Whether robot-assisted laparoscopic fundoplication is better for gastroesophageal reflux disease in adults: a systematic review and meta-analysis

Robotic-assisted hiatal hernia repairs with and without magnetic sphincter augmentation (MSA): short- and long-term patient-centered outcomes in a single academic center

INTRODUCTION

Hiatal Hernia (HH) repairs are commonly performed using a laparoscopic (L) approach. Recently, the robotic-assisted (RA) approach was introduced. The objective of the study is to describe our experience and analyze patient-centered clinical outcomes of RA-HH repairs with and without MSA (Magnetic Sphincter Augmentation).

METHODS

Patients who underwent RA-HH repair with or without MSA between April 2018 and February 2023 were included. The data were summarized using mean and standard deviation for all continuous variables. Frequency and percent were used for categorical data. Postoperative endoscopy and/or barium swallow were done on all patients. Postoperative clinical follow-up occurred at 2 weeks, 3,6,12, and 24 months. At 6 months, the Gastroesophageal Reflux Disease Health-Related Quality-of-Life (GERD-HRQL) scale was used to assess quality of life and symptom severity. The data were analyzed for both MSA and non-MSA patients and reported at 2 years. All data management and analysis were conducted using Stata V.18.

RESULTS

Overall, the study included 295 patients. 30-day readmission and ED visit rates were 7.51% and 14.92%, respectively. In-hospital postoperative complication rate was 10.85%. We had no 30-day mortality. Conversion to open was 0.34%. Hospital length of stay was 0-1 day in 82.03% of cases. GERD-HRQL score decreased from 8.78 preoperatively to 1.34 at 6 months with 86.1% of patients reporting a score of 0. Our follow-up rate at year 2 from the index procedure was 74% ( 217 patients out of 295). Hernia recurrence rate at 24 months was 3.93%. PPI use at 2 years was 38.71%. MSA group had more post-op globus at 24 months (5.13% vs 1.12%) but similar rates of post-op heartburn and PPI use.

CONCLUSION

RA-HH at our center appears to be safe and feasible with low recurrence rates at 24 months. MSA had similar rates of PPI use but more post-op globus compared to the non-MSA group at 2 years.

Robotic hiatus hernia surgery: learning curve and lessons learned

New procedures like the robotic approach require proficiency to ensure patient safety and satisfactory functional results. Hiatal hernia surgery serves as a suitable training procedure for upper gastrointestinal tract surgeons transitioning to the robotic approach. This study aims to evaluate the outcomes of implementing the robotic approach in hiatal hernia surgery at a tertiary hospital and to assess the associated learning curve. A retrospective review was conducted on 54 patients (58 surgeries) between June 2019 and March 2024, including both primary and revision robotic antireflux surgeries. The study focused on perioperative outcomes, symptom resolution, and the surgical learning curve, assessed using Cumulative Sum analysis. The results showed that global surgical time averaged 124 ± 57 (54-350) min, 127 ± 38 (116-139) for Primary Surgery and 164 ± 84 (115-212) min for Revisional Surgery. There were no conversions to laparoscopic or open approach. The global median of hospital stay was 2 days (2 for Primary Surgery and 3 for Revisional Surgery) and three patients required readmission (2 for Primary Surgery and 1 for Revisional Surgery). Postoperative complications occurred in 3 patients. Symptom resolution was achieved in 90% of Primary Surgery group and 85.7% of Revisional Surgery group. Learning curve described three phases: 1-training (case 1 to 14), 2-plateau (15 to 25) and 3-expertise phase (25 onwards). The robotic approach in hiatal hernia surgery is feasible with minimal morbidity, short hospital stays, and excellent functional results. With previous experience in laparoscopic approach and esophagogastric surgery the learning curve can be reduced to 14 procedures.

Opinion, uptake and current practice of robot-assisted upper gastrointestinal and oesophagogastric surgery in the UK: AUGIS national survey results

INTRODUCTION

The uptake of upper gastrointestinal (GI) robotic surgery in the United Kingdom (UK), and Europe more widely, is expanding rapidly. This study aims to present a current snapshot of the practice and opinions of the upper GI community with reference to robotic surgery, with an emphasis on tertiary cancer (oesophagogastric) resection centres.

METHODS

An electronic survey was circulated to the UK upper GI surgical community via national mailing lists, social media and at an open-invitation conference on robotic upper GI surgery in January 2023. The survey included questions on surgeons' current practice or planned adoption (if any) of robotics at individual and unit level, and their opinions on robotic upper GI surgery in general. Priority ranking and Likert-scale response options were used.

RESULTS

In total, 81 respondents from 43 hospitals were included. Thirty-four resectional centres responded, including 30 of 31 (97%) recognised upper GI cancer centres in England. Respondents reported performing robotic surgery in 21 of 34 (61.8%) resectional centres, with a median of 65 procedures per centre performed at the time of the survey (range 0-500, interquartile range 93.75). Every centre without a robotic programme expressed a desire or had active plans to implement one. Respondents ranked surgeon ergonomics as the most important reason for pursuing robotics, followed by improvements in patient outcomes and oncological efficacy.

CONCLUSIONS

Robotic upper GI practice is nascent but rapidly growing in the UK with plans for uptake in almost all tertiary centres. There is growing opinion that this is likely to become the predominant surgical approach in future with benefits to both patients and surgeons. This snapshot offers a point of reference to all stakeholders in upper GI surgery.

Robotic-assisted treatment of paraesophageal hernias in the emergency setting: a retrospective study

Emergency treatment of paraesophageal hernias can be carried out through laparotomy or minimally invasive approaches, however, evidence in this regard is weak. The aim of our study was to assess safety and feasibility of the robotic-assisted treatment of paraesophageal hernias in the emergency setting. At the Bellinzona e Valli Regional Hospital, Switzerland, we conducted a retrospective analysis of patients operated on from January 2020 to January 2024 with robotic surgery for emergency presentation of paraesophageal hernias. Demographic and clinical details, operative techniques, and postoperative outcomes were collected and analyzed. Out of 82 patients who underwent robotic-assisted paraesophageal hernia repair, 17 were treated in the emergency setting. Median age was 79 years (IQR 77-85), 3 (17.6%) patients were male, and median BMI was 23.9 kg/m2 (IQR 21.0-26.0). Most frequent presentation symptoms were pain (100%), regurgitation (88.2%), and dyspnea (17.6%). No intraoperative complication, conversion to open surgery or stomach resections were recorded. Two complications of grade 3 according to the Clavien-Dindo classification and one of grade 2 occurred; all were successfully treated until resolution. The median length of hospital stay was 8 days (IQR 5-16). After a mean follow-up of 15.9 months (IQR 6.5-25.6) only two small axial asymptomatic recurrences that required no treatment. Despite limitations, our study demonstrated a very low rate of intra- and postoperative complications, likely supporting the safety and feasibility of robotic-assisted treatment for paraesophageal hernias in emergency settings. Larger studies with a control arm are needed to validate our initial findings.

Proctored adoption of robotic hiatus hernia surgery: outcomes and learning curves in a high-volume UK centre

BACKGROUND

The adoption of new surgical technologies is inevitably accompanied by a learning curve. With the increasing adoption of robotic techniques in benign foregut surgery, it is imperative to define optimal learning pathways, to ensure a clinically safe introduction of such a technique. The aim of this study was to assess the learning curve for robotic hiatal hernia repair with a pre-defined adoption process and proctoring.

METHODS

The learning curve was assessed in four surgeons in a high-volume tertiary referral centre, performing over a 100 hiatal hernia repairs annually. The robotic adoption process included simulation-based training and a multi-day wet lab-based course, followed by robotic operations proctored by robotic upper GI experts. CUSUM analysis was performed to assess changes in operating time in sequential cases.

RESULTS

Each surgeon (A, B, C and D) performed between 22 and 32 cases, including a total of 109 patients. Overall, 40 cases were identified as 'complex' (36.7%), including 16 revisional cases (16/109, 14.7%). With CUSUM analysis inflection points for operating time were seen after 7 (surgeon B) to 15 cases (surgeon B).

CONCLUSION

The learning curve for robotic laparoscopic fundoplication may be as little as 7-15 cases in the setting of a clearly organized learning pathway with proctoring. By integrating these organized learning pathways learning curves may be shortened, ensuring patient safety, preventing detrimental outcomes due to longer learning curves, and accelerating adoption and integration of novel surgical techniques.

Paediatric robotic surgery: a narrative review

The benefits of minimally invasive surgery (MIS) compared with traditional open surgery, including reduced postoperative pain and a reduced length of stay, are well recognised. A significant barrier for MIS in paediatric populations has been the technical challenge posed by laparoscopic surgery in small working spaces, where rigid instruments and restrictive working angles act as barriers to safe dissection. Thus, open surgery remains commonplace in paediatrics, particularly for complex major surgery and for surgical oncology. Robotic surgical platforms have been designed to overcome the limitations of laparoscopic surgery by offering a stable 3-dimensional view, improved ergonomics and greater range of motion. Such advantages may be particularly beneficial in paediatric surgery by empowering the surgeon to perform MIS in the smaller working spaces found in children, particularly in cases that may demand intracorporeal suturing and anastomosis. However, some reservations have been raised regarding the utilisation of robotic platforms in children, including elevated cost, an increased operative time and a lack of dedicated paediatric equipment. This article aims to review the current role of robotics within the field of paediatric surgery.

A Narrative Review on Treatment of Giant Hiatal Hernia

Background: The current gold standard of treatment for giant hiatal hernias (GHHs) is laparoscopic surgery. Laparoscopic surgery was performed as a less invasive procedure for paraesophageal hernias more than 25 years ago. Its viability and safety have almost all been shown. Materials and Methods: A review of recent and current studies' literature was done. Prospective randomized trials, systematic reviews, clinical reviews, and original articles were all investigated. The data were gathered in the form of a narrative evaluation. We examine the state of laparoscopic GHH repair today and outline the GHH management strategy. Results: In this review, we clear up misunderstandings of GHH and address bad habits that may have contributed to poor results, and we have consequently performed a methodical evaluation of GHH. First, we address subcategorizing GHH and provide criteria to define them. The preoperative workup strategies are then discussed, with a focus on any pertinent and frequent atypical symptoms, indications for surgery, timing of surgery, and the importance of surgery. The approach to the techniques and the logic behind surgery are then presented along with some important dissection techniques. Finally, we debate the role of mesh reinforcement and evaluate the data in terms of recurrence, reoperation rate, complications, and delayed stomach emptying. Finally, we suggest a justification for common postoperative investigations. Conclusions: Surgery is the only effective treatment for GHH at the moment. If the right operational therapy principles are applied, this is generally successful. There is a growing interest in laparoscopic paraesophageal hiatal hernia repair as a result of the introduction of laparoscopic antireflux surgery. Today's less invasive procedures provide a better therapeutic choice with a lower risk.

Robotic Surgery and Functional Esophageal Disorders: A Systematic Review and Meta-Analysis

The functional disease of the esophago-gastric junction (EGJ) is one of the most common health problems. It often happens that patients suffering from GERD need surgical management. The laparoscopic fundoplication has been considered the gold standard surgical treatment for functional diseases of the EGJ. The aim of our meta-analysis is to investigate functional outcomes after robotic fundoplication compared with conventional laparoscopic fundoplication. A prospective search of online databases was performed by two independent reviewers using the search string "robotic and laparoscopic fundoplication", including all the articles from 1996 to December 2021. The risk of bias within each study was assessed with the Cochrane ROBINS-I and RoB 2.0 tools. Statistical analysis was performed using Review Manager version 5.4. In addition, sixteen studies were included in the final analysis, involving only four RCTs. The primary endpoints were functional outcomes after laparoscopic (LF) and robotic fundoplication (RF). No significant differences between the two groups were found in 30-day readmission rates (p = 0.73), persistence of symptomatology at follow-up (p = 0.60), recurrence (p = 0.36), and reoperation (p = 0.81). The laparoscopic fundoplication represents the gold standard treatment for the functional disease of the EGJ. According to our results, the robotic approach seems to be safe and feasible as well. Further randomized controlled studies are required to better evaluate the advantages of robotic fundoplication.

A systematic review of robot-assisted anti-reflux surgery to examine reporting standards

Robot-assisted anti-reflux surgery (RA-ARS) is increasingly being used to treat refractory gastro-oesophageal reflux disease. The IDEAL (Idea, Development, Exploration, Assessment, Long-term follow up) Collaboration's framework aims to improve the evaluation of surgical innovation, but the extent to which the evolution of RA-ARS has followed this model is unclear. This study aims to evaluate the standard to which RA-ARS has been reported during its evolution, in relation to the IDEAL framework. A systematic review from inception to June 2020 was undertaken to identify all primary English language studies pertaining to RA-ARS. Studies of paraoesophageal or giant hernias were excluded. Data extraction was informed by IDEAL guidelines and summarised by narrative synthesis. Twenty-three studies were included: two case reports, five case series, ten cohort studies and six randomised controlled trials. The majority were single-centre studies comparing RA-ARS and laparoscopic Nissen fundoplication. Eleven (48%) studies reported patient selection criteria, with high variability between studies. Few studies reported conflicts of interest (30%), funding arrangements (26%), or surgeons' prior robotic experience (13%). Outcome reporting was heterogeneous; 157 distinct outcomes were identified. No single outcome was reported in all studies.The under-reporting of important aspects of study design and high degree of outcome heterogeneity impedes the ability to draw meaningful conclusions from the body of evidence. There is a need for further well-designed prospective studies and randomised trials, alongside agreement about outcome selection, measurement and reporting for future RA-ARS studies.

Robotic-Assisted Minimally Invasive Surgery in Children

Currently, minimally invasive surgery (MIS) includes conventional laparo-thoracoscopic surgery and robot-assisted surgery (RAS) or robotic surgery. Robotic surgery is performed with robotic devices, for example the Da Vinci system from Intuitive Surgical, which has a miniaturized camera capable of image magnification, a three-dimensional image of the surgical field, and the instruments are articulated with 7 degrees of freedom of movement, and the surgeon operates in a sitting position at a surgical console near the patient. Robotic surgery has gained an enormous surge in use on adults, but it has been slowly accepted for children, although it offers important advantages in complex surgeries. The areas of application of robotic surgery in the pediatric population include urological, general surgery, thoracic, oncological, and otorhinolaryngology, the largest application has been in urological surgery. There is evidence that robotic surgery in children is safe and it is important to offer its benefits. Intraoperative complications are rare, and the frequency of postoperative complications ranges from 0–15%. Recommendations for the implementation of a pediatric robotic surgery program are included. The future will be fascinating with upcoming advancements in robotic surgical systems, the use of artificial intelligence, and digital surgery.

Cumulative summation analysis of learning curve for robotic-assisted hiatal hernia repairs

BACKGROUND

Robotic-assisted laparoscopic surgery (RALS) is evolving as an important surgical approach in the field of general surgery. We aimed to evaluate the learning curve for RALS procedures involving repair of hiatal hernias.

METHODS

A series of robotic-assisted hiatal hernia (HH) repairs were performed between 2013 and 2017 by a surgeon at a single institution. Data were entered into a retrospective database. Patient demographics and intraoperative parameters including console time (CT), surgery time (ST), and total operative time (OT) were examined and abstracted for learning curve analysis using the cumulative sum (CUSUM) method. Assessment of perioperative and post-operative outcomes were calculated using descriptive statistics.

RESULTS

The average age of the patients was 57.4 years, average BMI was 29.9 kg/m², median American Society of Anesthesiologists (ASA) classification was 2, and average Charlson Comorbidity Index (CCI) score was 2.8. The series had a mean CT of 132.6 min, mean ST of 145.1 min, and mean OT of 197.4 min. The CUSUM learning curve for CT was best approximated as a third-order polynomial consisting of three unique phases: the initial training phase (case 1-40), the improvement phase (case 41-85), and the mastery phase (case 86 onwards). There was no significant difference in perioperative complications between the phases. Short-term clinical outcomes were comparable with national standards and did not correlate significantly with operative experience.

CONCLUSIONS

The three phases identified with CUSUM analysis represented characteristic stages of the learning curve for robotic hiatal hernia procedures. Our data suggest the training phase is achieved after 40 cases and a high level of mastery is achieved after approximately 85 cases. Thus, the CUSUM method serves as a useful tool for objectively evaluating practical skills for surgeons and can ultimately help establish milestones that assess surgical competency during robotic surgery training.

Robotic Complex Fundoplication in Patients at High-Risk to Fail

Background:

This study was undertaken to analyze our outcomes after robotic fundoplication for GERD in patients with failed antireflux procedures, with type IV (i.e., giant) hiatal hernias, or after extensive intra-abdominal surgery with mesh, and to compare our results to outcomes predicted by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator and to national outcomes reported by NSQIP.

Methods:

100 patients undergoing robotic fundoplication for the aforementioned factors were prospectively followed.

Results:

100 patients, aged 67 (67 ± 10.3) years with body mass index (BMI) of 26 (25 ± 2.9) kg/m² underwent robotic fundoplication for failed antireflux fundoplications (43%), type IV hiatal hernias (31%), or after extensive intra-abdominal surgery with mesh (26%). Operative duration was 184 (196 ± 74.3) min with an estimated blood loss of 24 (51 ± 82.9) mL. Length of stay was 1 (2 ± 3.6) day. Two patients developed postoperative ileus. Two patients were readmitted within 30 days for nausea.

Nationally reported outcomes and those predicted by NSQIP were similar. When comparing our actual outcomes to predicted and national NSQIP outcomes, actual outcomes were superior for serious complications, any complications, pneumonia, surgical site infection, deep vein thrombosis, readmission, return to OR, and sepsis (P < 0.05); our actual outcomes were not worse for renal failure, deaths, cardiac complications, and discharge to a nursing facility.

Conclusions:

Our patients were not a selective group; rather they were more complex than reported in NSQIP. Most of our results after robotic fundoplication were superior to predicted and national outcomes. The utilization of the robotic platform for complex operations and fundoplications to treat patients with GERD is safe and efficacious.

Safety of robotic assisted laparoscopic recurrent paraesophageal hernia repair: insights from a large single institution experience

BACKGROUND

Laparoscopic repair of recurrent as opposed to primary paraesophageal hernias (PEHs) are historically associated with increased peri-operative complication rates, worsened outcomes, and increased conversion rates. The robotic platform may aid surgeons in these complex revision procedures. The aim of this study was to compare the outcomes of patients undergoing robotic assisted laparoscopic (RAL) repair of recurrent as opposed to primary PEHs.

METHODS

Patients undergoing RAL primary and recurrent PEH repairs from 2009 to 2017 at a single institution were reviewed. Demographics, use of mesh, estimated blood loss, intra-operative complications, conversion rates, operative time, rates of esophageal/gastric injury, hospital length of stay, re-admission/re-operation rates, recurrence, dysphagia, gas bloat, and pre- and post-operative proton pump inhibitor (PPI) use were analyzed. Analysis was accomplished using Chi-square test/Fischer's exact test for categorical variables and the Mann-Whitney U test for continuous variables.

RESULTS

There were 298 patients who underwent RAL PEH repairs (247 primary, 51 recurrent). They were followed for a median (interquartile range) of 120 (44, 470) days. There were no significant differences in baseline demographics between groups. Patients in the recurrent PEH group had longer operative times, increased use of mesh, and increased length of hospital stay. They were also less likely to undergo fundoplication. There were no significant differences in estimated blood loss, incidence of intra-operative complications, re-admission rates, incidence of post-operative dysphagia and gas bloat, and incidence of post-operative PPI use. There were no conversions to open operative intervention or gastric/esophageal injury/leaks.

CONCLUSIONS

Although repair of recurrent PEHs are historically associated with worse outcomes, in this series, RAL recurrent PEH repairs have similar peri-operative and post-operative outcomes as compared to primary PEH repairs. Whether this is secondary to the potential advantages afforded by the robotic platform deserves further study.

Integrating Robotic Technology Into Resident Training: Challenges and Recommendations From the Front Lines

PURPOSE

To develop recommendations for improving the integration of robotic technology into today's apprentice-based resident training.

METHOD

During a national meeting in 2017, 24 robotic surgeons were interviewed about their experiences integrating robotic technology into resident training. Qualitative thematic analysis of interview notes and recordings revealed themes related to challenges and recommendations.

RESULTS

Four themes emerged, each corresponding to a general recommendation for integrating robotic technology into training. The first, surgical techniques versus tools, contrasts faculty's sequential mastery-surgical techniques first, then the robotic tool-with residents' simultaneous learning. The recommendation is to create separate learning opportunities for focused skill acquisition. The second theme, timing of exposure to the robotic tool, describes trainees' initial focus on tool use for basic surgical steps. The recommendation is to increase access to basic robotic cases. The third theme covers the relationship of laparoscopic and robotic surgery. The recommendation is to emphasize similar and dissimilar features during all minimally invasive surgical cases. The fourth theme, use of the dual console (which enables two consoles to operate the robot, the primary determines the secondary's functionality), highlights the unique teaching opportunities this console creates. The recommendation is for surgeons to give verbal guidance so residents completely understand surgical techniques.

CONCLUSIONS

Surgical educators should consider technique versus tool, timing of exposure to the tool, overlapping and varying features of robotic and laparoscopic surgery, and use of the dual console as they develop curricula to ensure thorough acquisition and synthesis of all elements of robotic surgery.

Robotic-assisted minimally invasive esophagectomy versus the conventional minimally invasive one: A meta-analysis and systematic review

BACKGROUND

Conventional video-assisted minimally invasive esophagectomy (MIE) is safe and associated with low rates of morbidity and mortality, but the two-dimensional monitor reduces eye-hand harmony and viewing yield. Robotic-assisted minimally invasive esophagectomy (RAMIE) with its virtual reality simulators offers a realistic three-dimensional environment that facilitates dissection in the narrow working space, but it is expensive and requires longer operative time. Therefore, the aim of this meta-analysis was to assess the safety and feasibility of RAMIE versus MIE in patients with esophageal cancer.

MATERIAL AND METHODS

PubMed, EMBASE, Cochrane library, and Chinese Biomedical Literature databases were systematically searched up to 21 September 2018 for case-controlled studies that compared RAMIE with MIE.

RESULT

Eight case-controlled studies involving 1862 patients (931 under RAMIE and 931 under MIE) were considered. No statistically significant difference between the two techniques was observed regarding R0 resection rate (OR = 1.1174, P = 0.8647), conversion to open (OR = 0.7095, P = 0.7519), 30-day mortality rate (OR = 0.8341, P = 0.7696), 90-day mortality rate (OR = 0.3224, P = 0.3329), in-hospital mortality rate (OR = 0.3733, P = 0.3895), postoperative complications, number of harvested lymph nodes (mean difference [MD] = 0.8216, P = 0.2039), operation time (MD = 24.3655 min, P = 0.2402), and length of stay in hospitals (LOS) (MD = -5.0228 day, P = 0.1342). The meta-analysis showed that RAMIE was associated with a significantly fewer estimated blood loss (EBL) (MD = -33.2268 mL, P = 0.0075). And the vocal cord palsy rate was higher in the MIE group compared with RAMIE, and the difference was significant (OR = 0.5696, P = 0.0447).

CONCLUSION

This meta-analysis indicated that RAMIE and MIE display similar feasibility and safety when used in esophagectomy. However, randomized controlled studies with larger sample sizes are needed to evaluate the benefit and harm in patients with esophageal cancer undergoing RAMIE.

Evaluation of conventional laparoscopic versus robot-assisted laparoscopic redo hiatal hernia and antireflux surgery: a cohort study

Surgery for refractory gastroesophageal reflux disease (GERD) and hiatal hernia leads to recurrence or persisting dysphagia in a minority of patients. Redo antireflux surgery in GERD and hiatal hernia is known for higher morbidity and mortality. This study aims to evaluate conventional versus robot-assisted laparoscopic redo antireflux surgery, with the objective to detect possible advantages for the robot-assisted approach. A single institute cohort of 75 patients who underwent either conventional laparoscopic or robot-assisted laparoscopic redo surgery for recurrent GERD or severe dysphagia between 2008 and 2013 were included in the study. Baseline characteristics, symptoms, medical history, procedural data, hospital stay, complications and outcome were prospectively gathered. The main indications for redo surgery were dysphagia, pyrosis or a combination of both in combination with a proven anatomic abnormality. The mean time to redo surgery was 1.9 and 2.0 years after primary surgery for the conventional and robot-assisted groups, respectively. The number of conversions was lower in the robot-assisted group compared to conventional laparoscopy (1/45 vs. 5/30, p = 0.035) despite a higher proportion of patients with previous surgery by laparotomy (9/45 vs. 1/30, p = 0.038). Median hospital stay was reduced by 1 day (3 vs. 4, p = 0.042). There were no differences in mortality, complications or outcome. Robotic support, when available, can be regarded beneficial in redo surgery for GERD and hiatal hernia. Results of this observational study suggest technical feasibility for minimal-invasive robot-assisted redo surgery after open primary antireflux surgery, a reduced number of conversions and shorter hospital stay.

Laparoscopic surgery: A qualified systematic review

AIM: To review current applications of the laparoscopic surgery while highlighting the standard procedures across different fields.

METHODS: A comprehensive search was undertaken using the PubMed Advanced Search Builder. A total of 321 articles were found in this search. The following criteria had to be met for the publication to be selected: Review article, randomized controlled trials, or meta-analyses discussing the subject of laparoscopic surgery. In addition, publications were hand-searched in the Cochrane database and the high-impact journals. A total of 82 of the findings were included according to matching the inclusion criteria. Overall, 403 full-text articles were reviewed. Of these, 218 were excluded due to not matching the inclusion criteria.

RESULTS: A total of 185 relevant articles were identified matching the search criteria for an overview of the current literature on the laparoscopic surgery. Articles covered the period from the first laparoscopic application through its tremendous advancement over the last several years. Overall, the biggest advantage of the procedure has been minimizing trauma to the abdominal wall compared with open surgery. In the case of cholecystectomy, fundoplication, and adrenalectomy, the procedure has become the gold standard without being proven as a superior technique over the open surgery in randomized controlled trials. Faster recovery, reduced hospital stay, and a quicker return to normal activities are the most evident advantages of the laparoscopic surgery. Positive outcomes, efficiency, a lower rate of wound infections, and reduction in the perioperative morbidity of minimally invasive procedures have been shown in most indications.

CONCLUSION: Improvements in surgical training and developments in instruments, imaging, and surgical techniques have greatly increased safety and feasibility of the laparoscopic surgical procedures.

Computer-assisted abdominal surgery: new technologies

BACKGROUND

Computer-assisted surgery is a wide field of technologies with the potential to enable the surgeon to improve efficiency and efficacy of diagnosis, treatment, and clinical management.

PURPOSE

This review provides an overview of the most important new technologies and their applications.

METHODS

A MEDLINE database search was performed revealing a total of 1702 references. All references were considered for information on six main topics, namely image guidance and navigation, robot-assisted surgery, human-machine interface, surgical processes and clinical pathways, computer-assisted surgical training, and clinical decision support. Further references were obtained through cross-referencing the bibliography cited in each work. Based on their respective field of expertise, the authors chose 64 publications relevant for the purpose of this review.

CONCLUSION

Computer-assisted systems are increasingly used not only in experimental studies but also in clinical studies. Although computer-assisted abdominal surgery is still in its infancy, the number of studies is constantly increasing, and clinical studies start showing the benefits of computers used not only as tools of documentation and accounting but also for directly assisting surgeons during diagnosis and treatment of patients. Further developments in the field of clinical decision support even have the potential of causing a paradigm shift in how patients are diagnosed and treated.

Robot-assisted oesophageal and gastric surgery for benign disease: antireflux operations and Heller's myotomy

BACKGROUND

Robot-assisted general surgery operations are being performed more frequently. This review investigates whether robotic assistance results in significant advantages or disadvantages for the operative treatment of gastro-oesophageal reflux disease and achalasia.

METHODS

The electronic databases (Medline, Embase, PubMed) were searched for original English language publications for antireflux surgery and Heller's myotomy between January 1990 and December 2013.

RESULTS

Thirty-three publications included antireflux operations and 20 included Heller's myotomy. The publications indicate that the safety and effectiveness of robotic surgery is similar to that of conventional minimally invasive surgery for both operations. The six randomized trials of robot-assisted versus laparoscopic antireflux surgery showed no significant advantages but significantly higher costs for the robotic method. Gastric perforation during non-redo robotic fundoplication occurred in four trials.

CONCLUSIONS

No consistent advantage for robot-assisted antireflux surgery has been demonstrated, and there is an increased cost with current robotic technology. A reported advantage for robotic in reducing the perforation rate during Heller's myotomy for achalasia remains unproven. Gastric perforation during robotic fundoplication may be due to the lack of haptic feedback combined with the superhuman strength of the robot.

Thoracoscopic versus robotic approaches: advantages and disadvantages

The overall advantages of thoracoscopy over thoracotomy in terms of patient recovery have been fairly well established. The use of robotics, however, is a newer and less proven modality in the realm of thoracic surgery. Robotics offers distinct advantages and disadvantages in comparison with video-assisted thoracoscopic surgery. Robotic technology is now used for a variety of complex cardiac, urologic, and gynecologic procedures including mitral valve repair and microsurgical treatment of male infertility. This article addresses the potential benefits and limitations of using the robotic platform for the performance of a variety of thoracic operations.

Robotic Nissen fundoplication for gastroesophageal reflux disease: a meta-analysis of prospective randomized controlled trials

PURPOSE

Since its introduction, the Da Vinci surgical system for the treatment of gastroesophageal reflux disease (GERD) has been the subject of much controversy. Several prospective randomized controlled trials, conducted to assess its effectiveness and safety, have revealed differences. We performed this meta-analysis to evaluate the efficiency and safety of robotic Nissen fundoplication for GERD.

METHODS

We performed a comprehensive search of PubMed, Embase, and OVID-MEDLINE, from 1950 to the present, with daily updates generated by a computer, to identify all published papers on robotic Nissen fundoplication for the treatment of GERD. The meta-analysis was performed by Review Manager Version 5.0. Differences of the overall effect were considered significant at P < 0.05 with a 95 % confidence interval (95 % CI).

RESULTS

Five studies with a collective total of 160 patients were included. Apart from intra-operative and post-operative complications, which were excluded because of incomplete primary data, there were no significant differences in outcomes, including of total operation interval (P = 0.16), effective operation interval (P = 0.95), post-operative dysphagia (P = 0.94), intra-operative conversion (P = 0.94), re-operation (P = 0.43), hospital stay (P = 0.97) and in-hospital costs (P = 0.08).

CONCLUSIONS

As current data do not clarify the advantages of the Da Vinci surgical system in Nissen fundoplication for GERD, we believe that a large a multi-center controlled trial is warranted.

Robotics: The next step?

Robotic systems were introduced 15 years ago to support complex endoscopic procedures. The technology is increasingly used in gastro-intestinal surgery. In this article, literature on experimental- and clinical research is reviewed and ergonomic issues are discussed.

METHODS

literature review was based on Medline search using a large variety of search terms, including e.g. robot(ic), randomized, rectal, oesophageal, ergonomics. Review articles on relevant topics are discussed with preference.

RESULTS

There is abundant evidence of supremacy in performing complex endoscopic surgery tasks when using the robot in an experimental setting. There is little high-level evidence so far on translation of these merits to clinical practice.

DISCUSSION

Robotic systems may appear helpful in complex gastro-intestinal surgery. Moreover, dedicated computer based technology integrated in telepresence systems opens the way to integration of planning, diagnostics and therapy. The first high tech add-ons such as near infrared technology are under clinical evaluation.

How does robotic anti-reflux surgery compare with traditional open and laparoscopic techniques: a cost and outcomes analysis

BACKGROUND

Conventional laparoscopic fundoplications (CLF) have been the gold standard for Nissen fundoplications (NFs) for two decades. The advent of a robotic approach for fundoplication procedures creates a potential alternative. Thus, we used a national database to examine perioperative outcomes with respect to open, laparoscopic, and robotic approaches.

METHODS

The University Health System Consortium is an alliance of medical centers, numbering over 115 academic institutions and their 271 affiliated hospitals. We used International Classification of Diseases codes to elicit patients over the age of 18 years who received NF procedures.

RESULTS

A total of 12,079 patients of similar demographic background received fundoplication procedures from October 2008 to June 2012. Of those, 2,168 were open fundoplications (OF), 9,572 were CLF, and 339 were robot-assisted laparoscopic fundoplications (RLF). CLF and RLF displayed no significance in mortality (0.1 vs. 0 %; p = 0.5489), morbidity (4.0 vs. 5.6 %; p = 0.1744), length of stay (2.8 ± 3.6 vs. 3.0 ± 3.5; p = 0.3242), and intensive care unit (ICU) cases (8.4 vs. 11.5 %; p = 0.051). However, CLF remained superior, with a lower 30-day re-admission rate (1.8 vs. 3.6 %; p < 0.05) and cost (US$7,968 ± 6,969 vs. US$10,644 ± 6,041; p < 0.05). When RLF was compared with OF, RLF had significantly improved morbidity (5.6 vs. 11 %; p < 0.05), length of stay (6.1 ± 7.2 vs. 3.0 ± 3.5 days; p < 0.05), less ICU admission (11.5 vs. 23.1 %; p <0.05) and less cost (US$10,644 ± 6,041 vs. US$12,766 ± 13,982; p < 0.05).

CONCLUSIONS

Current data suggests that robot-assisted NF procedures have similar patient outcomes to conventional laparoscopic NF, with the exception of added cost and higher re-admission rate. While the higher costs are expected given the new technology, increasing re-admission rates are concerning and may represent the level of experience of the surgeon as well as the robotic learning curve.

Robot-assisted gastroesophageal surgery: usefulness and limitations

Robot-assisted surgery overcomes some of the limitations of traditional laparoscopic surgery. We present our experience and lessons learned in two surgical units dedicated to gastro-esophageal surgery. From June 2009 to January 2013, we performed 130 robot-assisted gastroesophageal procedures, including Nissen fundoplication (29), paraesophageal hernia repair (18), redo for failed antireflux surgery (11), esophagectomy (19), subtotal (5) or wedge (4) gastrectomy, Heller myotomy for achalasia (22), gastric bypass for morbid obesity (12), thoracoscopic leiomyomectomy (4), Morgagni hernia repair (3), lower-third esophageal diverticulectomy (1) and two diagnostic procedures. There were 80 men and 50 women with a median age of 54 years (interquartile range: 46-65). Ten patients (7.7 %) had severe postoperative complications: eight after esophagectomy (three leaks-two cervical and one thoracic-managed conservatively), one stapler failure, one chylothorax, one case of gastric migration to the thorax, one case of biliary peritonitis, and one patient with a transient ventricular dyskinesia. One redo procedure needed reoperation because of port-site bleeding, and one patient died of pulmonary complications after a giant paraesophageal hernia repair; 30-day mortality was, therefore, 0.8 %. There were six elective and one forced conversions (hemorrhage), so total conversion was 5.4 %. Median length of stay was 4 days (IQ range 3-7). Robot-assisted gastroesophageal surgery is feasible and safe, and may be applied to most common procedures. It seems of particular value for Heller myotomy, large paraesophageal hernias, redo antireflux surgery, transhiatal dissection, and hand-sewn intrathoracic anastomosis.

Robot-assisted minimally invasive esophagectomy is equivalent to thoracoscopic minimally invasive esophagectomy

The use of the surgical robot has been increasing in thoracic surgery. Its three-dimensional view and instruments with surgical wrists may provide advantages over traditional thoracoscopic techniques. Our initial experience with thoracoscopic robot-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer was compared with our traditional thoracoscopic minimally invasive esophagectomy (MIE) approach for esophageal cancer. A retrospective review of a prospective database was performed. From July 2008 to October 2009, 43 patients underwent MIE resection. Patients who had benign disease and intrathoracic anastomosis were excluded. Results are presented as mean ± SD. Significance was set as P < 0.05. Eleven patients who underwent RAMIE and 26 who underwent MIE were included in the cohort. No differences in age, sex, race, body mass index, or preoperative radiotherapy or chemotherapy between the groups were observed. No significant differences in operative time, blood loss, number of resected lymph nodes, postoperative complications, days of mechanical ventilation, length of intensive care unit stay, or length of hospital stay were also observed. In this short-term study, RAMIE was found to be equivalent to thoracoscopic MIE and did not offer clear advantages.

Laparoscopic versus robot-assisted Nissen fundoplication in an infant pig model

PURPOSE

Surgical robots are designed to facilitate dissection and suturing, although objective data on their superiority are lacking. This study compares conventional laparoscopic Nissen fundoplication (CLNF) to robot-assisted Nissen fundoplication (RANF) using computer-based workflow analysis in an infant pig model.

METHODS

CLNF and RANF were performed in 12 pigs. Surgical workflow was segmented into phases. Time required to perform specific actions was compared by t test. The quality of knot-tying was evaluated by a skill scoring system. Cardia yield pressure (CYP) was determined to test the efficacy of the fundoplications, and the incidence of complications was compared.

RESULTS

There was no difference in average times to complete the various phases, despite faster robotic knot-tying (p = 0.001). Suturing quality was superior in CLNF (p = 0.02). CYP increased similarly in both groups. Workflow-interrupting hemorrhage and pneumothorax occurred more frequently during CLNF (p = 0.040 and 0.044, respectively), while more sutures broke during RANF (p = 0.001).

CONCLUSION

The robot provides no clear temporal advantage compared to conventional laparoscopy for fundoplication, although suturing was faster in RANF. Fewer complications were noted using the robot. RANF and CLNF were equally efficient anti-reflux procedures. For robotic surgery to manifest its full potential, more complex operations may have to be evaluated.

Ambulatory laparoscopic fundoplication for gastroesophageal reflux disease: a systematic review

BACKGROUND

Ambulatory laparoscopic fundoplication for gastroesophageal reflux disease (GERD) has been developed in order to increase patients' satisfaction and to save bed costs. The aim of this systematic review was to assess the advantages and disadvantages of ambulatory surgery in patients undergoing elective fundoplication for GERD.

METHODS

Two reviewers independently searched and identified 15 prospective or retrospective nonrandomized studies dealing with ambulatory laparoscopic fundoplication for GERD in the Medline, Cancerlit, and Embase databases between January 1990 and July 2010. Outcomes were postoperative mortality, morbidity, conversion and reoperation rates, mean operative time, hospital admission or readmission, unexpected consultation, and patient satisfaction. Because only one comparative study was identified, data compilation and relative risk evaluation through meta-analysis were not possible.

RESULTS

A total of 1459 adult patients underwent an ambulatory laparoscopic fundoplication for GERD, 876 in a day-case setting and 583 in an outpatient setting. The procedure appears feasible for selected patients and expert surgeons, and it has a very low mortality rate and conversion, reoperation, and overall morbidity rates of 3.6, 0.6, and 11.1%, respectively. Hospital admission, nonprogrammed consultation, and hospital readmission rates were as high as 20, 11, and 12%, respectively. No study looked at comparative long-term functional results between ambulatory and inpatient procedures. Patient satisfaction rates based on self-evaluation were high.

CONCLUSION

The data available to date in the literature, mostly of level 4 evidence, suggest that laparoscopic fundoplication for GERD appears to be safe and feasible in a day-surgery setting, subject to careful patient selection and surgeon expertise. Randomized control trials are urgently needed to better evaluate this promising care management.