No differences in short-term morbidity and mortality after robot-assisted laparoscopic versus laparoscopic resection for colonic cancer: a case-control study of 263 patients

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

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

Comparison of robotic right colectomy and laparoscopic right colectomy: a systematic review and meta-analysis

BACKGROUND

For right colon surgery, there is an increasing body of literature comparing the safety of robotic right colectomy (RRC) with laparoscopic right colectomy (LRC). The aim of the present systematic review and meta-analysis is to assess the safety and efficacy of RRC versus LRC, including homogeneous subgroup analyses for extracorporeal anastomosis (EA) and intracorporeal anastomosis (IA).

METHODS

PubMed, Web of Science, Embase, and Cochrane Library databases were searched for studies published between January 2000 and January 2022. Length of hospital stay, operation time, rate of conversion to laparotomy, time to first flatus, number of harvested lymph nodes, estimated blood loss, rate of overall complication, ileus, anastomotic leakage, wound infection, and total costs were measured.

RESULTS

Forty-two studies (RRC: 2772 patients; LRC: 12,469 patients) were evaluated. Regardless of the type of anastomosis, RRC showed shorter length of hospital stay, lower rate of conversion to laparotomy, shorter time to first flatus, lower rate of overall complications, and a higher number of harvested lymph nodes compared with LRC, but longer operative time and higher total costs. In the IA subgroup, RRC had a shorter length of hospital stay, longer operative time, and lower rate of conversion to laparotomy compared with LRC, with no difference for the remaining outcomes. In the EA subgroup, RRC had a longer operative time, lower estimated blood loss, lower rate of overall complications, and higher total costs compared with LRC, with the other outcomes being similar.

CONCLUSION

The safety and efficacy of RRC is superior to LRC, especially when an intracorporeal anastomosis is performed. Most included articles were retrospective, offering low-quality evidence and limited conclusions.

Dynamics of Peripheral Blood Immune Cells during the Perioperative Period after Digestive System Resections: A Systematic Analysis of the Literature

An operation in itself is a kind of trauma and may lead to immunosuppression followed by a bounce back. Not many studies exist that describe dynamics of the distribution of peripheral blood (PB) immune cells during the perioperative period. Considering this scarcity, we aggregated the data on the dynamics of immune cells in patients with digestive system resections during the perioperative period and the relationship with short- and long-term prognoses. By the systematic retrieval of documents, we collected perioperative period data on white blood cells (WBC), lymphocytes, neutrophil-lymphocyte ratio (NLR), CD4⁺ T cells, CD8⁺ T cells, helper T cells (Th), B cells, natural killer cells (NK), dendritic cells (DCs), regulatory T cells (Tregs), regulatory B cells (Bregs), and Myeloid derived suppressor cells (MDSC). The frequency and distribution of these immune cells and the relationship with the patient's prognosis were summarized. A total of 1916 patients' data were included. Compared with before surgery, WBC, lymphocytes, CD4⁺ cells, CD8⁺ T cells, MDSC, and NK cells decreased after surgery, and then returned to preoperative levels. After operation DCs increased, then gradually recovered to the preoperative level. No significant changes were found in B cell levels during the perioperative period. Compared with the preoperative time-point, Tregs and Bregs both increased postoperatively. Only high levels of the preoperative and/or postoperative NLR were found to be related to the patient's prognosis. In summary, the surgery itself can cause changes in peripheral blood immune cells, which might change the immunogenicity. Therefore, the immunosuppression caused by the surgical trauma should be minimized. In oncological patients this might even influence long-term results.

Robotic multiquadrant colorectal procedures: A single-center experience and a systematic review of the literature

Purpose

Robotic surgery has been progressively implemented for colorectal procedures but is still limited for multiquadrant abdominal resections. The present study aims to describe our experience in robotic multiquadrant colorectal surgeries and provide a systematic review and meta-analysis of the literature investigating the outcomes of robotic total proctocolectomy (TPC), total colectomy (TC), subtotal colectomy (STC), or completion proctectomy (CP) compared to laparoscopy.

Methods

At our institution 16 consecutive patients underwent a 2- or 3-stage totally robotic total proctocolectomy (TPC) with ileal pouch-anal anastomosis. A systematic review of the literature was performed to select studies on robotic and laparoscopic multiquadrant colorectal procedures. Meta-analyses were used to compare the two approaches.

Results

In our case series, 14/16 patients underwent a 2-stage robotic TPC for ulcerative colitis with a mean operative time of 271.42 (SD:37.95) minutes. No conversion occurred. Two patients developed postoperative complications. The mean hospital stay was 8.28 (SD:1.47) days with no readmissions. Mortality was nil. All patients underwent loop-ileostomy closure, and functional outcomes were satisfactory. The literature appraisal was based on 23 retrospective studies, including 736 robotic and 9,904 laparoscopic multiquadrant surgeries. In the robotic group, 36 patients underwent STC, 371 TC, 166 TPC, and 163 CP. Pooled data analysis showed that robotic TC and STC had a lower conversion rate (OR = 0.17;95% CI, 0.04–0.82; p = 0.03) than laparoscopic TC and STC. The robotic approach was associated with longer operative time for TC and STC (MD = 104.64;95% CI, 18.42–190.87; p = 0.02) and TPC and CP (MD = 38.8;95% CI, 18.7–59.06; p = 0.0002), with no differences for postoperative complications and hospital stay. Reports on urological outcomes, sexual dysfunction, and quality of life were missing.

Conclusions

Our experience and the literature suggest that robotic multiquadrant colorectal surgery is safe and effective, with low morbidity and mortality rates. Nevertheless, the overall level of evidence is low, and functional outcomes of robotic approach remain largely unknown.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022303016.

Influence of steep Trendelenburg position on postoperative complications: a systematic review and meta-analysis

Intraoperative physiologic changes related to the steep Trendelenburg position have been investigated with the widespread adoption of robot-assisted pelvic surgery (RAPS). However, the impact of the steep Trendelenburg position on postoperative complications remains unclear. We conducted a meta-analysis to compare RAPS to laparoscopic/open pelvic surgery with regards to the rates of venous thromboembolism (VTE), cardiac, and cerebrovascular complications. Meta-regression was performed to evaluate the influence of confounding risk factors. Ten randomized controlled trials (RCTs) and 47 non-randomized controlled studies (NRSs), with a total of 380,125 patients, were included. Although RAPS was associated with a decreased risk of VTE and cardiac complications compared to laparoscopic/open pelvic surgery in NRSs [risk ratio (RR), 0.59; 95% CI 0.51–0.72, p < 0.001 and RR 0.93; 95% CI 0.58–1.50, p = 0.78, respectively], these differences were not confirmed in RCTs (RR 0.92; 95% CI 0.52–1.62, p = 0.77 and RR 0.93; 95% CI 0.58–1.50, p = 0.78, respectively). In subgroup analyses of laparoscopic surgery, there was no significant difference in the risk of VTE and cardiac complications in both RCTs and NRSs. In the meta-regression, none of the risk factors were found to be associated with heterogeneity. Furthermore, no significant difference was observed in cerebrovascular complications between RAPS and laparoscopic/open pelvic surgery. Our meta-analysis suggests that the steep Trendelenburg position does not seem to affect postoperative complications and, therefore, can be considered safe with regard to the risk of VTE, cardiac, and cerebrovascular complications. However, proper individualized preventive measures should still be implemented during all surgeries including RAPS to warrant patient safety.

Short-term outcomes in robot-assisted compared to laparoscopic colon cancer resections: a systematic review and meta-analysis

Background

Robot-assisted surgery is increasingly adopted in colorectal surgery. However, evidence for the implementation of robot-assisted surgery for colon cancer is sparse. This study aims to evaluate the short-term outcomes of robot-assisted colon surgery (RCS) for cancer compared to laparoscopic colon surgery (LCS).

Methods

Embase, MEDLINE, and Cochrane Library were searched between January 1, 2005 and October 2, 2020. Randomized clinical trials and observational studies were included. Non-original literature was excluded. Primary endpoints were anastomotic leakage rate, conversion to open surgery, operative time, and length of hospital stay. Secondary endpoints were surgical efficacy and postoperative morbidity. We evaluated risk of bias using RoB2 and ROBINS-I quality assessment tools. We performed a pooled analysis of primary and secondary endpoints. Heterogeneity was assessed by I², and possible causes were explored by sensitivity- and meta-regression analyses. Publication bias was evaluated by Funnel plots and Eggers linear regression test. The level of evidence was assessed by GRADE.

Results

Twenty studies enrolling 13,799 patients (RCS 1740 (12.6%) and LCS 12,059 (87.4%) were included in the meta-analysis that demonstrated RCS was superior regarding: anastomotic leakage (odds ratio (OR) = 0.54, 95% CI [0.32, 0.94]), conversion (OR = 0.31, 95% CI [0.23, 0.41]), overall complication rate (OR = 0.85, 95% CI [0.73, 1.00]) and time to regular diet (MD =  − 0.29, 95% CI [− 0.56, 0.02]). LCS proved to have a shortened operative time compared to RCS (MD = 42.99, 95% CI [28.37, 57.60]). Level of evidence was very low according to GRADE.

Conclusion

RCS showed advantages in colonic cancer surgery regarding surgical efficacy and morbidity compared to LCS despite a predominant inclusion of non-RCT with serious risk of bias assessment and a very low level of evidence.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08782-7.

Robotic Versus Conventional Laparoscopic Surgery for Colorectal Cancer: A Systematic Review and Meta-Analysis with Trial Sequential Analysis

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Background

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

Objectives

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

Design

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

Findings

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

Conclusions

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

Limitations

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

Future work

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

Funding

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

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Robotic versus laparoscopic colorectal surgery

BACKGROUND

Robotic approaches have become increasingly used for colorectal surgery. The aim of this study is to examine the safety and efficacy of robotic colorectal procedures in an adult population.

STUDY DESIGN

A systematic review of articles in both PubMed and Embase comparing laparoscopic and robotic colorectal procedures was performed. Clinical trials and observational studies in an adult population were included. Approaches were evaluated in terms of operative time, length of stay, estimated blood loss, number of lymph nodes harvested, and perioperative complications. Mean net differences and odds ratios were calculated to examine treatment effect of each group.

RESULTS

Two hundred eighteen articles were identified, and 17 met the inclusion criteria, representing 4,342 patients: 920 robotic and 3,422 in the laparoscopic group. Operative time for the robotic approach was 38.849 minutes longer (95% confidence interval: 17.944 to 59.755). The robotic group had lower estimated blood loss (14.17 mL; 95% confidence interval: -27.63 to -1.60), and patients were 1.78 times more likely to be converted to an open procedure (95% confidence interval: 1.24 to 2.55). There was no difference between groups with respect to number of lymph nodes harvested, length of stay, readmission rate, or perioperative complication rate.

CONCLUSIONS

The robotic approach to colorectal surgery is as safe and efficacious as conventional laparoscopic surgery. However, it is associated with longer operative time and an increased rate of conversion to laparotomy. Further prospective randomized controlled trials are warranted to examine the cost-effectiveness of robotic colorectal surgery before it can be adopted as the new standard of care.

How Has the Robot Contributed to Colon Cancer Surgery?

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

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

Objectives

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

Materials and Methods

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

Results

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

Conclusions

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

Robotic versus laparoscopic surgery for colonic disease: a meta-analysis of postoperative variables

INTRODUCTION

An increasing number of studies have been published since the introduction of robotic technology into general surgery. Gastrointestinal surgery is an area of special interest for the robotic surgeon. Colonic surgery can be challenging depending on the disease and the operative approach. We seek to perform a meta-analysis comparing robotic surgery against laparoscopic surgery in this particular field.

MATERIALS AND METHODS

We performed a systematic search of MEDLINE database from January 2001 to July 2013 supplemented by manual searches of bibliographies of key relevant articles. Randomized controlled trials and cohort studies were selected for review and for collection of postoperative data (length of stay, time to first flatus and complications).

RESULTS

After careful review, nine studies were considered for analysis. Non-pooled data showed a slight trend toward laparoscopy with increased number of events without statistical significance. Pooled data demonstrated a statistical significance for return to bowel function in the right and mixed robotic colectomy arm (WSMD -0.33, 95 % CI -0.5, -0.1; p < 0.005 and WSMD -0.26, 95 % CI -0.51, 0.0; p = 0.05). Pooled data of length of stay and complications showed no statistical significance between robotic and laparoscopic colonic surgery.

DISCUSSION

Robotic surgery is a comparable option when dealing with colonic disease, either benign or malignant. No difference in complication rate or length of stay was found when comparing the two. Robotic surgery appears to have an advantage over laparoscopy in regards to return of bowel function when dealing with right colectomies.

A meta-analysis of robotic versus laparoscopic colectomy

BACKGROUND

Robotics, as an innovation of minimally invasive surgical methods, is developing rapidly for colectomy. But there is still no consensus on its comparative merit compared with laparoscopic resections. We conducted this meta-analysis that included randomized controlled trials and nonrandomized controlled trials of robotic colectomy (RC) versus laparoscopic colectomy (LC) to evaluate whether the safety and efficacy of RC are equivalent to those of LC.

METHODS

A search of five databases (PubMed, Embase, Cochrane Library, Ovid, and Web of Science), gray literature, hand searches, reference, and forward citation were performed for studies that compared clinical or oncologic outcomes of LC with RC. Clinical outcomes evaluated were conversion rates, operation times, estimated blood loss, length of hospital stay, and complications. Oncologic outcome evaluated was the number of lymph nodes collected.

RESULTS

A total of 14 studies were identified that included 125,989 patients in total, 4934 in the robotic cohort and 121,055 in the laparoscopic cohort. Meta-analysis suggested that there was a significantly longer hospital stay in the laparoscopic group (mean difference [MD] -0.65; 95% confidence interval [CI] -1.02 to -0.27; P = 0.0008). Robotic surgery was associated with a significantly lower complication rate (odds ratio 0.78; 95% CI 0.72-0.85; P ＜ 0.00001) and a significantly shorter time to recovery of bowel function (MD -0.58; 95% CI -0.96 to -0.20; P = 0.003). There were statistically significant differences in estimated blood loss (MD -19.24; 95% CI -29.38 to -9.09; P = 0.0002) and intraoperative conversion to open (odds ratio 0.56; 95% CI 0.44-0.72; P < 0.00001), but not clinical relevant. There were no significant differences in the number of lymph nodes extracted between the two groups. However, operating time (MD 49.25; 95% CI 36.78-61.72; P < 0.00001) was longer for RC than for LC.

CONCLUSIONS

RC can be performed safely and effectively with the number of lymph nodes extracted similar to LC. In addition, it can provide potential advantages of a shorter hospital stay, a shorter time to recovery of bowel function, and lower occurrence of postoperative complications. These findings seem to support the use of robotics for the minimally invasive surgical management of colectomy. However, RC had longer operating time. Future studies involving RC should focus on minimizing duration of operation.

A Comparative Study of Single-Port Laparoscopic Surgery Versus Robotic-Assisted Laparoscopic Surgery for Rectal Cancer

INTRODUCTION

Conventional laparoscopic surgery is the treatment of choice for many abdominal procedures. To further reduce surgical trauma, new minimal invasive procedures such as single-port laparoscopic surgery (SPLS) and robotic assisted laparoscopic surgery (RALS) have emerged. The aim of this study was to compare the early results of SPLS versus RALS in the treatment of rectal cancer.

METHODS

We performed a retrospective analysis of prospectively collected data on patients who had undergone SPLS (n = 36) or RALS (n = 56) in the period between 2010 and 2012. Operative and short-term oncological outcomes were compared.

RESULTS

The RALS group had fewer patients with low rectal cancer and more patients with mid-rectal tumors (P = .017) and also a higher rate of intraoperative complications (14.3% vs 0%, P = .021). The rate of postoperative complications did not differ (P = .62). There were no differences in circumferential resection margins, distal resection margins, or completeness of the mesorectal fascia. The RALS group had a larger number of median harvested lymph nodes (27 vs 13, P = .001). The SPLS group had fewer late complications (P = .025). There were no locoregional recurrences in either of the groups. There was no difference in median follow-up time between groups (P = .58).

CONCLUSION

Both SPLS and RALS may have a role in rectal surgery. The short-term oncological outcomes were similar, although RALS harvested more lymph nodes than the SPLS procedure. However, SPLS seems to be safer with regard to intraoperative and late postoperative complications.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Laparoscopic approach to gastrointestinal malignancies: Toward the future with caution

After the rapid acceptance of laparoscopy to manage multiple benign diseases arising from gastrointestinal districts, some surgeons started to treat malignancies by the same way. However, if the limits of laparoscopy for benign diseases are mainly represented by technical issues, oncologic outcomes remain the foundation of any procedures to cure malignancies. Cancerous patients represent an important group with peculiar aspects including reduced survival expectancy, worsened quality of life due to surgery itself and adjuvant therapies, and challenging psychological impact. All these issues could, potentially, receive a better management with a laparoscopic surgical approach. In order to confirm such aspects, similarly to testing the newest weapons (surgical or pharmacologic) against cancer, long-term follow-up is always recommendable to assess the real benefits in terms of overall survival, cancer-free survival and quality of life. Furthermore, it seems of crucial importance that surgeons will be correctly trained in specific oncologic principles of surgical oncology as well as in modern miniinvasive technologies. Therefore, laparoscopic treatment of gastrointestinal malignancies requires more caution and deep analysis of published evidences, as compared to those achieved for inflammatory bowel diseases, gastroesophageal reflux disease or diverticular disease. This review tries to examine the evidence available to date for the use of laparoscopy and robotics in malignancies arising from the gastrointestinal district.