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Massias S, Vadhwana B, Arjomandi Rad A, Hollingshead J, Patel V. Feasibility, clinical outcomes, and learning curves of robotic-assisted colorectal cancer surgery in a high-volume district general hospital: a cohort study. Ann Med Surg (Lond) 2024; 86:5744-5749. [PMID: 39359778 PMCID: PMC11444557 DOI: 10.1097/ms9.0000000000002545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Accepted: 08/25/2024] [Indexed: 10/04/2024] Open
Abstract
Introduction Robotic-assisted surgery (RAS) is one of the most influential surgical advances with widespread clinical and health-economic benefits. West Hertfordshire Teaching Hospital NHS Trust was the first in the UK to simultaneously integrate two CMR Surgical Versius robots. This study aims to investigate clinical outcomes of RAS, explore surgeon learning curves and assess the feasibility of implementation within a district general hospital (DGH). Methods A prospective cohort study of 100 consecutive patient data were collected between July 2022 and August 2023, including demographics, operative and clinical variables, and compared with laparoscopic surgery (LS) data from the National Bowel Cancer Audit. Surgeon learning curves were analysed using sequential surgical and console times. Results In the RAS cohort, the median age was 70 (IQR 57-78 years) and 60% were male. Retrieval of a minimum of 12 lymph nodes significantly increased in RAS compared to LS (95% vs. 88%, P=0.05). The negative mesorectal margin rate was similar between RAS and LS (97% vs. 91%, P=0.10), as well as length of stay greater than 5 days (42% vs. 39%, P=0.27). For anterior resections performed by the highest volume surgeon (n=16), surgical time was reduced over 1 year by 35% (304.9-196.9 min), whilst console time increased by 111% (63.0-132.8 min). Conclusions Key quality performance indicators were either unchanged or improved with RAS. There is potential for improved theatre utilisation and cost-savings with increased RAS. This study demonstrates the feasibility and easy integration of robotic platforms into DGHs, offering wider training opportunities for the next generation of surgeons.
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Affiliation(s)
- Samuel Massias
- Department of Surgery, West Hertfordshire Teaching Hospitals NHS Trust, Watford General Hospital
| | - Bhamini Vadhwana
- Department of Surgery, West Hertfordshire Teaching Hospitals NHS Trust, Watford General Hospital
- Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital, London
| | - Arian Arjomandi Rad
- Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford, UK
| | - James Hollingshead
- Department of Surgery, West Hertfordshire Teaching Hospitals NHS Trust, Watford General Hospital
| | - Vanash Patel
- Department of Surgery, West Hertfordshire Teaching Hospitals NHS Trust, Watford General Hospital
- Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital, London
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Xu K, Shen H, Tian Y, Tong W, Li F. Robotic left colectomy and intracorporeal overlap anastomosis for descending-sigmoid cancer with da Vinci Xi® robotic platform-a video vignette. Tech Coloproctol 2024; 28:114. [PMID: 39167100 DOI: 10.1007/s10151-024-02978-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 07/12/2024] [Indexed: 08/23/2024]
Abstract
This video vignette illustrates the application of the da Vinci Xi® robotic platform for robotic left colectomy and intracorporeal overlap anastomosis in a 51-year-old patient diagnosed with sigmoid-descending colon junction cancer. Emphasizing the advantages of robotic surgery in colorectal procedures, the video showcases a complete mesocolic excision, involving steps such as medial-to-lateral dissection, mobilization of the splenic flexure, ligation of the left colic and sigmoid arteries, and resection of an abdominal wall nodule. The presentation highlights the surgical precision and efficiency achieved, including minimal blood loss and no complications, with an operation time of 190 min. The postoperative outcome was favorable, with the patient discharged on the eighth day and subsequent management involving chemotherapy and hyperthermic intraperitoneal chemotherapy (HIPEC) for stage pT4bN1aM1c moderately differentiated adenocarcinoma. This case underscores the enhanced capabilities of robotic platforms in complex colorectal surgeries, particularly in achieving cytoreductive surgery (CRS) and ensuring anastomosis safety with improved R0 resection rates.
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Affiliation(s)
- Kun Xu
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Haode Shen
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Yue Tian
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Weidong Tong
- Department of General Surgery, Shapingba District Chinese Medicine Hospital, Chongqing, 400030, China.
| | - Fan Li
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China.
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Kamara M, Baur K, Langmeyer J, Huebner M, Ramm C, Cleary RK. Early discharge after enhanced recovery rectal resection does not increase emergency department visits and readmissions: a single institution analysis. Surg Endosc 2024; 38:4251-4259. [PMID: 38862825 DOI: 10.1007/s00464-024-10967-9] [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] [Received: 01/20/2024] [Accepted: 05/27/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Same-day discharge after colectomy in enhanced recovery pathways has been shown to be feasible. It is not clear how early patients with rectal resections may be safely discharged. The study aim was to determine if patients discharged ≤ 3 days after rectal resections are associated with increased rates of emergency department (ED) visits and hospital readmissions. METHODS Retrospective analysis of enhanced recovery low anterior resection, abdominoperineal resection, and proctocolectomy patients in a prospectively maintained single institution colorectal surgery database from 01/01/2018 to 07/15/2022. Clinic visits were scheduled within 4-7 days and at 30 days after discharge, and every 1-2 weeks for stoma patients until no longer needed. Logistic regression models were used to analyze the association of discharge on postoperative days (POD)-1-3, POD-4-5, and POD ≥ 6 days with incidence of ED visits and readmissions. RESULTS A total of 118 patients met inclusion criteria, 76 with stomas. Median postoperative length of stay was 5 [IQR 6.5] days. Mean age was 58.6 years; 59.3% were ASA-3; and 69.5% had a minimally invasive surgical approach. ED visits were not significantly different between discharge-day groups (p = 0.096). No patients were discharged same-day, one without a stoma was discharged on POD-1, ten patients (2 with stomas) on POD-2, and twenty-four patients (13 with stomas) on POD-3. ED visits were lowest for the POD-1-3 group (14.3%) but not significantly different than later discharge groups (p = 0.166). Readmission rate was also lowest for the POD-1-3 group (11.4%) and also not significantly different than later discharge groups (p = 0.261) and this was confirmed with logistic regression. Complication rate was lowest in the POD-1-3 group (p < 0.001). CONCLUSION Early discharge after enhanced recovery partial or complete proctectomy is not associated with increased ED visits and readmissions. Follow up studies should identify post-discharge resources that allow safe early discharge and that may be standardized and generalizable.
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Affiliation(s)
- Maseray Kamara
- Department of Surgery, Trinity Health Ann Arbor, Ann Arbor, MI, USA
| | - Katherine Baur
- Department of Surgery, Trinity Health Ann Arbor, Ann Arbor, MI, USA
| | - Jessie Langmeyer
- Department of Surgery, Trinity Health Ann Arbor, Ann Arbor, MI, USA
| | - Marianne Huebner
- Center for Statistical Training and Consulting, Michigan State University, East Lansing, MI, USA
| | - Carole Ramm
- Department of Academic Research, Trinity Health Ann Arbor, Ann Arbor, MI, USA
| | - Robert K Cleary
- Department of Surgery, Trinity Health Ann Arbor, Ann Arbor, MI, USA.
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Willis MA, Toews I, Meerpohl JJ, Kalff JC, Vilz TO. Robot-assisted versus conventional laparoscopic surgery for rectal cancer. Cochrane Database Syst Rev 2024; 7:CD015626. [PMID: 39041375 PMCID: PMC11264320 DOI: 10.1002/14651858.cd015626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
OBJECTIVES This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms of robot-assisted surgery for rectal cancer resection.
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Affiliation(s)
- Maria A Willis
- Department of General, Visceral, Thorax and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Ingrid Toews
- Institute for Evidence in Medicine, Medical Center & Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine, Medical Center & Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Jörg C Kalff
- Department of General, Visceral, Thorax and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Tim O Vilz
- Department of General, Visceral, Thorax and Vascular Surgery, University Hospital Bonn, Bonn, Germany
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Chen ZL, Du QL, Zhu YB, Wang HF. A systematic review and meta-analysis of short-term outcomes comparing the efficacy of robotic versus laparoscopic colorectal surgery in obese patients. J Robot Surg 2024; 18:167. [PMID: 38592362 DOI: 10.1007/s11701-024-01934-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 03/24/2024] [Indexed: 04/10/2024]
Abstract
This meta-analysis was conducted to evaluate and contrast the effectiveness of robotic-assisted and laparoscopic colorectal surgery in the treatment of obese patients. In February 2024, we carried out an exhaustive search of key global databases including PubMed, Embase, and Google Scholar, limiting our focus to studies published in English and Chinese. We excluded reviews, protocols lacking published results, articles derived solely from conference abstracts, and studies not relevant to our research objectives. To analyze categorical variables, we utilized the Cochran-Mantel-Haenszel method along with random-effects models, calculating inverse variances and presenting the outcomes as odds ratios (ORs) along with their 95% confidence intervals (CIs). Statistical significance was determined when p values were less than 0.05. In our final meta-analysis, we included eight cohort studies, encompassing a total of 5,004 patients. When comparing the robotic surgery group to the laparoscopic group, the findings revealed that the robotic group experienced a longer operative time (weighted mean difference (WMD) = 37.53 min, 95% (CI) 15.58-59.47; p = 0.0008), a shorter hospital stay (WMD = -0.68 days, 95% CI -1.25 to -0.10; p = 0.02), and reduced blood loss (WMD = -49.23 mL, 95% CI -64.31 to -34.14; p < 0.00001). No significant differences were observed between the two groups regarding overall complications, conversion rates, surgical site infections, readmission rates, lymph node yield, anastomotic leakage, and intestinal obstruction. The results of our study indicate that robot-assisted colorectal surgery offers benefits for obese patients by shortening the length of hospital stay and minimizing blood loss when compared to laparoscopic surgery. Nonetheless, it is associated with longer operation times and shows no significant difference in terms of overall complications, conversion rates, rehospitalization rates, and other similar metrics.
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Affiliation(s)
- Zhi-Long Chen
- Department of Vascular Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China.
| | - Qiu-Lin Du
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Yan-Bin Zhu
- Department of Vascular Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Hai-Fei Wang
- Department of Vascular Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
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Dohrn N, Burgdorf SK, de Heer P, Klein MF, Jensen KK. The current application and evidence for robotic approach in abdominal surgery: A narrative literature review. Scand J Surg 2024; 113:21-27. [PMID: 38497506 DOI: 10.1177/14574969241232737] [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: 03/19/2024]
Abstract
The current application of robotic surgery is evolving at a high pace in the current years. The technical advantages enable several abdominal surgical procedures to be performed minimally invasive instead of open surgery. Furthermore, procedures previously performed successfully using standard laparoscopy are now performed with a robotic approach, with conflicting results. The present narrative review reports the current literature on the robotic surgical procedures typically performed in a typical Scandinavian surgical department: colorectal, hernia, hepato-biliary, and esophagogastric surgery.
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Affiliation(s)
- Niclas Dohrn
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen, Blegdamsvej 9,2100 København Ø, Denmark
| | | | - Pieter de Heer
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen, Denmark
| | - Mads Falk Klein
- Department of Surgery, Copenhagen University Hospital-Herlev & Gentofte, Herlev, Denmark
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Shafiei SB, Shadpour S, Sasangohar F, Mohler JL, Attwood K, Jing Z. Development of performance and learning rate evaluation models in robot-assisted surgery using electroencephalography and eye-tracking. NPJ SCIENCE OF LEARNING 2024; 9:3. [PMID: 38242909 PMCID: PMC10799032 DOI: 10.1038/s41539-024-00216-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 01/08/2024] [Indexed: 01/21/2024]
Abstract
The existing performance evaluation methods in robot-assisted surgery (RAS) are mainly subjective, costly, and affected by shortcomings such as the inconsistency of results and dependency on the raters' opinions. The aim of this study was to develop models for an objective evaluation of performance and rate of learning RAS skills while practicing surgical simulator tasks. The electroencephalogram (EEG) and eye-tracking data were recorded from 26 subjects while performing Tubes, Suture Sponge, and Dots and Needles tasks. Performance scores were generated by the simulator program. The functional brain networks were extracted using EEG data and coherence analysis. Then these networks, along with community detection analysis, facilitated the extraction of average search information and average temporal flexibility features at 21 Brodmann areas (BA) and four band frequencies. Twelve eye-tracking features were extracted and used to develop linear random intercept models for performance evaluation and multivariate linear regression models for the evaluation of the learning rate. Results showed that subject-wise standardization of features improved the R2 of the models. Average pupil diameter and rate of saccade were associated with performance in the Tubes task (multivariate analysis; p-value = 0.01 and p-value = 0.04, respectively). Entropy of pupil diameter was associated with performance in Dots and Needles task (multivariate analysis; p-value = 0.01). Average temporal flexibility and search information in several BAs and band frequencies were associated with performance and rate of learning. The models may be used to objectify performance and learning rate evaluation in RAS once validated with a broader sample size and tasks.
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Affiliation(s)
- Somayeh B Shafiei
- Intelligent Cancer Care Laboratory, Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14263, USA.
| | - Saeed Shadpour
- Department of Animal Biosciences, University of Guelph, Guelph, Ontario, N1G 2W1, Canada
| | - Farzan Sasangohar
- Department of Industrial and Systems Engineering, Texas A&M University, College Station, TX, 77843, USA
| | - James L Mohler
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14263, USA
| | - Kristopher Attwood
- Department of Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14263, USA
| | - Zhe Jing
- Department of Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14263, USA
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8
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Haas EM, Secchi Del Rio R, Reif de Paula T, Margain Trevino D, Presacco S, Hinojosa-Gonzalez DE, Weaver M, LeFave JP. The robotic NICE procedure outperforms conventional laparoscopic extracorporeal-assisted colorectal resection: results of a matched cohort analysis. Surg Endosc 2024; 38:390-399. [PMID: 37803185 DOI: 10.1007/s00464-023-10452-9] [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] [Received: 04/14/2023] [Accepted: 09/06/2023] [Indexed: 10/08/2023]
Abstract
INTRODUCTION We introduced the robotic NICE procedure for left-sided colorectal resection in 2018 in which the entire procedure is performed without loss of pneumoperitoneum and without an abdominal wall incision by performing natural orifice-assisted transrectal extraction of the specimen and intracorporeal anastomosis. We compare the results of the NICE procedure versus conventional laparoscopic resection, which was our standard approach prior to 2018. METHODS A matched pair case-control study compared patients following the NICE procedure versus those who underwent laparoscopic left-sided colorectal resection with conventional extracorporeal-assisted technique. Cases were performed at an Academic Medical Center and recorded in a prospective database to analyze perioperative outcomes. RESULTS From a total cohort of 352 patients, 83 were matched in each group. When comparing the NICE procedure vs. the Extracorporeal-Assisted laparoscopic group, there were no significant differences in age (58.5 vs. 59.3 years old), sex (47 vs. 42 Female), body mass index (27.4 vs. 27.5 kg/m2), ASA, diagnosis, or type of surgery. Operative time (198.8 vs. 197.7 min), blood loss (56.0 vs. 53.3 ml), intraoperative complications (0.0% vs. 0.0%), and conversion rates (0.0% vs. 0.0%) were similar in both groups. The NICE procedure was associated with significantly earlier return of bowel function (40.7 vs. 23.6 h), shorter length of stay (3.1 vs. 2.2 days), and lower total opioid use (94.6 vs. 70.5 morphine milligram equivalents). Overall, there were no differences in postoperative abscess formation, complications, readmission, or reoperation rates. CONCLUSION When compared to conventional laparoscopic resection, the NICE procedure is associated with short-term benefits including earlier recovery and less opioid use without increased operative time or increased risk of complications. Multicenter studies are recommended to validate benefits and limitations of this technique.
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Affiliation(s)
- Eric M Haas
- Houston Methodist Hospital, Houston, TX, USA.
- HCA Gulf Coast Division, Houston, TX, USA.
- Houston Colon PLLC, Houston, TX, USA.
| | | | | | | | | | | | - Matthew Weaver
- HCA Gulf Coast Division, Houston, TX, USA
- Houston Colon PLLC, Houston, TX, USA
| | - Jean-Paul LeFave
- Houston Methodist Hospital, Houston, TX, USA
- Houston Colon PLLC, Houston, TX, USA
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Shafiei SB, Shadpour S, Intes X, Rahul R, Toussi MS, Shafqat A. Performance and learning rate prediction models development in FLS and RAS surgical tasks using electroencephalogram and eye gaze data and machine learning. Surg Endosc 2023; 37:8447-8463. [PMID: 37730852 PMCID: PMC10615961 DOI: 10.1007/s00464-023-10409-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/14/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVE This study explored the use of electroencephalogram (EEG) and eye gaze features, experience-related features, and machine learning to evaluate performance and learning rates in fundamentals of laparoscopic surgery (FLS) and robotic-assisted surgery (RAS). METHODS EEG and eye-tracking data were collected from 25 participants performing three FLS and 22 participants performing two RAS tasks. Generalized linear mixed models, using L1-penalized estimation, were developed to objectify performance evaluation using EEG and eye gaze features, and linear models were developed to objectify learning rate evaluation using these features and performance scores at the first attempt. Experience metrics were added to evaluate their role in learning robotic surgery. The differences in performance across experience levels were tested using analysis of variance. RESULTS EEG and eye gaze features and experience-related features were important for evaluating performance in FLS and RAS tasks with reasonable results. Residents outperformed faculty in FLS peg transfer (p value = 0.04), while faculty and residents both excelled over pre-medical students in the FLS pattern cut (p value = 0.01 and p value < 0.001, respectively). Fellows outperformed pre-medical students in FLS suturing (p value = 0.01). In RAS tasks, both faculty and fellows surpassed pre-medical students (p values for the RAS pattern cut were 0.001 for faculty and 0.003 for fellows, while for RAS tissue dissection, the p value was less than 0.001 for both groups), with residents also showing superior skills in tissue dissection (p value = 0.03). CONCLUSION Findings could be used to develop training interventions for improving surgical skills and have implications for understanding motor learning and designing interventions to enhance learning outcomes.
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Affiliation(s)
- Somayeh B Shafiei
- Intelligent Cancer Care Laboratory, Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14263, USA.
| | | | - Xavier Intes
- Rensselaer Polytechnic Institute, 110 8th Street, Troy, NY, 12180, USA
| | - Rahul Rahul
- Rensselaer Polytechnic Institute, 110 8th Street, Troy, NY, 12180, USA
| | - Mehdi Seilanian Toussi
- Intelligent Cancer Care Laboratory, Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14263, USA
| | - Ambreen Shafqat
- Intelligent Cancer Care Laboratory, Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14263, USA
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10
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Pervaiz SS, D'Adamo C, Mavanur A, Wolf JH. A retrospective comparison of 90-day outcomes, length of stay, and readmissions between robotic-assisted and laparoscopic colectomy. J Robot Surg 2023; 17:2205-2209. [PMID: 37277593 DOI: 10.1007/s11701-023-01642-7] [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] [Received: 02/12/2023] [Accepted: 05/28/2023] [Indexed: 06/07/2023]
Abstract
Investigations generally assess 30 days of perioperative outcomes with robotic-assisted and laparoscopic colectomy. Outcomes beyond 30 days serve as a quality metric of surgical services and an assessment of 90 days of outcomes may have greater clinical utility. The purpose of this study was to assess 90 days of outcomes, length of stay (LOS), and readmissions among patients who underwent a robotic-assisted versus laparoscopic colectomy using a national database. Patients undergoing either robotic-assisted or laparoscopic colectomy were identified using Current Procedural Terminology (CPT) codes within PearlDiver, a national, inpatient records database from 2010 to 2019. Outcomes were defined using the National Surgical Quality Improvement Program (NSQIP) risk calculator and identified using International Classification of Disease (ICD) diagnosis codes. Categorical variables were compared using chi-square tests, and continuous variables were compared using paired t tests. Covariate-adjusted regression models were also constructed to evaluate these associations while accounting for potential confounders. A total of 82,495 patients were assessed in this study. At 90 days, patients of the laparoscopic colectomy cohort experienced a higher rate of complications than patients who underwent robotic-assisted colectomy (9.5 vs. 6.6%, p < 0.001). There were no significant differences in LOS (6 vs. 6.5 days, p = 0.08) and readmissions (6.1 vs. 6.7%, p = 0.851) at 90 days. Patients undergoing robotic-assisted colectomy have a lower risk for morbidity at 90 days. Neither approach is superior for LOS nor 90 days of readmissions. Both techniques are effective minimally invasive procedures, yet patients may gain a greater risk benefit from robotic colectomy.
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Affiliation(s)
- Sahir S Pervaiz
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher D'Adamo
- Department of Family and Community Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Arun Mavanur
- Department of Surgery, Sinai Hospital, Baltimore, MD, USA
- Department of Surgery, Georgetown University, Washington, DC, USA
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Joshua H Wolf
- Department of Surgery, Sinai Hospital, Baltimore, MD, USA.
- Department of Surgery, Georgetown University, Washington, DC, USA.
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11
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Ahuja V, Paredes LG, Leeds IL, Perkal MF, King JT. Clinical outcomes of elective robotic vs laparoscopic surgery for colon cancer utilizing a large national database. Surg Endosc 2023; 37:7199-7205. [PMID: 37365394 DOI: 10.1007/s00464-023-10215-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/11/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Prior studies have shown comparable outcomes between laparoscopic and robotic approaches across a range of surgeries; however, these have been limited in size. This study investigates differences in outcomes following robotic (RC) vs laparoscopic (LC) colectomy across several years utilizing a large national database. METHODS We analyzed data from ACS NSQIP for patients who underwent elective minimally invasive colectomies for colon cancer from 2012 to 2020. Inverse probability weighting with regression adjustment (IPWRA) incorporating demographics, operative factors, and comorbidities was used. Outcomes included mortality, complications, return to the operating room (OR), post-operative length of stay (LOS), operative time, readmission, and anastomotic leak. Secondary analysis was performed to further assess anastomotic leak rate following right and left colectomies. RESULTS We identified 83,841 patients who underwent elective minimally invasive colectomies: 14,122 (16.8%) RC and 69,719 (83.2%) LC. Patients who underwent RC were younger, more likely to be male, non-Hispanic White, with higher body mass index (BMI) and fewer comorbidities (for all, P < 0.05). After adjustment, there were no differences between RC and LC for 30-day mortality (0.8% vs 0.9% respectively, P = 0.457) or overall complications (16.9% vs 17.2%, P = 0.432). RC was associated with higher return to OR (5.1% vs 3.6%, P < 0.001), lower LOS (4.9 vs 5.1 days, P < 0.001), longer operative time (247 vs 184 min, P < 0.001), and higher rates of readmission (8.8% vs 7.2%, P < 0.001). Anastomotic leak rates were comparable for right-sided RC vs LC (2.1% vs 2.2%, P = 0.713), higher for left-sided LC (2.7%, P < 0.001), and highest for left-sided RC (3.4%, P < 0.001). CONCLUSIONS Robotic approach for elective colon cancer resection has similar outcomes to its laparoscopic counterpart. There were no differences in mortality or overall complications, however anastomotic leaks were highest after left RC. Further investigation is imperative to better understand the potential impact of technological advancement such as robotic surgery on patient outcomes.
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Affiliation(s)
- Vanita Ahuja
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA
| | - Lucero G Paredes
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA.
- National Clinician Scholars Program, Yale University School of Medicine, New Haven, CT, 06510-8088, USA.
- Department of Surgery, Maine Medical Center, Portland, ME, USA.
| | - Ira L Leeds
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA
| | - Melissa F Perkal
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA
| | - Joseph T King
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
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12
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Abdelnaby A, Alcabes A. Can Colorectal Surgery Be Performed as an Outpatient Surgery? Adv Surg 2023; 57:279-285. [PMID: 37536859 DOI: 10.1016/j.yasu.2023.04.008] [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: 08/05/2023]
Abstract
The potential to discharge patients safely within the same day after colorectal surgery has developed over time with concurrent advances in concepts of enhanced recovery pathways, along with minimally invasive techniques available to surgeons. The advent of planned same-day discharges after elective colectomy is made possible by research establishing improved length of stay with minimal morbidity in patients undergoing minimally invasive surgery and especially minimally invasive surgery in the setting of an enhanced recovery after surgery (ERAS) protocol. In tracing the timeline of research and development of knowledge in this setting, the safety of outpatient colorectal surgery can be established.
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Affiliation(s)
- Abier Abdelnaby
- Colon and Rectal Surgical Services, Montefiore Medical Center, Bronx, NY, USA; Department of Surgery, The University Hospital for Albert Einstein College of Medicine, 1825 Eastchester Road, Bronx, NY 10461, USA.
| | - Analena Alcabes
- Department of Surgery, The University Hospital for Albert Einstein College of Medicine, 1825 Eastchester Road, Bronx, NY 10461, USA; Montefiore Medical Center, Bronx, NY, USA
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13
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Formisano G, Ferraro L, Salaj A, Giuratrabocchetta S, Piccolo G, Di Raimondo G, Bianchi PP. Robotic Total Mesorectal Excision for Low Rectal Cancer: A Narrative Review and Description of the Technique. J Clin Med 2023; 12:4859. [PMID: 37510973 PMCID: PMC10381747 DOI: 10.3390/jcm12144859] [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: 06/21/2023] [Revised: 07/21/2023] [Accepted: 07/22/2023] [Indexed: 07/30/2023] Open
Abstract
Robotic surgery may offer significant advantages for treating extraperitoneal rectal cancer. Although laparoscopy has been shown to be safe and effective, laparoscopic total mesorectal excision (TME) remains technically challenging and is still performed in selected centers. Robotic anterior resection (RAR) may overcome the drawback of conventional laparoscopy, providing high-quality surgery with favorable oncological outcomes. Moreover, recent data show how RAR offers clinical and oncological benefits when affording difficult TMEs, such as low and advanced rectal tumors, in terms of complication rate, specimen quality, recurrence rate, and survival. This series aims to review the most recent and relevant literature, reporting mid- and long-term oncological outcomes and focusing on minimally invasive RAR for low rectal cancer.
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Affiliation(s)
- Giampaolo Formisano
- Department of Surgery, Asst Santi Paolo e Carlo, Dipartimento di Scienze della Salute, University of Milan, 20122 Milan, Italy
| | - Luca Ferraro
- Department of General Surgery, Asst Santi Paolo e Carlo, 20142 Milan, Italy
| | - Adelona Salaj
- Department of Surgery, Asst Santi Paolo e Carlo, Dipartimento di Scienze della Salute, University of Milan, 20122 Milan, Italy
| | - Simona Giuratrabocchetta
- Department of Surgery, Asst Santi Paolo e Carlo, Dipartimento di Scienze della Salute, University of Milan, 20122 Milan, Italy
| | - Gaetano Piccolo
- Department of Surgery, Asst Santi Paolo e Carlo, Dipartimento di Scienze della Salute, University of Milan, 20122 Milan, Italy
| | - Giulia Di Raimondo
- Department of Surgery, Asst Santi Paolo e Carlo, Dipartimento di Scienze della Salute, University of Milan, 20122 Milan, Italy
| | - Paolo Pietro Bianchi
- Department of Surgery, Asst Santi Paolo e Carlo, Dipartimento di Scienze della Salute, University of Milan, 20122 Milan, Italy
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14
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Nann S, Rana A, Karatassas A, Eteuati J, Tonkin D, McDonald C. Robot-assisted general surgery is safe during the learning curve: a 5-year Australian experience. J Robot Surg 2023:10.1007/s11701-023-01560-8. [PMID: 36897528 PMCID: PMC10374810 DOI: 10.1007/s11701-023-01560-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/02/2023] [Indexed: 03/11/2023]
Abstract
Robot-assisted general surgery has become increasingly common in the Australian public sector since 2003. It provides significant technical advantages compared to laparoscopic surgery. Currently, it is estimated that the learning curve for surgeons starting off with robotic surgery is complete after 15 cases. This is a retrospective case series, following the progress of four surgeons with minimal robotic experience over 5 years. Patients undergoing colorectal procedures and hernia repairs were included. 303 robotic cases were included in this study, 193 colorectal surgeries and 110 hernia repairs. 20.2% of colorectal patients experienced an adverse event and 10.0% of hernia patients had a complication. The learning curve was correlated to the average docking time, and it was found that this was complete after 2 years, or after a minimum of 12 to 15 cases. Patient length of stay decreases as surgeon experience increases. Robotic surgery is a safe approach to colorectal surgery and hernia repairs with some potential benefits in terms of patient outcomes as surgeon experience increases.
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Affiliation(s)
- Silas Nann
- University of Adelaide, North Terrace, Adelaide, South Australia, 5000, Australia. .,Royal Adelaide Hospital, Adelaide, South Australia, Australia.
| | - Abdul Rana
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Alex Karatassas
- University of Adelaide, North Terrace, Adelaide, South Australia, 5000, Australia
| | - Jimmy Eteuati
- The Lyell McEwin Hospital, South Australia, Elizabeth Vale, Adelaide, Australia
| | - Darren Tonkin
- The Queen Elizabeth Hospital, South Australia, Woodville South, Adelaide, Australia
| | - Christopher McDonald
- University of Adelaide, North Terrace, Adelaide, South Australia, 5000, Australia.,The Lyell McEwin Hospital, South Australia, Elizabeth Vale, Adelaide, Australia
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15
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[Robot-assisted rectal resections-Scoping review for level 1a evidence and retrospective analysis of in-clinic data]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:138-146. [PMID: 36449038 PMCID: PMC9898418 DOI: 10.1007/s00104-022-01774-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/28/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Robot-assisted rectal resections are said to overcome the known difficulties of laparoscopic rectal surgery through technical advantages, leading to better treatment results; however, published studies reported very heterogeneous results. The aim of this paper is therefore to determine whether there is class 1a evidence comparing robotic versus laparoscopic rectal resections. Furthermore, we would like to compare the treatment results of our clinic with the calculated effects from the literature. MATERIAL AND METHODS A systematic literature search for class 1a evidence was performed and the calculated effects for 7 preselected outcomes were compared. We then analyzed all elective rectal resections performed in our hospital between 2017 and 2020 and compared the treatment outcomes with the results of the identified meta-analyses. RESULTS The results of the 7 identified meta-analyses did not show homogeneous effects for the outcomes operating time and conversion rate, while the calculated effects of the other outcomes studied were largely consistent. Our patient data showed that robotic rectal resections were associated with significantly longer operation times, while the other outcomes were hardly influenced by the surgical technique. DISCUSSION Although class 1a meta-analyses comparing robotic and laparoscopic rectal resections already exist, they do not enable an evidence-based recommendation regarding the preference of one of the two surgical techniques. The analysis of our patient data showed that the results achieved in our clinic are largely consistent with the observed effects of the meta-analyses.
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16
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Soliman SS, Flanagan J, Wang YH, Stopper PB, Rolandelli RH, Nemeth ZH. Comparison of Robotic and Laparoscopic Colectomies Using the 2019 ACS NSQIP Database. South Med J 2022; 115:887-892. [DOI: 10.14423/smj.0000000000001479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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17
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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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18
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Lee GC, Bhama AR. Minimally Invasive and Robotic Surgery for Ulcerative Colitis. Clin Colon Rectal Surg 2022; 35:463-468. [PMID: 36591398 PMCID: PMC9797258 DOI: 10.1055/s-0042-1758137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Significant advancements have been made over the last 30 years in the use of minimally invasive techniques for curative and restorative operations in patients with ulcerative colitis (UC). Numerous studies have demonstrated the safety and feasibility of laparoscopic and robotic approaches to subtotal colectomy (including in the urgent setting), total proctocolectomy, completion proctectomy, and pelvic pouch creation. Data show equivalent or improved short-term postoperative outcomes with minimally invasive techniques compared to open surgery, and equivalent or improved long-term bowel function, sexual function, and fertility. Overall, while minimally invasive techniques are safe and feasible for properly selected UC patients, surgeons must remember to abide by the principles of high-quality proctectomy and pouch creation and convert to open if necessary.
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Affiliation(s)
- Grace C. Lee
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Anuradha R. Bhama
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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19
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Robotic-assisted versus laparoscopic rectal surgery in obese and morbidly obese patients: ACS-NSQIP analysis. J Robot Surg 2022; 17:637-643. [PMID: 36269488 PMCID: PMC10076395 DOI: 10.1007/s11701-022-01462-1] [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: 08/27/2022] [Accepted: 10/09/2022] [Indexed: 10/24/2022]
Abstract
Laparoscopic rectal surgery within the confines of a narrow pelvis may be associated with a high rate of open conversion. In the obese and morbidly obese patient, the complexity of laparoscopic surgery increases substantially. Robotic technology is known to reduce the risk of conversion, but it is unclear if it can overcome the technical challenges associated with obesity. The ACS NSQIP database was used to identify obese patients who underwent elective laparoscopic or robotic-assisted rectal resection from 2015 to 2016. Obesity was defined as a body mass index (BMI) greater than or equal to 30 kg/m2. Morbid obesity was defined as a BMI greater than or equal to 35 kg/m2. The primary outcome was unplanned conversions to open. Other outcomes measures assessed included anastomotic leak, operative time, surgical site infections, length of hospital stay, readmissions and mortality. Statistical analyses were performed using SPSS 22.0 (IBM SPSS, USA). 1490 patients had robotic-assisted and 4967 patients had laparoscopic rectal resections between 2015 and 2016. Of those patients, 561 obese patients had robotic-assisted rectal resections and 1824 patients underwent laparoscopic rectal surgery. In the obese cohort, the rate of unplanned conversion to open in the robotic group was 14% compared to 24% in the laparoscopic group (P < 0.0001). Median operative time was significantly longer in the robotic group (248 min vs. 215 min, P < 0.0001). There was no difference in anastomotic leak or systemic sepsis between the laparoscopic and robotic rectal surgery groups. In morbidly obese patients (BMI ≥ 35 kg/m2), the rate of unplanned conversion to open in the robotic group was 19% compared to 26% in the laparoscopic group (P < 0.027). There was no difference in anastomotic leak, systemic sepsis or surgical site infection rates between robotic and laparoscopic rectal resection. Multivariate analysis showed that robotic-assisted surgery was associated with fewer unplanned conversions to open (OR 0.28, P < 0.0001). Robotic-assisted surgery is associated with a decreased risk of conversion to open in obese and morbidly obese patients when compared to conventional laparoscopic surgery. However, robotic surgery was associated with longer operative time and despite improvement in the rate of conversion to open, there was no difference in complications or length of stay. Our findings are limited by the retrospective non-randomised nature of the study, demographic differences between the two groups, and the likely difference in surgeon experience between the two groups. Large randomised controlled studies are needed to further explore the role of robotic rectal surgery in obese and morbidly obese patients.
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20
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Huang Z, Li T, Zhang G, Zhou Z, Shi H, Tang C, Yang L, Lei X. Comparison of open, laparoscopic, and robotic left colectomy for radical treatment of colon cancer: a retrospective analysis in a consecutive series of 211 patients. World J Surg Oncol 2022; 20:345. [PMID: 36253768 PMCID: PMC9578184 DOI: 10.1186/s12957-022-02796-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 09/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background Robotic surgery has been widely used in the radical treatment of colonic cancer. However, it is unclear what advantages the robotic approach offers over other approaches in left colectomy. This study aims to explore the advantage of robotic surgery in left colectomy by comparing open, laparoscopic, and robotic surgery. Methods A retrospective analysis was performed on the clinical data of patients with radical left colectomy for colon cancer who were admitted to the Department of General Surgery, The First Affiliated Hospital of Nanchang University, from November 2012 to November 2017. Two hundred eleven patients included were divided into the open surgery group (OS, n=49), laparoscopic surgery group (LS, n=92), and robotic surgery group (RS, n=70) according to surgical techniques. The clinicopathologic data were collected for clinical outcome assessment. Finally, the clinical value of RS in radical left colectomy was further evaluated by propensity score matching (PSM) analysis. Results Three groups were similar in demographics and clinical characteristics. Compared with OS, LS and RS groups had better intraoperative and perioperative clinical outcomes. Moreover, the RS group exhibited the minimum operative times, length of stay (LOS), and evaluated blood loss. LS and RS also exhibited less perioperative and postoperative long-term complications. Three groups showed similar postoperative pathological outcomes. The overall survival and disease-free survival were also similar among the three groups (all P > 0.05). Cox regression analysis showed surgical approach was not a prognostic factor for overall survival (P = 0.671) and disease-free survival (P = 0.776). PSM analysis of RS and LS by clinical characteristics showed RS showed shorter operation time (P < 0.001) and LOS for patients without complications (P = 0.005). However, no significant differences were found in perioperative and long-term postoperative complications, pathological outcomes, overall survival, and disease-free survival. Conclusions Among three techniques for radical left colectomy, LS and RS had significant advantages over OS in short-term clinical outcomes, and no significant differences were found in overall, disease-free survival, local recurrence, and distant metastasis incidence. Moreover, RS shows better perioperative clinical outcomes but without compromising survival compared with LS. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-022-02796-8.
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Affiliation(s)
- Zhixiang Huang
- Gastrointernal Surgical Institute, Nanchang University, Nanchang, 330006, Jiangxi, China.,China-Japan Union Hospital Of Jilin University, 130000, Chang Chun, China
| | - Taiyuan Li
- Gastrointernal Surgical Institute, Nanchang University, Nanchang, 330006, Jiangxi, China.,Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Genghua Zhang
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Zhen Zhou
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Haoran Shi
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Cheng Tang
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Lingling Yang
- Department of Gastroenterology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Xiong Lei
- Gastrointernal Surgical Institute, Nanchang University, Nanchang, 330006, Jiangxi, China. .,Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China.
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21
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Outcomes and Cost Analysis of Robotic Versus Laparoscopic Abdominoperineal Resection for Rectal Cancer: A Case-Matched Study. Dis Colon Rectum 2022; 65:1279-1286. [PMID: 35195554 DOI: 10.1097/dcr.0000000000002394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Although laparoscopy for abdominoperineal resection has been well defined, the literature lacks comparative studies on robotic abdominoperineal resection. Because robotic abdominoperineal resections typically do not require splenic mobilization or an anastomosis for reconstruction, the mean console time is expected to be shorter than low anterior resection. We hypothesized that robotic and laparoscopic abdominoperineal resection would provide similar oncologic and financial outcomes. OBJECTIVE The study aimed to compare the perioperative, oncologic, and economic outcomes of the robotic and laparoscopic abdominoperineal resection. DESIGN This was a retrospective, case-matched patient cohort. SETTINGS This study was conducted at a tertiary referral center. PATIENTS This study included all patients who underwent either laparoscopic or robotic abdominoperineal resections between January 2008 and April 2017; they were case-matched in a 1:1 ratio based on age ±5 years, BMI ±3 kg/m 2 , and sex criteria. MAIN OUTCOME MEASURES Perioperative, oncologic, and economic (including survival) outcomes were compared. Because of institutional policy, actual cost values are presented as the lowest direct cost value as "100%," and other values are presented as proportional to the index value. RESULTS We examined 68 patients (34 in each group). Both groups had similar preoperative characteristics, including preoperative chemoradiation rates. Operative time (319 vs 309 min), length of stay (7.2 vs 7.4 d), postoperative complications (38.2% vs 41.2%), conversion to open (5 vs 4), complete mesorectal excision (76.4% vs 79.4%), radial margin involvement (2.9% vs 8.9%), and direct hospital cost parameters (mean difference 26%, median difference 43%) were comparable between robotic and laparoscopic abdominoperineal resection groups, respectively (all p > 0.05). Local recurrence, disease-free survival, and overall survival rates (85.3% vs 76.5%) were also similar after 22 months of follow-up between the groups. LIMITATIONS The main limitations of this study are its retrospective nature and the variety in concomitant procedures. CONCLUSIONS Robotic abdominoperineal resections provided in carefully matched patients with rectal cancer showed similar perioperative and short-term oncologic outcomes compared to laparoscopic abdominoperineal resections. Our study was not powered to detect a significant increase in cost with robotic abdominoperineal resections. See Video Abstract at http://links.lww.com/DCR/B920 . RESULTADOS Y ANLISIS DE COSTO DE LA RESECCIN ABDOMINOPERINEAL LAPAROSCPICA VS LA ROBTICA EN CASOS DE CNCER DE RECTO ESTUDIO DE CASOS EMPAREJADOS ANTECEDENTES:Si bien la resección abdominoperineal laparoscópica está bien definida, la literatura carece de estudios comparativos sobre la resección abdominoperineal robótica. Dado que las resecciones abdominoperineales robóticas generalmente no requieren movilización esplénica o una anastomosis en casos de reconstrucción, se supone que el tiempo medio en la consola sea más corto que durante una resección anterior baja. Hipotéticamente las resecciones abdominoperineales robóticas y laparoscópicas nos proporcionarían resultados oncológicos y económicos similares.OBJETIVO:Comparar los resultados perioperatorios, oncológicos y económicos de la resección abdominoperineal robótica y laparoscópica.DISEÑO:Esta fue una cohorte de pacientes retrospectiva, emparejada por casos.AJUSTE:Estudio realizado en un centro de referencia terciario.PACIENTES:Todos los pacientes que se sometieron a resecciones abdominoperineales LAParoscópicas o ROBóticas entre Enero de 2008 y Abril de 2017 fueron identificados y emparejados según la edad ±5, el IMC ±3 y los criterios de sexo en una proporción de 1:1.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon los resultados perioperatorios, oncológicos y económicos (incluida la sobrevida). Debido a la política institucional, los valores de costos reales se presentan como el valor de costo directo más bajo al 100% y los otros valores se presentan como proporcionales al valor índice.RESULTADOS:Se analizaron 68 pacientes (LAP-34 y ROB-34). Ambos grupos tenían características preoperatorias similares, incluidas las tasas de radio-quimioterapia pre-operatoria. Los tiempos operatorios fueron de 319 y 309 minutos, la estadía hospitalaria de 7 días en los dos grupos, las complicaciones post-operatorias fueron de 38,2% LAP frente a 41,2% ROB, la tasa de conversion fué de 5 a 4, la excisión total del mesorrecto de 76,4% frente a 79,4%, la resección radial con afectación de los márgenes de 2,9% frente a 8,9% y los parámetros de costes hospitalarios directos (diferencia de medias 26%, diferencia de medianas 43%) fueron comparables entre los grupos, de resección abdominoperineal robótica y laparoscópica, respectivamente (todos p > 0,05). Las tasas de recurrencia local, sobrevida libre de enfermedad y sobrevida general (85,3% frente a 76,5%) también fueron similares después de 22 meses de seguimiento entre los grupos.LIMITACIONES:La naturaleza retrospectiva y la variedad de procedimientos concomitantes fueron las principales limitaciones de este estudio.CONCLUSIONES:Las resecciones abdominoperineales robóticas proporcionaron resultados oncológicos perioperatorios y a corto plazo similares en pacientes con cáncer de recto cuidadosamente emparejados en comparación con las resecciones abdominoperineales laparoscópicas. Nuestro estudio no fue diseñado para detectar un aumento significativo en el costo relacionado con la resección abdominoperineal robótica. Consulte Video Resumen en http://links.lww.com/DCR/B920 . (Traducción-Dr. Xavier Delgadillo ).
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22
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Minimally Invasive Surgery Approach is Not Associated With Differences in Long-Term Bowel Function Patient-Reported Outcomes After Elective Sigmoid Colectomy. J Surg Res 2022; 274:85-93. [DOI: 10.1016/j.jss.2021.12.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/26/2021] [Accepted: 12/15/2021] [Indexed: 11/17/2022]
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23
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Kubo N, Sakurai K, Tamamori Y, Fukui Y, Kuroda K, Aomatsu N, Nishii T, Tachimori A, Maeda K. Less Severe Intra-Abdominal Infections in Robotic Surgery for Gastric Cancer Compared with Conventional Laparoscopic Surgery: A Propensity Score-matched Analysis. Ann Surg Oncol 2022; 29:3922-3933. [PMID: 35181811 DOI: 10.1245/s10434-022-11410-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 01/20/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The impact of robotic gastrectomy (RG) for gastric cancer (GC) on the incidence of postoperative complication is debatable and unclear. METHODS This study enrolled 200 patients with GC who were surgically treated and consisted of 100 RG and 100 laparoscopic gastrectomy (LG) cases using an ultrasonic scalpel. The short-term outcomes were compared between the two groups. These outcomes were compared using a 1:1 propensity score (PS)-matching analysis. RESULTS After PS matching, 76 cases in each group were well matched. Mean surgical time was significantly longer in the RG group than in the LG group (393 vs. 342 min, p < 0.005), whereas mean blood loss during surgery was significantly lower in the RG group than in the LG group (30.1 vs. 50.1 mL, p = 0.023). The median number of surgeons who attend the main part of the surgery was significantly less in the RG group than in the LG group (2.0 vs. 3.0, p = 0.01). The rate of severe intra-abdominal infectious complication was significantly lower in the RG group than in the LG group (0% vs. 9.2%, p = 0.014). The duration from surgery to adjuvant chemotherapy was significantly shorter in the RG group than in the LG group (29.6 ± 11.0 vs. 45.2 ± 27.8 days, p = 0.046). CONCLUSIONS RG using an ultrasonic scalpel may be a viable alternative to LG because of the improvement in the rate of postoperative intra-abdominal infectious complications after curative surgery for GC.
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Affiliation(s)
- Naoshi Kubo
- Department of Gastroenterological Surgery, Osaka City General Hospital, Osaka, Japan.
| | - Katsunobu Sakurai
- Department of Gastroenterological Surgery, Osaka City General Hospital, Osaka, Japan
| | - Yutaka Tamamori
- Department of Gastroenterological Surgery, Osaka City General Hospital, Osaka, Japan
| | - Yasuyuki Fukui
- Department of Gastroenterological Surgery, Osaka City General Hospital, Osaka, Japan
| | - Kenji Kuroda
- Department of Gastroenterological Surgery, Osaka City General Hospital, Osaka, Japan
| | - Naoki Aomatsu
- Department of Gastroenterological Surgery, Osaka City General Hospital, Osaka, Japan
| | - Takafumi Nishii
- Department of Gastroenterological Surgery, Osaka City General Hospital, Osaka, Japan
| | - Akiko Tachimori
- Department of Gastroenterological Surgery, Osaka City General Hospital, Osaka, Japan
| | - Kiyoshi Maeda
- Department of Gastroenterological Surgery, Osaka City General Hospital, Osaka, Japan
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24
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Stitzenberg KB. Advances in Rectal Cancer Surgery. Clin Colorectal Cancer 2022; 21:55-62. [DOI: 10.1016/j.clcc.2022.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 01/18/2022] [Accepted: 01/20/2022] [Indexed: 12/16/2022]
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25
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Palomba G, Dinuzzi VP, Capuano M, Anoldo P, Milone M, De Palma GD, Aprea G. Robotic versus laparoscopic colorectal surgery in elderly patients in terms of recovery time: a monocentric experience. J Robot Surg 2021; 16:981-987. [PMID: 34743288 PMCID: PMC8572529 DOI: 10.1007/s11701-021-01332-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 10/29/2021] [Indexed: 02/07/2023]
Abstract
Colorectal cancer has a great socio-sanitary relevance. It represents the third cancer by incidence and mortality. Ageing plays a major role in the development of colorectal cancer and this tumour, in patients aged 65 and older, has gradually increased over the past decade. The robotic technique is considered the evolution of conventional laparoscopy. Few studies evaluate the effects of robotic surgery in elderly patient, and even fewer are those that compare it with laparoscopic surgery in this population. The aim of this study was to evaluate the perioperative outcomes of robotic colorectal surgery compared to laparoscopic colorectal surgery in patients older than 65 years. We conducted a retrospective study enrolling 83 elderly patients (age > 65) undergoing robotic and laparoscopic colectomy (32 and 51, respectively) between January 2019 and January 2021. For statistical analysis, p values were calculated using t test and chi-square test. p < 0.05 is the criterion for statistical significance. Statistical analyses were performed with the Number Cruncher Statistical System (NCSS) 2020 data analysis version 20.0.1 (Utah, USA). The operation time was higher in robotic left (p = 0.003, mean time 249.6 vs 211.7 min) and right (p = 0.004, mean time 238.5 vs 183.5 min) hemicolectomy and similar for procedures on rectosigmoid and rectum when compared to laparoscopic technique. In terms of length of hospital stay and recovery of bowel function, these values were significantly lower for robotic group in left hemicolectomy (p = 0.004), rectum (p = 0.003) and rectosigmoid (p = 0.003), while right hemicolectomy was similar in two groups (p = 0.26). There was no statistically significant difference between the groups regarding conversion rate, postoperative complications, length of specimen, number of lymph nodes encountered and oncological results. Colorectal robotic surgery in elderly patients appears as a feasible and safe surgical approach when compared to the laparoscopic one, showing a shorter recovery and a reduction of length of stay with similar oncological outcomes even if with an increase of operating times.
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Affiliation(s)
- Giuseppe Palomba
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Sergio Pansini 5, 80131, Naples, Italy.
| | - Vincenza Paola Dinuzzi
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Sergio Pansini 5, 80131, Naples, Italy
| | - Marianna Capuano
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Sergio Pansini 5, 80131, Naples, Italy
| | - Pietro Anoldo
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Sergio Pansini 5, 80131, Naples, Italy
| | - Marco Milone
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Sergio Pansini 5, 80131, Naples, Italy
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Sergio Pansini 5, 80131, Naples, Italy
| | - Giovanni Aprea
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Sergio Pansini 5, 80131, Naples, Italy
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Rückbeil O, Sebestyen U, Schlick T, Krüger CM. [Structured Implementation and Modular In-house Training as Key Success Factors in Robotically Assisted Surgery - Evaluation Using the Example of Colorectal Surgery]. Zentralbl Chir 2021; 147:35-41. [PMID: 34607387 DOI: 10.1055/a-1552-4236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES To demonstrate the applicability of structured implementation of robotic assisted surgery (RAS) and to evaluate a modular training procedure during the implementation phase in in-house mentoring. METHOD Execution of a self-defined PDCA (PDCA: Plan-Do-Check-Act) implementation cycle accompanied by prospective data collection of patient characteristics, operation times, complications, conversion rates and postoperative length of stay of a modularly defined training operation (robotic assisted rectosigmoid resection - RARSR). RESULTS Evaluation of 100 consecutive cases distributed among 3 trainees and an in-house mentor as internal control group. Presentation of qualitatively safe and successful implementation with a short learning curve of the training operation with balanced patient characteristics. CONCLUSIONS Structured implementation enables the safe introduction of RAS in visceral surgery. In this context, modular training operations can facilitate the adoption of RAS by users under everyday conditions. For the first time, we demonstrate this within an in-house mentoring approach.
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Affiliation(s)
- Oskar Rückbeil
- Chirurgie/Zentrum für Robotik, Immanuel Klinik Rüdersdorf, Rüdersdorf bei Berlin, Germany
| | - Uwe Sebestyen
- Chirurgie/Zentrum für Robotik, Immanuel Klinik Rüdersdorf, Rüdersdorf bei Berlin, Germany
| | - Tilman Schlick
- Chirurgie/Zentrum für Robotik, Immanuel Klinik Rüdersdorf, Rüdersdorf bei Berlin, Germany
| | - Colin M Krüger
- Chirurgie/Zentrum für Robotik, Immanuel Klinik Rüdersdorf, Rüdersdorf bei Berlin, Germany
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Gunnells D, Cannon J. Robotic Surgery in Crohn's Disease. Clin Colon Rectal Surg 2021; 34:286-291. [PMID: 34512197 DOI: 10.1055/s-0041-1729862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Surgery for Crohn's disease presents unique challenges secondary to the inflammatory nature of the disease. While a minimally invasive approach to colorectal surgery has consistently been associated with better patient outcomes, adoption of laparoscopy in Crohn's disease has been limited due to these challenges. Robotic assisted surgery has the potential to overcome these challenges and allow more complex patients to undergo a minimally invasive operation. Here we describe our approach to robotic assisted surgery for terminal ileal Crohn's disease.
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Affiliation(s)
- Drew Gunnells
- Division of Gastrointestinal Surgery, University of Alabama, Birmingham, Alabama
| | - Jamie Cannon
- Division of Gastrointestinal Surgery, University of Alabama, Birmingham, Alabama
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Update on Robotic Total Mesorectal Excision for Rectal Cancer. J Pers Med 2021; 11:jpm11090900. [PMID: 34575677 PMCID: PMC8472541 DOI: 10.3390/jpm11090900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/04/2021] [Accepted: 09/06/2021] [Indexed: 12/16/2022] Open
Abstract
The minimally invasive treatment of rectal cancer with Total Mesorectal Excision is a complex and challenging procedure due to technical and anatomical issues which could impair postoperative, oncological and functional outcomes, especially in a defined subgroup of patients. The results from recent randomized controlled trials comparing laparoscopic versus open surgery are still conflicting and trans-anal bottom-up approaches have recently been developed. Robotic surgery represents the latest consistent innovation in the field of minimally invasive surgery that may potentially overcome the technical limitations of conventional laparoscopy thanks to an enhanced dexterity, especially in deep narrow operative fields such as the pelvis. Results from population-based multicenter studies have shown the potential advantages of robotic surgery when compared to its laparoscopic counterpart in terms of reduced conversions, complication rates and length of stay. Costs, often advocated as one of the main drawbacks of robotic surgery, should be thoroughly evaluated including both the direct and indirect costs, with the latter having the potential of counterbalancing the excess of expenditure directly related to the purchase and maintenance of robotic equipment. Further prospectively maintained or randomized data are still required to better delineate the advantages of the robotic platform, especially in the subset of most complex and technically challenging patients from both an anatomical and oncological standpoint.
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Tagliabue F, Burati M, Chiarelli M, Cioffi U, Zago M. Robotic surgery in colon cancer: current evidence and future perspectives – narrative review. Artif Intell Gastrointest Endosc 2021; 2:110-116. [DOI: 10.37126/aige.v2.i4.110] [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: 03/10/2021] [Revised: 05/14/2021] [Accepted: 08/19/2021] [Indexed: 02/06/2023] Open
Abstract
In the last 10 years, surgery has been developing towards minimal invasiveness; therefore, robotic surgery represents the consequent evolution of laparoscopic surgery. Worldwide, surgeons’ performances have been upgraded by the ergonomic developments of robotic systems, leading to several benefits for patients. The introduction into the market of the new Da Vinci Xi system has made it possible to perform all types of surgery on the colon, an in selected cases, to combine interventions in other organs or viscera at the same time. Optimization of the suprapubic surgical approach may shorten the length of hospital stay for patients who undergo robotic colonic resection. From this perspective, single-port robotic colectomy, has reduced the number of robotic ports needed, allowing a better anesthetic outcome and faster recovery. The introduction on the market of new surgical robotic systems from multiple manufacturers is bound to change the landscape of robotic surgery and yield high-quality surgical outcomes.
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Affiliation(s)
- Fulvio Tagliabue
- Department of Emergency and Robotic Surgery, A. Manzoni Hospital–ASST Lecco, Lecco 23900, Italy
| | - Morena Burati
- Department of Emergency and Robotic Surgery, A. Manzoni Hospital–ASST Lecco, Lecco 23900, Italy
| | - Marco Chiarelli
- Department of Emergency and Robotic Surgery, A. Manzoni Hospital–ASST Lecco, Lecco 23900, Italy
| | - Ugo Cioffi
- Department of Surgery, University of Milan, Milano 20122, Italy
| | - Mauro Zago
- Department of Emergency and Robotic Surgery, A. Manzoni Hospital–ASST Lecco, Lecco 23900, Italy
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Formisano G, Ferraro L, Salaj A, Giuratrabocchetta S, Pisani Ceretti A, Opocher E, Bianchi PP. Update on Robotic Rectal Prolapse Treatment. J Pers Med 2021; 11:706. [PMID: 34442349 PMCID: PMC8399170 DOI: 10.3390/jpm11080706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 11/16/2022] Open
Abstract
Rectal prolapse is a condition that can cause significant social impairment and negatively affects quality of life. Surgery is the mainstay of treatment, with the aim of restoring the anatomy and correcting the associated functional disorders. During recent decades, laparoscopic abdominal procedures have emerged as effective tools for the treatment of rectal prolapse, with the advantages of faster recovery, lower morbidity, and shorter length of stay. Robotic surgery represents the latest evolution in the field of minimally invasive surgery, with the benefits of enhanced dexterity in deep narrow fields such as the pelvis, and may potentially overcome the technical limitations of conventional laparoscopy. Robotic surgery for the treatment of rectal prolapse is feasible and safe. It could reduce complication rates and length of hospital stay, as well as shorten the learning curve, when compared to conventional laparoscopy. Further prospectively maintained or randomized data are still required on long-term functional outcomes and recurrence rates.
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Affiliation(s)
- Giampaolo Formisano
- Division of General and Robotic Surgery, Dipartimento di Scienze della Salute, Università di Milano, 20142 Milano, Italy; (G.F.); (A.S.); (S.G.); (P.P.B.)
| | - Luca Ferraro
- Division of General and Robotic Surgery, Dipartimento di Scienze della Salute, Università di Milano, 20142 Milano, Italy; (G.F.); (A.S.); (S.G.); (P.P.B.)
| | - Adelona Salaj
- Division of General and Robotic Surgery, Dipartimento di Scienze della Salute, Università di Milano, 20142 Milano, Italy; (G.F.); (A.S.); (S.G.); (P.P.B.)
| | - Simona Giuratrabocchetta
- Division of General and Robotic Surgery, Dipartimento di Scienze della Salute, Università di Milano, 20142 Milano, Italy; (G.F.); (A.S.); (S.G.); (P.P.B.)
| | - Andrea Pisani Ceretti
- Division of General and HPB Surgery, Dipartimento di Scienze della Salute, Università di Milano, 20142 Milano, Italy; (A.P.C.); (E.O.)
| | - Enrico Opocher
- Division of General and HPB Surgery, Dipartimento di Scienze della Salute, Università di Milano, 20142 Milano, Italy; (A.P.C.); (E.O.)
| | - Paolo Pietro Bianchi
- Division of General and Robotic Surgery, Dipartimento di Scienze della Salute, Università di Milano, 20142 Milano, Italy; (G.F.); (A.S.); (S.G.); (P.P.B.)
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Manigrasso M, Vertaldi S, Anoldo P, D’Amore A, Marello A, Sorrentino C, Chini A, Aprea S, D’Angelo S, D’Alesio N, Musella M, Vitiello A, De Palma GD, Milone M. Robotic Colorectal Cancer Surgery. How to Reach Expertise? A Single Surgeon-Experience. J Pers Med 2021; 11:jpm11070621. [PMID: 34208988 PMCID: PMC8307843 DOI: 10.3390/jpm11070621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/02/2021] [Accepted: 06/28/2021] [Indexed: 12/13/2022] Open
Abstract
The complexity associated with laparoscopic colorectal surgery requires several skills to overcome the technical difficulties related to this procedure. To overcome the technical challenges of laparoscopic surgery, a robotic approach has been introduced. Our study reports the surgical outcomes obtained by the transition from laparoscopic to robotic approach in colorectal cancer surgery to establish in which type of approach the proficiency is easier to reach. Data about the first consecutive 15 laparoscopic and the first 15 consecutive robotic cases are extracted, adopting as a comparator of proficiency the last 15 laparoscopic colorectal resections for cancer. The variables studied are operative time, number of harvested nodes, conversion rate, postoperative complications, recovery outcomes. Our analysis includes 15 patients per group. Our results show that operative time is significantly longer in the first 15 laparoscopic cases (p = 0.001). A significantly lower number of harvested nodes was retrieved in the first 15 laparoscopic cases (p = 0.003). Clavien Dindo I complication rate was higher in the first laparoscopic group, but without a significant difference among the three groups (p = 0.09). Our results show that the surgeon needed no apparent learning curve to reach their laparoscopic standards. However, further multicentric prospective studies are needed to confirm this conclusion.
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Affiliation(s)
- Michele Manigrasso
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (M.M.); (A.V.)
- Correspondence:
| | - Sara Vertaldi
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (S.V.); (P.A.); (A.D.); (A.M.); (C.S.); (A.C.); (G.D.D.P.); (M.M.)
| | - Pietro Anoldo
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (S.V.); (P.A.); (A.D.); (A.M.); (C.S.); (A.C.); (G.D.D.P.); (M.M.)
| | - Anna D’Amore
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (S.V.); (P.A.); (A.D.); (A.M.); (C.S.); (A.C.); (G.D.D.P.); (M.M.)
| | - Alessandra Marello
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (S.V.); (P.A.); (A.D.); (A.M.); (C.S.); (A.C.); (G.D.D.P.); (M.M.)
| | - Carmen Sorrentino
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (S.V.); (P.A.); (A.D.); (A.M.); (C.S.); (A.C.); (G.D.D.P.); (M.M.)
| | - Alessia Chini
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (S.V.); (P.A.); (A.D.); (A.M.); (C.S.); (A.C.); (G.D.D.P.); (M.M.)
| | - Salvatore Aprea
- “Federico II” University Hospital, Via Pansini 5, 80131 Naples, Italy; (S.A.); (S.D.); (N.D.)
| | - Salvatore D’Angelo
- “Federico II” University Hospital, Via Pansini 5, 80131 Naples, Italy; (S.A.); (S.D.); (N.D.)
| | - Nicola D’Alesio
- “Federico II” University Hospital, Via Pansini 5, 80131 Naples, Italy; (S.A.); (S.D.); (N.D.)
| | - Mario Musella
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (M.M.); (A.V.)
| | - Antonio Vitiello
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (M.M.); (A.V.)
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (S.V.); (P.A.); (A.D.); (A.M.); (C.S.); (A.C.); (G.D.D.P.); (M.M.)
| | - Marco Milone
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (S.V.); (P.A.); (A.D.); (A.M.); (C.S.); (A.C.); (G.D.D.P.); (M.M.)
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Grimaud LW, Chen FV, Chang J, Ziogas A, Sfakianos J, Badani KK, Uchio E, Anton-Culver H, Gin G. Comparison of Perioperative Outcomes for Radical Nephrectomy Based on Surgical Approach for Masses Greater than 10cm. J Endourol 2021; 35:1785-1792. [PMID: 34148404 DOI: 10.1089/end.2020.1164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction and Objective Robotic-assisted radical nephrectomy (RRN) is increasingly utilized as an alternative to laparoscopic radical nephrectomy (LRN) but there are concerns over costs and objective benefit. In the setting of very large renal masses (>10 cm), comparison between techniques is limited and it is unclear whether a robotic approach confers any perioperative benefit over LRN or open radical nephrectomy (ORN). In this study, perioperative outcomes of RRN, LRN, and ORN for very large renal masses are compared. Methods Using the National Cancer Database, patients were identified who underwent radical nephrectomy for kidney tumors >10 cm diagnosed from 2010-2015. Patients were analyzed according to surgical approach. Perioperative outcomes, including conversion to open, length of stay, readmission rates, positive surgical margins, and 30 and 90-day mortality were compared among cohorts. Results A total of 9288 patients met inclusion criteria (RRN = 842, LRN = 2326, ORN = 6120). Compared to ORN, recipients of RRN or LRN had similar rates of 30-day readmission and 30- and 90-day mortality. Length of hospital stay was significantly shorter in RRN (-1.73 days ±0.19; p<0.0001) and LRN (-1.40 days ±0.12; p<0.0001) compared to ORN. LRN had a higher rate of conversion to open compared to RRN (OR 1.48; 95% CI 1.10-1.98; p=0.0087). Conversion to open from RRN or LRN added 1.3 additional days of inpatient stay. Over the study period, RRN use increased from 4.1% to 14.8%, LRN from 20.9% to 25.6%, while ORN use decreased from 75% to 59.6%. Conclusions Minimally invasive approaches are increasingly utilized in very large renal masses. RRN has lower rates of conversion to open but produces comparable perioperative outcomes to LRN. Minimally invasive approaches have a shorter length of inpatient stay but otherwise report similar surgical margin status, readmission rates, and mortality rates compared to open radical nephrectomy.
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Affiliation(s)
- Logan Wilson Grimaud
- University of California Irvine, 8788, Urology, 101 The City Drive South, Orange, California, United States, 92868;
| | - Felix V Chen
- University of California Irvine, 8788, Urology, Orange, California, United States;
| | - Jenny Chang
- University of California Irvine, 8788, Medicine, 301 Med Surge II, Irvine, California, United States, 92697;
| | - Argyrios Ziogas
- University of California Irvine School of Medicine, 12219, Medicine, Irvine, California, United States;
| | - John Sfakianos
- Icahn School of Medicine at Mount Sinai, 5925, Urology, New York, New York, United States;
| | - Ketan K Badani
- Icahn School of Medicine at Mount Sinai, Urology, New York, New York, United States;
| | - Edward Uchio
- UCI Health, 14447, Urology, 333 City Blvd. West, Suite 2100, Orange, California, United States, 92868-3201;
| | - Hoda Anton-Culver
- University of California Irvine School of Medicine, 12219, Medicine , Irvine, California, United States;
| | - Greg Gin
- UCI, 8788, 333 City Blvd. West, Suite 2100, Orange, California, United States, 92868.,VA Medical Center Long Beach, 19974, Long Beach, California, United States, 90822-5201;
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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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Postoperative Pain After Enhanced Recovery Pathway Robotic Colon and Rectal Surgery: Does Specimen Extraction Site Matter? Dis Colon Rectum 2021; 64:735-743. [PMID: 33955408 DOI: 10.1097/dcr.0000000000001868] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The current opioid crisis has motivated surgeons to critically evaluate ways to balance postoperative pain while decreasing opioid use and thereby reducing opioids available for community diversion. The longest incision for robotic colorectal surgery is the specimen extraction site incision. Intracorporeal techniques allow specimen extraction to be at any location. OBJECTIVE This study was designed to determine whether the Pfannenstiel location is associated with less pain and opioid use than other abdominal wall specimen extraction sites. DESIGN This was a retrospective cohort study. SETTINGS The study was conducted with a prospectively maintained colorectal surgery database (July 2018 through October 2019). PATIENTS Patients with enhanced recovery robotic colorectal resections with specimen extraction were included. MAIN OUTCOME MEASURES Propensity score weighting was used to derive adjusted rates for numeric pain scores, inpatient opioid use, opioids prescribed at discharge, opioid refills after discharge, and other related outcomes. For comparing outcomes between groups, p values were calculated using weighted χ2, Fisher exact, and t tests. RESULTS There were 137 cases (70.9%) with Pfannenstiel extraction site incisions and 56 (29.0%) at other locations (7 midline, 49 off-midline). There was no significant difference in transversus abdominis plane blocks and epidural analgesia use between groups. Numeric pain scores, overall benefit of analgesia scores, inpatient postoperative opioid use, opioids prescribed at discharge and taken after discharge, and opioid refills were not significantly different between groups. Nonopioid pain analgesics (acetaminophen, nonsteroidal anti-inflammatory drugs, and gabapentin) prescribed at discharge were significantly less in the Pfannenstiel group (90.19% vs 98.45%; p = 0.006). Postoperative complications and readmissions were not different between groups. LIMITATIONS This study was conducted at a single institution. CONCLUSIONS The Pfannenstiel incision as the specimen extraction site choice in minimally invasive surgery is associated with similar postoperative pain and opioid use as extraction sites in other locations for patients having robotic colorectal resections. Specimen extraction sites may be chosen based on patient factors other than pain and opioid use. See Video Abstract at http://links.lww.com/DCR/B495. DOLOR POSTOPERATORIO DESPUS DE VAS DE RECUPERACIN MEJORADA EN CIRUGA ROBTICA DE COLON Y RECTO IMPORTA EL LUGAR DE EXTRACCIN DE LA MUESTRA ANTECEDENTES:La actual crisis de opioides ha motivado a los cirujanos a evaluar críticamente, formas para equilibrar el dolor postoperatorio, disminuyendo el uso de opioides y por lo tanto, disminuyendo opioides disponibles para el desvío comunitario. La incisión más amplia en cirugía colorrectal robótica, es la incisión del sitio de extracción de la muestra. Las técnicas intracorpóreas permiten que la extracción de la muestra se realice en cualquier sitio.OBJETIVO:El estudio fue diseñado para determinar si la ubicación del Pfannenstiel está asociada con menos dolor y uso de opioides, a otros sitios de extracción de la muestra en la pared abdominal.DISEÑO:Estudio de cohorte retrospectivo.AJUSTES:Estudio de base de datos de cirugía colorrectal mantenida prospectivamente (7/2018 a 10/2019).PACIENTES:Se incluyeron resecciones robóticas colorrectales con recuperación mejorada y extracción de muestras.PRINCIPALES MEDIDAS DE RESULTADO:Se utilizó la ponderación del puntaje de propensión para derivar las tasas ajustadas para los puntajes numéricos de dolor, uso de opioides en pacientes hospitalizados, opioides recetados al alta, recarga de opioides después del alta y otros resultados relacionados. Para comparar los resultados entre los grupos, los valores p se calcularon utilizando chi-cuadrado ponderado, exacto de Fisher y pruebas t.RESULTADOS:Hubo 137 (70,9%) casos con incisiones en el sitio de extracción de Pfannenstiel y 56 (29,0%) en otras localizaciones (7 en la línea media, 49 fuera de la línea media). No hubo diferencias significativas en los bloqueos del plano transverso del abdomen y el uso de analgesia epidural entre los grupos. Las puntuaciones numéricas de dolor, puntuaciones de beneficio general de la analgesia, uso postoperatorio de opioides en pacientes hospitalizados, opioides recetados al alta y tomados después del alta, y las recargas de opioides, no fueron significativamente diferentes entre los grupos. Los analgésicos no opioides (acetaminofén, antiinflamatorios no esteroideos, gabapentina) prescritos al alta, fueron significativamente menores en el grupo de Pfannenstiel (90,19% frente a 98,45%, p = 0,006). Las complicaciones postoperatorias y los reingresos, no fueron diferentes entre los grupos.LIMITACIONES:Una sola institución.CONCLUSIÓN:La incisión de Pfannenstiel como sitio de extracción de la muestra en cirugía mínimamente invasiva, se asocia con dolor postoperatorio y uso de opioides similar, a otros sitios de extracción en pacientes sometidos a resecciones robóticas colorrectales. Sitios de extracción de la muestra, pueden elegirse en función de factores del paciente distintos al dolor y uso de opioides. Consulte Video Resumen en http://links.lww.com/DCR/B495.).
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Wong SW, Ang ZH, Yang PF, Crowe P. Robotic colorectal surgery and ergonomics. J Robot Surg 2021; 16:241-246. [PMID: 33886064 DOI: 10.1007/s11701-021-01240-5] [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: 01/12/2021] [Accepted: 04/11/2021] [Indexed: 11/26/2022]
Abstract
Improved ergonomics for the operating surgeon may be an advantage of robotic colorectal surgery. Perceived robotic ergonomic advantages in visualisation include better exposure, three-dimensional vision, surgeon camera control, and line of sight screen location. Postural advantages include seated position and freedom from the constraints of the sterile operating field. Manipulation benefits include articulated instruments with seven degrees of freedom movement, elimination of fulcrum effect, tremor filtration, and scaling of movement. Potential ergonomic detriments of robotic surgery include lack of haptic feedback, visual, and mental strain from increased operating time and interruptions to workflow from crowding.
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Affiliation(s)
- Shing Wai Wong
- Department of General Surgery, Prince of Wales Hospital, Sydney, NSW, Australia.
- Prince of Wales Clinical School, The University of New South Wales, Sydney, NSW, Australia.
| | - Zhen Hao Ang
- Department of General Surgery, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Phillip F Yang
- Department of General Surgery, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Philip Crowe
- Department of General Surgery, Prince of Wales Hospital, Sydney, NSW, Australia
- Prince of Wales Clinical School, The University of New South Wales, Sydney, NSW, Australia
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Donlon NE, Nugent TS, Free R, Hafeez A, Kalbassi R, Neary PC, O'Riordain DS. Robotic versus laparoscopic anterior resections for rectal and rectosigmoid cancer: an institutional experience. Ir J Med Sci 2021; 191:845-851. [PMID: 33846946 DOI: 10.1007/s11845-021-02625-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: 01/02/2021] [Accepted: 04/08/2021] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Colorectal surgery has evolved with the advent of laparoscopic techniques and now robotic-assisted surgery. There is significant literature supporting the use of laparoscopic techniques over open surgery with evidence of enhanced post-operative recovery, reduced use of opioids, smaller incisions and equivalent oncological outcomes. Robotic minimally invasive surgery addresses some of the limitations of laparoscopic surgery, providing surgical precision and improvements in perception and dexterity with a resulting decrease in tissue damage. METHODS We retrospectively reviewed the medical records of patients who underwent robotic-assisted anterior resection for cancer of the rectum or rectosigmoid junction in our institution since our robotic programme began in 2017. Patient demographics were identified via electronic databases and patient charts. A matched cohort of laparoscopic cases was identified. RESULTS A total of 51 consecutive robotic-assisted anterior resections were identified and case matched with laparoscopic resections for comparison. Robotic-assisted surgery was associated with a shorter length of stay (p = 0.04), reduced initial post-operative analgesia requirements (p < 0.01) and no significant difference in time to bowel movement or stoma functioning (p = 0.84). All patients had an R0 resection, and there was no statistical difference in lymph node yield between the groups (p = 0.14). Robotic surgery was associated with a longer operative duration (p < 0.001). CONCLUSION In this early experience, robotic surgery has proven feasible and safe and is comparable to laparoscopic surgery in terms of completeness of resection and recovery. As costs and operating times decline and as technology progresses, robotic surgery may one day replace traditional laparoscopic techniques.
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Affiliation(s)
- Noel E Donlon
- Department of Colorectal Surgery, Beacon Hospital, Dublin, Ireland.
| | - Tim S Nugent
- Department of Colorectal Surgery, Beacon Hospital, Dublin, Ireland
| | - Ross Free
- Department of Colorectal Surgery, Beacon Hospital, Dublin, Ireland
| | - Adnan Hafeez
- Department of Colorectal Surgery, Beacon Hospital, Dublin, Ireland
| | - Resa Kalbassi
- Department of Colorectal Surgery, Beacon Hospital, Dublin, Ireland
| | - Paul C Neary
- Department of Colorectal Surgery, Beacon Hospital, Dublin, Ireland
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Abstract
Abstract
Introduction Minimally invasive surgery has revolutionized surgical management in the treatment of colorectal neoplasms, reducing morbidity and mortality, hospitalization, inactivity time and minimizing cost, as well as providing adequate oncological results when compared to the conventional approach. Robotic surgery, with Da Vinci Platform, emerges as a step ahead for its potentials. The objective of this article is to report the single institutional experience with the use of Da Vinci Platform in robotic colorectal surgeries performed at a reference center in oncological surgery in Brazil.
Materials and methods A retrospective cohort study was conducted based on the prospective database of patients from the institution submitted to robotic surgery for treatment of colorectal cancer from July 2012 to September 2017. Clinical and surgical variables were analyzed as predictors of morbidity and mortality.
Results A total of 117 patients underwent robotic surgery. The complications related to surgery occurred in 33 patients (28%), the most frequent being anastomotic fistula and surgical wound infection, which corresponded to 11% and 3%, respectively. Conversion rate was 1.7%. Median length of stay was 5 days. The only variable associated with increase of complications and death risk was BMI >30, with p-value of 0.038 and 0.027, respectively.
Conclusion Robotic surgery is safe and feasible for approaching colorectal cancer surgeries, presenting satisfactory results regarding length of hospital stay and rate of operative complications, as well as presenting a low rate of conversion. Obesity has been shown to be a risk factor for surgical complication in robotic colorectal surgery.
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Optimizing outcomes in colorectal surgery: cost and clinical analysis of robotic versus laparoscopic approaches to colon resection. J Robot Surg 2021; 16:107-112. [PMID: 33634355 DOI: 10.1007/s11701-021-01205-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 01/25/2021] [Indexed: 01/18/2023]
Abstract
The use of robotics in colorectal surgery has been steadily increasing, however, reported longer operative times and increased cost has limited its widespread adoption. We investigated the cost of elective colorectal surgery based on type of anatomic resection and the impact of a standardized protocol for robotic colectomies. A retrospective review was conducted of 279 elective colectomies at a single institution between 2013 and 2017. Clinical outcomes and detailed cost data were compared based on open, laparoscopic, or robotic surgical approach and stratified by anatomic resection. Robotic, laparoscopic and open colectomy rates were 35, 34 and 31%, respectively. While total costs were similar in robotic and laparoscopic surgery, anatomic resection stratification showed that low anterior resection (LAR) was significantly cheaper ($14,093 vs $17,314). When a standardized surgical protocol was implemented for robotic colectomies, significant reductions in operative times, length of stay, total cost, and operative cost were observed. Robotic surgery may be most cost effective for elective LAR compared to laparoscopic or open approaches. A standardized surgical protocol for robotic surgery may help reduce costs by reducing operative times, operating rooms expenditure, and lengths of stay.
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Current status of robotic surgery in colorectal residency training programs. Surg Endosc 2021; 36:307-313. [PMID: 33523270 DOI: 10.1007/s00464-020-08276-y] [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: 08/16/2020] [Accepted: 12/24/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Robotic surgery (RS) has been increasingly incorporated into colorectal surgery (CRS) training. The degree to which RS has been integrated into CRS residency training is not well described. METHODS A web-based survey was sent to all 2019 accredited CRS residency programs within the United States and Canada. Program directors (PDs) were queried on how robotic surgery had been integrated into their program, specifics on RS curriculum and opinions on RS training during general surgery residency. We compared survey responses by program type (university-based, university-affiliated programs, or independent programs) and by geographic region. In addition, a chi-square test was used to evaluate differences in survey responses with respect to robotic curriculum components. RESULTS Of 66 programs, 42 (64%) responded to the survey. Of the responding programs, 35 (83%) were university-based or university-affiliated, while 7 (17%) were independent. Most programs were in the Midwest (33%). Forty-one (98%) reported having a surgical robot in use at their institution, with 95% reporting active participation of CRS residents in RS. While 74% of programs have a formal RS training curriculum for CRS residents, there was considerable variability in the curriculum elements employed by each institution, and the differences in proportions of these elements were significant (χ2 99.8, p < 0.001). The median operative approach to abdominopelvic cases was estimated to be 33% robotic, 40% laparoscopic and 20% open. There were no significant differences in the survey responses between university/university-affiliated and independent programs (p > 0.05) or among the different regions (p > 0.05). CONCLUSIONS This study demonstrated that almost all CRS residencies have integrated RS and have trainees operating at the robotic console. Most programs have a robotics curriculum and there are expanding indications for RS within CRS. This expansion calls for discussion on implementation of training standards such as curricular requisites, baseline competency assessments, and definitions of minimum case requirements to ensure adequate training.
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Mathis-Ullrich F, Scheikl PM. [Robots in the operating room-(co)operation during surgery]. GASTROENTEROLOGE 2020; 16:25-34. [PMID: 33362879 PMCID: PMC7753502 DOI: 10.1007/s11377-020-00496-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 12/22/2022]
Abstract
Hintergrund Medizinrobotik birgt das Potenzial, chirurgische oder endoluminale Eingriffe zu verbessern, indem diese Technologie hochpräzise Bewegungen und übermenschliche Perzeption ermöglicht. Ziel der Arbeit Darstellung historischer, existierender und zukünftiger robotischer Assistenten sowie Herausstellung deren Auswirkungen auf die robotische Chirurgie und Endoskopie. Methoden Insbesondere werden historische Medizinroboter sowie konventionelle Telemanipulatoren vorgestellt und diese mit minimal-invasiven Kontinuumsrobotern und neuartigen robotischen Konzepten aus Praxis und Forschung verglichen. Zusätzlich wird eine Perspektive für die zukünftige Generation von Chirurgie- und Endoskopierobotern geboten. Schlussfolgerung Roboterassistierte Medizin bietet einen großen Mehrwert für die Qualität der Intervention sowie Sicherheit für Chirurgen und Patientinnen. Zukünftig werden vermehrt Prozessschritte (teil‑)autonom in Kooperation mit Experten durchgeführt.
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Affiliation(s)
- F Mathis-Ullrich
- Institut für Anthropomatik und Robotik (IAR), Health Robotics and Automation Laboratory (HERA), Karlsruher Institut für Technologie (KIT), Engler-Bunte-Ring 8, 76131 Karlsruhe, Deutschland
| | - P M Scheikl
- Institut für Anthropomatik und Robotik (IAR), Health Robotics and Automation Laboratory (HERA), Karlsruher Institut für Technologie (KIT), Engler-Bunte-Ring 8, 76131 Karlsruhe, Deutschland
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Gehrman J, Angenete E, Björholt I, Lesén E, Haglind E. Cost-effectiveness analysis of laparoscopic and open surgery in routine Swedish care for colorectal cancer. Surg Endosc 2020; 34:4403-4412. [PMID: 31630289 DOI: 10.1007/s00464-019-07214-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 10/09/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Laparoscopic surgery for colorectal cancer has been shown in clinical trials to be effective regarding short-term outcomes and oncologically safe. Health economic analyses have been performed early in the learning curve when adoption of laparoscopic surgery was not extensive. This cost-effectiveness analysis evaluates laparoscopic versus open colorectal cancer surgery in Swedish routine care. METHODS In this national retrospective cohort study, data were retrieved from the Swedish ColoRectal Cancer Registry. Clinical effectiveness, resource use and unit costs were derived from this and other sources with nationwide coverage. The study period was 2013 and 2014 with 1 year follow-up. Exclusion criterion comprised cT4-tumors. Clinical effectiveness was estimated in a composite endpoint of all-cause resource-consuming events in inpatient care, readmissions and deaths up to 90 days postoperatively. Up to 1 year, events predefined as related to the primary surgery were included. Costs included resource-consuming events, readmissions and sick leave and were estimated for both the society and healthcare. Multivariable regression analyses were used to adjust for differences in baseline characteristics between the groups. RESULTS After exclusion of cT4 tumors, the cohort included 7707 patients who underwent colorectal cancer surgery: 6060 patients in the open surgery group and 1647 patients in the laparoscopic group. The mean adjusted difference in clinical effectiveness between laparoscopic and open colorectal cancer surgery was 0.23 events (95% CI 0.12 to 0.33). Mean adjusted differences in costs (open minus laparoscopic surgery) were $4504 (95% CI 2257 to 6799) and $4480 (95% CI 2739 to 6203) for the societal and the healthcare perspective respectively. In both categories, resource consuming events in inpatient care were the main driver of the results. CONCLUSION In a national cohort, laparoscopic colorectal cancer surgery was associated with both superior outcomes for clinical effectiveness and cost versus open surgery.
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Affiliation(s)
- Jacob Gehrman
- Department of Surgery, Institute of Clinical Sciences, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, Sahlgrenska Academy, University of Gothenburg, 416 50, Gothenburg, Sweden. .,PharmaLex (Formerly Nordic Health Economics), Medicinaregatan 8, 413 90, Gothenburg, Sweden.
| | - Eva Angenete
- Department of Surgery, Institute of Clinical Sciences, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, Sahlgrenska Academy, University of Gothenburg, 416 50, Gothenburg, Sweden
| | - Ingela Björholt
- Department of Surgery, Institute of Clinical Sciences, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, Sahlgrenska Academy, University of Gothenburg, 416 50, Gothenburg, Sweden.,PharmaLex (Formerly Nordic Health Economics), Medicinaregatan 8, 413 90, Gothenburg, Sweden
| | - Eva Lesén
- PharmaLex (Formerly Nordic Health Economics), Medicinaregatan 8, 413 90, Gothenburg, Sweden
| | - Eva Haglind
- Department of Surgery, Institute of Clinical Sciences, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, Sahlgrenska Academy, University of Gothenburg, 416 50, Gothenburg, Sweden
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Wilkie B, Summers Z, Hiscock R, Wickramasinghe N, Warrier S, Smart P. Robotic colorectal surgery in Australia: a cohort study examining clinical outcomes and cost. AUST HEALTH REV 2020; 43:526-530. [PMID: 30922441 DOI: 10.1071/ah18093] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 12/14/2018] [Indexed: 11/23/2022]
Abstract
Objective The aim of this study was to compare robotic versus laparoscopic colorectal operations for clinical outcomes, safety and cost. Methods A retrospective cohort study was performed of 213 elective colorectal operations (59 robotic, 154 laparoscopic), matched by surgeon and operation type. Results No differences in age, body mass index, median American Society of Anesthesiologists score or presence of cancer were observed between the laparoscopic or robotic surgery groups. However, patients undergoing robotic colorectal surgery were more frequently male (P = 0.004) with earlier T stage tumours (P = 0.02) if cancer present. Procedures took longer in cases of robotic surgery (302 vs 130 min; P < 0.001), and patients in this group were more frequently admitted to intensive care units (P < 0.001). Overall length of stay was longer (7 vs 5 days; P = 0.03) and consumable cost was A$2728 higher per patient in the robotic surgery group. Conclusion Robotic colorectal surgery appears to be safe compared with current laparoscopic techniques, albeit with longer procedure times and overall length of stay, more frequent intensive care admissions and higher consumables cost. What is known about the topic? Robotic surgery is an emerging alternative to traditional laparoscopic approaches in colorectal surgery. International trials suggest the two techniques are equivalent in safety. What does this paper add? This is an original cohort study examining clinical outcomes in Australian colorectal robotic surgery. The data suggest it may be safe, but this paper demonstrates key issues in the implementation and audit of novel surgical technologies in relatively low-volume centres. What are implications for practitioners? In our study, patients undergoing robotic colorectal surgery at a single centre in Australia had equivalent measured clinical outcomes to those undergoing laparoscopic surgery. However, practitioners may counsel patients that robotic procedures are typically longer and more expensive, with a longer overall hospital admission and a higher likelihood of intensive care admission.
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Affiliation(s)
- Bruce Wilkie
- Department of Surgery, Eastern Health, 8 Arnold Street, Box Hill, Vic. 3128, Australia. ; ; and Corresponding author.
| | - Zara Summers
- Department of Surgery, Eastern Health, 8 Arnold Street, Box Hill, Vic. 3128, Australia. ;
| | - Richard Hiscock
- Epworth Healthcare, 89 Bridge Road, Richmond, Vic. 3121, Australia.
| | | | - Satish Warrier
- Department of Surgery, Peter McCallum Cancer Centre, 305 Grattan Street, Melbourne, Vic. 3000, Australia. ; and General Surgery and Gastroenterology Clinical Institute, Epworth Healthcare, 89 Bridge Road, Richmond, Vic. 3121, Australia
| | - Philip Smart
- Department of Surgery, Eastern Health, 8 Arnold Street, Box Hill, Vic. 3128, Australia. ; ; and General Surgery and Gastroenterology Clinical Institute, Epworth Healthcare, 89 Bridge Road, Richmond, Vic. 3121, Australia
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Is robotic surgery feasible at a safety net hospital? Surg Endosc 2020; 35:4452-4458. [PMID: 32880747 DOI: 10.1007/s00464-020-07948-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/25/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Robotic surgery offers potential advantages of improved ability to complete procedures using a minimally invasive approach, recovery, and clinical outcomes. It has been previously established that safety net hospitals are outliers for surgical complications. As such, the adoption of new technology may not achieve the same outcomes as other institutions. We hypothesized that, compared to laparoscopic and open surgeries, robotic surgeries have fewer post-operative Clavien-Dindo complications at our safety net hospital. METHODS All robotic surgeries performed from 2017 to 2019 at a single, safety net hospital were reviewed. Cases were matched 1:3 to laparoscopic controls. Surgeries commonly performed open were additionally matched 1:3 to open counterparts. The primary outcome was Clavien-Dindo complications at 90 days post-operatively. Secondary outcomes included inadvertent enterotomy, conversion to open, operative duration, wound class, surgical site infection (SSI), surgical site occurrence (SSO), length of stay (LOS), reoperation, readmission, and recurrence. RESULTS A total of 160 robotic surgeries were included and matched to 480 laparoscopic surgeries and 108 open surgeries. Open surgeries were associated with greater risk of Clavien-Dindo complication (OR = 2.7, p = 0.040, 95% confidence interval 1.0-6.9) than either robotic or laparoscopic surgeries. Robotic cases had increased operative duration when compared to laparoscopic (p < 0.001) but not open cases (p = 0.093). No difference was seen in enterotomy, conversion to open, SSI, SSO, LOS, reoperation, readmission, or recurrence between robotic and laparoscopic, and robotic and open cases. CONCLUSION Robotic surgery is safe and feasible at a safety net hospital. Robotic and laparoscopic surgeries were associated with fewer Clavien-Dindo complications than open surgery, but no differences were seen between robotic and laparoscopic cases. Robotic surgery, compared to both laparoscopic and open surgery, had longer operative durations. Further studies are needed to assess the value of robotic as opposed to laparoscopic surgery in a safety net setting.
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Lo BD, Zhang GQ, Stem M, Sahyoun R, Efron JE, Safar B, Atallah C. Do specific operative approaches and insurance status impact timely access to colorectal cancer care? Surg Endosc 2020; 35:3774-3786. [PMID: 32813058 DOI: 10.1007/s00464-020-07870-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 08/05/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The increased use of minimally invasive surgery in the management of colorectal cancer has led to a renewed focus on how certain factors, such as insurance status, impact the equitable distribution of both laparoscopic and robotic surgery. Our goal was to analyze surgical wait times between robotic, laparoscopic, and open approaches, and to determine whether insurance status impacts timely access to treatment. METHODS After IRB approval, adult patients from the National Cancer Database with a diagnosis of colorectal cancer were identified (2010-2016). Patients who underwent radiation therapy, neoadjuvant chemotherapy, had wait times of 0 days from diagnosis to surgery, or had metastatic disease were excluded. Primary outcomes were days from cancer diagnosis to surgery and days from surgery to adjuvant chemotherapy. Multivariable Poisson regression analysis was performed. RESULTS Among 324,784 patients, 5.9% underwent robotic, 47.5% laparoscopic, and 46.7% open surgery. Patients undergoing robotic surgery incurred the longest wait times from diagnosis to surgery (29.5 days [robotic] vs. 21.7 [laparoscopic] vs. 17.2 [open], p < 0.001), but the shortest wait times from surgery to adjuvant chemotherapy (48.9 days [robotic] vs. 49.9 [laparoscopic] vs. 54.8 [open], p < 0.001). On adjusted analysis, robotic surgery was associated with a 1.46 × longer wait time to surgery (IRR 1.462, 95% CI 1.458-1.467, p < 0.001), but decreased wait time to adjuvant chemotherapy (IRR 0.909, 95% CI 0.905-0.913, p < 0.001) compared to an open approach. Private insurance was associated with decreased wait times to surgery (IRR 0.966, 95% CI 0.962-0.969, p < 0.001) and adjuvant chemotherapy (IRR 0.862, 95% CI 0.858-0.865, p < 0.001) compared to Medicaid. CONCLUSION Though patients undergoing robotic surgery experienced delays from diagnosis to surgery, they tended to initiate adjuvant chemotherapy sooner compared to those undergoing open or laparoscopic approaches. Private insurance was independently associated not only with access to robotic surgery, but also shorter wait times during all stages of treatment.
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Affiliation(s)
- Brian D Lo
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21205, USA
| | - George Q Zhang
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21205, USA
| | - Miloslawa Stem
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21205, USA
| | - Rebecca Sahyoun
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21205, USA
| | - Jonathan E Efron
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21205, USA
| | - Bashar Safar
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21205, USA
| | - Chady Atallah
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21205, USA.
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Abstract
With the rapid adoption of robotics in colorectal surgery, there has been growing interest in the pace at which surgeons gain competency, as it may aid in self-assessment or credentialing. Therefore, we sought to evaluate the learning curve of an expert laparoscopic colorectal surgeon who performed a variety of colorectal procedures robotically. This is a retrospective review of a prospective database of 111 subsequent colorectal procedures performed by a single colorectal surgeon. The cumulative summation technique (CUSUM) was used to construct a learning curve for robotic proficiency by analyzing total operative and console times. Postoperative outcomes including length of stay, 30-day complications, and 30-day readmission rates were evaluated. Chi-square and one-way ANOVA (including Kruskal-Wallis) tests were used to evaluate categorical and continuous variables. Our patient cohort had a mean age of 62.4, mean BMI of 26.9, and mean ASA score of 2.41. There were two conversions to open surgery. The CUSUM graph for console time indicated an initial decrease at case 13 and another decrease at case 83, generating 3 distinct performance phases: learning (n = 13), competence (n = 70), and mastery (n = 28). An interphase comparison revealed no significant differences in age, gender, BMI, ASA score, types of procedures, or indications for surgery between the three phases. Over the course of the study, both mean surgeon console time and median length of stay decreased significantly (p = 0.00017 and p = 0.016, respectively). Although statistically insignificant, there was a downward trend in total operative time and postoperative complication rates. Learning curves for robotic colorectal surgery are commonly divided into three performance phases. Our findings contribute to the construction of a reliable learning curve for the transition of colorectal surgeons to robotics. Furthermore, they may help guide the stepwise training and credentialing of new robotic surgeons.
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Hu KY, Wu R, Szabo A, Ridolfi TJ, Ludwig KA, Peterson CY. Laparoscopic Versus Robotic Proctectomy Outcomes: An ACS-NSQIP Analysis. J Surg Res 2020; 255:495-501. [PMID: 32622164 DOI: 10.1016/j.jss.2020.05.094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/11/2020] [Accepted: 05/24/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The robotic platform is increasingly used in colorectal surgery. Recent upgrades in the robotic platform and introduction of proctectomy-specific reports from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) warrant updated evaluation of minimally invasive proctectomy outcomes. The aim of this study was to compare outcomes in robotic versus laparoscopic proctectomy using ACS-NSQIP data. MATERIALS AND METHODS The ACS-NSQIP data set was used to identify adult patients undergoing elective robotic and laparoscopic proctectomy in 2016 and 2017. Demographics, preoperative and intraoperative data, and postoperative outcomes were collected. Propensity-weighted analysis was used to estimate the effect of robotic versus laparoscopic surgery on outcomes. RESULTS Of 3845 patients meeting inclusion criteria, 2681 (70%) underwent a laparoscopic approach and 1164 (30%) underwent a robotic approach. Patients undergoing a robotic procedure were more likely to be older, have higher American Society of Anesthesiologists scores, low rectal tumors, and have undergone chemotherapy or radiation before surgery. After propensity adjustment, a robotic approach was associated with a decrease in conversion to open operation (estimated mean difference, -6.7%; P < 0.01), length of stay (-0.6 d; P = 0.01), occurrence of postoperative ileus (-3.7%; P = 0.01), and an increase in operative time (20.3 min; P < 0.01). CONCLUSIONS Using data from a national cohort, we found that compared with laparoscopy, robotic proctectomy is associated with decreased conversion to open operation, longer operation time, decreased length of stay, and decreased postoperative ileus. Our study identified several advantages to a robotic approach; however, further work is needed to assess cost-effectiveness in conjunction with clinical outcomes.
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Affiliation(s)
- Katherine Y Hu
- Division of Colorectal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ruizhe Wu
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Aniko Szabo
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Timothy J Ridolfi
- Division of Colorectal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kirk A Ludwig
- Division of Colorectal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Carrie Y Peterson
- Division of Colorectal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
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Abstract
The global numbers of robotic gastrointestinal surgeries are increasing. However, the evidence base for robotic gastrointestinal surgery does not yet support its widespread adoption or justify its cost. The reasons for its continued popularity are complex, but a notable driver is the push for innovation - robotic surgery is seen as a compelling solution for delivering on the promise of minimally invasive precision surgery - and a changing commercial landscape delivers the promise of increased affordability. Novel systems will leverage the robot as a data-driven platform, integrating advances in imaging, artificial intelligence and machine learning for decision support. However, if this vision is to be realized, lessons must be heeded from current clinical trials and translational strategies, which have failed to demonstrate patient benefit. In this Perspective, we critically appraise current research to define the principles on which the next generation of gastrointestinal robotics trials should be based. We also discuss the emerging commercial landscape and define existing and new technologies.
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Outcomes of Minimally Invasive Versus Open Proctectomy for Rectal Cancer: A Propensity-Matched Analysis of Bi-National Colorectal Cancer Audit Data. Dis Colon Rectum 2020; 63:778-787. [PMID: 32109916 DOI: 10.1097/dcr.0000000000001654] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Minimally invasive surgery is commonly used in the treatment of rectal cancer, despite the lack of evidence to support oncological equivalence or improved recovery compared with open surgery. OBJECTIVE This study aims to analyze prospectively collected data from a large Australasian colorectal cancer database. DESIGN This is a retrospective cohort study using propensity score matching. SETTING This study was conducted using data supplied by the Bi-National Colorectal Cancer Audit. PATIENTS A total of 3451 patients who underwent open (n = 1980), laparoscopic (n = 1269), robotic (n = 117), and transanal total mesorectal excision (n = 85) for rectal cancer were included in this study. MAIN OUTCOME MEASURE The primary outcome was positive margin rates (circumferential resection margin and/or distal resection margin) in patients treated with curative intent. RESULTS Propensity score matching yielded 1132 patients in each of the open and minimally invasive surgery groups. Margin positivity rates and lymph node yields did not differ between groups. The open group had a significantly lower total complication rate (27.6% vs 35.8%, p < 0.0001), including a lower rate of postoperative small-bowel obstruction (1.2% vs 2.5%, p = 0.03). The minimally invasive surgery group had significantly lower wound infection rate (2.9% vs 5.0%, p = 0.02) and a shorter length of hospital stay (8 vs 9 days, p < 0.0001). There was no difference in 30-day mortality. LIMITATIONS Results are limited by the quality of registry data entries. CONCLUSION In this patient population, minimally invasive proctectomy demonstrated similar margin rates in comparison with open proctectomy, with a reduced length of stay but a higher overall complication rate. See Video Abstract at http://links.lww.com/DCR/B190. RESULTADOS DE LA PROCTECTOMÍA MÍNIMA INVASIVA VERSUS ABIERTA PARA EL CÁNCER DE RECTO: UN ANÁLISIS DE PROPENSIÓN DE LOS DATOS BINACIONALES DE AUDITORÍA DEL CÁNCER COLORRECTAL: La cirugía mínima invasiva, frecuentemente se utiliza en el tratamiento del cáncer rectal, a pesar de la falta de evidencia que respalde la equivalencia oncológica o la mejor recuperación, en comparación con la cirugía abierta.El estudio tiene como objetivo analizar datos prospectivamente obtenidos, de una gran base de datos de cáncer colorrectal de Australia.Estudio de cohorte retrospectivo utilizando el emparejamiento de puntaje de propensión.Este estudio se realizó utilizando datos proporcionados por la Auditoría Binacional del Cáncer Colorrectal.Se incluyeron en este estudio un total de 3451 pacientes que se trataron de manera abierta (n = 1980), laparoscópica (n = 1269), robótica (n = 117) y taTME (n = 85) para cáncer rectal.Los resultados primarios fueron de tasas de margen positivas (margen de resección circunferencial y/o margen de resección distal) en pacientes con intención curativa.La coincidencia de puntaje de propensión arrojó 1132 pacientes en cada uno de los grupos de cirugía abierta y mínima invasiva. Las tasas de positividad del margen y los rendimientos de los ganglios linfáticos no difirieron entre los dos grupos. El grupo abierto tuvo una tasa de complicaciones totales significativamente menor (27.6% vs 35.8%, p <0.0001), incluida una tasa menor de obstrucción postoperatoria del intestino delgado (1.2% vs 2.5%, p = 0.03). El grupo de cirugía mínimamente invasiva tuvo una tasa de infección de la herida significativamente menor (2.9% frente a 5.0%, p = 0,02) y una estancia hospitalaria más corta (8 frente a 9 días, p <0.0001). No hubo diferencias en la mortalidad a los 30 días.Los resultados están limitados por la calidad de la entrada de datos de registro.En esta población de pacientes, la proctectomía mínima invasiva demostró tasas de margen similares en comparación con la proctectomía abierta, con una estadía reducida pero una tasa más alta de complicaciones en general. Consulte Video Resumen en http://links.lww.com/DCR/B190. (Traducción-Dr. Fidel Ruiz Healy).
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Crippa J, Grass F, Larson DW. Author response to: Is robotic approach associated with a lower risk of conversion in rectal cancer surgery compared with laparoscopic approach? Br J Surg 2020; 107:e227. [PMID: 32352562 DOI: 10.1002/bjs.11599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 02/26/2020] [Indexed: 11/07/2022]
Affiliation(s)
- J Crippa
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - F Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - D W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Frailer Patients Undergoing Robotic Colectomies for Colon Cancer Experience Increased Complication Rates Compared With Open or Laparoscopic Approaches. Dis Colon Rectum 2020; 63:588-597. [PMID: 32032198 DOI: 10.1097/dcr.0000000000001598] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Minimally invasive surgical techniques are routinely promoted as alternatives to open surgery because of improved outcomes. However, the impact of robotic surgery on certain subsets of the population, such as frail patients, is poorly understood. OBJECTIVE The purpose of our study was to examine the association between frailty and minimally invasive surgical approaches with colon cancer surgery. DESIGN This is a retrospective study of prospectively collected outcomes data. Thirty-day surgical outcomes were compared by frailty and surgical approach using doubly robust multivariable logistic regression with propensity score weighting, and testing for interaction effects between frailty and surgical approach. SETTING Patients undergoing an open, laparoscopic, or robotic colectomy for primary colon cancer, 2012 to 2016, were identified from the American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS Patients undergoing a colectomy with an operative indication for primary colon cancer were selected. MAIN OUTCOME MEASURES The primary outcomes measured were 30-day postoperative complications. RESULTS After propensity score weighting of patients undergoing colectomy, 33.8% (n = 27,649) underwent an open approach versus 34.3% (n = 28,058) underwent laparoscopic surgery versus 31.9% (n = 26,096) underwent robotic surgery. Robotic (OR, 0.53; 95% CI, 0.42-0.69, p < 0.001) and laparoscopic (OR, 0.58; 95% CI, 0.52-0.66, p < 0.001) surgeries were independently associated with decreased rates of major complications. Frailer patients had increased complication rates (OR, 1.56; 95% CI, 1.07-2.25, p = 0.018). When considering the interaction effects between surgical approach and frailty, frailer patients undergoing robotic surgery were more likely to develop a major complication (combined adjusted OR, 3.15; 95% CI, 1.34-7.45, p = 0.009) compared with patients undergoing open surgery. LIMITATIONS Use of the modified Frailty Index as an associative proxy for frailty was a limitation of this study. CONCLUSIONS Although minimally invasive surgical approaches have decreased postoperative complications, this effect may be reversed in frail patients. These findings challenge the belief that robotic surgery provides a favorable alternative to open surgery in frail patients. See Video Abstract at http://links.lww.com/DCR/B163. LOS PACIENTES MÁS FRÁGILES SOMETIDOS A COLECTOMÍA ROBÓTICA POR CÁNCER DE COLON EXPERIMENTAN MAYORES TASAS DE COMPLICACIONES EN COMPARACIÓN CON ABORDAJES LAPAROSCÓPICO O ABIERTO: Las técnicas quirúrgicas mínimamente invasivas estan frecuentement promovidas como alternativas a la cirugía abierta debido a sus mejores resultados. Sin embargo, el impacto de la cirugía robótica en ciertos subgrupos de población, como el caso de los pacientes endebles, es poco conocido.El propósito de nuestro estudio fue examinar la asociación entre la fragilidad de los pacientes y el aborgaje quirúrgico mínimamente invasivo para la cirugía de cáncer de colon.Estudio retrospectivo de datos de resultados recolectados prospectivamente. Los resultados quirúrgicos a 30 días se compararon entre fragilidad y abordaje quirúrgico utilizando la regresión logística multivariable doblemente robusta con ponderación de puntaje de propensión y pruebas de efectos de interacción entre fragilidad y abordaje quirúrgico.Los pacientes identificados en la base de datos del Programa Nacional de Mejora de la Calidad Quirúrgica del Colegio Estadounidense de Cirujanos, que fueron sometidos a una colectomía abierta, laparoscópica o robótica por cáncer de colon primario, de 2012 a 2016.Todos aquellos pacientes seleccionados con indicación quirúrgica de cáncer primario de colon que fueron sometidos a una colectomía.Las complicaciones postoperatorias a 30 días.Luego de ponderar el puntaje de propensión de los pacientes colectomizados, el 33.8% (n = 27,649) fué sometido a laparotomía versus el 34.3% (n = 28,058) operados por laparoscopía versus el 31.9% (n = 26,096) operados con tecnica robótica. Las cirugías robóticas (OR 0.53, IC 95% 0.42-0.69, p < 0.001) y laparoscópicas (OR 0.58, IC 95% 0.52-0.66, p < 0.001) se asociaron de forma independiente con una disminución de las tasas de complicaciones mayores. Los pacientes más delicados tenían mayores tasas de complicaciones (OR 1.56, IC 95% 1.07-2.25, p = 0.018). Al considerar los efectos de interacción entre el abordaje quirúrgico y la fragilidad, los pacientes más débiles sometidos a cirugía robótica tenían más probabilidades de desarrollar una complicación mayor (OR ajustado combinado 3.15, IC 95% 1.34-7.45, p = 0.009) en comparación con los pacientes sometidos a cirugía abierta.El uso del índice de fragilidad modificado como apoderado asociativo de la fragilidad.Si bien los abordajes quirúrgicos mínimamente invasivos han disminuido las complicaciones postoperatorias, este efecto puede revertirse en pacientes lábiles. Estos hallazgos desafían la creencia de que la cirugía robótica proporciona una alternativa favorable a la cirugía abierta en pacientes frágiles. Consulte Video Resumen en http://links.lww.com/DCR/B163. (Traducción-Dr. Xavier Delgadillo).
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