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Rosen SA, Rupji M, Liu Y, Paul Olson TJ. Robotic Proctectomy: Beyond the Initial Learning Curve. Am Surg 2023; 89:5332-5339. [PMID: 36560892 DOI: 10.1177/00031348221146931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Multiple authors have described an initial learning curve (LC) for robotic proctectomy (RP), but there is scant literature regarding continued technical progression beyond this stage. Total operating time is the most commonly used metric to measure proficiency. Our goal was to examine RP experience after the initial LC looking for evidence of further technical progression. METHODS We reviewed our robotic surgery database for a single surgeon during operations 100 through 550 to identify 83 RPs for tumor. These were divided into quartiles by series order, indicating surgeon experience level over time. Demographics and outcomes were compared among the groups. We defined percent console time (PCT) as a new metric. PCT was defined as console time divided by total operative time (TOT). RESULTS From March 2014 through March 2019, 450 robotic colorectal operations were performed, including 83 RPs for polyp or cancer. No significant differences were found among the quartiles in regard to demographics, tumor features, hospital stay, conversions, or readmissions. As experience was gained, there were significant increases in intracorporeal anastomosis (ICA), TOT, and PCT. Complications decreased with experience. Number of lymph nodes in the specimen increased. On multivariate analysis, later experience group, body mass index ≥30, and ICA were associated with increased PCT. DISCUSSION ICA became a routine part of RP after the initial LC, with increases in TOT and PCT. Number of lymph nodes increased and number and severity of complications decreased with experience. Increased PCT may indicate increased expertise during RP.
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Affiliation(s)
- Seth A Rosen
- Department of Surgery, Emory University, Atlanta, GA, USA
| | - Manali Rupji
- Department of Biostatistics, Emory University, Atlanta, GA, USA
| | - Yuan Liu
- Department of Biostatistics, Emory University, Atlanta, GA, USA
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2
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Fleming CA, Harji D, Salut C, Cauvin T, Robert G, Denost Q. Robotic-assisted soft-tissue pelvic exenteration for primary and recurrent pelvic tumours: IDEAL stage 2a evaluation. Br J Surg 2023; 110:923-926. [PMID: 36441181 DOI: 10.1093/bjs/znac422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/05/2022] [Accepted: 11/07/2022] [Indexed: 07/20/2023]
Affiliation(s)
| | - Deena Harji
- Department of Colorectal Surgery, CHU, Bordeaux, France
| | | | - Thomas Cauvin
- Department of Colorectal Surgery, CHU, Bordeaux, France
| | | | - Quentin Denost
- Bordeaux Colorectal Institute, Clinique Tivoli, Bordeaux, France
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3
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Ravendran K, Abiola E, Balagumar K, Raja AZ, Flaih M, Vaja SP, Muhidin AO, Madouros N. A Review of Robotic Surgery in Colorectal Surgery. Cureus 2023; 15:e37337. [PMID: 37182014 PMCID: PMC10169093 DOI: 10.7759/cureus.37337] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2023] [Indexed: 05/16/2023] Open
Abstract
Colorectal surgery is a treatment for colorectal lesions. Technological advancements have given the rise to robotic colorectal surgery, a procedure that limits excessive blood loss via 3D pin-point precision capabilities during surgeries. The aim of this study is to review robotic surgery in colorectal treatment procedures in order to dictate its ultimate merits. This is a literature review utilising PubMed and Google Scholar; it only includes case studies and case reviews related to robotic colorectal surgeries. Literature reviews are excluded. We incorporated abstracts from all articles and full publications were examined to compare the benefits of robotic surgery in colorectal treatments. The number of articles reviewed was 41 literature spanning from 2003 to 2022. We found that robotic surgeries yielded finer marginal resections, greater amounts of lymph node resections and earlier recovery of bowel functions. The patients also spent less time in hospital after surgery. The obstacles on the other hand are it costs longer operative hours and further training, which is expensive. Studies show robotic approach is a choice for treating rectal cancer. However further studies would be needed to conclude the best approach. This is especially true with patients treated for anterior colorectal resections. Based on the evidence it's safe to say that the upsides outweigh the downsides, but advancements and further research in robotic colorectal surgeries are still necessary to reduce operative hours and cost. Surgical societies should also take the initiative and set up effective training programmes for colorectal robotic surgeries, as trained physicians result in better treatment outcomes.
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4
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Sekkat H, Souadka A, Alaoui L, Rafik A, Belkhadir Z, Amrani L, Benkabbou A, Mohsine R, Majbar AM. The learning curve of laparoscopic rectal cancer surgery of millennial surgeons: Lessons for a safe implementation in low- and middle-income countries. J Minim Access Surg 2023; 19:296-304. [PMID: 37056092 PMCID: PMC10246625 DOI: 10.4103/jmas.jmas_78_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 05/12/2022] [Accepted: 07/11/2022] [Indexed: 03/19/2023] Open
Abstract
Objective This study aimed to analyse the learning curve (LC) in laparoscopic rectal cancer resections of 2 millennial surgeons during the implementation of the first laparoscopic rectal cancer surgery programme in low- and middle-income country (LMIC) cancer centre. Methods All consecutive patients operated by two millennial surgeons for primary rectal adenocarcinoma between January 2018 and March 2020 were included. The LC was analysed for operative duration and conversion to open surgery using both cumulative sum (CUSUM) and/or variable life-adjusted display (VLAD) charts. Results Eighty-four patients were included, 45 (53.6%) men with a mean age of 57.3 years. Abdominoperineal resection was performed in 31 (36.9%) cases and resections were extended to other organs in 20 (23.8%) patients. Thirteen patients (15.5%) had conversion to open surgery. Using CUSUM, Learning curve based on conversion was completed at 12 cases for the first surgeon versus 10 cases for the second. While using VLAD and learning curve-CUSUM (LC-CUSUM), the cases needed were 26 vs 24 respectively. The median operative duration was 314 min with a LC completed at cases (17 vs. 26), and (18 vs. 29) using, respectively, standard and LC-CUSUM. Conclusions This study shows a safe and short LC of millennial surgeons during the implementation of a laparoscopic rectal cancer surgery in an LMIC cancer centre, and the valuable use of modern statistical methods in the prospective assessment of LC safety during surgical training.
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Affiliation(s)
- Hamza Sekkat
- Department of Digestive Surgical Oncology, National Institute of Oncology, IBN Sina University Hospital, Rabat, Morocco
- Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Amine Souadka
- Department of Digestive Surgical Oncology, National Institute of Oncology, IBN Sina University Hospital, Rabat, Morocco
- Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Leila Alaoui
- Department of Statistics, Cancer Research Institute, Fez, Morocco
| | - Ali Rafik
- Department of Digestive Surgical Oncology, National Institute of Oncology, IBN Sina University Hospital, Rabat, Morocco
- Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Zakaria Belkhadir
- Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
- Department of Anesthesiology and Intensive Care, National Institute of Oncology, IBN Sina University Hospital, Rabat, Morocco
| | - Laila Amrani
- Department of Digestive Surgical Oncology, National Institute of Oncology, IBN Sina University Hospital, Rabat, Morocco
- Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Amine Benkabbou
- Department of Digestive Surgical Oncology, National Institute of Oncology, IBN Sina University Hospital, Rabat, Morocco
- Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Raouf Mohsine
- Department of Digestive Surgical Oncology, National Institute of Oncology, IBN Sina University Hospital, Rabat, Morocco
- Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Anass Mohammed Majbar
- Department of Digestive Surgical Oncology, National Institute of Oncology, IBN Sina University Hospital, Rabat, Morocco
- Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
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5
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Flynn J, Larach JT, Kong JCH, Rahme J, Waters PS, Warrier SK, Heriot A. Operative and oncological outcomes after robotic rectal resection compared with laparoscopy: a systematic review and meta-analysis. ANZ J Surg 2023; 93:510-521. [PMID: 36214098 DOI: 10.1111/ans.18075] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 09/15/2022] [Accepted: 09/17/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Most studies comparing robotic and laparoscopic surgery, show little difference in clinical outcomes to justify the expense. We systematically reviewed and pooled evidence from studies comparing robotic and laparoscopic rectal resection. METHOD Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica (EMBASE), and Cochrane databases were searched for studies between 1996 and 2021 comparing clinical outcomes between laparoscopic and robotic rectal surgeries involving total mesorectal excision. Outcome measures included operative times, conversions to open, complications, recurrence and survival rates. RESULTS Fifty eligible studies compared outcomes between robotic and laparoscopic rectal resections; three were randomized trials. Pooled results showed significantly longer operating times for robotic surgery but lower conversion and complications rates, shorter lengths of stay in hospital, better rates of complete mesorectal resection and better three-year overall survival. However, the low number of randomized studies makes most data subject to bias. CONCLUSION Available evidence supports the safety and ongoing use of robotic rectal cancer surgery, while further high-quality evidence is sought to justify the expense.
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Affiliation(s)
- Julie Flynn
- Department of Surgery, Epworth Healthcare, Richmond, Victoria, Australia
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of post graduate studies, University of Melbourne, Parkville, Melbourne, Victoria, Australia
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jose T Larach
- Department of Surgery, Epworth Healthcare, Richmond, Victoria, Australia
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Departamento de Cirugía Digestiva, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Joseph C H Kong
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of post graduate studies, University of Melbourne, Parkville, Melbourne, Victoria, Australia
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jessica Rahme
- Department of Surgery, Epworth Healthcare, Richmond, Victoria, Australia
- General Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Peadar S Waters
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Satish K Warrier
- Department of Surgery, Epworth Healthcare, Richmond, Victoria, Australia
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of post graduate studies, University of Melbourne, Parkville, Melbourne, Victoria, Australia
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Alexander Heriot
- Department of Surgery, Epworth Healthcare, Richmond, Victoria, Australia
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of post graduate studies, University of Melbourne, Parkville, Melbourne, Victoria, Australia
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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6
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Burghgraef TA, Sikkenk DJ, Crolla RMPH, Fahim M, Melenhorst J, Moumni ME, Schelling GVD, Smits AB, Stassen LPS, Verheijen PM, Consten ECJ. Assessing the learning curve of robot-assisted total mesorectal excision: a multicenter study considering procedural safety, pathological safety, and efficiency. Int J Colorectal Dis 2023; 38:9. [PMID: 36630001 PMCID: PMC9834356 DOI: 10.1007/s00384-022-04303-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 01/12/2023]
Abstract
PURPOSE Evidence regarding the learning curve of robot-assisted total mesorectal excision is scarce and of low quality. Case-mix is mostly not taken into account, and learning curves are based on operative time, while preferably clinical outcomes and literature-based limits should be used. Therefore, this study aims to assess the learning curve of robot-assisted total mesorectal excision. METHODS A retrospective study was performed in four Dutch centers. The primary aim was to assess the safety of the individual and institutional learning curves using a RA-CUSUM analysis based on intraoperative complications, major postoperative complications, and compound pathological outcome (positive circumferential margin or incomplete TME specimen). The learning curve for efficiency was assessed using a LC-CUSUM analysis for operative time. Outcomes of patients before and after the learning curve were compared. RESULTS In this study, seven participating surgeons performed robot-assisted total mesorectal excisions in 531 patients. Learning curves for intraoperative complications, postoperative complications, and compound pathological outcome did not exceed predefined literature-based limits. The LC-CUSUM for operative time showed lengths of the learning curve ranging from 12 to 35 cases. Intraoperative, postoperative, and pathological outcomes did not differ between patients operated during and after the learning curve. CONCLUSION The learning curve of robot-assisted total mesorectal excision based on intraoperative complications, postoperative complications, and compound pathological outcome did not exceed predefined limits and is therefore suggested to be safe. Using operative time as a surrogate for efficiency, the learning curve is estimated to be between 12 and 35 procedures.
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Affiliation(s)
- T A Burghgraef
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands.
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands.
| | - D J Sikkenk
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
| | - R M P H Crolla
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - M Fahim
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - J Melenhorst
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - M El Moumni
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | | | - A B Smits
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - L P S Stassen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - P M Verheijen
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
| | - E C J Consten
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
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7
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Vanella S, Bottazzi EC, Farese G, Murano R, Noviello A, Palma T, Godas M, Crafa F. Minimally invasive colorectal surgery learning curve. World J Gastrointest Endosc 2022; 14:731-736. [PMID: 36438877 PMCID: PMC9693684 DOI: 10.4253/wjge.v14.i11.731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/01/2022] [Accepted: 10/31/2022] [Indexed: 11/14/2022] Open
Abstract
The learning curve in minimally invasive colorectal surgery is a constant subject of discussion in the literature. Discordant data likely reflects the varying degrees of each surgeon’s experience in colorectal, laparoscopic or robotic surgery. Several factors are necessary for a successful minimally invasive colorectal surgery training program, including: Compliance with oncological outcomes; dissection along the embryological planes; constant presence of an expert tutor; periodic discussion of the morbidity and mortality rate; and creation of a dedicated, expert team.
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Affiliation(s)
- Serafino Vanella
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Enrico Coppola Bottazzi
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Giancarlo Farese
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Rosa Murano
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Adele Noviello
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Tommaso Palma
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Maria Godas
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Francesco Crafa
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
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8
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Burghgraef TA, Sikkenk DJ, Verheijen PM, Moumni ME, Hompes R, Consten ECJ. The learning curve of laparoscopic, robot-assisted and transanal total mesorectal excisions: a systematic review. Surg Endosc 2022; 36:6337-6360. [PMID: 35697853 PMCID: PMC9402498 DOI: 10.1007/s00464-022-09087-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/29/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The standard treatment of rectal carcinoma is surgical resection according to the total mesorectal excision principle, either by open, laparoscopic, robot-assisted or transanal technique. No clear consensus exists regarding the length of the learning curve for the minimal invasive techniques. This systematic review aims to provide an overview of the current literature regarding the learning curve of minimal invasive TME. METHODS A systematic literature search was performed. PubMed, Embase and Cochrane Library were searched for studies with the primary or secondary aim to assess the learning curve of either laparoscopic, robot-assisted or transanal TME for rectal cancer. The primary outcome was length of the learning curve per minimal invasive technique. Descriptive statistics were used to present results and the MINORS tool was used to assess risk of bias. RESULTS 45 studies, with 7562 patients, were included in this systematic review. Length of the learning curve based on intraoperative complications, postoperative complications, pathological outcomes, or a composite endpoint using a risk-adjusted CUSUM analysis was 50 procedures for the laparoscopic technique, 32-75 procedures for the robot-assisted technique and 36-54 procedures for the transanal technique. Due to the low quality of studies and a high level of heterogeneity a meta-analysis could not be performed. Heterogeneity was caused by patient-related factors, surgeon-related factors and differences in statistical methods. CONCLUSION Current high-quality literature regarding length of the learning curve of minimal invasive TME techniques is scarce. Available literature suggests equal lengths of the learning curves of laparoscopic, robot-assisted and transanal TME. Well-designed studies, using adequate statistical methods are required to properly assess the learning curve, while taking into account patient-related and surgeon-related factors.
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Affiliation(s)
- Thijs A Burghgraef
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands.
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands.
| | - Daan J Sikkenk
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
| | - Paul M Verheijen
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
| | - Mostafa El Moumni
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Roel Hompes
- Department of Surgery, University Medical Center Amsterdam, Location AMC, Amsterdam, the Netherlands
| | - Esther C J Consten
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
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9
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Consensus-led recommendations defining practical principles of achieving optimal surgical outcomes in robotic colorectal surgery in the Asia-Pacific region. J Robot Surg 2022; 17:457-463. [PMID: 35773553 PMCID: PMC10076381 DOI: 10.1007/s11701-022-01439-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 06/12/2022] [Indexed: 10/17/2022]
Abstract
Recent innovations within the field of robotic surgery have particular relevance to colorectal surgery. Although a robotic approach has been associated with satisfactory outcomes, there remains a wide variation in levels of adoption. In particular, this study focuses on patient positioning, docking, and table placement, with the intent of understanding the strength of opinion of colorectal surgeons in the Asia-Pacific region to the practical application of these developments to achieve optimal surgical outcomes. Using a modified Delphi methodology, a steering group of colorectal surgeons with experience in robotic surgery from across the Asia-Pacific region identified 35 consensus statements. An online 4-point Likert scale questionnaire was distributed to surgeons in the Asia-Pacific region using convenience sampling. Respondents were excluded from further analysis if they did not perform colorectal surgery or had no experience in robotic surgery. A total of 140 responses (71.8% response rate) were received between August and October 2021. 22 statements attained a very high degree of agreement (≥ 90%). High agreement (< 90% and ≥ 75%) was achieved in another 12, and one failed to meet the consensus threshold (< 75%). A set of five recommendations were developed based on these results. The high levels of agreement demonstrate recognition amongst colorectal surgeons within the Asia-Pacific region of the potential advantage of recent improvements in robotic surgery technology to further improve surgical outcomes. The recommendations may inform a set of practical principles to help standardise the use of colorectal robotic surgery, which may also be relevant to other surgical fields.
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10
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Huang P, Li S, Li P, Jia B. The Learning Curve of Da Vinci Robot-Assisted Hemicolectomy for Colon Cancer: A Retrospective Study of 76 Cases at a Single Center. Front Surg 2022; 9:897103. [PMID: 35846959 PMCID: PMC9276975 DOI: 10.3389/fsurg.2022.897103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Aims Robotic-assisted right hemicolectomy (RARH) has many benefits in treating colon cancer, but it is a new technology that needs to be evaluated. This study aims to assess the learning curve (LC) of RARH procedures with the complete mesoscopic exception and D3 lymph node dissection for colon carcinoma. Methods A retrospective analysis was performed on a consecutive series of 76 patients who underwent RARH from July 2014 to March 2018. The operation time was evaluated using the cumulative sum (CUSUM) method to analyze the LC. The patients were categorized into two groups based on the LC: Phase I and Phase II. Statistical methods were used to compare clinicopathological data on intraoperative and perioperative outcomes at different stages of the study. Results The peak point of the LC was observed in the 27th case. Using the CUSUM method, we divide the LC into two stages. Stage 1 (initial learning stage): Cases 1–27 and Stage 2 (proficiency phase): Cases 28–76. There were no obvious distinctions between the two patients’ essential characteristics (age, sex, body mass index, clinical stage, and ASA score). The mean operation time of each group is 187.37 ± 45.56 min and 161.1 ± 37.74 min (P = 0.009), respectively. The intraoperative blood loss of each group is 170.4 ± 217.2 ml and 95.7 ± 72.8 ml (P = 0.031), respectively. Conclusion Based on the LC with CUSUM analysis, the data suggest that the learning phase of RARH was achieved after 27 cases. The operation time and the intraoperative blood loss decrease with more cases performed.
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Affiliation(s)
- Pu Huang
- Medical School of Chinese PLA, Beijing, China
- Department of General Surgery, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Sen Li
- Medical School of Chinese PLA, Beijing, China
- Department of General Surgery, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Peng Li
- Department of General Surgery, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Baoqing Jia
- Medical School of Chinese PLA, Beijing, China
- Department of General Surgery, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
- Correspondence: Baoqing Jia
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11
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Di Franco G, Lorenzoni V, Palmeri M, Furbetta N, Guadagni S, Gianardi D, Bianchini M, Pollina LE, Melfi F, Mamone D, Milli C, Di Candio G, Turchetti G, Morelli L. Robot-assisted pancreatoduodenectomy with the da Vinci Xi: can the costs of advanced technology be offset by clinical advantages? A case-matched cost analysis versus open approach. Surg Endosc 2022; 36:4417-4428. [PMID: 34708294 DOI: 10.1007/s00464-021-08793-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 10/17/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Robot-assisted pancreatoduodenectomy (RPD) has shown some advantages over open pancreatoduodenectomy (OPD) but few studies have reported a cost analysis between the two techniques. We conducted a structured cost-analysis comparing pancreatoduodenectomy performed with the use of the da Vinci Xi, and the traditional open approach, and considering healthcare direct costs associated with the intervention and the short-term post-operative course. MATERIALS AND METHODS Twenty RPD and 194 OPD performed between January 2011 and December 2020 by the same operator at our high-volume multidisciplinary center for robot-assisted surgery and for pancreatic surgery, were retrospectively analyzed. Two comparable groups of 20 patients (Xi-RPD-group) and 40 patients (OPD-group) were obtained matching 1:2 the RPD-group with the OPD-group. Perioperative data and overall costs, including overall variable costs (OVCs) and fixed costs, were compared. RESULTS No difference was reported in mean operative time: 428 min for Xi-RPD-group versus 404 min for OPD, p = 0.212. The median overall length of hospital stay was significantly lower in the Xi-RPD-group: 10 days versus 16 days, p = 0.001. In the Xi-RPD-group, consumable costs were significantly higher (€6149.2 versus €1267.4, p < 0.001), while hospital stay costs were significantly lower: €5231.6 versus €8180 (p = 0.001). No significant differences were found in terms of OVCs: €13,483.4 in Xi-RPD-group versus €11,879.8 in OPD-group (p = 0.076). CONCLUSIONS Robot-assisted surgery is more expensive because of higher acquisition and maintenance costs. However, although RPD is associated to higher material costs, the advantages of the robotic system associated to lower hospital stay costs and the absence of difference in terms of personnel costs thanks to the similar operative time with respect to OPD, make the OVCs of the two techniques no longer different. Hence, the higher costs of advanced technology can be partially compensated by clinical advantages, particularly within a high-volume multidisciplinary center for both robot-assisted and pancreatic surgery. These preliminary data need confirmation by further studies.
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Affiliation(s)
- Gregorio Di Franco
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy.,Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | | | - Matteo Palmeri
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy.,Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | - Niccolò Furbetta
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy.,Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | - Simone Guadagni
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy.,Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | - Desirée Gianardi
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy.,Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | - Matteo Bianchini
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy.,Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | | | - Franca Melfi
- Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | - Domenica Mamone
- Pharmaceutical Unit: Medical Device Management, University Hospital of Pisa, Pisa, Italy
| | - Carlo Milli
- Board of Directors, University Hospital of Pisa, Pisa, Italy
| | - Giulio Di Candio
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy.,Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | | | - Luca Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy. .,Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy. .,EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy.
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12
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Baek SJ, Piozzi GN, Kim SH. Optimizing outcomes of colorectal cancer surgery with robotic platforms. Surg Oncol 2022; 43:101786. [DOI: 10.1016/j.suronc.2022.101786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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13
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Ielpo B, Podda M, Burdio F, Sanchez-Velazquez P, Guerrero MA, Nuñez J, Toledano M, Morales-Conde S, Mayol J, Lopez-Cano M, Espín-Basany E, Pellino G. Cost-Effectiveness of Robotic vs. Laparoscopic Surgery for Different Surgical Procedures: Protocol for a Prospective, Multicentric Study (ROBOCOSTES). Front Surg 2022; 9:866041. [PMID: 36227017 PMCID: PMC9549953 DOI: 10.3389/fsurg.2022.866041] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/31/2022] [Indexed: 11/29/2022] Open
Abstract
Background The studies which address the impact of costs of robotic vs. laparoscopic approach on quality of life (cost-effectiveness studies) are scares in general surgery. Methods The Spanish national study on cost-effectiveness differences among robotic and laparoscopic surgery (ROBOCOSTES) is designed as a prospective, multicentre, national, observational study. The aim is to determine in which procedures robotic surgery is more cost-effective than laparoscopic surgery. Several surgical operations and patient populations will be evaluated (distal pancreatectomy, gastrectomy, sleeve gastrectomy, inguinal hernioplasty, rectal resection for cancer, Heller cardiomiotomy and Nissen procedure). Discussion The results of this study will demonstrate which treatment (laparoscopic or robotic) and in which population is more cost-effective. This study will also assess the impact of previous surgical experience on main outcomes.
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Affiliation(s)
- Benedetto Ielpo
- Hepato-Biliary and Pancreatic Surgery Unit, Department of Surgery, Hospital del Mar, Barcelona, Spain
- *Correspondence: Benedetto Ielpo
| | - Mauro Podda
- Department of Surgical Science, Emergency Surgery Unit, University of Cagliari, Cagliari, Italy
| | - Fernando Burdio
- Hepato-Biliary and Pancreatic Surgery Unit, Department of Surgery, Hospital del Mar, Barcelona, Spain
| | | | - Maria-Alejandra Guerrero
- Hepato-Biliary and Pancreatic Surgery Unit, Department of Surgery, Hospital del Mar, Barcelona, Spain
| | - Javier Nuñez
- IVEC (Instituto de Validación de la Eficiencia Clínica), Fundación de Investigación HM Hospitales, Madrid, Spain
| | - Miguel Toledano
- General Surgery Department, University Hospital Rio Hortega, Valladolid, Spain
| | - Salvador Morales-Conde
- Unit of Innovation in Minimally Invasive Surgery, Department of Surgery, University Hospital Virgen del Rocio, University of Seville, Seville, Spain
| | - Julio Mayol
- Department of Surgery, Hospital Clinico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - Manuel Lopez-Cano
- Abdominal Wall Surgery Unit, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona, UAB, Barcelona, Spain
| | - Eloy Espín-Basany
- Colorectal Surgery, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona, UAB, Barcelona, Spain
| | - Gianluca Pellino
- Colorectal Surgery, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona, UAB, Barcelona, Spain
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania “Luigi Vanvitelli”, Naples, Italy
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Robot-Assisted Total Mesorectal Excision Versus Laparoscopic Total Mesorectal Excision: A Retrospective Propensity Score-Matched Cohort Analysis in Experienced Centers. Dis Colon Rectum 2022; 65:218-227. [PMID: 34459449 DOI: 10.1097/dcr.0000000000002031] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The superiority of robot-assisted over laparoscopic total mesorectal excision has not been proven. Most studies do not consider the learning curve while comparing the surgical technique. OBJECTIVE This study aims to compare laparoscopic with robot-assisted total mesorectal excision performed by surgeons who completed the learning curve of the technique. DESIGN This is a multicenter retrospective propensity score-matched analysis. SETTINGS The study was performed in 2 large, dedicated robot-assisted hospitals and 5 large, dedicated laparoscopic hospitals. PATIENTS Patients were included if they underwent a robot-assisted or laparoscopic total mesorectal excision for rectal cancer with curative intent at a dedicated center for the minimally invasive technique between January 1, 2015, and December 31, 2017. INTERVENTIONS We compared robot-assisted with laparoscopic total mesorectal excision. MAIN OUTCOME MEASURES The main outcome was conversion to laparotomy during surgery. Secondary outcomes were postoperative morbidity and positive circumferential resection margin. RESULTS A total of 884 patients were included and, after matching, 315 patients per treatment group remained. Conversion was similar between laparoscopic and robot-assisted total mesorectal excision (4.4% vs 2.5% (p = 0.20)). Positive circumferential resection margin was equal (3.2% vs 4.4% (p = 0.41)). Overall morbidity was comparable as well, although a lower rate of wound infections was observed in the robot-assisted group (5.7% vs 1.9% (p = 0.01)). More primary anastomoses were constructed in the robot-assisted group (50.8% vs 68.3% (p < 0.001)). Finally, more open procedures were performed in dedicated laparoscopic centers, with an overrepresentation of cT4N+ tumors in this group. LIMITATIONS This is a retrospective multicenter cohort; however, propensity score matching was applied to control for confounding by indication. CONCLUSIONS Robot-assisted and laparoscopic total mesorectal excision are equally safe in terms of short-term outcomes. However, with the robot-assisted approach, more primary anastomoses were constructed, and a lower wound infection rate was observed. See Video Abstract at http://links.lww.com/DCR/B677.ESCISIÓN MESORRECTAL TOTAL ASISTIDA POR ROBOT VERSUS ESCISIÓN MESORRECTAL TOTAL LAPAROSCÓPICA: UNA PUNTUACIÓN DE PROPENSIÓN RETROSPECTIVA ANÁLISIS DE COHORTES EMPAREJADAS EN CENTROS EXPERIMENTADOS. ANTECEDENTES No se ha demostrado la superioridad de la escisión mesorrectal total asistida por robot sobre la laparoscópica. La mayoría de los estudios no tienen en cuenta la curva de aprendizaje al comparar la técnica quirúrgica. OBJETIVO Este estudio tiene como objetivo comparar la escisión mesorrectal total laparoscópica con la asistida por robot realizada por cirujanos que completaron la curva de aprendizaje de la técnica. DISEO Este es un análisis multicéntrico retrospectivo emparejado por puntuación de propensión. AJUSTES El estudio se realizó en dos grandes hospitales dedicados asistidos por robots y cinco grandes hospitales laparoscópicos dedicados. PACIENTES Se incluyeron pacientes que se sometieron a escisión mesorrectal total asistida por robot o laparoscópica para cáncer de recto con intención curativa, en un centro dedicado a la técnica mínimamente invasiva entre el 1 de enero de 2015 y el 31 de diciembre de 2017. INTERVENCIONES Comparamos la escisión mesorrectal total asistida por robot con la laparoscópica. PRINCIPALES MEDIDAS DE RESULTADO El principal resultado fue la conversión a laparotomía durante la cirugía. Los resultados secundarios fueron la morbilidad posoperatoria y el margen circunferencial positivo. RESULTADOS Se incluyó a un total de 884 pacientes y, después de emparejar, quedaron 315 pacientes por grupo de tratamiento. La conversión fue similar entre la escisión mesorrectal total laparoscópica y asistida por robot (4,4% frente a 2,5% [p = 0,20]). El margen de resección circunferencial positivo fue igual (3,2% vs 4,4% [p = 0,41]). La morbilidad general también fue comparable, aunque se observó una menor tasa de infecciones de heridas en el grupo asistido por robot (5,7% frente a 1,9% [p = 0,01]). Se construyeron más anastomosis primarias en el grupo asistido por robot (50,8% frente a 68,3% [p < 0,001]). Finalmente, se realizaron procedimientos más abiertos en centros laparoscópicos dedicados, con una sobrerrepresentación de tumores cT4N + en este grupo. LIMITACIONES Ésta es una cohorte multicéntrica retrospectiva; sin embargo, se aplicó el emparejamiento por puntuación de propensión para controlar los factores de confusión por indicación. CONCLUSIONES La escisión mesorrectal total asistida por robot y laparoscópica son igualmente seguras en términos de resultados a corto plazo. Sin embargo, con el abordaje asistido por robot, se construyeron más anastomosis primarias y se observó una menor tasa de infección de la herida. Consulte Video Resumen en http://links.lww.com/DCR/B677. (Traducción-Dr. Gonzalo Hagerman).
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15
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Operative and Survival Outcomes of Robotic-Assisted Surgery for Colorectal Cancer in Elderly and Very Elderly Patients: A Study in a Tertiary Hospital in South Korea. JOURNAL OF ONCOLOGY 2022; 2022:7043380. [PMID: 35140787 PMCID: PMC8818427 DOI: 10.1155/2022/7043380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/02/2021] [Accepted: 01/12/2022] [Indexed: 12/24/2022]
Abstract
Materials and Methods Data of all patients ≥75 years who underwent a robotic-assisted curative resection in Korea University Anam Hospital, Seoul, South Korea, between January 2007 and January 2021 were extracted from a prospectively maintained colorectal cancer database. Patients were subdivided into the three groups according to the age: youngest-old (YO: 75–80 years), middle-old (MO: 81–85), and oldest-old (OO: ≥86 years). Intraoperative findings, postoperative, and oncological outcomes were compared between the groups. Results Seventy-six consecutive patients (female 52.6%) were included; mean age was 80 years (SD 0.33); mean body mass index (BMI), 23.8 20.9 kg/m2 (SD 3.58); mean total operative time, 279 min (SD 80.93); mean blood loss, 186 ml (SD 204.03); mean postoperative length of stay, 14 days (SD 12.03). Major complications were seen in 2.1% of patients. The 30-day mortality rate was 0%. Average number of lymph node harvested was 20.9 (SD 12.33). Postoperative complications were not statistically different between the groups. Mean follow-up time for cancer-specific survival (CSS) was 99.28 months for the YO, 72.11 months for MO, and 31.25 months for OO groups (p = 0.045). The CSS rates at 5 years were 27.0%, 21.0%, and 0%, respectively. Recurrence risk was 10.50 times higher in the OO group than the others (adjusted HR, 95% CI 1.868–59.047, p = 0.008). In the multivariable analysis, TNM stage was not a risk factor for CSS in all groups. The number of the harvested nodes was a protective factor for recurrence (HR of 0.932, 95% CI 0.875–0.992, p = 0.027) and CSS (HR of 0.928, 95% CI 0.861–0.999, p = 0.047) in elderly patients. Conclusion Robotic surgery is highly feasible in elderly and very elderly colorectal cancer patients, providing a favorable operative safety profile and an acceptable cancer-specific survival outcome.
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Katsuno H, Hanai T, Endo T, Morise Z, Uyama I. The double bipolar method for robotic total mesorectal excision in patients with rectal cancer. Surg Today 2022; 52:978-985. [PMID: 35000035 DOI: 10.1007/s00595-021-02418-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 09/28/2021] [Indexed: 11/26/2022]
Abstract
Although meta-analyses and systematic reviews have clarified the benefits of robotic surgery, few studies have focused on robotic rectal surgery (RRS) and the use of Endowrist® instruments. Therefore, we evaluated RRS using the double bipolar method (DBM) and compared its short-term outcomes with those of RRS using the single bipolar method (SBM). This study enrolled 157 consecutive patients and all procedures were performed by the same surgeon and recorded through short video clips. We analyzed the patient demographics and short-term clinical outcomes. Although this observational study has several limitations, the console time for total mesorectal excision using the DBM was significantly shorter than that using the SBM. Although the DBM did not demonstrate a specific learning curve, it was a safe and feasible procedure even for patients with advanced disease. Further studies are needed to evaluate the cost-effectiveness of the DBM.
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Affiliation(s)
- Hidetoshi Katsuno
- Department of Surgery, Okazaki Medical Center, Fujita Health University, Gotanda 1, Harisaki, Okazaki, Aichi, 444-0827, Japan.
| | - Tsunekazu Hanai
- Department of Surgery, School of Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Tomoyoshi Endo
- Department of Surgery, Okazaki Medical Center, Fujita Health University, Gotanda 1, Harisaki, Okazaki, Aichi, 444-0827, Japan
| | - Zenichi Morise
- Department of Surgery, Okazaki Medical Center, Fujita Health University, Gotanda 1, Harisaki, Okazaki, Aichi, 444-0827, Japan
| | - Ichiro Uyama
- Department of Surgery, School of Medicine, Fujita Health University, Toyoake, Aichi, Japan
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Lorenzoni V, Barbieri G, Saia F, Meucci F, Martinelli GL, Cerillo AG, Berti S, Candolfi P, Turchetti G. The cost-effectiveness of transcatheter aortic valve implantation: exploring the Italian National Health System perspective and different patient risk groups. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2021; 22:1349-1363. [PMID: 34019220 PMCID: PMC8558181 DOI: 10.1007/s10198-021-01314-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 04/28/2021] [Indexed: 05/09/2023]
Abstract
OBJECTIVES To assess the cost-effectiveness (CE) of transcatheter aortic valve implantation (TAVI) in Italy, considering patient groups with different surgical risk. METHODS A Markov model with a 1-month cycle length, comprising eight different health states, defined by the New York Heart Association functional classes (NYHA I-IV), with and without stroke plus death, was used to estimate the CE of TAVI for intermediate-, high-risk and inoperable patients considering surgical aortic valve replacement or medical treatment as comparators according to the patient group. The Italian National Health System perspective and 15-year time horizon were considered. In the base-case analysis, effectiveness data were retrieved from published efficacy data and total direct costs (euros) were estimated from national tariffs. A scenario analysis considering a micro-costing approach to estimate procedural costs was also considered. The incremental cost-effectiveness ratio (ICER) was expressed both in terms of costs per life years gained (LYG) and costs per quality adjusted life years (QALY). All outcomes and costs were discounted at 3% per annum. Univariate and probabilistic sensitivity analyses (PSA) were performed to assess robustness of results. RESULTS Over a 15-year time horizon, the higher acquisition costs for TAVI were partially offset in all risk groups because of its effectiveness and safety profile. ICERs were €8338/QALY, €11,209/QALY and €10,133/QALY, respectively, for intermediate-, high-risk and inoperable patients. ICER values were slightly higher in the scenario analysis. PSA suggested consistency of results. CONCLUSIONS TAVI would be considered cost-effective at frequently cited willingness-to-pay thresholds; further studies could clarify the CE of TAVI in real-life scenarios.
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Affiliation(s)
- V Lorenzoni
- Institute of Management, Scuola Superiore Sant'Anna, Pisa, Italy.
| | - G Barbieri
- Edwards Lifesciences Italia S.p.A, Milan, Italy
| | - F Saia
- Cardio-Thoracic-Vascular Department, RCCS University Hospital of Bologna, Policlinico S. Orsola, Bologna, Italy
| | - F Meucci
- Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - G L Martinelli
- Department of Cardiac Surgery, IRCCS MultiMedica Sesto San Giovanni, Milano, Italy
| | - A G Cerillo
- Division of Cardiac Surgery, Careggi University Hospital, Florence, Italy
| | - S Berti
- Fondazione C.N.R Regione Toscana G. Monasterio, Massa, Italy
| | - P Candolfi
- Edwards Lifesciences S.A., Nyon, Switzerland
| | - G Turchetti
- Institute of Management, Scuola Superiore Sant'Anna, Pisa, Italy
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18
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Yu J, Zhang Q, Fan MX, Han XG, Liu B, Tian W. Learning curves of robot-assisted pedicle screw fixations based on the cumulative sum test. World J Clin Cases 2021; 9:10134-10142. [PMID: 34904083 PMCID: PMC8638049 DOI: 10.12998/wjcc.v9.i33.10134] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/29/2021] [Accepted: 09/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In robot-assisted (RA) spine surgery, the relationship between the surgical outcome and the learning curve remains to be evaluated.
AIM To analyze the learning curve of RA pedicle screw fixation (PSF) through fitting the operation time curve based on the cumulative summation method.
METHODS RA PSFs that were initially completed by two surgeons at the Beijing Jishuitan Hospital from July 2016 to March 2019 were analyzed retrospectively. Based on the cumulative sum of the operation time, the learning curves of the two surgeons were drawn and fit to polynomial curves. The learning curve was divided into the early and late stages according to the shape of the fitted curve. The operation time and screw accuracy were compared between the stages.
RESULTS The turning point of the learning curves from Surgeons A and B appeared in the 18th and 17th cases, respectively. The operation time [150 (128, 188) min vs 120 (105, 150) min, P = 0.002] and the screw accuracy (87.50% vs 96.30%, P = 0.026) of RA surgeries performed by Surgeon A were significantly improved after he completed 18 cases. In the case of Surgeon B, the operation time (177.35 ± 28.18 min vs 150.00 ± 34.64 min, P = 0.024) was significantly reduced, and the screw accuracy (91.18% vs 96.15%, P = 0.475) was slightly improved after the surgeon completed 17 RA surgeries.
CONCLUSION After completing 17 to 18 cases of RA PSFs, surgeons can pass the learning phase of RA technology. The operation time is reduced afterward, and the screw accuracy shows a trend of improvement.
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Affiliation(s)
- Jie Yu
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Qi Zhang
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Ming-Xing Fan
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Xiao-Guang Han
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Bo Liu
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Wei Tian
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing 100035, China
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19
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Cengiz TB, Benlice C, Ozgur I, Kaya G, Aytac E, Kalady MF, Steele SR, Liska D, Gorgun E. Cost-conscious robotic restorative proctectomy has similar economic and oncologic outcomes to open restorative proctectomy: Results of a long-term follow-up study. Int J Med Robot 2021; 17:e2331. [PMID: 34514721 DOI: 10.1002/rcs.2331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/19/2021] [Accepted: 09/07/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND In this study, we hypothesised that the direct hospital costs of robotic restorative proctectomy (RP) would be similar to those of open RP when a cost-conscious approach was employed in rectal cancer patients. METHODS We included consecutive patients with rectal cancer who underwent RP between 12/2011 and 10/2014. A cost-conscious approach was employed in robotic surgery. We compared demographics, long-term oncologic outcomes, and direct hospital costs between the open and robotic groups. RESULTS There were 32 robotic and 68 open RP procedures performed. Compared to open RP, the robotic RP group had a longer operative time but less estimated blood loss, intraoperative transfusions, overall short-term morbidity, decreased length of stay. After the initial five robotic cases, overall hospital costs were comparable between the groups (1 ± 0.5 vs. 1 ± 0.4, open and robotic RP, respectively, p = 0.90). CONCLUSION Increasing surgeon experience and a cost-conscious approach may improve the value of care of robotic RP in patients with rectal cancer.
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Affiliation(s)
- Turgut Bora Cengiz
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Cigdem Benlice
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ilker Ozgur
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gizem Kaya
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Erman Aytac
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Matthew F Kalady
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - David Liska
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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20
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Rondelli F, Sanguinetti A, Polistena A, Avenia S, Marcacci C, Ceccarelli G, Bugiantella W, De Rosa M. Robotic Transanal Total Mesorectal Excision (RTaTME): State of the Art. J Pers Med 2021; 11:jpm11060584. [PMID: 34205596 PMCID: PMC8233761 DOI: 10.3390/jpm11060584] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 06/05/2021] [Accepted: 06/15/2021] [Indexed: 12/30/2022] Open
Abstract
Total mesorectal excision (TME) is the gold standard technique for the surgical management of rectal cancer. The transanal approach to the mesorectum was introduced to overcome the technical difficulties related to the distal rectal dissection. Since its inception, interest in transanal mesorectal excision has grown exponentially and it appears that the benefits are maximal in patients with mid-low rectal cancer where anatomical and pathological features represent the greatest challenges. Current evidence demonstrates that this approach is safe and feasible, with oncological and functional outcome comparable to conventional approaches, but with specific complications related to the technique. Robotics might potentially simplify the technical steps of distal rectal dissection, with a shorter learning curve compared to the laparoscopic transanal approach, but with higher costs. The objective of this review is to critically analyze the available literature concerning robotic transanal TME in order to define its role in the management of rectal cancer and to depict future perspectives in this field of research.
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Affiliation(s)
- Fabio Rondelli
- Department of General Surgery and Surgical Specialties, University of Perugia, “S. Maria” Hospital, 05100 Terni, Italy; (F.R.); (A.S.); (S.A.); (C.M.)
| | - Alessandro Sanguinetti
- Department of General Surgery and Surgical Specialties, University of Perugia, “S. Maria” Hospital, 05100 Terni, Italy; (F.R.); (A.S.); (S.A.); (C.M.)
| | - Andrea Polistena
- Department of General and Laparoscopic Surgery–University Hospital, University of Rome, “Umberto I”, 00161 Rome, Italy;
| | - Stefano Avenia
- Department of General Surgery and Surgical Specialties, University of Perugia, “S. Maria” Hospital, 05100 Terni, Italy; (F.R.); (A.S.); (S.A.); (C.M.)
| | - Claudio Marcacci
- Department of General Surgery and Surgical Specialties, University of Perugia, “S. Maria” Hospital, 05100 Terni, Italy; (F.R.); (A.S.); (S.A.); (C.M.)
| | - Graziano Ceccarelli
- Department of General and Robotic Surgery, “San Giovanni Battista” Hospital, USL Umbria 2, 06034 Foligno, Italy; (G.C.); (W.B.)
| | - Walter Bugiantella
- Department of General and Robotic Surgery, “San Giovanni Battista” Hospital, USL Umbria 2, 06034 Foligno, Italy; (G.C.); (W.B.)
| | - Michele De Rosa
- Department of General and Robotic Surgery, “San Giovanni Battista” Hospital, USL Umbria 2, 06034 Foligno, Italy; (G.C.); (W.B.)
- Correspondence:
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21
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Ahmadi N, Mor I, Warner R. Comparison of outcome and costs of robotic and laparoscopic right hemicolectomies. J Robot Surg 2021; 16:429-436. [PMID: 34081291 DOI: 10.1007/s11701-021-01246-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 04/26/2021] [Indexed: 12/22/2022]
Abstract
To compare the outcomes of patients undergoing right hemicolectomy using laparoscopic or robotic approaches and perform a cost analysis. Retrospective review of all patients undergoing elective laparoscopic and robotic right hemicolectomies at a public and private hospital in NSW/QLD from January 2015 to June 2018. Cost analysis was calculated using actual and estimated costs by the local health district. A total of 101 patients were identified. 59 (58%) had Robotic resection, of which 44 (75%) had an intra-corporeal anastomosis. There were no demographic or oncological differences between the two groups. The robotic group had a significantly earlier time to bowels opening (2 vs 4 days, p < 0.001) and shorter length of stay (3 vs 5 days, p < 0.001). The robotic group had a lower rate of ileus (2% vs 14%, p = 0.02) and complications (5% vs 33%, p = 0.006). The mean lymph node harvest was higher in the robotic group (18 vs 14, p = 0.001). The operative time was longer in the robotic group (110 vs 97 min, p = 0.021). The total instrument costs of robotic surgery were A$2565.37 compared with $1507.50 for laparoscopic surgery. The cost of bed days was A$1167.00/day. The average difference in cost of care was calculated as A$1276.13 and A$464.43 less in the robotic with intra-corporeal and extra-corporeal anastomosis, respectively. Patients have significantly faster return to bowel function and shorter length of stay after Robotic vs laparoscopic right hemicolectomy and experience fewer complications. This difference in length of stay may make robotic right hemicolectomies more cost effective.
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Affiliation(s)
- Nima Ahmadi
- Department of Colorectal Surgery, The Tweed Hospital, Powell St, Tweed Heads, NSW, 2485, Australia
| | - Isabella Mor
- Department of Colorectal Surgery, The Tweed Hospital, Powell St, Tweed Heads, NSW, 2485, Australia.,Department of Colorectal Surgery, John Flynn Private Hospital, Tugun, QLD, 4224, Australia
| | - Ross Warner
- Department of Colorectal Surgery, The Tweed Hospital, Powell St, Tweed Heads, NSW, 2485, Australia. .,Department of Colorectal Surgery, John Flynn Private Hospital, Tugun, QLD, 4224, Australia.
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Baek SJ, Piozzi GN, Kim SH. Optimizing outcomes of colorectal cancer surgery with robotic platforms. Surg Oncol 2021; 37:101559. [PMID: 33839441 DOI: 10.1016/j.suronc.2021.101559] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/15/2021] [Accepted: 03/26/2021] [Indexed: 12/11/2022]
Abstract
Advanced robotic technology makes it easier to perform total mesorectal excision procedures in the narrow pelvis for rectal cancer while maintaining the advantages of minimally invasive surgery. Robotic surgery for rectal cancer leads to lower conversion rates and faster recovery of urogenital function than conventional laparoscopic surgery. However, longer operative time and high cost are major weaknesses of robotic surgery. To date, most other short-term surgical outcomes, pathologic outcomes, and long-term oncologic outcomes of robotic surgery have not shown significant advantages over laparoscopic surgery. However, robotic surgery is still a valid and highly anticipated surgical approach for rectal cancer because it greatly reduces the surgeon's workload and learning curve. There are also advantages when robotic techniques are applied to technically demanding procedures such as lateral pelvic lymph node dissection or intersphincteric resection. The introduction of new surgical robot systems, including the da Vinci® SP system, is expected to expand the applications of robotic surgery and provide new advantages.
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Affiliation(s)
- Se-Jin Baek
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Guglielmo Niccolò Piozzi
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Seon-Hahn Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University College of Medicine, Seoul, South Korea.
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Full robotic multivisceral resections: the Modena experience and literature review. Updates Surg 2021; 73:1177-1187. [PMID: 33570711 DOI: 10.1007/s13304-020-00939-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 12/07/2020] [Indexed: 12/29/2022]
Abstract
The robotic platform is becoming a multidisciplinary tool, versatile, and suitable for multiple procedures. Combined multivisceral resections may represent an alternative to sequential procedures with a potential favorable impact on postoperative morbidity, and on the timing of administration of adjuvant chemotherapy. We herein present our initial experience with full robotic multivisceral resections, and a review of the literature available. Between January 2018 and April 2020, 11 patients underwent multivisceral full robotic abdominal surgery: 4 patients presented with two synchronous tumors, 4 with primary cancer associated with a benign condition and 3 cases involved deep infiltrating endometriosis. Surgical teams enrolled were: General Surgery, Urology and Gynecology. A systematic bibliographic research up to April 2020 was conducted in PubMed. 4 colorectal resections combined with partial or radical nephrectomy were performed, as well as 2 right colectomies in combination with right adrenalectomy and gastric banding removal, 2 radical prostatectomies with Nissen Fundoplication and abdominal wall hernia repair, and 3 resections of deep pelvic endometriosis with colorectal involvement. Mean total operative time was 367 min. No intraoperative complication or conversion to open was registered. Overall postoperative complication rate was 18.2%. 26 papers were included in the review (10 case series and 16 case reports) with a total of 156 combined multivisceral robotic procedures recorded. Robotic combined multivisceral resections proved to be safe and feasible when performed in high volume centers by expert surgeons. The heterogeneity of reports does not allow for a standardization of the procedure. Further studies and accumulation of experience are needed.
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Grass F, Merchea A, Mathis KL, Mishra N, Heien H, Sangaralingham LR, Larson DW. Cost drivers of locally advanced rectal cancer treatment-An analysis of a leading healthcare insurer. J Surg Oncol 2021; 123:1023-1029. [PMID: 33497477 DOI: 10.1002/jso.26390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/01/2021] [Accepted: 01/10/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND To evaluate the economic burden of locally advanced rectal cancer (LARC) treatment from a society perspective through analysis of health insurance-derived data of commercially insured and Medicare Advantage (MA) patients. METHODS Retrospective cost analysis of patients undergoing rectal resection within a multimodal (neoadjuvant chemoradiation + adjuvant chemotherapy) treatment strategy between January 1, 2010 and October 31, 2018, using the claims OptumLabs Data Warehouse database. RESULTS In total, 1738 (935 commercial and 803 MA) patients were included. Overall treatment costs totaled $230,881,746 (on average $183 653 ± 82 384 per commercially insured and $73 681 ± 32 917 per MA patient). Cost distribution according to category (commercially insured patients) was: 29.92% related to outpatient care (follow-up visits/diagnostics), radiotherapy: 21.83%, index resection: 20.62%, chemotherapy: 17.44%, surgical inpatient: 6.32%, medical inpatient: 3.28%, emergency room: 0.58%. Relative cost distribution of the index resection itself differed marginally between the three approaches and was 21.49% for open, 19.30% for laparoscopic, and 20.93% for robotic surgery. Relative cost distributions of neoadjuvant, adjuvant, and outpatient treatments remained unchanged, independently of the surgical approach. This representation was similar in MA patients. CONCLUSION Index-surgery related costs were outweighed by costs related to oncological and outpatient workup/follow-up treatments independently of both surgical approach and insurance type.
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Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne, Switzerland
| | - Amit Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nitin Mishra
- Division of Colon and Rectal Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Herbert Heien
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Fiorillo C, Quero G, Menghi R, Cina C, Laterza V, De Sio D, Longo F, Alfieri S. Robotic rectal resection: oncologic outcomes. Updates Surg 2020; 73:1081-1091. [PMID: 33170489 PMCID: PMC8184562 DOI: 10.1007/s13304-020-00911-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 10/26/2020] [Indexed: 11/25/2022]
Abstract
Robotic surgery has progressively gained popularity in the treatment of rectal cancer. However, only a few studies on its oncologic effectiveness are currently present, with contrasting results. The purpose of this study is to report a single surgeon’s experience on robotic rectal resection (RRR) for cancer, focusing on the analysis of oncologic outcomes, both in terms of pathological features and long-term results. One-hundred and twenty-two consecutive patients who underwent RRR for rectal cancer from January 2013 to December 2019 were retrospectively enrolled. Patients’ characteristics and perioperative outcomes were collected. The analyzed oncologic outcomes were pathological features [distal (DM), circumferential margin (CRM) status and quality of mesorectal excision (TME)] and long-term outcomes [overall (OS) and disease-free survival (DFS)]. The mean operative time was 275 (± 60.5) minutes. Conversion rate was 6.6%. Complications occurred in 27 cases (22.1%) and reoperation was needed in 2 patients (1.5%). The median follow-up was 30.5 (5.9–86.1) months. None presented DM positivity. CRM positivity was 2.5% (2 cases) while a complete TME was reached in 94.3% of cases (115 patients). Recurrence rate was 5.7% (2 local, 4 distant and 1 local plus distant tumor relapse). OS and DFS were 90.7% and 83%, respectively. At the multivariate analysis, both CRM positivity and near complete/incomplete TME were recognized as negative prognostic factors for OS and DFS. Under appropriate logistic and operative conditions, robotic surgery for rectal cancer proves to be oncologically effective, with adequate pathological results and long-term outcomes. It also offers acceptable peri-operative outcomes, further confirming the safety and feasibility of the technique.
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Affiliation(s)
- Claudio Fiorillo
- Digestive Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS di Roma, Largo Agostino Gemelli, 8, 00168, Rome, Italy.
| | - Giuseppe Quero
- Digestive Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS di Roma, Largo Agostino Gemelli, 8, 00168, Rome, Italy
- Università Cattolica del Sacro Cuore di Roma, Rome, Italy
| | - Roberta Menghi
- Digestive Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS di Roma, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Caterina Cina
- Digestive Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS di Roma, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Vito Laterza
- Digestive Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS di Roma, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Davide De Sio
- Digestive Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS di Roma, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Fabio Longo
- Digestive Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS di Roma, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Sergio Alfieri
- Digestive Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS di Roma, Largo Agostino Gemelli, 8, 00168, Rome, Italy
- Università Cattolica del Sacro Cuore di Roma, Rome, Italy
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26
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Gómez Ruiz M, Lainez Escribano M, Cagigas Fernández C, Cristobal Poch L, Santarrufina Martínez S. Robotic surgery for colorectal cancer. Ann Gastroenterol Surg 2020; 4:646-651. [PMID: 33319154 PMCID: PMC7726686 DOI: 10.1002/ags3.12401] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/24/2020] [Accepted: 08/27/2020] [Indexed: 12/15/2022] Open
Abstract
Minimally invasive surgery has demonstrated many benefits in general surgery, particularly in colon and rectal procedures. On the other hand, it has some limitations that must be taken into account, especially technical drawback. Robotic surgery has incorporated many improvements to overcome this disadvantage, such as 3D visualization, articulating instruments assisting complex and precise movements. As a result, robotic colorectal surgery shows less intraoperative blood loss, shorter time to oral tolerance and initial flatus (particularly associated with "Enhanced Recovery After Surgery" protocol), less conversion rate to open surgery, shortened hospital stay, and longer distal margins compared to laparoscopic and open surgery. This approach also shows a shorter learning curve. Some studies suggest that it could decrease perioperatively or 30 days after the intervention's mortality, raise overall survival, reduce wound infection, and improve functional results, while others show no significant difference. However, it lengthens surgical time. Otherwise, the studies included do not show statistically significant changes in the number of resected lymph nodes and anastomotic leaks. Economic costs remain one of the major concerns, although to date there are no large-scale studies that have evaluated this aspect from a global point of view. Robotic surgery represents a qualitative leap in surgical instruments and, although there is no strong evidence in favor of the use of robotic surgery over laparoscopic or open surgery, there is enough evidence to support its use in colorectal surgery, with potential advantages for patients.
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Affiliation(s)
- Marcos Gómez Ruiz
- Colorectal Surgery UnitGeneral Surgery DepartmentMarqués de Valdecilla University HospitalSantanderSpain
- Valdecilla Biomedical Research Institute (IDIVAL)SantanderSpain
| | - Mario Lainez Escribano
- Colorectal Surgery UnitGeneral Surgery DepartmentMarqués de Valdecilla University HospitalSantanderSpain
| | - Carmen Cagigas Fernández
- Colorectal Surgery UnitGeneral Surgery DepartmentMarqués de Valdecilla University HospitalSantanderSpain
- Valdecilla Biomedical Research Institute (IDIVAL)SantanderSpain
| | - Lidia Cristobal Poch
- Colorectal Surgery UnitGeneral Surgery DepartmentMarqués de Valdecilla University HospitalSantanderSpain
- Valdecilla Biomedical Research Institute (IDIVAL)SantanderSpain
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Influence of robotics in surgical complication rate in elderly population with rectal cancer. Aging Clin Exp Res 2020; 32:1585-1589. [PMID: 31506905 DOI: 10.1007/s40520-019-01331-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 08/17/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Rectal cancer surgery is a technically complex procedure. Moreover, short-term outcomes show high rate of complications especially in elderly and laparoscopic surgery has not demonstrated to be able to reduce this complication rate. Robotics has several advantages in pelvic surgical procedures, which could have an impact in complication rates in elderly patients. AIMS The aim of our study is to demonstrate whether robotic surgery has any influence on the reduction of complications in the aged population undergoing rectal cancer. METHODS We performed a retrospective analysis of a prospective database of 151 patients who underwent robotic surgery for rectal cancer. We divided our population into three groups: under 65-year-old, between 65- and 80-year-old and above 80-year-old. We recorded complications in each group intra and post procedure. RESULTS The present study included 151 patients (94 males). Of them, 77 patients were under 66 year old, 63 patients were between 66 and 79 year old and 11 patients were 80 year old and above. The analysis showed conversion rates of 10.38%, 13.69%, 27.27%, and the complication rate of 23.4%, 23.8%, and 27.3% in each group. Univariate analysis showed no differences between the three groups. Nevertheless, there were statistical differences from BMI, ASA and neoadjuvant therapy. In multivariant analysis only neoadjuvant therapy was significant. CONCLUSIONS Robotic approach does not decrease complications in elderly population and conversion is similar in these age groups. So we should not rule out robotic surgery in elderly patients, although we must select each case with a multidisciplinary approach.
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28
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Chen Z, Zhu ZL, Wang P, Zeng F. Comparison of clinical efficacy between robotic-laparoscopic excision and traditional laparoscopy for rectal cancer: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e20704. [PMID: 32629643 PMCID: PMC7337608 DOI: 10.1097/md.0000000000020704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 05/15/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUNDS Laparoscopic surgery, robot-assisted surgery and open surgery are the most commonly consumed surgical techniques in daily living. Considering that in recent years, the situation of choosing laparoscopic surgery and robot-assisted surgery to treat rectal cancer in China is prosperous. Meanwhile, researches lacked in the comparison part between the 2, so we will systematically compare the clinical efficacy of robot-assisted resection and traditional laparoscopic resection for rectal cancer. METHODS AND ANALYSIS We will search Clinical research literature published before January 2020 in PubMed, Embase, the Cochrane library, Science Network, Wan Fang database, Chinese national knowledge infrastructure, and Chinese biomedicine that evaluate the correlation of rectal cancer with Leonardo's robot and traditional laparoscopy, from inception to July 2019. Weighted mean difference and odds ratio were used to compare the efficacy of robot-assisted resection versus conventional laparoscopic resection for rectal cancer, and the main indicators are operation time, complication rate, conversion rate, blood loss, and length of stay. RESULTS AND CONCLUSION This study will systematically evaluate the clinical efficacy of robot-assisted resection and traditional laparoscopic resection for rectal cancer, thus providing evidence to the clinical application. The results will be published in a peer-reviewed journal. ETHICS AND DISSEMINATION No ethical approval and participant consent are required, since this study data is based on published literature. The results of the study will be submitted to a peer-reviewed journal.PROSPERO registration number: CRD42020172161.
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29
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Trends of robotic-assisted surgery for thyroid, colorectal, stomach and hepatopancreaticobiliary cancer: 10 year Korea trend investigation. Asian J Surg 2020; 44:199-205. [PMID: 32571714 DOI: 10.1016/j.asjsur.2020.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/05/2020] [Accepted: 05/13/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The current position of robotic surgery in the field of minimally invasive surgery remains ambiguous. We evaluated long-term trends of robotic general surgery and the future direction of its development. METHODS Data on robotic cancer surgeries between 2005 and 2014 were retrospectively collected by volunteer institutions in the Republic of Korea. Spearman's correlation and logistic regression analyses were used to compare robotic and laparoscopic surgery trends in general surgery. RESULTS The odds that robotic surgery was performed instead of laparoscopic surgery significantly decreased in the fields of colorectal, stomach, and hepato-biliary-pancreatic surgery (odds ratio [OR]: 0.95, 95% confidence interval [CI]: 0.93-0.97; OR: 0.90, 95% CI: 0.88-0.92; and OR: 0.71, 95% CI: 0.65-0.78, respectively), except for thyroid surgery (OR: 1.28, 95% CI: 1.25-1.30). Of the total numbers of each procedure, proportions of robotic intersphincteric resections, abdominoperineal resections, and pylorus-preserving surgery performed significantly increased (r = 0.98, P < .001; r = 0.78, P = .01; and r = 0.86, P = .007, respectively). CONCLUSIONS The use of robotic surgery failed to preponderate that of laparoscopic surgery, except for thyroid surgery. Robotic surgery is increasingly preferred for limited fields or complex surgeries, but the use of robotics in simple surgeries has decreased.
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Hosseini S, Rezaei Y, Alizadeh Ghavidel A. Challenges and experience of setting up an aortic service. Asian Cardiovasc Thorac Ann 2020; 29:669-676. [PMID: 32469677 DOI: 10.1177/0218492320930841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Aortic surgery is a complex procedure posing high risks in comparison to other adult cardiac surgeries. Novel surgical approaches including minimally invasive procedures, sutureless aortic valve replacement, and transcatheter aortic valve implantation have been found to be acceptable alternatives to conventional surgeries. In addition, novel endovascular repair techniques and hybrid procedures have been introduced for the management of patients with thoracoabdominal aortic pathologies. However, these modalities are not readily available in every center, and such novel procedures impose a learning curve for surgeons and high costs for affected patients. In this review, we discuss the challenges of setting up an aortic service, having regard to the Iranian experience.
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Affiliation(s)
- Saeid Hosseini
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Yousef Rezaei
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Alizadeh Ghavidel
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Achilli P, Grass F, Larson DW. Robotic surgery for rectal cancer as a platform to build on: review of current evidence. Surg Today 2020; 51:44-51. [PMID: 32367173 DOI: 10.1007/s00595-020-02008-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 03/17/2020] [Indexed: 02/07/2023]
Abstract
Laparoscopy in colorectal surgery reduces the rate of postoperative complications, shortens the length of stay in hospital, and improves the quality of patient care. Despite these established benefits, the technical challenges of rectal resection for cancer have resulted in most operations being performed through open surgery in the USA. Moreover, controversy in the current literature questions the oncologic safety of a laparoscopic approach for rectal cancer. How then can surgeons innovate to overcome the technical challenges while preserving the critical oncological outcomes of high-quality rectal cancer surgery? Robotics may be a platform that allows us to overcome the technical challenges in the pelvis while maintaining both oncological outcomes and the benefits of a minimally invasive technique. Current evidence suggests that the quality of total mesorectal excision, the rates of circumferential margin involvement, and postoperative outcomes are comparable between robotic and laparoscopic surgery. While a robotic approach demonstrates lower conversion rates and reduced surgeon workload, the operative time is longer and initial costs are higher; however, time and future science will determine its true benefits. We review the current state of robotic surgery and its impact on rectal cancer surgery.
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Affiliation(s)
- Pietro Achilli
- Division of Colon and Rectal Surgery, Mayo Clinic Rochester MN, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic Rochester MN, 200 First Street SW, Rochester, MN, 55905, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic Rochester MN, 200 First Street SW, Rochester, MN, 55905, USA
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Rouanet P, Mermoud A, Jarlier M, Bouazza N, Laine A, Mathieu Daudé H. Combined robotic approach and enhanced recovery after surgery pathway for optimization of costs in patients undergoing proctectomy. BJS Open 2020; 4:516-523. [PMID: 32352227 PMCID: PMC7260409 DOI: 10.1002/bjs5.50281] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 02/15/2020] [Indexed: 12/31/2022] Open
Abstract
Background Enhanced recovery after surgery (ERAS) pathways are beneficial in proctocolectomy, but their impact on robotic low rectal proctectomy is not fully investigated. This study assessed the impact of an ERAS pathway on the outcomes and cost of robotic (RTME) versus laparoscopic (LTME) total mesorectal excision. Methods A retrospective review was performed of patients with rectal cancer in a single French tertiary centre for three yearly periods: 2011, LTME; 2015, RTME; and 2018, RTME with ERAS. Patient characteristics, operative and postoperative data, and costs were compared among the groups. Results A total of 220 consecutive proctectomies were analysed (71 LTME, 58 RTME and 91 RTME with ERAS). A prevalence of lower and locally advanced tumours was observed with RTME. The median duration of surgery increased with the introduction of RTME, but became shorter than that for LTME with greater robotic experience (226, 233 and 180 min for 2011, 2015 and 2018 respectively; P < 0·001). The median duration of hospital stay decreased significantly for RTME with ERAS (11, 10 and 8 days respectively; P = 0·011), as did the overall morbidity rate (39, 38 and 16 per cent; P = 0·002). Pathology results, conversion and defunctioning stoma rates remained stable. RTME alone increased the total cost by €2348 compared with LTME. The introduction of ERAS and improved robotic experience decreased costs by €1960, compared with RTME performed in 2015 without ERAS implementation. In patients with no co‐morbidity, costs decreased by €596 for RTME with ERAS versus LTME alone. Conclusion ERAS is associated with cost reductions in patients undergoing robotic proctectomy.
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Affiliation(s)
- P Rouanet
- Surgical Oncological Department, Montpellier, France
| | - A Mermoud
- Financial Department, Montpellier, France
| | - M Jarlier
- Biometrics Unit, Montpellier, France
| | - N Bouazza
- Clinical Research and Innovation Department, Montpellier, France
| | - A Laine
- Health Information Department, Montpellier Cancer Institute, University of Montpellier, Montpellier, France
| | - H Mathieu Daudé
- Health Information Department, Montpellier Cancer Institute, University of Montpellier, Montpellier, France
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Impact of robotic learning curve on histopathology in rectal cancer: A pooled analysis. Surg Oncol 2020; 34:121-125. [PMID: 32891316 DOI: 10.1016/j.suronc.2020.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/10/2020] [Accepted: 04/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND A beneficial impact of robotic proctectomy on circumferential resection margin (CRM) is expected due to the robot's articulating instruments in the pelvis. There are however concerns about a negative impact on the quality of total mesorectal excision (TME) due to the lack of tactile feedback. The aim of this study was to assess whether surgeons' learning curve impacted CRM and TME quality. METHODS In a multicenter study, individual patient data of robotic proctectomy for resectable rectal cancer were pooled. Patients were stratified into two phases of surgeons' learning curve. Cumulative sum (CUSUM) analysis was used to determine the transition from learning phase (LP) to plateau phase (PP), which were compared. CRM was microscopically measured in mm by pathologists. TME quality was classified by pathologists as complete, nearly complete or incomplete. T-test and Chi-squared tests were used to compare continuous and categorical variables, respectively. RESULTS 235 patients underwent robotic proctectomy by five surgeons. 83 LP patients were comparable to 152 PP patients for age (p = 0.20), gender (67.5% vs. 65.1% males; p = 0.72), BMI (p = 0.82), cancer stage (p = 0.36), neoadjuvant chemoradiation (p = 0.13), distance of tumor from anal verge (5.8 ± 4.4 vs. 5.5 ± 3.3; p = 0.56). CRM did not differ (7.7 ± 11.4 mm vs. 8.4 ± 10.3 mm; p = 0.62). The rate of complete TME quality was significantly improved in PP patients as compared to LP patients (73.5% vs. 92.1%; p < 0.001). CONCLUSION While learning had no impact on circumferential resection margins, the quality of TME significantly improved during surgeons' plateau phase as compared to their learning phase.
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Robotic versus laparoscopic surgery for rectal cancer: a comparative cost-effectiveness study. Tech Coloproctol 2020; 24:247-254. [PMID: 32020350 DOI: 10.1007/s10151-020-02151-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/17/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND The differences between the costs of robotic rectal resection and of the laparoscopic approach are still not well known. The aim of this study was to evaluate the cost-effectiveness of robotic versus laparoscopic surgery. METHODS We conducted an observational, comparative, prospective, non-randomized study on patients having laparoscopic and robotic rectal resection between February 2014 and March 2018 at the Sanchinarro University Hospital, Madrid. Outcome parameters included surgical and post-operative costs, quality adjusted life years (QALY) and incremental cost per QALY gained or the incremental cost effectiveness ratio (ICER). The primary endpoint was to compare cost effectiveness in the robotic and laparoscopic surgery groups. A willingness-to-pay of 20,000€ and 30,000€ per QALY was used as a threshold to determine the most cost-effective treatment. RESULTS A total of 81 RRR and 104 LRR were included. The mean operative costs were higher for RRR (4307.09€ versus 3834.58€; p = 0.04), although mean overall costs were similar (7272.03€ for RRR and 6968.63€ for the LLR; p = 0.44). Mean QALYs at 1 year for the RRR group (0.8482) was higher than that associated with LRR (0.6532) (p = 0.018). At a willingness-to-pay threshold of 20,000€ and 30,000€ there was a 95.54% and 97.18% probability, respectively, that RRR was more cost-effective than LRR. CONCLUSIONS Our data regarding the cost-effectiveness of RRR versus LRR shows a benefit for RRR.
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Katsuno H, Hanai T, Masumori K, Koide Y, Ashida K, Matsuoka H, Tajima Y, Endo T, Mizuno M, Cheong Y, Maeda K, Uyama I. Robotic Surgery for Rectal Cancer: Operative Technique and Review of the Literature. JOURNAL OF THE ANUS RECTUM AND COLON 2020; 4:14-24. [PMID: 32002472 PMCID: PMC6989125 DOI: 10.23922/jarc.2019-037] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 11/25/2019] [Indexed: 02/06/2023]
Abstract
The number of patients undergoing robotic surgery for rectal cancer has rapidly increased in Japan, since the government approved the procedure for national insurance coverage in April 2018. Robotic surgery has the potential to overcome some limitations of laparoscopic surgery, especially in the narrow pelvis, providing a three-dimensional view, articulated instruments, and a stable camera platform. Although meta-analyses and randomized controlled trials have failed to demonstrate the superiority of robotic surgery over laparoscopic surgery with respect to the short-term clinical outcomes, the published findings suggest that robotic surgery may be potentially beneficial for patients who are obese, male, or patients undergoing sphincter-preserving surgery for rectal cancer. The safety and feasibility of robotic surgery for lateral lymph node dissection, the standard procedure for locally advanced lower rectal cancer in Japan, have been demonstrated in some retrospective studies. However, additional prospective, randomized trials are required to determine the actual benefits of robotic surgery to ameliorate the urogenital and oncological outcomes. The cost of this approach is a long-standing principal concern. A literature search showed that the cost of robotic surgery for rectal cancer was 1.3-2.5 times higher per patient than that for the laparoscopic approach. We herein describe our surgical technique using a da Vinci Surgical System (S/Si/Xi) with 10 years of experience in performing robotic surgery. We also review current evidence regarding short-term clinical and long-term oncological outcomes, lateral lymph node dissection, and the cost of the procedure.
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Affiliation(s)
- Hidetoshi Katsuno
- Department of Surgery, Fujita Health University, School of Medicine, Toyoake, Japan
| | - Tsunekazu Hanai
- Department of Surgery, Fujita Health University, School of Medicine, Toyoake, Japan
| | - Koji Masumori
- Department of Surgery, Fujita Health University, School of Medicine, Toyoake, Japan
| | - Yoshikazu Koide
- Department of Surgery, Fujita Health University, School of Medicine, Toyoake, Japan
| | - Keigo Ashida
- Department of Surgery, Fujita Health University, School of Medicine, Toyoake, Japan
| | - Hiroshi Matsuoka
- Department of Surgery, Fujita Health University, School of Medicine, Toyoake, Japan
| | - Yosuke Tajima
- Department of Surgery, Fujita Health University, School of Medicine, Toyoake, Japan
| | - Tomoyoshi Endo
- Department of Surgery, Fujita Health University, School of Medicine, Toyoake, Japan
| | - Masahiro Mizuno
- Department of Surgery, Fujita Health University, School of Medicine, Toyoake, Japan
| | - Yeongcheol Cheong
- Department of Surgery, Fujita Health University, School of Medicine, Toyoake, Japan
| | - Kotaro Maeda
- International Medical Center, Fujita Health University Hospital, Toyoake, Japan
| | - Ichiro Uyama
- Department of Surgery, Fujita Health University, School of Medicine, Toyoake, Japan
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Robotic Surgery for Rectal Cancer and Cost-Effectiveness. JOURNAL OF MINIMALLY INVASIVE SURGERY 2019; 22:139-149. [PMID: 35601368 PMCID: PMC8980152 DOI: 10.7602/jmis.2019.22.4.139] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 11/27/2019] [Accepted: 11/28/2019] [Indexed: 02/01/2023]
Abstract
Robotic surgery is considered as one of the advanced treatment modality of minimally invasive surgery for rectal cancer. Robotic rectal surgery has been performed for three decades and its application is gradually expanding along with technology development. It has several technical advantages which include magnified three-dimensional vision, better ergonomics, multiple articulated robotic instruments, and the opportunity to perform remote surgery. The technical benefits of robotic system can help to manipulate more meticulously during technical challenging procedures including total mesorectal excision in narrow pelvis, lateral pelvic node dissection, and intersphincteric resection. It is also reported that robotic rectal surgery have been shown more favorable postoperative functional outcomes. Despite its technical benefits, a majority of studies have been reported that there is rarely clinical or oncologic superiority of robotic surgery for rectal cancer compared to conventional laparoscopic surgery. In addition, robotic rectal surgery showed significantly higher costs than the standard method. Hence, the cost-effectiveness of robotic rectal surgery is still questionable. In order for robotic rectal surgery to further develop in the field of minimally invasive surgery, there should be an obvious cost-effective advantages over laparoscopic surgery, and it is crucial that large-scale prospective randomized trials are required. Positive competition of industries in correlation with technological development may gradually reduce the price of the robotic system, and it will be helpful to increase the cost-effectiveness of robotic rectal surgery.
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37
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A Population-Based Study of 90-Day Hospital Cost and Utilization Associated With Robotic Surgery in Colon and Rectal Cancer. J Surg Res 2019; 245:136-144. [PMID: 31419638 DOI: 10.1016/j.jss.2019.07.052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/27/2019] [Accepted: 07/17/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND The role of robotic surgery in colorectal cancer remains contentious with most data arising from small, single-institution studies. METHODS Stage I-III colorectal cancer resections from 2008 to 2014 were identified in New York State. Propensity score-adjusted negative binomial models were used to compare cost and utilization between robotic, laparoscopic, and open resections. RESULTS A total of 12,218 patients were identified. For colectomy, the robotic-to-open conversion rate was 3%, and the laparoscopic-to-open conversion rate was 13%. For rectal resection, the robotic-to-open conversion rate was 7% and the laparoscopic-to-open conversion rate was 32%. In intention-to-treat analysis, there was no significant difference in cost across the surgical approaches, both in overall and stratified analyses. Both laparoscopic and robotic approaches were associated with decreased 90-d hospital utilization compared with open surgery in intention-to-treat analyses. CONCLUSIONS Robotic and laparoscopic colorectal cancer resections were not associated with a hospital cost benefit after 90 d compared with open but were associated with decreased hospital utilization. Conversion to open resection was common, and efforts should be made to prevent them. Future research should continue to measure how robotic and laparoscopic approaches can add value to the health care system.
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38
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Alsowaina KN, Schlachta CM, Alkhamesi NA. Cost-effectiveness of current approaches in rectal surgery. Ann Med Surg (Lond) 2019; 45:36-39. [PMID: 31360458 PMCID: PMC6639648 DOI: 10.1016/j.amsu.2019.07.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 07/04/2019] [Indexed: 02/07/2023] Open
Abstract
Colorectal cancer is ranked as the fourth malignant cause of mortality. With the tremendous revolution in the modern medical techniques, minimally invasive approaches have been incorporated into rectal surgery. The effectiveness of surgical procedures is usually measured by a combination of qualitative (quality of life) and quantitative (years of life) measures, while the costs should reflect the use of different resources that were involved in delivering the medical care and they are affected by several factors, including length of hospital stay. In this review, we provide an insight into the cost-effectiveness of the different types of rectal surgeries in order to present a systematic approach for future preferences. A comprehensive literature review using Medline (via PUBMED), Embase and Cochrane Central Register of clinical trials (via clinical trial.org) was performed. Minimally invasive rectal surgeries have considerable cost-effective properties that outweigh those of the open techniques in terms of earlier return to bowel function, lower morbidity rates, reduced pain, shorter length of hospital stay and the overall patients’ quality of life although there was no difference in long-term oncological and survival outcomes. The paucity of currently available long-term oncologic, quality of life, and economic outcomes may limit an adequate comparison of robotic surgeries to other surgical techniques. It is therefore recommended to conduct focused studies to help balance the cost/benefit factors along with other technical considerations aimed at reducing the cost of robotic systems with subsequent improvement of their cost-effectiveness. Colorectal cancer is the fourth cause of mortality. Minimally invasive surgery is now considered the standard of care. Cost of minimally invasive surgery is offset by the better outcomes due to less complications and shorter hospital stay. TaTME requires two working teams and two sets of instruments which increases the total cost. Robotic surgery in obese patients demonstrated superior results when it comes to hospital stay and overall complications. Well conducted clinical trials looking at cost effectiveness of new technologies in colorectal surgery are needed.
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Affiliation(s)
- Khalid N Alsowaina
- Canadian Surgical Technologies & Advanced Robotics (CSTAR), London Health Sciences Centre, Canada.,Department of Surgery, Western University, London, Ontario, Canada
| | - Christopher M Schlachta
- Canadian Surgical Technologies & Advanced Robotics (CSTAR), London Health Sciences Centre, Canada.,Department of Surgery, Western University, London, Ontario, Canada
| | - Nawar A Alkhamesi
- Canadian Surgical Technologies & Advanced Robotics (CSTAR), London Health Sciences Centre, Canada.,Department of Surgery, Western University, London, Ontario, Canada
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Guadagni S, Bianchini M, Palmeri M, Moglia A, Berchiolli RN, Morelli L. HALS, EVAR and robot-assisted surgery as minimally invasive approaches for abdominal aneurysm treatment. J Robot Surg 2019; 14:237-238. [PMID: 31243702 DOI: 10.1007/s11701-019-00987-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 06/17/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Simone Guadagni
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Matteo Bianchini
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
| | - Matteo Palmeri
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Andrea Moglia
- EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | | | - Luca Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy.,EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
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40
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Ng KT, Tsia AKV, Chong VYL. Robotic Versus Conventional Laparoscopic Surgery for Colorectal Cancer: A Systematic Review and Meta-Analysis with Trial Sequential Analysis. World J Surg 2019; 43:1146-1161. [PMID: 30610272 DOI: 10.1007/s00268-018-04896-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Minimally invasive surgery has been considered as an alternative to open surgery by surgeons for colorectal cancer. However, the efficacy and safety profiles of robotic and conventional laparoscopic surgery for colorectal cancer remain unclear in the literature. The primary aim of this review was to determine whether robotic-assisted laparoscopic surgery (RAS) has better clinical outcomes for colorectal cancer patients than conventional laparoscopic surgery (CLS). METHODS All randomized clinical trials (RCTs) and observational studies were systematically searched in the databases of CENTRAL, EMBASE and PubMed from their inception until January 2018. Case reports, case series and non-systematic reviews were excluded. RESULTS Seventy-three studies (6 RCTs and 67 observational studies) were eligible (n = 169,236) for inclusion in the data synthesis. In comparison with the CLS arm, RAS cohort was associated with a significant reduction in the incidence of conversion to open surgery (ρ < 0.001, I2 = 65%; REM: OR 0.40; 95% CI 0.30,0.53), all-cause mortality (ρ < 0.001, I2 = 7%; FEM: OR 0.48; 95% CI 0.36,0.64) and wound infection (ρ < 0.001, I2 = 0%; FEM: OR 1.24; 95% CI 1.11,1.39). Patients who received RAS had a significantly shorter duration of hospitalization (ρ < 0.001, I2 = 94%; REM: MD - 0.77; 95% CI 1.12, - 0.41; day), time to oral diet (ρ < 0.001, I2 = 60%; REM: MD - 0.43; 95% CI - 0.64, - 0.21; day) and lesser intraoperative blood loss (ρ = 0.01, I2 = 88%; REM: MD - 18.05; 95% CI - 32.24, - 3.85; ml). However, RAS cohort was noted to require a significant longer duration of operative time (ρ < 0.001, I2 = 93%; REM: MD 38.19; 95% CI 28.78,47.60; min). CONCLUSIONS This meta-analysis suggests that RAS provides better clinical outcomes for colorectal cancer patients as compared to the CLS at the expense of longer duration of operative time. However, the inconclusive trial sequential analysis and an overall low level of evidence in this review warrant future adequately powered RCTs to draw firm conclusion.
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Affiliation(s)
- Ka Ting Ng
- Faculty of Medicine, University of Malaya, Jalan Universiti, 50603, Kuala Lumpur, Malaysia.
| | - Azlan Kok Vui Tsia
- Department of Surgery, International Medical University, Bukit Jalil, 50603, Kuala Lumpur, Malaysia
| | - Vanessa Yu Ling Chong
- Department of Surgery, International Medical University, Bukit Jalil, 50603, Kuala Lumpur, Malaysia
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41
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Quero G, Rosa F, Ricci R, Fiorillo C, Giustiniani MC, Cina C, Menghi R, Doglietto GB, Alfieri S. Open versus minimally invasive surgery for rectal cancer: a single-center cohort study on 237 consecutive patients. Updates Surg 2019; 71:493-504. [PMID: 30868546 DOI: 10.1007/s13304-019-00642-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 03/09/2019] [Indexed: 12/18/2022]
Abstract
Minimally invasive surgery (MIS) is gaining popularity in rectal tumor treatment. However, contrasting data are available regarding its safety and efficacy. Our aim is to compare the open and MIS approaches for rectal cancer treatment. Two-hundred-thirty-seven patients were included: 113 open and 124 MIS rectal resections. After the propensity score matching analysis (PS), the cases were matched into 42 open and 42 MIS. Short- and long-term outcomes, and pathological findings were analyzed before and after PS. A further comparison of the same outcomes and costs was conducted between the laparoscopic and the robotic approaches. As a whole, a sphincter-preserving procedure was more frequently performed in the MIS group (110 vs 75 cases; p < 0.0001). The estimated blood loss during MIS was significantly lower than during open surgery [127 (± 92) vs 242 (± 122) mL; p < 0.0001], with clear advantages for the robotic approach over laparoscopy [113 (± 87) vs 147 (± 93) mL; p 0.01]. Complication rate was comparable between the two groups. A higher rate of CRM positivity was evidenced after open surgery (12.4% vs 1.7%; p 0.004). A higher number of lymph nodes was harvested in the MIS group [12.5 (± 6.4) vs 11 (± 5.6); p 0.04]. After PS, no difference in terms of perioperative outcomes was noted, with the only exception of a higher blood loss in the open approach [242 (± 122) vs 127 (± 92) mL; p < 0.0001]. For the matched cases, no difference in 5-year overall and disease-free survival was evidenced (p 0.50 and 0.88, respectively). Mean costs were higher for robotics as compared to laparoscopy [9812 (±1974)€ vs 9045 (± 1893)€; p 0.02]. MIS could be considered as a treatment option for rectal cancer. The PS study evidenced clear advantages in terms of estimated blood loss over the open surgery. Costs still remain the main limit for robotics.
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Affiliation(s)
- Giuseppe Quero
- Digestive Surgery Unit of the Fondazione Policlinico "A.Gemelli", Catholic University of Sacred Heart, Largo Agostino Gemelli 8, 00166, Rome, Italy.
| | - Fausto Rosa
- Digestive Surgery Unit of the Fondazione Policlinico "A.Gemelli", Catholic University of Sacred Heart, Largo Agostino Gemelli 8, 00166, Rome, Italy
| | - Riccardo Ricci
- Department of Pathology of the Fondazione Policlinico "A.Gemelli", Catholic University of Sacred Heart, Largo Agostino Gemelli 8, 00166, Rome, Italy
| | - Claudio Fiorillo
- Digestive Surgery Unit of the Fondazione Policlinico "A.Gemelli", Catholic University of Sacred Heart, Largo Agostino Gemelli 8, 00166, Rome, Italy
| | - Maria C Giustiniani
- Department of Pathology of the Fondazione Policlinico "A.Gemelli", Catholic University of Sacred Heart, Largo Agostino Gemelli 8, 00166, Rome, Italy
| | - Caterina Cina
- Digestive Surgery Unit of the Fondazione Policlinico "A.Gemelli", Catholic University of Sacred Heart, Largo Agostino Gemelli 8, 00166, Rome, Italy
| | - Roberta Menghi
- Digestive Surgery Unit of the Fondazione Policlinico "A.Gemelli", Catholic University of Sacred Heart, Largo Agostino Gemelli 8, 00166, Rome, Italy
| | - Giovanni B Doglietto
- Digestive Surgery Unit of the Fondazione Policlinico "A.Gemelli", Catholic University of Sacred Heart, Largo Agostino Gemelli 8, 00166, Rome, Italy
| | - Sergio Alfieri
- Digestive Surgery Unit of the Fondazione Policlinico "A.Gemelli", Catholic University of Sacred Heart, Largo Agostino Gemelli 8, 00166, Rome, Italy
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42
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Technical details and preliminary results of a full robotic type II endoleak treatment with the da Vinci Xi. J Robot Surg 2019; 13:505-509. [PMID: 30830571 DOI: 10.1007/s11701-019-00944-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 02/25/2019] [Indexed: 02/05/2023]
Abstract
Type II endoleak (T2E) represents a frequent and often challenging complication of endovascular aneurysm repair (EVAR). Endovascular treatment is the standard and most used strategy, but the recurrence after it remains high, especially due to lumbar arteries (LA) and inferior mesenteric artery (IMA) feeding. While conventional laparoscopy has been considered as an emerging method, robotic surgery is not reported yet for this indication. We herein describe our technique of minimally invasive T2E repair using a full robotic approach with the da Vinci Xi, reporting our preliminary experience with the first two patients who underwent this operation at our Institution. The procedure comprises two phases. The first phase consists of IMA ligation, left colon mobilization and infra-renal exposure of the anterior longitudinal ligament of the column and of the left side of the sac. The second phase entails the posterior aneurysm mobilization and the selective clipping of LA responsible of the T2E, as identified by the pre-operative CT scan. No intra-operative complications occurred and the average length of surgery was 183 min. The average length of hospitalization was 2.5 days. Robotic T2E repair can be considered a safe procedure and the da Vinci Xi, thanks to its increased dexterity and flexibility, allows to easily perform this multi-target operation (IMA and LA). The articulated instruments with motion scaling and tremor filtering facilitate a gently vascular dissection and an easy IMA and LA identification, dissection, and ligation. The TilePro function permits the operator to control from the console, with intra-operative color-Doppler ultrasound, the absence of residual endoleaks.
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43
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Furbetta N, Bianchini M, Palmeri M, Morelli L. New perspectives about the role of robot-assisted surgery for the treatment of endometriosis. J Robot Surg 2019; 13:609-610. [PMID: 30830570 DOI: 10.1007/s11701-019-00947-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 02/25/2019] [Indexed: 02/08/2023]
Affiliation(s)
- Niccolò Furbetta
- Department of Surgery, Translational and new Technologies in Medicine, University of Pisa, Pisa, Italy.
| | - Matteo Bianchini
- Department of Surgery, Translational and new Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Matteo Palmeri
- Department of Surgery, Translational and new Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Luca Morelli
- Department of Surgery, Translational and new Technologies in Medicine, University of Pisa, Pisa, Italy.,EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy
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44
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Bianchini M, Guadagni S, Morelli L. Costs-benefits of robot-assisted colorectal surgery: a different perspective. J Robot Surg 2019; 13:607-608. [PMID: 30805777 DOI: 10.1007/s11701-019-00936-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 02/18/2019] [Indexed: 02/05/2023]
Abstract
The costs of robot-assisted surgery (RAS) still represent a critical issue. Kulaylat et al. reported a propensity-matched study to compare the outcomes of colorectal surgery between a robotic and a laparoscopic group, concluding that RAS was burdened by higher costs. However, authors did not mention what da Vinci system, Si or Xi, they used and this could be crucial, as recently data published by our group on rectal resections showed that the use of the da Vinci Xi and the surgeon's increased experience could improve the results and significantly reduce the costs of RAS.
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Affiliation(s)
- Matteo Bianchini
- General Surgery Unit, Department of Oncology, Transplantation and New Technologies, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
| | - Simone Guadagni
- General Surgery Unit, Department of Oncology, Transplantation and New Technologies, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Luca Morelli
- General Surgery Unit, Department of Oncology, Transplantation and New Technologies, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy.,EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy
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45
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Williams A, Sebastian B, Ben-Tzvi P. Review and Analysis of Search, Extraction, Evacuation, and Medical Field Treatment Robots. J INTELL ROBOT SYST 2019. [DOI: 10.1007/s10846-019-00991-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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46
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Gianardi D, Palmeri M, Morelli L. The use of da Vinci Xi and the increased surgeon's experience could change the perspective over the cost-benefit ratio of robot-assisted surgery. Updates Surg 2018; 71:399-400. [PMID: 30588566 DOI: 10.1007/s13304-018-00617-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 12/13/2018] [Indexed: 02/05/2023]
Affiliation(s)
- Desirée Gianardi
- General Surgery Unit, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
| | - Matteo Palmeri
- General Surgery Unit, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Luca Morelli
- General Surgery Unit, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy.,EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy
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47
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Palmeri M, Di Franco G, Furbetta N, Morelli L. Comment on: 'Money for nothing'. The role of robotic-assisted laparoscopy for the treatment of endometriosis. J Robot Surg 2018; 13:529-530. [PMID: 30536132 DOI: 10.1007/s11701-018-00908-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 12/02/2018] [Indexed: 02/05/2023]
Affiliation(s)
- Matteo Palmeri
- General Surgery, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Pisa, Italy.
| | - Gregorio Di Franco
- General Surgery, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Niccolò Furbetta
- General Surgery, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Luca Morelli
- General Surgery, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Pisa, Italy.,EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy
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48
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Kawai K, Hata K, Tanaka T, Nishikawa T, Otani K, Murono K, Sasaki K, Kaneko M, Emoto S, Nozawa H. Learning Curve of Robotic Rectal Surgery With Lateral Lymph Node Dissection: Cumulative Sum and Multiple Regression Analyses. JOURNAL OF SURGICAL EDUCATION 2018; 75:1598-1605. [PMID: 29907462 DOI: 10.1016/j.jsurg.2018.04.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 04/21/2018] [Accepted: 04/30/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE This study aimed to assess the learning curve of robotic rectal surgery, a procedure that has gained increasing focus in recent years because it is expected that the advanced devices used in this approach provide advantages resulting in a shorter learning curve than that of laparoscopic surgery. However, no studies have assessed the learning curve of robotic rectal surgery, especially when lateral lymph node dissection is required. DESIGN This was a nonrandomized, retrospective study from a single institution. SETTING All consecutive patients who underwent robotic rectal or sigmoid colon surgery by a single surgeon between February 2012 and July 2016 in the University of Tokyo Hospital were enrolled. The learning curve for console time was assessed using a cumulative sum analysis and multiple linear regression analysis. PARTICIPANTS A total of 131 consecutive patients underwent robotic rectal or sigmoid colon surgery performed by a single experienced surgeon. Of these, 41 patients received lateral lymph node dissection. RESULTS A cumulative sum plot for console time demonstrated that the learning period could be divided into 3 phases: Phase I, Cases 1 to 19; Phase II, Cases 20 to 78; and Phase III, Cases 79 to 131. Multiple linear regression analysis indicated that console time decreased significantly from one phase to another (Phase I-II, Δconsole time 83.0 minutes; Phase II-III, Δconsole time 40.1 minutes). Other factors affecting console time included body mass index, operative procedure, and lateral lymph node dissection, but not neoadjuvant therapy (such as chemoradiotherapy) or depth of invasion. Lateral lymph node dissection required an additional 138.4 minutes. CONCLUSIONS Our findings suggest that the first phase of the learning curve consists of the first 19 cases, which seems sufficient to master the manipulation of robotic arms and to understand spatial relationships unique to the robotic procedure.
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Affiliation(s)
- Kazushige Kawai
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Keisuke Hata
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshiaki Tanaka
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takeshi Nishikawa
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kensuke Otani
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Koji Murono
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhito Sasaki
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Manabu Kaneko
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shigenobu Emoto
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroaki Nozawa
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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49
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Andolfi C, Umanskiy K. Appraisal and Current Considerations of Robotics in Colon and Rectal Surgery. J Laparoendosc Adv Surg Tech A 2018; 29:152-158. [PMID: 30325690 DOI: 10.1089/lap.2018.0571] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Robotic technology aims to obviate some of the limitations of conventional laparoscopic surgery, yet the role of robotics in colorectal surgery is still largely undefined and varies with respect to its application in abdominal versus pelvic surgery. METHODS With this review, we aimed to highlight current developments in colorectal robotic surgery. We systematically searched the following databases: PubMed, EMBASE, and Cochrane Library. We critically reviewed the available literature on the use of robotic technology in colon and rectal surgery. RESULTS Robotic colorectal surgery is oncologically safe and has short-term outcomes comparable to conventional laparoscopy, with potential benefits in rectal surgery. It has a shorter learning curve but increased operative times and costs. It offers potential advantages in the resection of rectal cancer, due to lower conversion rates. There is also a trend toward better outcomes in anastomotic leak rates, circumferential margin positivity, and perseveration of autonomic function. CONCLUSION Laparoscopy remains technically challenging and conversion rates are still high. Therefore, most cases of colorectal surgery are still performed open. Robotic surgery aims to overcome the limits of the laparoscopic technique. This new technology has many advantages in terms of articulating instruments, advanced three-dimensional optics, surgeon ergonomics, and improved accessibility to narrow spaces, such as the pelvis. However, further studies are needed to assess long-term results and benefits.
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Affiliation(s)
- Ciro Andolfi
- Department of Surgery, Section of Colon and Rectal Surgery, and Center for Simulation, The University of Chicago Pritzker School of Medicine , Chicago, Illinois
| | - Konstantin Umanskiy
- Department of Surgery, Section of Colon and Rectal Surgery, and Center for Simulation, The University of Chicago Pritzker School of Medicine , Chicago, Illinois
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A systematic review of the learning curve in robotic surgery: range and heterogeneity. Surg Endosc 2018; 33:353-365. [DOI: 10.1007/s00464-018-6473-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 09/20/2018] [Indexed: 12/18/2022]
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