The oncological and surgical safety of robot-assisted surgery in colorectal cancer: outcomes of a longitudinal prospective cohort study

Surgical Resection in Colorectal Liver Metastasis: An Umbrella Review

Surgical resection is the gold standard for treating synchronous colorectal liver metastases (CRLM). The resection of the primary tumor and metastatic lesions can follow different sequences: "simultaneous", "bowel-first", and "liver-first". Conservative approaches, such as parenchymal-sparing surgery and segmentectomy, may serve as alternatives to major hepatectomy. A comprehensive search of Medline, Epistemonikos, Scopus, and the Cochrane Library was conducted. Studies evaluating patients who underwent surgery for CRLM and reported survival results were included. Other secondary outcomes were analyzed, including disease-free survival, perioperative complications and mortality, and recurrence rates. Quality assessment was performed using the AMSTAR-2 method. No significant differences in overall survival, disease-free survival, and secondary outcomes were observed when comparing simultaneous to "bowel-first" resections, despite a higher rate of perioperative mortality in the former group. The 5-year OS was significantly higher for simultaneous resection compared to "liver-first" resection. No significant differences in OS and DFS were noted when comparing "liver-first" to "bowel-first" resection, or anatomic to non-anatomic resection. Our umbrella review validates simultaneous surgery as an effective oncological approach for treating SCRLM, though the increased risk of perioperative morbidity highlights the importance of selecting suitable patients. Non-anatomic resections might be favored to preserve liver function and enable future surgical interventions.

Safety and feasibility of robotic surgery for colon cancer patients with previous abdominal surgery: a propensity score-matching analysis

Robotic surgery is widely used in gastrointestinal surgery. While the application of robotic surgery for colon cancer patients with previous abdominal surgery (PAS) remains controversial for the fear of intra-abdominal adhesions. This study was aimed to evaluate the safety and feasibility of robotic colectomy for patients with PAS. The medical records of colon cancer patients who underwent robotic surgery at our hospital from June 2015 to August 2020 were extracted and analyzed. Propensity score-matching (PSM) analysis was implemented to minimize selection bias. We compared perioperative outcomes and postoperative complications between the patients with PAS or with no PAS (NPAS). A total of 79 patients (PAS group) and 348 patients (NPAS group) were included in our study. After PSM, 79 patients of PAS group and 79 patients of NPAS group were selected for further analysis. We did not find statistical difference in operative time, estimated blood loss, lymph nodes retrieved, length of hospital stay and hospital costs between the two groups. No difference was noted in the incidence of postoperative complications, conversion to open surgery and mortality between the two groups. According to the results of multivariate analysis, PAS was not identified as risk factor for postoperative complications. Left hemicolectomy and perioperative transfusion were associated with postoperative complications. PAS did not negatively affect the outcomes of robotic colectomy. After individually preoperative assessment, robotic surgery could be performed feasibly and safely for colon cancer patients with PAS.

Evaluation of an established colorectal robotic programme at an NHS district general hospital: audit of outcomes and systematic review of published data

INTRODUCTION

Robotic-assisted surgery (RAS) offers potential advantages over traditional surgical approaches. This study aimed to assess outcomes from a district general hospital (DGH) robotic colorectal programme against published data.

MATERIALS AND METHODS

The robotic programme was established following simulator, dry/wet lab training, and proctoring. We performed a case series analysing technical, patient, and oncological outcomes extracted from a prospective database of colorectal RAS cases (2015-2022). A registered systematic review (PROSPERO CRD42022300773; PubMed, Web of Science, EMBASE) of single-centre colorectal series from established robotic centres (n>200 cases) was completed and compared to local data using descriptive summary statistics. Risk of bias assessment was performed using an adapted version of the Cochrane ROBINS-I tool.

RESULTS

Two hundred thirty-two RAS cases were performed including 122 anterior resections, 56 APERs, 19 rectopexies, and 15 Hartmann's procedures. The median duration was 325 (IQR 265-400) min. Blood loss was < 100 ml in 97% of cases with 2 (0.9%) cases converted to open. Complications (Clavien-Dindo 3-5) occurred in 19 (8%) patients, with 3 (1.3%) deaths in < 30 days. Length of stay was 7 (IQR 5-11) days. In 169 rectal cancer cases, there were 9 (5.3%) cases with a positive circumferential or distal margin and lymph node yield of 17 (IQR 13-24). A systematic review of 1648 abstracts identified 13 studies from established robotic centres, totaling 4930 cases, with technical, patient, and oncological outcomes comparable to our own case series.

CONCLUSIONS

Outcomes from our robotic colorectal programme at a UK DGH are comparable with the largest published case series from world-renowned centres. Training and proctoring together with rolling audit must accompany the expansion of robotic surgery to safeguard outcomes.

Propensity score-matched analysis of the short-term outcomes of robotic versus laparoscopic surgery for rectal cancer

PURPOSE

The advantages of robot-assisted rectal surgery (RARS) over conventional laparoscope-assisted rectal surgery (LARS) remain controversial. This study was performed to compare the short-term outcomes of RARS and LARS.

METHODS

We retrospectively analyzed data of 207 patients who had undergone either RARS (n = 97) or LARS (n = 110) for rectal cancer (RC) from 2018 to 2020. A 1:1 matched propensity score-matched analysis was performed and the surgical outcomes of the two groups compared.

RESULTS

After matching, a well-balanced cohort of 136 patients was analyzed (n = 68 in each group), and there was no significant difference in the median operative time. The RARS group had less intraoperative blood loss than the LARS group. There were no significant differences in length of postoperative hospital stay or complication rate between the two groups. In the subgroup of lower RC, defined as the inferior edge of the tumor being within the rectum distal to the peritoneal reflection, the rate of sphincter preservation was higher in the RARS group (81.8% vs. 44.4%, p = 0.021).

CONCLUSION

This study shows that RARS is a safe and feasible approach for RC compared with LARS, RARS having the advantage of more often preserving the sphincter.

Application of artificial intelligence in diagnosis and treatment of colorectal cancer: A novel Prospect

In the past few decades, according to the rapid development of information technology, artificial intelligence (AI) has also made significant progress in the medical field. Colorectal cancer (CRC) is the third most diagnosed cancer worldwide, and its incidence and mortality rates are increasing yearly, especially in developing countries. This article reviews the latest progress in AI in diagnosing and treating CRC based on a systematic collection of previous literature. Most CRCs transform from polyp mutations. The computer-aided detection systems can significantly improve the polyp and adenoma detection rate by early colonoscopy screening, thereby lowering the possibility of mutating into CRC. Machine learning and bioinformatics analysis can help screen and identify more CRC biomarkers to provide the basis for non-invasive screening. The Convolutional neural networks can assist in reading histopathologic tissue images, reducing the experience difference among doctors. Various studies have shown that AI-based high-level auxiliary diagnostic systems can significantly improve the readability of medical images and help clinicians make more accurate diagnostic and therapeutic decisions. Moreover, Robotic surgery systems such as da Vinci have been more and more commonly used to treat CRC patients, according to their precise operating performance. The application of AI in neoadjuvant chemoradiotherapy has further improved the treatment and efficacy evaluation of CRC. In addition, AI represented by deep learning in gene sequencing research offers a new treatment option. All of these things have seen that AI has a promising prospect in the era of precision medicine.

Outcomes of Robot-Assisted Surgery in Rectal Cancer Compared with Open and Laparoscopic Surgery

With increasing trends for the adoption of robotic surgery, many centers are considering changing their practices from open or laparoscopic to robot-assisted surgery for rectal cancer. We compared the outcomes of robot-assisted rectal resection with those of open and laparoscopic surgery. We searched Medline, Web of Science, and CENTRAL databases until October 2022. All randomized controlled trials (RCTs) and prospective studies comparing robotic surgery with open or laparoscopic rectal resection were included. Fifteen RCTs and 11 prospective studies involving 6922 patients were included. The meta-analysis revealed that robotic surgery has lower blood loss, less surgical site infection, shorter hospital stays, and higher negative resection margins than open resection. Robotic surgery also has lower conversion rates, lower blood loss, lower rates of reoperation, and higher negative circumferential margins than laparoscopic surgery. Robotic surgery had longer operation times and higher costs than open and laparoscopic surgery. There were no differences in other complications, mortality, and survival between robotic surgery and the open or laparoscopic approach. However, heterogeneity between studies was moderate to high in some analyses. The robotic approach can be the method of choice for centers planning to change from open to minimally invasive rectal surgery. The higher costs of robotic surgery should be considered as a substitute for laparoscopic surgery (PROSPERO: CRD42022381468).

Robotic colon surgery in obese patients: a systematic review and meta-analysis

BACKGROUND

Colon cancer resection can be technically difficult in the obese (OB) population. Robotic surgery is a promising technique but its benefits remain uncertain in OB patients. The aim of this study is to compare OB versus non-obese (NOB) patients undergoing robotic colon surgery, as well as OB patients undergoing robotic versus open or laparoscopic colonic surgery.

METHODS

A systematic review and meta-analysis was performed. Primary outcome measures included length of stay (LOS), surgical site infection (SSI) rate, complications, anastomotic leak and oncological outcomes.

RESULTS

A total of eight studies were included, with five comparing OB and NOB patients undergoing robotic colon surgery included in meta-analysis. A total of 263 OB patients and 400 NOB patients formed the sample for meta-analysis. There was no significant difference between the two groups in operative time, conversion to open, LOS, lymph node yield, anastomotic leak and postoperative ileus. There was a trend towards a significant increase in overall complications and SSI in the OB group (32.3% OB versus 26.8% NOB for complications, 14.2% OB versus 9.9% NOB for SSI). The three included studies comparing surgical techniques were too heterogeneous to undergo meta-analysis.

CONCLUSION

Robotic colon surgery is safe in obese patients, but high-quality prospective evidence is lacking. Future studies should report on oncological safety and the cost-effectiveness of adopting the robotic technique in these challenging patients.

Advantages of the umbilical minilaparotomy-first approach in robotic rectal cancer surgery

BACKGROUND

Since 2018, we have performed robotic rectal cancer surgery at our institution via the umbilical mini-laparotomy-first approach. In the present technical note, we introduce the advantages of this approach.

METHODS

In this approach, a 3-cm mini-laparotomy and the wound protector attachment are performed prior to port placement for the da Vinci^® Xi system. During robotic surgery, the assistant can adjust the location of the camera port within the wound protector.

RESULTS

This approach is only different from the standard port placement in terms of the timing of minilaparotomy; therefore, there is no additional cost. This approach has several advantages. 1: Intraabdominal adhesion around the umbilicus can be dissected under direct vision. 2: Robot arm collision can be diminished. 3: The diverting stoma can be located just at the preoperative stoma-site marking. 4: The da Vinci^® camera is less likely to be dirty. 5: Assistant ports can be added through the wound protector. However, sometimes interference between the wound protector extends inside the abdomen and other ports can be a problem, especially in small patients. A smaller-size wound protector is thus recommended in such cases.

CONCLUSIONS

The umbilical minilaparotomy-first approach in robotic rectal cancer surgery is a simple and feasible technique with great advantages for not only ensuring successful robotic surgery but also reducing the stoma-associated complications.

National differences in implementation of minimally invasive surgery for colorectal cancer and the influence on short-term outcomes

Background

The timing and degree of implementation of minimally invasive surgery (MIS) for colorectal cancer vary among countries. Insights in national differences regarding implementation of new surgical techniques and the effect on postoperative outcomes are important for quality assurance, can show potential areas for country-specific improvement, and might be illustrative and supportive for similar implementation programs in other countries. Therefore, this study aimed to evaluate differences in patient selection, applied techniques, and results of minimal invasive surgery for colorectal cancer between the Netherlands and Sweden.

Methods

Patients who underwent elective minimally invasive surgery for T1-3 colon or rectal cancer (2012–2018) registered in the Dutch ColoRectal Audit or Swedish ColoRectal Cancer Registry were included. Time trends in the application of MIS were determined. Outcomes were compared for time periods with a similar level of MIS implementation (Netherlands 2012–2013 versus Sweden 2017–2018). Multilevel analyses were performed to identify factors associated with adverse short-term outcomes.

Results

A total of 46,095 Dutch and 8,819 Swedish patients undergoing MIS for colorectal cancer were included. In Sweden, MIS implementation was approximately 5 years later than in the Netherlands, with more robotic surgery and lower volumes per hospital. Although conversion rates were higher in Sweden, oncological and surgical outcomes were comparable. MIS in the Netherlands for the years 2012–2013 resulted in a higher reoperation rate for colon cancer and a higher readmission rate but lower non-surgical complication rates for rectal cancer if compared with MIS in Sweden during 2017–2018.

Conclusion

This study showed that the implementation of MIS for colorectal cancer occurred later in Sweden than the Netherlands, with comparable outcomes despite lower volumes. Our study demonstrates that new surgical techniques can be implemented at a national level in a controlled and safe way, with thorough quality assurance.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08974-1.

Early experience with the ARTISENTIAL® articulated instruments in laparoscopic low anterior resection with TME

Background

The notion of articulation in surgery has been largely synonymous with robotics. The ARTISENTIAL^® instruments aim at bringing advanced articulation to laparoscopy to overcome challenges in narrow anatomical spaces. In this paper, we present first single-center results of a series of low anterior resections, performed with ARTISENTIAL^®.

Methods

Between September 2020 and August 2021, at the Department of Surgery, St. Marienkrankenhaus Siegen, Siegen, Germany, patients with cancer of the mid- and low rectum were prospectively enrolled in a pilot feasibility study to evaluate the ARTISENTIAL^® articulated instruments in performing a laparoscopic low anterior resection. Perioperative and short-term postoperative data were analyzed.

Results

Seventeen patients (10 males/7 females) were enrolled in this study. The patients had a median age of 66 years (range 47–80 years) and a median body mass index of 28 kg/m² (range 23–33 kg/m²). The median time to rectal transection was 155 min (range 118–280 min) and the median total operative time was 276 min (range 192–458 min). The median estimated blood loss was 30 ml (range 5–70 ml) and there were no conversions to laparotomy. The median number of harvested lymph nodes was 15 (range 12–28). Total mesorectal excision (TME) quality was ‘good’ in all patients with no cases of circumferential resection margin involvement (R0 = 100%). The median length of stay was 9 days (range 7–14 days). There were no anastomotic leaks and the overall complication rate was 17.6%. There was one unrelated readmission with no mortality.

Conclusions

Low anterior resection with ARTISENTIAL^® is feasible and safe. All patients had a successful TME procedure with a good oncological outcome. We will now seek to evaluate the benefits of ARTISENTIAL^® in comparison with standard laparoscopic instruments through a larger study.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-022-02588-y.

Local recurrence of robot-assisted total mesorectal excision: a multicentre cohort study evaluating the initial cases

PURPOSE

Evidence regarding local recurrence rates in the initial cases after implementation of robot-assisted total mesorectal excision is limited. This study aims to describe local recurrence rates in four large Dutch centres during their initial cases.

METHODS

Four large Dutch centres started with the implementation of robot-assisted total mesorectal excision in respectively 2011, 2012, 2015, and 2016. Patients who underwent robot-assisted total mesorectal excision with curative intent in an elective setting for rectal carcinoma defined according to the sigmoid take-off were included. Overall survival, disease-free survival, systemic recurrence, and local recurrence were assessed at 3 years postoperatively. Subsequently, outcomes between the initial 10 cases, cases 11-40, and the subsequent cases per surgeon were compared using Cox regression analysis.

RESULTS

In total, 531 patients were included. Median follow-up time was 32 months (IQR: 19-50]. During the initial 10 cases, overall survival was 89.5%, disease-free survival was 73.1%, and local recurrence was 4.9%. During cases 11-40, this was 87.7%, 74.1%, and 6.6% respectively. Multivariable Cox regression did not reveal differences in local recurrence between the different case groups.

CONCLUSION

Local recurrence rate during the initial phases of implantation of robot-assisted total mesorectal procedures is low. Implementation of the robot-assisted technique can safely be performed, without additional cases of local recurrence during the initial cases, if performed by surgeons experienced in laparoscopic rectal cancer surgery.

The learning curve of robot-assisted vitreoretinal surgery - A randomized trial in a simulated setting

PURPOSE

To investigate the learning curve of robot-assisted vitreoretinal surgery compared to manual surgery in a simulated setting.

METHODS

The study was designed as a randomized controlled longitudinal study. Eight ophthalmic trainees in the 1st or 2nd year of their specialization were included. The participants were randomized to either manual or robot-assisted surgery. Participants completed repetitions of a test consisting of three vitreoretinal modules on the Eyesi virtual reality simulator. The primary outcome measure was time to learning curve plateau (minutes) for total test score. The secondary outcome measures were instrument movement (mm), tissue treatment (mm² ) and time with instruments inserted (seconds).

RESULTS

There was no significant difference in time to learning curve plateau for robot-assisted vitreoretinal surgery compared to manual. Robot-assisted vitreoretinal surgery was associated with less instrument movements (i.e. improved precision), -0.91 standard deviation (SD) units (p < 0.001). Furthermore, robot-assisted vitreoretinal surgery was associated with less tissue damage when compared to manual surgery, -0.94 SD units (p = 0.002). Lastly, robot-assisted vitreoretinal surgery was slower than manual surgery, 0.93 SD units (p < 0.001).

CONCLUSIONS

There was no significant difference between the lengths of the learning curves for robot-assisted vitreoretinal surgery compared to manual surgery. Robot-assisted vitreoretinal surgery was more precise, associated with less tissue damage, and slower.

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

Background

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

Methods

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

Results

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

Conclusion

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

Supplementary Information

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

Laparoscopic Versus Robot-Assisted Versus Transanal Low Anterior Resection: 3-Year Oncologic Results for a Population-Based Cohort in Experienced Centers

BACKGROUND

Laparoscopic, robot-assisted, and transanal total mesorectal excision are the minimally invasive techniques used most for rectal cancer surgery. Because data regarding oncologic results are lacking, this study aimed to compare these three techniques while taking the learning curve into account.

METHODS

This retrospective population-based study cohort included all patients between 2015 and 2017 who underwent a low anterior resection at 11 dedicated centers that had completed the learning curve of the specific technique. The primary outcome was overall survival (OS) during a 3-year follow-up period. The secondary outcomes were 3-year disease-free survival (DFS) and 3-year local recurrence rate. Statistical analysis was performed using Cox-regression.

RESULTS

The 617 patients enrolled in the study included 252 who underwent a laparoscopic resection, 205 who underwent a robot-assisted resection, and 160 who underwent a transanal low anterior resection. The oncologic outcomes were equal between the three techniques. The 3-year OS rate was 90% for laparoscopic resection, 90.4% for robot-assisted resection, and 87.6% for transanal low anterior resection. The 3-year DFS rate was 77.8% for laparoscopic resection, 75.8% for robot-assisted resection, and 78.8% for transanal low anterior resection. The 3-year local recurrence rate was in 6.1% for laparoscopic resection, 6.4% for robot-assisted resection, and 5.7% for transanal procedures. Cox-regression did not show a significant difference between the techniques while taking confounders into account.

CONCLUSION

The oncologic results during the 3-year follow-up were good and comparable between laparoscopic, robot-assisted, and transanal total mesorectal technique at experienced centers. These techniques can be performed safely in experienced hands.

Update on Robotic Total Mesorectal Excision for Rectal Cancer

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.

Simultaneous Robot Assisted Colon and Liver Resection for Metastatic Colon Cancer

Introduction

Simultaneous robot assisted colon and liver resections are being performed more frequently at present due to the expanded adoption of the robotic platform for surgical management of metastatic colon cancer. However, this approach has not been studied in detail with only case series available in the literature. The aim of this systematic review was to evaluate the current body of evidence on the feasibility of performing simultaneous robotic colon and liver resections.

Methods

A systematic review was performed through PubMed to identify relevant articles describing simultaneous colon and liver resections for metastatic colon cancer.

Results

A total of 28 patients underwent simultaneous resections robotically with an average operative time of 420.3 minutes and average blood loss of 275.6 ml. Postoperative stay was 8.6 days on average with all cases achieving negative surgical margins.

Conclusions

Robotic simultaneous resection of colorectal cancer with liver metastases is technically feasible and seems oncologically equivalent to open or laparoscopic surgery. Further studies are urgently needed to assess benefits of robotic surgery in the patient population.

Initial experience of Chinese surgical robot "Micro Hand S″ assisted versus open and laparoscopic total mesorectal excision for rectal cancer: Short-term outcomes in a single center

BACKGROUND

A Chinese surgical robot, Micro Hand S, was introduced for clinical use as a novel robotic platform. This study aimed to comprehensively compare the early experience of the Micro Hand S robot-assisted total mesorectal excision (TME) with conventional approaches.

METHODS

Between May 2017 and April 2018, 99 consecutive patients who underwent open, laparoscopic and Micro Hand S robot-assisted TME (O-/L-/RTME) for rectal cancer were included. Clinical and pathological outcomes were retrospectively analyzed. Surgical success as the primary endpoint was defined as the absence of (i) conversion, (ii) incomplete TME, (iii) involved circumferential and distal resection margins (CRM/DRM), (iv) severe complications.

RESULTS

The rate of surgical success was similar (89.7 vs. 86.4 vs. 84.6%, p = 0.851) in the three groups and the respective incidences were as follows: conversion (not applicable, 4.5 vs. 2.3%, p = 1.000), incomplete TME (6.9 vs. 6.8 vs. 3.8%, p = 0.980), involved CRM/DRM (0 vs. 2.3 vs. 3.8%, p = 0.592), severe complications (3.4 vs. 4.5 vs. 7.7%, p = 0.844). Compared with open and laparoscopic surgery, the robotic surgery was associated with longer operative time, less blood loss, earlier first flatus time and liquid intake time, and shorter length of hospital stay (p < 0.05).

CONCLUSIONS

The Micro Hand S assisted TME is safe and feasible, showing comparable outcomes than conventional approaches, with superiority in blood loss, recovery of bowel function, length of hospital stay, but with increased operative time.

A rare cause of lower gastrointestinal bleeding treated with robotic colorectal surgery

Background

Metastatic melanoma to the colon is rarely diagnosed with an incidence of only 0.3% and more than 95% of cases identified post-mortem. Survival for patients with metastatic melanoma to the colon is poor, with 5-year survival rates of 26.5%. Nonetheless, surgical resection of the colonic metastatic melanoma lesions is recommended as it is associated with improved survival. Additionally, surgical resection is also indicated for palliative reasons, as symptom resolution is achieved in 90% of such patients. Use of the surgical robot has increased dramatically in the past decades, especially in the field of colorectal surgery. Furthermore, recent studies have demonstrated comparable outcomes between patients undergoing either laparoscopic or robotic-assisted colorectal surgery for cancer. Here, we describe the first case, to the authors knowledge, of a robot-assisted sigmoid colectomy for metastatic melanoma.

Case presentation

A 72-year-old male with a history of metastatic melanoma diagnosed in 2015 with a favorable response to immunotherapy presented to the emergency department with symptomatic lower gastrointestinal bleeding (LGIB). Endoscopy demonstrated a friable melanotic lesion of the sigmoid colon with biopsy demonstrating histopathologic evidence of metastatic melanoma. After further evaluation, the patient consented for an elective robot-assisted segmental colectomy for palliative intent. Diagnostic laparoscopy identified no evidence of further intra-abdominal metastatic disease. After identifying the metastatic lesion in the sigmoid colon, the mesentery of involved segment of sigmoid colon adjacent to the lesion was divided using the bipolar electrosurgical vessel sealer device. The colon was divided both proximal and distal to the lesion using a robotic stapler and a tension-free colo-colonic anastomosis was created intracorporeally. Postoperatively, the patient had an unremarkable course and was discharged home on post-operative day 3. On follow-up, the patient was doing well with resolution of preoperative LGIB.

Conclusion

 This case highlights a rare presentation of metastatic melanoma to the colon in a patient presenting with LGIB. Furthermore, this case demonstrates the feasibility of the minimally invasive robotic-assisted approach for an uncommon pathology.

The effect of comprehensive nursing on the recovery speed and prognosis of elderly colon cancer patients

To explore the effect of comprehensive nursing on the recovery speed and prognosis of elderly colon cancer patients. A total of 110 elderly patients undergoing colon cancer surgery in our hospital from January 2018 to January 2020 were selected and divided into a control group (n=55, routine care) and an observation group (n=55, comprehensive nursing) according to the random number table method. The post-care stress state index score, surgical tolerance, postoperative recovery, postoperative complications, satisfaction, gastrointestinal quality of life index and other conditions were compared. The Numerical Rating Scale (NRS), Hamilton Depression Scale (HAMD) and Hamilton Anxiety Scale (HAMA) and other indicators scores in observation group were lower than those in the control group; the observation group had shorter postoperative hospital stay, bed time, first defecating time, first anal exhaust time; the postoperative complication rate of the observation group was 9.09%, which was lower than 25.45% of the control group; the satisfaction rate of the observation group was 94.55%, which was higher than 78.18% of the control group. All the above differences were statistically significant (P<0.05). The Gastrointestinal Quality of Life Index (GIQLI) score of the observation group was higher than that of the control group, and the difference was statistically significant (inter-group effect: F=172.100, P<0.001). The GIQLI score of both groups increased with time (time effect: F=69.270, P<0.001), and the grouping and time had an interactive effect (interactive effect: F=7.186, P<0.001). The application of comprehensive nursing in elderly patients with colon cancer has a remarkable effect. It can promote the rehabilitation of patients and improve the prognosis, which is worthy of promotion in clinic.

Short-term outcomes of robotic-assisted versus conventional laparoscopic-assisted surgery for rectal cancer: a propensity score-matched analysis

It remains controversial whether the advantages of robotic-assisted surgery are beneficial for rectal cancer (RC). The study aimed to evaluate the short-term outcomes of robotic-assisted rectal surgery (RARS) compared with those of conventional laparoscopic-assisted rectal surgery. We retrospectively analyzed 539 consecutive patients with stage I-IV RC who had undergone elective surgery between January 2010 and December 2020, using propensity score-matched analysis. After propensity score matching, we enrolled 200 patients (n = 100 in each groups). Before matching, significant group-dependent differences were observed in terms of age (p = 0.04) and body mass index (p < 0.01). After matching, clinicopathologic outcomes were similar between the groups, but estimated operative time was longer and postoperative lymphorrhea was more frequent in the RARS group. Estimated blood loss, rate of conversion to laparotomy, and incidence of anastomotic leakage or reoperation were significantly lower in the RARS group. No surgical mortality was observed in either group. No significant differences were observed in terms of positive resection margins or number of lymph nodes harvested. RARS was safe and technically feasible, and achieved acceptable short-term outcomes. The robotic technique showed some advantages in RC surgery that require validation in further studies.

Implementation of robot-assisted total mesorectal excision by multiple surgeons in a large teaching hospital: Morbidity, long-term oncological and functional outcome

BACKGROUND

Robot-assisted total mesorectal excision (TME) might offer benefits in less morbidity, better functional and long-term outcome over laparoscopic TME.

METHODS

All consecutive patients undergoing robot-assisted TME for rectal cancer during implementation between May 2015 and December 2019 performed by five surgeons in a single centre were included. Outcomes included local recurrence rate at 3 years, conversion rate, circumferential resection margin (CRM) positivity rate, 30-day postoperative morbidity and outcomes of low anterior resection syndrome (LARS) questionnaires.

RESULTS

In 105 robot-assisted TME, local recurrence rate at 3 years was 7.4%, conversion to open surgery rate was 8.6%, CRM positivity rate was 5.7%, 73.3% had good quality specimen, postoperative morbidity rate was 47.6% and anastomotic leakage rate was 9.0%. Incidence of major LARS was 55.3%.

CONCLUSIONS

results of this study described acceptable morbidity, functional and long-term outcome during implementation of robotic TME for rectal cancer by multiple surgeons in a single centre.

The art of robotic colonic resection: a review of progress in the past 5 years

Surgery is developing in the direction of minimal invasiveness, and robotic surgery is becoming increasingly adopted in colonic resection procedures. The ergonomic improvements of robot promote surgical performance, reduce workload for surgeons and benefit patients. Compared with laparoscopy-assisted colon surgery, the robotic approach has the advantages of shorter length of hospital stay, lower rate of conversion to open surgery, and lower rate of intraoperative complications for short-term outcomes. Synchronous robotic liver resection with colon cancer is feasible. The introduction of the da Vinci Xi System (Intuitive Surgical, Inc., Sunnyvale, CA, USA) has introduced more flexibility to colonic operations. Optimization of the suprapubic surgical approach may shorten the length of hospital stay for patients who undergo robotic colonic resection. Single-port robotic colectomy reduces the number of robotic ports for better looking and faster recovery. Intestinal anastomosis methods using totally robotic surgery result in shorter time to bowel function recovery and tolerance to a solid diet, although the operative time is longer. Indocyanine green is used as a tracer to assess blood supplementation in the anastomosis and marks lymph nodes during operation. The introduction of new surgical robots from multiple manufacturers is bound to change the landscape of robotic surgery and yield high-quality surgical outcomes. The present article reviews recent advances in robotic colonic resection over the past five years.

Omnidirectional camera and head-mount display contribute to the safety of laparoscopic surgery

BACKGROUND

We focused on the availability of an omnidirectional camera and head-mount display (HMD). If the laparoscope is an omnidirectional camera, captured images are sent to the HMD worn by the operator in real time. The operator can thus view the image as they like without moving the camera and obtain a 360° view intuitively. However, the surgical system that can be used for actual laparoscopic operations has not yet been developed. In this study, we aimed to show that an omnidirectional camera and HMD would be useful in laparoscopic surgery.

MATERIAL AND METHODS

Eleven medical students and twelve surgical residents (Surgeons group) participated in this study. We created an experimental box with five marks randomly attached inside the box, and the inside cannot be seen from the outside. We measured the time it took to identify all marks between conventional laparoscope and substitute system in each group.

RESULTS

In the substitute system, the time required for the task was significantly shorter than with conventional laparoscopy in each group.

CONCLUSION

An omnidirectional camera and HMD may be a useful new device for laparoscopic surgery. This system may help improve the safety of laparoscopic surgery.

Establishment of animal model manifested as bladder neurogenic changes generated by bilateral pelvic nerve injury in male rats

PURPOSE

To establish a male rat model of neurogenic bladder after bilateral pelvic nerve injury (BPNI) and investigate the factors associated with onset of neurogenic bladder.

METHODS

Twenty-four 8-week-old male Sprague-Dawley rats were randomly divided into three groups (n = 8 rats per group). Rats in 4-week and 8-week nerve injury group underwent BPNI, while rats in the sham group underwent a sham operation. Bladder functional analysis were performed and then bladders tissues were harvested for morphological examination and investigating the mRNA expression levels of target genes in all rats.

RESULTS

The bladder weight significantly increased in rats following BPNI. Functional analysis revealed non-voiding contractions and decreased detrusor contractility following BPNI, manifested as elevated post-void residual and bladder capacity while reduced maximum voiding pressure and voiding efficiency. The collagen area in bladder tissue and mRNA expression levels of target genes significantly increased at 4 or 8 weeks post-BPNI except Smad3. At 4 weeks post-BPNI, expression levels of vesicular acetylcholine transporter were reduced, then returned to baseline at 8 weeks. Expression levels of tyrosine hydroxylase were reduced at both 4 and 8 weeks post-BPNI.

CONCLUSIONS

A neurogenic bladder animal model was successfully established by performing BPNI in male rats, characterized by impaired voiding function, bladder detrusor fibrosis, and reduced neurotransmitter release.

Short- and long-term outcomes for transvaginal specimen extraction versus minilaparotomy after robotic anterior resection for colorectal cancer: a mono-institution retrospective study

BACKGROUND

Colorectal cancer resection surgery with transvaginal specimen extraction is becoming increasingly accepted and used by surgeons. However, few publications on robotic anterior sigmoid colon and rectal cancer resection with transvaginal specimen extraction (TVSE) have been reported, and a clinical outcome comparison between conventional robotic minilaparotomy (LAP) and transvaginal specimen extraction in anterior sigmoid colon and rectal cancer resection has not been performed. The current study compared the short- and long-term outcomes of TVSE and LAP for sigmoid colon cancer and rectal cancer in a mono-institution.

METHODS

From December 2014 to October 2018, 45 patients who underwent TVSE and 45 patients who underwent LAP matched by tumor location, tumor stage, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, gender, and age at the same period were included in the current study. The short- and long-term outcomes of TVSE and LAP were discussed.

RESULTS

No significant differences were found in patient characteristics. For the short-term outcomes, the operative time in the TVSE group was longer than that in the LAP group, and the postoperative pain and additional analgesia were lower in the TVSE group. Patients in the TVSE group required slightly less time to pass first flatus. There were no significant differences in overall complications, time to regular diet, length of hospital stay after surgery, estimated blood loss, or pathological outcomes. For long-term outcomes, the 3-year overall survival (94.9% vs. 91.7%, p = 0.702) and 3-year disease-free survival (88.4% vs. 86.2%, p = 0.758) were comparable between the two groups.

CONCLUSION

The robotic TVSE is safe and feasible in selected sigmoid/upper rectal cancer patients with tumor diameter < 5 cm. This approach has slightly better short-term outcomes in terms of less postoperative pain and less analgesic requirements without any significant difference in long-term outcomes.

Evolution of Robotic Surgery in a Colorectal Cancer Unit in India

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

The comparison of the process of manual and robotic positioning of the electrode performing radiofrequency ablation under the control of a surgical navigation system

This study is aimed at the comparison of the process of manual and robotic positioning of the electrode performing radiofrequency ablation under the control of a surgical navigation system. The main hypothesis of this experiment was that the use of a collaborative manipulator (KUKA iiwa) will allow to position the active part of the electrode relative to the center of the tumor more accurately and from the first attempt. We also monitor the stability of the electrode′s velocity during insertion and consider some advantages in ergonomics using the robotic manipulator. We use three more criteria to compare the surgeon's and robotic performance, unlike other studies, where only the target point's accuracy criterion is observed. The main idea is to examine the movement parameters of the electrode that can lead to potential patient trauma. Sphere-shaped tumor phantoms measuring 8 mm in diameter were filled with contrast and inserted in bovine livers. 10 livers were used for the robotic experiment and an equal quantity for manual surgery. The livers were encased in silicone phantoms designed to imitate the liver position in a real patient's abdominal cavity. Analysis of CT data gave the opportunity to find the entry and the target point for each tumor phantom. This data was loaded into a surgical navigation system that was used to track and record the position of the RF-electrode during the operation for further analysis. The standard deviation of points from the programmed linear trajectory totaled in the average 0.3 mm for the robotic experiment and 2.33 mm for the manual operation with a maximum deviation of 0.55 mm and 7.99 mm respectively. Standard deviation from the target point was 2.69 mm for the collaborative method and 2.49 mm for the manual method. The average velocity was 2.97 mm/s for the manipulator and 3.12 mm/s for the manual method, but the standard deviation of the velocity relative to the value of the average velocity was 0.66 mm/s and 3.05 mm/s respectively. Thus, in two criteria out of three, the manipulator is superior to the surgeon, and equality is established in one. Surgeons also noticed advantages in ergonomics performing the procedure using the manipulator. This experiment was produced as part of the work on the developing of a robotic multifunctional surgical complex. We can confirm the potential advantages of using collaborative robotic manipulators for minimally invasive surgery in case of practice for cancer treatment.

Robotic-assisted right colectomy versus laparoscopic approach: case-matched study and cost-effectiveness analysis

AIM

The aim of this study is to compare clinical and oncological outcomes of robot-assisted right colectomy with those of conventional laparoscopy-assisted right colectomy, reporting for the first time in literature, a cost-effectiveness analysis.

METHODS

This is a case-matched prospective non-randomized study conducted from October 2013 to October 2017 at Sanchinarro University Hospital, Madrid. Patients with right-sided colonic adenocarcinoma or adenoma, not suitable endoscopic resection were treated with robot-assisted right colectomy and a propensity score-matched (1:1) was used to balance preoperative characteristics of a laparoscopic control group. Perioperative, postoperative, long-term oncological results and costs were analysed, and quality-adjusted life years (QALY), and the cost-effectiveness ratio (ICER) were calculated. The primary end point was to compare the cost-effectiveness differences between both groups. A willingness-to-pay of 20,000 and 30,000 per QALY was used as a threshold to recognize which treatment was most cost effective.

RESULTS

Thirty-five robot-assisted right colectomies were included and a group of 35 laparoscopy-assisted right colectomy was selected. Compared with the laparoscopic group, the robotic group was associated with longer operation times (243 min vs. 179 min, p < 0.001). No significant difference was observed in terms of total costs between the robotic and laparoscopic groups (9455.14 vs 8227.50 respectively, p = 0.21). At a willingness-to-pay threshold of 20,000 and 30,000, there was a 78.78-95.04% probability that the robotic group was cost effective relative to laparoscopic group.

CONCLUSION

Robot-assisted right colectomy is a safe and feasible technique and is a cost-effective procedure.

Locoregional recurrences after transanal total mesorectal excision of rectal cancer during implementation

Background

Transanal total mesorectal excision (TaTME) has been proposed as an approach in patients with mid and low rectal cancer. The TaTME procedure has been introduced in the Netherlands in a structured training pathway, including proctoring. This study evaluated the local recurrence rate during the implementation phase of TaTME.

Methods

Oncological outcomes of the first ten TaTME procedures in each of 12 participating centres were collected as part of an external audit of procedure implementation. Data collected from a cohort of patients treated over a prolonged period in four centres were also collected to analyse learning curve effects. The primary outcome was the presence of locoregional recurrence.

Results

The implementation cohort of 120 patients had a median follow up of 21·9 months. Short‐term outcomes included a positive circumferential resection margin rate of 5·0 per cent and anastomotic leakage rate of 17 per cent. The overall local recurrence rate in the implementation cohort was 10·0 per cent (12 of 120), with a mean(s.d.) interval to recurrence of 15·2(7·0) months. Multifocal local recurrence was present in eight of 12 patients. In the prolonged cohort (266 patients), the overall recurrence rate was 5·6 per cent (4·0 per cent after excluding the first 10 procedures at each centre).

Conclusion

TaTME was associated with a multifocal local recurrence rate that may be related to suboptimal execution rather than the technique itself. Prolonged proctoring, optimization of the technique to avoid spillage, and quality control is recommended.

Robotic Colorectal Surgery

The role of robotics in colon and rectal surgery has been established as an important and effective tool for the surgeon. Its inherent technologies have provided for increased visualization and ease of dissection in the minimally invasive approach to surgery. The value of the robot is apparent in the more challenging aspects of colon and rectal procedures, including the intracorporeal anastomosis for right colectomies and the low pelvic dissection for benign and malignant diseases.

Robotic Surgery for Rectal Cancer: Operative Technique and Review of the Literature

The number of patients undergoing robotic surgery for rectal cancer has rapidly increased in Japan, since the government approved the procedure for national insurance coverage in April 2018. Robotic surgery has the potential to overcome some limitations of laparoscopic surgery, especially in the narrow pelvis, providing a three-dimensional view, articulated instruments, and a stable camera platform. Although meta-analyses and randomized controlled trials have failed to demonstrate the superiority of robotic surgery over laparoscopic surgery with respect to the short-term clinical outcomes, the published findings suggest that robotic surgery may be potentially beneficial for patients who are obese, male, or patients undergoing sphincter-preserving surgery for rectal cancer. The safety and feasibility of robotic surgery for lateral lymph node dissection, the standard procedure for locally advanced lower rectal cancer in Japan, have been demonstrated in some retrospective studies. However, additional prospective, randomized trials are required to determine the actual benefits of robotic surgery to ameliorate the urogenital and oncological outcomes. The cost of this approach is a long-standing principal concern. A literature search showed that the cost of robotic surgery for rectal cancer was 1.3-2.5 times higher per patient than that for the laparoscopic approach. We herein describe our surgical technique using a da Vinci Surgical System (S/Si/Xi) with 10 years of experience in performing robotic surgery. We also review current evidence regarding short-term clinical and long-term oncological outcomes, lateral lymph node dissection, and the cost of the procedure.

Robotic Surgery for Rectal Cancer and Cost-Effectiveness

Robotic surgery is considered as one of the advanced treatment modality of minimally invasive surgery for rectal cancer. Robotic rectal surgery has been performed for three decades and its application is gradually expanding along with technology development. It has several technical advantages which include magnified three-dimensional vision, better ergonomics, multiple articulated robotic instruments, and the opportunity to perform remote surgery. The technical benefits of robotic system can help to manipulate more meticulously during technical challenging procedures including total mesorectal excision in narrow pelvis, lateral pelvic node dissection, and intersphincteric resection. It is also reported that robotic rectal surgery have been shown more favorable postoperative functional outcomes. Despite its technical benefits, a majority of studies have been reported that there is rarely clinical or oncologic superiority of robotic surgery for rectal cancer compared to conventional laparoscopic surgery. In addition, robotic rectal surgery showed significantly higher costs than the standard method. Hence, the cost-effectiveness of robotic rectal surgery is still questionable. In order for robotic rectal surgery to further develop in the field of minimally invasive surgery, there should be an obvious cost-effective advantages over laparoscopic surgery, and it is crucial that large-scale prospective randomized trials are required. Positive competition of industries in correlation with technological development may gradually reduce the price of the robotic system, and it will be helpful to increase the cost-effectiveness of robotic rectal surgery.

The impact of robotic total mesorectal excision on survival of patients with rectal cancer-a propensity matched analysis

INTRODUCTION

Robotic surgery can overcome some limitations of laparoscopic total mesorectal excision (L-TME), improving the quality of the surgery. We aim to compare the medium-term oncological outcomes of L-TME vs. robotic total mesorectal excision (R-TME) for rectal cancer.

METHODS

A retrospective analysis was performed including patients who underwent L-TME or R-TME between 2011 and 2017. Patients presenting with metastatic disease or R1 resection were excluded. From a total of 680 patients, 136 cases of R-TME were matched based on age, gender, stage and time of follow-up with an equal number of patients who underwent L-TME. We compared 3-year disease-free survival (DFS) and overall survival (OS).

RESULTS

Major complications were lower in the robotic group (13.2% vs. 22.8%, p = 0.04), highlighting the anastomotic leakage rate (7.4% vs. 16.9%, p = 0.01). The 3-year DFS rate for all stages was 69% for L-TME and 84% for R-TME (p = 0.02). For disease stage III, the 3-year DFS was significantly higher in the R-TME group. OS was also significantly superior in the robotic group for every stage, reaching 86% in stage III. In the multivariate analysis, R-TME was a significant positive prognostic factor for distant metastasis (OR 0.2 95% CI 0.1, 0.6, p = 0.001) and OS (OR 0.2 95% CI 0.07, 0.4, p = 0.000). Moreover, major complications were also found to have a negative impact on OS (OR 8.3 95% CI 3.2, 21.6, p = 0.000).

CONCLUSION

R-TME for rectal cancer can achieve better oncological outcomes compared with L-TME, especially in stage III rectal cancers. However, a longer follow-up period is needed to confirm these findings.

Modern perioperative medicine - past, present, and future

Modern perioperative medicine has dramatically altered the care for patients undergoing major surgery. Anaesthetic and surgical practice has been directed at mitigating the surgical stress response and reducing physiological insult. The development of standardised enhanced recovery programmes combined with minimally invasive surgical techniques has lead to reduction in length of stay, morbidity, costs, and improved outcomes. The enhanced recovery after surgery (ERAS) society and its national chapters provide a means for sharing best practice in this field and developing evidence based guidelines. Research has highlighted persisting challenges with compliance as well as ensuring the effectiveness and sustainability of ERAS. There is also a growing need for increasingly personalised care programmes as well as complex geriatric assessment of frailer patients. Continuous collection of outcome and process data combined with machine learning, offers a potentially powerful solution to delivering bespoke care pathways and optimising individual management. Long-term data from ERAS programmes remain scarce and further evaluation of functional recovery and quality of life is required.

Short- and long-term outcomes of robotic surgery for rectal cancer: a single-center retrospective cohort study

PURPOSE

This study aimed to clarify the short- and long-term outcomes of robotic surgery with or without lateral lymph node dissection (LLND) for rectal cancer at Fujita Health University Hospital, Aichi, Japan, during a self-pay period.

METHODS

We retrospectively evaluated 115 consecutive patients who underwent robotic surgery for rectal cancer between September 2009 and March 2018, with a median follow-up period of 48 months. Total mesorectal excision was completed by two certified surgeons using a da Vinci S, Si, or Xi Surgical System with an entirely robotic single-docking technique. The surgical and pathological outcomes, morbidity, and oncological results were examined.

RESULTS

Lateral lymph node dissection was performed in 26 patients (22.6%). Neither conversion to open surgery nor perioperative blood transfusion occurred. Ten patients (8.7%) experienced Clavien-Dindo grade III postoperative complications. Pathologically, both the distal and radial margins were negative in all cases. The 5-year relapse-free survival rates for stages I, II, III, and IV were 93.5%, 100%, 83.8%, and not reached, respectively.

CONCLUSIONS

Even in the period before coverage by the health insurance system, robotic surgery for rectal cancer performed by experienced surgeons was safe and technically feasible, with favorable perioperative results and long-term oncological outcomes, including rates of the relapse-free survival.