Robotic ileocolic resection with intracorporeal anastomosis for Crohn's disease

The outcomes of robotic ileocolic resection in Crohn's disease compared with laparoscopic and open surgery: a meta-analysis and systematic review

BACKGROUND

This is the first review providing insights into the outcomes of robotic ileocolic resection for Crohn's disease, potentially guiding improved surgical decisions and patient outcomes and comparing outcomes with laparoscopic and open approaches.

METHODS

The review was registered prospectively with PROSPERO (CRD42024504839). A comprehensive search of MEDLINE, Embase, Scopus, and Cochrane Central databases for studies on robotic ileocolic resection for Crohn's disease from inception to February 2024 was conducted. Eligible studies included participants over 18 years of age with Crohn's disease undergoing robotic ileocolic resection. Data were extracted according to PRISMA guidelines. For single-arm analyses, the random-effects model was used, while two-arm analyses employed the inverse variance and Mantel-Haenszel methods.

RESULTS

The analysis included eight studies with 5760 patients, among whom 369 underwent robotic ileocolic resection. The mean operative time for robotic procedures was 226 min. Postoperative complications included ileus in 12.50% and wound complications in 7.00%, while reoperations and readmissions occurred in 3.60% and 13.20% of patients, respectively. When compared with laparoscopic procedures, robotic procedures showed shorter length of hospital stay and longer operative times but similar total complication, reoperation, and conversion rates. In contrast, robotic procedures had fewer total postoperative complications compared with open surgeries, despite longer operative times.

CONCLUSIONS

Robotic ileocolic resection for Crohn's disease, while having a longer operative time, results in fewer postoperative complications compared with open surgery and shows comparable outcomes to laparoscopic procedures with shorter hospital stays.

Laparoscopic robotic-assisted ileo-caecal resection with intracorporeal anastomosis in children with Crohn disease: initial experience of a paediatric center and surgical feasibility

PURPOSE

Pediatric-onset Crohn's disease (CD) presents with a more aggressive course than adults. Surgical treatment is still necessary in many patients. The laparoscopic technique for treating terminal ileal CD is deemed safe and feasible, with the advantage to perform an intra-corporeal anastomosis (ICA). The robotic platform facilitates ICA creation thanks to 3D-visualization, tenfold magnification and better dexterity. The aim of this study was to report our initial experience of robotic ileocecal resection (RICR) with ICA in children with CD.

METHODS

Six patients underwent RICR for CD. Patient characteristics, intraoperative details, and postoperative outcomes were collected. The surgical technique consisted in an intra-corporeal ICR with a stapled side-to-side ileo-colic anastomosis.

RESULTS

The mean age at surgery was 14.8 years. The mean operative time was 210.8 min. No intraoperative complications or conversions were recorded. Bowel function returned on postoperative day 3 and the mean hospital stay was 8 days. Two minor complications were treated conservatively and 1 major (anastomotic dehiscence) required reoperation.

CONCLUSION

RICR is a safe and feasible technique in pediatric CD of terminal ileum. The robot offers advantages over other techniques for the precision of the suture, avoiding extracorporeal anastomosis. However, larger studies are needed to confirm these preliminary results.

Outcomes of robotic surgery for inflammatory bowel disease using the Medtronic Hugo™ Robotic-Assisted Surgical platform: a single center experience

PURPOSE

The aim of the study was to compare the perioperative outcomes of patients affected by inflammatory bowel disease (IBD) who underwent surgery performed through laparoscopy or using the Medtronic Hugo™ RAS.

METHODS

This is a retrospective study from a prospectively maintained database comparing laparoscopic vs. robotic-assisted surgery for IBD from 01/11/2017 to 15/04/2024. All procedures were performed by a single surgeon robotic-naïve with a large experience in laparoscopic surgery for IBD. The robotic procedures were performed using the Medtronic Hugo™ RAS platform. Outcomes were 30-day postoperative complications, operative time, conversion rate, intraoperative complications, length of hospital stay, and readmission rate.

RESULTS

Among 121 consecutive patients, 80 underwent laparoscopic (LG) and 41 robotic-assisted surgery (RG). Baseline, preoperative and disease-specific characteristics were comparable except for older age (50 [38-56] vs. 38 [28-54] years; p = 0.05) and higher albumin level (42 [40-44] vs. 40 [38-42] g/L, p = 0.006) in the RG. The intracorporeal anastomosis was more frequent in the RG (80% vs. 6%; p < 0.001) with longer operative time (240 vs. 205 min; p = 0.006), while the conversion rate was not different (5% vs. 10%, p = 0.49). Surgical procedure types were equally distributed between the two groups, and the rate of intra-abdominal septic complication (IASC) was comparable across the different procedures. Postoperative complications were similar, including the rate of IASC (5% vs. 5%, p = 1), postoperative ileus (5% vs. 7.5%, p = 0.71), bleeding (2% vs. 5%, p = 0.66), and Clavien-Dindo > 2 complications (7% vs. 6%; p = 1).

CONCLUSION

IBD surgery performed using the Medtronic Hugo™ RAS is safe and feasible, with similar postoperative outcomes when compared to the laparoscopic approach.

Minimally Invasive Surgery for Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis of Robotic Versus Laparoscopic Surgical Techniques

BACKGROUND

We aimed to evaluate outcomes of robotic versus conventional laparoscopic colorectal resections in patients with inflammatory bowel disease [IBD].

METHODS

Comparative studies of robotic versus laparoscopic colorectal resections in patients with IBD were included. The primary outcome was total post-operative complication rate. Secondary outcomes included operative time, conversion to open surgery, anastomotic leaks, intra-abdominal abscess formation, ileus occurrence, surgical site infection, re-operation, re-admission rate, length of hospital stay, and 30-day mortality. Combined overall effect sizes were calculated using a random-effects model and the Newcastle-Ottawa Scale was used to assess risk of bias.

RESULTS

Eleven non-randomized studies [n = 5566 patients] divided between those undergoing robotic [n = 365] and conventional laparoscopic [n = 5201] surgery were included. Robotic platforms were associated with a significantly lower overall post-operative complication rate compared with laparoscopic surgery [p = 0.03]. Laparoscopic surgery was associated with a significantly shorter operative time [p = 0.00001]. No difference was found in conversion rates to open surgery [p = 0.15], anastomotic leaks [p = 0.84], abscess formation [p = 0.21], paralytic ileus [p = 0.06], surgical site infections [p = 0.78], re-operation [p = 0.26], re-admission rate [p = 0.48], and 30-day mortality [p = 1.00] between the groups. Length of hospital stay was shorter following a robotic sub-total colectomy compared with conventional laparoscopy [p = 0.03].

CONCLUSION

Outcomes in the surgical management of IBD are comparable between traditional laparoscopic techniques and robotic-assisted minimally invasive surgery, demonstrating the safety and feasibility of robotic platforms. Larger studies investigating the use of robotic technology in Crohn's disease and ulcerative colitis separately may be of benefit with a specific focus on important IBD-related metrics.

The Role of Minimally Invasive Surgery in the Management of Inflammatory Bowel Disease: Current Trends and Future Directions

Minimally invasive surgery (MIS) provides superior results in the surgical treatment of inflammatory bowel disease (IBD). There exist various minimally invasive procedures, each possessing its own set of benefits and drawbacks. This literature review outlines these methodologies and underscores their importance in enhancing the outcomes of patients with IBD. A grand total of 192 studies were carefully chosen and succinctly summarized. Conventional multiport laparoscopy is the most widely used MIS for IBD, with single-incision laparoscopy showing even better results. Robotic surgery offers comparable results but at higher costs and longer operation times. In the future, there will be widespread acceptance of single-incision laparoscopy and robotic surgery due to improved training and reduced expenses. Further research into the technology's utility in different IBD presentations could increase its usage.

A new surgical technique: robotic intracorporeal Kono-S anastomosis in Crohn's - a safety and feasibility case series on short-term outcomes

AIM

The Kono-S anastomosis was introduced as a possible solution to the high surgical recurrence rates in Crohn's disease. However, this technique is known to be challenging, which is why it was originally performed in an extracorporeal setting. The aim of this case series was to assess safety, in terms of intra-/postoperative complications, and feasibility, in terms of successful performance of anastomosis, of a robot-assisted intracorporeal Kono-S anastomosis.

METHOD

This is a prospective single-centre consecutive case series. Patients were considered eligible if they were diagnosed with refractory Crohn's disease with significant bowel stenosis of the terminal ileum. All patients underwent robot-assisted intracorporeal Kono-S anastomosis. Perioperative care was provided according to the Enhanced Recovery After Surgery® protocol. Follow-up for postoperative complications was 30 days.

RESULTS

Twenty patients were included, of whom 11 (55%) were men. The median age was 30 years [interquartile range (IQR) 22-51 years] and the median BMI was 25 kg/m2 (IQR 19-28 kg/m2). Intracorporeal Kono-S anastomosis was successfully performed in all cases. The median operating time was 155 min (IQR 144-176 min) and the median length of stay was 3 days (IQR 1-5 days). No conversions or 30-day mortality were observed. One patient experienced anastomotic leakage, which was treated with radiologically guided drainage. A total of three patients experienced postoperative complications in the first 30 days.

CONCLUSION

Performance of intracorporeal robot-assisted Kono-S anastomosis seems safe and feasible in this case series for Crohn's disease. Since this is a first case series, further research is required to confirm results in a larger population-based cohort.

First Mexican Consensus on Crohn's disease

INTRODUCTION

Crohn's disease (CD) is a subtype of chronic and incurable inflammatory bowel disease. It can affect the entire gastrointestinal tract and its etiology is unknown.

OBJECTIVE

The aim of this consensus was to establish the most relevant aspects related to definitions, diagnosis, follow-up, medical treatment, and surgical treatment of Crohn's disease in Mexico.

MATERIAL AND METHODS

Mexican specialists in the areas of gastroenterology and inflammatory bowel disease were summoned. The consensus was divided into five modules, with 69 statements. Applying the Delphi panel method, the pre-meeting questions were sent to the participants, to be edited and weighted. At the face-to-face meeting, all the selected articles were shown, underlining their level of clinical evidence; all the statements were discussed, and a final vote was carried out, determining the percentage of agreement for each statement.

RESULTS

The first Mexican consensus on Crohn's disease was produced, in which recommendations for definitions, classifications, diagnostic aspects, follow-up, medical treatment, and surgical treatment were established.

CONCLUSIONS

Updated recommendations are provided that focus on definitions, classifications, diagnostic criteria, follow-up, and guidelines for conventional medical treatment, biologic therapy, and small molecule treatment, as well as surgical management.

Implementation of a robotic surgical practice in inflammatory bowel disease

Robotics adoption has increased in colorectal surgery. While there are well-established advantages and standardised techniques for cancer patients, the use of robotic surgery in inflammatory bowel disease (IBD) has not been studied yet. To evaluate the feasibility and safety of robotic surgery for IBD patients. Prospectively data in IBD patients having robotic resection at Guy's and St Thomas' hospital. All resections performed by a single colorectal surgeon specialised in IBD, utilising DaVinci platform. July 2021 to January 2023, 59 robotic IBD cases performed, 14 ulcerative colitis (UC) and 45 Crohn's disease (CD). Average age; CD patients 35, UC 33 years. Average Body mass index (BMI); 23 for CD and 26.9 for UC patients. In total, we performed 31 ileo-caecal resections (ICR) with primary anastomosis (18 Kono-S anastomosis, 6 mechanical anastomosis and 7 ileo-colostomy), of those 4 had multivisceral resections (large bowel, bladder, ovary). Furthermore, 14 subtotal colectomy (1 emergency), 8 proctectomy, 3 panproctocolectomy and 3 ileoanal J pouch. 18 of the 45 patients (45.0%) with Crohn's disease had ongoing fistulating disease to other parts of the GI tract (small or large bowel). ICR were performed using different three ports position, depending on the anatomy established prior to surgery with magnetic resonance images (MRI). One patient had conversion to open due to anaesthetic problems and one patient required re-operation to refashion stoma. 98.0% cases completed robotically. Median Length of hospital stay (LOS) was 7 days for CD and 7 for UC cases, including LOS in patients on pre-operative parenteral nutrition. Robotic colorectal techniques can be safely used for patients with IBD, even with fistulating disease. Future research and collaborations are necessary to standardize technique within institutions.

Ileocolic resection for Crohn's disease: robotic intracorporeal compared to laparoscopic extracorporeal anastomosis

Laparoscopy is the first-line approach in ileocolic resection for Crohn's disease. Emerging data has shown better short-term outcomes with robotic right colectomy for cancer when compared to laparoscopic approach. However, robotic ileocolic resection for Crohn's disease has only shown faster return to bowel function. We aimed to evaluate short-term outcomes of ileocolic resection for Crohn's disease between robotic intracorporeal anastomosis (RICA) and laparoscopic extracorporeal anastomosis (LECA). Patients undergoing minimally invasive ileocolic resections for Crohn's disease were retrospectively identified using a prospectively maintained database between 2014 and 2021 in two referral centers. Among the 239 patients, 70 (29%) underwent RICA while 169 (71%) LECA. Both groups were similar according to baseline and preoperative characteristics. RICA was associated with more intraoperative adhesiolysis and longer operative time [RICA: 238 ± 79 min vs. LECA: 143 ± 52 min; p < 0.001]. 30-day postoperative complications were not different between the two groups [RICA: 17/70(24%) vs. LECA: 54/169(32%); p = 0.238]. Surgical site infections [RICA: 0/70 vs. LECA: 16/169(10%); p = 0.004], intra-abdominal septic complications [RICA: 0/70 vs. LECA: 14/169(8%); p = 0.012], and Clavien-Dindo ≥ III complications [RICA: 1/70(1%) vs. LECA: 15/169(9%); p = 0.044] were less frequent in RICA. Return to bowel function [RICA: 2.1 ± 1.1 vs. LECA: 2.6 ± 1.2 days; p = 0.002] and length of stay [RICA: 3.4 ± 2.2 vs. LECA: 4.2 ± 2.5 days; p = 0.015] were shorter after RICA, with similar readmission rates. RICA demonstrated better short-term postoperative outcomes than LECA, with reduced Clavien-Dindo ≥ III complications, surgical site infections, intra-abdominal septic complications, shorter length of stay, and faster return to bowel function, despite the longer operative time.

Minimally invasive surgery in Crohn's disease: state-of-the-art review

Surgery for Crohn's disease (CD) has undergone significant advancements over the last two decades, especially minimally invasive surgery. In addition to its feasibility and safety, minimally invasive surgery provides manifold advantages, including a decreased hospitalization duration, improved aesthetic results, and fewer occurrences of intra-abdominal adhesions. Due to the special intraoperative characteristics of CD, such as chronic inflammation, a thickened mesentery, fistulas, abscesses and large masses, a minimally invasive approach seems to be challenging. Complete implementation of this technique for complex disease has yet to be studied. In this review, we provide a review on the applicability of minimally invasive surgery in CD and future perspectives for the technical advances in the field.

Incisional hernia rates between intracorporeal and extracorporeal anastomosis in minimally invasive ileocolic resection for Crohn's disease

PURPOSE

One-third of patients with Crohn's disease (CD) require multiple surgeries during their lifetime. So, reducing the incisional hernia rate is crucial. We aimed to define incisional hernia rates after minimally invasive ileocolic resection for CD, comparing intracorporeal anastomosis with Pfannenstiel incision (ICA-P) versus extracorporeal anastomosis with midline vertical incision (ECA-M).

METHODS

This retrospective cohort compares ICA-P versus ECA-M from a prospectively maintained database of consecutive minimally invasive ileocolic resections for CD performed between 2014 and 2021 in a referral center.

RESULTS

Of the 249 patients included: 59 were in the ICA-P group, 190 in the ECA-M group. Both groups were similar according to baseline and preoperative characteristics. Overall, 22 (8.8%) patients developed an imaging-proven incisional hernia: seven at the port-site and 15 at the extraction-site. All 15 extraction-site incisional hernias were midline vertical incisions [7.9%; p = 0.025], and 8 patients (53%) required surgical repair. Time-to-event analysis showed a 20% rate of extraction-site incisional hernia in the ECA-M group after 48 months (p = 0.037). The length of stay was lower in the intracorporeal anastomosis with Pfannenstiel incision group [ICA-P: 3.3 ± 2.5 vs. ECA-M: 4.1 ± 2.4 days; p = 0.02] with similar 30-day postoperative complication [11(18.6) vs. 59(31.1); p = 0.064] and readmission rates [7(11.9) vs. 18(9.5); p = 0.59].

CONCLUSION

Patients in the ICA-P group did not encounter any incisional hernias while having shorter hospital length of stay and similar 30-day postoperative complications or readmission compared to ECA-M. Therefore, more consideration should be given to performing intracorporeal anastomosis with Pfannenstiel incision during Ileocolic resection in patients with CD to reduce hernia risk.

Incisional Hernia rates between Intracorporeal and Extracorporeal Anastomosis in Minimally Invasive Ileocolic Resection for Crohn's disease.. [DOI: 10.21203/rs.3.rs-2591968/v1]

Purpose: One-third of patients with Crohn’s disease (CD) require multiple surgeries during their lifetime. So, reducing the incisional hernia rate is crucial. We aimed to define incisional hernia rates after minimally invasive ileocolic resection for CD, comparing intracorporeal anastomosis with Pfannenstiel incision (ICA-P) versus extracorporeal anastomosis with midline vertical incision (ECA-M). Methods: This retrospective cohort compares ICA-P versus ECA-M from a prospectively maintained database of consecutive minimally invasive ileocolic resections for CD performed between 2014 and 2021 in a referral center. Results: Of the 249 patients included: 59 were in the ICA-P group, 190 in the ECA-M group. Both groups were similar according to baseline and preoperative characteristics. Overall, 22 (8.8%) patients developed an imaging-proven incisional hernia: seven at the port-site and 15 at the extraction-site. All 15 extraction-site incisional hernias were midline vertical incisions [7.9%; p=0.025], and 8 patients (53%) required surgical repair. Time-to-event analysis showed a 20% rate of extraction-site incisional hernia in the ECA-M group after 48 months (p =0.037). The length of stay was lower in the intracorporeal anastomosis with Pfannenstiel incision group [ICA-P: 3.3±2.5 vs. ECA-M: 4.1±2.4 days; p=0.02] with similar 30-day postoperative complication [11(18.6) vs. 59(31.1); p=0.064] and readmission rates [7(11.9) vs. 18(9.5); p=0.59]. Conclusion: Patients in the ICA-P group did not encounter any incisional hernias while having shorter hospital length of stay and similar 30-day postoperative complications or readmission compared to ECA-M. Therefore, more consideration should be given to performing intracorporeal anastomosis with Pfannenstiel incision during Ileocolic resection in patients with CD to reduce hernia risk.

Operating on the Mesentery in Robotic Colonic Surgery—General Techniques

During colorectal surgery the mesentery is the organ on which the greatest amount of operating time is focused. It has recently gained increasing attention. This technical review focuses on the mesentery during robotic colonic procedures. Specifically, we focus upon how to access, dissect, and divide the mesentery using the robotic platform. We also touch on the management of bleeding and some specific disease etiologies.

Intracorporeal versus extracorporeal anastomosis for robotic ileocolic resection in Crohn's disease

To date, there is no cohort in the literature focusing on the impact of the type of anastomosis in robotic ileocolonic resections for Crohn's Disease (CD). We aimed to compare short-term postoperative outcomes of robotic ileocolic resection for CD between patients who had intracorporeal (ICA) or extracorporeal anastomosis (ECA). We retrospectively included all consecutive robotic ileocolonic resections for CD at our institution between 2014 and 2020. We compared baseline, perioperative characteristics, and postoperative outcomes between ICA and ECA. The analysis included 89 patients: 71% underwent ICA and 29% ECA. Groups were similar in age, sex, body mass index, smoking, CD duration, Montreal classification, surgical history, and previous CD medical treatments. Return to bowel function was achieved sooner in the ICA group (ICA 1.6 ± 0.7 day, ECA 2.1 ± 0.8 days; p = 0.026) despite longer operative time (ICA 235 ± 79 min, ECA 172 ± 51 min; p < 0.001), but no statistical difference was found regarding ileus rate and length of stay. Overall, 30-day postoperative complication rate was 23.6% (ICA 22.2%, ECA 26.9%; p = 0.635). There were no abdominal septic complications, anastomotic leaks, or severe postoperative complications. In conclusion, robotic ileocolic resection for CD shows acceptable 30 days outcomes for both ICA and ECA. ICA was associated with a faster return to bowel function without impact on the length of stay or 30-day complications. Further studies are needed to confirm the benefits of ICA in the setting of ileocolic resections for CD.

Morbidly Obese Patients with Ileocolic Crohn's Disease May Benefit from Robotic Surgery

Background and Objectives:

Obesity is increasing as a comorbid condition for patients requiring surgery for Crohn’s disease. Minimally invasive colectomy is ideal for a patient with combined obesity and Crohn’s disease. However laparoscopic colon resection is associated with high operative conversion rates in these cases. Data examining the use of robotic surgery in the obese patient with Crohn’s disease is sparse.

Methods:

We examined the feasibility and outcomes of performing a minimally invasive colectomy using the Da Vinci robot in a prospective case series of morbidly obese patients with ileal Crohn’s disease.

Results:

A robotic ileocolectomy was performed in four morbidly obese patients with Crohn’s disease. There were no operative conversions or complications with a median length of stay of 3 days.

Conclusion:

A robotic approach is a promising minimally invasive surgical alternative to laparoscopic surgery for these complex patients.

[Minimally invasive and robot-assisted surgery for chronic inflammatory bowel disease : Current status and evidence situation]

The majority of cases of inflammatory bowel disease (IBD) can be treated by minimally invasive surgery. The advantages of standard laparoscopic approaches compared to open surgery with respect to short-term and long-term outcome parameters have been adequately proven with evidence level 1 for ileocecal resection in Crohn's disease. For many other indications there are at least several larger registry or case-control studies that have shown advantages for laparoscopy. For robot-assisted surgery the feasibility has principally been demonstrated for IBD, whereby at least for ulcerative colitis limited data suggest comparable results to the standard laparoscopic approach. Single port approaches have so far not been able to demonstrate any relevant advantages in IBD surgery. Major advantages for transanal minimally invasive surgery (TAMIS) for performing restorative proctocolectomy could not be demonstrated in two larger case-controlled studies but it was at least shown to be a comparable alternative to standard laparoscopy. Overall, it seems unlikely that the recently described new laparoscopic approaches will result in measurable advantages for the patient in comparison to standard laparoscopy as the access trauma is not significantly changed. In general, the indications to perform minimally invasive surgery must always be based on the basic principles of IBD surgery and contraindications have to be considered in individual cases as the advantages of laparoscopic approaches are levelled out in the long run.