Robotic colorectal surgery: a systematic review

Collaborative Implementation of Robotic Surgery Into an Academic Pediatric Surgery Practice

INTRODUCTION

Robotic surgery continues to drive evolution in minimally invasive surgery. Due to the confined operative fields encountered, pediatric surgeons may uniquely benefit from the precise control offered by robotic technologies compared to open and laparoscopic techniques. We describe a unique collaborative implementation of robotic surgery into an academic pediatric surgery practice through adult robotic surgeon partnership. We compare robotic cholecystectomy (RC) and laparoscopic cholecystectomy (LC) outcomes, hypothesizing that RC will be equivalent to LC in key quality outcomes.

METHODS

We evaluate 14 mo of systems development and training, and 24 mo of collaborative operative experience evoking a purposeful tiered case progression, establishing core robotic competencies, prior to advancing operative complexity. Univariate analyses compared LC versus RC.

RESULTS

36 robotic operations were performed in children aged 8-18 y, in a tiered progression from 24 cholecystectomies to 2 ileocecectomies, 2 paraesophageal hernia repairs, 1 anterior rectopexy, 1 spleen-preserving distal pancreatectomy, 1 Heller myotomy, 1 choledochal cyst resection with roux-en-y hepaticojejunostomy, 1 median arcuate ligament release, and 1 thoracic esophageal duplication cyst resection. For LC and RC, there were no significant differences in procedure duration, discharge opioids, hospital readmission, or rates of surgical site infection or bile duct injury.

CONCLUSIONS

Robotic surgery has potential to significantly enhance pediatric surgery. RC appears equivalent to LC but presents multiple additional theoretical benefits in pediatric patients. Our pilot program experience supports the feasibility and safety of pediatric robotic surgery. We emphasize the importance of a stepwise progression in operative difficulty and collaboration with adult robotic surgery experts.

Perceptions of theatre team members to robotic assisted surgery and the aid of technology in colorectal surgery

The implementation of robotic assisted surgery (RAS) has brought in a change to the perception and roles of theatre staff, as well as the dynamics of the operative environment and team. This study aims to identify and describe current perceptions of theatre staff in the context of RAS. 12 semi-structured interviews were conducted in a tertiary level university hospital, where RAS is utilised in selected elective settings. Interviews were conducted by an experienced research nurse to staff of the colorectal department operating theatre (nursing, surgical and anaesthetics) with some experience in operating within open, laparoscopic and RAS surgical settings. Thematic analysis on all interviews was performed, with formation of preliminary themes. Respondents all discussed advantages of all modes of operating. All respondents appreciated the benefits of minimally invasive surgery, in the reduced physiological insult to patients. However, interviewees remarked on the current perceived limitations of RAS in terms of logistics. Some voiced apprehension and anxieties about the safety if an operation needs to be converted to open. An overarching theme with participants of all levels and backgrounds was the 'Teamwork' and the concept of the [robotic] team. The physical differences of RAS changes the traditional methods of communication, with the loss of face-to-face contact and the physical 'separation' of the surgeon from the rest of the operating team impacting theatre dynamics. It is vital to understand the staff cultures, concerns and perception to the use of this relatively new technology in colorectal surgery.

Framework for pediatric robotic surgery program development

Pediatric robotic surgery has seen increasing implementation for its many benefits over the past two decades. As more pediatric surgeons gain exposure to robotic surgery, the interest in utilizing this technology is growing. However, there are no guidelines or existing framework for developing pediatric general surgery robotic programs. Programmatic development can be challenging, requiring institutional support, a minimum 12-month multistep process in partnership with the robot manufacturer, and organization of a local dedicated team. A cornerstone to all program building is collaboration and communication with key stakeholders who are committed to establishing a robotic surgery program. In this manuscript, we detail numerous best practices for implementation, followed by three variations of programmatic development, each drawing lessons from one of three practice settings: (i) A children's hospital in a large medical center associated with an adult hospital, (ii) a free-standing children's hospital, and (iii) a community-based practice. We aim for this article to provide a framework that can serve as a guide for those beginning this process, consolidating the key resources and strategies used to develop a robust pediatric robotic surgery program.

Comparative analysis of short-term outcomes and oncological results between robotic-assisted and laparoscopic surgery for rectal cancer by multiple surgeon implementation: a propensity score-matched analysis

Robotic-assisted surgery (RAS) is becoming increasingly common for the surgical treatment of rectal cancer. However, the use and implementation of robotic surgery remains controversial. This study aimed to compare the short-term outcomes of robotic surgery, focusing on pathological results and disease-free survival (DFS), in our cohort with initial robotic experience by multiple surgeon implementation. This retrospective study enrolled 571 patients diagnosed with rectal cancer, who were treated with chemoradiotherapy and surgery between January 2015 and December 2021. Surgical outcomes after RAS and laparoscopic surgery (LS) were compared using a propensity score-matching (PSM) analysis. After matching, 200 patients (100 in each group) were included. The median operative time was significantly longer in the RAS group than in the LS group (p < 0.001). The conversion and morbidity rates were similar between the groups. A significantly higher rate of complete mesorectal excision (92% vs. 72%; p = 0.001) and number of lymph nodes harvested (p = 0.009) was observed in the RAS group. There were no statistically significant differences between the groups regarding circumferential and distal resection margin involvement. The 3-year overall and disease-free survival rate was similar between the two groups (p = 0.849 and p = 0.582, respectively). Two patients in the LS group developed local recurrence and 27 patients (15.4%) developed metastatic disease. Multivariate analysis showed that tumor stage III was the only factor associated with disease-free survival (HR, 9.34; (95% CI 1.13-77.1), p = 0.038). RAS and LS showed similar outcomes in terms of perioperative, anatomopathological, and disease-free survival, after multiple surgeon implementations.

The Senhance Surgical System in Colorectal Surgery: A Systematic Review

The Senhance Surgical System allows for infrared eye tracking, haptic feedback, and an adjustable upright seat allowing for improved ergonomics. This systematic review was designed with the aim of reviewing the current literature pertaining to the use of the Senhance Surgical System in colorectal surgery. Medline, EMBASE, and CENTRAL were searched. Articles were eligible for inclusion if they evaluated adults undergoing colorectal surgery with the Senhance Surgical System. The primary outcome was intraoperative efficacy; as defined by operative time, estimated blood loss (EBL), and conversion. A DerSimonian and Laird inverse variance random-effects meta-analysis was used to generate overall effect size estimates and narrative review was provided for each outcome. Six observational studies with 223 patients (mean age: 63.7, 41.2% female, mean BMI: 24.4 kg/m²) were included. The most common indication for surgery was colorectal cancer (n = 180, 80.7%) and the most common operation was anterior resection (n = 72, 32.3%). Meta-analyses demonstrated a pooled total operative time of 229.8 min (95% CI 189.3-270.4, I² = 0%), console time of 141.3 min (95% CI 106.5-176.1, I² = 0%), and docking time of 10.8 min (95% CI 6.4-15.2, I² = 0%). The pooled EBL was 37.0 mL (95% CI 24.7-49.2, I² = 20%). Overall, there were nine (4.0%) conversions to laparoscopy/laparotomy. The Senhance Surgical System has an acceptable safety profile, reasonable docking and console times, low conversion rates, and an affordable case cost across a variety of colorectal surgeries. Further prospective, comparative trials with other robotic surgical platforms are warranted.

Minimally Invasive Spine Surgery: An Overview

Spinal surgery is undergoing a major transformation toward a minimally invasive paradigm. This shift is being driven by multiple factors, including the need to address spinal problems in an older and sicker population, as well as changes in patient preferences and reimbursement patterns. Increasingly, minimally invasive surgical techniques are being used in place of traditional open approaches due to significant advancements and implementation of intraoperative imaging and navigation technologies. However, in some patients, due to specific anatomic or pathologic factors, minimally invasive techniques are not always possible. Numerous algorithms have been described, and additional efforts are underway to better optimize patient selection for minimally invasive spinal surgery (MISS) procedures in order to achieve optimal outcomes. Numerous unique MISS approaches and techniques have been described, and several have become fundamental. Investigators are evaluating combinations of MISS techniques to further enhance the surgical workflow, patient safety, and efficiency.

Laparoscopic versus robotic-assisted, left-sided colectomies: intra- and postoperative outcomes of 683 patients

Background

Robotic-assisted colorectal surgery has gained more and more popularity over the last years. It seems to be advantageous to laparoscopic surgery in selected situations, especially in confined regions like a narrow male pelvis in rectal surgery. Whether robotic-assisted, left-sided colectomies can serve as safe training operations for less frequent, low anterior resections for rectal cancer is still under debate. Therefore, the aim of this study was to evaluate intra- and postoperative results of robotic-assisted laparoscopy (RAL) compared to laparoscopic (LSC) surgery in left-sided colectomies.

Methods

Between June 2015 and December 2019, 683 patients undergoing minimally invasive left-sided colectomies in two Swiss, high-volume colorectal centers were included. Intra- and postoperative outcome parameters were collected and analyzed.

Results

A total of 179 patients undergoing RAL and 504 patients undergoing LSC were analyzed. Baseline characteristics showed similar results. Intraoperative complications occurred in 0.6% of RAL and 2.0% of LSC patients (p = 0.193). Differences in postoperative complications graded Dindo ≥ 3 were not statistically significant (RAL 3.9% vs. LSC 6.3%, p = 0.227). Occurrence of anastomotic leakages showed no statistically significant difference [RAL n = 2 (1.1%), LSC n = 8 (1.6%), p = 0.653]. Length of hospital stay was similar in both groups. Conversions to open surgery were significantly higher in the LSC group (6.2% vs.1.7%, p = 0.018), while stoma formation was similar in both groups [RAL n = 1 (0.6%), LSC n = 5 (1.0%), p = 0.594]. Operative time was longer in the RAL group (300 vs. 210.0 min, p < 0.001).

Conclusion

Robotic-assisted, left-sided colectomies are safe and feasible compared to laparoscopic resections. Intra- and postoperative complications are similar in both groups. Most notably, the rate of anastomotic leakages is similar. Compared to laparoscopic resections, the analyzed robotic-assisted resections have longer operative times but less conversion rates. Further prospective studies are needed to confirm the safety of robotic-assisted, left-sided colectomies as training procedures for low anterior resections.

Augmented Reality: Moving Robotics Forward

Compared with other fields, adoption of robotics in colorectal surgery remains relatively slow. One of the reasons for this is that the expected benefits of robotics, such as greater accuracy, speed, and better patient outcomes, are not born out in evidence comparing use of robotics for colorectal procedures to conventional laparoscopy. But evidence also suggests that outcomes with colorectal robotic procedures depend on the experience of the surgeon, suggesting that a steep learning curve is acting as a barrier to the benefits of robotics being realized. In this paper, we analyze exactly why surgeon skill and proficiency is such a critical factor in colorectal surgery, especially around the most complex procedures associated with cancer. Shortening of the learning curve is crucial for both the adoption of the technique and the efficient use of expert trainers. Looking beyond the basics of training and embracing a new generation of digital learning technologies that facilitate peer-to-peer collaboration and development beyond the confines of individual institutions may be an important contributor to achieve these goals in the future.

Safety with Innovation in Colon and Rectal Robotic Surgery

Robotic colorectal surgery has been touted as a possible way to overcome the limitations of laparoscopic surgery and has shown promise in rectal resections, thus shifting traditional open surgeons to a minimally invasive approach. The safety, efficacy, and learning curve have been established for most colorectal applications. With this and a robust sales and marketing model, utilization of the robot for colorectal surgery continues to grow steadily. However, this disruptive technology still requires standards for training, privileging and credentialing, and safe implementation into clinical practice.

Short-term clinical outcomes of a European training programme for robotic colorectal surgery

BACKGROUND

Despite there being a considerable amount of published studies on robotic colorectal surgery (RCS) over the last few years, there is a lack of evidence regarding RCS training pathways. This study examines the short-term clinical outcomes of an international RCS training programme (the European Academy of Robotic Colorectal Surgery-EARCS).

METHODS

Consecutive cases from 26 European colorectal units who conducted RCS between 2014 and 2018 were included in this study. The baseline characteristics and short-term outcomes of cases performed by EARCS delegates during training were analysed and compared with cases performed by EARCS graduates and proctors.

RESULTS

Data from 1130 RCS procedures were collected and classified into three cohort groups (323 training, 626 graduates and 181 proctors). The training cases conversion rate was 2.2% and R1 resection rate was 1.5%. The three groups were similar in terms of baseline characteristics with the exception of malignant cases and rectal resections performed. With the exception of operative time, blood loss and hospital stay (training vs. graduate vs. proctor: operative time 302, 265, 255 min, p < 0.001; blood loss 50, 50, 30 ml, p < 0.001; hospital stay 7, 6, 6 days, p = 0.003), all remaining short-term outcomes (conversion, 30-day reoperation, 30-day readmission, 30-day mortality, clinical anastomotic leak, complications, R1 resection and lymph node yield) were comparable between the three groups.

CONCLUSIONS

Colorectal surgeons learning how to perform RCS under the EARCS-structured training pathway can safely achieve short-term clinical outcomes comparable to their trainers and overcome the learning process in a way that minimises patient harm.

Evolution of Robotic Surgery in a Colorectal Cancer Unit in India

Only a handful of institutions in the country have an established robotic surgery program. Evolution of robotic surgery in the colorectal division, from inception to recent times, is presented here. All the patients undergoing robotic colorectal surgery from the inception of the program (September 2014) to August 2019 were identified. The patient and treatment details and short-term outcomes were collected retrospectively from the prospectively maintained database. The cohort was divided into four chronological groups (group 1 being the oldest) to assess the surgical trends. There were 202 patients. Seventy-one percent were male. Mean BMI was 23.25. Low rectal tumours were most common (47%). A total of 74.3% patients received neo-adjuvant treatment. Multivisceral resection was done in 22 patients, including 4 synchronous liver resections. Average operating time for standard rectal surgery was 280 min with average blood loss of 235 ml. The mean nodal yield was 14. Circumferential resection margin positivity was 6.4%. The mean hospital stay for pelvic exenteration was significantly higher than the rest of the surgeries (except for posterior exenteration and total proctocolectomy) (p = 0.00). Clavin-Dindo grade 3 and 4 complications were seen in 10% patients. As the experience of the team increased, more complex cases were performed. Blood loss, margin positivity, nodal yield, leak rates and complications were evaluated group wise (excluding those with additional procedures) to assess the impact of experience. We did not find any significant change in the parameters studied. With increasing experience, the complexity of surgical procedures performed on da Vinci Xi platform can be increased in a systematic manner. Our short-term outcomes, i.e. nodes harvested, margin positivity, hospital stay and morbidity, are on par with world standards. However, we did not find any significant improvement in these parameters with increasing experience.

Effective implementation and adaptation of structured robotic colorectal programme in a busy tertiary unit

BACKGROUND

Safety and feasibility of robotic colorectal surgery has been reported as increasing over the last decade. However safe implementation and adaptation of such a programme with comparable morbidities and acceptable oncological outcomes remains a challenge in a busy tertiary unit. We present our experience of implementation and adaptation of a structured robotic colorectal programme in a high-volume center in the United Kingdom.

METHODS

Two colorectal surgeons underwent a structured robotic colorectal training programme consisting of time on simulation console, dry and wet laboratory courses, case observation, and initial mentoring. Data were collected on consecutive robotic colorectal cancer resections over a period of 12 months and compared with colorectal cancer resections data of the same surgeons' record prior to the adaptation of the new technique. Patient demographics including age, gender, American Society of Anesthesiologist score (ASA), Clavien-Dindo grading, previous abdominal surgeries, and BMI were included. Short-term outcomes including conversion to open, length of stay, return to theatre, 30- and 90-days mortality, blood loss, and post-operative analgesia were recorded. Tumour site, TNM staging, diverting stoma, neo-adjuvant therapy, total mesorectal excision (TME) grading and positive resection margins (R1) were compared. p values less than or equal to 0.05 were considered statistically significant.

RESULTS

Ninety colorectal cancer resections were performed with curative intent from June 2018 to June 2020. Thirty robotic colorectal cancer resections (RCcR) were performed after adaption of programme and were compared with 60 non-robotic colorectal cancer resections (N-RCcR) prior to implementation of technique. There was no conversion in the RCcR group; however, in N-RCcR group, five had open resection from start and the rest had laparoscopic surgery. In laparoscopic group, there were six (10.9%) conversions to open (two adhesions, three multi-visceral involvements, one intra-operative bleed). Male-to-female ratio was 20:09 in RCcR group and 33:20 in N-RCcR groups. No significant differences in gender (p = 0.5), median age (p = 0.47), BMI (p = 0.64) and ASA scores (p = 0.72) were present in either groups. Patient characteristics between the two groups were comparable aside from an increased proportion of rectal and sigmoid cancers in RCcR group. Mean operating time, and returns to theaters were comparable in both groups. Complications were fewer in RCcR group as compared to N-RCcR (16.6% vs 25%). RCcR group patients have reduced length of stay (5 days vs 7 days) but this is not statistically significant. Estimated blood loss and conversion to open surgery was significantly lesser in the robotic group (p < 0.01). The oncological outcomes from surgery including TNM, resection margin status, lymph node yield and circumferential resection margin (for rectal cancers) were all comparable. There was no 30-day mortality in either group.

CONCLUSION

Implementation and integration of robotic colorectal surgery is safe and effective in a busy tertiary center through a structured training programme with comparable short-term survival and oncological outcomes during learning curve.

Research as the gatekeeper: introduction ofrobotic-assisted surgery into the public sector

Objective Within Australia, robotic-assisted surgery (RAS) has largely been undertaken within the private sector, and predominately based within urology. This is rapidly developing, with RAS becoming increasingly prevalent across surgical specialties and within public hospitals. At this point in time there is a need to consider how this generation of the technology can be appropriately and safely introduced into the public health system given its prohibitive costs and lack of high-level long-term evidence. Methods This paper describes a unique approach used to govern the establishment of a new RAS program within a large public tertiary referral hospital in Australia. This included the creation of a comprehensive governance framework that covered research, training and operational components, with research being the ultimate gatekeeper to accessing the technology. Results Taking this novel approach, both benefits and challenges were encountered. Although initially there was a trade-off of activity to enable time for the research program to be developed, it was found the model strengthened patient safety in introducing the technology, fostered a breadth of surgical speciality involvement, ensured uniformity of data collection and, in the longer term, will enable a significant contribution to be made to the evidence regarding the appropriateness of RAS being used across several surgical specialties. Conclusions There is potential for this comprehensive governance framework to be transferred to other public hospitals commencing or with existing RAS programs and to be applied to the introduction of other new and expensive surgical technology. What is known about the topic? RAS is rapidly evolving and becoming increasingly prevalent across surgical specialities in major public hospitals. Consequently, it is important that this new technology is safely and appropriately implemented into the public health system. What does this paper add? This article describes the benefits and implementation challenges of a novel RAS approach, including a comprehensive governance framework that covered research, training and operational components, with research being the ultimate gatekeeper to accessing the technology. What are the implications for practitioners? This comprehensive governance framework can be transferred to other public hospitals introducing, or already using, new and expensive surgical technology.

Clinical, pathological, and oncologic outcomes of robotic-assisted versus laparoscopic proctectomy for rectal cancer: A meta-analysis of randomized controlled studies

Although several meta-analyses regarding robot-assisted proctectomy (RP) and laparoscopic proctectomy (LP) in patients with rectal cancer are constantly being published, meta-analyses considering randomized controlled trials (RCTs) are still rare. It is therefore necessary to conduct an appropriate meta-analysis to provide reliable evidence for clinical decision-making. Databases such as PubMed, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials (CCTR) and Cochrane Database of Systematic Reviews (CDSR) were used to collect RCTs assessing the effectiveness and safety of RP and LP. Article search was performed until August 2019. Data were extracted and the quality was evaluated by two reviewers independently, according to the inclusion and exclusion criteria. Data were analyzed using R software. Eight RCTs were included involving 999 patients, 495 of them underwent RP and 504 underwent LP. The results showed that the RP group had a longer operative time (P < 0.01), a lower conversion rate (P = 0.03), a longer distance to the distal margin (DDM) (P = 0.001), and a lower incidence of erectile dysfunction (P = 0.02). No significant differences were found in perioperative mortality, complication rates, PRM, number of harvested lymph nodes, length of hospital stay and time to first bowel movement between the two groups. Current evidence suggests that RP is superior to LP in short-term clinical outcomes, which is similar to LP regarding pathological outcomes and has better DDM outcomes. However, the comparison between RP and LP regarding long-term oncology outcomes still require further multi-center and large RCT samples to confirm our evidences.

Factors supporting and constraining the implementation of robot-assisted surgery: a realist interview study

OBJECTIVE

To capture stakeholders' theories concerning how and in what contexts robot-assisted surgery becomes integrated into routine practice.

DESIGN

A literature review provided tentative theories that were revised through a realist interview study. Literature-based theories were presented to the interviewees, who were asked to describe to what extent and in what ways those theories reflected their experience. Analysis focused on identifying mechanisms through which robot-assisted surgery becomes integrated into practice and contexts in which those mechanisms are triggered.

SETTING

Nine hospitals in England where robot-assisted surgery is used for colorectal operations.

PARTICIPANTS

Forty-four theatre staff with experience of robot-assisted colorectal surgery, including surgeons, surgical trainees, theatre nurses, operating department practitioners and anaesthetists.

RESULTS

Interviewees emphasised the importance of support from hospital management, team leaders and surgical colleagues. Training together as a team was seen as beneficial, increasing trust in each other's knowledge and supporting team bonding, in turn leading to improved teamwork. When first introducing robot-assisted surgery, it is beneficial to have a handpicked dedicated robotic team who are able to quickly gain experience and confidence. A suitably sized operating theatre can reduce operation duration and the risk of de-sterilisation. Motivation among team members to persist with robot-assisted surgery can be achieved without involvement in the initial decision to purchase a robot, but training that enables team members to feel confident as they take on the new tasks is essential.

CONCLUSIONS

We captured accounts of how robot-assisted surgery has been introduced into a range of hospitals. Using a realist approach, we were also able to capture perceptions of the factors that support and constrain the integration of robot-assisted surgery into routine practice. We have translated these into recommendations that can inform future implementations of robot-assisted surgery.

Working towards clinical effectiveness-a multi-disciplinary approach to robotic surgery

The importance of a multi-disciplinary team (MDT) approach to conventional surgical techniques has strong empirical support. The MDT approach to robotic-assisted surgery (RAS) has not been clearly defined, which encourages prospectively poor MDT performance. Poor performance of the MDT approach, allied to the constant evolution of technology-assisted surgery, can generate unacceptable operative and patient outcomes. This review offers a nursing perspective to the complex paradigm of thoracic RAS, demonstrating key indicators to perioperative MDT engagement. This will be achieved by offering a rationale for RAS in pulmonary resection, identifying additional surgeries where utility is demonstrated. Evaluation of the available evidence will synthesize clinical quality indicators, while key strategies in effective MDT development can be summarised. Conclusively, bespoke and experiential knowledge will be shared, based upon the investigatory findings discussed throughout this article. Allied to a recommended developmental framework, this perspective should allow for transfer of knowledge, creation and replication of useful interventions. Lung cancer is an ever-increasing global concern, currently being the co-modal cancer with an estimated 2.09 million cases worldwide. Populations are ageing and with annual global costs of at least $1.16 trillion, effective treatments are required. RAS shows promise in treating large and complex lesions when compared to a video-assisted thoracoscopic surgery (VATS) approach. A critical indicator being enhanced vision and dexterity in comparison to a VATS approach. Economically, RAS has proven to be an expensive technique, however, when initial purchase costs are excluded, intra-operatively, there are ways to narrow the expense gap and make RAS cheaper. When assessing per hospital stay, exclusive of initial purchase cost, RAS is found to be cheaper than open thoracotomy. This article demonstrates that RAS for pulmonary resection has utility for complex lesions where a VATS approach would be unsuitable. Crucially, as with all complex surgery, the MDT must be performed effectively for optimum patient outcomes.

Safe adoption of robotic colorectal surgery using structured training: early Irish experience

Robotic surgery enhances the precision of minimally invasive surgery through improved three-dimensional views and articulated instruments. There has been increasing interest in adopting this technology to colorectal surgery and this has recently been introduced to the Irish health system. This paper gives an account of our early institutional experience with adoption of robotic colorectal surgery using structured training. Analysis was conducted of a prospectively maintained database of our first 55 consecutive robotic colorectal cases, performed by four colorectal surgeons, each at the beginning of his robotic surgery experience, using the Da Vinci Si^® system and undergoing training as per the European Academy of Robotic Colorectal Surgery (EARCS) programme. Overall surgical and oncological outcomes were interrogated. Fifty-five patients underwent robotic surgery between January 2017 and January 2018, M:F 34:21, median age (range) 60 (35-87) years. Thirty-three patients had colorectal cancer and 22 had benign pathologies. Eleven rectal cancer patients had neoadjuvant chemoradiotherapy. BMI was > 30 in 21.8% of patients and 56.4% of patients had previous abdominal surgery. Operative procedures performed were low anterior resection (n = 19), sigmoid colectomy (n = 9), right colectomy (n = 22), ventral mesh rectopexy (n = 3), abdominoperineal resection (n = 1) and reversal of Hartmann's procedure (n = 1). Median blood loss was 40 ml (range 0-400). Mean operative time (minutes) was 233 (SD 79) for right colectomy and 368 (SD 105) for anterior resection. Median length of hospital stay was 6 days (IQR 5-7). There was no 30-day mortality, intraoperative complications, conversion to laparoscopic or open, or anastomotic leakage. Median lymph nodes harvest was 15 in non-neoadjuvant cases (range 7-23) and 8 in neoadjuvant cases (2-14). Our early results demonstrate that colorectal robotic surgery can be adopted safely for both benign and neoplastic conditions using a structured training programme without compromising clinical or oncological outcomes. The early learning curve can be time intensive.

Robotic rectal cancer surgery in obese patients may lead to better short-term outcomes when compared to laparoscopy: a comparative propensity scored match study

PURPOSE

Laparoscopic rectal surgery in obese patients is technically challenging. The technological advantages of robotic instruments can help overcome some of those challenges, but whether this translates to superior short-term outcomes is largely unknown. The aim of this study is to compare the short-term surgical outcomes of obese (BMI ≥ 30) robotic and laparoscopic rectal cancer surgery patients.

METHODS

All consecutive obese patients receiving laparoscopic and robotic rectal cancer resection surgery from three centres, two from the UK and one from Portugal, between 2006 and 2017 were identified from prospectively collated databases. Robotic surgery patients were propensity score matched with laparoscopic patients for ASA grade, neoadjuvant radiotherapy and pathological T stage. Their short-term outcomes were examined.

RESULTS

A total of 222 patients were identified (63 robotic, 159 laparoscopic). The 63 patients who received robotic surgery were matched with 61 laparoscopic patients. Cohort characteristics were similar between the two groups. In the robotic group, operative time was longer (260 vs 215 min; p = 0.000), but length of stay was shorter (6 vs 8 days; p = 0.014), and thirty-day readmission rate was lower (6.3% vs 19.7%; p = 0.033).

CONCLUSIONS

In this study population, robotic rectal surgery in obese patients resulted in a shorter length of stay and lower 30-day readmission rate but longer operative time when compared to laparoscopic surgery. Robotic rectal surgery in the obese may be associated with a quicker post-operative recovery and reduced morbidity profile. Larger-scale multi-centre prospective observational studies are required to validate these results.

Implementation of robotic rectal surgery training programme: importance of standardisation and structured training

Purpose

A structured training programme is essential for the safe adoption of robotic rectal cancer surgery. The aim of this study is to describe the training pathway and short-term surgical outcomes of three surgeons in two centres (UK and Portugal) undertaking single-docking robotic rectal surgery with the da Vinci Xi and integrated table motion (ITM).

Methods

Prospectively, collected data for consecutive patients who underwent robotic rectal cancer resections with the da Vinci Xi and ITM between November 2015 and September 2017 was analysed. The short-term surgical outcomes of the first ten cases of each surgeon (supervised) were compared with the subsequent cases (independent). In addition, the Global Assessment Score (GAS) forms from the supervised cases were analysed and the GAS cumulative sum (CUSUM) charts constructed to investigate the training pathway of the participating surgeons.

Results

Data from 82 patients was analysed. There were no conversions to open, no anastomotic leaks and no 30-day mortality. Mean operation time was 288 min (SD 63), median estimated blood loss 20 (IQR 20–20) ml and median length of stay 5 (IQR 4–8) days. Thirty-day readmission and reoperation rates were 4% (n = 3) and 6% (n = 5) respectively. When comparing the supervised cases with the subsequent solo cases, there were no statistically significant changes in any of the short-term outcomes with the exception of mean operative time, which was significantly shorter in the independent cases (311 vs 275 min, p = 0.038). GAS form analysis and GAS CUSUM charting revealed that ten proctoring cases were enough for trainee surgeons to independently perform robotic rectal resections with the da Vinci Xi.

Conclusions

Our results show that by applying a structured training pathway and standardising the surgical technique, the single-docking procedure with the da Vinci Xi is a valid, reproducible technique that offers good short-term outcomes in our study population.

Precision in robotic rectal surgery using the da Vinci Xi system and integrated table motion, a technical note

Robotic rectal surgery is becoming increasingly more popular among colorectal surgeons. However, time spent on robotic platform docking, arm clashing and undocking of the platform during the procedure are factors that surgeons often find cumbersome and time consuming. The newest surgical platform, the da Vinci Xi, coupled with integrated table motion can help to overcome these problems. This technical note aims to describe a standardised operative technique of single docking robotic rectal surgery using the da Vinci Xi system and integrated table motion. A stepwise approach of the da Vinci docking process and surgical technique is described accompanied by an intra-operative video that demonstrates this technique. We also present data collected from a prospectively maintained database. 33 consecutive rectal cancer patients (24 male, 9 female) received robotic rectal surgery with the da Vinci Xi during the preparation of this technical note. 29 (88%) patients had anterior resections, and four (12%) had abdominoperineal excisions. There were no conversions, no anastomotic leaks and no mortality. Median operation time was 331 (249–372) min, blood loss 20 (20–45) mls and length of stay 6.5 (4–8) days. 30-day readmission rate and re-operation rates were 3% (n = 1). This standardised technique of single docking robotic rectal surgery with the da Vinci Xi is safe, feasible and reproducible. The technological advances of the new robotic system facilitate the totally robotic single docking approach.

Value-based assessment of robotic pancreas and liver surgery

Current healthcare economic evaluations are based only on the perspective of a single stakeholder to the healthcare delivery process. A true value-based decision incorporates all of the outcomes that could be impacted by a single episode of surgical care. We define the value proposition for robotic surgery using a stakeholder model incorporating the interests of all groups participating in the provision of healthcare services: patients, surgeons, hospitals and payers. One of the developing and expanding fields that could benefit the most from a complete value-based analysis is robotic hepatopancreaticobiliary (HPB) surgery. While initial robot purchasing costs are high, the benefits over laparoscopic surgery are considerable. Performing a literature search we found a total of 18 economic evaluations for robotic HPB surgery. We found a lack of evaluations that were carried out from a perspective that incorporates all of the impacts of a single episode of surgical care and that included a comprehensive hospital cost assessment. For distal pancreatectomies, the two most thorough examinations came to conflicting results regarding total cost savings compared to laparoscopic approaches. The most thorough pancreaticoduodenectomy evaluation found non-significant savings for total hospital costs. Robotic hepatectomies showed no cost savings over laparoscopic and only modest savings over open techniques. Lastly, robotic cholecystectomies were found to be more expensive than the gold-standard laparoscopic approach. Existing cost accounting data associated with robotic HPB surgery is incomplete and unlikely to reflect the state of this field in the future. Current data combines the learning curves for new surgical procedures being undertaken by HPB surgeons with costs derived from a market dominated by a single supplier of robotic instruments. As a result, the value proposition for stakeholders in this process cannot be defined. In order to solve this problem, future studies must incorporate (I) quality of life, survival, and return to independent function alongside data such as (II) intent-to-treat analysis of minimally-invasive surgery accounting for conversions to open, (III) surgeon and institution experience and operative time as surrogates for the learning curve; and (IV) amortization and maintenance costs as well as direct costs of disposables and instruments.

Robotic colorectal surgery: previous laparoscopic colorectal experience is not essential

A background in minimally invasive colorectal surgery (MICS) has been thought to be essential prior to robotic-assisted colorectal surgery (RACS). Our aim was to determine whether MICS is essential prior to starting RACS training based on results from our initial experience with RACS. Two surgeons from our centre received robotic training through the European Academy of Robotic Colorectal Surgery (EARCS). One surgeon had no prior formal MICS training. We reviewed the first 30 consecutive robotic colorectal procedures from a prospectively maintained database between November 2014 and January 2016 at our institution. Fourteen patients were male. Median age was 64.5 years (range 36-82) and BMI was 27.5 (range 20-32.5). Twelve procedures (40%) were performed by the non-MICS-trained surgeon: ten high anterior resections (one conversion), one low anterior resection and one abdomino-perineal resection of rectum (APER). The MICS-trained surgeon performed nine high and four low anterior resections, one APER and in addition three right hemicolectomies and one abdominal suture rectopexy. There were no intra-operative complications and two patients required re-operation. Median post-operative stay was five days (range 1-26). There were two 30-day re-admissions. All oncological resections had clear margins and median node harvest was 18 (range 9-39). Our case series demonstrates that a background in MICS is not essential prior to starting RACS training. Not having prior MICS training should not discourage surgeons from considering applying for a robotic training programme. Safe and successful robotic colorectal services can be established after completing a formal structured robotic training programme.

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.

Use of the new da Vinci Xi® during robotic rectal resection for cancer: a pilot matched-case comparison with the da Vinci Si®

BACKGROUND

The aim of this study was to compare the short-term outcomes of robotic rectal resection with total mesorectal excision (TME) for rectal cancer, with the use of the new da Vinci Xi® (Xi-RobTME group) and the da Vinci Si® (Si-RobTME group).

METHODS

Ten patients with histologically confirmed rectal cancer underwent robot-assisted TME with the use of the new da Vinci Xi. The outcomes of Xi-RobTME group were compared with a Si-RobTME group selected using a case-matched methodology.

RESULTS

Overall operative times and mean hospital stays were shorter in the Xi-RobTME group. Surgeries were fully robotic with a complete take-down of the splenic flexure in all Xi-RobTME cases, while only four cases of the Si-RobTME group were fully robotic, with two cases of complete take-down of the splenic flexure.

CONCLUSIONS

The new da Vinci Xi could offer some advantages with respect to the da Vinci Si in rectal resection for cancer. Copyright © 2016 John Wiley & Sons, Ltd.

A novel approach for robotic mobilization of the splenic flexure

BACKGROUND

The techniques of robotic splenic flexure mobilization in the colorectal surgery setting are not well defined and have been challenging due to limited range of motion of the second-generation robotic platform in multiple quadrants.

METHODS

This report describes a novel technique for robotic splenic flexure mobilization with medial-to-lateral approach without a need for robotic cart repositioning during left-sided colon and rectal surgery. The dissection is started with ligation of the inferior mesenteric artery and vein. Unique in this approach, entering the lesser sac is accomplished by extension of the dissection cranially by lifting up the mesocolon from the anterior surface of the pancreatic body toward the stomach.

RESULTS

This technique presented in the video allows the mobilization of the splenic flexure without excessive tractions and avoidance of potential splenic injuries.

CONCLUSIONS

The described novel approach demonstrates total robotic splenic flexure takedown without excessive traction, with improved visualization, and reduction of potential risk of splenic injury. This approach provides totally robotic mobilization of the splenic flexure at single docking without changing the patient's position.

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.

Robot-assisted versus laparoscopic-assisted surgery for colorectal cancer: a meta-analysis

BACKGROUND AND OBJECTIVES

Robotic surgery is positioned at the cutting edge of minimally invasive management of colorectal cancer. We performed a meta-analysis of data from randomized controlled trials (RCTs) and non-RCTs (NRCTs) that compared the clinicopathological outcomes of robotic-assisted colorectal surgery (RACS) with those of laparoscopic-assisted colorectal surgery (LACS). Inferences on the feasibility and the relative safety and efficacy have been drawn.

METHODS

A literature search for relevant studies was performed on MEDLINE, Ovid, Embase, Cochrane Library, and Web of Science databases. Inter-group differences in the standardized mean differences and relative risk were assessed. Operation times, conversion rates to open surgery, estimated blood loss (EBL), early postoperative morbidity, and length of hospital stay (LHS) were compared. Oncologic outcomes assessed were number of lymph nodes harvested and lengths of proximal and distal resection margins.

RESULTS

Twenty-four studies (2 RCTs and 22 NRCTs [5 prospective plus 17 retrospective]) with a total of 3318 patients were included. Of these, 1466 (44.18 %) patients underwent RACS and 1852 (55.82 %) underwent LACS. Conversion rates, EBL and LHS were significantly lower, while the operation times and total costs were similar between RACS and LACS. Complication rates and oncological accuracy of resection showed no significant difference.

CONCLUSION

Based on this meta-analysis, RACS appears to be a promising surgical approach with its safety and efficacy comparable to that of LACS in patients undergoing colorectal surgery. Further studies are required to evaluate the long-term cost-efficiency as well as the functional and oncologic outcomes of RACS.

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.

A review on robotic surgery in rectal cancer

Robotic surgery has the upper hand when compared to the laparoscopic approach in terms of superior visualisation, flexibility in movement, steadiness and accessibility to confined anatomical spaces. Nevertheless, limitations still exist with regards to cost, reduced tactile sensation, time-consuming setup and a significant learning curve to achieve. Although studies have shown better or at least comparable outcomes between the robotic and laparoscopic approach, the limitations mentioned result in poor penetrance among centres and surgeons. Advancements in robotic surgery technology and attaining the acquired skillset will translate into better clinical outcomes for patients.

Robot-assisted versus standard laparoscopic colorectal surgery

BACKGROUND AND OBJECTIVES

Over the years, there has been a continual shift toward more minimally invasive surgical techniques, such as the use of laparoscopy in colorectal surgery. Recently, there has been increasing adoption of robotic technology. Our study aims to compare and contrast robot-assisted and laparoscopic approaches to colorectal operations.

METHODS

Forty patients undergoing laparoscopic or robotic colorectal surgery performed by 2 surgeons at an academic center, regardless of indication, were included in this retrospective review. Patients undergoing open approaches were excluded. Study outcomes included operative time, estimated blood loss, length of stay, complications, and conversion rate to an open procedure.

RESULTS

Twenty-five laparoscopic and fifteen robot-assisted colorectal surgeries were performed. The mean patient age was 61.1 ± 10.7 years in the laparoscopic group compared with 61.1 ± 8.5 years in the robotic group (P = .997). Patients had a similar body mass index and history of abdominal surgery. Mean blood loss was 163.3 ± 249.2 mL and 96.8 ± 157.7 mL, respectively (P = .385). Operative times were similar, with 190.8 ± 84.3 minutes in the laparoscopic group versus 258.4 ± 170.8 minutes in the robotic group (P = .183), as were lengths of hospital stay: 9.6 ± 7.3 and 6.5 ± 3.8 days, respectively (P = .091). In addition, there was no difference in the number of lymph nodes harvested between the laparoscopic group (14.0 ± 6.5) and robotic group (12.3 ± 4.2, P = .683).

CONCLUSIONS

In our early experience, the robotic approach to colorectal surgery can be considered both safe and efficacious. Furthermore, it also preserves oncologically sufficient outcomes when performed for cancer operations.

Effect of BMI on Short-Term Outcomes with Robotic-Assisted Laparoscopic Surgery: a Case-Matched Study

BACKGROUND

Many benefits of minimally invasive surgery are lost in the obese, but robotic-assisted laparoscopic surgery (RALS) may offer advantages in this population. Our goal was to compare outcomes for RALS in obese and non-obese patients.

METHODS

A prospective database was reviewed for colorectal resections using RALS. Patients were stratified into obese (BMI > 30 kg/m(2)) and non-obese cohorts (BMI < 30 kg/m(2)), then case-matched for comparability. The main outcome measures were operative time, conversion rate, length of stay and complication, readmission, and reoperation rates between groups.

RESULTS

Forty-five patients were evaluated in each cohort. The BMI was significantly different (p < 0.01). All other demographics were well matched. There were no significant differences in operative time (p = 0.86), blood loss (p = 0.38), intraoperative complications (p = 0.54), or conversion rates (p = 0.91) across cohorts. Length of stay was comparable between groups (p = 0.45). Postoperatively, the complication (p = 0.87), readmission (p = 1.00), and reoperation rates (p = 0.95) were similar. There were no mortalities. For malignant cases (37.8 %), the lymph node yield (p = 0.48) and positive margins (p = 1.00) were similar and acceptable in both cohorts.

CONCLUSIONS

In our matched RALS series, perioperative and postoperative outcomes were similar between obese and non-obese patients undergoing colorectal surgery. RALS is a feasible option in the surgical setting of the obese patient. Further controlled studies are warranted to explore the full benefits.

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

PURPOSE

Robotic surgery (RS) overcomes the limitations of previous conventional laparoscopic surgery (CLS). Although meta-analyses have been published recently, our study evaluated the latest comparative surgical, urologic, and sexual results for rectal cancer and compares RS with CLS in patients with rectal cancer only.

METHODS

We searched three foreign databases (Ovid-MEDLINE, Ovid-Embase, and Cochrane Library) and five Korean databases (KoreaMed, KMbase, KISS, RISS, and KisTi) during July 2013. The Cochrane Risk of Bias and the Methodological Index for Non-Randomized were utilized to evaluate quality of study. Dichotomous variables were pooled using the risk ratio (RR), and continuous variables were pooled using the mean difference (MD). All meta-analyses were conducted with Review Manager, V. 5.3.

RESULTS

Seventeen studies involving 2,224 patients were included. RS was associated with a lower rate of intraoperative conversion than that of CLS (RR, 0.28; 95% confidence interval [CI], 0.15-0.54). Time to first flatus was short (MD, -0.13; 95% CI, -0.25 to -0.01). Operating time was longer for RS than that for CLS (MD, 49.97; 95% CI, 20.43-79.52, I(2) = 97%). International Prostate Symptom Score scores at 3 months better RS than CLS (MD, -2.90; 95% CI, -5.31 to -0.48, I(2) = 0%). International Index of Erectile Function scores showed better improvement at 3 months (MD, -2.82; 95% CI, -4.78 to -0.87, I(2) = 37%) and 6 months (MD, -2.15; 95% CI, -4.08 to -0.22, I(2) = 0%).

CONCLUSION

RS appears to be an effective alternative to CLS with a lower conversion rate to open surgery, a shorter time to first flatus and better recovery in voiding and sexual function. RS could enhance postoperative recovery in patients with rectal cancer.

Robotic colonic resection

Innovative robotic technologies are aiming to help surgeons overcome the limits of conventional laparoscopic surgery. Recent studies have shown that robotic colorectal surgery is safe and provides favorable results in comparison to conventional laparoscopic techniques. Further studies and long-term follow-up are required to assess the outcomes and potential benefits of robotic colon surgery over laparoscopic surgery.

National disparities in minimally invasive surgery for rectal cancer

BACKGROUND

Social and racial disparities have been identified as factors contributing to differences in access to care and oncologic outcomes in patients with colorectal cancer. The aim of this study was to investigate national disparities in minimally invasive surgery (MIS), both laparoscopic and robotic, across different racial, socioeconomic and geographic populations of patients with rectal cancer.

METHODS

We utilized the American College of Surgeons National Cancer Database to identify patients with rectal cancer from 2004 to 2011 who had undergone definitive surgical procedures through either an open, laparoscopic or robotic approach. Inclusion criteria included only one malignancy and no adjuvant therapy. Multivariate analysis was performed to investigate differences in age, gender, race, income, education, insurance coverage, geographic setting and hospital type in relation to the surgical approach.

RESULTS

A total of 8633 patients were identified. The initial surgical approach included 46.5% open (4016), 50.9% laparoscopic (4393) and 2.6% robotic (224). In evaluating type of insurance coverage, patients with private insurance were most likely to undergo laparoscopic surgery [OR (odds ratio) 1.637, 95% CI 1.178-2.275], although there was a less statistically significant association with robotic surgery (OR 2.167, 95% CI 0.663-7.087). Patients who had incomes greater than $46,000 and received treatment at an academic center were more likely to undergo MIS (either laparoscopic or robotic). Race, education and geographic setting were not statistically significant characteristics for surgical approach in patients with rectal cancer.

CONCLUSIONS

Minimally invasive approaches for rectal cancer comprise approximately 53% of surgical procedures in patients not treated with adjuvant therapy. Robotics is associated with patients who have higher incomes and private insurance and undergo surgery in academic centers.

Robotic surgery for rectal cancer can overcome difficulties associated with pelvic anatomy

INTRODUCTION

Total mesorectal excision (TME) for rectal cancer can be challenging to perform in the presence of difficult pelvic anatomy. In our previous studies based on open and laparoscopic TME, we found that pelvic MRI-based pelvimetry could well reflect anatomical difficulty of the pelvis and operative time increased in direct proportion to the difficulty. We explored different outcomes of robotic surgery for TME based on classifications of difficult pelvic anatomies to determine whether this method can overcome these challenges.

METHODS

We reviewed data from 182 patients who underwent robotic surgery for rectal cancer between January 2008 and August 2010. Patient demographics, pathologic outcomes, pelvimetric results, and operative and postoperative outcomes were assessed. The data were compared between easy, moderate, and difficult groups classified by MRI-based pelvimetry.

RESULTS

Comparing the three groups, there was no difference between the groups in terms of operative and pathologic outcomes, including operation time. High BMI, history of preoperative chemoradiotherapy, and lower tumor levels were significantly associated with longer operation time (p < 0.001, p < 0.001, p = 0.009), but the pelvimetric parameter was not.

CONCLUSION

There was no difference between the easy, moderate, and difficult groups in terms of surgical outcomes, such as operation time, for robotic rectal surgery. The robot system can provide more comfort during surgery for the surgeon, and may overcome challenges associated with difficult pelvic anatomy.

Robotic versus laparoscopic total mesorectal excision for rectal cancer: a meta-analysis of eight studies

BACKGROUND

Robotic surgery has been used successfully in many branches of surgery, but there is little evidence in the literature on its use in rectal cancer (RC). We conducted this meta-analysis of randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) to evaluate whether the safety and efficacy of robotic total mesorectal excision (RTME) in patients with RC are equivalent to those of laparoscopic TME (LTME).

METHODS

Pubmed, Embase, Cochrane Library, Ovid, and Web of Science databases were searched. Studies clearly documenting a comparison of RTME with LTME for RC were selected. Operative and recovery outcomes, early postoperative morbidity, and oncological parameters were evaluated.

RESULTS

Eight studies were identified that included 1229 patients in total, 554 (45.08 %) in the RTME group and 675 (54.92 %) in the LTME group. Compared with LTME, RTME was associated with lower conversion rate (OR 0.23, 95 % CI [0.10, 0.52]; P = 0.0004), lower positive rate of circumferential resection margins (CRM) (2.74 % vs 5.78 %, OR 0.44, 95 % CI [0.20, 0.96], P = 0.04), and lesser incidence of erectile dysfunction (ED) (OR 0.09, 95 % CI [0.02, 0.41]; P = 0.002). Operation time, estimated blood loss, recovery outcome, postoperative morbidity and mortality, length of hospital stay, number of lymph nodes harvested, distal resection margin (DRM), proximal resection margin (PRM), and local recurrence had no significant differences between the two groups.

CONCLUSIONS

RTME is safe and feasible and may be an alternative treatment for RC. More international multicenter prospective large sample RCTs investigating the long-term oncological and functional outcomes are needed to determine the advantages of RTME over LTME in RC.

Robotic surgery is ready for prime time in India: Against the motion

The use of Robotic Surgery as a purported adjunct and aid to Minimal Access Surgery (MAS) is growing in several areas. The acknowledged advantages as also the obvious and hidden disadvantages of Robotic Surgery are highlighted. Survey of literature shows that while Robotic Surgery is “feasible” and the results are “comparable” there is no convincing evidence that it is any better than MAS or even open surgery in most areas. To move “Robotic Surgery is ready for prime time in India” with no less than two dozen robots, many sub-optimally utilized for a population of 1.2 billion seems untenable.

Laparoscopic versus Robotic-assisted Rectal Surgery: A Comparison of Postoperative Outcomes

Rectal surgery continues to be an area of advancement for minimally invasive techniques. However, there is controversy regarding whether a robotic approach imparts any advantages over established laparoscopic procedures. The aim of this study was to analyze and compare outcomes of laparoscopic and robotic rectal resection operations. A single-institution retrospective review was performed identifying 83 consecutive patients undergoing low rectal resection requiring proximal diversion between 2009 and 2013. The cohort was comprised of 38 laparoscopic and 45 robotic cases. Data were analyzed for postoperative outcomes as well as 30-day morbidity and mortality. Male gender frequency, body mass index, and American Society of Anesthesiologists class were higher in the robotic group (71%, 28.6 kg/m2, and 2.6, respectively) compared with the laparoscopic group (42%, 23.7 kg/m2, and 2.2, respectively; P < 0.01). Length of stay was significantly longer for patients undergoing laparoscopic (7.5 days) compared with robotic procedures (5.7 days, P < 0.01). This difference was even greater when comparing patients who underwent a hybrid laparoscopic-assisted open total mesorectal excision (TME) with robotic TME (8.2 vs 5.7 days, respectively, P < 0.01). Conversion rate was 7.9 per cent for the laparoscopic group and zero per cent for the robotic ( P = 0.09). There were no mortalities in either group. A pure laparoscopic or robotic rectal surgery may be associated with a shorter hospital stay compared with a laparoscopic-assisted approach.

The safety and effectiveness of Da Vinci surgical system compared with open surgery and laparoscopic surgery: a rapid assessment

OBJECTIVE

The primary objectives of this rapid assessment were to assess the clinical evidence of Da Vinci surgical system (DVSS) comparing with open procedures and laparoscopic procedures, and in order to provide the evidence for health decision makers and clinician.

METHODS

A comprehensive search of electronic databases (EMbase, PubMed, The Cochrane Library, Web of Science, CNKI, VIP, CBM and Wanfang) and HTA websites were completed up to 9 October, 2013. Two reviews (Jiajie Yu and Yingqiang Wang) independently extracted data of the manuscripts, and assessed quality of included studies using AMSTAR tools. Qualitative description and GRADE were used to report the outcomes and evidence quality.

OUTCOMES

A total of 17 studies were included: 3 were HTA and 14 were SR/meta-analysis. The included studies focused on prostatectomy, nephrectomy, hysterectomy colorectal surgery, and cardiac surgery. DVSS was shown to be associated with statistically significant reduction in length of hospital stay, blood loss, and transfusion rate compared with open and laparoscopic surgery, but increase in operative time when compared with open surgery.

CONCLUSION

Based on the evidence included in this rapid assessment, DVSS has a limited impact on several clinical outcomes. Considering no available data from randomized controlled trials and much higher cost, decisions will be complex and need to be made carefully. Decision makers should cut down the quantity of purchasing and reasonable allocate them.

Outcomes of robotic-assisted colorectal surgery compared with laparoscopic and open surgery: a systematic review

BACKGROUND

Robotic technology has been applied to colorectal surgery over the last decade. The aim of this review is to analyze the outcomes of robotic colorectal surgery systematically and to provide objective information to surgeons.

METHODS

Studies were searched and identified using PubMed and Google Scholar from Jan 2001 to Feb 2013 with the search terms "robot," "robotic," "colon," "rectum," "colorectal," and "colectomy." Appropriate data in the studies about the outcomes of robotic colorectal surgery were analyzed.

RESULTS

Sixty-nine publications were included in this review and composed of 39 case series, 29 comparative studies, and 1 randomized controlled trial. Most of the studies reported that robotic surgery showed a longer operation time, less estimated blood loss, shorter length of hospital stay, lower complication and conversion rates, and comparable oncologic outcomes compared to laparoscopic or open surgery.

CONCLUSION

Robotic colorectal surgery is a safe and feasible option. Robotic surgery showed comparable short-term outcomes compared to laparoscopic surgery or open surgery. However, the long operation time and high cost are the limitations of robotic surgery.

Evolving treatment strategies for colorectal cancer: A critical review of current therapeutic options

Management of rectal cancer has markedly evolved over the last two decades. New technologies of staging have allowed a more precise definition of tumor extension. Refinements in surgical concepts and techniques have resulted in higher rates of sphincter preservation and better functional outcome for patients with this malignancy. Although, preoperative chemoradiotherapy followed by total mesorectal excision has become the standard of care for locally advanced tumors, many controversial matters in management of rectal cancer still need to be defined. These include the feasibility of a non-surgical approach after a favorable response to neoadjuvant therapy, the ideal margins of surgical resection for sphincter preservation and the adequacy of minimally invasive techniques of tumor resection. In this article, after an extensive search in PubMed and Embase databases, we critically review the current strategies and the most debatable matters in treatment of rectal cancer.

Robotic versus laparoscopic total mesorectal excision for rectal cancer: a meta-analysis

BACKGROUND

Robotic surgery has been used successfully in many branches of surgery; but there is little evidence in the literature on its use in rectal cancer (RC). We conducted this meta-analysis that included randomized controlled trials and nonrandomized controlled trials of robotic total mesorectal excision (RTME) versus laparoscopic total mesorectal excision (LTME) to evaluate whether the safety and efficacy of RTME in patients with RC are equivalent to those of LTME.

MATERIALS AND METHODS

Pubmed, Embase, Cochrane Library, Ovid, and Web of Science databases were searched. Studies clearly documenting a comparison of RTME with LTME for RC were selected. Operative and recovery outcomes, early postoperative morbidity, and oncological parameters were evaluated.

RESULTS

Eight studies were identified that included 1229 patients in total, 554 (45.08%) in the RTME and 675 (54.92%) in the LTME. Meta-analysis suggested that the conversion rate to open surgery in RTME was significantly lower than in LTME (P = 0.0004). There were no significant differences in operation time, estimated blood loss, recovery outcome, postoperative morbidity and mortality, length of hospital stay, and the oncological accuracy of resection and local recurrence between the two groups. The positive rate of circumferential resection margins (P = 0.04) and the incidence of erectile dysfunction (P = 0.002) were lower in RTME compared with LTME.

CONCLUSIONS

RTME for RC is safe and feasible, and the short- and medium-term oncological and functional outcomes are equivalent or preferable to LTME. It may be an alternative treatment for RC. More multicenter randomized controlled trials investigating the long-term oncological and functional outcomes are required to determine the advantages of RTME over LTME in RC.

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

Rectal cancer is one of the common cancers in India. Surgical management is the mainstay of initial treatment for majority of patients. Minimally invasive surgery has gained acceptance for the surgical treatment of rectal cancer because, compared with laparotomy, it is associated with fewer complications, shorter hospitalization, and faster recovery. The aim of this study is to evaluate the safety, feasibility, technique, and outcomes (postoperative, oncological, and functional) of robotic-assisted rectal surgery in comparison with open surgery in the Indian population. A prospective randomized study was undertaken from August 2011 to December 2012. Fifty patients who presented with rectal carcinoma were randomized to either robotic arm (RA) or open arm (OA) group. Both groups were matched for clinical stage and operation type. Technique and feasibility of robotic-assisted surgery in terms of operating time, estimated blood loss, margins status, total number of lymph nodes retrieved, hospital stay, conversion to open procedure, complications, and functional outcomes were analyzed. The mean operative time was significantly longer in the RA than in the OA group (310 vs 246 min, P < 0.001) but was significantly reduced in the latter part of the robotic-assisted patients compared with the initial patients. The mean estimated blood loss was significantly less in the RA compared with the OA group (165.14 vs 406.04 ml, P < 0.001). None of the patients had margin positivity. The mean distal resection margin was significantly longer in the RA than in the OA group (3.6 vs 2.4 cm, P < 0.001). A total of 100 % of patients in the RA group had complete mesorectal excision while two patients in the OA group had incomplete mesorectal excision. The average number of retrieved lymph nodes was adequate for accurate staging. The number of lymph nodes removed by robotic method is slightly higher than the open method (16.88 vs 15.20) but with no statistical significance. Conversion rate was nil. The mean hospital stay was significantly shorter in the RA group (7.52 vs 13.24 days, P < 0.001). Postoperative and functional outcomes were comparable between the two groups. Robotic-assisted surgery is an emerging technique in our country. Robotic-assisted rectal cancer surgery is safe with low conversion rates and acceptable morbidity and is oncologically feasible.

Robotic versus laparoscopic coloanal anastomosis with or without intersphincteric resection for rectal cancer

Robotic surgery is increasingly used in the field of rectal cancer surgery. This study aimed to compare the short- and long-term outcomes between robotic and laparoscopic ultralow anterior resection (uLAR) and coloanal anastomosis (CAA). Between January 2007 and December 2010, a retrospective chart review was performed for all patients with low rectal cancer who underwent curative uLAR and CAA with or without intersphincteric resection using either a robotic or a laparoscopic approach. The study excluded patients with tumors invading the levator ani or external sphincter, patients with T4 cancers invading the prostate or vagina, and patients for whom an open approach was used. Patients' short- and long-term outcomes were evaluated. This study enrolled 84 consecutive patients (47 in the robotic group and 37 in the laparoscopic group). The patient characteristics and operative data did not differ significantly between the groups except for the rate of conversion to open surgery (robot, 2.1 % vs laparoscopy, 16.2 %; p = 0.02). The postoperative outcomes also were similar in the two groups, but the hospital stay was shorter in the robotic group than in the laparoscopic group (robot, 9 days vs laparoscopy, 11 days; p = 0.011). No postoperative mortality occurred. The median follow-up period was 31.5 months. No difference was shown in local recurrence, 3-year overall survival, or disease-free survival between the two groups. Robotic uLAR and CAA with or without ISR is a safe and feasible surgical approach with a lower conversion rate, a shorter hospital stay, and similar oncologic outcomes compared with a laparoscopic approach. Further prospective and case-control cohort studies with longer follow-up periods are required.