Short-term outcomes of single-site robotic cholecystectomy versus four-port laparoscopic cholecystectomy: a prospective, randomized, double-blind trial

Establishment of a 24/7 robotic acute care surgery program at a large academic medical center

BACKGROUND

For many years, robotic surgery has been an option for various elective surgical procedures. Though robotic surgery has not traditionally been the first choice for acute surgical patients, recent work has shown promise in broader applications. However, there are limited data regarding how to establish an institutional robotics program for higher acuity patients. This project aimed to map a pathway for the creation of an acute care surgery robotic program at a large academic medical center.

METHODS

Various stakeholders were gathered jointly with our surgical faculty: anesthesia, operating room leadership, surgical technologists, circulating nurses, Central Sterile Supply, and Intuitive Surgical Inc. representatives. Staff underwent robotics training, and surgical technologists were trained as bedside first assistants. Nontraditional robotic operating rooms were allocated for coordinated placement of appropriate cases, and pre-made case carts were arranged with staff to be available at all hours. A workflow was created between surgical faculty and staff to streamline add-on robotic cases to the daily schedule.

RESULTS

Six faculty and two fellows are now credentialed in robotics surgery, and additional surgeons are undergoing training. Numerous staff have completed training to perform operative assistant duties. The operating capacity of robotic acute care surgeries has more than doubled in just one year, from 77 to 172 cases between 2022 and 2023, respectively. Two add-on cases can be accommodated per day. Select patients are being offered robotic surgeries in the acute surgical setting, and ongoing efforts are being made to create guidelines for which patients would best benefit from robotic procedures.

CONCLUSIONS

Launching a successful robotic surgery program requires a coordinated, multidisciplinary effort to ensure seamless integration into daily operations. Additional assistance from outside technology representatives can help to ensure comfort with procedures. Further studies are needed to determine the acute patient population that may benefit most from robotic surgery.

Robotic versus laparoscopic general surgery in the emergency setting: a systematic review

Robot-assisted general surgery, an advanced technology in minimally invasive procedures, is increasingly employed in elective general surgery, showing benefits over laparoscopy in specific cases. Although laparoscopy remains a standard approach for common acute abdominal conditions, the role of robotic surgery in emergency general surgery remains uncertain. This systematic review aims to compare outcomes in acute general surgery settings for robotic versus laparoscopic surgeries. A PRISMA-compliant systematic search across MEDLINE, EMBASE, Science Citation Index Expanded, and the Cochrane Library was conducted. The literature review focused on articles comparing perioperative outcomes of emergency general surgery managed laparoscopically versus robot-assisted. A descriptive analysis was performed, and outcome measures were recorded. Six articles, involving 1,063 patients, compared outcomes of robotic and laparoscopic procedures. Two articles covered cholecystectomies, while the others addressed ileocaecal resection, subtotal colectomy, hiatal hernia and repair of perforated gastrojejunal ulcers. The level of evidence was low. Laparoscopic bowel resection in patients with inflammatory bowel disease (IBD) had higher complications; no significant differences were found in complications for other operations. Operative time showed no differences for cholecystectomies, but robotic approaches took longer for other procedures. Robotic cases had shorter hospital length of stay, although the associated costs were significantly higher. Perioperative outcomes for emergency robotic surgery in selected general surgery conditions are comparable to laparoscopic surgery. However, recommending robotic surgery in the acute setting necessitates a well-powered large population study for stronger evidence.

Robotic-assisted cholecystectomy versus conventional laparoscopic cholecystectomy for benign gallbladder disease: a systematic review and meta-analysis

Laparoscopic cholecystectomy (LC) is the established gold standard treatment for benign gallbladder diseases. However, robotic cholecystectomy is still controversial. Therefore, we aimed to compare intraoperative and postoperative outcomes in LC and robotic-assisted cholecystectomy (RAC) in patients with nonmalignant gallbladder conditions. PubMed, Scopus, Cochrane Library, and Web of Science were systematically searched for studies comparing RAC to LC in patients with benign gallbladder disease. Only randomized trials and non-randomized studies with propensity score matching were included. Mean differences (MDs) were computed for continuous outcomes and odds ratios (ORs) for binary endpoints, with 95% confidence intervals (CIs). Heterogeneity was assessed with I2 statistics. Statistical analysis was performed using Software R, version 4.2.3. A total of 13 studies comprising 22,440 patients were included, of whom 10,758 patients (47.94%) underwent RAC. The mean age was 48.5 years and 65.2% were female. Compared with LC, RAC significantly increased operative time (MD 12.59 min; 95% CI 5.62-19.55; p < 0.01; I2 = 79%). However, there were no significant differences between the groups in hospitalization time (MD -0.18 days; 95% CI - 0.43-0.07; p = 0.07; I2 = 89%), occurrence of intraoperative complications (OR 0.66; 95% CI 0.38-1.15; p = 0.14; I2 = 35%) and bile duct injury (OR 0.99; 95% CI 0.64, 1.55; p = 0.97; I2 = 0%). RAC was associated with an increase in operative time compared with LC without increasing hospitalization time or the incidence of intraoperative complications. These findings suggest that RAC is a safe approach to benign gallbladder disease.

Early Single-Center Experience of DaVinci® Single-Port (SP) Robotic Surgery in Colorectal Patients

Background: DaVinci® single-port (SP) robotic surgery offers several benefits compared to traditional multiport laparoscopic or robotic surgeries. One of the main advantages is that it allows for a minimally invasive approach, resulting in a single, smaller incision and reduced trauma to the patient's body, leading to less postoperative pain, faster recovery, and reduced risk of complications. The cosmesis of a single port with minimal visible scarring is also an attractive aspect to the patients; however, many surgeons use an additional port for energy device, stapler use, and drain insertion. Pure single-port surgery with one incision is still rare. Here, we share our experience of our first 10 cases using the SP robotic platform in colorectal surgery. Methods: From May 2023 to December 2023, colorectal patients who underwent SP robotic surgery were analyzed. Placement of the incision was the umbilicus for eight patients, and right lower quadrant for two patients, through which ileostomy maturation was performed. Data on perioperative parameters and postoperative outcomes were analyzed, with a median follow-up of 4.6 months (range 0.6-7.4 months). Results: A total of 10 colorectal patients underwent DaVinci® single-port robotic colorectal surgery at our institution during this period. The patient demographic was four males (40%) and six females (60%) with a median age of 63.5 years (range 50-75 years). Median body mass index (BMI) was 22.89 kg/m2 (range 19.92-26.84 kg/m2). Nine patients were diagnosed with colorectal cancer, and one patient was diagnosed with a rectal gastrointestinal tumor. One patient underwent anterior resection and cholecystectomy simultaneously. Mean operation time was 222 min (range 142-316 min), and mean wound size was 3.25 cm (range 2.5-4.5 cm). Nine patients underwent surgery with single incision through which a single-port trocar was inserted, and one patient had one additional port for drain insertion. Mean hospital stay was 6 days (range 4-8 days) with one postoperative complication of bleeding requiring transfusion, but there was no readmission within 30 days. Conclusions: Overall, our experience with single-port robotic colorectal surgery has been promising. With only one patient with additional port for drain insertion, all nine patients underwent SP-robotic surgery with single incision for colon as well as rectal surgeries. Compared to an average postoperative length of stay of 6.5-8 days in laparoscopic colorectal surgeries reported in literature, SP-robotic surgery 33showed faster recovery of 6 days highlighting its benefits in patient recovery and satisfaction.

Clinical status and future prospects of single-incision robotic-assisted surgery: a review

Since the advent of conventional multiport laparoscopic surgery, the prosperity of minimally invasive surgery has been thriving on the advancement of endoscopic techniques. Cosmetic superiority, recovery benefits, and noninferior surgical outcomes weigh single-incision laparoscopic surgery as a promising modality. Although there are surgical challenges posed by steep learning curve and technological difficulties, such as instruments collision, triangulation loss and limited retraction, the establishment of robotic surgical platform as a solution to all is inspiring. Furthermore, with enhanced instrument maneuverability and stability, robotic ergonomic innovations adopt the advantages of single-incision laparoscopic surgery and surmount its recognized barriers by introducing a novel combination, single-incision robotic-assisted surgery. As was gradually diffused in general surgery and other specialties, single-incision robotic-assisted surgery manifests privileges in noninferior clinical outcomes an satisfactory cosmetic effect among strictly selected patients, and has the potential of a preferable surgical option for minimally invasive surgery.

Laparoscopic versus robotic abdominal and pelvic surgery: a systematic review of randomised controlled trials

BACKGROUND

The current evidence is inconclusive on whether robotic or laparoscopic surgery is the optimal platform for minimally invasive surgery. Existing comparisons techniques focus on short-term outcomes only, while potentially being confounded by a lack of standardisation in robotic procedures. There is a pertinent need for an up-to-date comparison between minimally invasive surgical techniques. We aimed to systematically review randomised controlled trials comparing robotic and laparoscopic techniques in major surgery.

METHODS

Embase, Medline and Cochrane Library were searched from their inception to 13th September 2022. Included studies were randomised controlled trials comparing robotic and laparoscopic techniques in abdominal and pelvic surgery. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Short-term, health-related quality of life, and long-term, outcomes were analysed.

RESULTS

Forty-five studies, across thirteen procedures, involving 7364 patients were included. All of the studies reported non-significant differences in mortality between robotic and laparoscopic surgery. In majority of studies, there was no significant difference in complication rate (n = 31/35, 85.6%), length of postoperative stay (n = 27/32, 84.4%), and conversion rate (n = 15/18, 83.3%). Laparoscopic surgery was associated with shorter operative time (n = 16/31, 51.6%) and lower total cost (n = 11/13, 84.6%). Twenty three studies reported on quality of life outcomes; majority (n = 14/23, 60.9%) found no significant differences.

CONCLUSION

There were no significant differences between robotic surgery and laparoscopic surgery with regards to mortality and morbidity outcomes in the majority of studies. Robotic surgery was frequently associated with longer operative times and higher overall cost. Selected studies found potential benefits in post-operative recovery time, and patient-reported outcomes; however, these were not consistent across procedures and trials, with most studies being underpowered to detect differences in secondary outcomes. Future research should focus on assessing quality of life, and long-term outcomes to further elucidate where the robotic platform could lead to patient benefits, as the technology evolves.

Fragility of statistically significant findings from randomized trials in comparing laparoscopic versus robotic abdominopelvic surgeries

BACKGROUND

Utility of robotic over laparoscopic approach has been an area of debate across all surgical specialties over the past decade. The fragility index (FI) is a metric that evaluates the frailty of randomized controlled trials (RCTs) findings by altering the status of patients from an event to non-event until significance is lost. This study aims to evaluate the robustness of RCTs comparing laparoscopic and robotic abdominopelvic surgeries through the FI.

METHODS

A search was conducted in MEDLINE and EMBASE for RCTs with dichotomous outcomes comparing laparoscopic and robot-assisted surgery in general surgery, gynecology, and urology. The FI and reverse fragility Index (RFI) metrics were used to assess the strength of findings reported by RCTs, and bivariate correlation was conducted to analyze relationships between FI and trial characteristics.

RESULTS

A total of 21 RCTs were included, with a median sample size of 89 participants (Interquartile range [IQR] 62-126). The median FI was 2 (IQR 0-15) and median RFI 5.5 (IQR 4-8.5). The median FI was 3 (IQR 1-15) for general surgery (n = 7), 2 (0.5-3.5) for gynecology (n = 4), and 0 (IQR 0-8.5) for urology RCTs (n = 4). Correlation was found between increasing FI and decreasing p-value, but not sample size, number of outcome events, journal impact factor, loss to follow-up, or risk of bias.

CONCLUSION

RCTs comparing laparoscopic and robotic abdominal surgery did not prove to be very robust. While possible advantages of robotic surgery may be emphasized, it remains novel and requires further concrete RCT data.

High rate of stone-related complications after stapling the cystic duct during laparoscopic cholecystectomy-an underrecognized risk

BACKGROUND

Laparoscopic staplers (LS) have been suggested as a safe alternative to metal clips in laparoscopic cholecystectomy when the cystic duct is too inflamed or wide for complete clip occlusion. We aimed to evaluate the perioperative outcomes of patients whose cystic ducts were controlled by LS and evaluate the risk factors for complications.

METHODS

Patients who underwent laparoscopic cholecystectomy with LS used to control the cystic duct from 2005 to 2019 were retrospectively identified from an institutional database. Patients were excluded for open cholecystectomy, partial cholecystectomy, or cancer. Potential risk factors for complications were assessed using logistic regression analysis.

RESULTS

Among 262 patients, 191 (72.9%) were stapled for size and 71 (27.1%) for inflammation. In total, 33 (16.3%) patients had Clavien-Dindo grade ≥ 3 complications, with no significant difference when surgeons chose to staple for duct size versus inflammation (p = 0.416). Seven patients had bile duct injury. A large proportion had Clavien-Dindo grade ≥ 3 postoperative complications specifically related to bile duct stones [n = 29 (11.07%)]. Intraoperative cholangiogram was protective against postoperative complications [odds ratio (OR) = 0.18 (p = 0.022)].

CONCLUSION

Whether these high complication rates reflect a technical issue with stapling, more challenging anatomy, or worse disease, findings question whether the use of LS during laparoscopic cholecystectomy is truly a safe alternative to the already accepted methods of cystic duct ligation and transection. Based on these findings, an intraoperative cholangiogram should be performed when considering a linear stapler during laparoscopic cholecystectomy to: (1) ensure the biliary tree is free of stones; (2) prevent inadvertent transection of the infundibulum rather than the cystic duct; and, (3) allow opportunity for safe alternative strategies when an IOC is not able to confirm anatomy. Otherwise, surgeons employing LS devices should be aware that patients are at higher risk for complications.

Implementation of robotic surgery in Dubai: a focus on outcomes

The rapid acceptance of robotic surgery in gallbladder, inguinal, and ventral hernia surgery has led to the growth of robotic surgery programs around the world. As this is new technology, implementation of such programs needs to be done safely, with a focus on patient outcomes. We herein describe the implementation of a new robotic surgery program in a major hospital in the Middle East. A laparoendoscopic surgeon led the program after training and proctoring. Competency based credentialing were created and put in place. To confirm safety of the program, all laparoscopic and robotic cholecystectomy and hernia operations were followed, and perioperative data analyzed. Out of the 304 patients included in this study, 157 were performed using the robotic approach. In the cholecystectomy group (n = 103) the single site approach offered shorter operative times (P < 0.05). Both the single site robotic and the robotic assisted approaches resulted in less pain (P < 0.05). In the inguinal hernia group (n = 146) the laparoscopic approach offered shorter operative times (P < 0.05), but the robotic approach was associated with less pain (P < 0.05). In the ventral hernia group (n = 55), the open approach offered the best operative times, but the robotic approach was associated with the least amount of pain (P < 0.05). This is the first report of the implementation of a robotic program in the MENA region where the primary measure of success is outcomes. We show that monitoring cholecystectomy, inguinal or ventral hernia data can confirm the quality of the program before expansion and moving forward to more complex procedures.

Robotic Cholecystectomies: What Are They Good for? - A Retrospective Study - Robotic versus Conventional Cases

INTRODUCTION

Robot-assisted cholecystectomies are often criticized as expensive with uncertain benefit to patients. Characterization of robotic surgery benefits, as well as specific factors that drive cost, has the potential to shape the current debate.

METHODS

The surgical cost and outcomes among patients who underwent robotic (n = 283) or non-robotic (n = 1438) laparoscopic cholecystectomies between 2012 and 2018 at a single academic institution were examined retrospectively. All cholecystectomies were primary surgical procedures with no secondary procedures. We also examined the subset of robotic (n = 277) and non-robotic (n = 1108) outpatient procedures.

RESULTS

Robotic cholecystectomies were associated with higher median total cost compared to conventional procedures, largely attributable to variable costs and surgical costs. Patients who underwent conventional cholecystectomy had longer mean lengths of stays (1.7 versus 1.1 days) compared to robotic procedures-with over 10 times as many requiring hospital admission.

CONCLUSIONS

At present, robotic cholecystectomies have a little value to patients and institutions outside of surgical training. Prior to narrowing the analysis to outpatient cases, difference in total cost between procedures was less pronounced due to more frequent inpatient management following conventional procedures. Future optimization of robotic consumables and free market competition among system manufacturers may increase financial feasibility by decreasing variable costs associated with robotic surgery.

A systematic review of robot-assisted cholecystectomy to examine the quality of reporting in relation to the IDEAL recommendations: systematic review

INTRODUCTION

Robotic cholecystectomy (RC) is a recent innovation in minimally invasive gallbladder surgery. The IDEAL (idea, development, exploration, assessment, long-term study) framework aims to provide a safe method for evaluating innovative procedures. This study aimed to understand how RC was introduced, in accordance with IDEAL guidelines.

METHODS

Systematic searches were used to identify studies reporting RC. Eligible studies were classified according to IDEAL stage and data were collected on general study characteristics, patient selection, governance procedures, surgeon/centre expertise, and outcome reporting.

RESULTS

Of 1425 abstracts screened, 90 studies were included (5 case reports, 38 case series, 44 non-randomized comparative studies, and 3 randomized clinical trials). Sixty-four were single-centre and 15 were prospective. No authors described their work in the context of IDEAL. One study was classified as IDEAL stage 1, 43 as IDEAL 2a, 43 as IDEAL 2b, and three as IDEAL 3. Sixty-four and 51 provided inclusion and exclusion criteria respectively. Ethical approval was reported in 51 and conflicts of interest in 34. Only 21 reported provision of training for surgeons in RC. A total of 864 outcomes were reported; 198 were used in only one study. Only 30 reported a follow-up interval which, in 13, was 1 month or less.

CONCLUSION

The IDEAL framework was not followed during the adoption of RC. Few studies were conducted within a research setting, many were retrospective, and outcomes were heterogeneous. There is a need to implement appropriate tools to facilitate the incremental evaluation and reporting of surgical innovation.

Comparison of a new gasless method and the conventional CO2 pneumoperitoneum method in laparoendoscopic single-site cholecystectomy: a prospective randomized clinical trial

To avoid CO₂ pneumoperitoneum-associated cardiopulmonary side-effects during conventional laparoscopic surgeries, we have developed a gasless laparoscopic operation field formation (LOFF) device for laparoendoscopic single-site surgery. The aim of this study is to analyze the safety and efficacy of the LOFF device for laparoendoscopic single-site cholecystectomy and to verify its advantage of avoiding CO₂ pneumoperitoneum-associated complications. In this prospective, randomized, observer-blinded clinical trial, eligible participants were randomized in a 1:1 ratio to undergo either conventional CO₂ pneumoperitoneum assisted laparoendoscopic single-site cholecystectomy (LESS) or the new gasless LOFF device assisted laparoendoscopic single-site cholecystectomy (LOFF-LESS). Outcomes including intra-operative respiratory and hemodynamic parameters, operation time, conversion rate, complication rate, et al were compared between the two groups. A total of 100 patients were randomized to the LESS group [n = 50; mean (SD) age, 49.5 (13.9) years; 24 (48.0%) women] and the LOFF-LESS group [n = 50, mean (SD) age, 47.4 (13.3) years; 27 (54.0%) women]. Compared with the LOFF-LESS group, the LESS group witnessed significant fluctuations in intra-operative respiratory and hemodynamic parameters. The tracheal extubation time of the LESS group was significantly longer (P = 0.001). The gasless LOFF device is safe and feasible for simple laparoscopic cholecystectomy and has a predominance of avoiding CO₂ pneumoperitoneum-associated cardiopulmonary side-effects. Trial registration number: ChiCTR2000033702.

The Evidence Behind Robot-Assisted Abdominopelvic Surgery : A Systematic Review

BACKGROUND

Use of robot-assisted surgery has increased dramatically since its advent in the 1980s, and nearly all surgical subspecialties have adopted it. However, whether it has advantages compared with laparoscopy or open surgery is unknown.

PURPOSE

To assess the quality of evidence and outcomes of robot-assisted surgery compared with laparoscopy and open surgery in adults.

DATA SOURCES

PubMed, EMBASE, Scopus, and the Cochrane Central Register of Controlled Trials were searched from inception to April 2021.

STUDY SELECTION

Randomized controlled trials that compared robot-assisted abdominopelvic surgery with laparoscopy, open surgery, or both.

DATA EXTRACTION

Two reviewers independently extracted study data and risk of bias.

DATA SYNTHESIS

A total of 50 studies with 4898 patients were included. Of the 39 studies that reported incidence of Clavien-Dindo complications, 4 (10%) showed fewer complications with robot-assisted surgery. The majority of studies showed no difference in intraoperative complications, conversion rates, and long-term outcomes. Overall, robot-assisted surgery had longer operative duration than laparoscopy, but no obvious difference was seen versus open surgery.

LIMITATIONS

Heterogeneity was present among and within the included surgical subspecialties, which precluded meta-analysis. Several trials may not have been powered to assess relevant differences in outcomes.

CONCLUSION

There is currently no clear advantage with existing robotic platforms, which are costly and increase operative duration. With refinement, competition, and cost reduction, future versions have the potential to improve clinical outcomes without the existing disadvantages.

PRIMARY FUNDING SOURCE

None. (PROSPERO: CRD42020182027).

Intraoperative and postoperative outcomes of robot-assisted cholecystectomy: a systematic review

BACKGROUND

Rapid adoption of robotic-assisted general surgery procedures, particularly for cholecystectomy, continues while questions remain about its benefits and utility. The objective of this study was to compare the clinical effectiveness of robot-assisted cholecystectomy for benign gallbladder disease as compared with the laparoscopic approach.

METHODS

A literature search was performed from January 2010 to March 2020, and a narrative analysis was performed as studies were heterogeneous.

RESULTS

Of 887 articles screened, 44 met the inclusion criteria (range 20-735,537 patients). Four were randomized controlled trials, and four used propensity-matching. There were variable comparisons between operative techniques with only 19 out of 44 studies comparing techniques using the same number of ports. Operating room time was longer for the robot-assisted technique in the majority of studies (range 11-55 min for 22 studies, p < 0.05; 15 studies showed no difference; two studies showed shorter laparoscopic times), while conversion rates and intraoperative complications were not different. No differences were detected for the length of stay, surgical site infection, or readmissions. Across studies comparing single-port robot-assisted to multi-port laparoscopic cholecystectomy, there was a higher rate of incisional hernia; however, no differences were noted when comparing single-port robot-assisted to single-port laparoscopic cholecystectomy.

CONCLUSIONS

Clinical outcomes were similar for benign, elective gallbladder disease for robot-assisted compared with laparoscopic cholecystectomy. Overall, the rates of complications were low. More high-quality studies are needed as the robot-assisted technique expands to more complex gallbladder disease, where its utility may prove increasingly beneficial.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020156945.

Laparoscopic surgery and robotic surgery for single-incision cholecystectomy: an updated systematic review

The role of single-incision laparoscopic cholecystectomy (SILC) and single-incision robotic cholecystectomy (SIRC) is still unclear. We update the summarization of the feasibility and safety of SILC and SIRC. A comprehensive search of SILC and SIRC of English literature published on PubMed database between January 2015 and November 2020 was performed. A total of 70 articles were included: 41 covering SILC alone, 21 showing SIRC alone, 7 reporting both, and 1 study not specified. In total, 7828 cases were recorded (SILC/SIRC/not specified, 6234/1544/50); and the gender of 7423 cases was definitively reported: the female rate was 64.0% (SILC/SIRC/not specified, 62.1%/71.5%/74.0%). The weighted mean for body mass index (BMI), operative time, blood loss and post-operative hospital stay was 25.5 kg/m² (SILC/SIRC, 25.0/27.0 kg/m²), 73.8 min (SILC/SIRC, 68.2/88.8 min), 12.6 mL (SILC/SIRC, 12.1/14.8 mL) and 2.5 days (SILC/SIRC, 2.8/1.9 days), respectively. The pooled prevalence of an additional port, conversion to open surgery, post-operative complications, intraoperative biliary injury, and incisional hernia was 4.1% (SILC/SIRC, 4.7%/1.9%), 0.9% (SILC/SIRC, 0.7%/1.5%), 5.9% (SILC/SIRC, 6.2%/4.1%), 0.1% (SILC/SIRC, 0.2%/0.09%), and 2.1% (SILC/SIRC, 1.4%/4.8%), respectively. Compared with conventional laparoscopic cholecystectomy, SIRC has experienced more postoperative incisional hernias (risk difference = 0.05, 95% confidence interval 0.02-0.07; P < 0.0001). By far, SILC and SIRC have not been considered a standard procedure. With the innovation of medical devices and gradual accumulation of surgical experience, feasibility and safety of performing SILC and SIRC will improve.

Low long-term incidence of incisional hernia after cholecystectomy: A systematic review with meta-analysis

BACKGROUND

Various surgical approaches are available for cholecystectomy, but their long-term outcomes, such as incidence of incisional hernia, are largely unknown. Our aim was to investigate the long-term incidence of incisional hernia after cholecystectomy for different surgical approaches.

METHODS

This systematic review and meta-analysis was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A protocol was registered on PROSPERO (CRD42020178906). Three databases were searched for original studies on long-term complications of cholecystectomy with n > 40 and follow-up ≥6 months for incisional hernia. Risk of bias within the studies was assessed using the Newcastle-Ottawa Scale and the Cochrane "risk of bias" tool. Meta-analysis of the incidence of incisional hernia after 6 and 12 months was conducted when possible.

RESULTS

We included 89 studies. Of these, 77 reported on multiport or single-incision laparoscopic cholecystectomy. Twelve studies reported on open cholecystectomy and 4 studies on robotic cholecystectomy. Weighted mean incidence proportion of incisional hernia after multi-port laparoscopic cholecystectomy was 0.3% (95% confidence interval 0-0.6) after 6 months and 0.2% after 12 months (95% confidence interval 0.1-0.3). Weighted mean incidence of incisional hernia 12 months postoperatively was 1.5% (95% confidence interval 0.4-2.6) after open cholecystectomy and 4.5% (95% confidence interval 0.4-8.6) after single-incision laparoscopic cholecystectomy. No meta-analysis could be conducted for robotic cholecystectomy, but incidences ranged from 0% to 16.7%.

CONCLUSION

We found low 1-year incidences of incisional hernia after multiport laparoscopic and open cholecystectomy, whereas risks of incisional hernia were considerably higher after single-incision laparoscopic and robotic cholecystectomy.

Research quality and transparency, outcome measurement and evidence for safety and effectiveness in robot-assisted surgery: systematic review

BACKGROUND

Robot-assisted surgery (RAS) has potential panspecialty surgical benefits. High-quality evidence for widespread implementation is lacking. This systematic review aimed to assess the RAS evidence base for the quality of randomized evidence on safety and effectiveness, specialty 'clustering', and outcomes for RAS research.

METHODS

A systematic review was undertaken according to PRISMA guidelines. All pathologies and procedures utilizing RAS were included. Studies were limited to RCTs, the English language and publication within the last decade. The main outcomes selected for the review design were safety and efficacy, and study purpose. Secondary outcomes were study characteristics, funding and governance.

RESULTS

Searches identified 7142 titles, from which 183 RCTs were identified for data extraction. The commonest specialty was urology (35·0 per cent). There were just 76 unique study populations, indicating significant overlap of publications; 103 principal studies were assessed further. Only 64·1 per cent of studies reported a primary outcome measure, with 29·1 per cent matching their registration/protocol. Safety was assessed in 68·9 per cent of trials; operative complications were the commonest measure. Forty-eight per cent of trials reported no significant difference in safety between RAS and comparator, and 11 per cent reported RAS to be superior. Efficacy or effectiveness was assessed in 80·6 per cent of trials; 43 per cent of trials showed no difference between RAS and comparator, and 24 per cent reported that RAS was superior. Funding was declared in 47·6 per cent of trials.

CONCLUSION

The evidence base for RAS is of limited quality and variable transparency in reporting. No patterns of harm to patients were identified. RAS has potential to be beneficial, but requires continued high-quality evaluation.

Next-generation robotics in gastrointestinal surgery

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.

Robotic Biliary Surgery

Robotic cholecystectomy is safe and feasible approach and can be combined with common bile duct exploration to address complicated pathology in a single setting. This article summarizes reported outcomes after robotic biliary surgery. A technical overview of robotic multiport and single port cholecystectomy is provided. Last, the approach to benign bile duct disease during robotic cholecystectomy, including reconstruction of the biliary tree, is described.

Robotic Single-Port Platform in General, Urologic, and Gynecologic Surgeries: A Systematic Review of the Literature and Meta-analysis

BACKGROUND

Robotic platforms have recently acquired progressive importance in different surgical fields, such as urology, gynecology, and general surgery. Through the years, new surgical robots have become available as single-port robotic platform. The study is aimed to value the single-port robotic platform characteristics in different surgical specialties.

METHODS

The terms "LESS" OR "single port" OR "single site" AND "robot" OR "robotic" were systematically used to search the PubMed and Scopus databases. A total of 57 studies were considered eligible for the present review. The articles included were divided according to the surgical field in which the study was conducted: General surgery (29 articles), Gynecology (18 articles), Urology (10 articles).

RESULTS

Most part of the articles showed the feasibility of robotic single-port surgical procedures and described advantages in terms of cosmetic, hospital stay, and in some series even cost reduction. A meta-analysis was conducted, showing a significant increment of complications using RSP if compared with SLPS and a trend (P = 0.008) when RSP was compared with LESS. The comparison of different techniques in terms of conversion to laparotomy did not show any significant difference.

CONCLUSION

Robotic single port potentially furnishes an important surgical and post-operatory improvement; however, some limits still prolong the surgical time and complication rate.

Robotic compared with laparoscopic cholecystectomy: A propensity matched analysis

BACKGROUND

As robotic surgery becomes more ubiquitous, determining clinical benefit is necessary to justify the cost and time investment required to become proficient. We hypothesized that robotic cholecystectomy would be associated with improved clinical outcomes but also increased cost as compared with standard laparoscopic cholecystectomy.

MATERIALS AND METHODS

All patients undergoing robotic or laparoscopic cholecystectomy at a single academic hospital between 2007 and 2017 were identified using an institutional clinical data repository. Patients were stratified by operative approach (robotic versus laparoscopic) for comparison and propensity score matched 1:10 based on relevant comorbidities and demographics. Categorical variables were analyzed by the χ² test and continuous variables using the Mann-Whitney U test.

RESULTS

A total of 3,255 patients underwent cholecystectomy during the study period. We observed no differences in demographics or body mass index, but greater rates of diabetes mellitus, hypertension, and gastroesophageal reflux disease were present in the laparoscopic group. After matching (n = 106 robotic, n = 1,060 laparoscopic), there were no differences in preoperative comorbidities. Patients who underwent robotic cholecystectomy had lesser durations of stay (robotic: 0.1 ± 0.7 versus laparoscopic: 0.8 ± 1.9, P < .0001) and lesser 90-day readmission rates (robotic: 0% [0], laparoscopic: 4.1% [43], P = 0.035); however, both operative and hospital costs were greater compared with laparoscopic cholecystectomy.

CONCLUSION

Robotic cholecystectomy is associated with lesser duration of stay and lesser readmission rate within 90 days of the index operation, but also greater operative duration and hospital cost compared with laparoscopic cholecystectomy. Hospitals and surgeons need to consider the improved clinical outcomes but also the monetary and time investment required before pursuing robotic cholecystectomy.

European association for endoscopic surgery (EAES) consensus statement on single-incision endoscopic surgery

BACKGROUND

Laparoscopic surgery changed the management of numerous surgical conditions. It was associated with many advantages over open surgery, such as decreased postoperative pain, faster recovery, shorter hospital stay and excellent cosmesis. Since two decades single-incision endoscopic surgery (SIES) was introduced to the surgical community. SIES could possibly result in even better postoperative outcomes than multi-port laparoscopic surgery, especially concerning cosmetic outcomes and pain. However, the single-incision surgical procedure is associated with quite some challenges.

METHODS

An expert panel of surgeons has been selected and invited to participate in the preparation of the material for a consensus meeting on the topic SIES, which was held during the EAES congress in Frankfurt, June 16, 2017. The material presented during the consensus meeting was based on evidence identified through a systematic search of literature according to a pre-specified protocol. Three main topics with respect to SIES have been identified by the panel: (1) General, (2) Organ specific, (3) New development. Within each of these topics, subcategories have been defined. Evidence was graded according to the Oxford 2011 Levels of Evidence. Recommendations were made according to the GRADE criteria.

RESULTS

In general, there is a lack of high level evidence and a lack of long-term follow-up in the field of single-incision endoscopic surgery. In selected patients, the single-incision approach seems to be safe and effective in terms of perioperative morbidity. Satisfaction with cosmesis has been established to be the main advantage of the single-incision approach. Less pain after single-incision approach compared to conventional laparoscopy seems to be considered an advantage, although it has not been consistently demonstrated across studies.

CONCLUSIONS

Considering the increased direct costs (devices, instruments and operating time) of the SIES procedure and the prolonged learning curve, wider acceptance of the procedure should be supported only after demonstration of clear benefits.

Updates in Urologic Robot Assisted Surgery

Modern robotics is an advanced minimally invasive technology with the advantages of wristed capability, three-dimensional optics, and tremor filtration compared with conventional laparoscopy. Urologists have been early adopters of robotic surgical technology: robotics have been used in urologic oncology for more than 20 years and there has been an increasing trend for utilization in benign urologic pathology in the last couple of years. The continuing development and interest in robotics are aimed at surgical efficiency as well as patient outcomes. However, despite its advantages, improvements in haptics, system size, and cost are still desired. This article explores the current use of robotics in urology as well as future improvements on the horizon.

Robotic-assisted versus laparoscopic cholecystectomy for benign gallbladder diseases: a systematic review and meta-analysis

BACKGROUND

Robotic surgery, an emerging technology, has some potential advantages in many complicated endoscopic procedures compared with laparoscopic surgery. But robot-assisted cholecystectomy (RAC) is still a controversial issue on its comparative merit compared with conventional laparoscopic cholecystectomy (LC). The aim of this study was to evaluate the safety and efficacy of RAC compared with LC for benign gallbladder disease.

METHODS

A systematic literature search was conducted using the PubMed, EMBASE, and Cochrane Library databases (from their inception to December 2017) to obtain comparative studies assessing the safety and efficacy between RAC and LC. The quality of the literature was assessed, and the data analyzed using R software, random effects models were applied.

RESULTS

Twenty-six studies, including 5 RCTs and 21 NRCSs (3 prospective plus 18 retrospective), were included. A total of 4004 patients were included, of which 1833 patients (46%) underwent RAC and 2171 patients (54%) underwent LC. No significant differences were found in intraoperative complications, postoperative complications, readmission rate, hospital stay, estimated blood loss, and conversion rate between RAC and LC groups. However, RAC was related to longer operative time compared with LC (MD = 12.04 min, 95% CI 7.26-16.82) in RCT group, which was consistent with NRCS group; RAC also had a higher rate of incisional hernia in NRCS group (RR = 3.06, 95% CI 1.42-6.57), and one RCT reported that RAC was similar to LC (RR = 7.00, 95% CI 0.38-129.84).

CONCLUSIONS

The RAC was not found to be more effective or safer than LC for benign gallbladder diseases, which indicated that RAC is a developing procedure instead of replacing LC at once. Given the higher costs, the current evidence is in favor of LC in cholecystectomy.

Safety of single-incision robotic cholecystectomy for benign gallbladder disease: a systematic review

BACKGROUND

Multiport laparoscopic cholecystectomy (MLC) is the gold standard technique for cholecystectomy. In order to reduce postoperative pain and improve cosmetic results, the application of the single-incision laparoscopic cholecystectomy (SILC) technique was introduced, leading surgeons to face important challenges. Robotic technology has been proposed to overcome some of these limitations. The purpose of this review is to assess the safety of single-incision robotic cholecystectomy (SIRC) for benign disease.

METHODS

An Embase and Pubmed literature search was performed in February 2017. Randomized controlled trial and prospective observational studies were selected and assessed using PRISMA recommendations. Primary outcome was overall postoperative complication rate. Secondary outcomes were postoperative bile leak rate, total conversion rate, operative time, wound complication rate, postoperative hospital stay, and port site hernia rate. The outcomes were analyzed in Forest plots based on fixed and random effects model. Heterogeneity was assessed using the I² statistic.

RESULTS

A total of 13 studies provided data about 1010 patients who underwent to SIRC for benign disease of gallbladder. Overall postoperative complications rate was 11.6% but only 4/1010 (0.4%) patients required further surgery. A postoperative bile leak was reported in 3/950 patients (0.3%). Conversion occurred in 4.2% of patients. Mean operative time was 86.7 min including an average of 42 min should be added as for robotic console time. Wound complications occurred in 3.7% of patients. Median postoperative hospital stay was 1 day. Port site hernia at the latest follow-up available was reported in 5.2% of patients.

CONCLUSIONS

The use of the Da Vinci robot in single-port cholecystectomy seems to have similar results in terms of incidence and grade of complications compared to standard laparoscopy. In addition, it seems affected by the same limitations of single-port surgery, consisting of an increased operative time and incidence of port site hernia.

Single-site robotic cholecystectomy versus multi-port laparoscopic cholecystectomy: A systematic review and meta-analysis

OBJECTIVE

To investigate the outcomes of single-site robotic cholecystectomy (SSRC) compared to multi-port laparoscopic cholecystectomy (MLC), evaluate the safety and feasibility of SSRC.

METHODS

To find relevant studies, the electronic databases PubMed, MEDLINE, The Cochrane Library, and EMBASE were used to seek information in English literature from 2011 to 2017. Studies comparing SSRC to MLC, for any indication, were included in the analysis. This systematic review and meta-analysis was performed with RevMan Version 5.3.

RESULTS

Seven studies (two randomized control trails (RCTs) and five comparative studies, n = 1657 patients) were included in our analysis. The data showed that the SSRC and MLC had equivalent outcomes for operative time (MD = -3.06, 95% CI: -7.61-1.49, p = 0.19), bleeding (OR = 1.63, 95%CI: 0.40-6.56, p = 0.49), postoperative complications (OR = 1.11, 95%CI: 0.35-3.51, p = 0.86), bile leakage (OR = 0.38, 95%CI: 0.07-2.00, p = 0.26), wound infection (OR = 1.92, 95%CI: 0.86-4.32, p = 0.11), conversion rate (OR = 1.30, 95% CI: 0.71-2.37, p = 0.40), and hospital stay (MD = -0.02, 95% CI: -0.60-0.57, p = 0.96). However, in the SSRC group the risk of incisional hernia is higher than the MLC group (OR = 4.23, 95% CI: 1.87-9.58, p = 0.0005), incidence of incisional hernia rate in SSRC group is higher than MLC group (5.8% vs. 0.9%), and the total costs in the SSRC group is higher than MLC group (MD = 3.51, 95% CI: 0.31-6.71, p = 0.03).

CONCLUSIONS

The medical cost is significantly higher in SSRC compared with MLC, and SSRC can increasing the risk of incisional hernia. Therefore, surgeons must be carefully balanced its advantage, disadvantage and risk.

[Robotic approach to hepatobiliary surgery. German version]

Robot-assisted hepatobiliary surgery has been steadily growing in recent years. It represents an alternative to the open and laparoscopic approaches in selected patients. Endowristed instruments and enhanced visualization provide important advantages in terms of selective bleeding control, microsuturing, and dissection. Cholecystectomies and minor hepatectomies are being performed with comparable results to open and laparoscopic surgery. Even complex procedures, such as major and extended hepatectomies, can have excellent outcomes, in expert hands. The addition of indocyanine green fluorescence provides an additional advantage for recognition of the vascular and biliary anatomy. Future innovations will allow for expanding its use and indications. Robotic surgery has become a very important component of modern minimally invasive surgery and the development of new robotic technology will facilitate a broader adoption of this technique.

Robot-assisted laparoscopic surgery versus conventional laparoscopic surgery in randomized controlled trials: A systematic review and meta-analysis

Importance

This review provides a comprehensive comparison of treatment outcomes between robot-assisted laparoscopic surgery (RLS) and conventional laparoscopic surgery (CLS) based on randomly-controlled trials (RCTs).

Objectives

We employed RCTs to provide a systematic review that will enable the relevant community to weigh the effectiveness and efficacy of surgical robotics in controversial fields on surgical procedures both overall and on each individual surgical procedure.

Evidence review

A search was conducted for RCTs in PubMed, EMBASE, and Cochrane databases from 1981 to 2016. Among a total of 1,517 articles, 27 clinical reports with a mean sample size of 65 patients per report (32.7 patients who underwent RLS and 32.5 who underwent CLS), met the inclusion criteria.

Findings

CLS shows significant advantages in total operative time, net operative time, total complication rate, and operative cost (p < 0.05 in all cases), whereas the estimated blood loss was less in RLS (p < 0.05). As subgroup analyses, conversion rate on colectomy and length of hospital stay on hysterectomy statistically favors RLS (p < 0.05).

Conclusions

Despite higher operative cost, RLS does not result in statistically better treatment outcomes, with the exception of lower estimated blood loss. Operative time and total complication rate are significantly more favorable with CLS.

The utilization of fluorescent cholangiography during robotic cholecystectomy at an inner-city academic medical center

In recent years, fluorescent cholangiography using Indocyanine green (ICG) dye has been used to aid identification of structures during robotic cholecystectomy. We sought to compare cholecystectomy with ICG dye versus laparoscopic cholecystectomy at an inner-city academic medical center. Between January 2013 and July 2016, we identified 287 patients of which 191 patients underwent laparoscopic cholecystectomy and 96 patients underwent robotic cholecystectomy with ICG dye. Preoperative risk variables of interest included age, sex, race, body mass index (BMI), and acute cholecystitis. Primary outcome of interest was conversion to open procedures while secondary outcome was length of stay. The two groups were similar in their BMI (31.98 vs. 31.10 kg/m² for the laparoscopic and robotic, respectively, p = 0.32). The laparoscopic group had a greater mean age compared to the robotic group (47.77 vs. 43.61 years, p = 0.04). There was no significant difference in sex and emergency surgery between the two groups. Fewer open conversions were found in the robotic than the laparoscopic group [2 (2.1%) vs. 17 (8.9%), p = 0.03]. In multiple logistic regression, robotic cholecystectomy with ICG also showed a lower risk of conversion compared to laparoscopic cholecystectomy, but the difference did not reach statistical significance (OR 0.42, 95% CI 0.11-1.65, p = 0.22). ICG fluorescent cholangiography during robotic cholecystectomy may contribute to proper identification of biliary structures and may reduce the rates of open conversion. The preliminary results of fewer open conversions are promising. Further studies with a large randomized prospective controlled study should be taken for further evaluation.

A randomized controlled trial for evaluation of lower abdominal laparoscopic cholecystectomy

BACKGROUND

To improve minimally invasive outcomes, we designed a new procedure, lower abdominal laparoscopic cholecystectomy (LALC). This study was conducted to evaluate the effects of LALC versus classical (CLC) and single-incision (SILC) laparoscopic cholecystectomy on reducing systemic acute inflammatory response, improving cosmesis, and postoperative pain relief.

MATERIAL AND METHODS

Beginning from July 2014, 105 patients meeting the inclusion criteria were randomly assigned to three groups: LALC, CLC, and SILC. The primary endpoint was the determination of systemic inflammatory response to the surgery. Other outcome measures included cosmesis, postoperative pain, and perioperative indices.

RESULTS

Each of the three groups consisted of 35 patients. The duration of the operation was significantly longer in the SILC group (p= .005). The rates of adverse events were similar. Changes in interleukin-6 (p =  .001) and tumor-necrosis factor-α (p =  .016) measured before and after surgery differed significantly; patients who underwent LALC had the smallest change in inflammatory response. Cosmesis scores at one (p =  .002) and 12 (p =  .004) weeks after surgery favored LALC and SILC. Significant differences in pain scores at four (p =  .011) and 12 h (p =  .024) postoperatively were also observed.

CONCLUSIONS

In selected patients, LALC shows more advantages in terms of lower systemic inflammatory response, improved cosmesis, and a favorable postoperative pain profile when compared with CLC and SILC.

Robotic versus conventional laparoscopic cholecystectomy: A comparative study of medical resource utilization and clinical outcomes

Conventional laparoscopic cholecystectomy (CLC) is currently the standard of surgical procedure for gallstone disease. Robotic cholecystectomy (RC) has revolutionized the field of minimally invasive surgery; it is safe and ergonomic, but expensive. The aim of this study is to compare the medical resource utilization and clinical outcomes between the two procedures. This study was conducted retrospectively by assessing data of the clinical outcomes and medical resource of 78 patients receiving RC and 367 patients receiving CLC. We reviewed the data of operation times, length of hospital stay, hospital charges, outpatient department visits, outpatient department service charges, and postoperative complications, which were retrieved from the health information system (HIS) database in this hospital. Patients in both groups had similar demographic and clinical features. The RC group had longer length of hospital stay (p=0.056), significantly longer operation time (p=0.035), and much more hospital charges (p=0.001). The RC group, however, experienced less postoperative complication rates (average 3.8% vs. 20.4%, p=0.001). Conversion rate was 1.9% in the CLC group versus 0% in the RC group (p=0.611). Most complications were mild, and following the Clavien-Dindo classification, there were two cases (2.5%) Grade I for the RC group; 50 cases (13.6%) Grade I and 14 cases (3.81%) Grade II for the CLC group (p<0.001 and 0.001, respectively). Procedure-related complications of Grade IIIa status were encountered in nine patients (2.45%) in the CLC group and none in the RC group (p=0.002).The RC group consumed more medical resources in the index hospitalization; however, they experienced significantly less postoperative complications.

New Developments in Robotics and Single-site Gynecologic Surgery

Within the last 10 years there have been significant advances in minimal-access surgery. Although no emerging technology has demonstrated improved outcomes or fewer complications than standard laparoscopy, the introduction of the robotic surgical platform has significantly lowered abdominal hysterectomy rates. While operative time and cost were higher in robotic-assisted procedures when the technology was first introduced, newer studies demonstrate equivalent or improved robotic surgical efficiency with increased experience. Single-port hysterectomy has not improved postoperative pain or subjective cosmetic results. Emerging platforms with flexible, articulating instruments may increase the uptake of single-port procedures including natural orifice transluminal endoscopic cases.

Robotic cholecystectomy versus conventional laparoscopic cholecystectomy: A meta-analysis

BACKGROUND

Robotic cholecystectomy is a novel approach that offers the surgeon improved high-definition, 3-dimensional views and enhanced instrument ergonomics, which represent a technical development from previous operative platforms that include conventional and single-incision laparoscopy. This review compares its short-term outcomes with conventional laparoscopic cholecystectomy by a meta-analysis.

METHODS

A literature search was conducted using the MEDLINE, EMBASE, and PubMed databases (January 1990-October 2015). Studies identified were appraised with standard selection criteria. Data were extracted and a meta-analysis performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses.

RESULTS

Thirteen studies, 12 retrospective trials and one randomized controlled trial comprising 1,589 patients (laparoscopic cholecystectomy, n = 921; robotic cholecystectomy, n = 668) were examined. There was a trend of a greater median total operative time (115.3 min vs 128.0 min; pooled MD = 31.22, 95% confidence interval = -2.48 to 59.96; Z = 2.13; P = .03) and preoperative time (32.4 min vs 53.4 min; pooled MD = 20.98, 95% confidence interval = 15.74 to 26.23; Z = 7.84; P < .001) in the robotic cholecystectomy group. Intraoperative complications (P = .52), conversion rate (P = .06), estimated blood loss (P = .55), postoperative complications (P = .28), duration of hospital stay (P = .36), and readmission rate (P = .85) were similar between both groups.

CONCLUSION

Robotic cholecystectomy is associated with greater operative times related primarily to the preparatory phase of the operation but with similar safety and perioperative outcome as conventional laparoscopic cholecystectomy. For it to gain acceptance, future studies are required to define specific measures to quantify equipment benefits to the surgeon and to evaluate the potential advantage of its use in the acute setting.

Cosmesis, patient satisfaction, and quality of life after da Vinci Single-Site cholecystectomy and multiport laparoscopic cholecystectomy: short-term results from a prospective, multicenter, randomized, controlled trial

BACKGROUND

Single-incision laparoscopic cholecystectomy evolved from the traditional multiport laparoscopic technique. Prior trials have demonstrated improved cosmesis with the single-incision technique. Robotic single-site surgery minimizes the technical difficulties associated with laparoscopic single-incision approach. This is the first prospective, randomized, controlled study comparing robotic single-site cholecystectomy (RSSC) and multiport laparoscopic cholecystectomy (MPLC) in terms of cosmesis and patient satisfaction.

METHODS

Patients with symptomatic benign gallbladder disease were randomized to RSSC or MPLC. Data included perioperative variables such as operative time, conversion and complications and cosmesis satisfaction, body image perception, quality of life using validated questionnaires, at postoperative visits of 2, 6 weeks and 3 months.

RESULTS

One hundred thirty-six patients were randomized to RSSC (N = 83) and MPLC (N = 53) at 8 institutions. Both cohorts were dominated by higher enrollment of females (RSSC = 78%, MPLC = 92%). The RSSC and MPLC cohorts were otherwise statistically matched. Operative time was longer for RSSC (61 min vs. 44 min, P < 0.0001). There were no differences in complication rates. RSSC demonstrated a significant superiority in cosmesis satisfaction and body image perception (P value < 0.05 at every follow-up). There was no statistically significant difference in patient-reported quality of life. Multivariate analysis of female patients demonstrated significantly higher preference for RSSC over MPLC in cosmesis satisfaction and body image perception with no difference seen in overall quality of life.

CONCLUSIONS

Results from this trial show that RSSC is associated with improved cosmesis satisfaction and body image perception without a difference in observed complication rate. The uncompromised safety and the improved cosmesis satisfaction and body image perception provided by RSSC for female patients support consideration of the robotic single-site approach. ClinicalTrials.gov identifier NCT01932216.

Future of Minimally Invasive Colorectal Surgery

Minimally invasive surgery is slowly taking over as the preferred operative approach for colorectal diseases. However, many of the procedures remain technically difficult. This article will give an overview of the state of minimally invasive surgery and the many advances that have been made over the last two decades. Specifically, we discuss the introduction of the robotic platform and some of its benefits and limitations. We also describe some newer techniques related to robotics.

Pain related to robotic cholecystectomy with lower abdominal ports: effect of the bilateral ultrasound-guided split injection technique of rectus sheath block in female patients: A prospective randomised trial

BACKGROUND

Robotic cholecystectomy (RC) using port sites in the lower abdominal area (T12-L1) rather than the upper abdomen has recently been introduced as an alternative procedure for laparoscopic cholecystectomy. Therefore, we investigated the time course of different components of pain and the analgesic effect of the bilateral ultrasound-guided split injection technique for rectus sheath block (sRSB) after RC in female patients.

METHODS

We randomly assigned 40 patients to undergo ultrasound-guided sRSB (RSB group, n = 20) or to not undergo any block (control group, n = 20). Pain was subdivided into 3 components: superficial wound pain, deep abdominal pain, and referred shoulder pain, which were evaluated with a numeric rating scale (from 0 to 10) at baseline (time of awakening) and at 1, 6, 9, and 24 hours postoperatively. Consumption of fentanyl and general satisfaction were also evaluated 1 hour (before discharge from the postanesthesia care unit) and 24 hours postoperatively (end of study).

RESULTS

Superficial wound pain was predominant only at awakening, and after postoperative 1 hour in the control group. Bilateral ultrasound-guided sRSB significantly decreased superficial pain after RC (P < 0.01) and resulted in a better satisfaction score (P < 0.05) 1 hour after RC in the RSB group compared with the control group. The cumulative postoperative consumption of fentanyl at 6, 9, and 24 hours was not significantly different between groups.

CONCLUSIONS

After RC with lower abdominal ports, superficial wound pain predominates over deep intra-abdominal pain and shoulder pain only at the time of awakening. Afterwards, superficial and deep pain decreased to insignificant levels in 6 hours. Bilateral ultrasound-guided sRSB was effective only during the first hour. This limited benefit should be balanced against the time and risks entailed in performing RSB.

Robotic-Assisted Versus Laparoscopic Colectomy Results in Increased Operative Time Without Improved Perioperative Outcomes

BACKGROUND

Interest in robotic technology is burgeoning within the field of colorectal surgery. However, benefits of robotic-assisted colectomy (RAC) compared with laparoscopic colectomy (LC) remain ambiguous.

STUDY DESIGN

Patients who underwent minimally invasive colectomy during 2012-2013 were identified from the National Surgical Quality Improvement Program (NSQIP) database. Short-term perioperative outcomes were compared between 1:1 propensity-matched groups. A subset analysis was performed among patients who underwent segmental resections.

RESULTS

Among the 15,976 patients included, 498 (3.1 %) colectomies were performed with robotic assistance. After matching for demographic, clinical, and treatment characteristics, there were no differences between RAC and LC in complications such as wound infection, urinary tract infection, cardiopulmonary or thromboembolic events, renal insufficiency, anastomotic leaks, transfusions, readmissions, or 30-day mortality (all p > 0.05). However, operative time was markedly higher for RAC (196 vs. 166 min, p < 0.001). Among segmental resections, operative time remained significantly longer for RAC (190 vs. 153 min, p < 0.001) without differences in perioperative outcomes (all p > 0.05).

CONCLUSION

In this early experience, RAC resulted in similar perioperative outcomes when compared to LC but was associated with longer operative time. Given the focus on value-based healthcare, utilizing RAC in straightforward colectomies may not be financially justifiable at this stage of adoption.