Does robotics improve minimally invasive rectal surgery? Functional and oncological implications

Robotic versus conventional laparoscopic technique for the treatment of left-sided colonic diverticular disease: a systematic review with meta-analysis

PURPOSE

Minimally invasive surgery has been universally accepted as a valid option for the treatment of diverticular disease, provided specific expertise is available. Over the last decade, there has been a growing interest in the application of robotic approaches for diverticular disease. We aimed at evaluating whether robotic colectomy may offer some advantages over the laparoscopic approach for surgical treatment of diverticular disease by meta-analyzing the available data from the medical literature.

METHODS

The PubMed/Medline, EMBASE, and Web Of Sciences electronic databases were searched for literature up to December 2020. Inclusion criteria considered all comparative studies evaluating robotic versus laparoscopic colectomy for diverticulitis eligible. The conversion rate to the open approach was evaluated as the primary outcome.

RESULTS

The data of 4177 patients from nine studies were included in the analysis. There were no significant differences in the baseline characteristics. Patients undergoing laparoscopic colectomy compared to those who underwent surgery with a robotic approach had a significantly higher risk of conversion into an open procedure (12.5% vs. 7.4%, p < 0.00001) and abbreviated hospital stay (p < 0.0001) at the price of a longer operating time (p < 0.00001).

CONCLUSION

Compared with conventional laparoscopic surgery, the robotic approach offers significant advantages in terms of conversion rate and shortened hospital stay for the treatment of diverticular disease. However, because of the lack of available evidence, it is impossible to draw definitive conclusions.

Do People Trust in Robot-Assisted Surgery? Evidence from Europe

(1) Background: The goal of the paper was to establish the factors that influence how people feel about having a medical operation performed on them by a robot. (2) Methods: Data were obtained from a 2017 Flash Eurobarometer (number 460) of the European Commission with 27,901 citizens aged 15 years and over in the 28 countries of the European Union. Logistic regression (odds ratios, OR) to model the predictors of trust in robot-assisted surgery was calculated through motivational factors, using experience and sociodemographic independent variables. (3) Results: The results obtained indicate that, as the experience of using robots increases, the predictive coefficients related to information, attitude, and perception of robots become more negative. Furthermore, sociodemographic variables played an important predictive role. The effect of experience on trust in robots for surgical interventions was greater among men, people between 40 and 54 years old, and those with higher educational levels. (4) Conclusions: The results show that trust in robots goes beyond rational decision-making, since the final decision about whether it should be a robot that performs a complex procedure like a surgical intervention depends almost exclusively on the patient’s wishes.

Functional outcomes after laparoscopic versus robotic-assisted rectal resection: a systematic review and meta-analysis

Surgical resection is crucial for curative treatment of rectal cancer. Through multidisciplinary treatment, including radiochemotherapy and total mesorectal excision, survival has improved substantially. Consequently, more patients have to deal with side effects of treatment. The most recently introduced surgical technique is robotic-assisted surgery (RAS) which seems equally effective in terms of oncological control compared to laparoscopy. However, RAS enables further advantages which maximize the precision of surgery, thus providing better functional outcomes such as sexual function or contience without compromising oncological results. This review was done according to the PRISMA and AMSTAR-II guidelines and registered with PROSPERO (CRD42018104519). The search was planned with PICO criteria and conducted on Medline, Web of Science and CENTRAL. All screening steps were performed by two independent reviewers. Inclusion criteria were original, comparative studies for laparoscopy vs. RAS for rectal cancer and reporting of functional outcomes. Quality was assessed with the Newcastle-Ottawa scale. The search retrieved 9703 hits, of which 51 studies with 24,319 patients were included. There was a lower rate of urinary retention (non-RCTs: Odds ratio (OR) [95% Confidence Interval (CI)] 0.65 [0.46, 0.92]; RCTs: OR[CI] 1.29[0.08, 21.47]), ileus (non-RCTs: OR[CI] 0.86[0.75, 0.98]; RCTs: OR[CI] 0.80[0.33, 1.93]), less urinary symptoms (non-RCTs mean difference (MD) [CI] - 0.60 [- 1.17, - 0.03]; RCTs: - 1.37 [- 4.18, 1.44]), and higher quality of life for RAS (only non-RCTs: MD[CI]: 2.99 [2.02, 3.95]). No significant differences were found for sexual function (non-RCTs: standardized MD[CI]: 0.46[- 0.13, 1.04]; RCTs: SMD[CI]: 0.09[- 0.14, 0.31]). The current meta-analysis suggests potential benefits for RAS over laparoscopy in terms of functional outcomes after rectal cancer resection. The current evidence is limited due to non-randomized controlled trials and reporting of functional outcomes as secondary endpoints.

Functional outcomes after laparoscopic versus robotic-assisted rectal resection: a systematic review and meta-analysis

Surgical resection is crucial for curative treatment of rectal cancer. Through multidisciplinary treatment, including radiochemotherapy and total mesorectal excision, survival has improved substantially. Consequently, more patients have to deal with side effects of treatment. The most recently introduced surgical technique is robotic-assisted surgery (RAS) which seems equally effective in terms of oncological control compared to laparoscopy. However, RAS enables further advantages which maximize the precision of surgery, thus providing better functional outcomes such as sexual function or contience without compromising oncological results. This review was done according to the PRISMA and AMSTAR-II guidelines and registered with PROSPERO (CRD42018104519). The search was planned with PICO criteria and conducted on Medline, Web of Science and CENTRAL. All screening steps were performed by two independent reviewers. Inclusion criteria were original, comparative studies for laparoscopy vs. RAS for rectal cancer and reporting of functional outcomes. Quality was assessed with the Newcastle–Ottawa scale. The search retrieved 9703 hits, of which 51 studies with 24,319 patients were included. There was a lower rate of urinary retention (non-RCTs: Odds ratio (OR) [95% Confidence Interval (CI)] 0.65 [0.46, 0.92]; RCTs: OR[CI] 1.29[0.08, 21.47]), ileus (non-RCTs: OR[CI] 0.86[0.75, 0.98]; RCTs: OR[CI] 0.80[0.33, 1.93]), less urinary symptoms (non-RCTs mean difference (MD) [CI] − 0.60 [− 1.17, − 0.03]; RCTs: − 1.37 [− 4.18, 1.44]), and higher quality of life for RAS (only non-RCTs: MD[CI]: 2.99 [2.02, 3.95]). No significant differences were found for sexual function (non-RCTs: standardized MD[CI]: 0.46[− 0.13, 1.04]; RCTs: SMD[CI]: 0.09[− 0.14, 0.31]). The current meta-analysis suggests potential benefits for RAS over laparoscopy in terms of functional outcomes after rectal cancer resection. The current evidence is limited due to non-randomized controlled trials and reporting of functional outcomes as secondary endpoints.

Robotic Versus Laparoscopic Minimally Invasive Surgery for Rectal Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of elective rectal resection for rectal cancer in adults by robotic surgery compared with conventional laparoscopic surgery.

SUMMARY OF BACKGROUND DATA

Technological advantages of robotic surgery favor precise dissection in narrow spaces. However, the evidence base driving recommendations for the use of robotic surgery in rectal cancer primarily hinges on observational data.

METHODS

We searched MEDLINE, Embase, and CENTRAL for randomized controlled trials (until August 2016) comparing robotic surgery versus conventional laparoscopic surgery. Data on the following endpoints were evaluated: circumferential margin status, mesorectal grade, number of lymph nodes harvested, rate of conversion to open surgery, postoperative complications, and operative time. Data were summarized as relative risks (RR) or weighted mean differences (WMDs) with 95% confidence intervals (95% CIs). Risk of bias of studies was assessed with standard methods.

RESULTS

Five trials were eligible, including 334 robotic and 337 laparoscopic surgery cases. Meta-analysis showed that RS was associated with lower conversion rate (7.3%; 4 studies, 544 participants, RR 0.58; 95% CI 0.35-0.97, P = 0.04, I = 0%) and longer operating time (MD 38.43 minutes, 95% CI 31.84-45.01: P < 0.00001) compared with laparoscopic surgery. Perioperative mortality, rate of circumferential margin involvement (2 studies, 489 participants, RR 0.82, 95% CI 0.39-1.73), and lymph nodes collected (mean 17.4 Lymph Nodes; 5 trials, 674 patients, MD -0.35, 95% CI -1.83 to 1.12) were similar. The quality of the evidence was moderate for most outcomes.

CONCLUSION

Evidence of moderate quality supports that robotic surgery for rectal cancer produces similar perioperative outcomes of oncologic procedure adequacy to conventional laparoscopic surgery. Robotic surgery portraits lower rate of conversion to open surgery, while operating time is significantly longer than by laparoscopic approach.

Oncological Outcomes After Robotic Proctectomy for Rectal Cancer: Analysis of a Prospective Database

OBJECTIVE

The aim of this study is to evaluate the oncological outcomes of robotic total mesorectal excision (TME) at an NCI designated cancer center.

SUMMARY BACKGROUND DATA

The effectiveness of laparoscopic TME could not be established, but the robotic-assisted approach may hold some promise, with improved visualization and ergonomics for pelvic dissection. Oncological outcome data is presently lacking.

METHODS

Patients who underwent total mesorectal excision or tumor-specific mesorectal excision for rectal cancer between April 2009 and April 2016 via a robotic approach were identified from a prospective single-institution database. The circumferential resection margin (CRM), distal resection margin, and TME completeness rates were determined. Kaplan-Meier analysis of disease-free survival and overall survival was performed for all patients treated with curative intent.

RESULTS

A total of 276 patients underwent robotic proctectomy during the study period. Robotic surgery was performed initially by 1 surgeon with 3 additional surgeons progressively transitioning from open to robotic during the study period with annual increase in the total number of cases performed robotically. Seven patients had involved circumferential resection margins (2.5%), and there were no positive distal or proximal resection margins. One hundred eighty-six patients had TME quality assessed, and only 1 patient (0.5%) had an incomplete TME. Eighty-three patients were followed up for a minimum of 3 years, with a local recurrence rate of 2.4%, and a distant recurrence rate of 16.9%. Five-year disease-free survival on Kaplan-Meier analysis was 82%, and 5-year overall survival was 87%.

CONCLUSIONS

Robotic proctectomy for rectal cancer can be performed with good short and medium term oncological outcomes in selected patients.

Preservation of Pathologic Outcomes in Robotic versus Open Resection for Rectal Cancer: Can the Robot Fill the Minimally Invasive Gap?

Open resection remains the standard of care in the surgical management of rectal cancer with recent studies unable to prove noninferiority of laparoscopic resection. Few studies directly compare robotic versus open techniques. This is a retrospective chart review of all consecutive patients undergoing robotic or open rectal cancer resection during a three-year period. The primary endpoint was a composite of complete mesorectal excision, circumferential resection margin <1 mm, and distal resection margin <1 mm. The study cohort included 64 patients undergoing robotic (n = 28) or open (n = 36) resection. Successful surgical resection was similar between the robotic (75%) and open (76%) approaches. Robotic resection was associated with significantly lower blood loss ( P = 0.02) and significantly longer operative times ( P = 0.009) compared with open resection. Length of hospital stay and complications were similar between groups. Both male gender ( P = 0.03) and shorter tumor distance from the anal verge ( P = 0.01) were predictors for unsuccessful surgical resection in open, but not robotic, surgery. Pathologic outcomes are similar between robotic and open rectal cancer resection, even early in the learning curve. Tumor distance from the anal verge complicates open total mesorectal excision; however, robotic surgery is less impacted. Robotic resection may be a promising minimally invasive approach for rectal cancer resection.

Robotic surgery for rectal cancer: the future?

Robotic technology currently offers some technical advantages in pelvic dissection compared with competing minimally invasive techniques, and adoption for the surgical treatment of rectal cancer is rapidly increasing worldwide. While there are some early data demonstrating modest improvement in patient outcomes, benefits in terms of long-term oncological outcomes, as well as potential improvements in surgeon-centered outcomes such as fatigue and repetitive stress injury are actively being investigated. Rapid innovation, with the impending release of several new robotic platforms, is likely to further expand the application of these technologies, improve on current limitations, and reduce capital and consumable costs. It is imperative that, as the technology develops and adoption increases further, clinician and research led programs drive safe implementation with a patient-first approach.

A Meta-Analysis of Randomized Controlled Trials on the Use of Suction Drains Following Rectal Surgery

BACKGROUND

Anastomotic leakage is one of the most feared complications of rectal resections. The role of drains in limiting this occurrence or facilitating its early recognition is still poorly defined. We aimed to study whether the presence of prophylactic pelvic drains affects the surgical outcomes of patients undergoing rectal surgery with extraperitoneal anastomosis.

METHODS

PubMed, EMBASE, and the Cochrane Library were systematically searched for randomized controlled trials comparing drained with undrained anastomoses following rectal surgery. We evaluated possible differences on the relative incidences of anastomotic leakage, pelvic collection or sepsis, bowel obstruction, reoperation rate, and overall mortality. A meta-analysis of relevant studies was performed with RevMan 5.3.

RESULTS

A total of 760 patients from 4 randomized controlled studies were considered eligible for data extraction. The use of drains did not show any advantage in terms of anastomotic leak (OR 0.99), pelvic complications (OR 0.87), reintervention (OR 0.84) and mortality. Contrariwise, the incidence of postoperative bowel obstruction was significantly higher in the drained group (OR 1.61).

CONCLUSIONS

The routine utilization of pelvic drains does not confer any significant advantage in the prevention of postoperative complications after rectal surgery with extraperitoneal anastomosis. Moreover, a higher risk of postoperative bowel obstruction can be of concern.