Robotic right colon resection: evaluation of first 50 consecutive cases for malignant disease

Robotic CME in 110 consecutive cases: feasibility and short-term technical and oncological outcomes

BACKGROUND

Complete mesocolic excision (CME) has been introduced from open surgery, to compare right colon cancer surgery to total mesorectal excision for rectal cancer and it is currently being applied by robotic approach. CME concept is based on the complete removal of right mesocolon and the dissection deep at the level of the central feeding vessels. Aside the CME, intracorporeal anastomosis completes a total minimally invasive approach to the treatment of right colon cancer. This study retrospectively analyzed the feasibility and efficacy of robotic CME and intracorporeal anastomosis in a cohort of consecutive patients affected with right colon cancer.

METHODS

The data of 110 patients undergone a robotic CME with IA anastomosis for right colon cancer from 2018 to 2023 were prospectively collected and retrospectively analyzed. Intraoperative, postoperative, and short-middle term outcomes were considered for analysis, as well as pathologic and oncologic outcomes. A time-to-event analysis was performed using the Kaplan-Meier method for OS and DFS.

RESULTS

All patients underwent a robotic right colectomy. Median operative time was 184 min, blood loss was negligible, no intraoperative complications occurred. Three conversions (2.7%) were experienced due to bulky lymph nodes and severe local advanced tumor. Mean postoperative stay was 6 days. Six postoperative complications occurred, 4 postoperative ileus, 1 late dehiscence of the colonic stump and an iatrogenic colonic perforation. The latter needed reintervention.

CONCLUSIONS

Robotic CME with central vessels ligation seems feasible and safe, with acceptable morbidity and adequate short-middle term outcomes.

Robotic splenic flexure cancer resection: technique and short-term outcomes

BACKGROUND

Surgical approach for splenic flexure cancer is demanding due to the complex regional anatomy and the variety of vascular and lymphatic reticula. Minimally invasive approach is recommended to reduce morbidity and postoperative stay, however, laparoscopic SFC resection may results challenging due to vascular and lymphatic dissection. Robotic assistance may help in performing such a procedure thanks to its enhanced dexterity, increased range of motion, enhanced precision and visualization.

METHODS

From a database of 287 colorectal procedures, data of twelve consecutive patients who underwent elective splenic flexure resection for SFC with curative intent from 2018 to 2024 at our institution were included in this retrospective cohort study. Parameters considered for statistical analysis were operative time, time to bowel canalization, length of postoperative stay, and 30-day postoperative complications. Kaplan-Meier method was used for univariate survival analysis.

RESULTS

All patients underwent robotic left splenic flexure resections for cancer using the da Vinci Si surgical system in the first 9 and the Vinci Xi surgical system in the last 3 procedures. Median operative time was 267 minutes. Median operative time in the three procedures carried out by Xi system was 200 minutes. All procedures were R0. One postoperative complication occurred. Three conversions were needed, one for pulmonary failure and two for technical difficulties in severe locally advanced tumor.

CONCLUSIONS

Robotic splenic flexure resection for SFC seems to be safe and feasible, Xi system is promising in reducing time and ameliorate a fast postoperative recovery. Further studies are needed to confirm the role of robotic in splenic flexure resection for SFC.

Comparison of Postoperative Outcomes and Long-Term Survival Rates between Patients Who Underwent Robotic and Laparoscopic Complete Mesocolic Excision for Right-Sided Colon Cancer

Introduction: Right colon cancer often requires surgical intervention, and complete mesocolic excision (CME) has emerged as a standard procedure. The study aims to evaluate and compare the safety and efficacy of robotic and laparoscopic CME for patients with right colon cancer and 5-year survival rates examined to determine the outcomes. Materials and Methods: Patients who underwent CME for right-sided colon cancer between 2014 and 2021 were included in this study. Group differences of age, body mass index, operation time, bleeding amount, total harvested lymph nodes, and postoperative stay were analyzed by the Mann-Whitney U test. Group differences of sex, American Society of Anesthesiology, and tumor, node, and metastasis stage were analyzed by the Chi-squared test. Disease-free and overall survival were assessed using Kaplan-Meier curves with the log-rank Mantel-Cox test. Results: From 109 patients, 74 of them were 1:1 propensity score matched and used for analysis. Total harvested lymph node (P ≤ .001) and estimated blood loss (P = .031) were found to be statistically significant between the groups. We found no statistically significant difference between the groups in terms of disease-free and overall survival (P = .27, .86, respectively), and the mortality rate was 9.17%, with no deaths directly attributed to the surgery. Conclusions: Study shows that minimally invasive surgery is a feasible option for CME in right colon cancers, with acceptable overall survival rates. Although the robotic approach has a higher lymph node yield, there was no significant difference in survival rates. Further randomized trials are needed to determine the clinical significance of both approaches.

Complete mesocolic excision versus standard resection for colon cancer: a systematic review and meta-analysis of perioperative safety and an evaluation of the use of a robotic approach

PURPOSE

Complete mesocolic excision (CME) has been associated with improved oncological outcomes in treatment of colon cancer. However, widespread adoption is limited partly because of the technical complexity and perceived risks of the approach. The aim of out study was to evaluate the safety of CME compared to standard resection and to compare robotic versus laparoscopic approaches.

METHODS

Two parallel searches were undertaken in MEDLINE, Embase and Web of Science databases 12 December 2021. The first was to evaluate IDEAL stage 3 evidence to compare complication rates as a surrogate marker of perioperative safety between CME and standard resection. The second independent search compared lymph node yield and survival outcomes between minimally invasive approaches.

RESULTS

There were four randomized control trials (n = 1422) comparing CME to standard resection, and three studies comparing laparoscopic (n = 164) to robotic (n = 161) approaches. Compared to standard resection, CME was associated with a reduction in Clavien-Dindo grade 3 or higher complication rates (3.56% vs. 7.24%, p = 0.002), reduced blood loss (113.1 ml vs. 137.6 ml, p < 0.0001) and greater mean lymph node harvest (25.6 vs. 20.9 nodes, p = 0.001). Between the robotic and laparoscopic groups, there were no significant differences in complication rates, blood loss, lymph node yield, 5-year disease-free survival (OR 1.05, p = 0.87) and overall survival (OR 0.83, p = 0.54).

CONCLUSIONS

Our study demonstrated improved safety with CME. There was no difference in safety or survival outcomes between robotic and laparoscopic CME. The advantage of a robotic approach may lie in the reduced learning curve and an increased penetration of minimally invasive approach to CME. Further studies are required to explore this.

PROSPERO ID

CRD42021287065.

A Systematic Review of Varying Definitions and the Clinical Significance of Fredet's Fascia in the Era of Complete Mesocolic Excision

BACKGROUND

Fredet's fascia represents a crucial landmark for vascular surgical anatomy, especially in minimally invasive complete mesocolic excision (CME) for right-sided colon adenocarcinoma. Fredet's fascia allows access to the gastrocolic trunk of Henle (GCTH), the most critical step in both open and minimally invasive right-sided CME techniques. Despite this, a recent workshop of expert surgeons on the standardization of the laparoscopic right hemicolectomy with CME did not recognize or include the term of Fredet's fascia or area. Hence, we undertook a systematic review of articles that include the terms "Fredet's fascia or area", or synonyms thereof, with special emphasis on the types of articles published, the nationality, and the relevance of this area to surgical treatments.

METHODS

We conducted a systematic review up to 15 July 2022 on PubMed, WOS, SCOPUS, and Google Scholar.

RESULTS

The results of the study revealed that the term "Fredet's fascia" is poorly used in the English language medical literature. In addition, the study found controversial and conflicting data among authors regarding the definition of "Fredet's fascia" and its topographical limits.

CONCLUSIONS

Knowledge of Fredet's fascia's surgical relevance is essential for colorectal surgeons to avoid accidental injuries to the superior mesenteric vascular pedicle during minimally invasive right hemicolectomies with CME. In order to avoid confusion and clarify this fascia for future use, we suggest moving beyond the use of the eponymous term by using a "descriptive term" instead, based on the fascia's anatomic structure. Fredet's fascia could, therefore, be more appropriately renamed "sub-mesocolic pre-duodenopancreatic fascia".

Right colectomy from open to robotic - a single-center experience with functional outcomes in a learning-curve setting

Purpose

Right colectomy (RC) is a frequently performed procedure. Beneath standard conventional open surgery (COS), various minimally invasive techniques had been introduced. Several advantages had recently been described for robotic approaches over COS or conventional laparoscopy. Nevertheless, novel minimally invasive techniques require continuous benchmarking against standard COS to gain maximum patient safety. Bowel dysfunction is a frequent problem after RC. Together with general complication rates postoperative bowel recovery are used as surrogate parameters for postoperative patient outcome in this study.

Methods

Retrospective, 10-year single-center analysis of consecutive patients who underwent sequentially either COS (n = 22), robotic-assisted (ECA: n = 39), or total robotic surgery (ICA: n = 56) for oncologic RC was performed.

Results

The conversion from robotic to open surgery rate was low (overall: 3.2%). Slightly longer duration of surgery had been observed during the early phase after introduction of the robotic program to RC (ECA versus COS, p = 0.044), but not anymore thereafter (versus ICA). No differences were observed in oncologic parameters including rates of tumor-negative margins, lymph node-positive patients, and lymph node yield during mesocolic excision. Both robotic approaches are beneficial regarding postoperative complication rates, especially wound infections, and shorter length of in-hospital stay compared with COS. The duration until first postoperative stool is the shortest after ICA (COS: 4 [2–8] days, ECA: 3 [1–6] days, ICA: 3 [1–5] days, p = 0.0004). Regression analyses reveal neither a longer duration of surgery nor the extent of mesocolic excision, but the degree of minimally invasiveness and postoperative systemic inflammation contribute to postoperative bowel dysfunction, which prolongs postoperative in-hospital stay significantly.

Conclusion

The current study reflects the institutional learning curve of oncologic RC during implementation of robotic surgery from robotic-assisted to total robotic approach without compromises in oncologic results and patient safety. However, the total robotic approach is beneficial regarding postoperative bowel recovery and general patient outcome.

Right colectomy with intracorporeal anastomosis for cancer: a prospective comparison between robotics and laparoscopy

Robotics in right colectomy are still under debate. Available studies compare different techniques of ileocolic anastomosis but results are non-conclusive. Our study aimed to compare intraoperative outcomes, and short-term postoperative results between robotic and standard laparoscopic right colectomies for cancer with intracorporeal anastomosis (ICA) fashioned with the same technique. All consecutive patients scheduled for laparoscopic or robotic right hemicolectomies with ICA for cancer in two hospitals, one of which is a tertiary care centre, were prospectively enrolled in our prospective observational study, from April 2018 to December 2019. ICA was fashioned with the same stapled hand-sewn technique. Continuous and categorical variables were analysed using t test and chi-squared test as required. Statistical significance was set at p < 0.05. Forty patients underwent laparoscopic surgery, and 48 underwent robotic right colectomy and were included in the intention-to-treat analysis. Operative time was not statistically different between the two groups (robotic group 265.9 min vs laparoscopic group 254.2 min, p = 0.29). The robotic group had a significantly shorter time for stump oversewing (ileum reinforcement: robotic group 9.3 min vs laparoscopic group 14.2 min, p < 0.001; colon reinforcement: robotic 7.7. min, laparoscopy 13.9 min, p < 0.001) and for ICA (robotic 31.6 min vs laparoscopy 43.0, p < 0.001). One patient underwent extracorporeal anastomosis in the robotic group. The short-term outcomes were comparable between standard laparoscopic and robotic right colectomies with ICA. The limitation of the study is its small sample size and the fact that it was done in two institutions under the supervision of one person. Our data demonstrate that intracorporeal ileocolic anastomosis is safe, and faster and easier with robotic systems. Robotics can facilitate more challenging ICA in minimally invasive surgery.

Ileo-colic intra-corporeal anastomosis during robotic right colectomy: a systematic literature review and meta-analysis of different techniques

PURPOSE

Robotic assistance could increase the rate of ileo-colic intra-corporeal anastomosis (ICA) during robotic right colectomy (RRC). However, although robotic ICA can be accomplished with several different technical variants, it is not clear whether some of these technical details should be preferred. An evaluation of the possible advantage of one respect to another would be useful.

METHODS

We conducted a systematic review of literature on technical details of robotic ileo-colic ICA, from which we performed a meta-analysis of clinical outcomes. The extracted data allowed a comparative analysis regarding the outcome of overall complication (OC), bleeding rate (BR) and leakage rate (LR), between (1) mechanical anastomosis with robotic stapler, versus laparoscopic stapler, versus totally hand-sewn anastomosis and (2) closure of enterocolotomy with manual double layer, versus single layer, versus stapled.

RESULTS

A total of 30 studies including 2066 patients were selected. Globally, the side-to-side, isoperistaltic anastomosis, realized with laparoscopic staplers, and double-layer closure for enterocolotomy, is the most common technique used. According to the meta-analysis, the use of robotic stapler was significantly associated with a reduction of the BR with respect to mechanical anastomosis with laparoscopic stapler or totally hand-sewn anastomosis. None of the other technical aspects significantly influenced the outcomes.

CONCLUSIONS

ICA fashioning during RRC can be accomplished with several technical variants without evidence of a clear superiority of anyone of these techniques. Although the use of robotic staplers could be associated with some benefits, further studies are necessary to draw conclusions.

Preliminary exploration of robotic complete mesocolic excision for colon cancer with the domestically produced Chinese minimally invasive Micro Hand S surgical robot system

OBJECTIVE

To summarize our initial experience with robot-assisted complete mesocolic excision (R-CME) using a domestically produced Chinese surgical robot by a short-term evaluation.

METHODS

From March 2018 to December 2018, 25 patients with colon cancer underwent Micro Hand S R-CME. The operative findings, morbidities and oncological findings were analysed.

RESULT

The median operative duration was 210 (range, 180-235) min, and the median estimated blood loss volume was 55 (range, 25-125) ml. The median number of lymph nodes harvested was 42 (range, 21-77), and the median length of hospital stay after the operation was 7 (range, 5-9) days. There were no severe complications except for seven cases of grade I complications and five cases of grade II complications. The conversion rate was 0%. There were no cases of 30-day readmission or 30-day mortality.

CONCLUSION

R-CME using a domestically produced surgical robot for selected colon cancer patients is technically feasible and safe.

Robotic-assisted right colectomy versus laparoscopic approach: case-matched study and cost-effectiveness analysis

AIM

The aim of this study is to compare clinical and oncological outcomes of robot-assisted right colectomy with those of conventional laparoscopy-assisted right colectomy, reporting for the first time in literature, a cost-effectiveness analysis.

METHODS

This is a case-matched prospective non-randomized study conducted from October 2013 to October 2017 at Sanchinarro University Hospital, Madrid. Patients with right-sided colonic adenocarcinoma or adenoma, not suitable endoscopic resection were treated with robot-assisted right colectomy and a propensity score-matched (1:1) was used to balance preoperative characteristics of a laparoscopic control group. Perioperative, postoperative, long-term oncological results and costs were analysed, and quality-adjusted life years (QALY), and the cost-effectiveness ratio (ICER) were calculated. The primary end point was to compare the cost-effectiveness differences between both groups. A willingness-to-pay of 20,000 and 30,000 per QALY was used as a threshold to recognize which treatment was most cost effective.

RESULTS

Thirty-five robot-assisted right colectomies were included and a group of 35 laparoscopy-assisted right colectomy was selected. Compared with the laparoscopic group, the robotic group was associated with longer operation times (243 min vs. 179 min, p < 0.001). No significant difference was observed in terms of total costs between the robotic and laparoscopic groups (9455.14 vs 8227.50 respectively, p = 0.21). At a willingness-to-pay threshold of 20,000 and 30,000, there was a 78.78-95.04% probability that the robotic group was cost effective relative to laparoscopic group.

CONCLUSION

Robot-assisted right colectomy is a safe and feasible technique and is a cost-effective procedure.

Robotic surgery for colorectal disease: review of current port placement and future perspectives

Purpose

As robotic surgery is increasingly performed in patients with colorectal diseases, understanding proper port placement for robotic colorectal surgery is necessary. This review summarizes current port placement during robotic surgery for colorectal diseases and provides future perspective on port placements.

Methods

PubMed were searched from January 2009 to December 2018 using a combination of the search terms “robotic” [MeSH], “colon” [MeSH], “rectum” [MeSH], “colorectal” [MeSH], and “colorectal surgery” [MeSH]. Studies related to port placement were identified and included in the current study if they used the da Vinci S, Si, or Xi robotic system and if they described port placement.

Results

This review included 77 studies including a total of 3,145 operations. Fifty studies described port placement for left-sided and mesorectal excision; 17, 3, and 7 studies assessed port placement for right-sided colectomy, rectopexy, transanal surgery, respectively; and one study assessed surgery with reduced port placement. Recent literatures show that the single-docking technique included mobilization of the second and third robotic arms for the different parts without movement of patient cart and similar to previous dual or triple-docking technique. Besides, use of the da Vinci Xi system allowed a more simplified port configuration.

Conclusion

Robot-assisted colorectal surgery can be efficiently achieved with successful port placement without movement of patient cart dependent on the type of surgery and the robotic system.

Robotic transanal total mesorectal excision: A new perspective for low rectal cancer treatment. A case series

BACKGROUND

Rectal cancer treatment is still a challenging frontier in general surgery, as there is no general agreement on which surgical approach is best for its management. Total mesorectal excision (TME), influenced the practical approach to rectal cancer, and brought a significant improvement on tumor recurrence and patients survival. Robotic transanal surgery is a newer approach to rectal dissection whose purpose is to overcome the limits of the traditional transabdominal approach, improving accuracy of distal dissection and preservation of hypogastric innervation. An increasing interest on this new technique has raised, thanks to the excellent pathological and acceptable short-term clinical outcomes reported.

MATERIALS AND METHODS

Three consecutive cases of robotic transanal TME were prospectically performed between May 2017 and October 2017.

RESULTS

TME quality was Quirke 3 grade in all cases. Mean operative time was 530 min. None of the patients had intra-operatively or post-operatively complications.

CONCLUSIONS

Robotic transanal TME is a very recent procedure. Acclaimed greatest advantage of robotic transanal TME is the facilitation of dissection with an in-line view, which translates in an improved surgical field exposure and visualization. Further investigations are needed to assure the actual value of robotic transanal approach.

Robotic right colectomy in a patient with ventriculoperitoneal shunt. Report of a case

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Laparoscopic surgery in patients with VPS tubes was previously contraindicated.

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Robotic right colectomy is associated with improved recovery.

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No need of VPS catheter manipulation is needed in robotic surgery.

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The first reported case of a robotic right colectomy with an intracorporeal anastomosis in a patients with a VPS.

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Robotic right colectomy is safe also in patients with VPS, with short hospital stay and fast postoperative recovery.

Introduction: Ventriculoperitoneal shunt procedure has become the most common neurosurgical method for hydrocephalus because it considerably improves patients prognosis.

Pneumoperitoneum has been considered a contraindication to laparoscopic surgery because of risk for increased intracranial pressure during pneumoperitoneum and/or malfunction/infection of the VP shunt itself. Laparoscopic resection of the cecum and of the rectum for cancer has been reported.

Presentation of case: A 74-year old man with ventriculoperitoneal shunt for normal pressure hydrocephalus referred to the emergency medicine ward for COPD, lower limb oedema and severe anemia. CT Scan showed a substenotic tumor of the right colon and non-specific enlarged regional lymph nodes, with no distant metastases. Colonoscopy confirmed the presence of an ulcerated tumor of the right colon involving half of the colic lumen. A right colectomy with CME was carried out, with a stapled intracorporeal ileocolic side-to-side isoperistaltic anastomosis and without manipulating the VPS catheter.

Discussion: Laparoscopic surgery in patients with VPS tubes was previously contraindicated because of the possibility of shunt-associated complications, that may include shunt malfunction due to increased intra-abdominal pressure, damage or infection of the catheter. Some authors reported that intracranial pressure increased up to 25 mmHg at a pneumoperitoneum pressure of 12 mmHgHerein we report, to our knowledge, the first case report of robotic assisted right colectomy for cancer in a patient with a VP shunt.

Conclusion: Robotic assistance may allow to perform colorectal resection safely and with low risk also in patients with ventriculoperitoneal shunt.

Robotic versus conventional laparoscopic surgery for rectal cancer: systematic review and meta-analysis

BACKGROUND

The purpose of this meta-analysis is to evaluate the evidence available on the safety as well as effectiveness of robotic resection as compared to conventional laparoscopic surgery for rectal cancer.

MATERIAL AND METHODS

A comparison of laparoscopic and robotic surgical treatments for rectal cancer was collected. Eligible trials that analyzed probabilistic hazard ratios (HR) for endpoints of interest (including perioperative morbidity) and postoperative complications were included in our review.

RESULTS

A total of six studies were included based on the present inclusion criteria. The pooled data showed that R-TME appeared to have association with remarkable reduction in the postoperative morbidity rate as compared to L-TME. Moreover, R-TME was also linked to lower conversion, decreased lymph node number, and longer operation time compared with L-TME. However, there was no difference in hospital stay, positive range of circumferential resection and blood loss between the two study groups.

CONCLUSIONS

Robotic rectal cancer surgery provides favorable outcomes and is considered as a safe surgical technique in terms of postoperative oncological safety. Like laparoscopic TME surgery, robotic surgery may be a valid alternative and complementary approach with beneficial effects on minimally-invasive surgery.

Robotic colectomy with intracorporeal anastomosis is feasible with no operative conversions during the learning curve for an experienced laparoscopic surgeon developing a robotics program

The benefits of performing a colectomy robotically instead of laparoscopically have not conclusively been demonstrated. Evaluation of studies is limited by sample size, retrospective design, heterogeneity of operative techniques, sparse adjustment for learning curve, and mixed results. Consequently, adoption of robotic colectomy by surgeons has been expectedly slow. The objectives of the study were to compare the outcomes of robotic colectomy to laparoscopic colectomy for patients with right-sided tumors undergoing a standardized completely intracorporeal operation and to examine the impact of prior experience with laparoscopic right colectomies on the performance of robotic right colectomies. Retrospective review of outcomes of consecutive patients undergoing a robotic right colectomy (robot) compared to those undergoing laparoscopic colectomy (LAP). LAP patients were further subdivided into a group during the learning curve (LC) and after the learning curve (post-LC). Data collected included operative time (OT), conversion to laparotomy, lymph nodes harvested (LN), length of stay (LOS), 30-day morbidity, and mortality. Comparison of continuous and categorical variables was assessed with the independent samples t test and Chi-square test, respectively. Data are expressed as mean ± SD, and significance defined as p < 0.05. 122 patients underwent robot (n = 21), LAP (n = 101), LC (n = 51), or post-LC (n = 50). OT was decreased for post-LC compared to LC (198 vs. 228 min). There were no conversions in robot and five with LAP. Morbidity was similar for robot (14%) compared to LAP (22%), LC (24%), or post-LC cases (20%). Median LOS was similar for robot vs. LAP (3 vs. 5 days). Robot had greater mean LN yield vs. LAP (19 vs. 14, p = 0.02). The initial outcomes with completely intracorporeal colectomy achieved robotically were equivalent to results during or after LC for laparoscopic resection. Proficiency gained with LAP seems to positively impact the initial results with the robot.

Long-term oncologic after robotic versus laparoscopic right colectomy: a prospective randomized study

OBJECTIVE

The aim of this study was to compare the long-term outcomes of robot-assisted right colectomy (RAC) with those for conventional laparoscopy-assisted right surgery (LAC) for treating right-sided colon cancer.

BACKGROUND

The enthusiasm for the robotic techniques has gained increasing interest in colorectal malignancies. However, the role of robotic surgery in the oncologic safety has not yet been defined.

METHODS

From September 2009 to July 2011, 71 patients with right-sided colonic cancer were randomized in the study. Adjuvant therapy and postoperative follow-up were similar in both groups. The primary and secondary endpoints of the study were hospital stay and survival, respectively. Data were analyzed by intention-to-treat principle.

RESULTS

The RAC and LAC groups did not differ significantly in terms of baseline clinical characteristics. Compared with the LAC group, RAC was associated with longer operation times (195 min vs. 129 min, P < 0.001) and higher cost ($12,235 vs. $10,319, P = 0.013). The median follow-up was 49.23 months (interquartile range 40.63-56.20). The combined 5-year disease-free rate for all tumor stages was 77.4% (95% confidence interval [CI], 60.6-92.1%) in the RAC group and 83.6% (95% CI 72.1-0.97.0%) in the LAC group (P = 0.442). The combined 5-year overall survival rates for all stages were 91.1% (95% CI 78.8-100%) in the RAC group and 91.0% (95% CI 81.3-100%) in the LAC group (P = 0.678). Using multivariate analysis, RAC was not a predictor of recurrence.

CONCLUSIONS

RAC appears to similar long-term survival as compared with LAC. However, we did not observe any clinical benefits of RAC which could translate to a decrease in expenditures.

TRIAL REGISTRY

http://www.ClinicalTrials.gov , number NCT00470951.

Right colectomy: consecutive 100 patients treated with laparoscopic and robotic technique for malignancy. Cumulative experience in a single centre

Robotic-assisted resections prove beneficial in overcoming potential limitation of laparoscopy, but clear evidences on patient's benefits are still lacking. We report our experience on 100 consecutive patients who underwent right colectomy with either robotic or laparoscopic approaches. Data were prospectively collected on a dedicated database (ASA score, age, operative time, conversion rate, re-operation rate, early complications, length of stay, and pathological results). Median total operative time was 160 min in LS group (IQR = 140-180) and 204 min for RS group (IQR = 180-230). Median time to first flatus was 2.5 days for LS group (IQR = 2 - 3) and 2 days for RS group (IQR = 1-2). Length of stay (median) was 8 days in LS group (IQR = 6-10) and 5 days in RS group (IQR = 5-7). No statistically significant difference was found between the 2 groups when the number of harvested nodes, the anastomotic leakage and the postoperative bleeding were analyzed. The 30-day mortality was 0% in LS and RS groups. Conversion rate for LS group was 14% (7/50 pts) and for RS group was 0% (0/50). Minimally invasive surgery is a feasible and safe technique. The RS may overcome some technical limitations of laparoscopic surgery and it achieves the same oncological results compared to LS but with higher costs. The lower conversion rate allows to expect better clinical outcomes and lower complication rate.

Advantages of Robotic Right Colectomy With Intracorporeal Anastomosis

Through retrospective review of consecutive charts, we compare the short-term and long-term clinical outcomes after robotic-assisted right colectomy with intracorporeal anastomosis (RIA) (n=89) and laparoscopic right colectomy with extracorporeal anastomosis (LEA) (n=135). Cohorts were similar in demographic characteristics, comorbidities, pathology, and perioperative outcomes (conversion, days to flatus and bowel movement, and length of hospitalization). The RIA cohort experienced statistically significant: less blood loss, shorter incision lengths, and longer specimen lengths than the LEA cohort. Operative times were significantly longer for the RIA group. No incisional hernias occurred in the RIA group, whereas the LEA group had 5 incisional hernias; mean follow-up was 33 and 30 months, respectively. RIA is effective and safe and provides some clinical advantages. Future studies may show that, in obese and other technically challenging patients, RIA facilitates resection of a longer, consistent specimen with less mesentery trauma that can be extracted through smaller incisions.

Robotic Right Colectomy for Colon Cancer: Comparison of Outcomes from a Single Institution with the ACS-NSQIP Database

BACKGROUND

Robotic surgery has increased in recent years for the treatment of colorectal cancer; however, it is not yet the standard of care. This study aims to compare the 30-day outcomes after robotic colectomy for right-sided colon cancer from our institution with those from a national dataset, the targeted colectomy American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

METHODS

Patients undergoing elective, robotic, right colon resection for stage I, II, and III colon cancer were identified within the targeted colectomy ACS-NSQIP database from 2012 to 2014. Patients meeting the same criteria were identified within a prospectively maintained institutional database from 2009 to 2015. Univariate analyses using chi-square tests and Student's t-tests were done where appropriate to compare baseline characteristics and outcomes between the two groups.

RESULTS

Patients at our institution had a significantly higher average number of lymph nodes retrieved (24.4 versus 20.1, P = .046). There was no statistically significant difference between the two groups regarding the incidence of wound infections, anastomotic leaks, blood transfusions, unplanned return to the operating room, or prolonged length of hospital stay. There were no 30-day mortalities at our institution and only one in the ACS-NSQIP database.

CONCLUSIONS

Our institutional experience with robotic right colon resection is equivalent to that of a national sample. This study demonstrates the safety of performing robotic right hemicolectomy for the treatment of colon cancer.

Totally robotic complete mesocolic excision for right-sided colon cancer

Complexity and operative risks of complete mesocolic excision (CME) seem to be important drawbacks to generalize this procedure in the surgical treatment of right colon cancer. Robotic systems have been developed to improve quality and outcomes of minimal invasive surgery. The aim of this study was to evaluate the feasibility of robotic right-sided CME and present our initial experience. A retrospective review of 37 patients undergoing totally robotic right-sided CME between February 2015 and November 2017 was performed. All the operations were carried out using the key principles of both CME with intracorporeal anastomosis and no-touch technique. Data on perioperative clinical findings and short-term outcomes were analyzed. There were 20 men and 17 women with a mean age of 64.4 ± 13.5 years and a body mass index of 26.8 ± 5.7 kg/m². The mean operative time and estimated blood loss were 289.8 ± 85.3 min and 77.4 ± 70.5 ml, respectively. Conversion to laparoscopy occurred in one patient (2.7%). All the surgical margins were clear and the mesocolic plane surgery was achieved in 27 (72.9%) of the cases. The mean number of harvested lymph nodes was 41.8 ± 11.9 (median, 40; range 22-65). The mean length of hospital stay was 6.6 ± 3.7 days. The intraoperative and postoperative complication rates were 5.4 and 21.6%, respectively. We believe that use of robot for right-sided CME is feasible and appears to provide remarkably a high number of harvested lymph nodes with good specimen quality.

Association between robot-assisted surgery and resection quality in patients with colorectal cancer

BACKGROUND

Resection quality after robot-assisted surgery for colorectal cancer have not previously been investigated in a nationwide study. The aim of the study was to examine the resection quality in robot-assisted versus laparoscopic surgery for colorectal cancer. Furthermore, 30-day mortality, postoperative complications, and conversion to open surgery were investigated.

METHODS

Patients undergoing either laparoscopic or robot-assisted surgery for colorectal cancer between 1 January 2010 and 31 December 2015 were included. The primary outcome was whether R0 resection was achieved. Secondary outcomes were 30-day mortality, postoperative complications, and conversions to laparotomy.

RESULTS

A total of 8615 and 3934 patients had a diagnosis of colon cancer and rectal cancer respectively. Of the patients with colon cancer, 511 patients underwent robot-assisted surgery and of the patients with rectal cancer, 706 patients underwent robot-assisted surgery. In the multivariate analysis, patients with colon cancer had an odds ratio (OR) = 0.63 (95%CI 0.45-0.88) for receiving R0 resection in the robot-assisted group compared to laparoscopy. For patients with rectal cancer, the OR was 1.20 (95%CI 0.89-1.61). No difference in 30-day mortality or postoperative complications were observed. The OR of conversion to laparotomy was lower in the robot-assisted group compared to the laparoscopic group in both patients with colon - and rectal cancer.

CONCLUSIONS

The study showed significant lower odds of receiving R0 resection in patients with colon cancer undergoing robot-assisted surgery. In patients with rectal cancer the robot-assisted surgery non-significantly increased the odds of receiving R0 resection.

Robotics confers an advantage in right hemicolectomy with intracorporeal anastomosis when matched against conventional laparoscopy

Comparisons between robotic and laparoscopic right hemicolectomy have been confounded by variations in operative technique. This study evaluates the two procedures after standardizing the intraoperative steps and perioperative management. Patients who underwent robotic right hemicolectomy with intracorporeal bowel anastomosis between July 2015 and June 2017 were matched with a laparoscopic group. Perioperative management was in accordance to an enhanced recovery protocol. Outcomes and histopathological data were compared. Thirty-two patients were included. Amongst the patients who did not undergo complete mesocolic excision, the median operative time did not differ between the two groups (p = 0.413). The robotic group recorded a statistically shorter time for intracorporeal anastomosis (13 vs 19 min, p = 0.024). Postoperative recovery and complication rates were similar, except for a greater lymph node harvest in the robotic group (41 vs 31, p = 0.038). Robotic surgery achieves short-term results comparable to existing conventional laparoscopy, notwithstanding the advantages of enhanced ergonomics.

Robotic right colectomy with intracorporeal anastomosis for malignancy

Techniques for robotic resection of the right colon have not been extensively published or adopted. We report our initial experience of robotic right colectomy with intracorporeal anastomosis and specimen extraction through a Pfannenstiel incision retrospectively. Twenty-one consecutive patients with a right colon cancer (n = 18) or polyp too large to remove endoscopically (n = 3) were treated at Mayo Clinic Rochester, Minnesota. Main outcomes measured were estimated blood loss, operative time, conversion rate, return of gastrointestinal function, length of stay, overall and severe complications, discharge status, and pathology. All 21 procedures were technically successful without the need for conversion. The mean total operative time was 250 ± 56 min, estimated blood loss was less than 100 mL in 19 (90%), only 1 (5%) ileus occurred, mean length of stay and return of gastrointestinal function was 4 ± 1.3 and 1 ± 0.6 days, respectively, only 1 (5%) patient experienced a Dindo grade ≥ 3 complication, and 20 (95%) were discharged to home. Mean number of nodes resected was 26 ± 12. Tumors were diagnosed as stage 0 in 3 (14%), stage I in 7 (33%), stage II in 4 (19%), stage III in 6 (28%), and stage IV in 1 (5%). Main limitations were nonrandomized nature, single institution experience, small patient sample size, and procedures only being performed by two surgeons. Finally, we conclude that robotic right colectomy with central mesocolic excision, intracorporeal anastomosis, and extraction through a Pfannenstiel incision is technically feasible, efficacious, oncologically acceptable, and safe to perform.

Is the bipolar vessel sealer device an effective tool in robotic surgery? A retrospective analysis of our experience and a meta-analysis of the literature about different robotic procedures by investigating operative data and post-operative course

BACKGROUND

The latest robotic bipolar vessel sealing tools have been described to be effective allowing to perform procedures with reduced blood loss and shorter operative times. The aim of this study was to assess the efficacy and reliability of these devices applied in different robotic procedures.

MATERIAL AND METHODS

All robotic operations, between 2014 and 2016, were performed using the EndoWrist One VesselSealer (EWO, Intuitive Surgical, Sunnyvale, CA), a bipolar fully wristed device. Data, including age, gender, body mass index (BMI), were collected. Robot docking time, intraoperative blood loss, robot malfunctioning and overall operative time were analyzed. A meta-analysis of the literature was carried out to point the attention to three different parameters (mean blood loss, operating time and hospital stay) trying to identify how different coagulation devices may affect them.

RESULTS

In 73 robotic procedures, the mean operative time was 118.2 minutes (75-125 minutes). Mean hospital stay was four days (2-10 days). There were two post-operative complications (2.74%).

CONCLUSIONS

The bipolar vessel sealer offers the efficacy of bipolar diathermy and the advantages of a fully wristed instrument. It does not require any change of instruments for coagulation or involvement of the bedside assistant surgeon. These characteristics lead to a reduction in operative time.

Is right colectomy a complete learning procedure for a robotic surgical program?

This study analyses the utility of right colectomy as a learning procedure at the beginning of a robotic surgical program. The hypothesis is that right colectomy contains all the technical steps necessary to acquire basic abilities in robotics surgery. The first 23 consecutive robotic right colectomy performed at the beginning of a robotic program were analysed. All surgical times were recorded in the operating room and second checked on a dedicated video-database. Specific robotic times were analysed using CUSUM method to evaluate the learning curve. CUSUM-derived learning phases were compared. Fourteen males and nine females with a mean age of 68.7 (46-84) underwent robotic right colectomy. The mean overall time was 265.3 min (180-320 min), docking time was 7 min (5-12 min), console time was 205.9 min (145-260 min), and anastomotic time was 43.6 (25-60 min). CUSUM analyses identified two learning phases: "starting phase" and "consolidation phase". Interphase comparison confirmed the significant (p < 0.05) differences between the two phases. Robotic technology facilitates the training process in minimally invasive colorectal surgery. At the beginning of the learning curve, right colectomy could represent a complete procedure to be proficient in robotic colorectal surgery.

A Comparison of Open, Laparoscopic, and Robotic Surgery in the Treatment of Right-sided Colon Cancer

INTRODUCTION

Multidimensional comparison between open, laparoscopy, and robotic surgery in the management of right-sided colon cancer are lacking. The aim of this study was to compare the early perioperative results and oncologic outcomes among the 3 different methods.

PATIENTS AND METHODS

Between June 2007 and 2011, a total of 96 patients who underwent right hemicolectomy in a single institution were classified into the open surgery (OS; n=33), the laparoscopy surgery (LS; n=43), and the robot surgery (RS; n=20) groups. Perioperative and oncologic outcomes were compared among the 3 groups.

RESULTS

Patient demographics were comparable. Operation time was significantly longer in the RS and LS than the OS (P<0.001). There was 1 OS conversion in LS. There was no difference of total retrieved lymph node numbers among the 3 groups. Postoperative recovery was faster and hospital stay was shorter in RS than OS. However, there was no difference between LS and RS. After the median 40 months' follow-up, 5-year disease-free survival was similar among the OS, LS, and RS (87.7%, 84%, and 89.5%, respectively). Total charge and total patient charge were significantly higher in RS than the others.

CONCLUSIONS

Our comparative study demonstrates that the RS have better short-term outcomes in reducing hospital stay compared with the OS, but similar to the LS. Although the oncologic outcomes are similar, the benefit of RS in right hemicolectomy is unclear considering a high cost of RS.

Robotic Total Mesorectal Excision for Rectal Cancer: A Series of 392 Cases and Mid-Term Outcomes from A Single Center in China

BACKGROUND

Robotic total mesorectal excision (RTME) for rectal cancer has recently been increasingly used; technical feasibility and short-term outcomes have been reported in detail. Few studies have presented clinical efficacy and mid-term outcomes for a large sample size. The aim of this study is to present oncologic efficacy and mid-term outcomes of robotic total mesorectal excision for rectal cancer and to provide our experiences regarding these surgically challenging issues.

METHODS

Three hundred ninety-two patients received RTME between March 2010 and June 2015. Patient characteristics, perioperative clinical results, complications, pathologic details, recurrence, and mid-term outcomes were evaluated.

RESULTS

Duration of surgery ranged from 80 to 388 min (median 224 min). There were no deaths during surgery and no anesthesiology complications in our series. The conversion rate was 1.1% (4/392). The postoperative complication rate was 10.2%; anastomosis leakage was the most common complication with an incidence of 4.1% (16/392). The median blood loss was 67.5±34.3 (20-600). The mean postoperative hospital stay was 12.1±6.1 (6-64). Circumferential resection margins were negative in 387 out of 392 cases (98.7%). The mean number of harvested lymph nodes was 14.6. Two deaths occurred during 30-day mortality. At a mean follow-up of 24 months (range 3-66 months), there were 35 deaths.

CONCLUSION

Our results suggest that RTME is technically feasible for rectal cancer and can yield good short- and mid-term oncologic outcomes.

Robotic right hemicolectomy: Analysis of 108 consecutive procedures and multidimensional assessment of the learning curve

PURPOSE

Surgeons tend to view the robotic right colectomy (RRC) as an ideal beginning procedure to gain proficiency in robotic general and colorectal surgery. Nevertheless, oncological RRC, especially if performed with intracorporeal ileocolic anastomosis confectioning, cannot be considered a technically easier procedure. The aim of this study was to assess the learning curve of the RRC performed for oncological purposes and to evaluate its safety and efficacy investigating the perioperative and pathology outcomes in the different learning phases.

METHODS

Data on a consecutive series of 108 patients undergoing RRC with intracorporeal anastomosis between June 2011 and September 2015 at our institution were prospectively collected to evaluate surgical and short-term oncological outcomes. CUSUM (Cumulative Sum) and Risk-Adjusted (RA) CUSUM analysis were performed in order to perform a multidimensional assessment of the learning curve for the RRC surgical procedure. Intraoperative, postoperative and pathological outcomes were compared among the learning curve phases.

RESULTS

Based on the CUSUM and RA-CUSUM analyses, the learning curve for RRC could be divided into 3 different phases: phase 1, the initial learning period (1st-44th case); phase 2, the consolidation period (45th-90th case); and phase 3, the mastery period (91th-108th case). Operation time, conversion to open surgery rate and the number of harvested lymph nodes significantly improve through the three learning phases.

CONCLUSIONS

The learning curve for oncological RRC with intracorporeal anastomosis is composed of 3 phases. Our data indicate that the performance of RRC is safe from an oncological point of view in all of the three phases of the learning curve. However, the technical skills necessary to significantly reduce operative time, conversion to open surgery rate and to significantly improve the number of harvested lymph nodes were achieved after 44 procedures. These data suggest that it might be prudent to start the RRC learning curve by treating only benign diseases and to reserve the performance of oncological resection to when at least the initial learning phase has been completed.

Robotic Right Colectomy with Modified Complete Mesocolic Excision: Long-Term Oncologic Outcomes

BACKGROUND

A modified complete mesocolic excision (mCME) technique for the treatment of right-sided colon cancer recently was shown by Hohenberger and colleagues to provide impressive long-term oncologic outcomes. This report aims to describe the authors' experience with robotic right colectomy using mCME. The safety, feasibility, and efficacy of this procedure are measured by complications, conversion rates, and 4-year oncologic outcomes.

METHODS

A retrospective study analyzed 100 consecutive patients who underwent robotic right colectomy with mCME and intracorporeal anastomosis at the authors' institution between November 2005 and November 2013. Intra- and postoperative clinical outcomes, pathologic data, and survival were analyzed.

RESULTS

Robotic right colectomy with mCME was successfully performed for all the patients. No conversions or intraoperative complications occurred. The major complication rate (Dindo 3 or 4) was 4 %. During a median follow-up period of 48.5 months (range 24-114 months), the survival rates were 94.5 % for disease-specific survival, 91.4 % for disease-free survival, and 90.3 % for overall survival.

CONCLUSIONS

The authors' experience confirms the feasibility and safety of mCME for the treatment of right-sided colon cancer. This technique provided satisfying short-term outcomes with promising 4-year oncologic results. However, the real benefits of the CME technique should be evaluated further by well-conducted randomized studies before its adoption in routine practice is recommended.

[Robotics in the operating room : Out of the niche into widespread application]

In the last few years robotic surgery has progressed from being confined to a small niche to a widespread application in routine visceral surgery; however, evidence for superiority of robotic surgery compared to laparoscopy from randomized studies with a sufficient number of patients is still lacking in most fields of visceral surgery. For complex operations that necessitate an extensive reconstruction phase, such as pancreatectomy, gastrectomy and esophagectomy, there is a potential benefit for the permanent and justified use of robotic surgery. Even in operations where delicate nerve preparation and radical surgical resection are simultaneously necessary, such as rectal resection, robotic surgery may provide certain benefits. In the long term there is a great potential for the integration of innovative techniques, such as navigation or other medical imaging procedures into robotic surgery, which can currently only partially be estimated. Care must be taken to avoid premature euphoria; however, due to the assumed great potential there is an urgent need for randomized studies to evaluate the possible benefits of robotic surgical techniques in visceral surgery in order to generate evidence for the welfare of patients.

Standardized technique for single-docking robotic rectal surgery

AIM

The aim of this technical note is to describe our standardized technique for rectal surgery using a single-docking totally robotic approach.

METHOD

The data related to patients who underwent single-docking robotic rectal surgery were analysed for the feasibility of this approach.

RESULTS

This technique was used in 124 consecutive patients who underwent rectal resection since July 2013. Male to female ratio of patients was 2:1 while median age was 67 years (range 24-92). The median operating time was 240 min (range 105-456), whilst blood loss was 10 ml (range 0-200). There was no evidence of intra-operative complications or conversions to either a laparoscopic or an open procedure. The median length of stay was 7 days (range 3-48).

CONCLUSION

A single-docking technique for robotic rectal surgery is safe and feasible. It can be considered as standard approach for pelvic robotic surgery.

Comparison of robotic and laparoscopic colorectal resections with respect to 30-day perioperative morbidity

BACKGROUND

Robotic surgery has emerged as a minimally invasive alternative to traditional laparoscopy. Robotic surgery addresses many of the technical and ergonomic limitations of laparoscopic surgery, but the literature regarding clinical outcomes in colorectal surgery is limited. We sought to compare robotic and laparoscopic colorectal resections with respect to 30-day perioperative outcomes.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was used to identify all patients who underwent robotic or laparoscopic colorectal surgery in 2013. We performed a logistic regression analysis to compare intraoperative variables and 30-day outcomes.

RESULTS

There were 8392 patients who underwent laparoscopic colorectal surgery and 472 patients who underwent robotic colorectal surgery. The robotic cohort had a lower incidence of unplanned intraoperative conversion (9.5% v. 13.7%, p = 0.008). There were no significant differences between robotic and laparoscopic surgery with respect to other intraoperative and postoperative outcomes, such as operative duration, length of stay, postoperative ileus, anastomotic leak, venous thromboembolism, wound infection, cardiac complications and pulmonary complications. On multivariable analysis, robotic surgery was protective for unplanned conversion, while male sex, malignancy, Crohn disease and diverticular disease were all associated with open conversion.

CONCLUSION

Robotic colorectal surgery has comparable 30-day perioperative morbidity to laparoscopic surgery and may decrease the rate of intraoperative conversion in select patients.

Comparison of perioperative and short-term outcomes between robotic and conventional laparoscopic surgery for colonic cancer: a systematic review and meta-analysis

Purpose

Reports from several case series have described the feasibility and safety of robotic surgery (RS) for colonic cancer. Experience is still limited in robotic colonic surgery, and a few meta-analysis has been conducted to integrate the results for colon cancer specifically. We conducted a systematic review of the available evidence comparing the surgical safety and efficacy of RS with that of conventional laparoscopic surgery (CLS) for colonic cancer.

Methods

We searched English databases (MEDLINE, Embase, and Cochrane Library), and Korean databases (KoreaMed, KMbase, KISS, RISS, and KisTi). Dichotomous variables were pooled using the risk ratio, and continuous variables were pooled using the mean difference (MD).

Results

The present study found that the RS group had a shorter time to resumption of a regular diet (MD, –0.62 days; 95% CI, –0.97 to –0.28), first passage of flatus (MD, –0.44 days; 95% CI, –0.66 to –0.23) and defecation (MD, –0.62 days; 95% CI, –0.77 to –0.47). Also, RS was associated with a shorter hospital stay (MD, –0.69 days; 95% CI, –1.12 to –0.26), a lower estimated blood loss (MD, –19.49 mL; 95% CI, –27.10 to –11.89) and a longer proximal margin (MD, 2.29 cm; 95% CI, 1.11-3.47). However, RS was associated with a longer surgery time (MD, 51.00 minutes; 95% CI, 39.38–62.62).

Conclusion

We found that the potential benefits of perioperative and short-term outcomes for RS than for CLS. For a more accurate understanding of RS for colonic cancer patients, robust comparative studies and randomized clinical trials are required.

Totally robotic rectal resection: an experience of the first 100 consecutive cases

INTRODUCTION

Robotic surgery provides an alternative option for a minimal access approach. It provides a stable platform with high definition three-dimensional views and improved access, which enhances the capabilities for precise dissection in a narrow surgical field. These distinctive features have made it an attractive option for colorectal surgeons.

AIM

The aim of this study was to present a standardised technique for single-docking robotic rectal resection and to analyse clinical outcomes of the first 100 robotic rectal procedures performed in a single centre between May 2013 and April 2015.

METHOD

Prospectively collected data related to 100 consecutive patients who underwent single-docking robotic rectal surgery was analysed for surgical and oncological outcomes.

RESULTS

Sixty-six patients were male, the median age was 67 years (range-24-92). Eighteen patients had neo-adjuvant chemoradiotherapy whilst 23 patients had BMI >30. Procedures performed included anterior resection (n = 74), abdominoperineal resection (n = 10), completion proctectomy (n = 9), restorative proctectomy with ileal pouch-anal anastomosis (IPAA) (n = 5) and Hartmann's procedure (n = 2). The median operating time was 240 min (range-135-456), and median blood loss was 10 ml (range 0-200). There was no conversion or intra-operative complication. Median length of stay was 7 days (range, 3-48) and readmission rate was 12 %. Thirty-day mortality was zero. Postoperatively, two patients had an anastomotic leak whilst two had small bowel obstruction. The median lymph node harvest was 18 (range, 6-43).

CONCLUSION

The single-docking robotic technique should be considered as an alternative option for rectal surgery. This approach is safe and feasible and in our study it has demonstrated favourable clinical outcomes.

Robotic versus laparoscopic low anterior resection for rectal cancer: a meta-analysis

BACKGROUND

The objective of this meta-analysis was to compare the clinical and oncologic outcomes of robotic low anterior resection (R-LAR) with conventional laparoscopic low anterior resection (L-LAR).

METHODS

A search in the MEDLINE, Embase, and Ovid databases was performed for studies published before July 2014 that compared the clinical and oncologic outcomes of R-LAR and L-LAR. The methodological quality of the selected studies was assessed. Depending on statistical heterogeneity, a fixed or random effects model was used for the meta-analysis. The clinical and oncologic outcomes evaluated included operative time, estimated blood loss, length of hospital stay, rate of conversion to open surgery, post-operative complications, circumferential margin status, and number of lymph nodes collected.

RESULTS

Eight studies, including 324 R-LAR cases and 268 conventional L-LAR cases, were analyzed. The meta-analysis showed that R-LAR was associated with a shorter hospital stay (mean difference (MD) = -1.03; 95% confidence interval (CI) = -1.78, -0.28; P = 0.007), lower conversion rate (odds ratio (OR) = 0.08; 95% CI = 0.02, 0.31; P = 0.0002), lower rate of circumferential margin involvement (OR = 0.5; 95% CI = 0.25, 1.01; P = 0.05), and lower overall complication rate (MD = 0.65; 95% CI = 0.43, 0.99; P = 0.04) compared with L-LAR. There was no difference in operative time (MD = 28.4; 95% CI = -3.48, 60.27; P = 0.08), the number of lymph nodes removed (MD = -0.63; 95% CI = -0.78, 2.05; P = 0.38), and days to return of bowel function (MD = -0.15; 95% CI = -0.37, 0.06; P = 0.17).

CONCLUSIONS

R-LAR was shown to be associated with a shorter hospital stay, lower conversion rate, lower rate of circumferential margin involvement, and lower overall complication rate compared with L-LAR. There were no differences in operative time, the number of lymph nodes removed, and days to return of bowel function.

Laparoscopic colorectal surgery: Current status and implementation of the latest technological innovations

The introduction of laparoscopy is an example of surgical innovation with a rapid implementation in many areas of surgery. A large number of controlled studies and meta-analyses have shown that laparoscopic colorectal surgery is associated with the same benefits than other minimally invasive procedures, including lesser pain, earlier recovery of bowel transit and shorter hospital stay. On the other hand, despite initial concerns about oncological safety, well-designed prospective randomized multicentre trials have demonstrated that oncological outcomes of laparoscopy and open surgery are similar. Although the use of laparoscopy in colorectal surgery has increased in recent years, the percentages of patients treated with surgery using minimally invasive techniques are still reduced and there are also substantial differences among centres. It has been argued that the limiting factor for the use of laparoscopic procedures is the number of surgeons with adequate skills to perform a laparoscopic colectomy rather than the tumour of patients’ characteristics. In this regard, future efforts to increase the use of laparoscopic techniques in colorectal surgery will necessarily require more efforts in teaching surgeons. We here present a review of recent controversies of the use of laparoscopy in colorectal surgery, such as in rectal cancer operations, the possibility of reproducing complete mesocolon excision, and the benefits of intra-corporeal anastomosis after right hemicolectomy. We also describe the results of latest innovations such as single incision laparoscopic surgery, robotic surgery and natural orifice transluminal endoscopic surgery for colon and rectal diseases.

How Has the Robot Contributed to Colon Cancer Surgery?

Robotic surgery is an emerging field in colorectal surgery and may overcome the limitations of conventional laparoscopic surgery, such as rigid instrumentation, poor ergonomics, and assistant-dependent camera movements and retraction. In addition, robotic-assisted colectomy appears to offer comparable outcomes to laparoscopic colectomy with limited long-term outcomes data. Prolonged operating time, increased costs and learning curve are the major drawbacks of robotic colectomy for colon cancer. Although new robotic platforms promise improved ingenuity through developing technology, the role of the robot in colon cancer surgery is still unclear.

Robotic surgery for colorectal cancer: systematic review of the literature

INTRODUCTION

Surgical practice has been changed since the introduction of robotic techniques and robotic colorectal surgery is an emerging field. Innovative robotic technologies have helped surgeons overcome many technical difficulties of conventional laparoscopic surgery. Herein, we review the clinical studies regarding the application of surgical robots in resections for colorectal cancer.

METHODS

A systematic review of the literature was conducted for articles published up to September 9, 2012, using the MEDLINE database. The keywords that were used in various combinations were: "surgical robotics," "robotic surgery," "computer-assisted surgery," "colectomy," "sigmoid resection," "sigmoidectomy," and "rectal resection."

RESULTS

Fifty-nine articles reporting on robot-assisted resections of colon and/or rectum were identified and 41 studies were finally included in the analysis. A total of 1635 colorectal procedures were performed: 254 right colectomies, 185 left colectomies/sigmoid resections, 969 anterior resections, 182 abdominoperineal or intersphincteric resections, 34 colectomies (without being specified as right or left), and 11 total/subtotal colectomies. In general, blood loss, conversion rates, and complications were low but the operative time was longer than the open procedures, whereas the duration of hospitalization was shorter. The number of harvested lymph nodes was also quite satisfactory.

CONCLUSIONS

Robotic colorectal operations provide favorable results, with acceptable operative times and low conversion rates and morbidity. Surgical robots may provide additional benefits treating challenging pathologies, such as rectal cancer. Further clinical studies and long-term follow-up are required to better evaluate the outcomes of robotic colorectal surgery.

Robotic versus Laparoscopic Approach in Colonic Resections for Cancer and Benign Diseases: Systematic Review and Meta-Analysis

Objectives

The aim of this systematic review and meta-analysis is to compare robotic colectomy (RC) with laparoscopic colectomy (LC) in terms of intraoperative and postoperative outcomes.

Materials and Methods

A systematic literature search was performed to retrieve comparative studies of robotic and laparoscopic colectomy. The databases searched were PubMed, Embase and the Cochrane Central Register of Controlled Trials from January 2000 to October 2014. The Odds ratio, Risk difference and Mean difference were used as the summary statistics.

Results

A total of 12 studies, which included a total of 4,148 patients who had undergone robotic or laparoscopic colectomy, were included and analyzed. RC demonstrated a longer operative time (MD 41.52, P<0.00001) and higher cost (MD 2.42, P<0.00001) than did LC. The time to first flatus passage (MD -0.51, P = 0.003) and the length of hospital stay (MD -0.68, P = 0.01) were significantly shorter after RC. Additionally, the intraoperative blood loss (MD -16.82, P<0.00001) was significantly less in RC. There was also a significantly lower incidence of overall postoperative complications (OR 0.74, P = 0.02) and wound infections (RD -0.02, P = 0.03) after RC. No differences in the postoperative ileus, in the anastomotic leak, or in the conversion to open surgery rate and in the number of harvested lymph nodes outcomes were found between the approaches.

Conclusions

The present meta-analysis, mainly based on observational studies, suggests that RC is more time-consuming and expensive than laparoscopy but that it results in faster recovery of bowel function, a shorter hospital stay, less blood loss and lower rates of both overall postoperative complications and wound infections.

Minimally invasive surgery for inflammatory bowel disease

Surgical management of inflammatory bowel disease is a challenging endeavor given infectious and inflammatory complications, such as fistula, and abscess, complex often postoperative anatomy, including adhesive disease from previous open operations. Patients with Crohn's disease and ulcerative colitis also bring to the table the burden of their chronic illness with anemia, malnutrition, and immunosuppression, all common and contributing independently as risk factors for increased surgical morbidity in this high-risk population. However, to reduce the physical trauma of surgery, technologic advances and worldwide experience with minimally invasive surgery have allowed laparoscopic management of patients to become standard of care, with significant short- and long-term patient benefits compared with the open approach. In this review, we will describe the current state-of the-art for minimally invasive surgery for inflammatory bowel disease and the caveats inherent with this practice in this complex patient population. Also, we will review the applicability of current and future trends in minimally invasive surgical technique, such as laparoscopic "incisionless," single-incision laparoscopic surgery (SILS), robotic-assisted, and other techniques for the patient with inflammatory bowel disease. There can be no doubt that minimally invasive surgery has been proven to decrease the short- and long-term burden of surgery of these chronic illnesses and represents high-value care for both patient and society.

Robot-assisted one-stage resection of rectal cancer with liver and lung metastases

The Da Vinci Surgical System may help to overcome some of the difficulties of laparoscopy for complicated abdominal surgery. The authors of this article present a case of robot-assisted, one-stage radical resection of three tumors, including robotic anterior resection for rectal cancer, segmental hepatectomy for liver metastasis, and wedge-shaped excision for lung metastasis. A 59-year-old man with primary rectal cancer and liver and lung metastases was operated upon with a one-stage radical resection approach using the Da Vinci Surgical System. Resection and anastomosis of rectal cancer were performed extracorporeally after undocking the robot. The procedure was successfully completed in 500 min. No surgical complications occurred during the intervention and postoperative period, and no conversion to laparotomy or additional trocars were required. To the best of our knowledge, this is the first case of simultaneous resection for rectal cancer with liver and lung metastases using the Da Vinci Surgery System to be reported. The procedure is feasible and safe and its main advantages for patient are avoiding repeated operation, reducing surgical trauma, shortening recovery time, and early implementation of postoperative adjuvant therapy.

Robotic transverse colectomy for mid-transverse colon cancer: surgical techniques and oncologic outcomes

Robot-assisted surgery for colon cancer has been reported in many studies, most of which worked on right and/or sigmoid colectomy. The aim of this study was to report our experience of robotic transverse colectomy with an intracorporeal anastomosis, provide details of the surgical technique, and present the theoretical benefits of the procedure. This is a retrospective review of prospectively collected data of robotic surgery for colorectal cancer performed by a single surgeon between May 2007 and February 2011. Out of 162 consecutive cases, we identified three robotic transverse colectomies, using a hand-sewn intracorporeal anastomosis. Two males and one female underwent transverse colectomies for malignant or premalignant disease. The mean docking time, time spent using the robot, and total operative time were 5, 268, and 307 min, respectively. There were no conversions to open or conventional laparoscopic technique. The mean length of specimen and number of lymph nodes retrieved were 14.1 cm and 6.7, respectively. One patient suffered from a wound seroma and recovered with conservative management. The mean hospital stay was 8.7 days. After a median follow-up of 72 months, there were no local or systemic recurrences. Robotic transverse colectomy seems to be a safe and feasible technique. It may minimize the necessity of mobilizing both colonic flexures, with facilitated intracorporeal hand-sewn anastomosis. However, further prospective studies with a larger number of patients are required to draw firm conclusions.