Robotic rectosigmoidectomy: pioneer case report in Brazil. Current scene in colorectal robotic surgery

[Colorectal endometriosis surgery: Technical and technological innovations in service of a complex surgery]

INTRODUCTION

Digestive endometriosis represents the most common form of deep endometriosis, significantly impacting patients' quality of life. The optimization of its surgical management has been marked by major technological advances. This review explores the evolution of colorectal endometriosis surgery, highlighting the progress in laparoscopy, the contribution of robotics, the shift towards organ preservation, and the optimization of postoperative care.

METHODS

A systematic literature search was conducted in the PubMed and Embase databases, focusing on clinical studies, meta-analyses, and international guidelines published between 1980 and 2025. Articles were selected based on their relevance to technical advancements and clinical outcomes.

RESULTS

Laparoscopy has replaced laparotomy, leading to a reduction in complications and an improvement in postoperative quality of life. Robotics, while not a groundbreaking revolution, provides advantages in precision and surgeon comfort. Conservative procedures have emerged as safe alternatives to systematic extensive segmental resection. Indication criteria have evolved to favor strategies tailored to the depth and extent of lesions while minimizing complication risks and preserving digestive function and quality of life. The standardization of procedures, the abandonment of systematic protective ileostomy, and enhanced recovery protocols have contributed to reducing surgical morbidity and improving patients' quality of life.

CONCLUSION

Technical and technological advancements have transformed colorectal endometriosis surgery. Surgical strategies are shifting towards personalized approaches, integrating minimally invasive surgery and optimized multidisciplinary management. The future lies in the continuous improvement of techniques and the better standardization of surgical indications.

Robotic colorectal surgery in Latin America: a systematic review on surgical outcomes

Background and objectives

Robotic approach in colorectal surgery is rapidly gaining interest, particularly in the context of rectal cancer resection. Despite economic barriers, substantial proliferation of robotic colorectal procedures has been observed throughout Latin America. However, there is a lack of data regarding intraoperative and early postoperative outcomes, as well as oncological and long-term results. This systematic review aims to provide an overview of the surgical outcomes of robotic-assisted colorectal approaches across Latin America.

Material and methods

A systematic literature search of electronic databases, including PubMed, LILACS, Scopus, Cochrane Library and Scielo, was performed and reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The main target of the literature search was studies that reported outcomes of colorectal robotic surgery in Latin America.

Results

A total of 9,694 published articles were identified from the initial search. Nine thousand six hundred thirty-six publications were excluded after title and abstract review and removal of duplicates. Fifty-eight articles were thoroughly reviewed, and 11 studies met the inclusion criteria. The critical appraisal of study quality (biases risk assessment) was performed according to the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis. In general, the overall study quality was poor. Of the 11 studies included in the analysis, ten addressed intraoperative and early postoperative outcomes, seven addressed oncological/pathological outcomes, and just one addressed long-term outcomes. Ten studies evaluated intraoperative and early postoperative outcomes, encompassing a total of 425 patients, the majority of whom were diagnosed with colorectal cancer. Morbidity rates exhibited a range between 0% and 45.9%, while mortality ranged from 0% to 2.5%.

Conclusion

Few studies have been published addressing intraoperative, postoperative, pathological, and oncological outcomes of robotic colorectal surgery in this region. Undoubtedly, there are unique challenges not encountered by developed countries, including economic obstacles in establishing structured training programmes and high-quality centres for the development of robotic surgery. Further studies are needed to assess the real extent of robotic surgery in the region and its results.

Systematic Review Registration

https://www.crd.york.ac.uk/, PROSPERO (CRD42023494112).

An Overview of Robotic Colorectal Surgery Adoption and Training in Brazil

Background and Objectives: Robotic surgical systems have rapidly become integrated into colorectal surgery practice in recent years, particularly for rectal resections, where the advantages of robotic platforms over conventional laparoscopy are more pronounced. However, as with any technological advancement, the initial high costs can be a limiting factor, leading to unequal health service access, especially in middle- and lower-income countries. Materials and Method: A narrative review was conducted with the objective of providing an overview of the escalating adoption, current training programmes, and certification process of robotic colorectal surgery in Brazil. Results: Brazil has witnessed a rapid increase in robotic platforms in recent years. Currently, there are 106 robotic systems installed nationwide. However, approximately 60% of the medical facilities which adopted robotic platforms are in the Southeast region, which is both the most populous and economically prosperous in the country. The Brazilian Society of Coloproctology recently established clear rules for the training programme and certification of colorectal surgeons in robotic surgery. The key components of the training encompass theoretical content, virtual robotic simulation, observation, assistance, and supervised procedures in colorectal surgery. Although the training parameters are well established, no colorectal surgery residency programme in Brazil has yet integrated the teaching and training of robotic surgery into its curriculum. Thus far, the training process has been led by private institutions and the industry. Conclusion: Despite the fast spread of robotic platforms across Brazil, several challenges still need to be addressed to democratise training and promote the widespread use of these platforms. It is crucial to tackle these obstacles to achieve greater integration of robotic technology in colorectal surgery throughout the country.

SURGICAL TECHNIQUES FOR THE TREATMENT OF RECTAL ENDOMETRIOSIS: A SYSTEMATIC REVIEW OF RANDOMIZED CONTROLLED TRIALS AND OBSERVATIONAL STUDIES

BACKGROUND

Endometriosis is a common disease in reproductive-age women and it is estimated to occur in up to 50% of those with infertility. Intestinal involvement is reported in up to a third of the cases. This condition is related to chronic pain and loss of quality of life, resulting in emotional, social and economic costs. Treatment consists of hormonal block and surgical resection, with variable side effects and efficacy. The best choice for surgical treatment for rectal endometriosis is a matter of discussion regarding the indication and the best technique to be employed.

OBJECTIVE

To summarize data on indications, results and complications of surgical techniques for the treatment of rectal endometriosis.

METHODS

This comprehensive systematic review is a compilation of the available literature and discussion, carried out by a team with experience in the surgical treatment of intestinal endometriosis. Data regarding indications, results and complications of conservative and radical techniques for the surgical treatment of rectal endometriosis was carefully reviewed. Searches of PubMed, EMBASE, and CENTRAL up to May 2021 were performed to identify randomized controlled trials (RCTs) and observational studies that compared at least two of the three surgical techniques of interest (i.e., shaving, discoid resection, segmental resection).

RESULTS

One RCT and nine case series studies with a total of 3,327 patients met the eligibility criteria. Participants ages ranged from a mean of 30.0 to 37.9 years old. Mean follow-up ranged from 1.2 to 42.76 months. With regards the methodological quality, overall the included studies presented a low risk of bias in the majority of the domains. Surgical treatment of rectal endometriosis is indicated for patients with obstructive symptoms and those with pain scores above 7/10. Patients with disease involving beyond muscularis propria of the rectum, documented in magnetic resonance imaging or transvaginal pelvic ultrasound with intestinal preparation, are candidates for discoid or segmental resection. The presence of multifocal disease, extension greater than 3 cm and infiltration greater than 50% of the loop circumference favor the radical technique. The distance from the lesion to the anal verge, age, symptoms and reproductive desire are other factors that influence the choice of the technique to be employed. The risk of complications and unfavorable functional results seems to be directly related to the complexity of the procedure.

CONCLUSION

The choice of surgical technique performed for the treatment of rectal endometriosis is a matter of discussion and depends not only on the preoperative staging, but also on the patient's expectations, risks and potential complications, recurrence rates and the expertise of the multidisciplinary team.

Obstructive rectal endometriosis treated by robot-assisted laparoscopic surgery: a case report

Background

Rectal endometriosis is a rare disease. A definitive diagnosis prior to surgery is often difficult. We encountered a patient with rectal sub-obstructive endometriosis that was treated by robot-assisted laparoscopic low anterior resection.

Case presentation

A 43-year-old woman visited our hospital with suspected stenosis caused by upper rectal cancer. She had a 2-year history of constipation. We were unable to confirm the diagnosis through detailed examinations, including laparoscopy. Robot-assisted laparoscopic low anterior resection with D3 lymph node dissection was performed for both diagnosis and treatment. The postoperative specimen showed a submucosal tumor. The pathological examination confirmed rectal endometriosis.

Conclusions

We herein describe a rare case of obstructive rectal endometriosis that we were unable to diagnose preoperatively. Robotic surgery was useful in this case, which involved extensive pelvic adhesion.

Bowel resection for intestinal endometriosis

Over the last twenty years, segmental resection (SR) has been the technique most frequently used to treat bowel endometriosis. Nowadays, it is most commonly performed by laparoscopy; however, there is evidence that it can be safely performed by robotic-assisted laparoscopic surgery. Rectovaginal fistula and anastomotic leakage are the two major complications of SR; other complications include pelvic abscess, postoperative bleeding, ureteral damage, and anastomotic stricture. Several studies showed that SR causes improvement in pain and intestinal symptoms; nerve-sparing SR may improve the functional outcomes. The rates of postoperative recurrence of bowel endometriosis vary across the studies, possibly because of the different definitions of recurrence.

A realist process evaluation of robot-assisted surgery: integration into routine practice and impacts on communication, collaboration and decision-making

Background

The implementation of robot-assisted surgery (RAS) can be challenging, with reports of surgical robots being underused. This raises questions about differences compared with open and laparoscopic surgery and how best to integrate RAS into practice.

Objectives

To (1) contribute to reporting of the ROLARR (RObotic versus LAparoscopic Resection for Rectal cancer) trial, by investigating how variations in the implementation of RAS and the context impact outcomes; (2) produce guidance on factors likely to facilitate successful implementation; (3) produce guidance on how to ensure effective teamwork; and (4) provide data to inform the development of tools for RAS.

Design

Realist process evaluation alongside ROLARR. Phase 1 – a literature review identified theories concerning how RAS becomes embedded into practice and impacts on teamwork and decision-making. These were refined through interviews across nine NHS trusts with theatre teams. Phase 2 – a multisite case study was conducted across four trusts to test the theories. Data were collected using observation, video recording, interviews and questionnaires. Phase 3 – interviews were conducted in other surgical disciplines to assess the generalisability of the findings.

Findings

The introduction of RAS is surgeon led but dependent on support at multiple levels. There is significant variation in the training provided to theatre teams. Contextual factors supporting the integration of RAS include the provision of whole-team training, the presence of handpicked dedicated teams and the availability of suitably sized operating theatres. RAS introduces challenges for teamwork that can impact operation duration, but, over time, teams develop strategies to overcome these challenges. Working with an experienced assistant supports teamwork, but experience of the procedure is insufficient for competence in RAS and experienced scrub practitioners are important in supporting inexperienced assistants. RAS can result in reduced distraction and increased concentration for the surgeon when he or she is supported by an experienced assistant or scrub practitioner.

Conclusions

Our research suggests a need to pay greater attention to the training and skill mix of the team. To support effective teamwork, our research suggests that it is beneficial for surgeons to (1) encourage the team to communicate actions and concerns; (2) alert the attention of the assistant before issuing a request; and (3) acknowledge the scrub practitioner’s role in supporting inexperienced assistants. It is beneficial for the team to provide oral responses to the surgeon’s requests.

Limitations

This study started after the trial, limiting impact on analysis of the trial. The small number of operations observed may mean that less frequent impacts of RAS were missed.

Future work

Future research should include (1) exploring the transferability of guidance for effective teamwork to other surgical domains in which technology leads to the physical or perceptual separation of surgeon and team; (2) exploring the benefits and challenges of including realist methods in feasibility and pilot studies; (3) assessing the feasibility of using routine data to understand the impact of RAS on rare end points associated with patient safety; (4) developing and evaluating methods for whole-team training; and (5) evaluating the impact of different physical configurations of the robotic console and team members on teamwork.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Recent surgical advances in colorectal cancer excision: toward optimal outcomes

Colorectal cancer is the third most common cancer affecting both males and females in the western world. Despite all the developments in the current treatment of colorectal cancer, it is still continuing to be an important factor of patient morbidity and mortality worldwide. Surgery is the mainstay of treatment for colorectal cancer. Over the last decade, there have been major changes and developments in the surgical treatment. Understanding the importance of the anatomy, technological advances in minimally invasive surgery and effects of chemoradiotherapy have changed the approaches to colorectal cancer treatment. Today, novel treatment strategies must be targeted not only minimally invasive approaches, but also aiming to increase patients’ quality of life without compromising the oncological principles.

Perioperative outcomes of robotic assisted laparoscopic surgery versus conventional laparoscopy surgery for advanced-stage endometriosis

Background and Objectives:

To determine perioperative outcome differences in patients undergoing robotic-assisted laparoscopic surgery (RALS) versus conventional laparoscopic surgery (CLS) for advanced-stage endometriosis.

Methods:

This retrospective cohort study at a minimally invasive gynecologic surgery center at 2 academically affiliated, urban, nonprofit hospitals included all patients treated by either robotic-assisted or conventional laparoscopic surgery for stage III or IV endometriosis (American Society for Reproductive Medicine criteria) between July 2009 and October 2012 by 1 surgeon experienced in both techniques. The main outcome measures were extent of surgery, estimated blood loss, operating room time, intraoperative and postoperative complications, and length of stay, with medians for continuous measures and distributions for categorical measures, stratified by body mass index values. Robotically assisted laparoscopy and conventional laparoscopy were then compared by use of the Wilcoxon rank sum, χ², or Fisher exact test, as appropriate.

Results:

Among 86 conventional laparoscopic and 32 robotically assisted cases, the latter had a higher body mass index (27.36 kg/m² [range, 23.90–34.09 kg/m²] versus 24.53 kg/m² [range, 22.27–26.96 kg/m²]; P < .0079) and operating room time (250.50 minutes [range, 176–328.50 minutes] versus 173.50 minutes [range, 123–237 minutes]; P < .0005) than did conventional laparoscopy patients. After body mass index stratification, obese patients varied in operating room time (282.5 minutes [range, 224–342 minutes] for robotic-assisted laparoscopy versus 174 minutes [range, 130–270 minutes] for conventional laparoscopy; P < .05). No other significant differences were noted between the robotic-assisted and conventional laparoscopy groups.

Conclusion:

Despite a higher operating room time, robotic-assisted laparoscopy appears to be a safe minimally invasive approach for patients, with all other perioperative outcomes, including intraoperative and postoperative complications, comparable with those in patients undergoing conventional laparoscopy.

Robotic hybrid technique in rectal surgery for deep pelvic endometriosis

BACKGROUND

Deep pelvic endometriosis is a complex disorder that affects 6% to 12% of all women in childbearing age. The incidence of bowel endometriosis ranges between 5.3% and 12%, with rectum and sigma being the most frequently involved tracts, accounting for about 80% of cases. It has been reported that segmental colorectal resection is the best surgical option in terms of recurrence rate and improvement of symptoms. The aim of this study is to analyze indications, feasibility, limits, and short-term results of robotic (Da Vinci Surgical System)-assisted laparoscopic rectal sigmoidectomy for the treatment of deep pelvic endometriosis.

PATIENTS AND METHODS

Between January 2006 and December 2010, 19 women with bowel endometriosis underwent colorectal resection through the robotic-assisted laparoscopic approach. Intraoperative and postoperative data were collected. All procedures were performed in a single center and short-term complications were evaluated.

RESULTS

Nineteen robotic-assisted laparoscopic colorectal resections for infiltrating endometriosis were achieved. Additional procedures were performed in 7 patients (37%). No laparotomic conversion was performed. No intraoperative complications were observed. The mean operative time was 370 minutes (range = 250-720 minutes), and the estimated blood loss was 250 mL (range = 50-350 mL). The overall complication rate was 10% (2 rectovaginal fistulae).

CONCLUSIONS

Deep pelvic endometriosis is a benign condition but may have substantial impact on quality of life due to severe pelvic symptoms. We believe that robotic-assisted laparoscopic colorectal resection is a feasible and relatively safe procedure in the context of close collaboration between gynecologists and surgeons for treatment of deep pelvic endometriosis with intestinal involvement, with low rates of complications and significant improvement of intestinal symptoms.

Robotic colorectal surgery: summary of the current evidence

BACKGROUND

Several studies have confirmed that laparoscopic colorectal surgery results in improved early post-operative outcomes. Nevertheless, conventional laparoscopic approach and instruments have several limitations. Robotic approach could potentially address of many of these limitations.

OBJECTIVES

This review aims to present a summary of the current evidence on the role of robotic colorectal surgery.

METHODS

A comprehensive search of electronic databases (Pubmed, Science Direct and Google scholar) using the key words "rectal surgery", "laparoscopic", "colonic" and "robotic." Evidence from these data was critically analysed and summarised to produce this article.

RESULTS

Robotic colorectal surgery is both safe and feasible. However, it has no clear advantages over standard laparoscopic colorectal surgery in terms of early postoperative outcomes or complications profile. It has shorter learning curve but increased operative time and cost. It could offer potential advantage in resection of rectal cancer as it has a lower conversion rates even in obese individuals, distal rectal tumours and patients who had preoperative chemoradiotherpy. There is also a trend towards better outcome in anastomotic leak rates, circumferential margin positivity and perseveration of autonomic function, but there was no clear statistical significance to support this from the currently available data.

CONCLUSION

The use of robotic approach seems to be capable of addressing most of the shortcomings of the standard laparoscopic surgery. The technique has proved its safety profile in both colonic and rectal surgery. However, the cost involved may restrict its use to patients with challenging rectal cancer and in specialist centres.

Robotic-assisted hysterectomy for the management of severe endometriosis: a retrospective review of short-term surgical outcomes

Robotic-assisted laparoscopic surgery appears to be safe and feasible for definitive management of patients with severe endometriosis.

Objectives:

The primary objective was to examine the safety and feasibility of robotic-assisted laparoscopy in a cohort of women treated surgically for stage III and IV endometriosis. The secondary objective was to explore whether the stage of endometriosis affected surgical outcome.

Methods:

In this cohort study, 43 women with severe endometriosis were treated with robot-assisted laparoscopic hysterectomy with unilateral or bilateral salpingo-oophorectomy for stage III (n = 19) or stage IV (n = 24) disease.

Results:

Histopathologic evaluation confirmed endometriosis in all patients, and fibroids were also shown in 12 patients. The median actual operative time was 145 min (range, 67–325 min), and the median blood loss was 100 mL (range, 20–400 mL). All but one of the procedures were completed successfully robotically. The length of hospital stay was 1 d for 95% of patients (41 of 43), and 2 patients had prolonged stays of 4 d and 5 d, respectively. One patient was readmitted for a vaginal cuff abscess; this represented the only complication identified in this series.

Conclusions:

Robot-assisted laparoscopic surgery appears to be a reasonably safe and feasible method for the definitive surgical management of women with severe endometriosis.

Robotic surgery for deep endometriosis: a paradigm shift

BACKGROUND

Minimally invasive surgery represents the gold standard for the management of deep infiltrating endometriosis (DIE). This study aimed to evaluate the feasibility of robotic surgery for the management of DIE.

METHODS

A 5-year retrospective cohort study was made of robotic procedures including: segmental bowel resections, removal of nodules from the rectovaginal septum (RVS) with or without rectal shaving and partial bladder resection.

RESULTS

Overall, 19 bowel resections, 23 removals of RVS nodules and five bladder resections were performed, alone or in combination. Associated posterior vaginal resections were performed in 12 cases. Neither intra-operative complications, nor conversion to laparotomy occurred. One anastomotic leakage was recorded.

CONCLUSION

This series of robotic procedures for DIE represents the largest currently available and it helps to promote robotics as a safe and attractive alternative to accomplish a comprehensive surgical treatment of DIE, especially when bowel or bladder resections are needed.

Robotic colonic surgery: is it advisable to commence a new learning curve?

BACKGROUND

Robotic surgery has potential advantages in rectal and pelvic surgery, in which the dissection is performed within a confined operative field. However, the position of robotic colonic surgery remains largely undefined with limited insight of whether it offers any potential advantages over open or laparoscopic colon surgery.

OBJECTIVES

The aim of this systematic review was to compare the short-term outcomes of the published robotic colonic surgery with those of laparoscopic colonic surgery.

DATA SOURCES

The search was performed in September 2012 with the use of PubMed, MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. The search terms used were "colorectal," "colon," "colectomy," and "robotic/robot."

DATA SELECTION

All studies reporting outcomes on robotic colonic resection were included in the review process. Colonic robotic data were compared with data on the short-term outcomes of laparoscopic colonic surgery from a Cochrane review and 4 main randomized controlled trials.

INTERVENTIONS

A comparison was conducted of robotic colonic surgery vs standard laparoscopic colonic surgery.

MAIN OUTCOME MEASURES

Short-term outcomes and the complication profile of colonic robotic surgery were compared with conventional multiple-port laparoscopic colonic surgery.

RESULTS

Fifteen robotic colonic surgery articles with 351 patients (173 males, 178 females) were considered for analysis. The operative time and financial cost of robotic colonic surgery was greater than standard laparoscopic colonic surgery with comparable short-term outcomes and early postoperative complications profile.

CONCLUSIONS

The present evidence on robotic colonic surgery has shown both feasibility and a safety profile comparable to standard laparoscopic colonic surgery. However, operative time and cost were greater in robotic colonic surgery, with no difference in the length of postoperative stay in comparison with standard laparoscopic colonic surgery. Whether the general surgical community should embark on a new learning curve for robotic colonic surgery can only be answered in the light of future studies.

Robotic surgery and standard laparoscopy: a surgical hybrid technique for use in colorectal endometriosis

AIM

The aim of our work was to assess the feasibility and possible benefits of a novel hybrid surgical technique in rectosigmoidal resection in patients with bowel endometriosis.

MATERIAL AND METHODS

A total of seven symptomatic and infertile women with severe bowel endometriosis underwent segmental bowel resection using the da Vinci surgical system and conventional laparoscopy. Statistical analysis was performed by Friedman test for non-parametric multiple comparisons.

RESULTS

The surgical procedure has a determined short mean operative time (210min) and short postoperative hospitalization (five days). In 100% of patients, the resected area showed disease-free margins. Follow-up, carried out at three, six and 12months after operation, showed a regression of painful symptoms in all operated patients (100%). Two patients (28.6%) aged≥35years eventually had natural pregnancies.

CONCLUSION

To the best of our knowledge, this report is the first concerning the use of a hybrid technique for intestinal resection in severe endometriosis, and comparing our data with that in the literature, its methodological and clinical advantages are evident. Moreover, the complete removal of endometriotic implants seems to offer good results in terms of postoperative fertility, although the study data do not allow us to draw definitive conclusions on the management of fertility.

The treatment of rectal endometriosis and the role of laparoscopic surgery

PURPOSE OF REVIEW

Rectal endometriosis is a very indolent disease whose treatment has been debated by a range of competing schools. Meanwhile, not all audiences in the scientific community are entirely familiar with the full aspects of the disease. Hence, the purpose of this review is to outline the basic as well as the recent literature pertaining to the disease, thus offering a broader view to the interested reader.

RECENT FINDINGS

Laparoscopic shaving or disc excision for rectal endometriotic nodules may be simple, safe options of controlling the disease. On the contrary, laparoscopic rectal resections, originally reserved for more extensive disease, are now more skillfully mastered by surgeons and gynecologists. Meta-analyses, retrospective, and prospective studies are being published frequently supporting one form of therapy at a time and discrediting another at other times.

SUMMARY

Laparoscopic shaving or disc excisions for rectal endometriotic foci or rectal resections are feasible and efficient methods for treating rectal endometriosis. More complex surgery to the bowel means more risk for complications. With the rising learning curve of the operators, laparoscopic rectal resections have become a safe option that should be offered to patients. The patient's preference to a particular treatment option should be central to the type of surgery to be elected.

Robotics as a new surgical minimally invasive approach to treatment of endometriosis: a systematic review

BACKGROUND

This systematic review evaluates the role of robotics in the surgical treatment of endometriosis.

METHODS

Electronic database searches were conducted in MEDLINE, Scopus, and ISI Web of Knowledge for relevant studies over the past 10 years.

RESULTS

Four published articles were found that used robotic assisted laparoscopy to perform endometriosis surgery. All four studies used the da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). Three studies were case reports, and one was a cohort study. Robotics appears to be as effective as conventional laparoscopy in the management of endometriosis. There were no reports of any major complications.

CONCLUSIONS

Few studies have been published and show us that robotic endometriosis surgery is feasible even in severe endometriosis cases without conversion. There is a lack of long-term outcome papers in the literature. Randomized controlled trials are necessary.