A propensity score matched comparison of intracorporeal and extracorporeal techniques for robotic-assisted sigmoidectomy in an enhanced recovery pathway

Robotic Sigmoidectomy for Diverticular Disease

Introduction: Historically, colon resection was recommended after one episode of complicated diverticulitis. However, current trends favor a more individualized approach. This review examines elective sigmoidectomy for complicated diverticulitis as well as robotic approaches for diverticular disease. Methods: The literature was reviewed for timely (post 2000) and relevant articles regarding robotics and diverticulitis. The articles included large prospective series, retrospective analysis, meta-analyses and randomized controlled trials. Results: Primary anastomosis with or without protective ileostomy has emerged as an alternative to the Hartman's procedure in emergent or urgent surgery in patients without significant comorbidities. Elective sigmoidectomy after an episode of complicated diverticulitis should be decided on a case-by-case basis considering patient characteristics, continued subacute symptoms, complications from the disease, and chance of recurrence episodes. Conclusions: There are several variations techniques for robotic sigmoidectomy outlined in this article, and familiarity with all can help depending on the logistics of the case. Minimally invasive colectomy provides superior patient satisfaction and outcomes.

Robotic Rectosigmoid Resection with Totally Intracorporeal Colorectal Anastomosis (TICA) for Recurrent Ovarian Cancer: A Case Series and Description of the Technique

BACKGROUND

Most patients with ovarian cancer relapse within 2 years. Prospective randomized trials, such as DESKTOP III and SOC-I, have shown the role of secondary cytoreduction in improving oncological outcomes in selected patients, when complete tumor resection is achieved. Recent retrospective series suggest that minimally invasive surgery is a feasible option in oligometastatic recurrences, such as rectal ones.

METHODS

Five patients with an isolated rectal recurrence infiltrating the bowel wall underwent a robotic rectosigmoid resection with totally intracorporeal colorectal anastomosis. The procedure began with retroperitoneal access to manage the vascular structures, followed by visceral resection with a minimally invasive approach. The standard steps of an en-bloc pelvic resection, including intracorporeal end-to-end anastomosis, were performed. The treatment data were evaluated.

RESULTS

The mean age of the patients was 54 years, and their mean body mass index was 30. All patients had at least one previous abdominal surgery and 60% had high-grade serous ovarian cancer at their initial diagnosis. Their mean platinum-free interval was 17.4 months. Complete secondary cytoreduction was achieved in all cases, with histopathology confirming bowel infiltration. The mean procedure duration was 294 min, with an estimated blood loss of 180 mL. No intraoperative complications occurred. The mean hospital stay was 8 days. One patient had a grade 2 postoperative complication. The mean follow-up period was 14 months, with only one patient experiencing a recurrence at the level of the abdominal wall.

CONCLUSIONS

Robotic rectosigmoid resection is a viable option for complete cytoreduction in isolated recurrent ovarian cancer.

Minimally invasive left colectomy with total intracorporeal anastomosis versus extracorporeal anastomosis. A single center cohort study. Stage 2b IDEAL framework for evaluating surgical innovation

PURPOSE

Performing intracorporeal anastomoses in minimally invasive colon surgery appears to provide better short-term outcomes for patients with colon cancer. The aim of the study is to compare surgical aspects and short-term outcomes between intracorporeal and extracorporeal techniques in left colectomies with both laparoscopic and robotic approaches and evaluate advantages and disadvantages of intracorporeal anastomosis according to IDEAL framework (Exploration, stage 2b).

METHODS

This is a single center, ambispective cohort study comparing total intracorporeal anastomosis (TIA) and standard surgery with extracorporeal anastomosis (EA). Patients with colon cancer treated by left colectomy, sigmoidectomy and high anterior resection by total intracorporeal anastomosis between May 2020 and January 2023 without exclusion criteria were prospectively included in a standardized database. Short-term outcomes in the group undergoing TIA were compared with a historical EA cohort. The main assessment outcomes were intraoperative complications, postoperative morbidity according to the Clavien-Dindo scale and the comparison of pathological. We conducted a preliminary comparative study within the TIA group between approaches, a primary analysis between the two anastomotic techniques, and a propensity score matched analysis including only the laparoscopic approach, between both anastomotic techniques.

RESULTS

Two hundred and forty-six patients were included: 103 who underwent TIA, 35 of them with laparoscopic approach and 68 with robotic approach, and a comparison group comprising another 103 eligible consecutive patients who underwent laparoscopic EA. There were no statistically significant differences between the two groups in terms of demographic variables. No statistically significant differences were observed in anastomotic dehiscence. Intraoperative complications are fewer in the TIA group, with a higher C-Reactive Protein levels. Relevant anastomotic bleeding and the number of retrieved lymph nodes were higher in EA group. Nevertheless, no differences were observed in terms of overall morbidity.

CONCLUSION

Minimally invasive left colectomy with intracorporeal resection and anastomosis is technically feasible and safe suing either a laparoscopic or a robotic approach. Clinical data from this cohort demonstrate outcomes comparable to those achieved through the conventional EA procedure in relation to postoperative morbidity and oncological efficacy, with indications suggesting that the utilization of robotic-assisted techniques may play a contributing role in enhancing overall treatment outcomes.

Robotic Proctectomy: Beyond the Initial Learning Curve

BACKGROUND

Multiple authors have described an initial learning curve (LC) for robotic proctectomy (RP), but there is scant literature regarding continued technical progression beyond this stage. Total operating time is the most commonly used metric to measure proficiency. Our goal was to examine RP experience after the initial LC looking for evidence of further technical progression.

METHODS

We reviewed our robotic surgery database for a single surgeon during operations 100 through 550 to identify 83 RPs for tumor. These were divided into quartiles by series order, indicating surgeon experience level over time. Demographics and outcomes were compared among the groups. We defined percent console time (PCT) as a new metric. PCT was defined as console time divided by total operative time (TOT).

RESULTS

From March 2014 through March 2019, 450 robotic colorectal operations were performed, including 83 RPs for polyp or cancer. No significant differences were found among the quartiles in regard to demographics, tumor features, hospital stay, conversions, or readmissions. As experience was gained, there were significant increases in intracorporeal anastomosis (ICA), TOT, and PCT. Complications decreased with experience. Number of lymph nodes in the specimen increased. On multivariate analysis, later experience group, body mass index ≥30, and ICA were associated with increased PCT.

DISCUSSION

ICA became a routine part of RP after the initial LC, with increases in TOT and PCT. Number of lymph nodes increased and number and severity of complications decreased with experience. Increased PCT may indicate increased expertise during RP.

Comparison of intracorporeal and extracorporeal anastomosis in left hemicolectomy: updated meta-analysis of retrospective control trials

BACKGROUND

The feasibility and effectiveness of selecting an intracorporeal or extracorporeal technique in left hemicolectomy remain poorly understood. This meta-analysis aimed to evaluate the difference between the two approaches regarding intraoperative and postoperative outcomes.

METHODS

A thorough exploration of online databases (PubMed, Embase, Cochrane, and Web of Science) was executed to identify randomized controlled trials, cohort studies, and case control studies. The outcomes contained four aspects: intraoperative outcomes, postoperative complications, postoperative patient conditions, and postoperative outcomes. All of these data were analyzed using RevMan 5.4. Seven retrospective control trials (intracorporeal, 396 patients; extracorporeal, 426 patients) were evaluated.

RESULTS

Compared to the extracorporeal group, the intracorporeal group demonstrated superiority in incision length (P = 0.005), overall complications (P = 0.01), time to first flatus (P < 0.001), time to first stool (P = 0.005), time to first diet (P < 0.001) and hospital stay duration (P = 0.001).

CONCLUSIONS

The intracorporeal technique is associated with superiority over the extracorporeal technique in reducing postoperative complications, promoting postoperative recovery of gastrointestinal function, and reducing hospital stay duration.

Robotic-assisted intracorporeal versus extracorporeal techniques in sigmoidectomy: a propensity score-matched analysis

Scarce research has been performed to assess the safety and efficacy of anastomosis technique on robotic-assisted sigmoidectomy. This study was designed to evaluate the difference between intracorporeal and extracorporeal techniques during robotic-assisted sigmoidectomy. Clinical data of 193 cases who received robotic-assisted sigmoidectomy were retrospectively collected and analyzed. Only 116 cases were available for analysis (intracorporeal group = 58 and extracorporeal group = 58) after propensity score matching. Independent sample t test was conducted to evaluate the continuous variables. Moreover, the statistical significance of categorical variables was tested using Chi-square or Fisher's exact tests. Statistical analysis showed that the intracorporeal group demonstrated greater superiorities in pain scale on the first and second postoperative day (P < 0.05), time of catheter indwelling (P = 0.009), and length of hospital stay (P = 0.019). Additionally, the intracorporeal technique contributed to fewer complications including urinary retention (P = 0.027) and hernia (P = 0.037) than the extracorporeal group. Our analysis revealed that intracorporeal technique was safe and feasible due to the shorter time of catheter indwelling and length of hospital stay and fewer post-operation complications.

Health-care expenditures are less for minimally invasive than open colectomy for colon cancer: A US commercial claims database analysis

BACKGROUND

Most studies comparing surgical platforms focus on short-term outcomes. In this study, we compare the expanding societal penetration of minimally invasive surgery (MIS) with open colectomy by assessing payer and patient expenditures up to one year for patients undergoing surgery for colon cancer.

METHODS

We analyzed the IBM MarketScan Database for patients who underwent left or right colectomy for colon cancer between 2013 and 2020. Outcomes included perioperative complications and total health-care expenditures up to 1 year following colectomy. We compared results for patients who had open colectomy (OS) to those with MIS operations. Subgroup analyses were performed for adjuvant chemotherapy (AC+) versus no adjuvant chemotherapy (AC-) groups and for laparoscopic (LS) versus robotic (RS) approaches.

RESULTS

Of 7,063 patients, 4,417 cases did not receive adjuvant chemotherapy (OS: 20.1%, LS: 67.1%, RS: 12.7%) and 2646 cases had adjuvant chemotherapy (OS: 28.4%, LS: 58.7%, RS: 12.9%) after discharge. MIS colectomy was associated with lower mean expenditure at index surgery and post-discharge periods for AC- patients (index surgery: $34,588 vs $36,975; 365-day post-discharge $20,051 vs $24,309) and for AC+ patients (index surgery: $37,884 vs $42,160; 365-day post-discharge $103,341vs $135,113; p < 0.001 for all comparisons). LS had similar index surgery expenditures but significantly higher expenditures at post-discharge 30 days (AC-: $2,834 vs $2276, p = 0.005; AC+: $9100 vs $7698, p = 0.020) than RS. The overall complication rate was significantly lower in the MIS group than the open group for AC- patients (20.5% vs 31.2%) and AC+ patients (22.6% vs 39.1%, both p < 0.001).

CONCLUSION

MIS colectomy is associated with better value at lower expenditure than open colectomy for colon cancer at the index operation and up to one year after surgery. RS expenditure is less than LS in the first 30 postoperative days regardless of chemotherapy status and may extend to 1 year for AC- patients.

Anastomotic Considerations in Diverticulitis

Diverticulitis is a common indication for colorectal surgery, both in the acute and the elective setting. The anastomosis between the colon and rectum is a critical component of colectomy for diverticular disease and should be approached thoughtfully. This article reviews important surgical considerations when creating a colorectal anastomosis in the setting of diverticular disease, whether following the reversal of an end colostomy, during an acute episode of diverticulitis, or electively for chronic or complicated disease. Timing of surgery and preoperative assessment, minimally invasive approaches, and intraoperative maneuvers and considerations are discussed.

Robotic Anastomotic Technique

The first robotic colectomy was performed 20 years ago. Since that time, the robotic surgery platform has made significant advancements and become increasingly prevalent in colorectal surgery. The da Vinci Xi system (Intuitive Surgical, Sunnyvale, CA) and technology such as integrated table motion has facilitated multiquadrant procedures. Intracorporeal anastomoses (ICAs) have proven benefit in the literature, including decreased length of stay, decreased narcotic requirements, and lower rate of postoperative wound infections and hernias. Additional studies have shown a lower conversion to open rate in robotic surgery compared with laparoscopy. In this article, we will describe techniques for creation of robotic ICAs.

Robotic left hemicolectomy with intracorporeal anastomosis: Description of the technique and initial results

AIM

The aim was to describe the robot-assisted intracorporeal anastomosis technique in left colon surgery (rLCS) and report the initial results.

METHOD

The rLCS was performed in 25 consecutive patients, starting with a Pfannenstiel incision and introducing a prepared anvil. The robot was docked and the affected segment resected. Colotomy was performed and the anvil was introduced in the proximal segment. End-to-end anastomosis was performed and reinforced. An air-leak test was performed.

RESULTS

The results varied in terms of patient's age, American Society of Anesthesiologists grade, weight and the technique performed. Most patients had cancer. There was no suture failure or mortality, and the mean hospital stay was 3 days.

CONCLUSIONS

The rLCS is a safe, reproducible technique with good initial results. Prospective studies should be performed to demonstrate its advantages.

Postoperative Pain After Enhanced Recovery Pathway Robotic Colon and Rectal Surgery: Does Specimen Extraction Site Matter?

BACKGROUND

The current opioid crisis has motivated surgeons to critically evaluate ways to balance postoperative pain while decreasing opioid use and thereby reducing opioids available for community diversion. The longest incision for robotic colorectal surgery is the specimen extraction site incision. Intracorporeal techniques allow specimen extraction to be at any location.

OBJECTIVE

This study was designed to determine whether the Pfannenstiel location is associated with less pain and opioid use than other abdominal wall specimen extraction sites.

DESIGN

This was a retrospective cohort study.

SETTINGS

The study was conducted with a prospectively maintained colorectal surgery database (July 2018 through October 2019).

PATIENTS

Patients with enhanced recovery robotic colorectal resections with specimen extraction were included.

MAIN OUTCOME MEASURES

Propensity score weighting was used to derive adjusted rates for numeric pain scores, inpatient opioid use, opioids prescribed at discharge, opioid refills after discharge, and other related outcomes. For comparing outcomes between groups, p values were calculated using weighted χ2, Fisher exact, and t tests.

RESULTS

There were 137 cases (70.9%) with Pfannenstiel extraction site incisions and 56 (29.0%) at other locations (7 midline, 49 off-midline). There was no significant difference in transversus abdominis plane blocks and epidural analgesia use between groups. Numeric pain scores, overall benefit of analgesia scores, inpatient postoperative opioid use, opioids prescribed at discharge and taken after discharge, and opioid refills were not significantly different between groups. Nonopioid pain analgesics (acetaminophen, nonsteroidal anti-inflammatory drugs, and gabapentin) prescribed at discharge were significantly less in the Pfannenstiel group (90.19% vs 98.45%; p = 0.006). Postoperative complications and readmissions were not different between groups.

LIMITATIONS

This study was conducted at a single institution.

CONCLUSIONS

The Pfannenstiel incision as the specimen extraction site choice in minimally invasive surgery is associated with similar postoperative pain and opioid use as extraction sites in other locations for patients having robotic colorectal resections. Specimen extraction sites may be chosen based on patient factors other than pain and opioid use. See Video Abstract at http://links.lww.com/DCR/B495.

DOLOR POSTOPERATORIO DESPUS DE VAS DE RECUPERACIN MEJORADA EN CIRUGA ROBTICA DE COLON Y RECTO IMPORTA EL LUGAR DE EXTRACCIN DE LA MUESTRA

ANTECEDENTES:La actual crisis de opioides ha motivado a los cirujanos a evaluar críticamente, formas para equilibrar el dolor postoperatorio, disminuyendo el uso de opioides y por lo tanto, disminuyendo opioides disponibles para el desvío comunitario. La incisión más amplia en cirugía colorrectal robótica, es la incisión del sitio de extracción de la muestra. Las técnicas intracorpóreas permiten que la extracción de la muestra se realice en cualquier sitio.OBJETIVO:El estudio fue diseñado para determinar si la ubicación del Pfannenstiel está asociada con menos dolor y uso de opioides, a otros sitios de extracción de la muestra en la pared abdominal.DISEÑO:Estudio de cohorte retrospectivo.AJUSTES:Estudio de base de datos de cirugía colorrectal mantenida prospectivamente (7/2018 a 10/2019).PACIENTES:Se incluyeron resecciones robóticas colorrectales con recuperación mejorada y extracción de muestras.PRINCIPALES MEDIDAS DE RESULTADO:Se utilizó la ponderación del puntaje de propensión para derivar las tasas ajustadas para los puntajes numéricos de dolor, uso de opioides en pacientes hospitalizados, opioides recetados al alta, recarga de opioides después del alta y otros resultados relacionados. Para comparar los resultados entre los grupos, los valores p se calcularon utilizando chi-cuadrado ponderado, exacto de Fisher y pruebas t.RESULTADOS:Hubo 137 (70,9%) casos con incisiones en el sitio de extracción de Pfannenstiel y 56 (29,0%) en otras localizaciones (7 en la línea media, 49 fuera de la línea media). No hubo diferencias significativas en los bloqueos del plano transverso del abdomen y el uso de analgesia epidural entre los grupos. Las puntuaciones numéricas de dolor, puntuaciones de beneficio general de la analgesia, uso postoperatorio de opioides en pacientes hospitalizados, opioides recetados al alta y tomados después del alta, y las recargas de opioides, no fueron significativamente diferentes entre los grupos. Los analgésicos no opioides (acetaminofén, antiinflamatorios no esteroideos, gabapentina) prescritos al alta, fueron significativamente menores en el grupo de Pfannenstiel (90,19% frente a 98,45%, p = 0,006). Las complicaciones postoperatorias y los reingresos, no fueron diferentes entre los grupos.LIMITACIONES:Una sola institución.CONCLUSIÓN:La incisión de Pfannenstiel como sitio de extracción de la muestra en cirugía mínimamente invasiva, se asocia con dolor postoperatorio y uso de opioides similar, a otros sitios de extracción en pacientes sometidos a resecciones robóticas colorrectales. Sitios de extracción de la muestra, pueden elegirse en función de factores del paciente distintos al dolor y uso de opioides. Consulte Video Resumen en http://links.lww.com/DCR/B495.).

A national database propensity score-matched comparison of minimally invasive and open colectomy for long-term opioid use

Background

Opioid dependence is a public health crisis and surgery is a risk factor for long-term opioid use. Though minimally invasive surgery (MIS) is associated with less perioperative pain, demonstrating an association with less long-term opioid use would be another reason to justify adoption of minimally invasive techniques. We compared the rates for long-term opioid prescriptions among patients in a large national database who underwent minimally invasive and open colectomy.

Methods

Using the MarketScan Database, we retrospectively analyzed patients undergoing colon resection for benign and malignant diseases between 2013 and 2017. Among opioid-naïve patients who had ≥ 1 opioid prescriptions filled perioperatively (30 days before surgery to 14 days after discharge), propensity score matching was applied for group comparisons [open (OS) versus MIS, and laparoscopic (LS) versus robotic-assisted surgery (RS)]. The primary outcome was long-term opioid use defined as the proportion of patients with ≥ 1 long-term opioid prescriptions filled 90–180 days after discharge. Risks factors for long-term opioid use were assessed using logistic regression.

Results

Among the 5413 matched pairs in the MIS versus OS cohorts, MIS significantly reduced long-term opioid use of ‘any opioids’ (13.3% vs. 20.9%), schedule II/III opioids (11.7% vs. 19.2%), and high-dose opioids (4.3% vs. 7.7%; all p < 0.001). Among the 1195 matched pairs in the RS versus LS cohorts, RS was associated with less high-dose opioids (2.1% vs. 3.8%, p = 0.015) 90–180 days after discharge. Other risk factors for long-term opioid use included younger age, benign indications, tobacco use, mental health conditions, and > 6 Charlson comorbidities.

Conclusion

Minimally invasive colectomy is associated with a significant reduction in long-term opioid use when compared to OS. Robotic-assisted colectomy was associated with less high-dose opioids compared to LS. Increasing adoption of minimally invasive surgery for colectomy and including RS, where appropriate, may decrease long-term opioid use.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08338-9.

The art of robotic colonic resection: a review of progress in the past 5 years

Surgery is developing in the direction of minimal invasiveness, and robotic surgery is becoming increasingly adopted in colonic resection procedures. The ergonomic improvements of robot promote surgical performance, reduce workload for surgeons and benefit patients. Compared with laparoscopy-assisted colon surgery, the robotic approach has the advantages of shorter length of hospital stay, lower rate of conversion to open surgery, and lower rate of intraoperative complications for short-term outcomes. Synchronous robotic liver resection with colon cancer is feasible. The introduction of the da Vinci Xi System (Intuitive Surgical, Inc., Sunnyvale, CA, USA) has introduced more flexibility to colonic operations. Optimization of the suprapubic surgical approach may shorten the length of hospital stay for patients who undergo robotic colonic resection. Single-port robotic colectomy reduces the number of robotic ports for better looking and faster recovery. Intestinal anastomosis methods using totally robotic surgery result in shorter time to bowel function recovery and tolerance to a solid diet, although the operative time is longer. Indocyanine green is used as a tracer to assess blood supplementation in the anastomosis and marks lymph nodes during operation. The introduction of new surgical robots from multiple manufacturers is bound to change the landscape of robotic surgery and yield high-quality surgical outcomes. The present article reviews recent advances in robotic colonic resection over the past five years.

Intracorporeal anastomosis versus extracorporeal anastomosis for minimally invasive colectomy

Outcomes advantages for the minimally invasive approach to colon and rectal surgery have been clearly described since the original report of a laparoscopic colectomy in 1991. Advancements in minimally invasive options for colon and rectal surgery have produced the need for critical evaluation of alternative and evolving techniques. The evolution and increased adoption of the minimally invasive robotic platform has allowed the intracorporeal anastomosis, previously described with the laparoscopic approach, to be more widely available to surgeon skill sets because of robotic articulating instruments and ergonomic advantages. Studies comparing intra- and extracorporeal techniques for laparoscopic right colectomy have demonstrated some outcomes advantages for the intracorporeal approach that include fewer conversions-to-open, fewer postoperative complications, and shorter hospital length of stay. Recent robotic-assisted comparisons have also shown an intracorporeal advantage and have extended the analysis to left-sided colorectal resections. Further upgrades in minimally invasive options and techniques warrant further evidence-based considerations for surgeons choosing between these options and techniques.