Robotic gastrointestinal surgery: learning curve, educational programs and outcomes

Challenges With Robot-Assisted Surgery Setup for Complex Minimally Invasive Upper Gastrointestinal Surgery

BACKGROUND

The utilization of robot-assisted approaches to surgery has increased significantly over the last two decades. This has introduced novel complexities into the operating room environment, requiring management of new challenges and workflow adaptation. This study aimed to analyze challenges in the surgical setup for complex upper gastrointestinal robot-assisted surgery (UGI-RAS) and identify opportunities for solutions.

METHODS

Direct observations of surgical setup processes for UGI-RAS were performed by a trained Human Factors researcher at a non-profit academic medical center in Southern California. Setup tasks were subdivided into five phases: (1) before wheels-in; (2) patient transfer and anesthesia induction; (3) patient preparation; (4) surgery preparation; and (5) robot docking. Start/end times for each phase/task were documented along with workflow disruption (FD) narratives and timestamps. Setup tasks and FDs were analyzed using descriptive statistics.

RESULTS

Twenty UGI-RAS setup procedures were observed between May-November 2023: sleeve gastrectomy +/- hiatal hernia repair (n = 9, 45.00%); para-esophageal hernia repair +/- fundoplication (n = 8, 40.00%); revision to Roux-en-Y gastric bypass (n = 2, 10.00%); and gastric band removal (n = 1, 5.00%). Frequent FDs included planning breakdowns (n = 20, 29.85%), equipment/supply management (n = 17, 25.37%), patient care coordination (n = 8, 11.94%), and equipment challenges (n = 8, 11.94%). Eleven of 20 observations were first-start cases, of which 10 experienced delayed starts.

DISCUSSION

Interventions aimed at improving workflows during UGI-RAS setup include performing pre-operative team huddles and conducting trainings aimed at team coordination and equipment challenges. These solutions could result in improved teamwork, efficiency, and communication while reducing case start delays and turnover time.

Colorectal Cancer: Current Updates and Future Perspectives

Colorectal cancer is a frequent neoplasm in western countries, mainly due to dietary and behavioral factors. Its incidence is growing in developing countries for the westernization of foods and lifestyles. An increased incidence rate is observed in patients under 45 years of age. In recent years, the mortality for CRC is decreased, but this trend is slowing. The mortality rate is reducing in those countries where prevention and treatments have been implemented. The survival is increased to over 65%. This trend reflects earlier detection of CRC through routine clinical examinations and screening, more accurate staging through advances in imaging, improvements in surgical techniques, and advances in chemotherapy and radiation. The most important predictor of survival is the stage at diagnosis. The screening programs are able to reduce incidence and mortality rates of CRC. The aim of this paper is to provide a comprehensive overview of incidence, mortality, and survival rate for CRC.

Nutritional status efficacy of early nutritional support in gastrointestinal care: A systematic review and meta-analysis

BACKGROUND

Gastrointestinal surgery is a complicated process used to treat many gastrointestinal diseases, and it is associated with a large trauma: Most patients often have different degrees of malnutrition and immune dysfunction before surgery and are prone to various infectious complications during postoperative recovery, thus affecting the efficacy of surgical treatment. Therefore, early postoperative nutritional support can provide essential nutritional supply, restore the intestinal barrier and reduce complication occurrence. However, different studies have shown different conclusions.

AIM

To assess whether early postoperative nutritional support can improve the nutritional status of patients based on literature search and meta-analysis.

METHODS

Articles comparing the effect of early nutritional support and delayed nutritional support were retrieved from PubMed, EMBASE, Springer Link, Ovid, China National Knowledge Infrastructure, China Biology Medicine databases. Notably, only randomized controlled trial articles were retrieved from the databases (from establishment date to October 2022). The risk of bias of the included articles was determined using Cochrane Risk of Bias V2.0. The outcome indicators, such as albumin, prealbumin, and total protein, after statistical intervention were combined.

RESULTS

Fourteen literatures with 2145 adult patients undergoing gastrointestinal surgery (1138 patients (53.1%) receiving early postoperative nutritional support and 1007 patients (46.9%) receiving traditional nutritional support or delayed nutritional support) were included in this study. Seven of the 14 studies assessed early enteral nutrition while the other seven studies assessed early oral feeding. Furthermore, six literatures had "some risk of bias," and eight literatures had "low risk". The overall quality of the included studies was good. Meta-analysis showed that patients receiving early nutritional support had slightly higher serum albumin levels, than patients receiving delayed nutritional support [MD (mean difference) = 3.51, 95%CI: -0.05 to 7.07, Z = 1.93, P = 0.05]. Also, patients receiving early nutritional support had shorter hospital stay (MD = -2.29, 95%CI: -2.89 to -1.69), Z = -7.46, P < 0.0001) shorter first defecation time (MD = -1.00, 95%CI: -1.37 to -0.64), Z = -5.42, P < 0.0001), and fewer complications (Odd ratio = 0.61, 95%CI: 0.50 to 0.76, Z = -4.52, P < 0.0001) than patients receiving delayed nutritional support.

CONCLUSION

Early enteral nutritional support can slightly shorten the defecation time and overall hospital stay, reduce complication incidence, and accelerate the rehabilitation process of patients undergoing gastrointestinal surgery.

Characteristics of the learning curve in robotic thoracic surgery in an emerging country

It is not established which factors impact the learning curve (LC) in robotic thoracic surgery (RTS), especially in emerging countries. The aim of this study is to analyze LC in RTS in Brazil and identify factors that can accelerate LC. We selected the first cases of two Brazilian surgeons who started their LC. We used CUSUM and the Lowess technique to measure LC for each surgeon and Poisson regression to assess factors associated with shorter console time (CT). 58 patients were operated by each surgeon and included in the analysis. Surgeries performed were different: Surgeon I (SI) performed 54 lobectomies (93.11%), whereas Surgeon II (SII) had a varied mix of cases. SI was proctored in his first 10 cases (17.24%), while SII in his first 41 cases (70.68%). The mean interval between surgeries was 8 days for SI and 16 days for SII. There were differences in the LC phases of the two surgeons, mainly regarding complications and conversions. There was shorter CT by 30% in the presence of a proctor, and by 20% with the Da Vinci Xi. Mix of cases did not seem to contribute to faster LC. Higher frequency between surgeries seems to be associated with a faster curve. Presence of proctor and use of bolder technologies reduced console time. We wonder if in phase 3 it is necessary to keep a proctor on complex cases to avoid serious complications. More studies are necessary to understand which factors impact the LC.

Developing a Robotic Surgery Curriculum: Selection of Virtual Reality Drills for Content Alignment

INTRODUCTION

Despite the importance of simulation-based training for robotic surgery, there is no consensus about its training curricula. Recently, a virtual reality (VR) platform (SimNow, Intuitive, Inc) was introduced with 33 VR drills but without evidence of their validity. As part of our creating a new robotic VR curriculum, we assessed the drills' validity through content mapping and the alignment between learning goals and drill content.

METHODS

Three robotically trained surgeons content-mapped all 33 drills for how well the drills incorporated 15 surgery skills and also rated the drills' difficulty, usefulness, relevance, and uniqueness. Drills were added to the new curriculum based on consensus about ratings and historic learner data. The drills were grouped according to similar skill sets and arranged in order of complexity.

RESULTS

The 33 drills were judged to have 12/15 surgery skills as primary goals and 13/15 as secondary goals. Twenty of the 33 drills were selected for inclusion in the new curriculum; these had 11/15 skills as primary goals and 11/15 as secondary goals. However, skills regarding energy sources, atraumatic handling, blunt dissection, fine dissection, and running suturing were poorly represented in the drills. Three previously validated inanimate drills were added to the curriculum to address lacking skill domains.

CONCLUSIONS

We identified 20 of the 33 SimNow drills as a foundation for a robotic surgery curriculum based on content-oriented evidence. We added 3 other drills to address identified gaps in drill content.

Development of biotissue training models for anastomotic suturing in pancreatic surgery

BACKGROUND

Anastomotic suturing is the Achilles heel of pancreatic surgery. Especially in laparoscopic and robotically assisted surgery, the pancreatic anastomosis should first be trained outside the operating room. Realistic training models are therefore needed.

METHODS

Models of the pancreas, small bowel, stomach, bile duct, and a realistic training torso were developed for training of anastomoses in pancreatic surgery. Pancreas models with soft and hard textures, small and large ducts were incrementally developed and evaluated. Experienced pancreatic surgeons (n = 44) evaluated haptic realism, rigidity, fragility of tissues, and realism of suturing and knot tying.

RESULTS

In the iterative development process the pancreas models showed high haptic realism and highest realism in suturing (4.6 ± 0.7 and 4.9 ± 0.5 on 1-5 Likert scale, soft pancreas). The small bowel model showed highest haptic realism (4.8 ± 0.4) and optimal wall thickness (0.1 ± 0.4 on -2 to +2 Likert scale) and suturing behavior (0.1 ± 0.4). The bile duct models showed optimal wall thickness (0.3 ± 0.8 and 0.4 ± 0.8 on -2 to +2 Likert scale) and optimal tissue fragility (0 ± 0.9 and 0.3 ± 0.7).

CONCLUSION

The biotissue training models showed high haptic realism and realistic suturing behavior. They are suitable for realistic training of anastomoses in pancreatic surgery which may improve patient outcomes.

Minimally invasive colorectal surgery learning curve

The learning curve in minimally invasive colorectal surgery is a constant subject of discussion in the literature. Discordant data likely reflects the varying degrees of each surgeon’s experience in colorectal, laparoscopic or robotic surgery. Several factors are necessary for a successful minimally invasive colorectal surgery training program, including: Compliance with oncological outcomes; dissection along the embryological planes; constant presence of an expert tutor; periodic discussion of the morbidity and mortality rate; and creation of a dedicated, expert team.

Association of robotic approach with patient-reported outcomes after pancreatectomy: a prospective cohort study

BACKGROUND

Robotic-assisted pancreatectomy continues to proliferate despite limited evidence supporting its benefits from the patient's perspective. We compared patient-reported outcomes (PROs) between patients undergoing robotic and open pancreatectomies.

METHODS

PROs, measured with the FACT-Hep, FACT-G, and HCS, were assessed in the immediate postoperative (i.e., preoperative to discharge) and recovery (i.e., discharge to three months postoperative) periods. Linear mixed models estimated the association of operative approach on PROs. Minimally important differences (MIDs) were also considered.

RESULTS

Among 139 patients, 105 (75.5%) underwent robotic pancreatectomies. Compared to those who underwent open operations, those who underwent robotic operations experienced worse FACT-Hep scores that were both statistically and clinically significant (mean difference [MD] 8.6 points, 95% CI 1.0-16.3). Declines in FACT-G (MD 4.3, 95% CI -1.0 to 9.6) and HCS (MD 4.3, 95% CI 0.8-7.9) scores appeared to contribute equally in both operative approaches to the decline in total FACT-Hep score. Patients who underwent robotic versus open operations both statistically and clinically significantly improved due to improvements in HCS (MD 6.1, 95% CI 2.3-9.9) but not in FACT-G (MD 1.2, 95% CI - 5.1-7.4).

CONCLUSION

The robotic approach to pancreas surgery might offer, from the patient's perspective, greater improvement in symptoms over the open approach by three months postoperatively.

The Learning Curve of Da Vinci Robot-Assisted Hemicolectomy for Colon Cancer: A Retrospective Study of 76 Cases at a Single Center

Background and Aims

Robotic-assisted right hemicolectomy (RARH) has many benefits in treating colon cancer, but it is a new technology that needs to be evaluated. This study aims to assess the learning curve (LC) of RARH procedures with the complete mesoscopic exception and D3 lymph node dissection for colon carcinoma.

Methods

A retrospective analysis was performed on a consecutive series of 76 patients who underwent RARH from July 2014 to March 2018. The operation time was evaluated using the cumulative sum (CUSUM) method to analyze the LC. The patients were categorized into two groups based on the LC: Phase I and Phase II. Statistical methods were used to compare clinicopathological data on intraoperative and perioperative outcomes at different stages of the study.

Results

The peak point of the LC was observed in the 27th case. Using the CUSUM method, we divide the LC into two stages. Stage 1 (initial learning stage): Cases 1–27 and Stage 2 (proficiency phase): Cases 28–76. There were no obvious distinctions between the two patients’ essential characteristics (age, sex, body mass index, clinical stage, and ASA score). The mean operation time of each group is 187.37 ± 45.56 min and 161.1 ± 37.74 min (P = 0.009), respectively. The intraoperative blood loss of each group is 170.4 ± 217.2 ml and 95.7 ± 72.8 ml (P = 0.031), respectively.

Conclusion

Based on the LC with CUSUM analysis, the data suggest that the learning phase of RARH was achieved after 27 cases. The operation time and the intraoperative blood loss decrease with more cases performed.

Robotic versus Laparoscopic Gastrectomy for Gastric Cancer: An Updated Systematic Review

Background and Objectives: Gastrectomy with D2 lymphadenectomy is the standard surgical treatment with curative intent for patients with gastric cancer (GC). Over the last three decades, surgeons have been increasingly adopting laparoscopic surgery for GC, due to its better short-term outcomes. In particular, laparoscopic gastrectomy (LG) has been routinely used for early gastric cancer (EGC) treatment. However, LG suffers from technical limitations and drawbacks, such as a two-dimensional surgical field of view, limited movement of laparoscopic tools, unavoidable physiological tremors and discomfort for operating surgeon. Therefore, robotic surgery has been developed to address such limitations. Materials and Methods: We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines in order to investigate the benefits and harms of robotic gastrectomy (RG) compared to the LG. PubMed/MEDLINE, Scopus, Cochrane Library (Cochrane Database of Systematic Re-views, Cochrane Central Register of Controlled Trials-CENTRAL) and Web of Science (Science and Social Science Citation Index) databases were used to search all related literature. Results: The 7 included meta-analyses covered an approximately 20 years-study period (2000-2020). Almost all studies included in the meta-analyses were retrospective ones and originated from Asian countries (China and Korea, in particular). Examined overall population ranged from 3176 to 17,712 patients. If compared to LG, RG showed both operative advantages (operative time, estimated blood loss, number of retrieved lymph nodes) and perioperative ones (time to first flatus, time to restart oral intake, length of hospitalization, overall complications, Clavien-Dindo (CD) ≥ III complications, pancreatic complications), in the absence of clear differences of oncological outcomes. However, costs of robotic approach appear significant. Conclusions: It is impossible to make strong recommendations, due to the statistical weakness of the included studies. Further randomized, possibly multicenter trials are strongly recommended, if we want to have our results confirmed.

Controversial Role of Robot in Primary and Revisional Bariatric Surgery Procedures: Review of the Literature and Personal Experience

Laparoscopy is the surgical standard of care for bariatric procedures; however, during the last two decades, the robotic approach has gained increasing interest. It is currently considered a safe and effective alternative to laparoscopy. This literature review investigates the role of the robotic approach for primary and revisional bariatric procedures, with the particular aim of comparing this technique with the standard-of-care laparoscopic approach. The feasibility of robotic dissection and suturing could have potential advantages: robotics may prevent the risk of leak and bleeding and other surgical complications, determining potential benefits in terms of operative time, length of hospital stay, and learning curve. Considering primary procedures, the literature reveals no advantages in robotic versus the laparoscopic approach for adjustable gastric banding and sleeve gastrectomy. Robotic Roux-en-Y gastric bypass is associated with a longer operative time and a shorter hospital length of stay than laparoscopy. The robotic approach in revisional surgery has been proven to be safe and effective. Despite the longer operative time, the robotic platform could achieve a lower bleeding rate compared with laparoscopy. The surgeon’s selection criteria related to referrals to the robotic approach of difficult-perceived cases could represent a bias. In conclusion, robotic surgery can be considered a safe and effective approach in both primary and revisional bariatric surgery, despite the lack of evidence to support its routine use in primary bariatric surgery. However, in revisional bariatric surgery and in surgical complex procedures, the robotic approach could have potential benefits in terms of surgical complications and learning curves.

Robotic Revision of Hepaticojejunostomy for Benign Biliary Stricture

Surgical revision of biliary enteric anastomoses (BEA) can be a challenging undertaking and a robotic platform may provide advantages that address many of the technical obstacles. We present our technical approach and outcomes for patients undergoing robotic revision of BEA for benign strictures. A retrospective review was performed for robot-assisted benign BEA revision at our institution. Operative details, perioperative metrics, and outcomes are reported. Four patients underwent anastomotic revision following previously failed non-operative management. There were no intraoperative complications, mean length of stay was 4-days, and all patients experienced resolution of presenting clinical signs and symptoms. No patients required reoperation and there was no mortality. Postoperative outcomes were consistent with findings reported for other interventional modalities. Based on our experience we conclude robotic intervention in this context is safe and improves the technical feasibility of this complex procedure.