Prospective Randomized Study Comparing Robotic-Assisted Surgery with Traditional Laparotomy for Rectal Cancer-Indian Study

Comparison of a robotic surgery program for rectal cancer: short- and long-term results from a comparative, retrospective study between two laparoscopic and robotic reference centers

BACKGROUND

It is assumed that robotic-assisted surgery (RAS) may facilitate complex pelvic dissection for rectal cancer compared to the laparoscopic-assisted resection (LAR). The aim of this study was to compare perioperative morbidity, short- and long-term oncologic, and functional outcomes between the RAS and LAR approaches.

METHODS

Between 2015 and 2021, all rectal cancers operated on by (LAR) or (RAS) were retrospectively reviewed in two colorectal surgery centers.

RESULTS

A total of 197 patients were included in the study, with 70% in the LAR group and 30% in the RAS group. The tumor location and stage were identical in both groups (not significant = NS). The overall postoperative mortality rate was not significantly different between the two groups. (0% LAR; 0.5% RAS; NS). The postoperative morbidity was similar between the two groups (60% LAR vs 57% RAS; NS). The number of early surgical re-interventions within the first 30 days was similar (10% for the LAR group and 3% for the RAS group; NS). The rate of complete TME was similar (88% for the LAR group and 94% for the RAS group; NS). However, the rate of circumferential R1 was significantly higher in the LAR group (13%) compared to the RAS group (2%) (p = 0.009). The 3-year recurrence rate did not differ between the two groups (77% for both groups; NS). After a mean follow-up of three years, the incidence of anterior resection syndrome was significantly lower in the LAR group compared to the RAS group (54 vs 76%; p = 0.030).

CONCLUSIONS

The use of a RAS was found to be reliable for oncologic outcomes and morbidity. However, the expected benefits for functional outcomes were not observed. Therefore, the added value of RAS for rectal cancer needs to be reassessed in light of new laparoscopic technologies and patient management options.

Radial resection margin distinguishes between superficial versus deep resection in colorectal cancer: a retrospective study

Randomized studies showed that robotic surgery was short-term useful and safe for cancer patients. We investigated whether robots improve deep resection margins or superficial resection margins for radial resection margins in terms of short-term results. From an institutional database, we selected all superficial groups (≤ 3 mm) and deeper groups (≥ 4 mm) with rectal cancer treated with resection for a year. We evaluated the short-term post-operative 90-day outcomes on a radial resection size-based margin differentiation, including the first bowel movement, length of hospital stay, sepsis, and harvested lymph node. The main results were grades III-IV on the Clavien-Dindo scale and complications. We found 120 patients who had oncologic resection of rectal cancer; 42 patients with a superficial radial resection margin of ≤ 3 mm, all the following outcomes improved: the harvested lymph node, proximal resection margin, TME, flatus time, liquid diet duration, anastomotic leakage, and sepsis. Among these advantages were a reduced risk of metastasis and an overall reduction in local recurrence.

Prince and princesses: The current status of robotic surgery in surgical oncology

Robotic surgery has experienced a dramatic increase in utilization across general surgery over the last two decades, including in surgical oncology. Although urologists and gynecologists were the first to show that this technology could be utilized in cancer surgery, the robot is now a powerful tool in the treatment of gastrointestinal, hepato-pancreatico-biliary, colorectal, endocrine, and soft tissue malignancies. While long-term outcomes are still pending, short-term outcomes have showed promise for this technologic advancement of cancer surgery.

Outcomes of Robot-Assisted Surgery in Rectal Cancer Compared with Open and Laparoscopic Surgery

With increasing trends for the adoption of robotic surgery, many centers are considering changing their practices from open or laparoscopic to robot-assisted surgery for rectal cancer. We compared the outcomes of robot-assisted rectal resection with those of open and laparoscopic surgery. We searched Medline, Web of Science, and CENTRAL databases until October 2022. All randomized controlled trials (RCTs) and prospective studies comparing robotic surgery with open or laparoscopic rectal resection were included. Fifteen RCTs and 11 prospective studies involving 6922 patients were included. The meta-analysis revealed that robotic surgery has lower blood loss, less surgical site infection, shorter hospital stays, and higher negative resection margins than open resection. Robotic surgery also has lower conversion rates, lower blood loss, lower rates of reoperation, and higher negative circumferential margins than laparoscopic surgery. Robotic surgery had longer operation times and higher costs than open and laparoscopic surgery. There were no differences in other complications, mortality, and survival between robotic surgery and the open or laparoscopic approach. However, heterogeneity between studies was moderate to high in some analyses. The robotic approach can be the method of choice for centers planning to change from open to minimally invasive rectal surgery. The higher costs of robotic surgery should be considered as a substitute for laparoscopic surgery (PROSPERO: CRD42022381468).

Outcomes of open vs laparoscopic vs robotic vs transanal total mesorectal excision (TME) for rectal cancer: a network meta-analysis

BACKGROUND

Total mesorectal excision (TME) for rectal cancer can be achieved using open (OpTME), laparoscopic (LapTME), robotic (RoTME), or transanal techniques (TaTME). However, the optimal approach for access remains controversial. The aim of this network meta-analysis was to assess operative and oncological outcomes of all four surgical techniques.

METHODS

Ovid MEDLINE, EMBASE, and PubMed databases were searched systematically from inception to September 2020, for randomised controlled trials (RCTs) comparing any two TME surgical techniques. A network meta-analysis using a Bayesian random-effects framework and mixed treatment comparison was performed. Primary outcomes were the rate of clear circumferential resection margin (CRM), defined as > 1 mm from the closest tumour to the cut edge of the tissue, and completeness of mesorectal excision. Secondary outcomes included radial and distal resection margin distance, postoperative complications, locoregional recurrence, disease-free survival, and overall survival. Surface under cumulative ranking (SUCRA) was used to rank the relative effectiveness of each intervention for each outcome. The higher the SUCRA value, the higher the likelihood that the intervention is in the top rank or one of the top ranks.

RESULTS

Thirty-two RCTs with a total of 6151 patients were included. Compared with OpTME, there was no difference in the rates of clear CRM: LapTME RR = 0.99 (95% (Credible interval) CrI 0.97-1.0); RoTME RR = 1.0 (95% CrI 0.96-1.1); TaTME RR = 1.0 (95% CrI 0.96-1.1). There was no difference in the rates of complete mesorectal excision: LapTME RR = 0.98 (95% CrI 0.98-1.1); RoTME RR = 1.1 (95% CrI 0.98-1.4); TaTME RR = 1.0 (95% CrI 0.91-1.2). RoTME was associated with improved distal resection margin distance compared to other techniques (SUCRA 99%). LapTME had a higher rate of conversion to open surgery when compared with RoTME: RoTME RR = 0.23 (95% CrI 0.034-0.70). Length of stay was shortest in RoTME compared to other surgical approaches: OpTME mean difference in days (MD) 3.3 (95% CrI 0.12-6.0); LapTME MD 1.7 (95% CrI - 1.1-4.4); TaTME MD 1.3 (95% CrI - 5.2-7.4). There were no differences in 5-year overall survival (LapTME HR 1.1, 95% CrI 0.74, 1.4; TaTME HR 1.7, 95% CrI 0.79, 3.4), disease-free survival rates (LapTME HR 1.1, 95% CrI 0.76, 1.4; TaTME HR 1.1, 95% CrI 0.52, 2.4), or anastomotic leakage (LapTME RR = 0.92 (95% CrI 0.63, 1.1); RoTME RR = 1.0 (95% CrI 0.48, 1.8); TaTME RR = 0.53 (95% CrI 0.19, 1.2). The overall quality of evidence as per Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessments across all outcomes including primary and secondary outcomes was deemed low.

CONCLUSIONS

In selected patients eligible for a RCT, RoTME achieved improved distal resection margin distance and a shorter length of hospital stay. No other differences were observed in oncological or recovery parameters between (OpTME), laparoscopic (LapTME), robotic (RoTME), or trans-anal TME (TaTME). However, the overall quality of evidence across all outcomes was deemed low.

Clinical Robotic Surgery Association (India Chapter) and Indian rectal cancer expert group’s practical consensus statements for surgical management of localized and locally advanced rectal cancer

Introduction

There are standard treatment guidelines for the surgical management of rectal cancer, that are advocated by recognized physician societies. But, owing to disparities in access and affordability of various treatment options, there remains an unmet need for personalizing these international guidelines to Indian settings.

Methods

Clinical Robotic Surgery Association (CRSA) set up the Indian rectal cancer expert group, with a pre-defined selection criterion and comprised of the leading surgical oncologists and gastrointestinal surgeons managing rectal cancer in India. Following the constitution of the expert Group, members identified three areas of focus and 12 clinical questions. A thorough review of the literature was performed, and the evidence was graded as per the levels of evidence by Oxford Centre for Evidence-Based Medicine. The consensus was built using the modified Delphi methodology of consensus development. A consensus statement was accepted only if ≥75% of the experts were in agreement.

Results

Using the results of the review of the literature and experts’ opinions; the expert group members drafted and agreed on the final consensus statements, and these were classified as “strong or weak”, based on the GRADE framework.

Conclusion

The expert group adapted international guidelines for the surgical management of localized and locally advanced rectal cancer to Indian settings. It will be vital to disseminate these to the wider surgical oncologists and gastrointestinal surgeons’ community in India.

Clinical Safety and Effectiveness of Robotic-Assisted Surgery in Patients with Rectal Cancer: Real-World Experience over 8 Years of Multiple Institutions with High-Volume Robotic-Assisted Surgery

Simple Summary

The aim of this retrospective observational study was to evaluate perioperative and short-term oncological outcomes of robotic-assisted rectal surgery (RRS) in hospitals with a high-volume of robotic-assisted surgeries. This study enrolled patients with rectal adenocarcinoma undergoing RRS from three high-volume institutions from December 2011 to June 2020. Compared with other studies, our results revealed the equivalent or superior perioperative and short-term oncological outcomes. Hence, RRS is an effective, safe, and feasible technique for patients with rectal cancers in high-volume hospitals.

Abstract

The perioperative and short-term oncological outcomes of robotic-assisted rectal surgery (RRS) are unclear. This retrospective observational study enrolled patients with rectal adenocarcinoma undergoing RRS from three high-volume institutions in Taiwan. Of the 605 enrolled patients, 301 (49.75%), 176 (29.09%), and 116 (19.17%) had lower, middle, and upper rectal cancers, respectively. Low anterior resection (377, 62.31%) was the most frequent surgical procedure. Intraoperative blood transfusion was performed in 10 patients (2%). The surgery was converted to an open one for one patient (0.2%), and ten (1.7%) patients underwent reoperation. The overall complication rate was 14.5%, including 3% from anastomosis leakage. No deaths occurred during surgery and within 30 days postoperatively. The positive rates of distal resection margin and circumferential resection margin were observed in 21 (3.5%) and 30 (5.0%) patients, respectively. The 5-year overall and disease-free survival rates for patients with stage I–III rectal cancer were 91.1% and 86.3%, respectively. This is the first multi-institutional study in Taiwan with 605 patients from three high-volume hospitals. The overall surgical and oncological outcomes were equivalent or superior to those estimated in other studies. Hence, RRS is an effective and safe technique for rectal resection in high-volume hospitals.

Robotic Surgery: At the Crossroads of a Data Explosion

BACKGROUND

For the last 20 years, controversies in robotic surgery focused on cost reduction, development of new platforms and technologies, creation and validation of curriculum and virtual simulators, and conduction of randomized clinical trials to determine the best applications of robotics [Leal Ghezzi and Campos in World J Surg 40:2550-2557, 2016].

METHODS

This review explores the robotic systems which are currently indicated for use or development in gastrointestinal/abdominal surgery. These systems are reviewed and analyzed for clinical impact in these areas. In a MEDLINE search of articles with the search terms abdominal, gastrointestinal, review and robotic surgery, a total of 4306 total articles as of 2021 were assessed. Publicly available information, highest cited articles and reviews were assessed by the authors to determine the most significant regarding clinical outcomes.

RESULTS

Despite this increased number of articles related to robotic surgery, ongoing controversies have led to limitation in the use of current and future robotic surgery platforms [Connelly et al. in J Robotic Surg 14:155-165, 2020]. Newer robotic platforms have limited studies or analysis that would allow meaningful definite conclusions. A multitude of new scenarios are possible due to this limited information.

CONCLUSION

Robotic surgery is in evolution to a larger conceptual field of computationally enhanced surgery (CES). Various terms have been used in the literature including computer-assisted surgery or digital Surgery [Ranev and Teixeira in Surg Clin North Am 100:209-218, 2020]. With the growth of technological changes inherent in CES, the ability to validate these improvements in outcomes will require new metrics and analytic tools. This learning feedback and metric analysis will generate the new opportunities in simulation, training and application [Julian and Smith in Int J Med Robot 15:e2037, 2019].

Robotic Versus Laparoscopic Partial Mesorectal Excision for Cancer of the High Rectum: A Single-Center Study with Propensity Score Matching Analysis

BACKGROUND

The role of robotic surgery for partial mesorectal excision (PME) in patients with high rectal cancer (RC) remains unexplored. This study aimed to compare the operative and postoperative outcomes of robotic (R-PME) versus laparoscopic (L-PME) PME for high RC.

METHODS

This was a single-center propensity score cohort study of consecutive patients diagnosed with RC in the high rectum (>10 to 15 cm from the anal verge) who underwent surgery between September 2012 and May 2019.

RESULTS

Of 131 selected patients (50 R-PME and 81 L-PME), 88 were matched using propensity score (44 per group). Operative and postoperative variables were similar between R-PME and L-PME patients, except for operative time (220 min and 190 min, respectively; p < 0.0001). No conversion was needed. Overall morbidity was 15.9%; 4 patients (4.5%) developed anastomotic leakage. The mean hospital stay was 7.25 days for R-PME vs. 7.64 days for L-PME (p = 0.597). R0 resection was achieved in 100% of R-PME and 90.9% of L-PME (p = 0.116). Only 3 patients (1 R-PME, 2 L-PME) received a permanent stoma (p = 1). No group differences were observed for overall or disease-free survival rates at 5 years. The costs of R-PME were significantly higher than those of L-PME.

CONCLUSION

Minimally invasive surgery can be performed safely for PME in high RC. No difference can be detected between R-PME and L-PME for both short- and long-term outcomes, leaving the choice of the surgical approach to the surgeon's experience. Specific health economic studies are needed to evaluate the cost-effectiveness of robotic surgery for RC.

[Robotic-assisted surgery of rectal cancer-Technique, limitations and results]

BACKGROUND

The number of oncological robotic-assisted rectal cancer resections is rapidly increasing in Germany and worldwide; however, the indications, technique and potential limitations of this surgical technique are still discussed.

MATERIAL AND METHODS

The standardized modular surgical technique, the results in our clinic and the currently published evidence are presented.

RESULTS

The procedure should be divided into seven modules in terms of standardization and teaching. After the learning curve there are principally no limitations or contraindications. The robotic-assisted approach is superior to open surgery in the following points: blood loss, lymph node harvest, negative circumferential resection margin (CRM), complication rate and length of hospital stay. In comparison to conventional laparoscopy the conversion rate and postoperative sexual and bladder function disorders are decreased. The operating time is longer.

CONCLUSION

Robotic-assisted rectal cancer resection is firmly established and standardized. The technique is superior to open surgery and conventional laparoscopy in some important aspects and is developing into the standard for this disease.

Research quality and transparency, outcome measurement and evidence for safety and effectiveness in robot-assisted surgery: systematic review

BACKGROUND

Robot-assisted surgery (RAS) has potential panspecialty surgical benefits. High-quality evidence for widespread implementation is lacking. This systematic review aimed to assess the RAS evidence base for the quality of randomized evidence on safety and effectiveness, specialty 'clustering', and outcomes for RAS research.

METHODS

A systematic review was undertaken according to PRISMA guidelines. All pathologies and procedures utilizing RAS were included. Studies were limited to RCTs, the English language and publication within the last decade. The main outcomes selected for the review design were safety and efficacy, and study purpose. Secondary outcomes were study characteristics, funding and governance.

RESULTS

Searches identified 7142 titles, from which 183 RCTs were identified for data extraction. The commonest specialty was urology (35·0 per cent). There were just 76 unique study populations, indicating significant overlap of publications; 103 principal studies were assessed further. Only 64·1 per cent of studies reported a primary outcome measure, with 29·1 per cent matching their registration/protocol. Safety was assessed in 68·9 per cent of trials; operative complications were the commonest measure. Forty-eight per cent of trials reported no significant difference in safety between RAS and comparator, and 11 per cent reported RAS to be superior. Efficacy or effectiveness was assessed in 80·6 per cent of trials; 43 per cent of trials showed no difference between RAS and comparator, and 24 per cent reported that RAS was superior. Funding was declared in 47·6 per cent of trials.

CONCLUSION

The evidence base for RAS is of limited quality and variable transparency in reporting. No patterns of harm to patients were identified. RAS has potential to be beneficial, but requires continued high-quality evaluation.

Robotic Total Mesorectal Excision for Rectal Cancer: Short-Term Oncological Outcomes of Initial 178 Cases

Emerging techniques in minimally invasive rectal resection include robotic total mesorectal excision (R-TME). The Da Vinci Surgical System offers precise dissection in narrow and deep confined spaces and is gaining increasing acceptance during recent times. The aim of this study is to analyse our initial experience of R-TME with Da Vinci Xi platform in terms of perioperative and oncological outcomes in the context of data from recently published randomised ROLARR trial amongst minimally invasive novice surgeons. Patients who underwent R-TME or tumour specific mesorectal excision for rectal cancer between May 2016 and November 2019 were identified from a prospectively maintained single institution colorectal database. Demographic, clinical-pathological and short-term oncological outcomes were analysed. Of the 178 patients, 117 (65.7%) and 31 (17.4%) patients had lower and mid third rectal cancer. Most of the tumours were locally advanced, cT3–T4: 138 (77.5%). One hundred/178 (56.2%) underwent sphincter preserving TME. Eighty-seven (48.8%) were grade II adenocarcinoma. Nonmucinous adenocarcinoma was the predominant histology, 138 (78.4%). One hundred one cases (56.7%) were pT3. The mean number of lymph node yield was 13 ± 5. Distal resection margin and circumferential resection margin were positive in 2 (1.12%), 12 cases (6.74%) respectively. Eleven cases (6.7%) had to be converted to open TME. Mean blood loss and duration of surgery was 170 ± 60 ml and 286 ± 45 min respectively. Five percent cases had an anastomotic leak. Grade IIIa–IIIb Clavien Dindo (CD) morbidity score was reported to be in 12 (6.75%) and 10 (5.61%) cases. Median length of hospitalisation was 7 days (range 4–14 days). Perioperative and pathologic outcomes following robotic rectal resection is associated with good short-term oncological outcomes and is safe, effective, and reproducible by a minimally invasive novice surgeon.

Prospective Study Comparing Clinical vs Indocyanine Green Fluorescence-Based Assessment of Line of Transection in Robotic Rectal Cancer Surgery-Indian Study

Anastomotic leakage continues to be the most feared postoperative complications in rectal surgery with negative impact on both short- and long-term outcomes. Fortunately, new surgical strategies have helped to offset this complication and improve surgical outcomes. Traditionally, perfusion is assessed by intraoperative visual judgment by the surgeon. These subjective methods lack predictive accuracy resulting in either excess or insufficient colonic resection. Indocyanine green (ICG) fluorescence has shown promise in identifying the adequacy of perfusion. After injection of ICG, the system projected high-resolution near-infrared real-time images of blood flow in mesentery and bowel wall. This novel imaging method is used intraoperatively for taking real-time informed decisions. We conducted a single institutional prospective study to identify the feasibility of ICG identification of vascularity of anastomotic site and its impact on the change of plan of surgical management in robotic rectal cancer surgery. Between September 2017 and April 2019, fifty patients undergoing robotic rectal cancer surgery were included in the study. The aim was to analyze the feasibility and clinical benefit of intraoperative near-infrared fluorescence imaging in determining the line of transection in comparison with the traditional method. Line of proximal transection of the bowel subjectively assessed by the surgical team was marked point B and that after ICG injection was marked point A if moved proximally and point C if moved distally. The vascular anatomy was clearly identified with no intraoperative or injection-related adverse effects. Of the 50 patients, the line of transaction remained the same in 6 patients (12%). Based on the fluorescence imaging, the surgical team opted for further proximal change of the transection line up to an "adequate" fluorescent portion in 3 patients (6%) and distally in 41 patients (82%). ICG-based infrared image-guided localization gives a real-time image of colon vascularity possibly affecting anastomotic leak. The ICG fluorescence imaging system is a simple, safe, and useful technique, performed within a short time, and it enables visual evaluation of the blood flow in the intestinal tract prior to anastomosis. Larger studies are needed before this can become the standard of care.

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.

Comparative Evaluation of the Short-Term Treatment Outcomes Between Open, Laparoscopic- and Robotic-Assisted Surgical Approaches for Rectal Cancer Treatment

The open surgeries and more recently minimal invasive surgeries aided by laparoscopic or robotic approaches are employed for rectal cancer treatment procedures. The open approach is the most commonly opted technique, but recent studies have also shown that laparoscopic total mesorectal excision (TME) has become the standard of care. There are certain shortcomings of laparoscopic surgery such as long learning curve, inadequate counter traction, limited dexterity, lack of tactile feedback and limited two-dimensional visions. Robotic surgery also offers several benefits to overcome the drawbacks of laparoscopic procedures, such as providing better dexterity and a more stable visualization. This study aims to analyse the surgical results in terms of completion of TME, short-term surgical outcomes and hospital stay in after open, laparoscopic- and robotic-assisted rectal resections respectively. A retrospective review of prospectively maintained database of patients operated for carcinoma rectum between January 2013 and August 2018 at Manipal Comprehensive Cancer Centre, Manipal-Vattikuti Institute of Robotic Surgery, Bangalore, was analysed in this study. The surgical parameters like completion of total mesorectal excision; proximal, distal and circumferential resection margins; number of nodes retrieved; and total post operative hospital stay were analysed in the open, laparoscopic-assisted and robotic-assisted groups. A total of 100 patients were included in the study consisting of 25, 25 and 50 patients each in the open, laparoscopic and robotic arms respectively. In case the desired results were not obtained using the advanced technique the procedure was converted and open technique was adopted. The conversion rate to open procedure was 8% (2of 25) in the laparoscopic-assisted group and 2% (1/50) in the robotic-assisted group. The average post operative hospital stay was 7.4, 7.36 and 6 days in the open, laparoscopic- and robotic-assisted group (p = 0.01) respectively. Robotic rectal resections show a trend towards better surgical results in the form of improved circumferential resection margins, completeness of TME and lower conversion rates.

Robotic Surgery for Rectal Cancer: Hype or Hope? (Indian Experience)

The primary goal to achieve cure in oncology is to reduce recurrence, maximize disease-free survival, maintain function, and optimize quality of life. Surgery remains the mainstay treatment modality in rectal cancer. The current trend is to perform least invasive method of doing complex surgeries while not compromising in the oncological of functional outcomes of patients. Total mesorectal excision (TME) for rectal cancer surgery entails removal of the rectum with its fascia as an intact unit while preserving surrounding vital structures. The procedure is technically challenging because of the narrow and deep pelvic cavity housing the rectum encased by fatty lymph vascular tissue within the perirectal fascia, distally the anal sphincter complex, and an intimate surrounded by vital structures like ureter, vessels, and nerves. Robotic technology enables overcoming these difficulties caused by complex pelvic anatomy. This system can facilitate better preservation of the pelvic autonomic nerve and thereby achieve favorable postoperative sexual and voiding functions after rectal cancer surgery. The nerve-preserving TME technique includes identification and preservation of the superior hypogastric plexus nerve, bilateral hypogastric nerves, pelvic plexus, and neurovascular bundles.

A comparison of open, laparoscopic and robotic total mesorectal excision: trial sequential analysis and network meta-analysis

AIM

Total mesorectal excision (TME) for rectal cancer can be achieved by employing open (OpTME), laparoscopic (LaTME) and robotic (RoTME) approaches but which of these has the best outcome? The aim of present study is to identify the most effective technique for rectal cancer by comparing all outcomes.

METHODS

Randomized controlled trials (RCTs) which compared at least two TME strategies were identified by literature search of electronic databases of articles published to June 2018. Network meta-analysis with trial sequential analysis was performed using a frequentist approach with random-effects meta-analysis. Data collection and analysis We conducted a systematic search of PubMed, EmBase, the Cochrane Library, CNKI, and Web of Science. Titles and abstracts of the retrieved publications were independently and blindly assessed by two authors.

RESULTS

Twenty-two RCTs with 4882 rectal cancer patients were included in this analysis. The trial sequential analysis demonstrated that the cumulative Z-curve crossed either the traditional boundary or the trial sequential monitoring boundaries, suggesting that OpTME resulted in a more complete TME specimen than LaTME (relative risk 1.05, 95% confidence interval 1.01-1.08). Network meta-analysis showed there was no significant difference in the other comparisons. Based on the P score of completeness of the TME specimen and circumferential resection margin positivity, the best technique was OpTME, followed by RoTME and then LaTME. However, this order was reversed when complications and mortality were considered. RoTME led to better lymph node harvest.

CONCLUSIONS

Although OpTME may give better pathological specimens, minimally invasive techniques may have advantages when considering lymph node harvest, complications and mortality. More RCTs are needed to determine which technique actually gives the best chance of survival.

A prospective randomized controlled trial comparing conventional Intuitive® procedure card recommended port placement with the modified Indian (Manipal) technique

Introduction

The da Vinci^® X hybrid systems (Intuitive Surgical^®, Sunnyvale CA) provides standard sites recommendations for port placement during robotic surgery; including that for colorectal procedures. The author's encountered challenges while adhering to the provided instructions, such as clash of instruments and arms and need for additional ports, and hence to overcome these challenges attempted a few innovative technical modifications. The surgical results as well as merits of the revised Indian (Manipal) port placement with single docking technique are presented here.

Methods

Twenty patients underwent robotic rectal resection at the Department of Surgical Oncology and Robotic Surgery, Manipal Comprehensive Cancer Centre, Bengaluru, India, between December 2017 and June 2018. A randomised controlled study was conducted to compare the two techniques. Ten patients were operated using hybrid da Vinci^® 'X' system using the manufacturer's recommendations and 10 by the modified Indian (Manipal) port placement with a single docking technique.

Result and Conclusions

The Indian (Manipal) modifications of port placements are optimal for colorectal procedures such as low anterior resection as well as for ultralow anterior resections. The intraoperative parameters compared between the recommendations of the Intuitive^® (da Vinci^® systems) and attempted modifications demonstrated statistically significant advantages with the use of the revised techniques. The improvements offered by this modification include no additional requirements of ports or staplers, lesser clash amongst instruments as well as arms, better mobilisation of splenic flexure amongst others.

Robotic versus laparoscopic rectal resection for sphincter-saving surgery: pathological and short-term outcomes in a single-center analysis of 130 consecutive patients

BACKGROUND

Minimally invasive sphincter-saving rectal resection represents a challenging procedure. Robotic surgery for rectal cancer has several advantages over conventional surgery in performing precise dissection and was proved to be safe and effective in previous studies. However, comparison between laparoscopic and robotic rectal resection has drawn contradictory results. The aim of the present study was to compare robotic and laparoscopic sphincter-saving rectal resections for short-term and pathological outcomes.

METHODS

Between January 2013 and May 2016, we performed a total of 258 robotic surgeries, including 146 colorectal resections (56%). For this study, we included the first 65 sphincter-saving robotic resections and compared them to the last 65 consecutive laparoscopic resections. The laparoscopic group was constituted by the last 65 consecutively operated patients who matched the inclusion criteria.

RESULTS

Patients' baseline characteristics were similar in both the groups. Conversion rate was greater in the laparoscopic group (17 vs. 5%, p=0.044). Reoperation rate, overall and severe morbidity, and median hospital stay were similar in both the groups. Quality of mesorectal excision specimen was considered complete or near complete in 97 and 96% in the laparoscopic and robotic groups, respectively. There was no difference in the rates of negative circumferential radial margin, distal margin, and surgical success measured by composite criteria.

CONCLUSION

The main finding of this study was that robotic proctectomy for sphincter-saving procedures offers similar quality of TME with a statistically significant lower rate of conversion when compared to laparoscopic proctectomy.

Robotic general surgery: current practice, evidence, and perspective

BACKGROUND

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

PURPOSE

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

CONCLUSIONS

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