Association between robot-assisted surgery and resection quality in patients with colorectal cancer

Long-term Outcomes of Robot-assisted Versus Laparoscopic Surgery for Colon Cancer: A Nationwide Register-based Cohort Study

OBJECTIVE

To determine long-term survival in patients undergoing robot-assisted surgery (RAS) or laparoscopic surgery (LAS) for colon cancer.

BACKGROUND

The potential long-term benefits of RAS compared with LAS for colon cancer are not well examined. Using a register-based approach, we aimed to compare these 2 surgical platforms in an analysis of long-term outcomes, including recurrence-free survival and all-cause- and colon cancer-specific mortality.

METHODS

A nationwide register-based cohort study of patients with Union for International Cancer Control stage I-III colon cancer undergoing planned RAS or LAS from 2010 through 2018. Patient demographic, clinical, and pathological data were retrieved from Danish national registers. Survival and recurrence rates were estimated by Cox proportional hazard multivariate regression analysis adjusting for baseline covariates.

RESULTS

A total of 7565 patients [LAS=6905 (91%) and RAS=660 (9%)] were included in the complete case survival analysis. Patients undergoing LAS had a significantly increased risk of cancer recurrence [LAS=1178 (17.1%), RAS=82 (12.4%), P =0.002] with a mean follow-up time of 4.93 years (standard deviation 2.47). The survival analysis of recurrence-free survival favored RAS [hazard ratio adjusted =0.80, 95% CI (0.64-1.00), P =0.049]. No associations between the 2 surgical platforms were evident regarding all-cause [hazard ratio adjusted =0.98, 95% CI (0.82-1.17), P =0.783] or colon cancer-specific mortality [hazard ratio adjusted =0.89, 95% CI (0.67-1.18), P =0.405].

CONCLUSIONS

Adopting RAS for colon cancer was associated with improved recurrence-free survival. However, it did not cause a lower all-cause- or colon cancer-specific mortality.

Comparison of robotic right colectomy and laparoscopic right colectomy: a systematic review and meta-analysis

BACKGROUND

For right colon surgery, there is an increasing body of literature comparing the safety of robotic right colectomy (RRC) with laparoscopic right colectomy (LRC). The aim of the present systematic review and meta-analysis is to assess the safety and efficacy of RRC versus LRC, including homogeneous subgroup analyses for extracorporeal anastomosis (EA) and intracorporeal anastomosis (IA).

METHODS

PubMed, Web of Science, Embase, and Cochrane Library databases were searched for studies published between January 2000 and January 2022. Length of hospital stay, operation time, rate of conversion to laparotomy, time to first flatus, number of harvested lymph nodes, estimated blood loss, rate of overall complication, ileus, anastomotic leakage, wound infection, and total costs were measured.

RESULTS

Forty-two studies (RRC: 2772 patients; LRC: 12,469 patients) were evaluated. Regardless of the type of anastomosis, RRC showed shorter length of hospital stay, lower rate of conversion to laparotomy, shorter time to first flatus, lower rate of overall complications, and a higher number of harvested lymph nodes compared with LRC, but longer operative time and higher total costs. In the IA subgroup, RRC had a shorter length of hospital stay, longer operative time, and lower rate of conversion to laparotomy compared with LRC, with no difference for the remaining outcomes. In the EA subgroup, RRC had a longer operative time, lower estimated blood loss, lower rate of overall complications, and higher total costs compared with LRC, with the other outcomes being similar.

CONCLUSION

The safety and efficacy of RRC is superior to LRC, especially when an intracorporeal anastomosis is performed. Most included articles were retrospective, offering low-quality evidence and limited conclusions.

Robotic versus Laparoscopic Total Mesorectal Excision Surgery in Rectal Cancer: Analysis of Medium-Term Oncological Outcomes

Background. Robotic systems can overcome some limitations of laparoscopic total mesorectal excision (L-TME), thus improving the quality of the surgery. So far, many studies have reported the technical feasibility and short-term oncological results of robotic total mesorectal excision (R-TME) in treating rectal cancer (RC); however, only a few evaluated the survival and long-term oncological outcomes. The following study compared the medium-term oncological data, 3-year overall survival (OS), and disease-free survival (DFS) of L-TME and R-TME in patients with rectal cancer. Methods. In this retrospective study, records of patients (patients with stage I-III rectal cancer) who underwent surgery (127 cases of L-TME and 148 cases of R-TME) at the Gansu Provincial Hospital between June 2016 and March 2018 were included in the analysis. Kaplan-Meier analysis evaluated the 3-year OS and DFS for all patients treated with curative intent. Results. The conversion rate was significantly higher, and the postoperative hospital stay was significantly longer in the L-TME group than in the R-TME group (all P<.05). Major complications were significantly lower in the robotic group (P<.05). The 3-year DFS rate (for all stages) was 74.8% for L-TME and 85.8% for R-TME (P = .021). For disease stage III, the 3-year DFS and OS were significantly higher in the R-TME group (P<.05). Conclusion. R-TME can achieve better oncological outcomes and is more beneficial for RC patients compared with L-TME, especially for those with stage III rectal cancers. Nevertheless, further randomized controlled trials and a longer follow-up period are needed to confirm these findings.

Comparison of clinical efficacy and postoperative inflammatory response between laparoscopic and open radical resection of colorectal cancer

BACKGROUND

In recent years, the incidence of colorectal cancer (CRC) has increased annually, which has seriously threatened the health and quality of life of patients. In the treatment of CRC, both laparoscopic and radical resection are widely used.

AIM

To explore and discuss clinical efficacy and postoperative inflammatory response of laparoscopic and open radical resection of CRC.

METHODS

A total of 96 patients with CRC diagnosed in our hospital from March 2016 to April 2021 were selected, and were divided into the study group (n = 48) and control group (n = 48) using a simple random method. The control group was treated with open radical resection of CRC, and the study group was treated with laparoscopic radical resection of CRC. The perioperative conditions (operation time, intraoperative blood loss, the recovery time of gastrointestinal function, number of lymph node dissections and length of hospital stay), inflammatory response index levels [interleukin (IL)-6, IL-8, IL-10, C-reactive protein (CRP)] before and after operation, pain stress response indices [levels of neuropeptide (NPY), prostaglandin E2 (PGE2), 5-hydroxytryptamine (5-HT)], and the incidence of the complications between the two groups were counted.

RESULTS

The operation time in the study group was (186.18 ± 33.54 min), which was longer than that of the control group (129.38 ± 26.83 min), but the intraoperative blood loss (111.34 ± 21.45 mL), recovery time of gastrointestinal function (25.35 ± 4.55 h), and hospital stay (10.09 ± 2.38 d) were better than those in the control group (163.77 ± 32.41 mL, 36.06 ± 7.13 h, 13.51 ± 3.66 d) (P < 0.05). There was no significant difference in the number of lymph node dissections between the study group (15.19 ± 3.04) and the control group (16.20 ± 2.98) (P > 0.05). There was no significant difference between the levels of serum IL-6 (9.79 ± 4.11 ng/mL), IL-8 (3.79 ± 1.71 ng/L), IL-10 (48.96 ± 12.51 ng/L) and CRP (7.98 ± 2.33 mg/L) in the study group and the control group (10.56 ± 3.78 ng/mL, 4.08 ± 1.45 ng/L, 50.13 ± 11.67 ng/L, 8.29 ± 2.60 mg/L) before the operation (P > 0.05). After the operation, there was no significant difference between the levels of serum IL-6 (19.11 ± 6.68 ng/mL). There was no significant difference in serum NPY (109.79 ± 13.46 UG/L), PGE2 (269.54 ± 37.34 ng/L), 5-HT (151.70 ± 18.86 ng/L) between the study group and the control group (113.29 ± 15.01 UG/L, 273.91 ± 40.04 ng/L, 148.85 ± 20.45 ng/L) before the operation (P > 0.05). The incidence of the complications in the study group (4.17%) was lower than that of the control group (18.75%) (P < 0.05).

CONCLUSION

Laparoscopic radical resection of CRC can reduce surgical trauma, inflammatory response and pain stress caused by surgery, which shortens rehabilitation of patients, with a low incidence of complications.

Robot-Assisted Minimally Invasive Breast Surgery: Recent Evidence with Comparative Clinical Outcomes

In recent times, robot-assisted surgery has been prominently gaining pace to minimize overall postsurgical complications with minimal traumatization, due to technical advancements in telerobotics and ergonomics. The aim of this review is to explore the efficiency of robot-assisted systems for executing breast surgeries, including microsurgeries, direct-to-implant breast reconstruction, deep inferior epigastric perforators-based surgery, latissimus dorsi breast reconstruction, and nipple-sparing mastectomy. Robot-assisted surgery systems are efficient due to 3D-based visualization, dexterity, and range of motion while executing breast surgery. The review describes the comparative efficiency of robot-assisted surgery in relation to conventional or open surgery, in terms of clinical outcomes, morbidity rates, and overall postsurgical complication rates. Potential cost-effective barriers and technical skills were also delineated as the major limitations associated with these systems in the clinical sector. Furthermore, instrument articulation of robot-assisted surgical systems (for example, da Vinci systems) can enable high accuracy and precision surgery due to its promising ability to mitigate tremors at the time of surgery, and shortened learning curve, making it more beneficial than other open surgery procedures.

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.

Robotic versus laparoscopic right colectomy for colon cancer: a nationwide cohort study

PURPOSE

On a national level, the minimally invasive approach is widely adopted in Denmark. The adoption of robotic colorectal surgery is increasing; however, the advantage of a robotic approach in right colectomy is still uncertain. The purpose of this study was to compare robotic right colectomy with laparoscopic right colectomy on a national level.

METHODS

This was a nationwide database study based on data from the Danish Colorectal Cancer Group database. Patients from all colorectal centers in Denmark in the period 2014-2018 treated with curative intend in an elective setting with either robotic or laparoscopic right colectomy were identified. Propensity score matching was performed to adjust for confounding, and the groups were compared on demographics, disease characteristics, operative data, and postoperative and pathology outcomes. Reporting was done in accordance with the STROBE statement.

RESULTS

In total, 4002 patients were available for analysis. Propensity score matching in ratio 2:1 identified 718 laparoscopic and 359 robotic cases. After matching, we found a higher lymph node yield in the robotic group compared to the laparoscopic group, (32.5 vs. 28.4, P < 0.001), while radicality, plane of dissection, and pathological disease stages showed no differences. There were no statistical differences in morbidity and mortality. Intracorporeal anastomosis (23.7% vs. 4.5%, P < 0.001) was more commonly performed with a robotic approach.

CONCLUSIONS

Robotic approach was associated with a significant higher lymph node yield and with similar postoperative morbidity compared to a laparoscopic approach for right colectomy.

Improved perioperative outcomes and reduced inflammatory stress response in malignant robot-assisted colorectal resections: a retrospective cohort study of 298 patients

Background

Robot-assisted surgery is increasingly implemented for the resection of colorectal cancer, although the scientific evidence for adopting this technique is still limited. This study’s main objective was to compare short-term complication rates, oncological outcomes, and the inflammatory stress response after colorectal resection for cancer performed laparoscopic or robot-assisted.

Methods

We conducted a retrospective cohort study comparing the robot-assisted approach to laparoscopic surgery for elective malignant colorectal neoplasm. Certified colorectal and da Vinci ® robotic surgeons performed resections at a Danish tertiary colorectal high volume center from May 2017 to March 2019. We analyzed the two surgical groups using uni- and multivariate regression analyses to detect differences in intra- and postoperative clinical outcomes and the inflammatory stress response.

Results

Two hundred and ninety-eight patients were enrolled in the study. Significant differences favoring robot-assisted surgery was demonstrated for; length of hospital stay (4 days, interquartile range (4, 5) versus 5 days, interquartile range (4–7), p < 0.001), and intraoperative blood loss (50 mL, interquartile range (20–100) versus 100 mL, interquartile range (50–150), p < 0.001) compared to laparoscopic surgery. The inflammatory stress response was significantly higher after laparoscopic compared to robot-assisted surgery reflected by an increase in C-reactive protein concentration (exponentiated coefficient = 1.23, 95% confidence interval (1.06–1.46), p = 0.008). No differences between the two groups were found concerning mortality, microradical resection rate, conversion to open surgery, and surgical or medical short-term complication rates.

Conclusion

Robot-assisted surgery is feasible and can be safely implemented for colorectal resections. The robot-assisted approach, when compared to laparoscopic surgery, was associated with improved intra- and postoperative outcomes. Extensive prospective studies are needed to determine the short- and long-term outcomes of robotic surgery for colorectal cancer.

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.

Oncological Outcomes of Robotic-Assisted Surgery With High Dissection and Selective Ligation Technique for Sigmoid Colon and Rectal Cancer

Background: Curative resection of sigmoid colon and rectal cancer includes "high tie" of the inferior mesenteric artery (IMA). However, IMA ligation compromises blood flow to the anastomosis, which may increase the complication rate. We present preliminary experiences of operative and oncologic outcomes of patients with rectal or sigmoid colon cancer who underwent robotic surgery employing the high dissection and selective ligation technique. Methods: Over May 2013 to April 2017, 113 stage I-III rectal or sigmoid colon cancer patients underwent robotic surgery with the single-docking technique at one institution. We performed D3 lymph node dissection and low-tie ligation of the IMA (i.e., high dissection and selective ligation technique). Clinicopathological features, perioperative parameters, and postoperative outcomes were retrospectively analyzed. Overall survival (OS) and disease-free survival (DFS) were calculated using the Kaplan-Meier method. Results: Sphincter preservation rate was 96.3% in rectal cancer patients. Median number of harvested lymph nodes was 12. Apical nodes were pathologically harvested in 84 (82.4%) patients. R0 resection was performed in 108 (95.6%) patients. Overall complication rate was 17.7%; but most complications were mild and the patients recovered uneventfully. Estimated 5-year OS was 86.1% and 3-year DFS was 79.6% after median follow-up periods of 49.1 months (range, 5.3-85.3). Conclusions: High dissection of the IMA and selective ligation of the major feeding vessel to the sigmoid colon or rectum can be safely performed using da Vinci Surgical System,yielding favorable clinical, and oncologic outcomes in rectal or sigmoid colon cancer treatment.

Robotic Total Mesorectal Excision for Rectal Cancer: Current Evidences and Future Perspectives

Despite the technical limitations of minimally invasive surgery, laparoscopic total mesorectal excision (LTME) for rectal cancer has short-term advantages over open surgery, but the pathological outcomes reported in randomized clinical trials are still in controversy. Minimally invasive robotic total mesorectal excision (RTME) has recently been gaining popularity as robotic surgical systems potentially provide greater benefits than LTME. Compared to LTME, RTME is associated with lower conversion rates and similar or better genitourinary functions, but its long-term oncological outcomes have not been established. Although the operating time of RTME is longer than that of LTME, RTME has a shorter learning curve, is more convenient for surgeons, and is better for sphincter-preserving operations than LTME. The robotic surgical system is a good technical tool for minimally invasive surgery for rectal cancer, especially in male patients with narrow deep pelvises. Robotic systems and robotic surgical techniques are still improving, and the contribution of RTME to the treatment of rectal cancer will continue to increase in the future.

Long-Term Outcomes of Robot-Assisted Surgery in Patients with Colorectal Cancer

BACKGROUND

Robotic technology has been proven to be a safe alternative to conventional laparoscopy with regards to the peri- and postoperative clinical outcomes. Oncological outcomes have been scarcely examined. The purpose of this study was to examine the disease-free survival in relation to the two surgical approaches: robot-assisted surgery and conventional laparoscopy. In addition, all-cause mortality and recurrence-free survival were investigated.

METHODS

Between January 2010 and December 2015, patients, undergoing either laparoscopic or robot-assisted elective, curative-intended surgery for colorectal cancer were included.

RESULTS

A total of 9184 patients underwent surgery in the study period: 5978 patients for colon cancer and 3206 patients for rectal cancer. Among patients with colon cancer, 331 patients (5.5%) underwent robot-assisted surgery, and 449 patients (14.0%) underwent robot-assisted surgery in the rectal cancer group. In the adjusted analyses, the hazard ratio (HR) for disease-free survival, for patients with colon cancer was 0.91 [95% confidence interval (CI) 0.71-1.18]. For patients with rectal cancer, the adjusted HR was 0.83 (95% CI 0.65-1.06). No difference in all-cause mortality and recurrence-free survival were observed.

CONCLUSIONS

The study demonstrated comparable rates of disease-free survival, all-cause mortality, and recurrence-free survival when comparing robot-assisted surgery with conventional laparoscopy in patients with colorectal cancer.