Universal suprapubic approach for complete mesocolic excision and central vascular ligation using the da Vinci Xi® system: from cadaveric models to clinical cases

The Combination of Laparoscopic and Robotic Surgery: First Experience with the Dexter Robotic System™ in Visceral Surgery

INTRODUCTION

For over two decades, abdominal surgical procedures have been safely performed robotically. After the first patent expiration, alternative robotic systems entered the market. The Dexter Robotic System™ is a small-format, modular, and robotic platform consisting of a surgeon's console, two patient carts with instrument arms, and one endoscope arm. We report our initial experiences with Dexter since its installation at our visceral surgery department.

METHODS

The system and surgical setup are described. Demographic and perioperative data of all operated patients as well as the system docking times were analyzed.

RESULTS

From 56 procedures performed with Dexter, the most common ones included cholecystectomy (n = 15), inguinal hernia repair (TAPP; unilateral n = 15; bilateral n = 3), and right oncologic hemicolectomy (n = 15). The median docking time was 6 min (2-16 min) and was reduced to 4 min in the last tertile of procedures performed.

CONCLUSIONS

In our experience, Dexter can be implemented without any major challenges, and visceral surgical procedures of simple to medium complexity can be performed safely. The simplicity and accessibility of the system along with the ease of switching between robotics and laparoscopy could be particularly suitable for beginners in robotic surgery.

Robotic approach to colonic resection: For some or for all patients?

The robotic approach is rapidly gaining momentum in colorectal surgery. Its benefits in pelvic surgery have been extensively discussed and are well established amongst those who perform minimally invasive surgery. However, the same cannot be said for the robotic approach for colonic resection, where its role is still debated. Here we aim to provide an extensive debate between selective and absolute use of the robotic approach for colonic resection by combining the thoughts of experts in the field of robotic and minimally invasive colorectal surgery, dissecting all key aspects for a critical view on this exciting new paradigm in colorectal surgery.

Developing a phantom for simulating robotic-assisted complete mesocolic excision using 3D printing and medical imaging

BACKGROUND

Robotic-assisted complete mesocolic excision is an advanced procedure mainly because of the great variability in anatomy. Phantoms can be used for simulation-based training and assessment of competency when learning new surgical procedures. However, no phantoms for robotic complete mesocolic excision have previously been described. This study aimed to develop an anatomically true-to-life phantom, which can be used for training with a robotic system situated in the clinical setting and can be used for the assessment of surgical competency.

METHODS

Established pathology and surgical assessment tools for complete mesocolic excision and specimens were used for the phantom development. Each assessment item was translated into an engineering development task and evaluated for relevance. Anatomical realism was obtained by extracting relevant organs from preoperative patient scans and 3D printing casting moulds for each organ. Each element of the phantom was evaluated by two experienced complete mesocolic excision surgeons without influencing each other's answers and their feedback was used in an iterative process of prototype development and testing.

RESULTS

It was possible to integrate 35 out of 48 procedure-specific items from the surgical assessment tool and all elements from the pathological evaluation tool. By adding fluorophores to the mesocolic tissue, we developed an easy way to assess the integrity of the mesocolon using ultraviolet light. The phantom was built using silicone, is easy to store, and can be used in robotic systems designated for patient procedures as it does not contain animal-derived parts.

CONCLUSIONS

The newly developed phantom could be used for training and competency assessment for robotic-assisted complete mesocolic excision surgery in a simulated setting.

Scarless laparoscopic incisions in Pfannenstiel (slip): the first 50 cases using an innovative approach in pediatric robotic surgery

Incisions in the supra-pubic region have been described robotic-assisted surgery to improve cosmetic results in adults, but seldom in children. We aimed to present an innovative trocar placement in the Pfannenstiel line, named Scarless Laparoscopic Incisions in Pfannenstiel (SLIP), and evaluate its feasibility for various intra-abdominal procedures and its cosmetic results in pediatric robotic surgery. We performed a monocentric prospective study, including children undergoing robotic-assisted surgeries using a SLIP approach (July 2019-September 2021). Data regarding demographics, surgery, and outcome were collected and reported as median (range), or number (percentage). Cosmetic results were evaluated with a questionnaire. A SLIP approach was performed in 50 children (24 cholecystectomies, 12 splenectomies, 2 cholecystectomies and splenectomies, 9 colonic resections, 2 choledochal cyst resections, and 1 pancreatic pseudocyst resection). Median age was 11 years (2-18) and median weight 35 kg (10.5-80). Conversion to laparoscopy occurred in two cases. Post-operative complications occurred in 5 patients (10%), after colectomies [intrabdominal abscess (n = 3), stoma dysfunction (n = 1), parietal abscess (n = 1)], of which 3 (6%) required reintervention (intrabdominal abscess n = 2, stoma dysfunction n = 1). Regarding scars, 68% (n = 28) of parents and patients reported the maximal score of 5/5 for global satisfaction and 63% (n = 26) had all scars hidden by underwear. SLIP approach is versatile and can be used in supra- and infra-mesocolic robotic-assisted procedures. The low complication rate shows its safety in both young children and teenagers and does not increase operative difficulties. It results in high patient satisfaction regarding scars, and a scarless abdomen.

Robotic CME in obese patients: advantage of robotic ultrasound scan for vascular dissection

Complete mesocolic excision (CME) in right-sided colon cancers appears to confer oncological benefits compared to conventional colectomy. Identification of the superior mesenteric vein (SMV) remains challenging. We describe the novel use of intra-operative robotic ultrasound scan (rUSS) in obese patients (BMI ≥ 29). All consecutive patients having robotic CME for colon cancer between 2014 and 2017 were included in this retrospective cohort study. Data were recorded on an ethics approved prospective database and included patient demographics, clinical and oncological outcomes. Patients were divided into group 1 (BMI ≤ 28) and group 2 (BMI ≥ 29). SMV first approach was employed in all cases and SMV detection was aided using rUSS in group 2. Primary outcome was postoperative morbidity. Secondary outcomes included conversion rate, operative time and length of stay (LOS). 41 (group 1, median 66 years) were compared to 32 patients (group 2, median 63 years). There were no conversions to laparoscopy or laparotomy. Median operative times for group 2 were 30 min longer (186 vs. 216 min, p = 0.05). Overall morbidity was similar (20% vs. 19% in group 1 and 2, p = 0.26). There was no significant difference between the two groups with regard to LOS (median 7 vs. 6 days, p = 0.48), readmissions (2 vs. 5, p = 0.13), R0 resection rate (98% vs. 94%, p = 0.43) and lymph node harvest (median 31 vs. 30, p = 0.28).CME can be technically more challenging than conventional colectomy in obese patients and is associated with longer operative times. The use of rUSS in obese patients can help to identify SMV and allow safer dissection.

Robotic complete mesocolic excision with central vascular ligation for right colonic tumours - a propensity score-matching study comparing with standard laparoscopy

BACKGROUND

Laparoscopic complete mesocolic excision (CME) of the right colon with central vascular ligation (CVL) is a technically demanding procedure. This study retrospectively evaluated the feasibility, safety and oncological outcomes of the procedure when performed using the da Vinci® robotic system.

METHODS

A prospective case series was collected over 3 years for patients with right colonic cancers treated by standardized robotic CME with CVL using the superior mesenteric vessels first approach. The CME group was compared to a 2 : 1 propensity score-matched non-CME group who had conventional laparoscopic right colectomy with D2 nodal dissection. Primary outcomes were total lymph node harvest and length of specimen. Secondary outcomes were operative time, postoperative complications, and disease-free and overall survival.

RESULTS

The study included 120 patients (40 in the CME group and 80 in the non-CME group). Lymph node yield was higher (29 versus 18, P = 0.006), the specimen length longer (322 versus 260 mm, P = 0.001) and median operative time was significantly longer (180 versus 130 min, P < 0.001) with robotic CME versus laparoscopy, respectively. Duration of hospital stay was longer with robotic CME, although not significantly (median 6 versus 5 days, P = 0.088). There were no significant differences in R0 resection rate, complications, readmission rates and local recurrence. A trend in survival benefit with robotic CME for disease-free (P = 0.0581) and overall survival (P = 0.0454) at 3 years was documented.

CONCLUSION

Robotic CME with CVL is feasible and, although currently associated with a longer operation time, it provides good specimen quality, higher lymph node yield and acceptable morbidity, with a disease-free survival advantage.

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.

Totally robotic right hemicolectomy: a multicentre case-matched technical and peri-operative comparison of port placements and da Vinci models

The objective of the study was to review the technical and peri-operative outcomes using the da Vinci Xi (dVXi) and da Vinci Si (dVSi) models with suprapubic port placement (SPPP) or traditional port placements (TPP) during a robotic right hemicolectomy (RRHC). A retrospective review was undertaken of prospectively maintained databases of RRHC performed by two senior colorectal surgeons in the USA and Australia. Data were prospectively collected for patient demographics, intra-operative technical outcomes and peri-operative clinical outcomes. A cohort of 138 patients underwent RRHC between 2013 and 2017: 134 (97%) had intra-corporeal anastomoses (ICA), 50% for polyp disease and 38% for cancer. 16 (12%) patients had post-operative complications, 11 (8%) of whom had only one complication. There were five (4%) anaemias requiring transfusion; five (4%) anastomotic bleeds; one (1%) leucocytosis/sepsis; two (1%) paralytic ileus; and two (1%) delayed readmissions. There were no conversions to open operations, anastomotic leaks, 30-day readmissions, or 30-day mortalities. With dVSi compared to dVXi, median (IQR) total operation time (TOT) reduced by 16% [134 (118-169) min versus 113 (90-132), p < 0.001]. dVXi had shorter console times (CST) [75 (62-97) min vs 94 (77-108), p = 0.004]. SPPP seemed more advantageous than TPP with less CST [75 (60-98) min versus 85 (70-106), p = 0.02]; less TOT [110 (90-130) min versus 130 (108-167), p < 0.001]; and shorter LOS [2 (2-3) days versus 3(2-3), p = 0.03]. There are operative technical improvements and peri-operative patient clinical benefits during RRHC with ICA using either da Vinci models or port placement configurations. It appears more advantageous to use dVXi with SPPP configuration as our preferred setup for RHHC. Many gastrointestinal surgeons foresee potential benefits of robotic surgery (RS) over conventional laparoscopic surgery, hence evaluation of RS in both routine and more complex operations is needed (Kwak and Kim in J Robot Surg 5:65-72, 2011).

A standardized suprapubic bottom-to-up approach in robotic right colectomy: technical and oncological advances for complete mesocolic excision (CME)

Backround

Several studies have demonstrated a direct correlation between lymph node yield and survival after colectomy for cancer. Complete mesocolic excision (CME) in right colectomy (RC) reduces local recurrence but is technically demanding. Here we report our early single center experience with robotic right colectomy comparing our standardized bottom-to-up (BTU) approach of robotic RC with CME and central vessel ligation (CVL) facilitated by a suprapubic access with the “classical” medial-to-lateral (MTL) strategy.

Methods

A 4-step BTU approach of robotic RC guided by embryonal planes in the process of retrocolic mobilization with suprapubic port placement was performed in the BTU-group (n = 24; all with intention to treat cancer). In step 1 CME was initiated with caudolateral mobilization of the right colon guided by the fascia of Toldt across the duodenum and up to the Trunk of Henle. Subsequently, dissection was performed BTU right of the middle supramesenteric vessels with central ileocolic vessel ligation in step 2. Subsequent to separation of the transverse retromesenteric space and completion of mobilization the hepatic flexure in step 3, the transverse mesocolon was then transected right of the middle colic vessels in step 4. An extracorporeal side to side anastomosis was performed. We compared the outcome of the BTU-group with a MTL-group (n = 7).

Results

Patient characteristics like age, gender, BMI, comorbidity (ASA) and M-status were comparable among groups. There was no conversion. Overall complication rate was 35.5%. We experienced no anastomoses insufficiency, grade Dindo/Clavien III/IV complication or mortality in this study. Type I and II complications and surgical characteristics incl. OR-time, ICU- and hospital-stay were comparable between the two groups. However, the lymph node yield was superior in the BTU-group (mean 40.2 ± 17.1) when compared with the MTL-group (16,3 nodes ±8.5; p <  0,001).

Conclusions

Compared to the classical MTL approach, robotic suprapubic BTU RC changes from a search of the layers bordering the oncological dissection to a consequent utilization of the planes as a retro-mesocolic guide during CME. The BTU strategy could bear the potential to increase the lymph node yield. Robotic systems may provide the technical requirements to combine advantages of both open and minimally invasive RC.

Totally robotic modified complete mesocolic excision and central vascular ligation for right-sided colon cancer: technical feasibility and mid-term oncologic outcomes

BACKGROUND

Recently, an operative strategy involving complete mesocolic excision (CME) and central vascular ligation (CVL) for colonic cancer has been introduced. We aimed to describe our initial experience and assess the long-term outcomes of robotic modified CME (mCME) and CVL (mCME+CVL) for right-sided colon cancer.

METHODS

Of the 677 patients with histologically confirmed, right-sided colon adenocarcinoma who underwent curative mCME+CVL between February 2008 and October 2016, 43 who were treated entirely using the robotic approach were included in this retrospective study. Survival rates were determined using the Kaplan-Meier method, and P values of < 0.05 indicated statistically significant differences.

RESULTS

The total operation and docking times were 293 (180-644) min and 5 (3-19) min, respectively, with an estimated blood loss of 50 (10-400) mL. The time to soft diet was 4 (1-16) days and the length of hospitalization was 8 (4-48) days. Based on the Clavien-Dindo classification, grade I, II, IIIa, IIIb, and IV complications were noted in 3 (7.0%), 5 (11.7%), 2 (4.7%), 1 (2.3%), and 0 (0%) patients, respectively. The proximal and distal resection margins were 14 (4-54) and 19 (4-48) cm, respectively, and 29 (6-157) lymph nodes were harvested per patient. The patients were followed-up for a median of 55 (2-109) months, during which the overall survival rate, median disease-free period, disease-free survival rate, and tumor recurrence rate were 93.6%, 38 (2-109) months, 81.1%, and 16.3% (7 patients), respectively.

CONCLUSIONS

Robotic mCME and CVL for right-sided colon cancer was feasible and safe. It can be added to the surgeon's toolbox as an optional strategy for the management of colon cancer patients.