon cancer patients is technically feasible and safe.

Fashioning enterotomy closure after totally laparoscopic ileocolic anastomosis for right colon cancer: a multicenter experience

BACKGROUND

Laparoscopic right hemicolectomy is a commonly performed procedure. Little is known on how to perform the enterotomy closure after stapled side-to-side intracorporeal anastomosis.

METHOD

A multicentric case-controlled study has been designed to compare different ways to fashion enterotomy closure: double layer versus single layer, sewn versus stapled, and robotic versus laparoscopic approach. Furthermore, additional characteristics including sutures' materials, interrupted versus running suture and the presence of deep corner suture has been investigated.

RESULTS

We collected data for 1092 patients who underwent right hemicolectomy at ten centers. We analyzed 176 robotic against 916 laparoscopic anastomosis: no significant differences were found in terms of bleedings (p = 0.455) and anastomotic leak (p = 0.405). We collected data from 126 laparoscopic sewn single-layer versus 641 laparoscopic sewn double-layer anastomosis: a significant reduction was recorded in terms of leaks in double-layer group (p = 0.02). About double-layer characteristics, we found a significant reduction of bleedings (p = 0.008) and leaks (p = 0.017) with a running suture; similarly, a reduction of bleedings (p = 0.001) and leaks (p = 0.005) was observed with the usage of deep corner closure. The presence of a barbed suture thread seemed to significantly reduce both bleedings (p = 0.001) and leaks (p = 0.001). We found no significant differences in terms of bleedings (p = 0.245) and anastomotic leak (p = 0.660) comparing sewn versus stapled anastomosis.

CONCLUSIONS

Fashioning a stapled ileocolic intracorporeal anastomosis, we can recommend the adoption of a double-layer enterotomy closure using a running barbed suture in the first layer. Totally, stapled closure and robotic assistance have to be considered a non-inferior alternative.

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.

Colorectal Cancer Surgery Using the Da Vinci Xi and Si Systems: Comparison of Perioperative Outcomes

PURPOSE

Robotic surgery for colorectal cancer is an emerging technique. Potential benefits as compared with the conventional laparoscopic surgery have been demonstrated. However, experience with the previous da Vinci Si robotic system revealed several unsolved problems. The novel features of the new da Vinci Xi increase operational flexibility and maneuverability and are expected to facilitate the performance of multiquadrant surgery.

METHODS

Between December 2011 and May 2015, 120 patients with colon or rectal cancer were operated on using the Si robotic system (the Si group). Between May 2015 and October 2017, 60 more patients with colon or rectal cancer were operated on using the Xi robotic system (the Xi group). The clinicopathological characteristics and perioperative outcomes of these 2 groups of patients were compared.

RESULTS

The 2 groups of patients were comparable with regard to baseline clinical characteristics, types of resection performed, and the proportion of patients undergoing neoadjuvant chemoradiation therapy. The statuses of resection margin, the numbers of lymph nodes harvested, and the rates of postoperative complications were also similar between the 2 groups. Nevertheless, a lower rate of diverting ileostomy, a shorter operation time, less estimated blood loss, and a faster postoperative recovery was observed in the Xi group.

CONCLUSIONS

Colorectal cancer surgery using the Xi robotic system was associated with improved perioperative outcomes. These benefits may be attributed to its improved, more user-friendly design.

Short- and long-term outcomes of totally robotic versus robotic-assisted right hemicolectomy for colon cancer: A retrospective study

Totally robotic right hemicolectomy (TRRH) is a novel alternative surgical method used for the treatment of colon cancer. The aim of this study was to compare both the short-and long-term outcomes of TRRH and robotic-assisted right hemicolectomy (RARH) for the treatment of colon cancer.We performed a 1:2 matched propensity score analysis. We then retrospectively analyzed all procedures (64 cases TRRH and 128 cases RARH) carried out by a single surgeon between December 4, 2014 and June 20, 2018 at a large center. Both short-and long-term surgical outcomes were compared between 2 different groups.Based on the propensity score matching, we selected 64 patients that had undergone TRRH treatment and 128 patients who had undergone RARH treatment. The preoperative clinical-pathological characteristics were well matched between the 2 groups. We observed no significant differences between the 2 groups in postoperative pathological outcomes. The mean operative time was found to be significantly longer in the TRRH group compared to the RARH group (168.2 ± 9.1 minutes vs 153.4 ± 7.4 minutes, P = .034). The mean operative incision length was found to be significantly longer in the TRRH group than in the RARH group (4.5 ± 0.6 cm vs 6.9 ± 1.1 cm, P = .023). Postoperative pain score (visual analog scale at day 1) was found to be significantly lower in the TRRH group than in the RARH group (2.9 ± 1.3 vs 4.1 ± 2.1, P = .005). The time to pass flatus was observed to be statistically lower in the TRRH group (P = .042). We observed 3 twists of mesentery in the RARH group, while none were observed in the TRRH group (P < .050). Both the 3-year overall survival (TRRH [91.6%] vs RARH [89.2%], P = .467) and the 3-year disease-free survival (TRRH [81.4%] vs RARH [78.2%], P = .551) were determined to be comparable between the 2 groups studied here.We show that TRRH is a safe and feasible treatment option for colon cancer patients in terms of both short- and long-term outcomes. High-volume, randomized, controlled trials with sufficient follow-up studies will need to be carried out in order to confirm this rationale.

Robotic colectomy with intracorporeal anastomosis is feasible with no operative conversions during the learning curve for an experienced laparoscopic surgeon developing a robotics program

The benefits of performing a colectomy robotically instead of laparoscopically have not conclusively been demonstrated. Evaluation of studies is limited by sample size, retrospective design, heterogeneity of operative techniques, sparse adjustment for learning curve, and mixed results. Consequently, adoption of robotic colectomy by surgeons has been expectedly slow. The objectives of the study were to compare the outcomes of robotic colectomy to laparoscopic colectomy for patients with right-sided tumors undergoing a standardized completely intracorporeal operation and to examine the impact of prior experience with laparoscopic right colectomies on the performance of robotic right colectomies. Retrospective review of outcomes of consecutive patients undergoing a robotic right colectomy (robot) compared to those undergoing laparoscopic colectomy (LAP). LAP patients were further subdivided into a group during the learning curve (LC) and after the learning curve (post-LC). Data collected included operative time (OT), conversion to laparotomy, lymph nodes harvested (LN), length of stay (LOS), 30-day morbidity, and mortality. Comparison of continuous and categorical variables was assessed with the independent samples t test and Chi-square test, respectively. Data are expressed as mean ± SD, and significance defined as p < 0.05. 122 patients underwent robot (n = 21), LAP (n = 101), LC (n = 51), or post-LC (n = 50). OT was decreased for post-LC compared to LC (198 vs. 228 min). There were no conversions in robot and five with LAP. Morbidity was similar for robot (14%) compared to LAP (22%), LC (24%), or post-LC cases (20%). Median LOS was similar for robot vs. LAP (3 vs. 5 days). Robot had greater mean LN yield vs. LAP (19 vs. 14, p = 0.02). The initial outcomes with completely intracorporeal colectomy achieved robotically were equivalent to results during or after LC for laparoscopic resection. Proficiency gained with LAP seems to positively impact the initial results with the robot.

Long-term oncologic after robotic versus laparoscopic right colectomy: a prospective randomized study

OBJECTIVE

The aim of this study was to compare the long-term outcomes of robot-assisted right colectomy (RAC) with those for conventional laparoscopy-assisted right surgery (LAC) for treating right-sided colon cancer.

BACKGROUND

The enthusiasm for the robotic techniques has gained increasing interest in colorectal malignancies. However, the role of robotic surgery in the oncologic safety has not yet been defined.

METHODS

From September 2009 to July 2011, 71 patients with right-sided colonic cancer were randomized in the study. Adjuvant therapy and postoperative follow-up were similar in both groups. The primary and secondary endpoints of the study were hospital stay and survival, respectively. Data were analyzed by intention-to-treat principle.

RESULTS

The RAC and LAC groups did not differ significantly in terms of baseline clinical characteristics. Compared with the LAC group, RAC was associated with longer operation times (195 min vs. 129 min, P < 0.001) and higher cost ($12,235 vs. $10,319, P = 0.013). The median follow-up was 49.23 months (interquartile range 40.63-56.20). The combined 5-year disease-free rate for all tumor stages was 77.4% (95% confidence interval [CI], 60.6-92.1%) in the RAC group and 83.6% (95% CI 72.1-0.97.0%) in the LAC group (P = 0.442). The combined 5-year overall survival rates for all stages were 91.1% (95% CI 78.8-100%) in the RAC group and 91.0% (95% CI 81.3-100%) in the LAC group (P = 0.678). Using multivariate analysis, RAC was not a predictor of recurrence.

CONCLUSIONS

RAC appears to similar long-term survival as compared with LAC. However, we did not observe any clinical benefits of RAC which could translate to a decrease in expenditures.

TRIAL REGISTRY

http://www.ClinicalTrials.gov , number NCT00470951.

Appraisal and Current Considerations of Robotics in Colon and Rectal Surgery

BACKGROUND

Robotic technology aims to obviate some of the limitations of conventional laparoscopic surgery, yet the role of robotics in colorectal surgery is still largely undefined and varies with respect to its application in abdominal versus pelvic surgery.

METHODS

With this review, we aimed to highlight current developments in colorectal robotic surgery. We systematically searched the following databases: PubMed, EMBASE, and Cochrane Library. We critically reviewed the available literature on the use of robotic technology in colon and rectal surgery.

RESULTS

Robotic colorectal surgery is oncologically safe and has short-term outcomes comparable to conventional laparoscopy, with potential benefits in rectal surgery. It has a shorter learning curve but increased operative times and costs. It offers potential advantages in the resection of rectal cancer, due to lower conversion rates. There is also a trend toward better outcomes in anastomotic leak rates, circumferential margin positivity, and perseveration of autonomic function.

CONCLUSION

Laparoscopy remains technically challenging and conversion rates are still high. Therefore, most cases of colorectal surgery are still performed open. Robotic surgery aims to overcome the limits of the laparoscopic technique. This new technology has many advantages in terms of articulating instruments, advanced three-dimensional optics, surgeon ergonomics, and improved accessibility to narrow spaces, such as the pelvis. However, further studies are needed to assess long-term results and benefits.

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.

The role of robotics in colorectal surgery

Robotic surgery is safe and feasible offering many potential advantages to the colorectal surgeon.

"Top down no-touch" technique in robotic complete mesocolic excision for extended right hemicolectomy with intracorporeal anastomosis

BACKGROUND

Proper identification of the mesocolic vessels is essential for achieving complete mesocolic excision (CME) in cases of colon cancer requiring an extended right hemicolectomy. In robotic procedures, we employed a "top down technique" to allow early identification of the gastrocolic trunk and middle colic vessels. The aim of our study was to illustrate the details of this technique in a series of 12 patients.

METHODS

The top down technique consists of two steps. First, the omental bursa was entered to identify the right gastroepiploic vein. Tracing down this vein as a landmark, the gastrocolic trunk was exposed, branches of this trunk and the middle colic vessels were divided. Second, dissection was directed to the ileocolic region and proceeded in an inferior-to-superior direction along the superior mesenteric vein to divide the ileocolic and right colic vessels consecutively. The ileotranverse anastomosis was created intracorporeally.

RESULTS

There were 8 males and 4 females with a mean age of 64.8 ± 16.9 years and a mean body mass index of 25.6 ± 3.7 kg/m². All the procedures were completed successfully. No conversions occurred. The mean operative time and blood loss were 312.1 ± 93.9 min and 110.0 ± 89.9 ml, respectively. The mean number of harvested lymph nodes was 45.2 ± 11.1. The mean length of hospital stay was 7.6 ± 4.7 days. Two patients had intraoperative complications and two had postoperative complications. There was no disease recurrence at a mean follow-up period of 10.4 ± 7.1 months.

CONCLUSIONS

The top down technique appears to be useful in robotic CME for an extended right hemicolectomy. Early identification of the gastrocolic trunk and middle colic vessels via this technique may prevent inadvertent vascular injury at the mesenteric root of the transverse colon.

A single surgeon's experience transitioning to robotic-assisted right colectomy with intracorporeal anastomosis

BACKGROUND

Despite substantial evidence demonstrating benefits of minimally invasive surgery, a large percentage of right colectomies are still performed via an open technique. Most laparoscopic right colectomies are completed as a hybrid procedure with extracorporeal anastomosis. As part of a pure minimally invasive procedure, intracorporeal anastomosis (ICA) may confer additional benefits for patients. The robotic platform may shorten the learning curve for minimally invasive right colectomy with ICA.

METHODS

From January 2014 to May 2016, 49 patients underwent robotic-assisted right colectomy by a board-certified colorectal surgeon (S.R). Extracorporeal anastomosis (ECA) was used in the first 20 procedures, whereas ICA was used in all subsequent procedures. Outcomes recorded in a database for retrospective review included operating time (OT), estimated blood loss (EBL), length of stay (LOS), conversion rate, complications, readmissions, and mortality rate.

RESULTS

Comparison of average OT, EBL, and LOS between extracorporeal and intracorporeal groups demonstrated no significant differences. For all patients, average OT was 141.6 ± 25.8 (range 86-192) min, average EBL was 59.5 ± 83.3 (range 0-500) mL, and average LOS was 3.4 ± 1.19 (range 1.5-8) days. Four patients required conversion, all of which occurred in the extracorporeal group. There were no conversions after the 18th procedure. The 60-day mortality rate was 0%. There were no anastomotic leaks, ostomies created, or readmissions. As the surgeon gained experience, a statistically significant increase in lymph node sampling was observed in oncologic cases (p = .02).

CONCLUSIONS

The robotic platform may help more surgeons safely and efficiently transition to a purely minimally invasive procedure, enabling more patients to reap the benefits of less invasive surgery. Transitioning from ECA to ICA during robotic right colectomy resulted in no significant change in OT or LOS. A lower rate of conversion to open surgery was noted with increased experience.

Totally robotic complete mesocolic excision for right-sided colon cancer

Complexity and operative risks of complete mesocolic excision (CME) seem to be important drawbacks to generalize this procedure in the surgical treatment of right colon cancer. Robotic systems have been developed to improve quality and outcomes of minimal invasive surgery. The aim of this study was to evaluate the feasibility of robotic right-sided CME and present our initial experience. A retrospective review of 37 patients undergoing totally robotic right-sided CME between February 2015 and November 2017 was performed. All the operations were carried out using the key principles of both CME with intracorporeal anastomosis and no-touch technique. Data on perioperative clinical findings and short-term outcomes were analyzed. There were 20 men and 17 women with a mean age of 64.4 ± 13.5 years and a body mass index of 26.8 ± 5.7 kg/m². The mean operative time and estimated blood loss were 289.8 ± 85.3 min and 77.4 ± 70.5 ml, respectively. Conversion to laparoscopy occurred in one patient (2.7%). All the surgical margins were clear and the mesocolic plane surgery was achieved in 27 (72.9%) of the cases. The mean number of harvested lymph nodes was 41.8 ± 11.9 (median, 40; range 22-65). The mean length of hospital stay was 6.6 ± 3.7 days. The intraoperative and postoperative complication rates were 5.4 and 21.6%, respectively. We believe that use of robot for right-sided CME is feasible and appears to provide remarkably a high number of harvested lymph nodes with good specimen quality.

Systematic review of operative outcomes of robotic surgical procedures performed with endoscopic linear staplers or robotic staplers

A comprehensive review of operative outcomes of robotic surgical procedures performed with the da Vinci robotic system using either endoscopic linear staplers (ELS) or robotic staplers is not available in the published literature. We conducted a literature search to identify publications of robotic surgical procedures in all specialties performed with either ELS or robotic staplers. Twenty-nine manuscripts and six abstracts with relevant information on operative outcomes published from January 2011 to September 2017 were identified. Given the relatively recent market release of robotic staplers in 2014, comparative perioperative clinical outcomes data on the performance of ELS vs. robotic staplers in robotic surgery is very sparse in the published literature. Only three comparative studies of surgeries with the da Vinci robotic system plus ELS vs. da Vinci plus robotic staplers were identified; two in robotic colorectal surgery and the other in robotic gastric bypass surgery. These comparative studies illustrate some nuances in device design and usability, which may impact outcomes and cost, and therefore may be important to consider when selecting the appropriate stapling technologies/technique for different robotic surgeries. Comparative perioperative data on the use of ELS vs. robotic staplers in robotic surgery is scarce (three studies), and current literature identifies both types of devices as safe and effective. Given the longer clinical history of ELS and its relatively more robust evidence base, there may be trade-offs to consider before switching to robotic staplers in certain robotic procedures. However, this literature review may serve as an initial reference for future research.

Robotics confers an advantage in right hemicolectomy with intracorporeal anastomosis when matched against conventional laparoscopy

Comparisons between robotic and laparoscopic right hemicolectomy have been confounded by variations in operative technique. This study evaluates the two procedures after standardizing the intraoperative steps and perioperative management. Patients who underwent robotic right hemicolectomy with intracorporeal bowel anastomosis between July 2015 and June 2017 were matched with a laparoscopic group. Perioperative management was in accordance to an enhanced recovery protocol. Outcomes and histopathological data were compared. Thirty-two patients were included. Amongst the patients who did not undergo complete mesocolic excision, the median operative time did not differ between the two groups (p = 0.413). The robotic group recorded a statistically shorter time for intracorporeal anastomosis (13 vs 19 min, p = 0.024). Postoperative recovery and complication rates were similar, except for a greater lymph node harvest in the robotic group (41 vs 31, p = 0.038). Robotic surgery achieves short-term results comparable to existing conventional laparoscopy, notwithstanding the advantages of enhanced ergonomics.

The da Vinci Xi: a review of its capabilities, versatility, and potential role in robotic colorectal surgery

The Xi is the latest da Vinci surgical system approved for use in colorectal surgery. With its novel overhead architecture, slimmer boom-mounted arms, extended instrument reach, guided targeting, and integrated auxiliary technology, the Xi manages to address several limitations of earlier models. The versatility of this new system allows it to be implemented in a wide range of colorectal procedures - from complex multiquadrant colectomies to challenging mesorectal dissections in the pelvis. While commonly criticized for its cost and prolonged operative time, robotic colorectal surgery holds the potential for enhanced ergonomics, superior precision, and a reduction in the learning curve involved in training an expert surgeon. This review appraises the existing literature on robotic colorectal surgery while elaborating how the improved capabilities of the Xi serve to usher in a new era of minimally invasive colorectal surgery.

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

INTRODUCTION

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Robotic right hemicolectomy: Analysis of 108 consecutive procedures and multidimensional assessment of the learning curve

PURPOSE

Surgeons tend to view the robotic right colectomy (RRC) as an ideal beginning procedure to gain proficiency in robotic general and colorectal surgery. Nevertheless, oncological RRC, especially if performed with intracorporeal ileocolic anastomosis confectioning, cannot be considered a technically easier procedure. The aim of this study was to assess the learning curve of the RRC performed for oncological purposes and to evaluate its safety and efficacy investigating the perioperative and pathology outcomes in the different learning phases.

METHODS

Data on a consecutive series of 108 patients undergoing RRC with intracorporeal anastomosis between June 2011 and September 2015 at our institution were prospectively collected to evaluate surgical and short-term oncological outcomes. CUSUM (Cumulative Sum) and Risk-Adjusted (RA) CUSUM analysis were performed in order to perform a multidimensional assessment of the learning curve for the RRC surgical procedure. Intraoperative, postoperative and pathological outcomes were compared among the learning curve phases.

RESULTS

Based on the CUSUM and RA-CUSUM analyses, the learning curve for RRC could be divided into 3 different phases: phase 1, the initial learning period (1st-44th case); phase 2, the consolidation period (45th-90th case); and phase 3, the mastery period (91th-108th case). Operation time, conversion to open surgery rate and the number of harvested lymph nodes significantly improve through the three learning phases.

CONCLUSIONS

The learning curve for oncological RRC with intracorporeal anastomosis is composed of 3 phases. Our data indicate that the performance of RRC is safe from an oncological point of view in all of the three phases of the learning curve. However, the technical skills necessary to significantly reduce operative time, conversion to open surgery rate and to significantly improve the number of harvested lymph nodes were achieved after 44 procedures. These data suggest that it might be prudent to start the RRC learning curve by treating only benign diseases and to reserve the performance of oncological resection to when at least the initial learning phase has been completed.

Robotic Right Colectomy with Modified Complete Mesocolic Excision: Long-Term Oncologic Outcomes

BACKGROUND

A modified complete mesocolic excision (mCME) technique for the treatment of right-sided colon cancer recently was shown by Hohenberger and colleagues to provide impressive long-term oncologic outcomes. This report aims to describe the authors' experience with robotic right colectomy using mCME. The safety, feasibility, and efficacy of this procedure are measured by complications, conversion rates, and 4-year oncologic outcomes.

METHODS

A retrospective study analyzed 100 consecutive patients who underwent robotic right colectomy with mCME and intracorporeal anastomosis at the authors' institution between November 2005 and November 2013. Intra- and postoperative clinical outcomes, pathologic data, and survival were analyzed.

RESULTS

Robotic right colectomy with mCME was successfully performed for all the patients. No conversions or intraoperative complications occurred. The major complication rate (Dindo 3 or 4) was 4 %. During a median follow-up period of 48.5 months (range 24-114 months), the survival rates were 94.5 % for disease-specific survival, 91.4 % for disease-free survival, and 90.3 % for overall survival.

CONCLUSIONS

The authors' experience confirms the feasibility and safety of mCME for the treatment of right-sided colon cancer. This technique provided satisfying short-term outcomes with promising 4-year oncologic results. However, the real benefits of the CME technique should be evaluated further by well-conducted randomized studies before its adoption in routine practice is recommended.

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.

Robot-assisted versus standard laparoscopic colorectal surgery

BACKGROUND AND OBJECTIVES

Over the years, there has been a continual shift toward more minimally invasive surgical techniques, such as the use of laparoscopy in colorectal surgery. Recently, there has been increasing adoption of robotic technology. Our study aims to compare and contrast robot-assisted and laparoscopic approaches to colorectal operations.

METHODS

Forty patients undergoing laparoscopic or robotic colorectal surgery performed by 2 surgeons at an academic center, regardless of indication, were included in this retrospective review. Patients undergoing open approaches were excluded. Study outcomes included operative time, estimated blood loss, length of stay, complications, and conversion rate to an open procedure.

RESULTS

Twenty-five laparoscopic and fifteen robot-assisted colorectal surgeries were performed. The mean patient age was 61.1 ± 10.7 years in the laparoscopic group compared with 61.1 ± 8.5 years in the robotic group (P = .997). Patients had a similar body mass index and history of abdominal surgery. Mean blood loss was 163.3 ± 249.2 mL and 96.8 ± 157.7 mL, respectively (P = .385). Operative times were similar, with 190.8 ± 84.3 minutes in the laparoscopic group versus 258.4 ± 170.8 minutes in the robotic group (P = .183), as were lengths of hospital stay: 9.6 ± 7.3 and 6.5 ± 3.8 days, respectively (P = .091). In addition, there was no difference in the number of lymph nodes harvested between the laparoscopic group (14.0 ± 6.5) and robotic group (12.3 ± 4.2, P = .683).

CONCLUSIONS

In our early experience, the robotic approach to colorectal surgery can be considered both safe and efficacious. Furthermore, it also preserves oncologically sufficient outcomes when performed for cancer operations.

How Has the Robot Contributed to Colon Cancer Surgery?

Robotic surgery is an emerging field in colorectal surgery and may overcome the limitations of conventional laparoscopic surgery, such as rigid instrumentation, poor ergonomics, and assistant-dependent camera movements and retraction. In addition, robotic-assisted colectomy appears to offer comparable outcomes to laparoscopic colectomy with limited long-term outcomes data. Prolonged operating time, increased costs and learning curve are the major drawbacks of robotic colectomy for colon cancer. Although new robotic platforms promise improved ingenuity through developing technology, the role of the robot in colon cancer surgery is still unclear.

Initial experience of robotic versus laparoscopic colectomy for transverse colon cancer: a matched case-control study

Background

Robotic surgery for transverse colon cancer has rarely been described. This study reports our initial experience in robotic resection for transverse colon cancer, by comparing robotic transverse colectomy (RC) to laparoscopic transverse colectomy (LC) in terms of safety, feasibility, short-term outcomes, and the surgeon’s psychological stress and physical pain.

Methods

The study population included the first 22 consecutive patients who underwent RC between March 2013 and December 2014 for histologically confirmed transverse colon adenocarcinoma. These patients were compared with 22 matched patients undergoing LC between December 2010 and February 2013. Patients were matched based on age, gender, body mass index (BMI), American Society of Anesthesiology (ASA) score, American Joint Committee on Cancer (AJCC) tumor stage, and tumor location (ratio 1:1). Mortality, morbidity, operative, and short-term oncologic outcomes were compared between groups. The operating surgeon’s stress and pain were assessed before and after surgery on a 0–100-mm visual analog scale.

Results

The demographic and preoperative characteristics were comparable between RC and LC patients. No group difference was observed for intraoperative complications, blood loss, postoperative pain, time to flatus, time to regular diet, and hospital stay. RC was associated with longer operative time than LC (260 min vs. 225 min; p = 0.014), but the overall operative and robotic time in the RC group decreased over time reflecting the increasing experience in performing this procedure. No conversion to laparotomy was observed in the RC group, while two LC patients were converted due to uncontrolled bleeding and technically difficult middle colic pedicle dissection. Postoperative complications (Dindo-Clavien grade I or II) occurred in 11.3 % of patients with no group difference. Mortality was nil. All resections were R0, with >12 lymph nodes harvested in 90.9 % of RC and 95.5 % of LC patients. The surgeon’s stress was not different between RC and LC, whereas the surgeon’s hand and neck/shoulder pain were significantly lower after RC.

Conclusions

RC for transverse colon cancer appears to be safe and feasible with short-term outcomes comparable to LC.

Robotic versus Laparoscopic Approach in Colonic Resections for Cancer and Benign Diseases: Systematic Review and Meta-Analysis

Objectives

The aim of this systematic review and meta-analysis is to compare robotic colectomy (RC) with laparoscopic colectomy (LC) in terms of intraoperative and postoperative outcomes.

Materials and Methods

A systematic literature search was performed to retrieve comparative studies of robotic and laparoscopic colectomy. The databases searched were PubMed, Embase and the Cochrane Central Register of Controlled Trials from January 2000 to October 2014. The Odds ratio, Risk difference and Mean difference were used as the summary statistics.

Results

A total of 12 studies, which included a total of 4,148 patients who had undergone robotic or laparoscopic colectomy, were included and analyzed. RC demonstrated a longer operative time (MD 41.52, P<0.00001) and higher cost (MD 2.42, P<0.00001) than did LC. The time to first flatus passage (MD -0.51, P = 0.003) and the length of hospital stay (MD -0.68, P = 0.01) were significantly shorter after RC. Additionally, the intraoperative blood loss (MD -16.82, P<0.00001) was significantly less in RC. There was also a significantly lower incidence of overall postoperative complications (OR 0.74, P = 0.02) and wound infections (RD -0.02, P = 0.03) after RC. No differences in the postoperative ileus, in the anastomotic leak, or in the conversion to open surgery rate and in the number of harvested lymph nodes outcomes were found between the approaches.

Conclusions

The present meta-analysis, mainly based on observational studies, suggests that RC is more time-consuming and expensive than laparoscopy but that it results in faster recovery of bowel function, a shorter hospital stay, less blood loss and lower rates of both overall postoperative complications and wound infections.

Robotic colonic resection

Innovative robotic technologies are aiming to help surgeons overcome the limits of conventional laparoscopic surgery. Recent studies have shown that robotic colorectal surgery is safe and provides favorable results in comparison to conventional laparoscopic techniques. Further studies and long-term follow-up are required to assess the outcomes and potential benefits of robotic colon surgery over laparoscopic surgery.

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.

Robotic general surgery: current practice, evidence, and perspective

BACKGROUND

Robotic technology commenced to be adopted for the field of general surgery in the 1990s. Since then, the da Vinci surgical system (Intuitive Surgical Inc, Sunnyvale, CA, USA) has remained by far the most commonly used system in this domain. The da Vinci surgical system is a master-slave machine that offers three-dimensional vision, articulated instruments with seven degrees of freedom, and additional software features such as motion scaling and tremor filtration. The specific design allows hand-eye alignment with intuitive control of the minimally invasive instruments. As such, robotic surgery appears technologically superior when compared with laparoscopy by overcoming some of the technical limitations that are imposed on the surgeon by the conventional approach.

PURPOSE

This article reviews the current literature and the perspective of robotic general surgery.

CONCLUSIONS

While robotics has been applied to a wide range of general surgery procedures, its precise role in this field remains a subject of further research. Until now, only limited clinical evidence that could establish the use of robotics as the gold standard for procedures of general surgery has been created. While surgical robotics is still in its infancy with multiple novel systems currently under development and clinical trials in progress, the opportunities for this technology appear endless, and robotics should have a lasting impact to the field of general surgery.

Robotic right colectomy with intracorporeal anastomosis: experience with 52 consecutive cases

BACKGROUND

In laparoscopic right hemicolectomy (LRC), extracorporeal or intracorporeal (ICA) anastomosis can be performed. Several authors have suggested advantages to ICA. This study reports our transition to and our experience with robotic right colectomy (RRC) with ICA.

MATERIALS AND METHODS

From June 2009 to September 2012 we performed 58 consecutive RRCs, of which 52 were with ICA. Data were prospectively stored and retrospectively reviewed.

RESULTS

Twenty-eight female and 30 male patients with a mean age of 71.6 ± 8.3 years (range, 52-89 years) were studied. Indications for surgery included adenocarcinoma (n=30), adenoma (n=20), diverticulitis (n=1), and Crohn's disease (n=1). For RRC with ICA (n=52), mean operative time (OT) was 193.2 ± 42.2 minutes (range, 123-239 minutes). Mean estimated blood loss (EBL) was 47.8 ± 59.5 mL (range, 5-300 mL). Mean length of hospital stay (LOS) was 3.7 ± 3.2 days (range, 1-21 days). Mean extraction-site incision size was 4.61 ± 0.78 cm (range, 2.5-6.5 cm). Mean lymph node harvest was 20.7 ± 8.2 (range, 6-40). Mean specimen length was 18.9 ± 7.2 cm (range 10-37). No intraoperative complications, conversions, or 30-day mortality occurred. Nine postoperative complications (19.1%) occurred, with one anastomotic leak (1.7%). For LRC with ICA as reported in the literature, OT ranges from 136 to 190 minutes, EBL ranges from 0 to 500 mL, median LOS ranges from 3 to 5 days, complication rates range from 6% to 15%, with ileus <22%, and conversion rates are <5%.

CONCLUSIONS

RRC with ICA is safe and feasible. OTs and outcomes compare favorably with those published in the literature for LRC with ICA. The robot may facilitate transition to ICA, and if future studies confirm advantages of ICA, the role of RRC may gain importance.

Comparative effectiveness in colon and rectal cancer

Treatment of colorectal cancer is becoming more uniform, with wider acceptance of standardized guidelines. However, areas of controversy exist where the appropriate treatment is not clear, including: should a segmental colectomy or a more extensive resection be performed in hereditary nonpolyposis colorectal cancer? should an asymptomatic primary cancer be resected in the presence of unresectable metastatic disease? what is the role of extended lymph node resection in colon and rectal cancer? are there clinically significant benefits for a robotic approach to colorectal resection versus a laparoscopic approach? This chapter will examine these issues and discuss how they may be resolved.

Robotic right colectomy with intracorporeal anastomosis compared with laparoscopic right colectomy with extracorporeal and intracorporeal anastomosis: a retrospective multicentre study

BACKGROUND

Growing evidence suggests that the intracorporeal fashioning of an anastomosis after a laparoscopic right colectomy may offer several advantages. However, due to the difficulty of the intracorporeal technique, laparoscopic extracorporeal confectioning of the anastomosis remains the most widely adopted technique. Although the purpose of the robotic approach was to overcome the limitations of the laparoscopic technique and to simplify the most demanding surgical procedures, such as performing an intracorporeal anastomosis, evidence is lacking that compares the robotic right colectomy with intracorporeal anastomosis (RRCIA) technique with both the conventional laparoscopic right colectomy with extracorporeal anastomosis (LRCEA) and the laparoscopic right colectomy with intracorporeal anastomosis confectioning (LRCIA) techniques. This study aims to compare the intraoperative and postoperative outcomes of the RRCIA to those of both the LRCEA and the LRCIA.

METHODS

A retrospective review of a prospectively maintained database of two Italian centres was performed on the data on patients undergoing an RRCIA, LRCEA or LRCIA for cancer or adenomas.

RESULTS

Two hundred and thirty-six patients (RRCIA = 102, LRCEA = 94, LRCIA = 40) met the criteria for inclusion in the study. The three groups were comparable in their demographic and baseline characteristics. No significant differences were found in the conversion to open rates, intraoperative blood loss, 30-day morbidity and mortality, number of lymphnodes harvested and other pathological characteristics. Compared with the LRCEA, the RRCIA required a longer operative time (P < 0.0001) but had better recovery outcomes, such as a shorter length of hospital stay (P < 0.0001). Compared with the LRCIA, the RRCIA had a shorter time to first flatus (P < 0.0001) but offered no advantages in terms of the length of the hospital stay.

CONCLUSION

Performing the RRCIA offers significantly better perioperative recovery outcomes compared with the LRCEA, with a substantial reduction in the length of the hospital stay. The RRCIA does not offer the same advantages compared with the LRCIA.

Robot-assisted single-incision total colectomy: a case report

BACKGROUND

Literature reports shows that robots provide an opportunity for meeting technical challenges associated with Laparo-endoscopic Single Site Surgery (LESS). Following previous success with robot-assisted single-incision right hemicolectomy, this paper reports experience with robot-assisted single-incision total colectomy.

METHODS

Through a single incision around the umbilicus, three robotic ports and a laparoscopic port were placed through the GelPOINT. With one intraoperative redocking of the robot, it was possible to access both right and left sides of the colon. The entire colon was externalized through the GelPOINT and the umbilical incision closed in layers.

RESULTS

The entire procedure took 227 minutes. There was minimal blood loss. The patient was discharged on post-operative day four with no complications. No wound site complications were observed in clinic one week after discharge.

CONCLUSIONS

Robot-assisted single-incision total colectomy is a feasible procedure associated with little increase in operative time.

Outcomes of robotic-assisted colorectal surgery compared with laparoscopic and open surgery: a systematic review

BACKGROUND

Robotic technology has been applied to colorectal surgery over the last decade. The aim of this review is to analyze the outcomes of robotic colorectal surgery systematically and to provide objective information to surgeons.

METHODS

Studies were searched and identified using PubMed and Google Scholar from Jan 2001 to Feb 2013 with the search terms "robot," "robotic," "colon," "rectum," "colorectal," and "colectomy." Appropriate data in the studies about the outcomes of robotic colorectal surgery were analyzed.

RESULTS

Sixty-nine publications were included in this review and composed of 39 case series, 29 comparative studies, and 1 randomized controlled trial. Most of the studies reported that robotic surgery showed a longer operation time, less estimated blood loss, shorter length of hospital stay, lower complication and conversion rates, and comparable oncologic outcomes compared to laparoscopic or open surgery.

CONCLUSION

Robotic colorectal surgery is a safe and feasible option. Robotic surgery showed comparable short-term outcomes compared to laparoscopic surgery or open surgery. However, the long operation time and high cost are the limitations of 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.