Robotic versus telerobotic laparoscopic cholecystectomy: duration of surgery and outcomes

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Robot assistant versus human or another robot assistant in patients undergoing laparoscopic cholecystectomy

BACKGROUND

The role of a robotic assistant in laparoscopic cholecystectomy is controversial. While some trials have shown distinct advantages of a robotic assistant over a human assistant others have not, and it is unclear which robotic assistant is best.

OBJECTIVES

The aims of this review are to assess the benefits and harms of a robot assistant versus human assistant or versus another robot assistant in laparoscopic cholecystectomy, and to assess whether the robot can substitute the human assistant.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded (until February 2012) for identifying the randomised clinical trials.

SELECTION CRITERIA

Only randomised clinical trials (irrespective of language, blinding, or publication status) comparing robot assistants versus human assistants in laparoscopic cholecystectomy were considered for the review. Randomised clinical trials comparing different types of robot assistants were also considered for the review.

DATA COLLECTION AND ANALYSIS

Two authors independently identified the trials for inclusion and independently extracted the data. We calculated the risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI) using the fixed-effect and the random-effects models based on intention-to-treat analysis, when possible, using Review Manager 5.

MAIN RESULTS

We included six trials with 560 patients. One trial involving 129 patients did not state the number of patients randomised to the two groups. In the remaining five trials 431 patients were randomised, 212 to the robot assistant group and 219 to the human assistant group. All the trials were at high risk of bias. Mortality and morbidity were reported in only one trial with 40 patients. There was no mortality or morbidity in either group. Mortality and morbidity were not reported in the remaining trials. Quality of life or the proportion of patients who were discharged as day-patient laparoscopic cholecystectomy patients were not reported in any trial. There was no significant difference in the proportion of patients who required conversion to open cholecystectomy (2 trials; 4/63 (weighted proportion 6.4%) in the robot assistant group versus 5/70 (7.1%) in the human assistant group; RR 0.90; 95% CI 0.25 to 3.20). There was no significant difference in the operating time between the two groups (4 trials; 324 patients; MD 5.00 minutes; 95% CI -0.55 to 10.54). In one trial, about one sixth of the laparoscopic cholecystectomies in which a robot assistant was used required temporary use of a human assistant. In another trial, there was no requirement for human assistants. One trial did not report this information. It appears that there was little or no requirement for human assistants in the other three trials. There were no randomised trials comparing one type of robot versus another type of robot.

AUTHORS' CONCLUSIONS

Robot assisted laparoscopic cholecystectomy does not seem to offer any significant advantages over human assisted laparoscopic cholecystectomy. However, all trials had a high risk of systematic errors or bias (that is, risk of overestimation of benefit and underestimation of harm). All trials were small, with few or no outcomes. Hence, the risk of random errors (that is, play of chance) is high. Further randomised trials with low risk of bias or random errors are needed.

Robot assistant for laparoscopic cholecystectomy

BACKGROUND

The role of a robotic assistant in laparoscopic cholecystectomy is controversial. While some trials have shown distinct advantages of robotic assistant over a human assistant, others have not, and it is unclear which robotic assistant is best.

OBJECTIVES

The aims of this review are to compare the safety of robot assistant versus human assistant in laparoscopic cholecystectomy and to assess whether the robot can substitute for the human assistant.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until May 2008 for identifying the randomised trials using The Cochrane Hepato-Biliary Group search strategy.

SELECTION CRITERIA

Only randomised clinical trials (irrespective of language, blinding, or publication status) comparing robot assistants versus human assistants in laparoscopic cholecystectomy were considered for the review. Randomised clinical trials comparing different types of robot assistants were also considered for the review.

DATA COLLECTION AND ANALYSIS

Two authors independently identified the trials for exclusion and independently extracted the data. We calculated the risk ratio, mean difference, or standardised mean difference with 95% confidence intervals using the fixed-effect and the random-effects models based on available case-analysis using RevMan 5.

MAIN RESULTS

We included five trials (all of high risk of bias) with 453 patients randomised: 159 to the robot-assistant group and 165 to the human assistant group (one trial report of 129 patients was a conference abstract, not reporting on the number of patients in each group). There was no statistically significant difference between the two groups for morbidity, conversion to open cholecystectomy, total operating time, or hospital stay when fixed-effect or random-effects model were used. The instrument set-up time was significantly lower in the human assistant group. In one trial, about one sixth of the laparoscopic cholecystectomies in which robot assistant was used, required temporary use of a human assistant. It appears that there was little or no requirement for human assistants in the other three published trials. In two of the three trials, which reported surgeons' preference, the surgeons preferred a robot assistant to a human assistant. There was no statistically significant difference in the accuracy when the random-effects model was used. There was no difference in the errors.

AUTHORS' CONCLUSIONS

Although robot-assisted laparoscopic cholecystectomy appears safe, there seems to be no significant advantages over human-assisted laparoscopic cholecystectomy. We were unable to identify trials comparing one type of robot assistant versus another. Further randomised trials with low bias-risk and random errors are needed.

Telerobotic-assisted laparoscopic right hemicolectomy: lateral to medial or medial to lateral dissection?

BACKGROUND

We previously reported that telerobotic-assisted laparoscopic colectomy was feasible and could be accomplished safely. Nonetheless, we found that the current iteration of da Vinci was not well suited to a lateral to medial (LtM) dissection of the colonic mesentery. The motion scaling made the large excursion arcs required for adequate exposure in a LtM dissection cumbersome to achieve.

AIM

As a result, the aim of this study was to compare the ability of the da Vinci telerobotic surgical system to perform telerobotic-assisted laparoscopic right hemicolectomy using a LtM dissection with a medial to lateral (MtL) dissection technique.

METHODS

We compared 8 consecutive da Vinci-assisted laparoscopic right hemicolectomies performed using a LtM dissection to 8 consecutive operations using a MtL dissection technique. Results were compared using analysis of variance.

RESULTS

Age for the 2 groups were not significantly different: LtM 64 (43 to 71) years and MtL 56 (39 to 68) years. Body mass index was similar: LtM 27 (22 to 34) and MtL 25 (20 to 32) kg/m. Total surgical time (including cystoscopy and intraoperative colonoscopy) were similar: LtM 212 (188 to 610) minutes and MtL 203 (135 to 220) minutes. There was no significant difference in lymph node harvest: LtM 12 (3 to 20) lymph nodes and MtL 18 (3 to 35) lymph nodes. There were no deaths or anastomotic leaks in either groups. Median length of stay was similar for both groups: LtM 5 (3 to 10) days and MtL 4 (2 to 9) days.

CONCLUSIONS

da Vinci-assisted laparoscopic right hemicolectomy using a MtL dissection technique achieves similar outcomes as a LtM dissection approach.

Telerobotic gastrointestinal surgery: phase 2--safety and efficacy

BACKGROUND

The Federal Drug Administration (FDA) approved the da Vinci surgical system for all abdominal operations in July 2000. In the past 6 years, virtually all gastrointestinal operations have been accomplished using telerobotic techniques. The purpose of this review is to summarize the short-term outcomes achieved with telerobotic gastrointestinal operations.

METHODS

All case series of telerobotic gastrointestinal operations identified by PubMed searches are included in this review.

RESULTS

Case series document the safety and efficacy of telerobotic cholecystectomy, fundoplication, Heller myotomy, gastric bypass, colectomy, gastrectomy, and pancreatectomy. The procedures were accomplished with low rates of conversion to laparoscopic operations, mortality, and morbidity. When comparison groups were available, the analysis shows that telerobotic operations required more time than the laparoscopic operations, although for telerobotic cholecystectomy and telerobotic fundoplication, this difference disappeared in 10 to 20 operations. Specific patient advantages were not identified for telerobotic operations compared with laparoscopic operations, except for a decreased esophageal perforation rate during telerobotic Heller myotomy. Surgeons benefited from the three-dimensional imaging, the handlike motions of the robotic instruments, and an ergonomically comfortable position.

CONCLUSION

All telerobotic gastrointestinal operations are feasible and can be performed with safety and efficacy. It is difficult to demonstrate patient-specific advantages of telerobotic surgery over laparoscopic operations. Nonetheless, telerobotic surgical systems offer distinct advantages to surgeons and may facilitate an increase in the number of surgeons performing advanced laparoscopic gastrointestinal operations. In addition, telerobotics offer a digital information platform that enables surgical simulation and augmented-reality surgery.

Robotic Cholecystectomy: Learning Curve, Advantages, and Limitations

BACKGROUND

Robotic cholecystectomy is safe, feasible procedure. Initial studies showed significant set up time and operating time but no clear clinical advantage of the robotic involvement. We have investigated the learning curve, advantages and limitation of the procedure.

MATERIAL AND METHODS

We reviewed all (n = 51) robotic cholecystectomies performed between July 2004 and December 2005. The surgery was performed using the da Vinci system. We recorded operative time, setup time of robotics instrumentation, conversion to laparoscopic or open cholecystectomy and complication of the procedure.

RESULTS

Forty-eight of the 51 procedures (94%) were completed robotically. We did not experience any significant complications directly related to robotics surgery. The mean +/- SD operating time was 77 +/- 22.3 min. The mean setup time for robotics (from incision until robot was in place, including draping the robot) was 24 +/- 8.8 min. However, the setup time significantly improved as we gained more experience: from 30.6 +/- 10.7 min (first 16 cases) to 18.3 +/- 4.0 min (cases 33-48). The mean robotic time was 34 +/- 16.1 min. We observed no significant improvement in robotic procedure time.

CONCLUSIONS

Robotic cholecystectomy offers significant advantages such as three-dimensional view, easier instrument manipulations and possibility of remote site surgery. We observed some shortcomings of robotic surgery such as need for larger and additional ports, and need for undocking the machine in case of cholangiography or change of patient position. Our data shows that the learning curve is between 16 to 32 procedures to significantly decrease the setup time and total operating time.

Long-Term Follow-up after Robotic Cholecystectomy

Most surgeons gain their first clinical experience with surgical robots when performing cholecystectomies. Although this procedure is rather easily applicable for the da Vinci surgical system, the long-term outcome after this operation has not yet been clarified. This study follows up our institutional first series of robotic cholecystectomies (June to November 2001). Patients were assessed on the basis of standardized management including a quality-of-life questionnaire, clinical examination, blood tests, and abdominal sonogram. The follow-up rate for 23 patients after robotic cholecystectomy was 100 per cent and the median follow-up time 33 (30–35) months. There was one (4%) recurrence of gallstone disease in a patient who suffered from solitary choledocholithiasis 29 months after robotic cholecystectomy. Abdominal sonogram, clinical examinations, and blood tests revealed no post-cholecystectomy-specific pathological findings. The main long-term symptoms were bloating (57%), heartburn (43%) and nausea (30%). Of the patients, 96 per cent (22 patients) felt that the operation had cured or significantly improved their specific preoperative symptoms. Long-term results after robotic laparoscopic cholecystectomy are excellent and comparable to those for the conventional laparoscopic procedure. The advanced vision control and instrument maneuverability of robotic surgery might open minimally invasive surgery also for complicated gallstone disease and bile duct surgery.

Advantages and limits of robot-assisted laparoscopic surgery: preliminary experience

BACKGROUND

In the last few years, robotics has been applied in clinical practice for a variety of laparoscopic procedures. This study reports our preliminary experience using robotics in the field of general surgery to evaluate the advantages and limitations of robot-assisted laparoscopy.

METHODS

Thirty-two consecutive patients were scheduled to undergo robot-assisted laparoscopic surgery in our units from March 2002 to July 2003. The indications were cholecystectomy, 20 patients; right adrenalectomy, two points; bilateral varicocelectomy, two points; Heller's cardiomyotomy, two points; Nissen's fundoplication, two points; total splenectomy, one point; right colectomy, one point; left colectomy, 1 point; and bilateral inguinal hernia repair, one point. In all cases, we used the da Vinci surgical system, with the surgeon at the robotic work station and an assistant by the operating table.

RESULTS

Twenty-nine of 32 procedures (90.6%) were completed robotically, whereas three were converted to laparoscopic surgery. Conversion to laparoscopy was due in two patients to minor bleeding that could not be managed robotically and to robot malfunction in the third patient. There were no deaths. Median hospital stay was 2.2 days (range, 2-8).

CONCLUSIONS

The main advantages of robot-assisted laparoscopic surgery are the availability of three-dimensional vision and easier instrument manipulation than can be obtain with standard laparoscopy. The learning curve to master the robot was >or= 10 robotic procedures. The main limitations are the large diameter of the instruments (8 mm) and the limited number of robotic arms (maximum, three). We consider these technical shortcomings to be the cause for our conversions, because it is difficult to manage bleeding episodes with only two operating instruments. The benefit to the patient must be evaluated carefully and proven before this technology can become widely accepted in general surgery.