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Kim A, Nyandoro MG, Vu L, Rajan R, Jacob A. Single-Center Experiences: A Comparison of Intracorporeal and Extracorporeal Anastomosis Outcomes in Right Hemicolectomy. Cureus 2024; 16:e59339. [PMID: 38689675 PMCID: PMC11060616 DOI: 10.7759/cureus.59339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 05/02/2024] Open
Abstract
Background Anastomosis formed in minimally invasive laparoscopic right hemicolectomy (LRH) may be achieved intra-corporeally (ICA) or extra-corporeally (ECA). This study compared the return of bowel function and other associated early patient outcomes and morbidity rates after an ICA or ECA in LRH. Methodology The study conducted a single-center retrospective cohort study of elective LRH from January 2021 to September 2023. Patient demographics, surgical techniques, and outcomes were analyzed using IBM SPSS Statistics for Windows, Version 29.0 (IBM Corp., Armonk, NY). Results Ninety participants underwent LRH, and the anastomotic type was evenly distributed - with male patients comprising 53 (58.9%) of the total. The mean age was 64 (standard deviation [SD] ±16.8) years, and the median body mass index (BMI) was 27.0 (interquartile range [IQR] = 7.8). The mean follow-up period was 5.1 (SD ± 6.0) months. Univariate analysis showed that ICA had a shorter time for return of bowel function (P < 0.01). Additionally, ICA was associated with lower pain scores (P < 0.01), low morbidity (P = 0.02), and shorter hospital stays (P = 0.01). When comparing ICA to ECA, no significant difference was observed for procedure duration (P = 0.13), anastomotic leak (AL, P = 1.00), surgical-site infections (P = 0.36), lymph node yield (P = 0.26), and any-cause mortality. Multivariate logistic regression, controlling for statistically insignificant confounding factors, revealed that ECA was significantly and independently associated with increased time to first flatus (odds ratio [OR] 2.3, P = 0.01) and higher average postoperative pain (OR 1.5, P = 0.02) compared to ICA. Conclusions This single-center experience showed that ICA is associated with a quicker return to normal bowel function and low morbidity outcomes. ICA participants were positively associated with clinically relevant and health economics outcomes of shorter hospital stays without significantly adding to the procedure's duration times or compromising principles of oncological resection yield.
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Affiliation(s)
- Audrey Kim
- General Surgery, Royal Perth Hospital, Perth, AUS
| | | | - Linda Vu
- General and Colorectal Surgery, Royal Perth Hospital, Perth, AUS
| | - Ruben Rajan
- General and Colorectal Surgery, Royal Perth Hospital, Perth, AUS
| | - Abraham Jacob
- General and Colorectal Surgery, Royal Perth Hospital, Perth, AUS
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2
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Squillaro AI, Kohn J, Weaver L, Yankovsky A, Milky G, Patel N, Kreaden US, Gaertner WB. Intracorporeal or extracorporeal anastomosis after minimally invasive right colectomy: a systematic review and meta-analysis. Tech Coloproctol 2023; 27:1007-1016. [PMID: 37561350 DOI: 10.1007/s10151-023-02850-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 07/31/2023] [Indexed: 08/11/2023]
Abstract
PURPOSE As part of the wide adoption of minimally invasive surgery, intracorporeal anastomosis is becoming increasingly common. The benefits of minimally invasive versus open right colectomy are well known although the additional benefits of an intracorporeal anastomosis, performed laparoscopically or robotically, are unclear. The aim of this study was to assess the current literature comparing intracorporeal and extracorporeal anastomosis in the setting of laparoscopic and robotic-assisted right colectomy. METHODS A systematic review and meta-analysis was conducted according to PRISMA and AMSTAR methods. Studies included were randomized controlled trials and prospective or retrospective cohort studies, between January 1 2010 and July 1 2021, comparing intracorporeal and extracorporeal anastomosis with laparoscopic and robotic approaches. Four groups were identified: laparoscopic extracorporeal anastomosis (L-ECA), laparoscopic intracorporeal anastomosis (L-ICA), robotic extracorporeal anastomosis (R-ECA), and robotic intracorporeal anastomosis (R-ICA). Operative time, rate of conversion to an open procedure, surgical site infection, reoperation within 30 days, postoperative complications within 30 days, and length of hospital stay were assessed. RESULTS Twenty-one retrospective cohort studies were included in the final analysis. R-ICA and R-ECA had comparable operative times, but a robotic approach required more time than laparoscopic (68 min longer, p < 0.00001). Conversion to open surgery was 55% less likely in the R-ICA group vs. L-ICA, and up to 94% less likely in the R-ICA group in comparison to the R-ECA group. Length of hospital stay was shorter for R-ICA by a half day vs. R-ECA, and up to 1 day less vs. L-ECA. There were no differences in postoperative complications, reoperations, or surgical site infections, regardless of approach. However, the included studies all had high risks of bias due to confounding variables and patient selection. CONCLUSION Robotic-assisted right colectomy with intracorporeal anastomosis was associated with shorter length of hospitalization and decreased rate of conversion to open surgery, compared to either laparoscopic or extracorporeal robotic approaches. Prospective studies are needed to better understand the true impact of robotic approach and intracorporeal anastomosis in right colectomy.
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Affiliation(s)
- A I Squillaro
- Department of Surgery, University of Minnesota, 420 Delaware St. S.E., Minneapolis, MN, 55455, USA.
- Division of Colon and Rectal Surgery, University of Minnesota, Mayo Mail Code 450, 420 Delaware St. S.E., Minneapolis, MN, 55455-0341, USA.
| | - J Kohn
- Department of Surgery, University of Minnesota, 420 Delaware St. S.E., Minneapolis, MN, 55455, USA
| | - L Weaver
- Department of Surgery, University of Minnesota, 420 Delaware St. S.E., Minneapolis, MN, 55455, USA
| | - A Yankovsky
- Global Access, Value and Economics, Intuitive Surgical, 1020 Kifer Road, Sunnyvale, CA, 94086, USA
| | - G Milky
- Global Access, Value and Economics, Intuitive Surgical, 1020 Kifer Road, Sunnyvale, CA, 94086, USA
| | - N Patel
- Global Access, Value and Economics, Intuitive Surgical, 1020 Kifer Road, Sunnyvale, CA, 94086, USA
| | - U S Kreaden
- Global Access, Value and Economics, Intuitive Surgical, 1020 Kifer Road, Sunnyvale, CA, 94086, USA
| | - W B Gaertner
- Department of Surgery, University of Minnesota, 420 Delaware St. S.E., Minneapolis, MN, 55455, USA
- Division of Colon and Rectal Surgery, University of Minnesota, Mayo Mail Code 450, 420 Delaware St. S.E., Minneapolis, MN, 55455-0341, USA
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Yao Q, Sun QN, Zhou JJ, Ma Y, Ren J, Wang LH, Wang DR. Robotic-assisted intracorporeal versus extracorporeal techniques in sigmoidectomy: a propensity score-matched analysis. J Robot Surg 2023; 17:2479-2485. [PMID: 37515681 DOI: 10.1007/s11701-023-01678-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/16/2023] [Indexed: 07/31/2023]
Abstract
Scarce research has been performed to assess the safety and efficacy of anastomosis technique on robotic-assisted sigmoidectomy. This study was designed to evaluate the difference between intracorporeal and extracorporeal techniques during robotic-assisted sigmoidectomy. Clinical data of 193 cases who received robotic-assisted sigmoidectomy were retrospectively collected and analyzed. Only 116 cases were available for analysis (intracorporeal group = 58 and extracorporeal group = 58) after propensity score matching. Independent sample t test was conducted to evaluate the continuous variables. Moreover, the statistical significance of categorical variables was tested using Chi-square or Fisher's exact tests. Statistical analysis showed that the intracorporeal group demonstrated greater superiorities in pain scale on the first and second postoperative day (P < 0.05), time of catheter indwelling (P = 0.009), and length of hospital stay (P = 0.019). Additionally, the intracorporeal technique contributed to fewer complications including urinary retention (P = 0.027) and hernia (P = 0.037) than the extracorporeal group. Our analysis revealed that intracorporeal technique was safe and feasible due to the shorter time of catheter indwelling and length of hospital stay and fewer post-operation complications.
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Affiliation(s)
- Qing Yao
- Northern Jiangsu People's Hospital Affiliated to Dalian Medical University, Yangzhou, 225001, China
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic, Yangzhou, 225001, China
| | - Qian-Nan Sun
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China
- Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic, Yangzhou, 225001, China
- Medical Research Center of Northern Jiangsu People's Hospital, Yangzhou, 225001, China
| | - Jia-Jie Zhou
- Northern Jiangsu People's Hospital Affiliated to Medical School of Nanjing University, Yangzhou, 225001, China
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic, Yangzhou, 225001, China
| | - Yue Ma
- Northern Jiangsu People's Hospital Affiliated to Medical School of Nanjing University, Yangzhou, 225001, China
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic, Yangzhou, 225001, China
| | - Jun Ren
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital, No. 98 Nantong West Road, Yangzhou, 225001, Jiangsu Province, China
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic, Yangzhou, 225001, China
| | - Liu-Hua Wang
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital, No. 98 Nantong West Road, Yangzhou, 225001, Jiangsu Province, China
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic, Yangzhou, 225001, China
| | - Dao-Rong Wang
- Northern Jiangsu People's Hospital Affiliated to Dalian Medical University, Yangzhou, 225001, China.
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital, No. 98 Nantong West Road, Yangzhou, 225001, Jiangsu Province, China.
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China.
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China.
- Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic, Yangzhou, 225001, China.
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Kay D, Cannon J. Robotic Anastomotic Technique. Clin Colon Rectal Surg 2023; 36:83-86. [PMID: 36619279 PMCID: PMC9815904 DOI: 10.1055/s-0042-1757789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The first robotic colectomy was performed 20 years ago. Since that time, the robotic surgery platform has made significant advancements and become increasingly prevalent in colorectal surgery. The da Vinci Xi system (Intuitive Surgical, Sunnyvale, CA) and technology such as integrated table motion has facilitated multiquadrant procedures. Intracorporeal anastomoses (ICAs) have proven benefit in the literature, including decreased length of stay, decreased narcotic requirements, and lower rate of postoperative wound infections and hernias. Additional studies have shown a lower conversion to open rate in robotic surgery compared with laparoscopy. In this article, we will describe techniques for creation of robotic ICAs.
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Affiliation(s)
- Danielle Kay
- Department of Colon and Rectal Surgery, Ochsner, New Orleans, Louisiana
| | - Jamie Cannon
- Department of Surgery, University of Alabama Birmingham, Birmingham, Alabama
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5
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Wang LM, Jong BK, Liao CK, Kou YT, Chern YJ, Hsu YJ, Hsieh PS, Tsai WS, You JF. Comparison of short-term and medium-term outcomes between intracorporeal anastomosis and extracorporeal anastomosis for laparoscopic left hemicolectomy. World J Surg Oncol 2022; 20:270. [PMID: 36030250 PMCID: PMC9419322 DOI: 10.1186/s12957-022-02735-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Few studies have evaluated the feasibility and safety of intracorporeal anastomosis (IA) for left hemicolectomy. Here, we aimed to investigate the potential advantages and disadvantages of laparoscopic left hemicolectomy with IA and compare the short- and medium-term outcomes between IA and extracorporeal anastomosis (EA). METHODS We retrospectively analyzed 133 consecutive patients who underwent laparoscopic left hemicolectomies from July 2016 to September 2019 and categorized them into the IA and EA groups. Patients with stage 4 disease and conversion to laparotomy or those lost to follow-up were excluded. Postoperative outcomes between IA and EA groups were compared. Short-term outcomes included postoperative pain score, bowel function recovery, complications, duration of hospital stay, and pathological outcome. Medium outcomes included overall survival and disease-free survival for at least 2 years. RESULTS After excluding ineligible patients, the remaining 117 underwent IA (n = 40) and EA (n = 77). The IA group had a shorter hospital stay, a shorter time to tolerate liquid or soft diets, and higher serum C-reactive protein level on postoperative day 3. There was no difference between two groups in operative time, postoperative pain, specimen length, or nearest margin. A 2-year overall survival (IA vs. EA: 95.0% vs. 93.5%, p = 0.747) and disease-free survival (IA vs. EA: 97.5% vs. 90.9%, p = 0.182) rates were comparable between two groups. CONCLUSIONS Laparoscopic left hemicolectomy with IA was technically feasible, with better short-term outcomes, including shorter hospital stays and shorter time to tolerate liquid or soft diets. The IA group had higher postoperative serum C-reactive protein level; however, no complications were observed. Regarding medium-term outcomes, the overall survival and disease-free survival rates were comparable between IA and EA procedures.
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Affiliation(s)
- Li-Ming Wang
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, No. 5, Fuxing Street, Guishan District, Taoyuan City, Taiwan
| | - Bor-Kang Jong
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, No. 5, Fuxing Street, Guishan District, Taoyuan City, Taiwan
| | - Chun-Kai Liao
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, No. 5, Fuxing Street, Guishan District, Taoyuan City, Taiwan
| | - Ya-Ting Kou
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, No. 5, Fuxing Street, Guishan District, Taoyuan City, Taiwan
| | - Yih-Jong Chern
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, No. 5, Fuxing Street, Guishan District, Taoyuan City, Taiwan
| | - Yu-Jen Hsu
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, No. 5, Fuxing Street, Guishan District, Taoyuan City, Taiwan
| | - Pao-Shiu Hsieh
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, No. 5, Fuxing Street, Guishan District, Taoyuan City, Taiwan
| | - Wen-Sy Tsai
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, No. 5, Fuxing Street, Guishan District, Taoyuan City, Taiwan
| | - Jeng-Fu You
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, No. 5, Fuxing Street, Guishan District, Taoyuan City, Taiwan.
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6
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Liang Y, Li L, Su Q, Liu Y, Yin H, Wu D. Short-term outcomes of intracorporeal and extracorporeal anastomosis in robotic right colectomy: a systematic review and meta-analysis. Tech Coloproctol 2022; 26:529-535. [PMID: 35347491 DOI: 10.1007/s10151-022-02599-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 02/10/2022] [Indexed: 12/01/2022]
Abstract
Ileocolic anastomosis is performed via extracorporeal or intracorporeal techniques in robotic right hemicolectomy. The aim of this meta-analysis was to compare the short-term outcomes of intracorporeal anastomosis (IA) and extracorporeal anastomosis (EA) for robotic right colectomy. The EMBASE, PubMed, and Cochrane Library databases were searched systematically (from inception until March 1, 2020) for randomized and non-randomized control trials reporting the short-term outcomes of IA and EA for robotic right colectomy. Five observational cohort studies involving 585 participants were included in our meta-analysis. Compared to the EA group, the IA group showed significantly longer operation time [weighted mean difference (WMD): 28.88, 95% confidence interval (CI) 13.88-43.89, p = 0.0002], lower rate of anastomotic leak (odds ratio: 0.26, 95% CI 0.08-0.85, p = 0.03), and shorter time to first flatus (WMD: - 0.57, 95% CI - 0.95 to 0.19, p = 0.003). However, pooled results revealed no difference in blood loss, complications, wound infection, incisional hernia, length of incision, and hospital stay between the IA and EA groups (p < 0.05). This meta-analysis indicated that IA was superior to EA in terms of anastomotic leak and time to first flatus, but inferior in terms of operation time. Large-scale, multicenter, randomized studies are needed to confirm our findings.
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Affiliation(s)
- Y Liang
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - L Li
- Department of Anorectal Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Q Su
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Y Liu
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - H Yin
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - D Wu
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China.
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7
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Lam TJR, Udonwa SA, Yaow CYL, Nistala KRY, Chong CS. Intracorporeal Versus Extracorporeal Anastomosis in Laparoscopic Colectomy: A Meta-Analysis and Systematic Review. CURRENT COLORECTAL CANCER REPORTS 2022. [DOI: 10.1007/s11888-022-00473-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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8
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Cleary RK, Silviera M, Reidy TJ, McCormick J, Johnson CS, Sylla P, Cannon J, Lujan H, Kassir A, Landmann R, Gaertner W, Lee E, Bastawrous A, Bardakcioglu O, Pandey S, Attaluri V, Bernstein M, Obias V, Franklin ME, Pigazzi A. Intracorporeal and extracorporeal anastomosis for robotic-assisted and laparoscopic right colectomy: short-term outcomes of a multi-center prospective trial. Surg Endosc 2022; 36:4349-4358. [PMID: 34724580 PMCID: PMC9085698 DOI: 10.1007/s00464-021-08780-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 10/13/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Studies to date show contrasting conclusions when comparing intracorporeal and extracorporeal anastomoses for minimally invasive right colectomy. Large multi-center prospective studies comparing perioperative outcomes between these two techniques are needed. The purpose of this study was to compare intracorporeal and extracorporeal anastomoses outcomes for robotic assisted and laparoscopic right colectomy. METHODS Multi-center, prospective, observational study of patients with malignant or benign disease scheduled for laparoscopic or robotic-assisted right colectomy. Outcomes included conversion rate, gastrointestinal recovery, and complication rates. RESULTS There were 280 patients: 156 in the robotic assisted and laparoscopic intracorporeal anastomosis (IA) group and 124 in the robotic assisted and laparoscopic extracorporeal anastomosis (EA) group. The EA group was older (mean age 67 vs. 65 years, p = 0.05) and had fewer white (81% vs. 90%, p = 0.05) and Hispanic (2% vs. 12%, p = 0.003) patients. The EA group had more patients with comorbidities (82% vs. 72%, p = 0.04) while there was no significant difference in individual comorbidities between groups. IA was associated with fewer conversions to open and hand-assisted laparoscopic approaches (p = 0.007), shorter extraction site incision length (4.9 vs. 6.2 cm; p ≤ 0.0001), and longer operative time (156.9 vs. 118.2 min). Postoperatively, patients with IA had shorter time to first flatus, (1.5 vs. 1.8 days; p ≤ 0.0001), time to first bowel movement (1.6 vs. 2.0 days; p = 0.0005), time to resume soft/regular diet (29.0 vs. 37.5 h; p = 0.0014), and shorter length of hospital stay (median, 3 vs. 4 days; p ≤ 0.0001). Postoperative complication rates were comparable between groups. CONCLUSION In this prospective, multi-center study of minimally invasive right colectomy across 20 institutions, IA was associated with significant improvements in conversion rates, return of bowel function, and shorter hospital stay, as well as significantly longer operative times compared to EA. These data validate current efforts to increase training and adoption of the IA technique for minimally invasive right colectomy.
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Affiliation(s)
- Robert K. Cleary
- Department of Surgery, Saint Joseph’s Mercy Hospital, 5325 Elliott Drive, Ste 104, Ann Arbor, MI 48106 USA
| | - Matthew Silviera
- Department of Surgery, Washington University School of Medicine, St. Louis, MO USA
| | - Tobi J. Reidy
- Department of Surgery, Franciscan Health, Indianapolis, IN USA
| | - James McCormick
- Colon and Rectal Surgery, Allegheny Health Network, Pittsburgh, PA USA
| | - Craig S. Johnson
- Department of Surgery, Oklahoma Surgical Hospital, Tulsa, OK USA
| | - Patricia Sylla
- Division of Colorectal Surgery, Department of Surgery, Mount Sinai Hospital, New York, NY USA
| | - Jamie Cannon
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL USA
| | - Henry Lujan
- Colon and Rectal Surgery, Jackson Health System, Miami, FL USA
| | - Andrew Kassir
- Colon and Rectal Clinical, Honor Health, Scottsdale, AZ USA
| | - Ron Landmann
- Department of Colon Rectal Surgery, Baptist MD Andersen Cancer Center, Jacksonville, FL USA
| | - Wolfgang Gaertner
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, MN USA
| | - Edward Lee
- Department of Surgery, Albany Medical College, Albany, NY USA
| | - Amir Bastawrous
- Colon and Rectal Clinic, Swedish Medical Center, Seattle, WA USA
| | - Ovunc Bardakcioglu
- Department of Colorectal, Las Vegas School of Medicine, University of Nevada, Las Vegas, Las Vegas, NV USA
| | - Sushil Pandey
- West Valley Colon and Rectal Surgery Center, Sun City, AZ USA
| | - Vikram Attaluri
- Colon and Rectal Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA USA
| | - Mitchell Bernstein
- Division of Colon and Rectal Surgery, NYU Langone Medical Center, New York, NY USA
| | - Vincent Obias
- Division of Colon and Rectal Surgery, The George Washington University Hospital, Washington, DC USA
| | | | - Alessio Pigazzi
- Division of Colon and Rectal Surgery, Weill Medical College Cornell University, New York, NY USA
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Ishizuka M, Shibuya N, Takagi K, Hachiya H, Tago K, Shimizu T, Matsumoto T, Aoki T, Kubota K. Postoperative Complications Associated With Intra- Versus Extracorporeal Anastomosis for Laparoscopic Right Colectomy. Am Surg 2021; 88:2831-2841. [PMID: 34039069 DOI: 10.1177/00031348211023417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare the postoperative complications of intracorporeal anastomosis (ICA) and extracorporeal anastomosis (ECA) in patients undergoing laparoscopic right colectomy (LRC). BACKGROUND Although several studies have compared postoperative complications of ICA and ECA after LRC, most were retrospective studies. METHODS We performed a comprehensive electronic search of the literature to identify studies that compared postoperative complications between ICA and ECA in patients who underwent LRC. We performed meta-analysis using random-effects models to calculate the risk ratio (RR) and 95% confidence interval (CI) of experiencing complications, and we analyzed heterogeneity using I2 statistics. RESULTS Fifteen studies consist of randomized controlled trials, case-control studies, and propensity score matching studies involving a total of 3219 patients who underwent LRC were included. Among 1377 patients who received ICA, 255 (18.5%) had postoperative complications, whereas among 1652 patients who received ECA, 373 (22.6%) had such complications. The results of the meta-analysis revealed that ICA was associated with a significantly reduced risk of postoperative complications (RR, .73; 95% CI: .57-.95; P = .02; I2 = 57%) compared with ECA. Although there was no significant difference between the 2 groups in risk of anastomotic leakage (RR, .67; 95% CI: .39-1.17; P = .16; I2 = 8%), there was a significant difference between them in risk of surgical site infection (RR, .50; 95% CI: .34-.71; P = .0002; I2 = 0%). CONCLUSIONS Intracorporeal anastomosis is associated with a reduced risk of postoperative complications compared with ECA in patients undergoing LRC.
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Affiliation(s)
- Mitsuru Ishizuka
- Department of Gastroenterological Surgery, 12756Dokkyo Medical University, Tochigi, Japan
| | - Norisuke Shibuya
- Department of Gastroenterological Surgery, 12756Dokkyo Medical University, Tochigi, Japan
| | - Kazutoshi Takagi
- Department of Gastroenterological Surgery, 12756Dokkyo Medical University, Tochigi, Japan
| | - Hiroyuki Hachiya
- Department of Gastroenterological Surgery, 12756Dokkyo Medical University, Tochigi, Japan
| | - Kazuma Tago
- Department of Gastroenterological Surgery, 12756Dokkyo Medical University, Tochigi, Japan
| | - Takayuki Shimizu
- Department of Gastroenterological Surgery, 12756Dokkyo Medical University, Tochigi, Japan
| | - Takatsugu Matsumoto
- Department of Gastroenterological Surgery, 12756Dokkyo Medical University, Tochigi, Japan
| | - Taku Aoki
- Department of Gastroenterological Surgery, 12756Dokkyo Medical University, Tochigi, Japan
| | - Keiichi Kubota
- Department of Gastroenterological Surgery, 12756Dokkyo Medical University, Tochigi, Japan
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10
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The impact of intracorporeal anastomosis in right laparoscopic colectomy in the surgical site infections and the hospital stay: a cohort study. Updates Surg 2021; 73:2125-2135. [PMID: 33590349 DOI: 10.1007/s13304-021-00998-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/04/2021] [Indexed: 10/22/2022]
Abstract
Ileocolic anastomosis in laparoscopic-assisted right colectomy is frequently performed extracorporeally. Intracorporeal anastomosis could be associated with several short-term benefits. However, it is a more technically demanding procedure. The primary endpoint of the study aimed to evaluate the postoperative surgical-site infection rate and its impact on the length of hospital stay after laparoscopic right colectomy with intracorporeal anastomosis compared to extracorporeal anastomoses. Between 2010 and 2019, 108 unselected consecutive patients underwent right colectomy. An observational comparative cohort study of two anastomosis techniques, intracorporeal (IA) versus extracorporeal (EA), was conducted. Data were extracted from a prospectively maintained colorectal surgery database of a university-affiliated hospital and retrospectively analyzed. The main exclusion criteria were emergency surgery and medical or anesthetic contraindication for laparoscopy. 53 patients underwent right colectomy with IA, and 55 had extracorporeal anastomoses. The groups did not differ in demographics, anesthetic risk, intraoperative data, pathological outcomes, or overall survival. Mean operative time was longer in the IA group (156.9 vs. 146.0 min; p = 0.061). A significant reduction in the anastomotic leak rate was observed in the IA group compared with the EA group (0 vs. 7.3%; p = 0.045) with no differences in the intraabdominal abscess rate (IA: 1.9% vs. EA: 1.8%; p = 0.97). The wound infection rate was 5.7% for IA and 10.9% for EA (p = 0.324). The hospital stay was significantly shorter for those who had intracorporeal anastomoses (5.2 ± 3.3 vs. 10.8 ± 9.6 days; p = 0.000). Right colectomy with intracorporeal anastomosis was associated with less surgical-site infections and a significantly shorter hospital stay than EA technique. Surgeons should consider the IA as the first option when performing laparoscopic right colectomy. Registration number: NCT04350203 ( http://www.clinicaltrials.gov ).
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Bastawrous AL, Brockhaus KK, Chang MI, Milky G, Shih IF, Li Y, Cleary RK. A national database propensity score-matched comparison of minimally invasive and open colectomy for long-term opioid use. Surg Endosc 2021; 36:701-710. [PMID: 33569727 PMCID: PMC8741658 DOI: 10.1007/s00464-021-08338-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 01/21/2021] [Indexed: 12/11/2022]
Abstract
Background Opioid dependence is a public health crisis and surgery is a risk factor for long-term opioid use. Though minimally invasive surgery (MIS) is associated with less perioperative pain, demonstrating an association with less long-term opioid use would be another reason to justify adoption of minimally invasive techniques. We compared the rates for long-term opioid prescriptions among patients in a large national database who underwent minimally invasive and open colectomy. Methods Using the MarketScan Database, we retrospectively analyzed patients undergoing colon resection for benign and malignant diseases between 2013 and 2017. Among opioid-naïve patients who had ≥ 1 opioid prescriptions filled perioperatively (30 days before surgery to 14 days after discharge), propensity score matching was applied for group comparisons [open (OS) versus MIS, and laparoscopic (LS) versus robotic-assisted surgery (RS)]. The primary outcome was long-term opioid use defined as the proportion of patients with ≥ 1 long-term opioid prescriptions filled 90–180 days after discharge. Risks factors for long-term opioid use were assessed using logistic regression. Results Among the 5413 matched pairs in the MIS versus OS cohorts, MIS significantly reduced long-term opioid use of ‘any opioids’ (13.3% vs. 20.9%), schedule II/III opioids (11.7% vs. 19.2%), and high-dose opioids (4.3% vs. 7.7%; all p < 0.001). Among the 1195 matched pairs in the RS versus LS cohorts, RS was associated with less high-dose opioids (2.1% vs. 3.8%, p = 0.015) 90–180 days after discharge. Other risk factors for long-term opioid use included younger age, benign indications, tobacco use, mental health conditions, and > 6 Charlson comorbidities. Conclusion Minimally invasive colectomy is associated with a significant reduction in long-term opioid use when compared to OS. Robotic-assisted colectomy was associated with less high-dose opioids compared to LS. Increasing adoption of minimally invasive surgery for colectomy and including RS, where appropriate, may decrease long-term opioid use. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08338-9.
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Affiliation(s)
| | - Kara K Brockhaus
- Inpatient Pharmacy, St. Joseph Mercy Hospital Ann Arbor, Ann Arbor, MI, USA
| | - Melissa I Chang
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, 5325 Elliott Dr. Suite 104, Ann Arbor, MI, 48106,, USA
| | - Gediwon Milky
- Global Health Economics and Outcomes Research, Intuitive Surgical, Inc., Sunnyvale, CA, USA.,Department of Pharmacy Practice, Purdue University, West Lafayette, IN, USA
| | - I-Fan Shih
- Global Health Economics and Outcomes Research, Intuitive Surgical, Inc., Sunnyvale, CA, USA
| | - Yanli Li
- Global Health Economics and Outcomes Research, Intuitive Surgical, Inc., Sunnyvale, CA, USA
| | - Robert K Cleary
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, 5325 Elliott Dr. Suite 104, Ann Arbor, MI, 48106,, USA.
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Guadagni S, Palmeri M, Bianchini M, Gianardi D, Furbetta N, Minichilli F, Di Franco G, Comandatore A, Di Candio G, Morelli L. Ileo-colic intra-corporeal anastomosis during robotic right colectomy: a systematic literature review and meta-analysis of different techniques. Int J Colorectal Dis 2021; 36:1097-1110. [PMID: 33486533 PMCID: PMC8119253 DOI: 10.1007/s00384-021-03850-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/15/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE Robotic assistance could increase the rate of ileo-colic intra-corporeal anastomosis (ICA) during robotic right colectomy (RRC). However, although robotic ICA can be accomplished with several different technical variants, it is not clear whether some of these technical details should be preferred. An evaluation of the possible advantage of one respect to another would be useful. METHODS We conducted a systematic review of literature on technical details of robotic ileo-colic ICA, from which we performed a meta-analysis of clinical outcomes. The extracted data allowed a comparative analysis regarding the outcome of overall complication (OC), bleeding rate (BR) and leakage rate (LR), between (1) mechanical anastomosis with robotic stapler, versus laparoscopic stapler, versus totally hand-sewn anastomosis and (2) closure of enterocolotomy with manual double layer, versus single layer, versus stapled. RESULTS A total of 30 studies including 2066 patients were selected. Globally, the side-to-side, isoperistaltic anastomosis, realized with laparoscopic staplers, and double-layer closure for enterocolotomy, is the most common technique used. According to the meta-analysis, the use of robotic stapler was significantly associated with a reduction of the BR with respect to mechanical anastomosis with laparoscopic stapler or totally hand-sewn anastomosis. None of the other technical aspects significantly influenced the outcomes. CONCLUSIONS ICA fashioning during RRC can be accomplished with several technical variants without evidence of a clear superiority of anyone of these techniques. Although the use of robotic staplers could be associated with some benefits, further studies are necessary to draw conclusions.
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Affiliation(s)
- Simone Guadagni
- General Surgery Unit, Department of Translational Research and new Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Matteo Palmeri
- General Surgery Unit, Department of Translational Research and new Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Matteo Bianchini
- General Surgery Unit, Department of Translational Research and new Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Desirée Gianardi
- General Surgery Unit, Department of Translational Research and new Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Niccolò Furbetta
- General Surgery Unit, Department of Translational Research and new Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Fabrizio Minichilli
- Unit of Environmental Epidemiology and Disease Registries, Institute of Clinical Physiology, National Council of Research, Pisa, Italy
| | - Gregorio Di Franco
- General Surgery Unit, Department of Translational Research and new Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Annalisa Comandatore
- General Surgery Unit, Department of Translational Research and new Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Giulio Di Candio
- General Surgery Unit, Department of Translational Research and new Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Luca Morelli
- General Surgery Unit, Department of Translational Research and new Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy ,Endo-CAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy
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Li J, Zhu S, Juan J, Yi B. Preliminary exploration of robotic complete mesocolic excision for colon cancer with the domestically produced Chinese minimally invasive Micro Hand S surgical robot system. Int J Med Robot 2020; 16:1-8. [PMID: 32865308 DOI: 10.1002/rcs.2148] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/31/2020] [Accepted: 08/11/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Jianmin Li
- School of Mechanical Engineering Tianjin University Tianjin China
| | - Shaihong Zhu
- Department of General Surgery Third Xiangya Hospital Central South University Changsha Hunan China
| | - Jiang Juan
- Department of General Surgery Third Xiangya Hospital Central South University Changsha Hunan China
| | - Bo Yi
- Department of General Surgery Third Xiangya Hospital Central South University Changsha Hunan China
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Genova P, Pantuso G, Cipolla C, Latteri MA, Abdalla S, Paquet JC, Brunetti F, de'Angelis N, Di Saverio S. Laparoscopic versus robotic right colectomy with extra-corporeal or intra-corporeal anastomosis: a systematic review and meta-analysis. Langenbecks Arch Surg 2020; 406:1317-1339. [PMID: 32902707 DOI: 10.1007/s00423-020-01985-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 09/02/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE The aim of the present systematic review and meta-analysis is to compare laparoscopic right colectomy (LRC) versus robotic right colectomy (RRC) using homogeneous subgroup analyses for extra-corporeal anastomosis (EA) and intra-corporeal anastomosis (IA). METHODS MEDLINE, Scopus, and Web of Science databases were searched up to April 2020 for prospective or retrospective studies comparing LRC versus RRC on at least one short- or long-term outcome. The primary outcome was the length of hospital stay (LOS). The secondary outcomes included operative and pathological results, survival, and total costs. LRC and RRC were compared using three homogeneous subgroups: without distinction by the type of anastomosis, EA only, and IA only. Pooled data analyses were performed using mean difference (MD) and random effects model. RESULTS Thirty-seven of 448 studies were selected. The included patients were 21,397 for the LRC group and 2796 for the RRC group. Regardless for the type of anastomosis, RRC showed shorter LOS, lower blood loss, lower conversion rate, shorter time to flatus, and lower overall complication rate compared with LRC, but longer operative time and higher total costs. In the EA subgroup, RRC showed similar LOS, longer operative time, and higher costs compared with LRC, the other outcomes being similar. In the IA subgroup, RRC showed shorter LOS and longer operative time compared with LRC, with no difference for the remaining outcomes. CONCLUSIONS Most included articles are retrospective, providing low-quality evidence and limiting conclusions. The more frequent use of the IA seems to explain the advantages of RRC over LRC.
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Affiliation(s)
- Pietro Genova
- Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), Paolo Giaccone University Hospital, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy.
| | - Gianni Pantuso
- Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), Unit of General and Oncological Surgery, Paolo Giaccone University Hospital, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - Calogero Cipolla
- Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), Unit of General and Oncological Surgery, Paolo Giaccone University Hospital, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - Mario Adelfio Latteri
- Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), Unit of General and Oncological Surgery, Paolo Giaccone University Hospital, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - Solafah Abdalla
- Department of Digestive Surgery and Surgical Oncology, Bicêtre University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Université Paris-Sud, 78 Rue du Général Leclerc, 94275, Le Kremlin Bicetre, France
| | - Jean-Christophe Paquet
- Unit of Digestive and Urologic Surgery, Groupe Hospitalier Nord-Essonne, Site de Longjumeau, 159 Rue du Président François Mitterrand, 91160, Longjumeau, France
| | - Francesco Brunetti
- Department of Digestive and Hepato-Pancreato-Biliary Surgery, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Université Paris-Est Créteil (UPEC), 51 Avenue du Maréchal de Lattre de Tassigny, 94010, Creteil, France
| | - Nicola de'Angelis
- Department of Digestive and Hepato-Pancreato-Biliary Surgery, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Université Paris-Est Créteil (UPEC), 51 Avenue du Maréchal de Lattre de Tassigny, 94010, Creteil, France
| | - Salomone Di Saverio
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Box 201, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
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Brown RF, Cleary RK. Intracorporeal anastomosis versus extracorporeal anastomosis for minimally invasive colectomy. J Gastrointest Oncol 2020; 11:500-507. [PMID: 32655928 DOI: 10.21037/jgo.2019.12.02] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Outcomes advantages for the minimally invasive approach to colon and rectal surgery have been clearly described since the original report of a laparoscopic colectomy in 1991. Advancements in minimally invasive options for colon and rectal surgery have produced the need for critical evaluation of alternative and evolving techniques. The evolution and increased adoption of the minimally invasive robotic platform has allowed the intracorporeal anastomosis, previously described with the laparoscopic approach, to be more widely available to surgeon skill sets because of robotic articulating instruments and ergonomic advantages. Studies comparing intra- and extracorporeal techniques for laparoscopic right colectomy have demonstrated some outcomes advantages for the intracorporeal approach that include fewer conversions-to-open, fewer postoperative complications, and shorter hospital length of stay. Recent robotic-assisted comparisons have also shown an intracorporeal advantage and have extended the analysis to left-sided colorectal resections. Further upgrades in minimally invasive options and techniques warrant further evidence-based considerations for surgeons choosing between these options and techniques.
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Affiliation(s)
- Rebecca F Brown
- Department of Colon and Rectal Surgery, St. Joseph Mercy Ann Arbor Hospital, Ann Arbor, MI, USA
| | - Robert K Cleary
- Department of Colon and Rectal Surgery, St. Joseph Mercy Ann Arbor Hospital, Ann Arbor, MI, USA
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Intracorporeal Anastomoses in Minimally Invasive Right Colectomies Are Associated With Fewer Incisional Hernias and Shorter Length of Stay. Dis Colon Rectum 2020; 63:685-692. [PMID: 32168093 PMCID: PMC7148181 DOI: 10.1097/dcr.0000000000001612] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Intracorporeal anastomosis is associated with several short-term benefits. However, it is a technically challenging procedure with potential risk OBJECTIVE:: The purpose of this study was to investigate differences in short-term complications and long-term incisional hernia rates after robotic right colectomy with intracorporeal versus extracorporeal anastomoses and standardized extraction sites. DESIGN This was a historical cohort study. SETTINGS The study was conducted at a single institution. PATIENTS All of the patients undergoing robotic right colectomy with intracorporeal anastomosis and a Pfannenstiel extraction site or extracorporeal anastomosis with a vertical midline extraction site from 2013 to 2017 were eligible. Exclusion criteria were conversion to laparotomy for tumor-related reasons or lack of follow-up. INTERVENTION Intracorporeal or extracorporeal anastomosis was performed, based on availability of the robotic stapler and appropriate bedside assistance. MAIN OUTCOME MEASURES The primary outcome was incisional hernia, diagnosed either clinically or on postoperative imaging, and analyzed using time-to-event analysis. A Cox proportional hazards model was used for multivariable analysis. Secondary outcomes were analyzed using parametric and nonparametric tests. Statistical significance was set at p < 0.05. RESULTS Of 164 patients who met all inclusion criteria, 67 had intracorporeal and 97 had extracorporeal anastomoses. Median follow-up time was similar in both groups (14 vs 15 mo; p = 0.73). The 1-year estimated incisional hernia rate was 12% for extracorporeal and 2% for intracorporeal anastomoses (p = 0.007); this difference was confirmed by multivariable modeling. The severity of postoperative complications was similar between the groups, but there was an increase in incisional infections and a shorter length of stay (1 day) for intracorporeal cases. LIMITATIONS The study was limited by its retrospective, single-surgeon nature. CONCLUSIONS Right colectomy with intracorporeal anastomosis and a Pfannenstiel extraction site may reduce the rate of incisional hernias compared with extracorporeal anastomosis with a vertical midline extraction site. The intracorporeal approach was also associated with a decreased length of stay but an increase in incisional surgical site infections. These findings have implications for healthcare use and patient-centered outcomes. See Video Abstract at http://links.lww.com/DCR/B147. ANASTOMOSIS INTRACORPÓREAS EN COLECTOMÍAS DERECHAS MÍNIMAMENTE INVASIVAS SE ASOCIAN CON MENOS HERNIAS INCISIONALES Y UNA ESTADÍA HOSPITALARIA MÁS BREVE: nastomosis intracorpórea se asocia con varios beneficios a corto plazo. Sin embargo, es un procedimiento técnicamente desafiante con riesgos potenciales.nvestigar las diferencias en las complicaciones a corto plazo y las tasas de hernia incisional a largo plazo después de la colectomía robótica derecha con anastomosis intracorpórea versus extracorpórea y sitios de extracción estandarizados.Estudio de cohorte histórico.cirujano individual, institución única.Todos los pacientes sometidos a colectomía robótica derecha con anastomosis intracorpórea y un sitio de extracción de Pfannenstiel o anastomosis extracorpórea con un sitio de extracción vertical de la línea media de 2013-2017 fueron elegibles. Los criterios de exclusión fueron la conversión a laparotomía por razones relacionadas con el tumor o la falta de seguimiento.nastomosis intracorpórea o extracorpórea, según la disponibilidad de grapadora robótica y la asistencia adecuada quirúrgica.El resultado primario fue la hernia incisional, diagnosticada clínicamente o en imágenes postoperatorias, y analizada mediante análisis de tiempo hasta el evento. Se usó un modelo de riesgos proporcionales de Cox para el análisis multivariable. Los resultados secundarios se analizaron mediante pruebas paramétricas y no paramétricas. La significación estadística se estableció en p < 0,05.De 164 pacientes que cumplieron con todos los criterios de inclusión, 67 tenían anastomosis intracorpóreas y 97 tenían anastomosis extracorpóreas. La mediana del tiempo de seguimiento fue similar en ambos grupos (14 versus 15 meses, p = 0,73). La tasa de hernia incisional estimada para un año fue del 12% para las anastomosis extracorpóreas y del 2% para las anastomosis intracorpóreas (p = 0,007); esta diferencia fue confirmada por el modelado multivariable. La gravedad de las complicaciones postoperatorias fue similar entre los grupos, pero hubo un aumento de las infecciones incisionales y una estancia más corta (un día) para los casos intracorpóreos.Retrospectiva, cirujano único.a colectomía derecha con anastomosis intracorpórea y un sitio de extracción de Pfannenstiel puede reducir la tasa de hernias incisionales en comparación con la anastomosis extracorpórea con un sitio de extracción vertical en la línea media. El enfoque intracorpóreo también se asoció con una disminución de la duración de la estadía, pero con un aumento de las infecciones del sitio quirúrgico incisional. Estos hallazgos tienen implicaciones para la utilización de recursos médicos y beneficios para pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B147. (Traducción-Dr. Adrian Ortega).
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Aiolfi A, Bona D, Guerrazzi G, Bonitta G, Rausa E, Panizzo V, Campanelli G, Micheletto G. Intracorporeal Versus Extracorporeal Anastomosis in Laparoscopic Right Colectomy: An Updated Systematic Review and Cumulative Meta-Analysis. J Laparoendosc Adv Surg Tech A 2020; 30:402-412. [PMID: 31971867 DOI: 10.1089/lap.2019.0693] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Purpose: The effect of intracorporeal anastomosis (IA) versus extracorporeal anastomosis (EA) in laparoscopic right hemicolectomy is controversial. The aim of this study was to evaluate the safety, effectiveness, and functional outcomes of IA compared with EA and to explore the timely tendency variations favoring one treatment over another. Materials and Methods: PubMed, EMBASE, and Web of Science were consulted. A systematic review, pairwise meta-analysis, and cumulative meta-analysis were conducted. Results: Twenty-three studies (3755 patients) were included: 45.7% underwent IA, whereas 54.3% underwent EA. The estimated pooled postoperative infectious complications, anastomotic leak, and overall complications risk ratios were 0.51 (95% confidence interval [CI]: 0.31 to 0.84; P = .009), 0.64 (95% CI: 0.40 to 1.03; P = .063), and 0.78 (95% CI: 0.62 to 0.97; P = .028), respectively. The cumulative meta-analysis showed a statistically significant timely tendency in favor of IA while considering infectious and overall complications. The estimated pooled mean difference of time to first flatus, first defecation, first oral diet, and hospital stay were -16.68 (P < .001), -25.94 (P < .001), -16.35 (P < .001), and -0.72 (P < .001), respectively. Again, the cumulative meta-analysis showed a statistically significant timely trend in favor of IA. No differences were found in term of operative time, conversion rate, ileus, bleeding, reoperation, 30-day readmission, and 30-day mortality. Conclusions: Compared with EA, IA seems to be associated with reduced postoperative infectious and overall complications. The time to first flatus, time to defecation, time to liquid diet, and hospital length of stay were estimated to be lower. A statistically significant timely trend favoring IA was noticed for postoperative infectious complications, overall complications, and recovery parameters. Further studies are warranted to confirm these results and to deeply investigate the supposed timely tendency convergence in favor of IA.
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Affiliation(s)
- Alberto Aiolfi
- Division of General Surgery, Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Davide Bona
- Division of General Surgery, Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Guglielmo Guerrazzi
- Department of Pathophysiology and Transplantation, INCO and Department of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Gianluca Bonitta
- Division of General Surgery, Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Emanuele Rausa
- Division of General Surgery, Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Valerio Panizzo
- Department of Pathophysiology and Transplantation, INCO and Department of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Giampiero Campanelli
- Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Varese, Italy
| | - Giancarlo Micheletto
- Department of Pathophysiology and Transplantation, INCO and Department of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
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Koerner C, Rosen SA. How robotics is changing and will change the field of colorectal surgery. World J Gastrointest Surg 2019; 11:381-387. [PMID: 31681459 PMCID: PMC6821936 DOI: 10.4240/wjgs.v11.i10.381] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 09/04/2019] [Accepted: 09/22/2019] [Indexed: 02/06/2023] Open
Abstract
During the last decade there has been a significant upward trend in colon and rectal minimally invasive surgery which can be attributed largely to the acceptance of robotic surgery platforms such as the da Vinci® robotic system. The fourth generation da Vinci® system, introduced in 2014, includes integrated table motion, intelligent laser targeted docking and more sophisticated instrumentation and imaging. These developments have enabled more surgeons to efficiently and safely perform multi-quadrant operations. Firefly® technology allows assessment of colon perfusion and identification of ureters, and has shown potential in detecting occult recurrence or metastasis using molecular-labelled tumor markers. Wristed instrumentation has increased the technical ease of intracorporeal anastomosis (ICA) for many surgeons, leading to more common use of ICA during right colectomy. Advanced imaging has shown potential to decrease the incidence of presacral nerve injury and improve urogenital outcomes after pelvic surgery, as has been the case in robotic urologic procedures. Finally, the robotic platform lends itself to surgical simulation for surgical trainees, as a pre-operative tool for mock operations and as an ongoing assessment tool for established colorectal surgeons. Given these advantages, surgeons should anticipate continued and increased utilization of this beneficial technology.
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Affiliation(s)
- Crystal Koerner
- Department of Surgery, Emory University, Atlanta, GA 30322, United States
| | - Seth Alan Rosen
- Division of Colorectal Surgery, Emory University, Atlanta, GA 30322, United States
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Intracorporeal versus extracorporeal anastomosis in minimally invasive right colectomy: an updated systematic review and meta-analysis. Tech Coloproctol 2019; 23:1023-1035. [PMID: 31646396 DOI: 10.1007/s10151-019-02079-7] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 09/05/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Minimally invasive colectomy has become the standard for treatment of colonic disease in many centers. Restoration of bowel continuity following resection can be achieved by intracorporeal (IC) or extracorporeal (EC) anastomosis. The aim of this systematic review was to assess the outcomes of IC compared to EC anastomosis in minimally invasive right colectomy. METHODS A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant systematic literature search for studies assessing the outcome of IC and EC anastomosis in laparoscopic and robot-assisted right colectomy was conducted. The primary outcome of this review was postoperative complications. Secondary outcomes included operative time, blood loss, length of stay, conversion to open surgery, and bowel recovery. RESULTS Twenty-five studies including 4450 patients were evaluated. 47.7% of patients had IC anastomosis and 52.3% had EC anastomosis. The weighted mean length of extraction site incision in the IC group was shorter than the EC group. The EC group had significantly higher odds of conversion to open surgery (OR 1.87, 95% CI 1-3.45, p = 0.046), total complications (OR 1.54, 95% CI 1.05-2.11, p = 0.007), anastomotic leakage (AL) (OR 1.95, 95% CI 1.4-2.7, p = 0.003), surgical site infection (SSI) (OR 1.69, 95% CI 1.4-2.6, p = 0.002), and incisional hernia (OR 3.14, 95% CI 1.85-5.33, p < 0.001) compared to the IC group. Both groups had similar rates of ileus, small bowel obstruction, bleeding, and intra-abdominal infection. CONCLUSION IC anastomosis was associated with significantly shorter extraction site incisions, earlier bowel recovery, fewer complications, and lower rates of conversion, AL, SSI, and incisional hernia than has the EC anastomosis.
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Abstract
PURPOSE OF REVIEW Despite the growth in laparoscopic surgery, comparable oncological outcomes, and reduced complication rates, the majority of colorectal surgery is still performed via an open approach. Reasons for this may include technical difficulties associated with operating in narrow spaces such as in the pelvis and inadequate experience. Robotic surgery provides potential solutions to some of these challenges. This review will summarize the state of the literature regarding robotic colorectal surgery. RECENT FINDINGS The most consistent benefit of robotic surgery is decreasing operative conversions, specifically in rectal cancer. In partial colectomies, there is evidence to support quicker return to bowel function. Oncologic outcomes compared to the laparoscopic approach are equivalent. Robotic surgery provides solutions to the challenges posed by laparoscopy, including wristed instruments, ease of intracorporeal suturing, and ergonomic advantages. Randomized trials to evaluate peri-operative outcomes will be important. If robotics is able to facilitate conversion of open colectomies to their minimally invasive equivalent, robotics may end up proving to be advantageous in the peri-operative and post-operative period. Continued studies are warranted.
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Affiliation(s)
- Harith H Mushtaq
- General Surgery, McGovern Medical School at UT Health, 6431 Fannin Street, MSB 4.331, Houston, TX, 77030, USA
| | - Shinil K Shah
- Minimally Invasive and Elective General Surgery, McGovern Medical School at UT Health, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | - Amit K Agarwal
- Colon and Rectal Surgery, McGovern Medical School at UT Health, 6431 Fannin Street, MSB 4.158, Houston, TX, 77030, USA.
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