Robotic Low Anterior Resection for Rectal Cancer: A National Perspective on Short-term Oncologic Outcomes. Ann Surg. 2015;262:1040-1045. [PMID: 25405559 DOI: 10.1097/sla.0000000000001017]

Comparative analysis of the safety and effectiveness of robotic natural orifice specimen extraction versus laparoscopic surgery for colorectal tumors through systematic review and meta-analysis

The purpose of this study and meta-analysis was to evaluate the perioperative and oncologic results of robotic NOSE versus laparoscopic surgery for colorectal tumors. We plan to perform an extensive electronic search on PubMed, CNKI, Embase, and the Cochrane Library to find research articles published from the beginning of the databases until July 2024 that examine the comparison between robotic natural orifice specimen extraction and laparoscopic surgery in patients with colorectal cancer. Both English and Chinese literature will be included. Literature screening will strictly follow predetermined criteria for inclusion and exclusion, specifically targeting randomized controlled trials and cohort studies. The evaluation of quality will be conducted with the Newcastle-Ottawa Scale (NOS). Review Manager 5.4.1 will be utilized to perform a meta-analysis of data gathered from the studies that are included. The ultimate evaluation included seven past cohort studies with a total of 1117 participants (545 who had robotic NOSE and 572 who had laparoscopic surgery). Patients who had robotic NOSE experienced notable enhancements in LOHS, time to first flatus, time to start the liquid diet, EBL, and postoperative ileus when compared to patients undergoing laparoscopic colorectal surgery. There were no notable discrepancies noted in terms of surgical duration, total complications, lymph node collection, and anastomotic leakage between the two methods. In conclusion, the use of robotic technology for extracting specimens through natural body openings in colorectal surgery is considered to be safe and achievable. It offers notable advantages over laparoscopic surgery, including reduced hospital stay, earlier time to first flatus and liquid intake, decreased EBL, and lower incidence of postoperative ileus.

Comparative analysis of safety and effectiveness between natural orifice specimen extraction and conventional transabdominal specimen extraction in robot-assisted colorectal cancer resection through systematic review and meta-analysis

The goal of this systematic review and meta-analysis is to evaluate the perioperative and oncologic results of natural orifice specimen extraction (NOSE) compared to conventional transabdominal specimen extraction (TASE) in robotic-assisted surgery for colorectal cancer. A comprehensive electronic search will be performed on PubMed, Embase, and the Cochrane Library to find research articles published from the beginning of the databases to July 2024 that focus on patients who have undergone robotic-assisted surgery for colorectal cancer. Specifically, this review will compare NOSE with conventional TASE. Only studies published in English will be considered. Literature screening will adhere closely to predetermined criteria for inclusion and exclusion, specifically targeting randomized controlled trials and cohort studies. The evaluation of quality will involve the use of the Newcastle-Ottawa Scale (NOS). Meta-analysis of the included studies' data will be performed using Review Manager 5.4.1. In the final analysis, 9 retrospective cohort studies comprising 1571 patients were included. Out of these, 732 patients opted for NOSE, while 839 patients chose conventional TASE in robotic colorectal surgery. Patients who received TASE experienced enhancements in hospital stay duration, time until first gas passage, wound infection rates, and time until the first intake of a liquid diet. Nevertheless, there were no notable distinctions noted between the two methods regarding surgery duration, projected blood loss, intestinal blockage, or frequency of anastomotic leakage. In patients undergoing robotic-assisted colorectal surgery, the safety and feasibility of NOSE are demonstrated. Compared to traditional TASE, it provides clear benefits including shorter hospital stays, earlier first flatus, quicker initiation of a liquid diet, and lower risk of wound infection.

Intersphincteric resection following robotic-assisted versus laparoscopy-assisted total mesorectal excision for middle and low rectal cancer: a multicentre propensity score analysis of 1571 patients

BACKGROUND

Robotic-assisted total mesorectal excision (RaTME) may be associated with reduced conversion to an open approach and a higher rate of complete total mesorectal excision (TME); however, studies on its advantages in intersphincteric resection (ISR) are inadequate.

MATERIALS AND METHODS

This retrospective multicenter cohort study enroled consecutive patients who underwent RaTME and laparoscopy-assisted total mesorectal excision (LaTME) at four medical centres between January 2020 and March 2023. Propensity score matching (PSM), inverse probability of treatment weight (IPTW), and multivariate logistic regression analyses were performed. The primary outcome was the ISR rate. Secondary outcomes were coloanal anastomosis (CAA), conversion to open surgery, conversion to transanal TME, abdominoperineal resection, postoperative morbidity and mortality within 30 days, and pathological outcomes.

RESULTS

Among the 1571 patients, 1211 and 450 underwent LaTME and RaTME, respectively, with corresponding ISR incidences of 5.3% and 8.4% ( P =0.024). After PSM and IPTW, RaTME remained associated with higher ISR rates (4.5% versus 9.4%, P =0.022 after PSM; 4.9% versus 9.2, P =0.005 after IPTW). This association remained in multivariate analysis after adjusting for other confounding factors. RaTME was further associated with a higher CAA rate, longer operating time, and higher hospitalization expenses.

CONCLUSIONS

RaTME may facilitate ISR in middle and low rectal cancers, showing an independent association with a higher ISR incidence, with pathological outcomes and complications comparable to those of LaTME. However, it may also require a longer operating time and incur higher hospitalization expenses.

Minimally Invasive Lower Anterior Resections - Better than Open But Not All the Same

Background/Objective: Optimal approach for lower anterior resection has been closely debated. The relatively new addition of the robotic approach adds a layer of complexity to this topic. The majority of the literature has compared the possible approaches between two techniques; however, only a few studies have comprehensively compared all 3 approaches at the same time, especially in a non-academic center.Study Design: This is a retrospective cohort study of a prospectively maintained database of data from a large group of private-practice colorectal surgeons in a large metropolitan area. Specifically, rectal resections using open, laparoscopic, and robotic approaches were queried. A total of 130 patients underwent open, laparoscopic, or robotic oncological lower anterior resection from 2016 to January 2020.Results: Statistical significance of length of stay was noted between the three approaches with the mean length of stay for open being 8.08 days, laparoscopic being 7.04 days, and robotic being 4.96 days (P < .005). No statistical significance was noted for estimated blood loss, operating time, or postoperative complications including anastomotic leak, ileus, pneumonia, pulmonary embolism, surgical site infection, and urinary tract infection. When directly comparing any minimally invasive surgery approach to open, estimated blood loss was decreased in addition to the shortened length of stay (P < .05).Conclusions: This study demonstrates that MIS LAR has significant benefit over the open approach. However, finding that robotic surgery had was superior to laparoscopic LAR which was surprising and important. This experience in the private world raises the question as to whether robotic LAR should be considered the standard of care.

Comparison of robotic-assisted versus conventional laparoscopic surgery in colorectal cancer resection: a systemic review and meta-analysis of randomized controlled trials

Introduction

There is still controversy on whether or not robot-assisted colorectal surgery (RACS) have advantages over laparoscopic-assisted colorectal surgery(LACS).

Materials and methods

The four databases (PubMed, Embase, Web of Science and Cochrane Library)were comprehensively searched for randomized controlled trials (RCTs) comparing the outcomes of RACS and LACS in the treatment of colorectal cancer from inception to 22 July 2023.

Results

Eleven RCTs were considered eligible for the meta-analysis. Compared with LACS,RACS has significantly longer operation time(MD=5.19,95%CI: 18.00,39.82, P<0.00001), but shorter hospital stay(MD=2.97,95%CI:-1.60,-0.33,P = 0.003),lower conversion rate(RR=3.62,95%CI:0.40,0.76,P = 0.0003), lower complication rate(RR=3.31,95%CI:0.64,0.89,P=0.0009),fewer blood loss(MD=2.71,95%CI:-33.24,-5.35,P = 0.007),lower reoperation rate(RR=2.12, 95%CI:0.33,0.96,P=0.03)and longer distal resection margin(MD=2.16, 95%CI:0.04,0.94, P = 0.03). There was no significantly difference in harvested lymph nodes, the time of first flatus, the time of first defecation,the time of first resume diet, proximal resection margin, readmission rates, mortalities and CRM+ rates between two group.

Conclusions

Our study indicated that RACS is a feasible and safe technique that can achieve better surgical efficacy compared with LACS in terms of short-term outcomes.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023447088.

Evaluation of an established colorectal robotic programme at an NHS district general hospital: audit of outcomes and systematic review of published data

INTRODUCTION

Robotic-assisted surgery (RAS) offers potential advantages over traditional surgical approaches. This study aimed to assess outcomes from a district general hospital (DGH) robotic colorectal programme against published data.

MATERIALS AND METHODS

The robotic programme was established following simulator, dry/wet lab training, and proctoring. We performed a case series analysing technical, patient, and oncological outcomes extracted from a prospective database of colorectal RAS cases (2015-2022). A registered systematic review (PROSPERO CRD42022300773; PubMed, Web of Science, EMBASE) of single-centre colorectal series from established robotic centres (n>200 cases) was completed and compared to local data using descriptive summary statistics. Risk of bias assessment was performed using an adapted version of the Cochrane ROBINS-I tool.

RESULTS

Two hundred thirty-two RAS cases were performed including 122 anterior resections, 56 APERs, 19 rectopexies, and 15 Hartmann's procedures. The median duration was 325 (IQR 265-400) min. Blood loss was < 100 ml in 97% of cases with 2 (0.9%) cases converted to open. Complications (Clavien-Dindo 3-5) occurred in 19 (8%) patients, with 3 (1.3%) deaths in < 30 days. Length of stay was 7 (IQR 5-11) days. In 169 rectal cancer cases, there were 9 (5.3%) cases with a positive circumferential or distal margin and lymph node yield of 17 (IQR 13-24). A systematic review of 1648 abstracts identified 13 studies from established robotic centres, totaling 4930 cases, with technical, patient, and oncological outcomes comparable to our own case series.

CONCLUSIONS

Outcomes from our robotic colorectal programme at a UK DGH are comparable with the largest published case series from world-renowned centres. Training and proctoring together with rolling audit must accompany the expansion of robotic surgery to safeguard outcomes.

Is robotic da Vinci Xi® superior to the da Vinci Si® for sphincter-preserving total mesorectal excision? Outcomes in 150 mid-low rectal cancer patients

The aim of this study was to determine the superiority between the robotic da Vinci Si® (Si group) and da Vinci Xi® (Xi group) generation in patients with mid-low rectal cancer. Between December 2011 and December 2017, 88 patients with mid-low rectal cancer were operated on using the Si robotic system, from January 2018 to May 2021, 62 more patients with mid-low rectal cancer were operated on using the Xi robotic system. Perioperative and postoperative short-term outcomes were compared between the two groups. Univariate and multivariate Cox-regression analysis were performed to determine factors affecting operating time. A cumulative sum (CUSUM) analysis was also performed to determine the learning curve of the primary surgeon. All patients underwent sphincter saving total mesorectal excision (TME). The overall operating time was significantly shorter in the Xi group (181.3 ± 31.8 min in Si group vs 123.6 ± 25.7 min in the Xi group, p < 0.001). There were no significant differences in terms of conversion rates, mean hospital stays, complications and histopathologic data. CUSUM analysis show completion of learning curve in 44th case of Si group. Univariate and multivariate analysis demonstrated that the learning curve of the primary surgeon (p < 0.001) and the type of robotic system (Xi) are only two factors associated with operating time (OR, 95% CI p; 3.656, 0.665-9.339, p < 0.001). Our study found that the robotic da Vinci Xi systems provide significantly shorter operating time comparing with Si systems, when performing sphincter-preserving TME in mid-low rectal cancer patients. Surgical system (da Vinci Xi) and primary surgeon learning curve are two independent risk factors which associated shortened operating time. Postoperative complication rates and histopathologic outcomes are similar in both groups.

Robotic and robotic-assisted vs laparoscopic rectal cancer surgery: A meta-analysis of short-term and long-term results

The usage of robotic surgery in rectal cancer (RC) is increasing, but there is an ongoing debate as to whether it provides any benefit. This study conducted a meta-analysis of rectal cancer surgery for short-term and long-term outcome by Robotic and robotic-assisted surgery (RS) vs laparoscopic surgery (LS).Pubmed, Embase, Ovid, CNKI, Cochrane Library and Web of Science databases were searched. Studies clearly documenting a comparison of short-term and long-term effect between RS and LS for RC were selected. Lymph node harvested, operation time, hospital stay, circumferential resection margins（CRM), complications, 3-year disease-free survival (DFS) and 5-year DFS parameters were evaluated. All data were performed by Review Manager 5.3 software. Nine studies were collected that included 1436 cases in total, 716 (49.86%) in the RS group, 720(50.14%) in the LS group. Compared with LS, RS was associated with longer operation time (MD 35.19, 95%CI [7.57, 62.81]; P = 0.01), but similar hospital stay (MD -0.43, 95%CI [-0.87,0.01]; P = 0.05).Lymph node harvested, CRM, complications, 3-year DFS, 5-year DFS had no significance difference between RS and LS groups（MD -0.67，95%CI[-1.53，0.19]；P = 0.13；MD 0.86，95%CI[0.54,1.37]；P = 0.52；MD 0.97，95%CI [0.73,1.29]；P = 0.86；MD 0.94，95%CI[0.60,1.48]；P = 0.79；MD 0.88，95%CI[0.52,1.47]；P = 0.61 respectively）.RS is feasible and safe for RC. It has an advantage in short -term outcome and a similar effect in long-term outcome compared with LS.

Outcomes of robot-assisted versus conventional laparoscopic low anterior resection in patients with rectal cancer: propensity-matched analysis of the National Clinical Database in Japan

BACKGROUND

Robot-assisted laparoscopic surgery has several advantages over conventional laparoscopy. However, population-based comparative studies for low anterior resection are limited. This article aimed to compare peri-operative results of robot-assisted low anterior resection (RALAR) and laparoscopy.

METHODS

This retrospective cohort study used data from patients treated with RALAR or conventional laparoscopic low anterior resection (CLLAR) between October 2018 and December 2019, as recorded in the Japanese National Clinical Database, a data set registering clinical information, perioperative outcomes, and mortality. Of note, the registry does not include information on the tumour location (centimetres from the anal verge) and diverting stoma creation. Perioperative outcomes, including rate of conversion to open surgery, were compared between RALAR and CLLAR groups. Confounding factors were adjusted for using propensity score matching.

RESULTS

Of 21 415 patients treated during the study interval, 20 220 were reviewed. Two homogeneous groups of 2843 patients were created by propensity score matching. The conversion rate to open surgery was significantly lower in the RALAR group than in the CLLAR group (0.7 versus 2.0 per cent; P < 0.001). The RALAR group had a longer operating time (median: 352 versus 283 min; P < 0.001), less intraoperative blood loss (15 versus 20 ml; P < 0.001), a lower in-hospital mortality rate (0.1 versus 0.5 per cent; P = 0.007), and a shorter postoperative hospital stay (median: 13 versus 14 days; P < 0.001) compared with the CLLAR group. The CLLAR group had a lower rate of readmission within 30 days (2.4 versus 3.3 per cent; P = 0.045).

CONCLUSION

These data highlight the reduced conversion rate, in-hospital mortality rate, intraoperative blood loss, and length of postoperative hospital stay for rectal cancer surgery in patients treated using robot-assisted laparoscopic surgery compared with laparoscopic low anterior resection.

Colorectal cancer surgery: by Cambridge Medical Robotics Versius Surgical Robot System-a single-institution study. Our experience

With the previous experiences in performing laparoscopic for over a period of 15 years and da Vinci colorectal surgeries from 2010 to 2013, we started operating using the Cambridge Medical Robotics (CMR) Versius Surgical Robot System. The aim of the study is a prospective analysis and evaluation of short-term results of consecutive patients to study the technical feasibility and oncological outcome of robot-assisted low anterior resection (LAR) and ultralow anterior resection (ULAR), using the CMR Versius Surgical Robot System. This study was conducted at single minimal access surgery institute. 31 patients with colorectal adenocarcinoma underwent robot-assisted LAR and ULAR between August 2019 and March 2020. Patient characteristics, perioperative parameters and complications were evaluated. Surgical and pathological outcomes such as quality of Total Mesorectal Excision (TME), free circumferential resection margins and number of lymph nodes dissected were also evaluated. Of 31 patients, 23 were men and 8 women, with mean age of 55.6 years. The mean robotic operative time was 51 min and the mean blood loss was 55 ml. The mean robot docking and undocking time was 17 min and 5 min, respectively. The mean hospital stay was 7 days. The longitudinal and circumferential resection margins were negative in all patients. Histopathological reports of 27 among 31 patients showed complete TME. Splenic flexure of colon mobilization was done laparoscopically. We feel that Versius robot has the qualities in terms of dexterity, vision and intuitive movements, and to translate this technical ability into oncological safety.

Robotic versus laparoscopic surgery for colorectal cancer: a case-control study

BACKGROUND

Robotic resections represent a novel approach to treatment of colorectal cancer. The aim of our study was to critically assess the implementation of robotic colorectal surgical program at our institution and to compare it to the established laparoscopically assisted surgery.

PATIENTS AND METHODS

A retrospective case-control study was designed to compare outcomes of consecutively operated patients who underwent elective laparoscopic or robotic colorectal resections at a tertiary academic centre from 2019 to 2020. The associations between patient characteristics, type of operation, operation duration, conversions, duration of hospitalization, complications and number of harvested lymph nodes were assessed by using univariate logistic regression analysis.

RESULTS

A total of 83 operations met inclusion criteria, 46 robotic and 37 laparoscopic resections, respectively. The groups were comparable regarding the patient and operative characteristics. The operative time was longer in the robotic group (p < 0.001), with fewer conversions to open surgery (p = 0.004), with less patients in need of transfusions (p = 0.004) and lower reoperation rate (p = 0.026). There was no significant difference between the length of stay (p = 0.17), the number of harvested lymph nodes (p = 0.24) and the overall complications (p = 0.58).

CONCLUSIONS

The short-term results of robotic colorectal resections were comparable to the laparoscopically assisted operations with fewer conversions to open surgery, fewer blood transfusions and lower reoperation rate in the robotic group.

Cost-Effectiveness and Quality-Adjusted Survival of Watch and Wait After Complete Response to Chemoradiotherapy for Rectal Cancer

BACKGROUND

Neoadjuvant chemoradiotherapy (CRT) followed by total mesorectal excision (TME) is the standard treatment for locally advanced rectal cancer. There is interest in deescalating local therapy after a clinical complete response to CRT. We hypothesized that a watch-and-wait (WW) strategy offers comparable cancer-specific survival, superior quality-adjusted survival, and reduced cost compared with upfront TME.

METHODS

We developed a decision-analytic model to compare WW, low anterior resection, and abdominoperineal resection for patients achieving a clinical complete response to CRT. Rates of local regrowth, pelvic recurrence, and distant metastasis were derived from series comparing WW with TME after pathologic complete response. Lifetime incremental costs and quality-adjusted life-years (QALY) were calculated between strategies, and sensitivity analyses were performed to study model uncertainty.

RESULTS

The base case 5-year cancer-specific survival was 93.5% (95% confidence interval [CI] = 91.5% to 94.9%) on a WW program compared with 95.9% (95% CI = 93.6% to 97.4%) after upfront TME. WW was dominant relative to low anterior resection, with cost savings of $28 500 (95% CI = $22 200 to $39 000) and incremental QALY of 0.527 (95% CI = 0.138 to 1.125). WW was also dominant relative to abdominoperineal resection, with a cost savings of $32 100 (95% CI = $21 800 to $49 200) and incremental QALY of 0.601 (95% CI = 0.213 to 1.208). WW remained dominant in sensitivity analysis unless the rate of surgical salvage fell to 73.0%.

CONCLUSIONS

Using current multi-institutional recurrence estimates, we observed comparable cancer-specific survival, superior quality-adjusted survival, and decreased costs with WW compared with upfront TME. Upfront TME was preferred when surgical salvage rates were low.

Real-world comparison of curative open, laparoscopic and robotic resections for sigmoid and rectal cancer-single center experience

There has been an increase in the utilization of robotic surgery in addition to traditional open or laparoscopic approaches. Aim of this study is to compare the short-term outcomes for open, laparoscopic, and robotic surgery for rectal and sigmoid cancer. One hundred and forty-seven patients (open n = 48, laparoscopic n = 49, robotic n = 50) undergoing curative resections by two surgeons between 2013 and 2020 were included. Data analyzed included patient demographics, tumor characteristics, length of stay, post-operative outcomes, and pathologic surrogates of oncologic results, including total mesorectal excision (TME) quality, circumferential resection margin (CRM) involvement and lymph node (LN) yield. Median age of population was 68 years (IQR 59-73), majority (68%) were males. Median distance from anal verge in the robotic surgery group was 8 cm, compared to 15 and 14.5 cm in the open and laparoscopic groups, respectively, p = 0.029, (laparoscopic vs robotic, p = 0.005 and open vs robotic, p = 0.027). Proportion of patients who received neoadjuvant radiotherapy in robotic surgery group was higher, p = 0.04. In sub-group of tumors between 3 and 7 cm from anal verge more patients in the robotic surgery group had sphincter preservation, p = 0.006. Length of stay, maximum C-reactive protein, and white blood cell rise favored minimally invasive approaches compared to open surgery. There were no differences in post-operative complications, lymph node yield or CRM positivity rate between the three groups. Robotic surgery approach is safe and allows sphincter preservation without compromising TME quality in rectal cancer surgery.

Optimizing outcomes of colorectal cancer surgery with robotic platforms

Advanced robotic technology makes it easier to perform total mesorectal excision procedures in the narrow pelvis for rectal cancer while maintaining the advantages of minimally invasive surgery. Robotic surgery for rectal cancer leads to lower conversion rates and faster recovery of urogenital function than conventional laparoscopic surgery. However, longer operative time and high cost are major weaknesses of robotic surgery. To date, most other short-term surgical outcomes, pathologic outcomes, and long-term oncologic outcomes of robotic surgery have not shown significant advantages over laparoscopic surgery. However, robotic surgery is still a valid and highly anticipated surgical approach for rectal cancer because it greatly reduces the surgeon's workload and learning curve. There are also advantages when robotic techniques are applied to technically demanding procedures such as lateral pelvic lymph node dissection or intersphincteric resection. The introduction of new surgical robot systems, including the da Vinci® SP system, is expected to expand the applications of robotic surgery and provide new advantages.

Clinical and oncological outcomes of the low ligation of the inferior mesenteric artery with robotic surgery in patients with rectal cancer following neoadjuvant chemoradiotherapy

Background/aim

The aim of this study is to compare clinical and oncologic outcomes of the high and low ligation techniques of the inferior mesenteric artery (IMA) in rectal cancer patients treated with robotic surgery after neoadjuvant chemoradiotherapy (nCRT).

Materials and methods

In this retrospective study, 77 patients with T3/T4-node negative rectal cancer with tumor penetration through the muscle wall (Stage 2) or node positive disease without distant metastases (Stage 3) who were treated electively with robotic surgical resection following nCRT at a single institution between January 2014 and January 2018 were analyzed. Patients were divided into 2 groups (38 patients were included in the low ligation group and 39 patients in the high ligation group).

Results

There was no statistical difference between the high ligation group and low ligation group in univariate analysis for 2-year overall survival and disease-free survival (OR = 1.146; 95% CI = 0.274 to 4.797; P = 0.950, and OR = 1.141; 95% CI = 0.564 to 2.308; P = 0.713, respectively). There was no significant difference between the 2 groups in the mean number of harvested lymph nodes and mean number of metastatic lymph nodes (P = 0.980 and P = 0.124, respectively). Anastomosis stricture was observed significantly less frequently in the low ligation group versus the high ligation group (2.6% and 28.2%, respectively) (P = 0.002). Also, the difference for the median length of hospital stay for the high and low ligation groups was statistically significant in favor of the low ligation group (P = 0.011).

Conclusion

In robotic rectal surgery, the low ligation technique of the IMA can reduce the rate of anastomosis stricture and provide similar oncological results as the high ligation technique.

Minimally Invasive Proctectomy for Rectal Cancer: A National Perspective on Short-term Outcomes and Morbidity

BACKGROUND

Prior randomized trials showed comparable short-term outcomes between open and minimally invasive proctectomy (MIP) for rectal cancer. We hypothesize that short-term outcomes for MIP have improved as surgeons have become more experienced with this technique.

METHODS

Rectal cancer patients who underwent elective abdominoperineal resection (APR) or low anterior resection (LAR) were included from the American College of Surgeons National Surgical Quality Improvement Program database (2016-2018). Patients were stratified based on intent-to-treat protocol: open (O-APR/LAR), laparoscopic (L-APR/LAR), robotic (R-APR/LAR), and hybrid (H-APR/LAR). Multivariable logistic regression analysis was used to assess the impact of operative approach on 30-day morbidity.

RESULTS

A total of 4471 procedures were performed (43.41% APR and 36.59% LAR); O-APR 42.72%, L-APR 20.99%, R-APR 16.79%, and H-APR 19.51%; O-LAR 31.48%, L-LAR 26.34%, R-LAR 17.48%, and H-LAR 24.69%. Robotic APR and LAR were associated with shortest length of stay and significantly lower conversion rate. After adjusting for other factors, lap, robotic and hybrid APR and LAR were associated with decreased risk of overall morbidity when compared to open approach. R-APR and H-APR were associated with decreased risk of serious morbidity. No difference in the risk of serious morbidity was observed between the four LAR groups.

CONCLUSION

Appropriate selection of patients for MIP can result in better short-term outcomes, and consideration for MIP surgery should be made.

Preoperative predictive risk to cancer quality in robotic rectal cancer surgery

BACKGROUND

Circumferential resection margin (CRM) involvement is widely considered the strongest predictor of local recurrence after TME. This study aimed to determine preoperative factors associated with a higher risk of pathological CRM involvement in robotic rectal cancer surgery.

METHODS

This was a retrospective review of a prospectively maintained database of consecutive adult patients who underwent elective, curative robotic low anterior or abdominoperineal resection with curative intent for primary rectal adenocarcinoma in a tertiary referral cancer center from March 2012 to September 2019. Pretreatment magnetic resonance imaging (MRI) reports were reviewed for all the patients. Risk factors for pathological CRM involvement were investigated using Firth's logistic regression and a predictive model based on preoperative radiological features was formulated.

RESULTS

A total of 305 patients were included, and 14 (4.6%) had CRM involvement. Multivariable logistic regression found both T3 >5 mm (OR 6.12, CI 1.35-36.44) and threatened or involved mesorectal fascia (OR 4.54, CI 1.33-17.55) on baseline MRI to be preoperative predictors of pathologic CRM positivity, while anterior location (OR 3.44, CI 0.72-33.13) was significant only on univariate analysis. The predictive model showed good discrimination (area under the receiver-operating characteristic curve >0.80) and predicted a 32% risk of positive CRM if all risk factors were present.

CONCLUSION

Patients with pre-operatively assessed threatened radiological margin, T3 tumors with greater than 5 mm extension and anterior location are at risk for a positive CRM. The predictive model can preoperatively estimate the CRM positivity risk for each patient, allowing surgeons to tailor management to improve oncological outcomes.

Role of minimally invasive surgery for rectal cancer

Rectal cancer is one of the most common malignancies worldwide. Surgical resection for rectal cancer usually requires a proctectomy with respective lymphadenectomy (total mesorectal excision). This has traditionally been performed transabdominally through an open incision. Over the last thirty years, minimally invasive surgery platforms have rapidly evolved with the goal to accomplish the same quality rectal resection through a less invasive approach. There are currently three resective modalities that complement the traditional open operation: (1) Laparoscopic surgery; (2) Robotic surgery; and (3) Transanal total mesorectal excision. In addition, there are several platforms to carry out transluminal local excisions (without lymphadenectomy). Evidence on the various modalities is of mixed to moderate quality. It is unreasonable to expect a randomized comparison of all options in a single trial. This review aims at reviewing in detail the various techniques in regard to intra-/perioperative benchmarks, recovery and complications, oncological and functional outcomes.

Laparoscopic Approach to Rectal Cancer-The New Standard?

Minimally invasive surgery has revolutionized the way surgeons perform colorectal surgery, and new technologies continually upend the way surgeons view and operate within the deep pelvis. Among other benefits, it is associated with decreased lengths of stay, wound and surgical site infections, pain scores, and has an overall lower complication rate vs. open surgery (1). Recently, however, the role of minimally invasive surgery has been called into question in the effective and safe treatment of rectal cancer. This manuscript will outline the history of minimally invasive rectal cancer surgery, examine evidence detailing its safety (compared with alternatives), and discuss important aspects of use, most notably the considerable learning curve required to achieve proficiency, the extent of its current use, and potential pitfalls. The current evidence suggests minimally invasive surgery is a very safe way to treat rectal cancer when performed by experienced and specialty trained surgeons.

Short- and long-term outcomes for transvaginal specimen extraction versus minilaparotomy after robotic anterior resection for colorectal cancer: a mono-institution retrospective study

BACKGROUND

Colorectal cancer resection surgery with transvaginal specimen extraction is becoming increasingly accepted and used by surgeons. However, few publications on robotic anterior sigmoid colon and rectal cancer resection with transvaginal specimen extraction (TVSE) have been reported, and a clinical outcome comparison between conventional robotic minilaparotomy (LAP) and transvaginal specimen extraction in anterior sigmoid colon and rectal cancer resection has not been performed. The current study compared the short- and long-term outcomes of TVSE and LAP for sigmoid colon cancer and rectal cancer in a mono-institution.

METHODS

From December 2014 to October 2018, 45 patients who underwent TVSE and 45 patients who underwent LAP matched by tumor location, tumor stage, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, gender, and age at the same period were included in the current study. The short- and long-term outcomes of TVSE and LAP were discussed.

RESULTS

No significant differences were found in patient characteristics. For the short-term outcomes, the operative time in the TVSE group was longer than that in the LAP group, and the postoperative pain and additional analgesia were lower in the TVSE group. Patients in the TVSE group required slightly less time to pass first flatus. There were no significant differences in overall complications, time to regular diet, length of hospital stay after surgery, estimated blood loss, or pathological outcomes. For long-term outcomes, the 3-year overall survival (94.9% vs. 91.7%, p = 0.702) and 3-year disease-free survival (88.4% vs. 86.2%, p = 0.758) were comparable between the two groups.

CONCLUSION

The robotic TVSE is safe and feasible in selected sigmoid/upper rectal cancer patients with tumor diameter < 5 cm. This approach has slightly better short-term outcomes in terms of less postoperative pain and less analgesic requirements without any significant difference in long-term outcomes.

Next-generation robotics in gastrointestinal surgery

The global numbers of robotic gastrointestinal surgeries are increasing. However, the evidence base for robotic gastrointestinal surgery does not yet support its widespread adoption or justify its cost. The reasons for its continued popularity are complex, but a notable driver is the push for innovation - robotic surgery is seen as a compelling solution for delivering on the promise of minimally invasive precision surgery - and a changing commercial landscape delivers the promise of increased affordability. Novel systems will leverage the robot as a data-driven platform, integrating advances in imaging, artificial intelligence and machine learning for decision support. However, if this vision is to be realized, lessons must be heeded from current clinical trials and translational strategies, which have failed to demonstrate patient benefit. In this Perspective, we critically appraise current research to define the principles on which the next generation of gastrointestinal robotics trials should be based. We also discuss the emerging commercial landscape and define existing and new technologies.

Evolution of Robotic Surgery in a Colorectal Cancer Unit in India

Only a handful of institutions in the country have an established robotic surgery program. Evolution of robotic surgery in the colorectal division, from inception to recent times, is presented here. All the patients undergoing robotic colorectal surgery from the inception of the program (September 2014) to August 2019 were identified. The patient and treatment details and short-term outcomes were collected retrospectively from the prospectively maintained database. The cohort was divided into four chronological groups (group 1 being the oldest) to assess the surgical trends. There were 202 patients. Seventy-one percent were male. Mean BMI was 23.25. Low rectal tumours were most common (47%). A total of 74.3% patients received neo-adjuvant treatment. Multivisceral resection was done in 22 patients, including 4 synchronous liver resections. Average operating time for standard rectal surgery was 280 min with average blood loss of 235 ml. The mean nodal yield was 14. Circumferential resection margin positivity was 6.4%. The mean hospital stay for pelvic exenteration was significantly higher than the rest of the surgeries (except for posterior exenteration and total proctocolectomy) (p = 0.00). Clavin-Dindo grade 3 and 4 complications were seen in 10% patients. As the experience of the team increased, more complex cases were performed. Blood loss, margin positivity, nodal yield, leak rates and complications were evaluated group wise (excluding those with additional procedures) to assess the impact of experience. We did not find any significant change in the parameters studied. With increasing experience, the complexity of surgical procedures performed on da Vinci Xi platform can be increased in a systematic manner. Our short-term outcomes, i.e. nodes harvested, margin positivity, hospital stay and morbidity, are on par with world standards. However, we did not find any significant improvement in these parameters with increasing experience.

Robotic surgery for rectal cancer as a platform to build on: review of current evidence

Laparoscopy in colorectal surgery reduces the rate of postoperative complications, shortens the length of stay in hospital, and improves the quality of patient care. Despite these established benefits, the technical challenges of rectal resection for cancer have resulted in most operations being performed through open surgery in the USA. Moreover, controversy in the current literature questions the oncologic safety of a laparoscopic approach for rectal cancer. How then can surgeons innovate to overcome the technical challenges while preserving the critical oncological outcomes of high-quality rectal cancer surgery? Robotics may be a platform that allows us to overcome the technical challenges in the pelvis while maintaining both oncological outcomes and the benefits of a minimally invasive technique. Current evidence suggests that the quality of total mesorectal excision, the rates of circumferential margin involvement, and postoperative outcomes are comparable between robotic and laparoscopic surgery. While a robotic approach demonstrates lower conversion rates and reduced surgeon workload, the operative time is longer and initial costs are higher; however, time and future science will determine its true benefits. We review the current state of robotic surgery and its impact on rectal cancer surgery.

A roadmap for robotic-assisted sigmoid resection in diverticular disease using a Senhance™ Surgical Robotic System: results and technical aspects

Since the turn of the century, robotic-assisted colorectal surgery has been synonymous with the da Vinci® robotic surgical system. We report in this study our first results in robotic-assisted sigmoid resection for diverticular disease using the Senhance™ Surgical Robotic System, while introducing a standardized roadmap for engaging the robotic arms. 12 patients underwent a sigmoid resection using the Senhance™ Surgical Robotic System. All four arms of the robotic system were engaged during all procedures according to a previously devised roadmap. A 4-trocar technique was used in all patients. Perioperative data, including those regarding technical difficulties, were collected and analyzed. Two procedures were converted into standard laparoscopy. There were no conversions to open surgery. The mean age of the patients was 62.5 years (47-79). One third of the patients were males. The mean BMI was 27 kg/m2 (19-38). The mean operative time, the mean console time and the mean docking time were 219 min (204-305), 149 min (124-205) and 10 min (6-15), respectively. The mean length of stay was 9 days (6-15). There was one major complication (8.3%, Clavien-Dindo IIIb). There were no mortalities. No other complications were observed. No patients were readmitted after discharge. The Senhance™ Surgical Robotic System can be used safely in sigmoid resection for diverticular disease after adequate training and systematic planning of the different steps of the procedure. Further experience is needed to judge the benefit for patient and surgeon, as well as the cost and time effectiveness.

Evolution of minimally invasive surgery for rectal cancer: update from the national cancer database

BACKGROUND

As the use of minimally invasive techniques in colorectal surgery has become increasingly prevalent, concerns remain about the oncologic effectiveness and long-term outcomes of minimally invasive low anterior resection (MI-LAR) for the treatment of rectal cancer.

STUDY DESIGN

The 2010-2015 National Cancer Database (NCDB) Participant Data Use File was queried for patients undergoing elective open LAR (OLAR) or MI-LAR for rectal adenocarcinoma. A 1:1 propensity match was performed on the basis of demographics, comorbidity, and tumor characteristics. Outcomes were compared between groups and Cox proportional hazard modeling was performed to identify independent predictors of mortality. A subset analysis was performed on high-volume academic centers.

RESULTS

35,809 patients undergoing LAR were identified of whom 18,265 (51.0%) underwent MI-LAR. After propensity matching, patients receiving MI-LAR were less likely to have a positive circumferential radial margin (CRM) (5.5% vs. 6.6%, p = 0.0094) or a positive distal margin (3.6% vs. 4.6%, p = 0.0022) and had decreased 90-day all-cause mortality (2.0% vs. 2.6%, p = 0.0238). MI-LAR resulted in decreased hospital length of stay (5 vs. 6 days, p < 0.0001) but a greater rate of 30-day readmission (7.6% vs. 6.5%, p = 0.0054). Long-term overall survival was improved with MI-LAR (79% vs. 76%, p < 0.0001). Cox proportional hazard modeling demonstrated a decreased risk of mortality with MI-LAR (HR 0.859, 95% CI 0.788-0.937).

CONCLUSION

MI-LAR is associated with improvement in CRM clearance and long-term survival. In the hands of experienced surgeons with advanced laparoscopy skills, MI-LAR appears safe and effective technique for the management of rectal cancer.

Essential advances in surgical and adjuvant therapies for colorectal cancer 2018-2019

Surgical resection and adjuvant chemotherapy are the only treatment modalities for localized colorectal cancer that can obtain a "cure." The goal in surgically treating primary colorectal cancer is complete tumor removal along with dissection of systematic D3 lymph nodes. Adjuvant treatment controls recurrence and improves the prognosis of patients after they undergo R0 resection. Various clinical studies have promoted the gradual spread and clinical use of new surgical approaches such as laparoscopic surgery, robotic surgery, and transanal total mesorectal excision (TaTME). Additionally, the significance of adjuvant chemotherapy has been established and it is now recommended in the JSCCR (the Japanese Society for Cancer of the Colon and Rectum) guideline as a standard treatment. Herein, we review and summarize current surgical treatment and adjuvant chemotherapy for localized colorectal cancer and discuss recent advances in personalized medicine related to adjuvant chemotherapy.

Short-term and long-term outcomes of robotic rectal surgery-from the real word data of 1145 consecutive cases in China

Background

Due to a limited patient sample size, substantial data on robotic rectal resection (RRR) is lacking. Here, we reported a large consecutive cases from the real word data to assess the safety and efficacy of RRR.

Methods

From September 2010 to June 2017, a total of 1145 consecutive RRR procedures were performed in patients with stage I–IV disease. We conducted an analysis based on information from a prospectively designed database to evaluate surgical outcomes, urogenital function, and long-term oncological outcomes.

Results

Of three types of RRR performed, 227 (24.2%) were abdominoperineal resections, 865 (75.5%) were anterior resections, and 3 (0.3%) were Hartmann. Conversion to an open procedure occurred in 5.9% of patients. The overall positive circumferential margin rate was 1.3%. Surgical complication rate and mortality were 16.2% and 0.8% within 30 days of surgery, respectively. Mean hospital stay after surgery and hospital cost were 6.3 ± 2.9 days and 10442.5 ± 3321.5 US dollars, respectively. Risk factors for surgical complications included male gender, tumor location (mid-low rectum), combined organ resection, and clinical T category (cT3–4). Urinary function and general sexual satisfaction decreased significantly 1 month after surgery for both sexes. Subsequently, both parameters increased progressively, and the values 1 year after surgery were comparable to those measured before surgery. At a median follow-up of 34.6 months, local recurrence and distant metastases occurred in 2.3% and 21.1% of patients, respectively.

Conclusions

Robotic rectal resection was safe with preserved urogenital function and arrived equivalent oncological outcomes in a nonselected group of patients with rectal cancer.

Impact of surgical approach on short-term oncological outcomes and recovery following low anterior resection for rectal cancer

AIM

The aim was to evaluate the influence of operative approach for low anterior resection (LAR) on oncological and postoperative outcomes. Minimally invasive surgical approaches are increasingly used for the treatment of rectal cancer with mixed outcomes.

METHOD

We compared patients undergoing LAR in the National Cancer Database between 2010 and 2015 by surgical approach. Multivariable regression was used to identify risk factors associated with conversion rate, prolonged length of stay (LOS) and 30-day unplanned readmission.

RESULTS

During the study period, 41 282 patients underwent LAR: 6035 robotic-assisted (RLAR) (14.6%), 13 826 laparoscopic (LLAR) (33.5%) and 21 421 open (OLAR) (51.9%). In propensity score matched analysis, RLAR compared to LLAR was associated with shorter LOS (6.3 vs 6.8 days, P < 0.0001), lower risk of prolonged LOS (22.1% vs 25.6%, P < 0.0001) and lower rate of conversion to open (7.5% vs 14.95%, P < 0.0001). Compared to OLAR, RLAR had shorter LOS (6.3 vs 7.8 days, P < 0.0001) and less prolonged LOS (14.1% vs. 20.9%, P < 0.0001). In multivariable analysis, for conversion to open, the laparoscopic approach was one of the risk factors; for prolonged LOS, conversion to open and non-robotic approaches (i.e. LLAR and OLAR) were risk factors; and for unplanned 30-day readmission, conversions and prolonged LOS were risk factors.

CONCLUSIONS

For patients with rectal cancer, RLAR shows recovery benefits over both open and laparoscopic LAR with reduced conversion to open compared with LLAR and less prolonged LOS compared with LLAR and OLAR. RLAR is associated with short-term oncological outcomes comparable to OLAR, supporting its use in minimally invasive surgery for rectal cancer.

Comparing pathologic outcomes for robotic versus laparoscopic Surgery in rectal cancer resection: a propensity adjusted analysis of 7616 patients

BACKGROUND

Margin negative resection of rectal cancer with minimally invasive techniques remains technically challenging. Robotic surgery has potential advantages over traditional laparoscopy. We hypothesize that the difference in the rate of negative margin status will be < 6% between laparoscopic and robotic approach.

METHODS

The National Cancer Database (2010-2014) was queried for adults with locally advanced rectal cancer who underwent neoadjuvant chemoradiation and curative resection to conduct an observational retrospective cohort study of a prospectively maintained database. Patients were grouped by either robotic (ROB) or laparoscopic (LAP) approach in an intent-to-treat analysis. Primary outcome was negative margin status, defined as a composite of circumferential resection margin and distal margin. Secondary outcomes included length of stay (LOS), readmission, 90-day mortality, and overall survival.

RESULTS

7616 patients with locally advanced rectal cancer who underwent minimally invasive resection were identified. 2472 (32%) underwent attempted robotic approach. The overall conversion rate was 13% and was increased in the laparoscopic group [LAP: 15% vs. ROB: 8%; OR 0.47; 95% CI (0.39, 0.57)]. Differences in margin negative resection rate were within the prespecified range of practical equivalence (LAP: 93% vs.: ROB 94%; 95% CI (0.69, 1.06); [Formula: see text] = 1). For secondary outcomes, there was no difference in 30-day readmission [LAP: 9% vs.: ROB 8%; 95% CI (0.84, 1.24)] and 90-day mortality [LAP: 1% vs.: ROB 1%; 95% CI (0.38, 1.24)]. While the median LOS was 5 days in both groups, the mean LOS was 0.6 (95% CI: 0.24, 0.89) days shorter in the robotic group.

CONCLUSION

This robust analysis supports either robotic or laparoscopic approach for resection of locally advanced rectal cancer from a margin perspective. Both have similar readmission and 5-year overall survival rates. Patients undergoing robotic surgery have a 0.6-day decrease in LOS and decreased conversion rate.

Robotic Versus Conventional Laparoscopic Surgery for Colorectal Cancer: A Systematic Review and Meta-Analysis with Trial Sequential Analysis

BACKGROUND

Minimally invasive surgery has been considered as an alternative to open surgery by surgeons for colorectal cancer. However, the efficacy and safety profiles of robotic and conventional laparoscopic surgery for colorectal cancer remain unclear in the literature. The primary aim of this review was to determine whether robotic-assisted laparoscopic surgery (RAS) has better clinical outcomes for colorectal cancer patients than conventional laparoscopic surgery (CLS).

METHODS

All randomized clinical trials (RCTs) and observational studies were systematically searched in the databases of CENTRAL, EMBASE and PubMed from their inception until January 2018. Case reports, case series and non-systematic reviews were excluded.

RESULTS

Seventy-three studies (6 RCTs and 67 observational studies) were eligible (n = 169,236) for inclusion in the data synthesis. In comparison with the CLS arm, RAS cohort was associated with a significant reduction in the incidence of conversion to open surgery (ρ < 0.001, I² = 65%; REM: OR 0.40; 95% CI 0.30,0.53), all-cause mortality (ρ < 0.001, I² = 7%; FEM: OR 0.48; 95% CI 0.36,0.64) and wound infection (ρ < 0.001, I² = 0%; FEM: OR 1.24; 95% CI 1.11,1.39). Patients who received RAS had a significantly shorter duration of hospitalization (ρ < 0.001, I² = 94%; REM: MD - 0.77; 95% CI 1.12, - 0.41; day), time to oral diet (ρ < 0.001, I² = 60%; REM: MD - 0.43; 95% CI - 0.64, - 0.21; day) and lesser intraoperative blood loss (ρ = 0.01, I² = 88%; REM: MD - 18.05; 95% CI - 32.24, - 3.85; ml). However, RAS cohort was noted to require a significant longer duration of operative time (ρ < 0.001, I² = 93%; REM: MD 38.19; 95% CI 28.78,47.60; min).

CONCLUSIONS

This meta-analysis suggests that RAS provides better clinical outcomes for colorectal cancer patients as compared to the CLS at the expense of longer duration of operative time. However, the inconclusive trial sequential analysis and an overall low level of evidence in this review warrant future adequately powered RCTs to draw firm conclusion.

TME for rectal cancer: consecutive 70 patients treated with laparoscopic and robotic technique-cumulative experience in a single centre

From January 2011 to December 2015, 70 consecutive patients underwent either laparoscopic surgery (LS) or robotic surgery (RS) total mesorectal excision (TME) for malignancy. Data were prospectically recorded in a dedicated local database including ASA score, age, operative time, conversion rate, re-operation rate, early complications, length of stay, and pathological results. We enrolled 70 consecutive patients, 35 treated with LS (18 M, 17 F), 35 treated with RS (23 M, 12 F). Median total operative time was 225 min in LS group (IQR 194-255) and 252.5 min for RS group (IQR 214-300). Median first flatus time was 2 days for LS group (IQR 1-3) and 1 day for RS group (IQR 1-2). Stool discharge time (median) was 4 days for LS group (IQR 2-5) and 2 days for RS group (IQR 1-3). Length of stay (median) was 8 days in LS group (IQR 7-10) and 7 days in RS group (IQR 5-8). It was not found any statistically significant difference between the two groups when we analyzed the number nodes harvested the postoperative complications. The 30 day mortality was 0% in both two groups. The conversion rate for LS group was 23% (8/35 pts) and that for RS group was 0% (0/35). The RS may overcome technical limitations of LS. In our experience, it is a feasible and safe technique, it achieves better clinical outcomes due to the lower conversion rate compared to LS, although with higher costs.

The Current Role of Robotics in Colorectal Surgery

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.

Oncological Outcomes After Robotic Proctectomy for Rectal Cancer: Analysis of a Prospective Database

OBJECTIVE

The aim of this study is to evaluate the oncological outcomes of robotic total mesorectal excision (TME) at an NCI designated cancer center.

SUMMARY BACKGROUND DATA

The effectiveness of laparoscopic TME could not be established, but the robotic-assisted approach may hold some promise, with improved visualization and ergonomics for pelvic dissection. Oncological outcome data is presently lacking.

METHODS

Patients who underwent total mesorectal excision or tumor-specific mesorectal excision for rectal cancer between April 2009 and April 2016 via a robotic approach were identified from a prospective single-institution database. The circumferential resection margin (CRM), distal resection margin, and TME completeness rates were determined. Kaplan-Meier analysis of disease-free survival and overall survival was performed for all patients treated with curative intent.

RESULTS

A total of 276 patients underwent robotic proctectomy during the study period. Robotic surgery was performed initially by 1 surgeon with 3 additional surgeons progressively transitioning from open to robotic during the study period with annual increase in the total number of cases performed robotically. Seven patients had involved circumferential resection margins (2.5%), and there were no positive distal or proximal resection margins. One hundred eighty-six patients had TME quality assessed, and only 1 patient (0.5%) had an incomplete TME. Eighty-three patients were followed up for a minimum of 3 years, with a local recurrence rate of 2.4%, and a distant recurrence rate of 16.9%. Five-year disease-free survival on Kaplan-Meier analysis was 82%, and 5-year overall survival was 87%.

CONCLUSIONS

Robotic proctectomy for rectal cancer can be performed with good short and medium term oncological outcomes in selected patients.

Laparoscopic vs. robotic rectal cancer surgery and the effect on conversion rates: a meta-analysis of randomized controlled trials and propensity-score-matched studies

BACKGROUND

The usage of robotic surgery in rectal cancer is increasing, but there is an ongoing debate as to whether it provides any benefit. The aim of the present study was to determine if robotic surgery results in less conversion to an open operation than laparoscopic rectal cancer surgery.

METHODS

A meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using Ovid Medline, PubMed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, ACP Journal Club and Database of Abstracts of Review of Effectiveness. Included were randomized controlled trials (RCTs) and propensity-score-matched (PSM) studies comparing a robotic vs. laparoscopic approach to rectal cancer surgery. The primary endpoint was conversion to open. All statistical analyses and data synthesis were conducted using STATA/IC version 14·2, Windows 64 bit (StataCorp LP, College Station, TX, USA) RESULTS: Six hundred and twenty-one studies were identified through electronic database search. After application of selection criteria as per PRISMA and MOOSE criteria, six RCTs and five PSM articles were analyzed. From the six RCTs, 512 robotic and 519 laparoscopic cases were evaluated. There was a significantly lower rate of conversion for the robotic surgery arm (4.1% vs. 8.1%, OR 0.28; 95% CI 0.00-0.57). Of the five PSM studies, 2097 robotic and 3053 laparoscopic cases were evaluated. There was a significantly lower conversion to open rate found in the robotic surgery cohort (7.4% vs. 15.6%; OR 0.39; 95% CI 0.30-0.47). Pooled RCT and PSM data demonstrated significantly lower conversion rates for robotic surgery (6.7% vs. 14.5%; OR 0.38; 95% CI 0.30-0.46).

CONCLUSIONS

Robotic surgery for rectal cancer is associated with reduced conversion to open surgery compared to a laparoscopic approach.

Preservation of Pathologic Outcomes in Robotic versus Open Resection for Rectal Cancer: Can the Robot Fill the Minimally Invasive Gap?

Open resection remains the standard of care in the surgical management of rectal cancer with recent studies unable to prove noninferiority of laparoscopic resection. Few studies directly compare robotic versus open techniques. This is a retrospective chart review of all consecutive patients undergoing robotic or open rectal cancer resection during a three-year period. The primary endpoint was a composite of complete mesorectal excision, circumferential resection margin <1 mm, and distal resection margin <1 mm. The study cohort included 64 patients undergoing robotic (n = 28) or open (n = 36) resection. Successful surgical resection was similar between the robotic (75%) and open (76%) approaches. Robotic resection was associated with significantly lower blood loss ( P = 0.02) and significantly longer operative times ( P = 0.009) compared with open resection. Length of hospital stay and complications were similar between groups. Both male gender ( P = 0.03) and shorter tumor distance from the anal verge ( P = 0.01) were predictors for unsuccessful surgical resection in open, but not robotic, surgery. Pathologic outcomes are similar between robotic and open rectal cancer resection, even early in the learning curve. Tumor distance from the anal verge complicates open total mesorectal excision; however, robotic surgery is less impacted. Robotic resection may be a promising minimally invasive approach for rectal cancer resection.

Systematic review analysis of robotic and transanal approaches in TME surgery- A systematic review of the current literature in regard to challenges in rectal cancer surgery

Several patients' and pathological characteristics in rectal surgery can significantly complicate surgical loco regional tumor clearance. The main factors are obesity, short tumor distance from anal verge, bulky tumors, and narrow pelvis, which have been shown to be associated to poor surgical results in open and laparoscopic approaches. Minimally invasive surgery has the potential to reduce perioperative morbidity with equivalent short- and long-term oncological outcomes compared to conventional open approach. Achilles' heel of laparoscopic approaches is conversion to open surgery. High risk for conversion is evident for patients with bulky and low tumors as well as male gender and narrow pelvis. Hence, patient's characteristics represent challenges in rectal cancer surgery especially in minimally invasive approaches. The available surgical techniques increased remarkably with recently developed and implemented improvements of minimally invasive rectal cancer surgery. The controversial discussions about sense and purpose of these novel approaches are still ongoing in the literature. Herein, we evaluate, if latest technical advances like transanal approach or robotic assisted surgery have the potential to overcome known challenges and pitfalls in rectal cancer surgery in demanding surgical cases and highlight the role of current minimally invasive approaches in rectal cancer surgery.

Appraisal and Current Considerations of Robotics in Colon and Rectal Surgery

BACKGROUND

Robotic technology aims to obviate some of the limitations of conventional laparoscopic surgery, yet the role of robotics in colorectal surgery is still largely undefined and varies with respect to its application in abdominal versus pelvic surgery.

METHODS

With this review, we aimed to highlight current developments in colorectal robotic surgery. We systematically searched the following databases: PubMed, EMBASE, and Cochrane Library. We critically reviewed the available literature on the use of robotic technology in colon and rectal surgery.

RESULTS

Robotic colorectal surgery is oncologically safe and has short-term outcomes comparable to conventional laparoscopy, with potential benefits in rectal surgery. It has a shorter learning curve but increased operative times and costs. It offers potential advantages in the resection of rectal cancer, due to lower conversion rates. There is also a trend toward better outcomes in anastomotic leak rates, circumferential margin positivity, and perseveration of autonomic function.

CONCLUSION

Laparoscopy remains technically challenging and conversion rates are still high. Therefore, most cases of colorectal surgery are still performed open. Robotic surgery aims to overcome the limits of the laparoscopic technique. This new technology has many advantages in terms of articulating instruments, advanced three-dimensional optics, surgeon ergonomics, and improved accessibility to narrow spaces, such as the pelvis. However, further studies are needed to assess long-term results and benefits.

The role of robotics in colorectal surgery

Robotic surgery is safe and feasible offering many potential advantages to the colorectal surgeon.

Abdominoperineal Resection for Rectal Cancer in the Twenty-First Century: Indications, Techniques, and Outcomes

BACKGROUND

Management of low rectal cancer continues to be a challenge, and decision making regarding the need for an abdominoperineal resection (APR) in patients with low-lying tumors is complicated. Furthermore, choices need to be made regarding need for modification of the surgical approach based on tumor anatomy and patient goals.

DISCUSSION

In this article, we address patient selection, preoperative planning, and intraoperative technique required to perform the three types of abdominoperineal resections for rectal cancer: extrasphincteric, extralevator, and intersphincteric. Attention is paid not only to traditional oncologic outcomes such as recurrence and survival but also to patient-reported outcomes and quality of life.

Propensity Score-Matched Analysis of Clinical and Financial Outcomes After Robotic and Laparoscopic Colorectal Resection

PURPOSE

The study aims to evaluate the clinical and financial outcomes of the use of robotic when compared to laparoscopic colorectal surgery and any changes in these over time.

METHODS

From the Premier Perspective database, patients who underwent elective laparoscopic and robotic colorectal resections from 2012 to 2014 were included. Laparoscopic colorectal resections were propensity score matched to robotic cases for patient, disease, procedure, surgeon specialty, and hospital type and volume. The two groups were compared for conversion, hospital stay, 30-day post-discharge readmission, mortality, and complications. Direct, cumulative, and total (including 30-day post-discharge) costs were evaluated. Clinical and financial outcomes were also separately assessed for each of the included years.

RESULTS

Of 36,701 patients, 32,783 (89.3%) had laparoscopic colorectal resection and 3918 (10.7%) had robotic colorectal resection; 4438 procedures (2219 in each group) were propensity score matched. For the entire period, conversion to open approach (4.7 vs. 3.7%, p = 0.1) and hospital stay (mean days [SD] 6 [5.3] vs. 5 [4.6], p = 0.2) were comparable between robotic and laparoscopic procedures. Surgical and medical complications were also the same for the two groups. However, the robotic approach was associated with lower readmission (6.3 vs. 4.8%, p = 0.04). Wound or abdominal infection (4.7 vs. 2.3%, p = 0.01) and respiratory complications (7.4 vs. 4.7%, p = 0.02) were significantly lower for the robotic group in the final year of inclusion, 2014. Direct, cumulative, and total (including 30-day post-discharge) costs were significantly higher for robotic surgery. The difference in costs between the two approaches reduced over time (direct cost difference: 2012, $2698 vs. 2013, $2235 vs. 2014, $1402).

CONCLUSION

Robotic colorectal surgery can be performed with comparable clinical outcomes to laparoscopy. With greater use of the technology, some further recovery benefits may be evident. The robotic approach is more expensive but cost differences have been diminishing over time.

Robotic surgery for rectal cancer: the future?

Robotic technology currently offers some technical advantages in pelvic dissection compared with competing minimally invasive techniques, and adoption for the surgical treatment of rectal cancer is rapidly increasing worldwide. While there are some early data demonstrating modest improvement in patient outcomes, benefits in terms of long-term oncological outcomes, as well as potential improvements in surgeon-centered outcomes such as fatigue and repetitive stress injury are actively being investigated. Rapid innovation, with the impending release of several new robotic platforms, is likely to further expand the application of these technologies, improve on current limitations, and reduce capital and consumable costs. It is imperative that, as the technology develops and adoption increases further, clinician and research led programs drive safe implementation with a patient-first approach.

Minimally Invasive Approaches for Surgical Management of Primary Liver Cancers

The benefits of minimally invasive approaches in oncologic surgery are increasingly recognized, and laparoscopic liver surgery has become increasingly widespread. In light of the complexity and technical challenges of hepatobiliary procedures, robotic approaches are also employed. The utility, safety, and oncologic integrity of these methods in the management of primary liver cancers are reported. PubMed was used to search the medical literature for studies and articles pertaining to laparoscopic and robotic liver surgery. Studies that particularly addressed hepatocellular carcinoma and cholangiocarcinoma were identified and reviewed. Laparoscopic liver surgery, including for major resections, has been shown to be safe in experienced hands without any compromise of oncologic outcomes for either hepatocellular carcinoma or intrahepatic cholangiocarcinoma. Some studies show improved clinical outcomes including shorter hospital stays and lower complication rates when compared to open surgery, particularly for patients with cirrhosis. Robotic liver surgeries seem to have equally acceptable clinical outcomes; however, there is limited data regarding oncologic integrity and considerable additional expense. Laparoscopic and robotic liver resections are both feasible and safe for the management of primary liver tumors. Future studies should aim to clarify specific indications and optimize applications of these approaches.