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

Complete mesocolic excision (CME) impacts survival only for Stage III right-sided colon cancer: a systematic review and meta-analysis

INTRODUCTION

Complete mesocolic excision (CME) is widely adopted for its assumed superior oncological outcome. However, it's unclear if all right-sided colon cancer patients benefit from CME. The aim of this systematic review is to investigate whether CME contributes to postoperative outcomes and to determine the surgical indications for CME.

MATERIAL AND METHODS

We searched eligible articles about CME versus non-CME procedures for right-sided colon cancer in the OVID Medline, Embase, and Cochrane CENTRAL databases, and a meta-analysis was conducted.

RESULTS

Twenty-two articles and seven abstracts involving 8088 patients were included in this study. Among them, 3803 underwent CME and 4285 non-CME procedures. The analysis showed that CME was favoured for three-year disease-free survival (DFS) and overall survival (OS), for local, systemic, and total recurrence, and for hospital stay durations. However, increased vascular injury and longer surgery time were observed in CME. Regarding the three-year OS, the superiority of CME was observed only in Stage III. Additionally, no significant differences were observed between CME and non-CME groups regarding overall complications, 30-day readmission rates, reoperation, or postoperative mortality rates.

CONCLUSIONS

CME for right-sided colon cancer should be considered, particularly in Stage III patients, to contribute to improved oncological outcomes. However, careful attention must be paid to the increased risk of vascular injury.

Systematic Review and Meta-Analysis of Laparoscopic versus Robotic-Assisted Surgery for Colon Cancer: Efficacy, Safety, and Outcomes-A Focus on Studies from 2020-2024

BACKGROUND

Minimally invasive surgery in the treatment of colon cancer has significantly advanced over the years. This systematic review and meta-analysis aimed to compare the operative outcomes of robotic and laparoscopic surgery in the treatment of colon cancer, focusing on operative time, hospital stay, conversion rates, anastomotic leak rates, and total number lymph node harvested.

METHODS

Following PRISMA guidelines, we conducted a systematic search across four databases up to January 2024, registering our protocol with PROSPERO (CRD42024513326). We included studies comparing robotic and laparoscopic surgeries for colon cancer, assessing operative time, hospital length of stay, and other perioperative outcomes. Risk of bias was evaluated using the JBI Critical Appraisal Checklist. Statistical analysis utilized a mix of fixed and random-effects models based on heterogeneity.

RESULTS

A total of 21 studies met the inclusion criteria, encompassing 50,771 patients, with 21.75% undergoing robotic surgery and 78.25% laparoscopic surgery. Robotic surgery was associated with longer operative times (SMD = -1.27, p < 0.00001) but shorter hospital stays (MD = 0.42, p = 0.003) compared to laparoscopic surgery. Conversion rates were significantly higher in laparoscopic procedures (OR = 2.02, p < 0.00001). No significant differences were found in anastomotic leak rates. A higher number of lymph nodes was harvested by robotic approach (MD = -0.65, p = 0.04). Publication bias was addressed through funnel plot analysis and Egger's test, indicating the presence of asymmetry (p = 0.006).

CONCLUSIONS

The choice of surgical method should be individualized, considering factors such as surgeon expertise, medical facilities, and patient-specific considerations. Future research should aim to elucidate long-term outcomes to further guide the clinical decision-making.

Assistance by adaptative damping on a complex bimanual task in laparoscopic surgery

PURPOSE

Laparoscopic surgery has improved outcomes in abdominal surgery, but presents kinematic restrictions for surgeons. Robotic comanipulation with adaptative damping has been investigated in simple laparoscopic tasks. The present protocol aimed to determine the contribution of adaptive damping in complex bimanual tasks approaching clinical setting.

METHODS

Fourteen residents in general surgery performed three exercises, and for each three repetitions without (classic repetitions) and three with robotic assistance (robotic repetitions) in a randomised order. The exercises chosen were trajectory, modified Pea on a Peg and intracorporeal suture. Task performance, gesture performance, workload and impression were measured. Also, a semi-directed interview was performed to collect the participants' feeling about companipulated robots and their potential application in clinical practice.

RESULTS

Adaptative damping assistance did not impact task performance, but allowed an economy of movement in the non-dominant hand during suture exercise (distance 916 ± 500 mm in classic vs. 563 ± 261 mm in robotic, p < 0.001). Perceived workload (p = 0.12) and user's impression were not different between classic and robotic repetitions, except novelty (p < 0.001). Participants' interviews revealed their interest for the robotic devices, particularly the gravity compensation, and were ready to use the adaptative damping provided an intermittent use, for example to dissect dangerous areas.

CONCLUSION

Adaptative damping applied by comanipulated robots does not influence the performance of the task, but improves the performance of the gesture itself, particularly for the non-dominant hand, and during the realisation of a complex task like suturing. For residents in digestive surgery, this assistance does increase workload, and they would use this help in the operating room under certain conditions.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Surgical outcomes of a prospective, phase 2 trial of robotic surgery for resectable right-sided colon cancer (the ROBOCOLO trial)

Aim

We evaluated the safety of robotic surgery for right-sided colon cancer in Japan.

Methods

This was a prospective, open-label, single-arm phase II trial conducted at two institutions. Patients ≥20 years old with stage I-III right-sided colon cancer and scheduled for radical resection with ≥D2 lymph node dissection were eligible. The criterion for surgeons was experience performing robot-assisted rectal resection in ≥40 cases. The primary endpoint was the postoperative complication rate ≤30 days after surgery.

Results

From August 2021 to February 2023, 42 patients were enrolled; three were excluded, with 39 analyzed as the full analysis set. The median age was 72 years, and the median body mass index was 23.2. The tumor was located in the cecum in 13 cases (33.3%), ascending colon in 20 cases (51.3%), and transverse colon in six cases (15.4%). Ileocolic resection was performed in 17 cases (43.5%) and right hemicolectomy in 22 cases (56.5%), both with D3 lymph node dissection. The median console time was 109 min, and the operative time was 170 min. The mean blood loss was 7.7 mL. Intracorporeal anastomosis was performed in 28 patients (71.8%). There were no conversions and no intraoperative adverse events. The median postoperative stay was 5 days. Postoperative complications occurred in four patients (10.2%; paralytic ileus [n = 3] and pneumonia [n = 1]). All postoperative complications were grade 1 or 2, with no mortalities noted. R0 resection was achieved in all patients.

Conclusions

This study demonstrated the safety and feasibility of robotic surgery for right-sided colon cancer.

Long-term oncological outcomes of robotic versus laparoscopic approaches for right colon cancer: a systematic review and meta-analysis

PURPOSE

The short-term outcomes of robotic right hemicolectomy for right colon cancer have been extensively studied in comparison to conventional laparoscopic right hemicolectomy. However, the long-term oncological outcomes of the two approaches have not been investigated, except in single-center retrospective studies. Therefore, this meta-analysis aimed to investigate the long-term oncological outcomes of robotic right hemicolectomy compared with those of laparoscopic right hemicolectomy for right colon cancer.

METHODS

We searched PubMed, EMBASE, and Cochrane Library for studies comparing robotic right hemicolectomy with conventional laparoscopic right hemicolectomy for right colon cancer from the date of database inception to August 2022. For survival data extraction, hazard ratios (HRs) with 95% confidence intervals (CI) were calculated using random- or fixed-effects models from the Kaplan-Meier survival curves in the included studies. All calculations and statistical tests were performed using Review Manager software, version 5.4.

RESULTS

A total of 523 patients (robotic right hemicolectomy, 230; laparoscopic right hemicolectomy, 293) from five studies were included in this meta-analysis. There were no significant differences in patient characteristics between the two groups. In terms of pathological characteristics, TNM stage was not different and revealed no differences in the number of harvested lymph nodes even though a larger number of lymph nodes were harvested in the robotic group in one study. Pooled analyses demonstrated no significant difference in disease-free survival (HR 0.72, 95% CI 0.46-1.13, p = 0.15) and overall survival (HR 0.73, 95% CI 0.48-1.13, p = 0.16) between robotic and laparoscopic right hemicolectomy for right colon cancer.

CONCLUSION

Robotic right hemicolectomy for right colon cancer is comparable with conventional laparoscopic right hemicolectomy in terms of long-term oncological survival. More prospective, multicenter, randomized trials are necessary to determine the oncologic safety of robotic right hemicolectomy.

Intracorporeal or extracorporeal anastomosis after minimally invasive right colectomy: a systematic review and meta-analysis

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.

Complete mesocolic excision for right hemicolectomy: an updated systematic review and meta-analysis

PURPOSE

Complete mesocolic excision improves lymphadenectomy for right hemicolectomy and respects the embryological planes. However, its effect on cancer-free and overall survival is questioned. Therefore, we aimed to determine the potential benefits of the technique by performing a systematic review of the literature and meta-analysis of the available evidence.

METHODS

Web of Science, PubMed/Medline, and Embase were searched on February 22, 2023. Original studies on short- and long-term oncological outcomes of adult patients undergoing right hemicolectomy with complete mesocolic excision as a treatment for primary colon cancer were considered for inclusion. Outcomes were extracted and pooled using a model with random effects.

RESULTS

A total of 586 publications were identified through database searching, and 18 from citation searching. Exclusion of 552 articles left 24 articles for inclusion. Meta-analysis showed that complete mesocolic excision increased the lymph node harvest (5 studies, 1479 patients, MD 9.62, 95% CI 5.83-13.41, p > 0.0001, I2 84%), 5-year overall survival (5 studies, 2381 patients, OR 1.88, 95% CI 1.14-3.09, p = 0.01, I2 66%), 5-year disease-free survival (4 studies, 1376 patients, OR 2.21, 95% CI 1.51-3.23, p < 0.0001, I2 0%) and decreased the incidence of local recurrence (4 studies, 818 patients, OR 0.27, 95% CI 0.09-0.79, p = 0.02, I2 0%) when compared to standard right hemicolectomy. Perioperative morbidity was similar between the techniques (8 studies, 3899 patients, OR 1.04, 95% CI 0.89-1.22, p = 0.97, I2 0%).

CONCLUSION

Meta-analysis of observational and randomised studies showed that right hemicolectomy with complete mesocolic excision for primary right colon cancer improves oncologic results without increasing morbidity/mortality. These results need to be confirmed by high-quality evidence and randomised trials in selected patients to assess who may benefit from the procedure.

Efficacy of transanal drainage tube in preventing anastomotic leakage after surgery for rectal cancer: A meta-analysis

BACKGROUND

Anastomotic leakage (AL) following rectal cancer surgery is an important cause of mortality and recurrence. Although transanal drainage tubes (TDTs) are expected to reduce the rate of AL, their preventive effects are controversial.

AIM

To reveal the effect of TDT in patients with symptomatic AL after rectal cancer surgery.

METHODS

A systematic literature search was performed using the PubMed, Embase, and Cochrane Library databases. We included randomized controlled trials (RCTs) and prospective cohort studies (PCSs) in which patients were assigned to two groups depending on the use or non-use of TDT and in which AL was evaluated. The results of the studies were synthesized using the Mantel-Haenszel random-effects model, and a two-tailed P value > 0.05 was considered statistically significant.

RESULTS

Three RCTs and two PCSs were included in this study. Symptomatic AL was examined in all 1417 patients (712 with TDT), and TDTs did not reduce the symptomatic AL rate. In a subgroup analysis of 955 patients without a diverting stoma, TDT reduced the symptomatic AL rate (odds ratio = 0.50, 95% confidence interval: 0.29–0.86, P = 0.012).

CONCLUSION

TDT may not reduce AL overall among patients undergoing rectal cancer surgery. However, patients without a diverting stoma may benefit from TDT placement.

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.

Robot-assisted versus laparoscopic short- and long-term outcomes in complete mesocolic excision for right-sided colonic cancer: a systematic review and meta-analysis

BACKGROUND

Complete mesocolic excision (CME) surgery is increasingly implemented for the resection of right-sided colonic cancer, possibly resulting in improved 5-year overall and disease-free survival compared to non-CME surgery. However, it is not clear what surgical platform should be used. The aim of this study was to compare the following outcomes between robot-assisted and laparoscopic CME-surgery for right-sided colonic cancer: (i) short-term clinical outcomes, (ii) pathological specimen quality, and (iii) long-term oncological outcomes.

METHODS

Medline, Embase, and Cochrane Database of Systematic Reviews were searched from inception until August 2021. Pooled proportions were calculated by applying the inverse variance method. Heterogeneity was explored by I-square and supplemented by sensitivity- and meta-regression analyses. The risk of bias was evaluated by either MINORS or Cochrane's risk-of-bias tool (RoB 2).

RESULTS

Fifty-five studies with 5.357 patients (740 robot-assisted and 4617 laparoscopic) were included in the meta-analysis. Overall postoperative morbidity was 17% [95% CI (14-20%)] in the robot-assisted group and 13% [95%CI (12-13%)] in the laparoscopic group. Robot-assisted CME was associated with a shorter hospital stay, lower intraoperative blood loss, a higher amount of harvested lymph nodes, and better 3-year oerall and disease-free survival. MINORS and RoB2 indicated a serious risk of bias across studies included.

CONCLUSIONS

This review which includes predominantly non-randomized studies suggests a possible advantage of the robot-assisted CME compared with a laparoscopic technique for several short-term outcomes.

Robotic colectomy with CME versus laparoscopic colon resection with or without CME for colon cancer: a systematic review and meta-analysis

INTRODUCTION

This systematic review with meta-analysis aimed to compare the robotic complete mesocolon excision (RCME) to laparoscopic colectomy (LC) with (LCME) or without CME (LC non-CME) in postoperative outcomes, harvested lymph nodes and disease-free survival.

METHODS

We performed a systematic review with meta-analysis according to PRISMA 2020 and AMSTAR 2 guidelines.

RESULTS

The literature search yielded seven comparative studies including 677 patients: 269 patients in the RCME group and 408 in the LC group. The pooled analysis concluded to a lower conversion rate in the RCME group (OR=0.17; 95% CI [0.04, 0.74], p=0.02). There was no difference between the two groups in terms of morbidity (OR=1.03; 95% CI [0.70, 1.53], p=0.87), anastomosis leakage (OR=0.83; 95% CI [0.18, 3.72], p=0.81), bleeding (OR=1.90; 95% CI [0.64, 5.58], p=0.25), wound infection (OR=1.37; 95% CI [0.51, 3.68], p=0.53), operative time (mean difference (MD)=36.32; 95% CI [-24.30, 96.93], p=0.24), hospital stay (MD=-0.94; 95% CI [-2.03, 0.15], p=0.09) and disease-free survival (OR=1.29; 95% CI [0.71, 2.35], p=0.41). In the subgroup analysis, the operative time was significantly shorter in the LCME group than RCME group (MD=50.93; 95% CI [40.05, 61.81], p<0.01) and we noticed a greater number of harvested lymph nodes in the RCME group compared with LC non-CME group (MD=8.96; 95% CI [5.98, 11.93], p<0.01).

CONCLUSIONS

The robotic approach for CME ensures a lower conversion rate than the LC. RCME had a longer operative time than the LCME subgroup and a higher number of harvested lymph nodes than the LC non-CME group.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Robotic oncologic colorectal surgery with a new robotic platform (CMR Versius): hope or hype? A preliminary experience from a full-robotic case-series

Background

The present case-series describes the first full-robotic colorectal resections performed with the new CMR Versius platform (Cambridge Medical Robotics Surgical, 1 Evolution Business Park, Cambridge, United Kingdom) by an experienced robotic surgeon.

Methods

In a period between July 2020 and December 2020, patients aged 18 years or older, who were diagnosed with colorectal cancer and were fit for minimally invasive surgery, underwent robotic colorectal resection with CMR Versius robotic platform at “Casa di Cura Cobellis” in Vallo della Lucania,Salerno, Italy. Three right colectomies, 2 sigmoid colectomies and 1 anterior rectal resection were performed. All the procedures were planned as fully robotic. Surgical data were retrospectively reviewed from a prospectively collected database.

Results

Four patients were male and 2 patients were female with a median (range) age of 66 (47–72) years. One covering ileostomy was created. Full robotic splenic flexure mobilization was performed. No additional laparoscopic gestures or procedures were performed in this series except for clipping and stapling which were performed by the assistant surgeon due to the absence of robotic dedicated instruments. Two ileocolic anastomoses, planned as robotic-sewn, were performed extracorporeally. One Clavien–Dindo II complication occurred due to a postoperative blood transfusion. Median total operative time was 160 (145–294) min for right colectomies, 246 (191–300) min for sigmoid colectomies and 250 min for the anterior rectal resection.

Conclusions

The present series confirms the feasibility of full-robotic colorectal resections while highlighting the strengths and the limitations of the CMR Versius platform in colorectal surgery. New devices will need more clinical development to be comparable to the current standard.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-022-02626-9.