Robotic-Assisted Versus Laparoscopic Colectomy Results in Increased Operative Time Without Improved Perioperative Outcomes

Robotic-assisted plate fixation of the anterior acetabulum - clinical description of a new technique

INTRODUCTION

We present a detailed procedure for the robotic-assisted plate osteosynthesis of an anterior acetabular fracture. The purpose of this work was to describe a robotic-assisted minimally invasive technique as a possible method for reducing complications, pain, and hospitalization. Another goal was to present technical recommendations and to assess potential pitfalls and problems of the new surgical approach.

METHODS

Surgery was performed in an interdisciplinary setting by an experienced orthopedic surgeon and a urologist. The DaVinci System with standard instruments was used. Reduction was achieved through indirect traction of a pin that was introduced into the femoral neck and direct manipulation via the plate. The plate position and fixation were achieved through 7 additional minimally invasive incisions.

RESULTS

The technique has multiple advantages, such as no detachment of the rectus abdominal muscle, a small skin incision, and minimal blood loss. Furthermore, this approach might lower the incidence of hernia formation, infection, and postoperative pain.

DISCUSSION

We see the presented technique as a demanding yet progressive and innovative surgical method for treating acetabular fractures with indications for anterior plate fixation.

TRIAL REGISTRATION

The study was approved by the local institutional review board (Nr. 248/18).

The Impact of Prolonged Operative Time Associated With Minimally Invasive Colorectal Surgery: A Report From the Surgical Care Outcomes Assessment Program

BACKGROUND

Increased operative time in colorectal surgery is associated with worse surgical outcomes. Laparoscopic and robotic operations have improved outcomes, despite longer operative times. Furthermore, the definition of "prolonged" operative time has not been consistently defined.

OBJECTIVE

The first objective was to define prolonged operative time across multiple colorectal operations and surgical approaches. The second was to describe the impact of prolonged operative time on length of stay and short-term outcomes.

DESIGN

A retrospective cohort study.

SETTING

Forty-two hospitals in the Surgical Care Outcomes Assessment Program from 2011 to 2019.

PATIENTS

There were a total of 23,098 adult patients (age 18 years or older) undergoing 6 common, elective colorectal operations: right colectomy, left/sigmoid colectomy, total colectomy, low anterior resection, IPAA, or abdominoperineal resection.

MAIN OUTCOME MEASURES

Prolonged operative time defined as the 75th quartile of operative times for each operation and approach. Outcomes were length of stay, discharge home, and complications. Adjusted models were used to account for factors that could impact operative time and outcomes across the strata of open and minimally invasive approaches.

RESULTS

Prolonged operative time was associated with longer median length of stay (7 vs 5 days open, 5 vs 4 days laparoscopic, 4 vs 3 days robotic) and more frequent complications (42% vs 28% open, 24% vs 17% laparoscopic, 27% vs 13% robotic) but similar discharge home (86% vs 87% open, 94% vs 94% laparoscopic, 93% vs 96% robotic). After adjustment, each additional hour of operative time above the median for a given operation was associated with 1.08 (1.06-1.09) relative risk of longer length of stay for open operations and 1.07 (1.06-1.09) relative risk for minimally invasive operations.

LIMITATIONS

Our study was limited by being retrospective, resulting in selection bias, possible confounders for prolonged operative time, and lack of statistical power for subgroup analyses.

CONCLUSIONS

Operative time has consistent overlap across surgical approaches. Prolonged operative time is associated with longer length of stay and higher probability of complications, but this negative effect is diminished with minimally invasive approaches. See Video Abstract .

EL IMPACTO DEL TIEMPO OPERATORIO PROLONGADO ASOCIADO CON LA CIRUGA COLORRECTAL MNIMAMENTE INVASIVA UN INFORME DEL PROGRAMA DE EVALUACIN DE RESULTADOS DE ATENCIN QUIRRGICA

ANTECEDENTES:El aumento del tiempo operatorio en la cirugía colorrectal se asocia con peores resultados quirúrgicos. Las operaciones laparoscópicas y robóticas han mejorado los resultados, a pesar de los tiempos operatorios más prolongados. Además, la definición de tiempo operatorio "prolongado" no se ha definido de manera consistente.OBJETIVO:Primero, definir el tiempo operatorio prolongado a través de múltiples operaciones colorrectales y enfoques quirúrgicos. En segundo lugar, describir el impacto del tiempo operatorio prolongado sobre la duración de la estancia y los resultados a corto plazo.DISEÑO:Estudio de cohorte retrospectivo.ESCENARIO:42 hospitales en el Programa de Evaluación de Resultados de Atención Quirúrgica de 2011-2019.PACIENTES:23 098 pacientes adultos (de 18 años de edad y mayores), que se sometieron a seis operaciones colorrectales electivas comunes: colectomía derecha, colectomía izquierda/sigmoidea, colectomía total, resección anterior baja, anastomosis ileoanal con bolsa o resección abdominoperineal.PRINCIPALES MEDIDAS DE RESULTADO:Tiempo operatorio prolongado definido como el cuartil 75 de tiempos operatorios para cada operación y abordaje. Los resultados fueron la duración de la estancia hospitalaria, el alta domiciliaria y las complicaciones. Se usaron modelos ajustados para tener en cuenta los factores que podrían afectar tanto el tiempo operatorio como los resultados en los estratos de abordajes abiertos y mínimamente invasivos.RESULTADOS:El tiempo operatorio prolongado se asoció con una estancia media más prolongada (7 vs. 5 días abiertos, 5 vs. 4 días laparoscópicos, 4 vs. 3 días robóticos), complicaciones más frecuentes (42 % vs. 28 % abiertos, 24 % vs. 17 % laparoscópica, 27% vs. 13% robótica), pero similar alta domiciliaria (86% vs. 87% abierta, 94% vs. 94% laparoscópica, 93% vs. 96% robótica). Después del ajuste, cada hora adicional de tiempo operatorio por encima de la mediana para una operación determinada se asoció con un riesgo relativo de 1,08 (1,06, 1,09) de estancia hospitalaria más larga para operaciones abiertas y un riesgo relativo de 1,07 (1,06, 1,09) para operaciones mínimamente invasivas.LIMITACIONES:Nuestro estudio estuvo limitado por ser retrospectivo, lo que resultó en un sesgo de selección, posibles factores de confusión por un tiempo operatorio prolongado y falta de poder estadístico para los análisis de subgrupos.CONCLUSIONES:El tiempo operatorio tiene una superposición constante entre los enfoques quirúrgicos. El tiempo operatorio prolongado se asocia con una estadía más prolongada y una mayor probabilidad de complicaciones, pero este efecto negativo disminuye con los enfoques mínimamente invasivos. ( Traducción-Dr. Mauricio Santamaria ).

Laparoscopic vs. robotic colectomy for left-sided diverticulitis

Diverticulitis is a prevalent gastrointestinal disease that often warrants surgical intervention. However, the optimal approach between traditional laparoscopy (LC) and robotic-assisted laparoscopy (RAC) for diverticulitis remains unclear. Our research compares these techniques in patients diagnosed with left-sided diverticulitis treated at a single, tertiary referral center from 2019 to 2022. Among the 134 patients, 86 underwent laparoscopic and 48 robotic-assisted surgeries. The surgeries included in this analysis are left colectomy, sigmoid colectomy, low anterior resection, and Hartmann's procedure. Primary outcomes were major morbidity and 30-day mortality. Secondary outcomes were operative time, conversion to open, length of stay, unplanned return to the operating room, 30-day readmission rate, and overall morbidity. While demographics and comorbidities were similar for both groups, the robotic-assisted group displayed a statistically significant longer operative time (198.0 ± 84.4 LC vs. 264.8 ± 78.5 min RAC, p < 0.001). When investigated further, there was a significant difference in operative time for uncomplicated diverticulitis cases favoring the LC approach (169.17 ± 58.1 LC vs. 244.82 ± 58.79 min RAC, p < 0.001). This significant difference, however, was not present in complicated diverticulitis cases. Other factors, such as overall and major morbidity, rate of conversion to open approach, ostomy creation, estimated blood loss, time to return of bowel function, length of stay, and 30-day readmission rate, did not significantly differ between the groups. There was no 30-day mortality in either group. Favorable patient outcomes, lack of significant difference in operative time compared with traditional laparoscopy, and absence of differences in morbidities or efficacy, raises an interesting question in the world of minimally invasive surgery: is the robotic-assisted approach emerging as the advantageous approach for complicated diverticulitis cases? We encourage additional, multi-center analysis of specifically complicated diverticulitis managed with both surgical approaches to investigate if these findings are replicated outside of our institution.

Robotic-assisted colectomy in children: a comparative study with laparoscopic surgery

The aim of this study was to compare outcomes of laparoscopic and robotic-assisted colectomy in children. All children who underwent a colectomy with a laparoscopic (LapC) or robotic-assisted (RobC) approach in our institution (January 2010-March 2023) were included. Demographics, surgical data, and post-operative outcomes within 30 days were collected. Additional cost related to the robotic approach was calculated. Comparisons were performed using Fisher tests for categorical variables and Mann-Whitney tests for continuous variables. A total of 55 colectomies were performed: 31 LapC and 24 RobC (median age: 14.9 years). Main indications included: inflammatory bowel disease (n = 36, 65%), familial adenomatous polyposis (n = 6, 11%), sigmoid volvulus (n = 5, 9%), chronic intestinal pseudo-obstruction (n = 3, 5%). LapC included 22 right, 4 left, and 5 total colectomies. RobC included 15 right, 4 left, and 5 total colectomies. Robotic-assisted surgery was associated with increased operative time (3 h vs 2.5 h, p = 0.02), with a median increase in operative time of 36 min. There were no conversions. Post-operative complications occurred in 35% of LapC and 38% of RobC (p = 0.99). Complications requiring treatment under general anesthesia (Clavien-Dindo 3) occurred in similar rates (23% in LapC vs 13% in RobC, p = 0.49). Length of hospitalization was 10 days in LapC and 8.5 days in RobC (p = 0.39). The robotic approach was associated with a median additional cost of 2156€ per surgery. Robotic-assisted colectomy is as safe and feasible as laparoscopic colectomy in children, with similar complication rates but increased operative times and cost.

Clinical outcomes of elective robotic vs laparoscopic surgery for colon cancer utilizing a large national database

BACKGROUND

Prior studies have shown comparable outcomes between laparoscopic and robotic approaches across a range of surgeries; however, these have been limited in size. This study investigates differences in outcomes following robotic (RC) vs laparoscopic (LC) colectomy across several years utilizing a large national database.

METHODS

We analyzed data from ACS NSQIP for patients who underwent elective minimally invasive colectomies for colon cancer from 2012 to 2020. Inverse probability weighting with regression adjustment (IPWRA) incorporating demographics, operative factors, and comorbidities was used. Outcomes included mortality, complications, return to the operating room (OR), post-operative length of stay (LOS), operative time, readmission, and anastomotic leak. Secondary analysis was performed to further assess anastomotic leak rate following right and left colectomies.

RESULTS

We identified 83,841 patients who underwent elective minimally invasive colectomies: 14,122 (16.8%) RC and 69,719 (83.2%) LC. Patients who underwent RC were younger, more likely to be male, non-Hispanic White, with higher body mass index (BMI) and fewer comorbidities (for all, P < 0.05). After adjustment, there were no differences between RC and LC for 30-day mortality (0.8% vs 0.9% respectively, P = 0.457) or overall complications (16.9% vs 17.2%, P = 0.432). RC was associated with higher return to OR (5.1% vs 3.6%, P < 0.001), lower LOS (4.9 vs 5.1 days, P < 0.001), longer operative time (247 vs 184 min, P < 0.001), and higher rates of readmission (8.8% vs 7.2%, P < 0.001). Anastomotic leak rates were comparable for right-sided RC vs LC (2.1% vs 2.2%, P = 0.713), higher for left-sided LC (2.7%, P < 0.001), and highest for left-sided RC (3.4%, P < 0.001).

CONCLUSIONS

Robotic approach for elective colon cancer resection has similar outcomes to its laparoscopic counterpart. There were no differences in mortality or overall complications, however anastomotic leaks were highest after left RC. Further investigation is imperative to better understand the potential impact of technological advancement such as robotic surgery on patient outcomes.

Berberine as a Potential Agent for the Treatment of Colorectal Cancer

Colorectal cancer (CRC) is one of the most commonly diagnosed and deadly malignancies worldwide. The incidence of CRC has been increasing, especially in young people. Although great advances have been made in managing CRC, the prognosis is unfavorable. Numerous studies have shown that berberine (BBR) is a safe and effective agent presenting significant antitumor effects. Nevertheless, the detailed underlying mechanism in treating CRC remains indistinct. In this review, we herein offer beneficial evidence for the utilization of BBR in the management and treatment of CRC, and describe the underlying mechanism(s). The review emphasizes several therapeutic effects of BBR and confirms that BBR could suppress CRC by modulating gene expression, the cell cycle, the inflammatory response, oxidative stress, and several signaling pathways. In addition, BBR also displays antitumor effects in CRC by regulating the gut microbiota and mucosal barrier function. This review emphasizes BBR as a potentially effective and safe drug for CRC therapy.

Single-incision robotic colectomy versus single-incision laparoscopic colectomy: A matched case control study

BACKGROUND

Single incision laparoscopic colectomy (SILC) and single incision robotic colectomy (SIRC) are both advanced minimally invasive operative techniques. However, studies comparing these two surgical methods have not been published. The purpose of this study is to compare and evaluate the short-term outcomes of SIRC with those of SILC.

METHODS

A total of 21 consecutive patients underwent SIRC and 136 consecutive patients underwent SILC in separate institutes between January 2013 and December 2019. We used retrospective cohort matching to analyze these patients.

RESULTS

Prior to matching, patients who underwent SIRC had a lower percentage of American Society of Anesthesiologists (ASA) grades III-IV (5% vs. 19%, P = 0.11) compared with patients who underwent SILC. The SIRC group revealed a higher proportion of sigmoid colon lesions and anterior resections than the SILC group (61% vs. 45%, P = 0.16). After 1:4 cohort matching, 21 patients were enrolled in the SIRC group and 84 patients were enrolled in the SILC group. No statistically significant difference in terms of operative time (SIRC: 185 ± 46 min, SILC: 208 ± 53 min; P = 0.51), estimated blood loss (SIRC: 12 ± 22 ml, SILC: 85 ± 234 ml; P = 0.12), and complications (SIRC: 4.7%, SIRC: 7.1%; P = 0.31) was observed between these groups. Length of postoperative hospital stay (SIRC: 8.3 ± 1.7 days, SILC: 9.3 ± 6.5; P = 0.10) and number of harvested lymph nodes (SIRC: 21.3 ± 10.3, SILC: 21.3 ± 9.5; P = 0.77) were also similar between the two groups. In subgroup analysis, numbers of harvested lymph node is less in SIRC than SILC (SIRC: 18.1 ± 4.7 vs. SILC: 18.9 ± 8.1, P = 0.04) in anterior resection.

CONCLUSION

SIRC and SILC are safe and feasible procedures with similar surgical and pathological outcomes for right- and left-side colectomy.

Surgical approach for rectal cancer: A network meta-analysis comparing open, laparoscopic, robotic and transanal TME approaches

BACKGROUND

The optimal approach for total mesorectal excision (TME) of rectal cancer remains controversial.

AIM

To compare short- and long-term outcomes after open (OpTME), laparoscopic (LapTME), robotic (RoTME) and transanal TME (TaTME).

METHODS

A systematic search of electronic databases was performed up to January 1, 2020 for randomized controlled trials (RCTs) comparing at least 2 TME strategies. A Bayesian arm-based random effect network meta-analysis (NMA) was performed, specifically, a mixed treatment comparison (MTC).

RESULTS

30 RCTs (and six updates) of 5586 patients with rectal cancer were included. No significant differences were identified in recurrence rates or survival rates. Operating time was shorter with OpTME (surface under the cumulative ranking curve [SUCRA] 0.96) compared to LapTME, RoTME and TaTME. Although OpTME was associated with the most blood loss (SUCRA 0.90) and had a slower recovery with increased length of stay (SUCRA 0.90) compared to the minimally invasive techniques, there was no difference in postoperative morbidity. OpTME was associated with a more complete TME specimen compared to LapTME (Risk Ratio [RR] 1.05, 95% Credible Interval [CrI] 1.01, 1.11), and TaTME had less involved CRMs (RR 0.173, 95% CrI 0.02, 0.76) versus LapTME. There were no differences between the modalities in terms of deep TME defects, DRM distance, or lymph node yield.

CONCLUSIONS

While OpTME was the most effective TME modality for short term histopathological resection quality, there was no difference in long-term oncologic outcomes. Minimally invasive approaches enhance postoperative recovery, at the cost of longer operating times. Technique selection should be based on individual tumour characteristics and patient expectations, as well as surgeon and institutional expertise.

Robotic surgery in colorectal cancer: the way forward or a passing fad

Introduced mainly to overcome the technical limitations of laparoscopy, robotic colorectal surgery (CRS) has been touted to provide superior optics, ergonomics, and surgeon autonomy. This technological advancement is nonetheless associated with certain drawbacks, mainly involving its cost and the lack of unequivocal benefit over conventional laparoscopy. In this era of evidence-based medicine, robotic CRS remains predominantly a subject of individual institution case series, retrospective studies, matched comparisons at best, and repeated reviews of the above literature. This article provides a critique of the more contemporary data regarding the use of robotics in colorectal cancer surgery and the controversies surrounding the literature.

Robotic versus laparoscopic elective colectomy for left side diverticulitis: a propensity score-matched analysis of the NSQIP database

PURPOSE

Robotic surgery might have an advantage over conventional laparoscopy for colonic diverticulitis. We intend to compare both approaches in the elective management of left side diverticulitis.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database (2012-2014) was surveyed for patients undergoing elective left/sigmoid colectomy for diverticulitis. Patient demographics, co-morbidities, disease complexity, and intraoperative details were matched on propensity scores derived from logistic regression model.

RESULTS

We identified 441 robotic and 6584 laparoscopic cases. Mean age was 56.8 years. Mean BMI was 29.5, and 46.5% of patients were males. Low preoperative albumin (< 3.5 mg/dl, 11.1% vs. 6.8%, p = 0.003), splenectomy (0.45% vs. 0.05%, p = 0.002), and enterotomy repair (1.1% vs. 0.4%, p = 0.029) were higher in the robotic group than the laparoscopic group. Hand assistance (35.8% vs. 42.9%, p = 0.003), splenic flexure takedown (41.5% vs. 49.2%, p = 0.002), and ureteric stent placement (18.6% vs. 23.5%, p = 0.017) were less common in the robotic group than the laparoscopic group. Case-matched analysis showed that robotic surgery was associated with shorter hospital stay (3.89 ± 2.18 days vs. 4.75 ± 3.25 days, p < 0.001), lower conversion rate (7.5% vs. 14.3%, p = 0.001), and longer operative time (219.2 ± 95.6 min vs. 188.8 ± 82.3 min, p < 0.001) than laparoscopic surgery. Robotic approach was associated with lower overall morbidity in multivariate analysis (OR = 0.72, 95% CI = 0.55-0.96), but not in case-matched analysis (14.4% vs. 19.2%, p = 0.058).

CONCLUSIONS

Robotic surgery is associated with shorter hospital stay and lower conversion rate and may offer lower overall morbidity than laparoscopy after elective left side colectomy for diverticulitis. Controlled prospective studies are needed to confirm these findings.

Do prolonged operative times obviate the benefits associated with minimally invasive colectomy?

BACKGROUND

Minimally invasive colectomy is associated with improved length of stay and decreased postoperative morbidity. Little is known regarding the impact of prolonged operative time on the benefits afforded by minimally invasive colectomy.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program procedure targeted colectomy dataset was queried to identify elective right and left colectomies performed between 2011 and 2017. Multivariable modeling was used to compare rates of composite 30-day death or serious morbidity, overall morbidity, mortality, anastomotic leak, surgical site infection, and length of stay for prolonged minimally invasive cases to those for average duration open cases.

RESULTS

A total of 16,602 right colectomies and 36,557 left colectomies were identified. Median operative times for open and minimally invasive right colectomies were 107 min and 129 min (P < .01), while that for open left colectomies was 128 min and 156 min for minimally invasive left colectomies (P < .01). Cohorts were stratified by quartiles of operative time with the highest (fourth) quartile defined as a prolonged operating time. When compared with an average duration open colectomy, prolonged minimally invasive right colectomies and left colectomies were associated with decreased risk-adjusted rates of overall morbidity, surgical site infection, and with lesser lengths of stay (P < .05). Prolonged minimally invasive left colectomies were also associated with improved rates of composite 30-day death or serious morbidity relative to average open left colectomies (odds ratio 0.66, 95% confidence interval, 0.54-0.79).

CONCLUSION

Prolonged operating times of an minimally invasive approach do not obviate the benefits of an minimally invasive approach to colectomy.

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.

What have we learned in minimally invasive colorectal surgery from NSQIP and NIS large databases? A systematic review

BACKGROUND

"Big data" refers to large amount of dataset. Those large databases are useful in many areas, including healthcare. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the National Inpatient Sample (NIS) are big databases that were developed in the USA in order to record surgical outcomes. The aim of the present systematic review is to evaluate the type and clinical impact of the information retrieved through NISQP and NIS big database articles focused on laparoscopic colorectal surgery.

METHODS

A systematic review was conducted using The Meta-Analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. The research was carried out on PubMed database and revealed 350 published papers. Outcomes of articles in which laparoscopic colorectal surgery was the primary aim were analyzed.

RESULTS

Fifty-five studies, published between 2007 and February 2017, were included. Articles included were categorized in groups according to the main topic as: outcomes related to surgical technique comparisons, morbidity and perioperatory results, specific disease-related outcomes, sociodemographic disparities, and academic training impact.

CONCLUSIONS

NSQIP and NIS databases are just the tip of the iceberg for the potential application of Big Data technology and analysis in MIS. Information obtained through big data is useful and could be considered as external validation in those situations where a significant evidence-based medicine exists; also, those databases establish benchmarks to measure the quality of patient care. Data retrieved helps to inform decision-making and improve healthcare delivery.

Propensity Score-Matched Analysis of Clinical and Financial Outcomes After Robotic and Laparoscopic Colorectal Resection

PURPOSE

The study aims to evaluate the clinical and financial outcomes of the use of robotic when compared to laparoscopic colorectal surgery and any changes in these over time.

METHODS

From the Premier Perspective database, patients who underwent elective laparoscopic and robotic colorectal resections from 2012 to 2014 were included. Laparoscopic colorectal resections were propensity score matched to robotic cases for patient, disease, procedure, surgeon specialty, and hospital type and volume. The two groups were compared for conversion, hospital stay, 30-day post-discharge readmission, mortality, and complications. Direct, cumulative, and total (including 30-day post-discharge) costs were evaluated. Clinical and financial outcomes were also separately assessed for each of the included years.

RESULTS

Of 36,701 patients, 32,783 (89.3%) had laparoscopic colorectal resection and 3918 (10.7%) had robotic colorectal resection; 4438 procedures (2219 in each group) were propensity score matched. For the entire period, conversion to open approach (4.7 vs. 3.7%, p = 0.1) and hospital stay (mean days [SD] 6 [5.3] vs. 5 [4.6], p = 0.2) were comparable between robotic and laparoscopic procedures. Surgical and medical complications were also the same for the two groups. However, the robotic approach was associated with lower readmission (6.3 vs. 4.8%, p = 0.04). Wound or abdominal infection (4.7 vs. 2.3%, p = 0.01) and respiratory complications (7.4 vs. 4.7%, p = 0.02) were significantly lower for the robotic group in the final year of inclusion, 2014. Direct, cumulative, and total (including 30-day post-discharge) costs were significantly higher for robotic surgery. The difference in costs between the two approaches reduced over time (direct cost difference: 2012, $2698 vs. 2013, $2235 vs. 2014, $1402).

CONCLUSION

Robotic colorectal surgery can be performed with comparable clinical outcomes to laparoscopy. With greater use of the technology, some further recovery benefits may be evident. The robotic approach is more expensive but cost differences have been diminishing over time.

The robotic approach significantly reduces length of stay after colectomy: a propensity score-matched analysis

PURPOSE

Robotic surgery has helped overcome several of the inherent limitations of conventional laparoscopy. The aim of this study is to identify any short-term advantage of robotic-assisted (RC) over laparoscopic colectomy (LC) using standardized nationwide data.

METHODS

Patients from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) 2012-2014 datasets who underwent elective LC or RC were compared for patient demographics, comorbidity, diagnosis, extent of colon resection, operative duration, and conversion rates. Thirty-day postoperative complications and post-discharge utilization of resources, readmission, and discharge to another facility were also evaluated. Propensity score matching was used to balance the sample size in the two groups.

RESULTS

Of 35,839 LC and RC procedures, 2482 cases were eligible for propensity score matching for the statistically significant variables (standardized difference > 0.10) and 1241 colectomy procedures were assigned to each group. Most of the major, minor surgical, and medical postoperative complications were comparable between the two groups. However, RC was associated with reduced 30-day postoperative septic complications (2.3 vs. 4%, p = 0.02), hospital stay (mean: 4.8 vs. 6.3 days, p = 0.001), and discharge to another facility (3.5 vs. 5.8%, p = 0.01). RC was, however, associated with readmission within 30 days after surgery (9.4 vs. 9.1%, p = 0.049). Postoperative ileus, anastomotic leak, reoperation, reintubation, and mortality were equivalent between RC and LC.

CONCLUSION

This propensity score-matched analysis suggests that RC is associated with some recovery benefits over LC. Greater experience with the technique may allow these advantages to counter some of the cost-related concerns that have deterred the more widespread utilization of robotic technology for colectomy.

Re-appraisal and consideration of minimally invasive surgery in colorectal cancer

Throughout history, surgeons have been on a quest to refine the surgical treatment options for their patients and to minimize operative trauma. During the last three decades, there have been tremendous advances in the field of minimally invasive colorectal surgery, with an explosion of different technologies and approaches offered to treat well-known diseases. Laparoscopic surgery has been shown to be equal or superior to open surgery. The boundaries of laparoscopy have been pushed further, in the form of single-incision laparoscopy, natural-orifice transluminal endoscopic surgery and robotics. This paper critically reviews the pathway of development of minimally invasive surgery, and appraises the different minimally invasive colorectal surgical approaches available to date.

Robotic Inguinal Hernia Repair: Technique and Early Experience

Laparoscopic inguinal hernia repair has been shown to have multiple advantages compared with open repair such as less postoperative pain and earlier resume of daily activities with a comparable recurrence rate. We speculate robotic inguinal hernia repair may yield equivalent benefits, while providing the surgeon added dexterity. One hundred consecutive robotic inguinal hernia repairs with mesh were performed with a mean age of 56 years (25–96). Fifty-six unilateral hernias and 22 bilateral hernias were repaired amongst 62 males and 16 females. Polypropylene mesh was used for reconstruction. All but, two patients were completed robotically. Mean operative time was 52 minutes per hernia repair (45–67). Five patients were admitted overnight based on their advanced age. Regular diet was resumed immediately. Postoperative pain was minimal and regular activity was achieved after an average of four days. One patient recurred after three months in our earlier experience and he was repaired robotically. Mean follow-up time was 12 months. These data, compared with laparoscopic approach, suggest similar recurrence rates and postoperative pain. We believe comparative studies with laparoscopic approach need to be performed to assess the role robotic surgery has in the treatment of inguinal hernia repair.

Robotics in Colorectal Surgery

Over the past few decades, robotic surgery has developed from a futuristic dream to a real, widely used technology. Today, robotic platforms are used for a range of procedures and have added a new facet to the development and implementation of minimally invasive surgeries. The potential advantages are enormous, but the current progress is impeded by high costs and limited technology. However, recent advances in haptic feedback systems and single-port surgical techniques demonstrate a clear role for robotics and are likely to improve surgical outcomes. Although robotic surgeries have become the gold standard for a number of procedures, the research in colorectal surgery is not definitive and more work needs to be done to prove its safety and efficacy to both surgeons and patients.

Laparoscopic versus robotic colectomy: a national surgical quality improvement project analysis

INTRODUCTION

Robotic colorectal surgery is being increasingly adopted. Our objective was to compare early postoperative outcomes between robotic and laparoscopic colectomy in a nationally representative sample.

METHODS

The American College of Surgeons National Surgical Quality Improvement Project Colectomy Targeted Dataset from 2012 to 2014 was used for this study. Adult patients undergoing elective colectomy with an anastomosis were included. Patients were stratified based on location of colorectal resection (low anterior resection (LAR), left-sided resection, or right-sided resection). Bivariate data analysis was performed, and logistic regression modeling was conducted to calculate risk-adjusted 30-day outcomes.

RESULTS

There were a total of 25,998 laparoscopic colectomies (30 % LAR's, 45 % left-sided, and 25 % right-sided) and 1484 robotic colectomies (54 % LAR's, 28 % left-sided, and 18 % right-sided). The risk-adjusted overall morbidity, serious morbidity, and mortality were similar between laparoscopic and robotic approaches in all anastomotic groups. Patients undergoing robotic LAR had a lower conversion rate (OR 0.47, 95 % CI 1.20-1.76) and postoperative sepsis rate (OR 0.49, 95 % CI 0.29-0.85) but a higher rate of diverting ostomies (OR 1.45, 95 % CI 1.20-1.76). Robotic right-sided colectomies had significantly lower conversion rates (OR 0.58, 95 % CI 0.34-0.96). Robotic colectomy in all groups was associated with a longer operative time (by 40 min) and a decreased length of stay (by 0.5 days).

CONCLUSIONS

In a nationally representative sample comparing laparoscopic and robotic colectomies, the overall morbidity, serious morbidity, and mortality between groups are similar while length of stay was shorter by 0.5 days in the robotic colectomy group. Robotic LAR was associated with lower conversion rates and lower septic complications. However, robotic LAR is also associated with a significantly higher rate of diverting ostomy. The reason for this relationship is unclear. Surgeon factors, patient factors, and technical factors should be considered in future studies.