Robotic colorectal surgery: hype or new hope? A systematic review of robotics in colorectal surgery

Short-term and long-term efficacy in robot-assisted treatment for mid and low rectal cancer: a systematic review and meta-analysis

OBJECTIVE

This study aims to conduct a meta-analysis to evaluate the short-term and long-term therapeutic effects of robot-assisted laparoscopic treatment in patients with mid and low rectal cancer.

METHODS

A comprehensive search strategy was employed to retrieve relevant literature from PubMed, NCBI, Medline, and Springer databases, spanning the database inception until August 2023. The focus of this systematic review was on controlled studies that compared the treatment outcomes of robot-assisted (Rob) and conventional laparoscopy (Lap) in the context of mid and low rectal cancer. Data extraction and literature review were meticulously conducted by two independent researchers (HMW and RKG). The synthesized data underwent rigorous analysis utilizing RevMan 5.4 software, adhering to established methodological standards in systematic reviews. The primary outcomes encompass perioperative outcomes and oncological outcomes. Secondary outcomes include long-term outcomes.

RESULT

A total of 11 studies involving 2239 patients with mid and low rectal cancer were included (3 RCTs and 8 NRCTs); the Rob group consisted of 1111 cases, while the Lap group included 1128 cases. The Rob group exhibited less intraoperative bleeding (MD =  -40.01, 95% CI: -57.61 to -22.42, P < 0.00001), a lower conversion rate to open surgery (OR = 0.27, 95% CI: 0.09 to 0.82, P = 0.02), a higher number of harvested lymph nodes (MD = 1.97, 95% CI: 0.77 to 3.18, P = 0.001), and a lower CRM positive rate (OR = 0.46, 95% CI: 0.23 to 0.95, P = 0.04). Additionally, the Rob group had lower postoperative morbidity rate (OR = 0.66, 95% CI: 0.53 to 0.82, P < 0.0001) and a lower occurrence rate of complications with Clavien-Dindo grade ≥ 3 (OR = 0.60, 95% CI: 0.39 to 0.90, P = 0.02). Further subgroup analysis revealed a lower anastomotic leakage rate (OR = 0.66, 95% CI: 0.45 to 0.97, P = 0.04). No significant differences were observed between the two groups in the analysis of operation time (P = 0.42), occurrence rates of protective stoma (P = 0.81), PRM (P = 0.92), and DRM (P = 0.23), time to flatus (P = 0.18), time to liquid diet (P = 0.65), total hospital stay (P = 0.35), 3-year overall survival rate (P = 0.67), and 3-year disease-free survival rate (P = 0.42).

CONCLUSION

Robot-assisted laparoscopic treatment for mid and low rectal cancer yields favorable outcomes, demonstrating both efficacy and safety. In comparison to conventional laparoscopy, patients experience reduced intraoperative bleeding and a lower incidence of complications. Notably, the method achieves comparable short-term and long-term treatment results to those of conventional laparoscopic surgery, thus justifying its consideration for widespread clinical application.

Robotic colorectal surgery: quality assessment of patient information available on the internet using webscraping

The primary goal of this study is to assess current patient information available on the internet concerning robotic colorectal surgery. Acquiring this information will aid in patients understanding of robotic colorectal surgery. Data was acquired through a web-scraping algorithm. The algorithm used two Python packages: Beautiful Soup and Selenium. The long-chain keywords incorporated into Google, Bing and Yahoo search engines were 'Da Vinci Colon-Rectal Surgery', 'Colorectal Robotic Surgery' and 'Robotic Bowel Surgery'. 207 websites resulted, were sorted and evaluated according to the ensuring quality information for patients (EQIP) score. Of the 207 websites visited, 49 belonged to the subgroup of hospital websites (23.6%), 46 to medical centers (22.2%), 45 to practitioners (21.7%), 42 to health care systems (20,2%), 11 to news services (5.3%), 7 to web portals (3.3%), 5 to industry (2.4%), and 2 to patient groups (0.9%). Only 52 of the 207 websites received a high rating. The quality of available information on the internet concerning robotic colorectal surgery is low. The majority of information was inaccurate. Medical facilities involved in robotic colorectal surgery, robotic bowel surgery and related robotic procedures should develop websites with credible information to guide patient decisions.

Robotic-assisted surgery for mid and low rectal cancer: a long but safe learning curve

The number of robotic-assisted procedures for rectal cancer is rising. The risk of this procedure when performed by surgeon with limited robotic experience is unknown and the precise duration of the learning curve debated. We, therefore, aimed to analyze the learning curve and its related safety in a single center before the development of mentoring programs. We prospectively recorded all robotic procedures performed for colorectal cancer between 2015 and 2020 by a single surgeon. Operative times for partial and total proctectomy were analyzed. The learning curve was defined by comparison with the standard duration of the laparoscopic procedure performed in expert centers (published in GRECCAR 5 and GRECCAR 6 trials) and calculated using a cumulative summation for learning curve test (LC-CUSUM). Among the 174 patients operated for colorectal cancer, we analyzed the outcomes of the 89 patients operated by partial and total robotic proctectomy. To reach repeatedly the same surgical duration as laparoscopic procedure for partial or complete proctectomy, the LC-CUSUM identified a learning curve of 57 patients. A severe morbidity in this population, defined by Clavien-Dindo classification ≥ 3, was observed in 15 cases (16.8%) with an anastomotic leak rate of 13.5%. The rate of completeness of mesorectal excision was 90% and the mean number of harvested lymph nodes was 15 (± 9). Using operative time as end-point, the learning curve of rectal cancer robotic surgery identified a cut-off of 57 patients. The technic remained safe with acceptable morbidity and oncological outcomes.

Application of the advance incision in robotic-assisted laparoscopic rectal anterior resection

Background

The incidence of rectal cancer is increasing each year. Robotic surgery is being used more frequently in the surgical treatment of rectal cancer; however, several problems associated with robotic surgery persist, such as docking the robot repeatedly to perform auxiliary incisions and difficulty exposing the operative field of obese patients. Herein we introduce a new technology that effectively improves the operability and convenience of robotic rectal surgery.

Objectives

To simplify the surgical procedure, enhance operability, and improve healing of the surgical incision, we developed an advance incision (AI) technique for robotic-assisted laparoscopic rectal anterior resection, and compared its safety and feasibility with those of intraoperative incision.

Methods

Between January 2016 and October 2021, 102 patients with rectal cancer underwent robotic-assisted laparoscopic rectal anterior resection with an AI or intraoperative incision (iOI) incisions. We compared the perioperative, incisional, and oncologic outcomes between groups.

Results

No significant differences in the operating time, blood loss, time to first passage of flatus, time to first passage of stool, duration of hospitalization, and rate of overall postoperative complications were observed between groups. The mean time to perform auxiliary incisions was shorter in the AI group than in the iOI group (14.14 vs. 19.77 min; p < 0.05). The average incision length was shorter in the AI group than in the iOI group (6.12 vs. 7.29 cm; p < 0.05). Postoperative incision pain (visual analogue scale) was lower in the AI group than in the iOI group (2.5 vs. 2.9 p = 0.048). No significant differences in incision infection, incision hematoma, incision healing time, and long-term incision complications, including incision hernia and intestinal obstruction, were observed between groups. The recurrence (AI group vs. iOI group = 4.0% vs. 5.77%) and metastasis rates (AI group vs. iOI group = 6.0% vs. 5.77%) of cancer were similar between groups.

Conclusion

The advance incision is a safe and effective technique for robotic-assisted laparoscopic rectal anterior resection, which simplifies the surgical procedure, enhances operability, and improves healing of the surgical incision.

Research on the Economics of Cancer-Related Health Care: An Overview of the Review Literature

We reviewed current literature reviews regarding economics of cancer-related health care to identify focus areas and gaps. We searched PubMed for systematic and other reviews with the Medical Subject Headings "neoplasms" and "economics" published between January 1, 2010, and April 1, 2020, identifying 164 reviews. Review characteristics were abstracted and described. The majority (70.7%) of reviews focused on cost-effectiveness or cost-utility analyses. Few reviews addressed other types of cancer health economic studies. More than two-thirds of the reviews examined cancer treatments, followed by screening (15.9%) and survivorship or end-of-life (13.4%). The plurality of reviews (28.7%) cut across cancer site, followed by breast (20.7%), colorectal (11.6%), and gynecologic (8.5%) cancers. Specific topics addressed cancer screening modalities, novel therapies, pain management, or exercise interventions during survivorship. The results indicate that reviews do not regularly cover other phases of care or topics including financial hardship, policy, and measurement and methods.

Operating on the Mesentery in Robotic Colonic Surgery—General Techniques

During colorectal surgery the mesentery is the organ on which the greatest amount of operating time is focused. It has recently gained increasing attention. This technical review focuses on the mesentery during robotic colonic procedures. Specifically, we focus upon how to access, dissect, and divide the mesentery using the robotic platform. We also touch on the management of bleeding and some specific disease etiologies.

Safety with Innovation in Colon and Rectal Robotic Surgery

Robotic colorectal surgery has been touted as a possible way to overcome the limitations of laparoscopic surgery and has shown promise in rectal resections, thus shifting traditional open surgeons to a minimally invasive approach. The safety, efficacy, and learning curve have been established for most colorectal applications. With this and a robust sales and marketing model, utilization of the robot for colorectal surgery continues to grow steadily. However, this disruptive technology still requires standards for training, privileging and credentialing, and safe implementation into clinical practice.

Comprehensive Learning Curve of Robotic Surgery: Discovery From a Multicenter Prospective Trial of Robotic Gastrectomy

OBJECTIVE

To evaluate the complication-based learning curve and identify learning-associated complications of robotic gastrectomy.

SUMMARY BACKGROUND DATA

With the increased popularity of robotic surgery, a sound understanding of the learning curve in the surgical outcome of robotic surgery has taken on great importance. However, a multicenter prospective study analyzing learning-associated morbidity has never been conducted in robotic gastrectomy.

METHODS

Data on 502 robotic gastrectomy cases were prospectively collected from 5 surgeons. Risk-adjusted cumulative sum analysis was applied to visualize the learning curve of robotic gastrectomy on operation time and complications.

RESULTS

Twenty-five cases, on average, were needed to overcome complications and operation time-learning curve sufficiently to gain proficiency in 3 surgeons. An additional 23 cases were needed to cross the transitional phase to progress from proficiency to mastery. The moderate complication rate (CD ≥ grade II) was 20% in phase 1 (cases 1-25), 10% in phase 2 (cases 26-65), 26.1% in phase 3 (cases 66-88), and 6.4% in phase 4 (cases 89-125) (P < 0.001). Among diverse complications, CD ≥ grade II intra-abdominal bleeding (P < 0.001) and abdominal pain (P = 0.01) were identified as major learning-associated morbidities of robotic gastrectomy. Previous experience on laparoscopic surgery and mode of training influenced progression in the learning curve.

CONCLUSIONS

This is the first study suggesting that technical immaturity substantially affects the surgical outcomes of robotic gastrectomy and that robotic gastrectomy is a complex procedure with a significant learning curve that has implications for physician training and credentialing.

Robotic colorectal surgery in Australia: a cohort study examining clinical outcomes and cost

Objective The aim of this study was to compare robotic versus laparoscopic colorectal operations for clinical outcomes, safety and cost. Methods A retrospective cohort study was performed of 213 elective colorectal operations (59 robotic, 154 laparoscopic), matched by surgeon and operation type. Results No differences in age, body mass index, median American Society of Anesthesiologists score or presence of cancer were observed between the laparoscopic or robotic surgery groups. However, patients undergoing robotic colorectal surgery were more frequently male (P = 0.004) with earlier T stage tumours (P = 0.02) if cancer present. Procedures took longer in cases of robotic surgery (302 vs 130 min; P < 0.001), and patients in this group were more frequently admitted to intensive care units (P < 0.001). Overall length of stay was longer (7 vs 5 days; P = 0.03) and consumable cost was A$2728 higher per patient in the robotic surgery group. Conclusion Robotic colorectal surgery appears to be safe compared with current laparoscopic techniques, albeit with longer procedure times and overall length of stay, more frequent intensive care admissions and higher consumables cost. What is known about the topic? Robotic surgery is an emerging alternative to traditional laparoscopic approaches in colorectal surgery. International trials suggest the two techniques are equivalent in safety. What does this paper add? This is an original cohort study examining clinical outcomes in Australian colorectal robotic surgery. The data suggest it may be safe, but this paper demonstrates key issues in the implementation and audit of novel surgical technologies in relatively low-volume centres. What are implications for practitioners? In our study, patients undergoing robotic colorectal surgery at a single centre in Australia had equivalent measured clinical outcomes to those undergoing laparoscopic surgery. However, practitioners may counsel patients that robotic procedures are typically longer and more expensive, with a longer overall hospital admission and a higher likelihood of intensive care admission.

Robotic ileocolic resection with intracorporeal anastomosis for Crohn's disease

The robotic platform can overcome limitations of the laparoscopic approach, particularly in the facilitation of intracorporeal anastomosis creation. We aim to share our institutional experience with robotic ileocolic resection for Crohn's disease (CD) and compare it to a laparoscopic cohort. We identified patients who underwent ileocolic resection for CD with a purely robotic (R) or laparoscopic (L) approach between February 2015 and 2018. Chart review was performed and preoperative, intraoperative, and postoperative data was collected. A total of 47 patients with a mean age of 35.2 years old were identified and 61% were female. Seventy percent [n = 33, (23 females, 69.6%)] of the cases were performed robotically and 30% of the cases [n = 14, (6 females, 42.8%)] were performed laparoscopically. The groups were well matched for age, gender, BMI as well as disease related factors (CD duration; clinical classification and location), perioperative immunosuppression, and surgical history. Time to bowel function was shorter by about 1 day in the robotic group (R: 1.9 ± 0.88 days vs. L: 2.7 ± 0.8 days, p = 0.003). Mean operative time was longer in the robotic group by 51 min and this difference was significant (p = 0.03), however 30.3% of patients underwent ureteral stent placement, which can account for added time in robotic cases. There were less conversions in the robotic group [R: 1(4.3%) vs. L: 1(7%)], but this was not significant. There were no intraoperative complications in either group. Complication (L: 21.4% vs. R: 15.1%, p = 0.605) and reoperation rates (L: 0% vs. R: 3.03%, p = 0.429) were similar. Robotic ileocolic resection for Crohn's disease is as safe and feasible as the laparoscopic approach. This was accomplished with no leaks, major morbidity or mortality and comparable length of stay, with 1 day shorter return of bowel function, and with a lower overall complication rate. The robotic approach offers advantages in Crohn's disease which should be studied further in prospective studies.

NASA-Task Load Index Differentiates Surgical Approach: Opportunities for Improvement in Colon and Rectal Surgery

OBJECTIVE

Surgeon workload, or human "cost" of performing a procedure, is not well understood in light of emerging surgical technologies. This pilot study quantified surgeon workload for colorectal procedures and identified patient, surgeon, and procedural factors impacting workload.

SUMMARY BACKGROUND DATA

Innovative technologies and procedures in surgery have generally been promoted for the advancement of patient care. The resulting surgeon workload is poorly studied with little knowledge of the contributing factors impacting workload.

METHODS

Surgeons completed NASA-Task Load Index (NASA-TLX) questionnaires to self-assess workload following abdominopelvic colon and rectal procedures. Corresponding patient data were retrieved from the medical record. Descriptive statistics, correlations, and ANOVA were performed to compare surgeon and patient factors, procedure type, and surgical approach on workload overall and by subscales.

RESULTS

Seven attending surgeons rated 238 surgeries, of which 218 (92%) had corresponding patient data. Surgeon experience and patient demographics had inconsistent effects on workload. A statistically significant 3-way interaction was identified among disease process, procedure type, and surgical approach on workload (F(9, 146) = 2.17, P = 0.027), but was limited to open procedures for neoplasia and inflammatory bowel disease patients. Proctectomy and colectomy procedures compared across open, laparoscopic, and robotic approaches showed significant differences in overall workload and subscales, where the robotic procedures required significantly less mental demand, physical demand, and effort, than open or laparoscopic (P < 0.05).

CONCLUSIONS

Patient characteristics, disease process, and surgical experience had inconsistent effects on surgeon workload. Major differences in workload were identified for procedure type and surgical approach, where robotic procedures required less mental demand, physical demand, and effort.

Robotic-Assisted versus Conventional Laparoscopic Approach for Rectal Cancer Surgery, First Egyptian Academic Center Experience, RCT

Background

Undoubtedly, robotic systems have largely penetrated the surgical field. For any new operative approach to become an accepted alternative to conventional methods, it must be proved safe and result in comparable outcomes. The purpose of this study is to compare the short-term operative as well as oncologic outcomes of robotic-assisted and laparoscopic rectal cancer resections.

Methods

This is a prospective randomized clinical trial conducted on patients with rectal cancer undergoing either robotic-assisted or laparoscopic surgery from April 2015 till February 2017. Patients' demographics, operative parameters, and short-term clinical and oncological outcomes were analyzed.

Results

Fifty-seven patients underwent permuted block randomization. Of these patients, 28 were assigned to undergo robotic-assisted rectal surgery and 29 to laparoscopic rectal surgery. After exclusion of 12 patients following randomization, 45 patients were included in the analysis. No significant differences exist between both groups in terms of age, gender, BMI, ASA score, clinical stage, and rate of receiving upfront chemoradiation. Estimated blood loss was evidently lower in the robotic than in the laparoscopic group (median: 200 versus 325 ml, p= 0.050). A significantly more distal margin is achieved in the robotic than in the laparoscopic group (median: 2.8 versus 1.8, p< 0.001). Although the circumferential radial margin (CRM) was complete in 18 patients (85.7%) in the robotic group in contrast to 15 patients (62.5%) in the laparoscopic group, it did not differ statistically (p=0.079). The overall postoperative complication rates were similar between the two groups.

Conclusion

To our knowledge, this is the first prospective randomized trial of robotic rectal surgery in the Middle East and Northern Africa region. Our early experience indicates that robotic rectal surgery is a feasible and safe procedure. It is not inferior to standard laparoscopy in terms of oncologic radicality and surgical complications. Organization number is IORG0003381. IRB number is IRB00004025.

Rectal Dissection Simulator for da Vinci Surgery: Details of Simulator Manufacturing With Evidence of Construct, Face, and Content Validity

BACKGROUND

Apprenticeship in training new surgical skills is problematic, because it involves human subjects. To date there are limited inanimate trainers for rectal surgery.

OBJECTIVE

The purpose of this article is to present manufacturing details accompanied by evidence of construct, face, and content validity for a robotic rectal dissection simulation.

DESIGN

Residents versus experts were recruited and tested on performing simulated total mesorectal excision. Time for each dissection was recorded. Effectiveness of retraction to achieve adequate exposure was scored on a dichotomous yes-or-no scale. Number of critical errors was counted. Dissection quality was tested using a visual 7-point Likert scale. The times and scores were then compared to assess construct validity. Two scorer results were used to show interobserver agreement. A 5-point Likert scale questionnaire was administered to each participant inquiring about basic demographics, surgical experience, and opinion of the simulator. Survey data relevant to the determination of face validity (realism and ease of use) and content validity (appropriateness and usefulness) were then analyzed.

SETTINGS

The study was conducted at a single teaching institution.

SUBJECTS

Residents and trained surgeons were included.

INTERVENTION

The study intervention included total mesorectal excision on an inanimate model.

MAIN OUTCOME MEASURES

Metrics confirming or refuting that the model can distinguish between novices and experts were measured.

RESULTS

A total of 19 residents and 9 experts were recruited. The residents versus experts comparison featured average completion times of 31.3 versus 10.3 minutes, percentage achieving adequate exposure of 5.3% versus 88.9%, number of errors of 31.9 versus 3.9, and dissection quality scores of 1.8 versus 5.2. Interobserver correlations of R = 0.977 or better confirmed interobserver agreement. Overall average scores were 4.2 of 5.0 for face validation and 4.5 of 5.0 for content validation.

LIMITATIONS

The use of a da Vinci microblade instead of hook electrocautery was a study limitation.

CONCLUSIONS

The pelvic model showed evidence of construct validity, because all of the measured performance indicators accurately differentiated the 2 groups studied. Furthermore, study participants provided evidence for the simulator's face and content validity. These results justify proceeding to the next stage of validation, which consists of evaluating predictive and concurrent validity. See Video Abstract at http://links.lww.com/DCR/A551.

Robotic simultaneous resection of rectal cancer and liver metastases

Surgical resection is the only potential cure for colorectal cancer with synchronous liver metastases (SLM). Simultaneous resection of colorectal cancer and SLM using robotic‐assistance has been rarely reported. We demonstrate that robotic‐assisted simultaneous resection of colorectal cancer and SLMs is feasible, safe, and has potential to demonstrate good oncologic outcomes.

Robotic rectal surgery: State of the art

Laparoscopic rectal surgery has demonstrated its superiority over the open approach, however it still has some technical limitations that lead to the development of robotic platforms. Nevertheless the literature on this topic is rapidly expanding there is still no consensus about benefits of robotic rectal cancer surgery over the laparoscopic one. For this reason a review of all the literature examining robotic surgery for rectal cancer was performed. Two reviewers independently conducted a search of electronic databases (PubMed and EMBASE) using the key words “rectum”, “rectal”, “cancer”, “laparoscopy”, “robot”. After the initial screen of 266 articles, 43 papers were selected for review. A total of 3013 patients were included in the review. The most commonly performed intervention was low anterior resection (1450 patients, 48.1%), followed by anterior resections (997 patients, 33%), ultra-low anterior resections (393 patients, 13%) and abdominoperineal resections (173 patients, 5.7%). Robotic rectal surgery seems to offer potential advantages especially in low anterior resections with lower conversions rates and better preservation of the autonomic function. Quality of mesorectum and status of and circumferential resection margins are similar to those obtained with conventional laparoscopy even if robotic rectal surgery is undoubtedly associated with longer operative times. This review demonstrated that robotic rectal surgery is both safe and feasible but there is no evidence of its superiority over laparoscopy in terms of postoperative, clinical outcomes and incidence of complications. In conclusion robotic rectal surgery seems to overcome some of technical limitations of conventional laparoscopic surgery especially for tumors requiring low and ultra-low anterior resections but this technical improvement seems not to provide, until now, any significant clinical advantages to the patients.

[Robotics in the operating room : Out of the niche into widespread application]

In the last few years robotic surgery has progressed from being confined to a small niche to a widespread application in routine visceral surgery; however, evidence for superiority of robotic surgery compared to laparoscopy from randomized studies with a sufficient number of patients is still lacking in most fields of visceral surgery. For complex operations that necessitate an extensive reconstruction phase, such as pancreatectomy, gastrectomy and esophagectomy, there is a potential benefit for the permanent and justified use of robotic surgery. Even in operations where delicate nerve preparation and radical surgical resection are simultaneously necessary, such as rectal resection, robotic surgery may provide certain benefits. In the long term there is a great potential for the integration of innovative techniques, such as navigation or other medical imaging procedures into robotic surgery, which can currently only partially be estimated. Care must be taken to avoid premature euphoria; however, due to the assumed great potential there is an urgent need for randomized studies to evaluate the possible benefits of robotic surgical techniques in visceral surgery in order to generate evidence for the welfare of patients.

Robotics in Colorectal Surgery

Over the past few decades, robotic surgery has developed from a futuristic dream to a real, widely used technology. Today, robotic platforms are used for a range of procedures and have added a new facet to the development and implementation of minimally invasive surgeries. The potential advantages are enormous, but the current progress is impeded by high costs and limited technology. However, recent advances in haptic feedback systems and single-port surgical techniques demonstrate a clear role for robotics and are likely to improve surgical outcomes. Although robotic surgeries have become the gold standard for a number of procedures, the research in colorectal surgery is not definitive and more work needs to be done to prove its safety and efficacy to both surgeons and patients.

Robotic surgery and its impact on teamwork in the operating theatre

Effective teamwork in the operating theatre is important for safe patient care. In robotic surgery, the surgeon is physically separated from the operating theatre team, which could potentially have an impact on teamwork. With robotic surgery increasing internationally, this article reviews relevant published literature on teamwork in the operating theatre and reflects on how this might be impacted by robotic surgery. We conclude by describing a research study we are currently undertaking on this topic.

Minimally Invasive Surgery for the Treatment of Colorectal Cancer

BACKGROUND

Reduction in operative trauma along with an improvement in endoscopic access has undoubtedly occupied surgical minds for at least the past 3 decades. It is not at all surprising that minimally invasive colon surgery has come a long way since the first laparoscopic appendectomy by Semm in 1981. It is common knowledge that the recent developments in video and robotic technologies have significantly furthered advancements in laparoscopic and minimally invasive surgery. This has led to the overall acceptance of the treatment of benign colorectal pathology via the endoscopic route. Malignant disease, however, is still primarily treated by conventional approaches.

METHODS AND RESULTS

This review article is based on a literature search pertaining to advances in minimally invasive colorectal surgery for the treatment of malignant pathology, as well as on personal experience in the field over the same period of time. Our search was limited to level I and II clinical papers only, according to the evidence-based medicine guidelines. We attempted to present our unbiased view on the subject relying only on the evidence available.

CONCLUSION

Focusing on advances in colorectal minimally invasive surgery, it has to be stated that there are still a number of unanswered questions regarding the surgical management of malignant diseases with this approach. These questions do not only relate to the area of boundaries set for the use of minimally invasive techniques in this field but also to the exact modality best suited to the treatment of every particular case whilst maintaining state-of-the-art oncological principles.

Effect of BMI on Short-Term Outcomes with Robotic-Assisted Laparoscopic Surgery: a Case-Matched Study

BACKGROUND

Many benefits of minimally invasive surgery are lost in the obese, but robotic-assisted laparoscopic surgery (RALS) may offer advantages in this population. Our goal was to compare outcomes for RALS in obese and non-obese patients.

METHODS

A prospective database was reviewed for colorectal resections using RALS. Patients were stratified into obese (BMI > 30 kg/m(2)) and non-obese cohorts (BMI < 30 kg/m(2)), then case-matched for comparability. The main outcome measures were operative time, conversion rate, length of stay and complication, readmission, and reoperation rates between groups.

RESULTS

Forty-five patients were evaluated in each cohort. The BMI was significantly different (p < 0.01). All other demographics were well matched. There were no significant differences in operative time (p = 0.86), blood loss (p = 0.38), intraoperative complications (p = 0.54), or conversion rates (p = 0.91) across cohorts. Length of stay was comparable between groups (p = 0.45). Postoperatively, the complication (p = 0.87), readmission (p = 1.00), and reoperation rates (p = 0.95) were similar. There were no mortalities. For malignant cases (37.8 %), the lymph node yield (p = 0.48) and positive margins (p = 1.00) were similar and acceptable in both cohorts.

CONCLUSIONS

In our matched RALS series, perioperative and postoperative outcomes were similar between obese and non-obese patients undergoing colorectal surgery. RALS is a feasible option in the surgical setting of the obese patient. Further controlled studies are warranted to explore the full benefits.

Open, Laparoscopic, and Robotic Surgery for Rectal Cancer: Medium-Term Comparative Outcomes from a Multicenter Study

Purpose

Several studies have demonstrated the oncologic equivalence of laparoscopic (LS) and open (OS) rectal cancer surgeries and have shown how challenging LS may become. Robotic surgery (RS) has emerged as a practical alternative, offering interesting advantages in comparison to both LS and OS. The aim of this study is to resolve the clinicopathologic outcome advantages of RS with respect to OS and LS techniques.

Methods

Patients with rectal cancer undergoing OS, RS, or LS were evaluated within the period from April 2009 to August 2011. The evaluations were carried out in 4 Italian hospitals. Perioperative clinicopathologic data, postoperative complications, and 3-year overall and disease-free survival (DFS) rates were analyzed.

Results

A total of 160 patients (94 male, 66 female) were included. A total of 105 patients underwent mini-invasive procedure (40 LS; 65 RS), whereas OS was performed in 55 patients. Anterior resection of rectal cancer was the most performed surgical procedure (139; 87%). Median operation time was significantly longer in the RS group (p<0.01). Regarding complication rates and quality of the surgical specimen evaluation, no statistical difference was found among the 3 groups. The shortest hospital stay (p<0.01) was obtained from the LS and RS groups. The median follow-up was 33 months without any significant difference in overall and DFS rates.

Conclusions

Although RS for rectal cancer requires more time to be performed than LS and OS techniques, the analysis shows comparatively the feasibility and safety of RS in terms of perioperative clinicopathologic and medium-term outcomes.

Total robotic radical rectal resection with da Vinci Xi system: single docking, single phase technique

OBJECTIVE

This study aims to assess the advantages of Da Vinci Xi system in rectal cancer surgery. It also assesses the initial oncological outcomes after rectal resection with this system from a tertiary cancer center in India.

INTRODUCTION

Robotic rectal surgery has distinct advantages over laparoscopy. Total robotic resection is increasing following the evolution of hybrid technology. The latest Da Vinci Xi system (Intuitive Surgical, Sunnyvale, USA) is enabled with newer features to make total robotic resection possible with single docking and single phase.

METHODS AND RESULTS

Thirty-six patients underwent total robotic resection in a single phase and single docking. We used newer port positions in a straight line. Median distance from the anal verge was 4.5 cm. Median robotic docking time and robotic procedure time were 9 and 280 min, respectively. Median blood loss was 100 mL. One patient needed conversion to an open approach due to advanced disease. Circumferential resection margin and longitudinal resection margins were uninvolved in all other patients. Median lymph node yield was 10. Median post-operative stay was 7 days. There were no intra-operative adverse events.

CONCLUSION

The latest Da Vinci Xi system has made total robotic rectal surgery feasible in single docking and single phase. With the new system, four arm total robotic rectal surgery may replace the hybrid technique of laparoscopic and robotic surgery for rectal malignancies. The learning curve for the new system appears to be shorter than anticipated. Early perioperative and oncological outcomes of total robotic rectal surgery with the new system are promising. Copyright © 2016 John Wiley & Sons, Ltd.

Laparoscopic versus robotic-assisted sacrocolpopexy for pelvic organ prolapse: a systematic review

The use of robot-assisted surgery (RAS) has gained popularity in the field of gynaecology, including pelvic floor surgery. To assess the benefits of RAS, we conducted a systematic review of randomized controlled trials comparing laparoscopic and robotic-assisted sacrocolpopexy. The Cochrane Library (1970–January 2015), MEDLINE (1966 to January 2015), and EMBASE (1974 to January 2015) were searched, as well as ClinicalTrials.gov and the International Clinical Trials Registry Platform. We identified two randomized trials (n = 78) comparing laparoscopic with robotic sacrocolpopexy. The Paraiso 2011 study showed that laparoscopic was faster than robotic sacrocolpopexy (199 ± 46 vs. 265 ± 50 min; p < .001), yet in the ACCESS trial, no difference was present (225 ± 62.3 vs. 246.5 ± 51.3 min; p = .110). Costs for using the robot were significantly higher in both studies, however, in the ACCESS trial, only when purchase and maintenance of the robot was included (LSC US$11,573 ± 3191 vs. RASC US$19,616 ± 3135; p < .001). In the Paraiso study, RASC was more expensive even without considering those costs (LSC US$ 14,342 ± 2941 vs. RASC 16,278 ± 3326; p = 0.008). Pain was reportedly higher after RASC, although at different time points after the operation. There were no differences in anatomical outcomes, pelvic floor function, and quality of life. The experience with RASC was tenfold lower than that with LSC in both studies. The heterogeneity between the two studies precluded a meta-analysis. Based on small randomized studies, with surgeons less experienced in RAS than in laparoscopic surgery, robotic surgery significantly increases the cost of a laparoscopic sacrocolpopexy. RASC would be more sustainable if its costs would be lower. Though RASC may have other benefits, such as reduction of the learning curve and increased ergonomics or dexterity, these remain to be demonstrated.

Laparoscopy Versus Robotic Surgery for Colorectal Cancer: A Single-Center Initial Experience

Background Minimally invasive approach has gained interest in the treatment of patients with colorectal cancer. The purpose of this study is to analyze the differences between laparoscopy and robotics for colorectal cancer in terms of oncologic and clinical outcomes in an initial experience of a single center. Materials and Methods Clinico-pathological data of 100 patients surgically treated for colorectal cancer from March 2008 to April 2014 with laparoscopy and robotics were analyzed. The procedures were right colonic, left colonic, and rectal resections. A comparison between the laparoscopic and robotic resections was made and an analysis of the first and the last procedures in the 2 groups was performed. Results Forty-two patients underwent robotic resection and 58 underwent laparoscopic resection. The postoperative mortality was 1%. The number of harvested lymph nodes was higher in robotics. The conversion rate was 7.1% for robotics and 3.4% for laparoscopy. The operative time was lower in laparoscopy for all the procedures. No differences were found between the first and the last procedures in the 2 groups. Conclusions This initial experience has shown that robotic surgery for the treatment of colorectal adenocarcinoma is a feasible and safe procedure in terms of oncologic and clinical outcomes, although an appropriate learning curve is necessary. Further investigation is needed to demonstrate real advantages of robotics over laparoscopy.

Endowrist versus wrist: a case-controlled study comparing robotic versus hand-assisted laparoscopic surgery for rectal cancer

BACKGROUND

Laparoscopic total mesorectal excision (TME) remains a technically challenging procedure. This study aims to compare the surgical outcomes of the robotic-assisted laparoscopic (RAL) versus hand-assisted laparoscopic (HAL) techniques in performing TME for patients with rectal cancers.

METHODS

A retrospective review of all patients who underwent RAL TME for rectal cancers was performed. These cases were matched for age, sex, and stage of malignancy with patients who underwent HAL TME. Data collected included age, sex, American Society of Anesthesiologists scores, comorbid conditions, types of surgical resections and operative times, perioperative complications, length of hospital stays, and histopathologic outcomes were analyzed.

RESULTS

From August 2008 to August 2011, 19 patients, with a median age of 62 (range, 47 to 92) years underwent RAL TME. Eight (42.1%) patients received neoadjuvant chemoradiotherapy. The median docking and operative times were 10 (range, 3 to 34) and 390 (range, 289 to 771) minutes, respectively. There was 1 (5.3%) conversion to open surgery. The grade of mesorectal excision was histopathologically reported as complete in all 19 cases. Positive circumferential margin was reported in 1 (5.3%) patient.Comparing the 2 groups, more patients in the RAL group received neoadjuvant chemoradiotherapy (8 vs. 3; P=0.048). The operative times were longer in the RAL group (390 vs. 225 min; P<0.001). A higher proportion of patients in the HAL group required conversion to open surgery (5 vs. 1; P=0.180) and developed perioperative morbidities (3 vs. 7; P=0.269). The median length of hospitalization was comparable between both groups (RAL: 7 vs. HAL: 6 d; P=0.476).The procedural cost was significantly higher in the RAL group (US$12,460 vs. US$8560; P<0.001), whereas the nonprocedural cost remained comparable between the 2 groups (RAL: US$4470 vs. HAL: US$4500; P=0.729).

CONCLUSIONS

RAL TME is associated with lower conversion and morbidity rates compared with HAL TME. The longer operating times and higher procedural costs are current limitations to its widespread adoption.

Initial experience of robotic versus laparoscopic colectomy for transverse colon cancer: a matched case-control study

Background

Robotic surgery for transverse colon cancer has rarely been described. This study reports our initial experience in robotic resection for transverse colon cancer, by comparing robotic transverse colectomy (RC) to laparoscopic transverse colectomy (LC) in terms of safety, feasibility, short-term outcomes, and the surgeon’s psychological stress and physical pain.

Methods

The study population included the first 22 consecutive patients who underwent RC between March 2013 and December 2014 for histologically confirmed transverse colon adenocarcinoma. These patients were compared with 22 matched patients undergoing LC between December 2010 and February 2013. Patients were matched based on age, gender, body mass index (BMI), American Society of Anesthesiology (ASA) score, American Joint Committee on Cancer (AJCC) tumor stage, and tumor location (ratio 1:1). Mortality, morbidity, operative, and short-term oncologic outcomes were compared between groups. The operating surgeon’s stress and pain were assessed before and after surgery on a 0–100-mm visual analog scale.

Results

The demographic and preoperative characteristics were comparable between RC and LC patients. No group difference was observed for intraoperative complications, blood loss, postoperative pain, time to flatus, time to regular diet, and hospital stay. RC was associated with longer operative time than LC (260 min vs. 225 min; p = 0.014), but the overall operative and robotic time in the RC group decreased over time reflecting the increasing experience in performing this procedure. No conversion to laparotomy was observed in the RC group, while two LC patients were converted due to uncontrolled bleeding and technically difficult middle colic pedicle dissection. Postoperative complications (Dindo-Clavien grade I or II) occurred in 11.3 % of patients with no group difference. Mortality was nil. All resections were R0, with >12 lymph nodes harvested in 90.9 % of RC and 95.5 % of LC patients. The surgeon’s stress was not different between RC and LC, whereas the surgeon’s hand and neck/shoulder pain were significantly lower after RC.

Conclusions

RC for transverse colon cancer appears to be safe and feasible with short-term outcomes comparable to LC.

Robotic colonic resection

Innovative robotic technologies are aiming to help surgeons overcome the limits of conventional laparoscopic surgery. Recent studies have shown that robotic colorectal surgery is safe and provides favorable results in comparison to conventional laparoscopic techniques. Further studies and long-term follow-up are required to assess the outcomes and potential benefits of robotic colon surgery over laparoscopic surgery.

Robotic surgery vs conventional laparoscopy for the treatment of rectal cancer: Review of the literature

Laparoscopic surgery has established itself as a safe and effective alternative to open surgery for the treatment of colorectal cancer. However, laparoscopic resection of rectal cancer, and in particular of the lower rectum, remains challenging in view of the limitations of operating in the confined pelvic space, limited movement of instruments with fixed tips, assistant-dependant two-dimensional view, easy camera fogging, and poor ergonomics. The introduction of robotic surgery and its application in particular to pelvic surgery, has potentially resolved many of these issues. To define the role of robotic surgery in total mesorectal excision for rectal cancer, a review of the current literature was performed using PubMed, Embase, Cochrane Library, and Google databases, identifying clinical trials comparing short-term outcomes of conventional laparoscopic total mesorectal excision with the robotic approach. Robotic surgery for rectal cancer is a safe alternative to conventional laparoscopy. However, randomised trials are needed to clearly establish its role.

A meta-analysis of robotic versus laparoscopic colectomy

BACKGROUND

Robotics, as an innovation of minimally invasive surgical methods, is developing rapidly for colectomy. But there is still no consensus on its comparative merit compared with laparoscopic resections. We conducted this meta-analysis that included randomized controlled trials and nonrandomized controlled trials of robotic colectomy (RC) versus laparoscopic colectomy (LC) to evaluate whether the safety and efficacy of RC are equivalent to those of LC.

METHODS

A search of five databases (PubMed, Embase, Cochrane Library, Ovid, and Web of Science), gray literature, hand searches, reference, and forward citation were performed for studies that compared clinical or oncologic outcomes of LC with RC. Clinical outcomes evaluated were conversion rates, operation times, estimated blood loss, length of hospital stay, and complications. Oncologic outcome evaluated was the number of lymph nodes collected.

RESULTS

A total of 14 studies were identified that included 125,989 patients in total, 4934 in the robotic cohort and 121,055 in the laparoscopic cohort. Meta-analysis suggested that there was a significantly longer hospital stay in the laparoscopic group (mean difference [MD] -0.65; 95% confidence interval [CI] -1.02 to -0.27; P = 0.0008). Robotic surgery was associated with a significantly lower complication rate (odds ratio 0.78; 95% CI 0.72-0.85; P ＜ 0.00001) and a significantly shorter time to recovery of bowel function (MD -0.58; 95% CI -0.96 to -0.20; P = 0.003). There were statistically significant differences in estimated blood loss (MD -19.24; 95% CI -29.38 to -9.09; P = 0.0002) and intraoperative conversion to open (odds ratio 0.56; 95% CI 0.44-0.72; P < 0.00001), but not clinical relevant. There were no significant differences in the number of lymph nodes extracted between the two groups. However, operating time (MD 49.25; 95% CI 36.78-61.72; P < 0.00001) was longer for RC than for LC.

CONCLUSIONS

RC can be performed safely and effectively with the number of lymph nodes extracted similar to LC. In addition, it can provide potential advantages of a shorter hospital stay, a shorter time to recovery of bowel function, and lower occurrence of postoperative complications. These findings seem to support the use of robotics for the minimally invasive surgical management of colectomy. However, RC had longer operating time. Future studies involving RC should focus on minimizing duration of operation.

The evolution of cancer surgery and future perspectives

Surgery is the oldest oncological discipline, dating back thousands of years. Prior to the advent of anaesthesia and antisepsis 150 years ago, only the brave, desperate, or ill-advised patient underwent surgery because cure rates were low, and morbidity and mortality high. However, since then, cancer surgery has flourished, driven by relentless technical innovation and research. Historically, the mantra of the cancer surgeon was that increasingly radical surgery would enhance cure rates. The past 50 years have seen a paradigm shift, with the realization that multimodal therapy, technological advances, and minimally invasive techniques can reduce the need for, or the detrimental effects of, radical surgery. Preservation of form, function, and quality of life, without compromising survival, is the new mantra. Today's surgeons, no longer the uneducated technicians of history, are highly trained medical professionals and together with oncologists, radiologists, scientists, anaesthetists and nurses, have made cancer surgeries routine, safe, and highly effective. This article will review the major advances that have underpinned this evolution.

European Association of Endoscopic Surgeons (EAES) consensus statement on the use of robotics in general surgery

Following an extensive literature search and a consensus conference with subject matter experts the following conclusions can be drawn: 1. Robotic surgery is still at its infancy, and there is a great potential in sophisticated electromechanical systems to perform complex surgical tasks when these systems evolve. 2. To date, in the vast majority of clinical settings, there is little or no advantage in using robotic systems in general surgery in terms of clinical outcome. Dedicated parameters should be addressed, and high quality research should focus on quality of care instead of routine parameters, where a clear advantage is not to be expected. 3. Preliminary data demonstrates that robotic system have a clinical benefit in performing complex procedures in confined spaces, especially in those that are located in unfavorable anatomical locations. 4. There is a severe lack of high quality data on robotic surgery, and there is a great need for rigorously controlled, unbiased clinical trials. These trials should be urged to address the cost-effectiveness issues as well. 5. Specific areas of research should include complex hepatobiliary surgery, surgery for gastric and esophageal cancer, revisional surgery in bariatric and upper GI surgery, surgery for large adrenal masses, and rectal surgery. All these fields show some potential for a true benefit of using current robotic systems. 6. Robotic surgery requires a specific set of skills, and needs to be trained using a dedicated, structured training program that addresses the specific knowledge, safety issues and skills essential to perform this type of surgery safely and with good outcomes. It is the responsibility of the corresponding professional organizations, not the industry, to define the training and credentialing of robotic basic skills and specific procedures. 7. Due to the special economic environment in which robotic surgery is currently employed special care should be taken in the decision making process when deciding on the purchase, use and training of robotic systems in general surgery. 8. Professional organizations in the sub-specialties of general surgery should review these statements and issue detailed, specialty-specific guidelines on the use of specific robotic surgery procedures in addition to outlining the advanced robotic surgery training required to safely perform such procedures.

A Comparative Study of Single-Port Laparoscopic Surgery Versus Robotic-Assisted Laparoscopic Surgery for Rectal Cancer

INTRODUCTION

Conventional laparoscopic surgery is the treatment of choice for many abdominal procedures. To further reduce surgical trauma, new minimal invasive procedures such as single-port laparoscopic surgery (SPLS) and robotic assisted laparoscopic surgery (RALS) have emerged. The aim of this study was to compare the early results of SPLS versus RALS in the treatment of rectal cancer.

METHODS

We performed a retrospective analysis of prospectively collected data on patients who had undergone SPLS (n = 36) or RALS (n = 56) in the period between 2010 and 2012. Operative and short-term oncological outcomes were compared.

RESULTS

The RALS group had fewer patients with low rectal cancer and more patients with mid-rectal tumors (P = .017) and also a higher rate of intraoperative complications (14.3% vs 0%, P = .021). The rate of postoperative complications did not differ (P = .62). There were no differences in circumferential resection margins, distal resection margins, or completeness of the mesorectal fascia. The RALS group had a larger number of median harvested lymph nodes (27 vs 13, P = .001). The SPLS group had fewer late complications (P = .025). There were no locoregional recurrences in either of the groups. There was no difference in median follow-up time between groups (P = .58).

CONCLUSION

Both SPLS and RALS may have a role in rectal surgery. The short-term oncological outcomes were similar, although RALS harvested more lymph nodes than the SPLS procedure. However, SPLS seems to be safer with regard to intraoperative and late postoperative complications.

Robotic surgery for rectal cancer: Current immediate clinical and oncological outcomes

Laparoscopic rectal surgery continues to be a challenging operation associated to a steep learning curve. Robotic surgical systems have dramatically changed minimally invasive surgery. Three-dimensional, magnified and stable view, articulated instruments, and reduction of physiologic tremors leading to superior dexterity and ergonomics. Therefore, robotic platforms could potentially address limitations of laparoscopic rectal surgery. It was aimed at reviewing current literature on short-term clinical and oncological (pathological) outcomes after robotic rectal cancer surgery in comparison with laparoscopic surgery. A systematic review was performed for the period 2002 to 2014. A total of 1776 patients with rectal cancer underwent minimally invasive robotic treatment in 32 studies. After robotic and laparoscopic approach to oncologic rectal surgery, respectively, mean operating time varied from 192-385 min, and from 158-297 min; mean estimated blood loss was between 33 and 283 mL, and between 127 and 300 mL; mean length of stay varied from 4-10 d; and from 6-15 d. Conversion after robotic rectal surgery varied from 0% to 9.4%, and from 0 to 22% after laparoscopy. There was no difference between robotic (0%-41.3%) and laparoscopic (5.5%-29.3%) surgery regarding morbidity and anastomotic complications (respectively, 0%-13.5%, and 0%-11.1%). Regarding immediate oncologic outcomes, respectively among robotic and laparoscopic cases, positive circumferential margins varied from 0% to 7.5%, and from 0% to 8.8%; the mean number of retrieved lymph nodes was between 10 and 20, and between 11 and 21; and the mean distal resection margin was from 0.8 to 4.7 cm, and from 1.9 to 4.5 cm. Robotic rectal cancer surgery is being undertaken by experienced surgeons. However, the quality of the assembled evidence does not support definite conclusions about most studies variables. Robotic rectal cancer surgery is associated to increased costs and operating time. It also seems to be associated to reduced conversion rates. Other short-term outcomes are comparable to conventional laparoscopy techniques, if not better. Ultimately, pathological data evaluation suggests that oncologic safety may be preserved after robotic total mesorectal excision. However, further studies are required to evaluate oncologic safety and functional results.

Quality of total mesorectal excision and depth of circumferential resection margin in rectal cancer: a matched comparison of the first 20 robotic cases

AIM

There are concerns about the impact of robotic proctectomy on the quality of total mesorectal excision (TME) and the impact of laparoscopic proctectomy on the depth of the circumferential resection margin (CRM). The aim of this study was to compare the first 20 consecutive robotic proctectomies performed in our unit with matched series of open and laparoscopic proctocolectomy performed by the same surgeon.

METHOD

Data on the first 20 consecutive patients treated with robotic proctectomy for rectal cancer, <12 cm from the anal verge, by the senior author (RB) were extracted from a prospectively maintained database. Groups of patients treated with open and laparoscopic proctectomy, matched for age, gender and body mass index (BMI) with those undergoing robotic proctectomy, were selected. The quality of the TME was judged as complete, nearly complete or incomplete. CRM clearance was reported in millimetres. Physiological parameters and operative severity were assessed.

RESULTS

Age (P = 0.619), Physiological and Operative Severity Score for the Enumeration of Morbidity and Mortality (POSSUM) score (P = 0.657), operative severity score (P = 0.977), predicted mortality (P = 0.758), comorbidities (P = 0.427), previous abdominal surgery (P = 0.941), tumour height (P = 0.912), location (P = 0.876), stage (P = 0.984), neoadjuvant chemoradiation (P = 0.625), operating time (P = 0.066), blood loss (P = 0.356), ileostomy (P = 0.934), conversion (P = 0.362), resection type (P = 1.000), flatus (P = 0.437), diet (P = 0.439), length of hospital stay (P = 0.978), complications (P = 0.671), reoperations (P = 0.804), reinterventions (P = 0.612), readmissions (P = 0.349), tumour size (P = 0.542; P = 0.532; P = 0.238), distal margin (P = 0.790), nodes harvested (P = 0.338) and pathology stage (P = 0.623) did not differ among the three groups. The quality of TME showed a trend to be lower following robotic surgery, although this was not statistically significant [open 95/5/15 (complete/nearly complete/incompete) vs laparoscopic 95/5/15 vs robotic 80/5/15; P = 0.235], but the degree of clearance at the CRM was significantly greater in robotic patients [open 8 (0-30) mm vs laparoscopic 4 (0-30) mm vs robotic 10.5 (1-30) mm; P = 0.02].

CONCLUSION

The study reports no statistically significant difference between open and laparoscopic techniques in the quality of TME during the learning curve of robotic proctectomy for rectal cancer and demonstrates an improved CRM.

Simultaneous development of laparoscopy and robotics provides acceptable perioperative outcomes and shows robotics to have a faster learning curve and to be overall faster in rectal cancer surgery: analysis of novice MIS surgeon learning curves

BACKGROUND

Laparoscopy offers some evidence of benefit compared to open rectal surgery. Robotic rectal surgery is evolving into an accepted approach. The objective was to analyze and compare laparoscopic and robotic rectal surgery learning curves with respect to operative times and perioperative outcomes for a novice minimally invasive colorectal surgeon.

METHODS

One hundred and six laparoscopic and 92 robotic LAR rectal surgery cases were analyzed. All surgeries were performed by a surgeon who was primarily trained in open rectal surgery. Patient characteristics and perioperative outcomes were analyzed. Operative time and CUSUM plots were used for evaluating the learning curve for laparoscopic versus robotic LAR.

RESULTS

Laparoscopic versus robotic LAR outcomes feature initial group operative times of 308 (291-325) min versus 397 (373-420) min and last group times of 220 (212-229) min versus 204 (196-211) min-reversed in favor of robotics; major complications of 4.7 versus 6.5 % (NS), resection margin involvement of 2.8 versus 4.4 % (NS), conversion rate of 3.8 versus 1.1 (NS), lymph node harvest of 16.3 versus 17.2 (NS), and estimated blood loss of 231 versus 201 cc (NS). Due to faster learning curves for extracorporeal phase and total mesorectal excision phase, the robotic surgery was observed to be faster than laparoscopic surgery after the initial 41 cases. CUSUM plots demonstrate acceptable perioperative surgical outcomes from the beginning of the study.

CONCLUSIONS

Initial robotic operative times improved with practice rapidly and eventually became faster than those for laparoscopy. Developing both laparoscopic and robotic skills simultaneously can provide acceptable perioperative outcomes in rectal surgery. It might be suggested that in the current milieu of clashing interests between evolving technology and economic constrains, there might be advantages in embracing both approaches.

Use of robotics in colon and rectal surgery

The pace of innovation in the field of surgery continues to accelerate. As new technologies are developed in combination with industry and clinicians, specialized patient care improves. In the field of colon and rectal surgery, robotic systems offer clinicians many alternative ways to care for patients. From having the ability to round remotely to improved visualization and dissection in the operating room, robotic assistance can greatly benefit clinical outcomes. Although the field of robotics in surgery is still in its infancy, many groups are actively investigating technologies that will assist clinicians in caring for their patients. As these technologies evolve, surgeons will continue to find new and innovative ways to utilize the systems for improved patient care and comfort.

Robotic surgery for rectal cancer: A systematic review of current practice

AIM: To give a comprehensive review of current literature on robotic rectal cancer surgery.

METHODS: A systematic review of current literature via PubMed and Embase search engines was performed to identify relevant articles from january 2007 to november 2013. The keywords used were: “robotic surgery”, “surgical robotics”, “laparoscopic computer-assisted surgery”, “colectomy” and “rectal resection”.

RESULTS: After the initial screen of 380 articles, 20 papers were selected for review. A total of 1062 patients (male 64.0%) with a mean age of 61.1 years and body mass index of 24.9 kg/m² were included in the review. Out of 1062 robotic-assisted operations, 831 (78.2%) anterior and low anterior resections, 132 (12.4%) intersphincteric resection with coloanal anastomosis, 98 (9.3%) abdominoperineal resections and 1 (0.1%) Hartmann’s operation were included in the review. Robotic rectal surgery was associated with longer operative time but with comparable oncological results and anastomotic leak rate when compared with laparoscopic rectal surgery.

CONCLUSION: Robotic colorectal surgery has continued to evolve to its current state with promising results; feasible surgical option with low conversion rate and comparable short-term oncological results. The challenges faced with robotic surgery are for more high quality studies to justify its cost.

Evolution of laparoscopy in colorectal surgery: An evidence-based review

Open surgery for colorectal disease has progressed significantly over the past century from humble beginnings to form the mainstay of treatment for colorectal cancer and a number of benign conditions. Following the introduction of laparoscopic abdominal surgery, the next stage in the evolution of the specialty began in the 1990s with the first laparoscopic colonic resection. Following some early concerns regarding its safety and oncological efficacy during the latter part of that decade, laparoscopic colorectal surgery rapidly came into mainstream use in the early part of the current century with evidence supporting its use being made available from large scale randomised controlled trials. This article provides an evidence-based summary of this evolutionary process as it relates to both benign and malignant colorectal disease, as well as discussion of the next phase of new technologies such as robotic surgery.

Integration of robotic surgery into routine practice and impacts on communication, collaboration, and decision making: a realist process evaluation protocol

BACKGROUND

Robotic surgery offers many potential benefits for patients. While an increasing number of healthcare providers are purchasing surgical robots, there are reports that the technology is failing to be introduced into routine practice. Additionally, in robotic surgery, the surgeon is physically separated from the patient and the rest of the team, with the potential to negatively impact teamwork in the operating theatre. The aim of this study is to ascertain: how and under what circumstances robotic surgery is effectively introduced into routine practice; and how and under what circumstances robotic surgery impacts teamwork, communication and decision making, and subsequent patient outcomes.

METHODS AND DESIGN

We will undertake a process evaluation alongside a randomised controlled trial comparing laparoscopic and robotic surgery for the curative treatment of rectal cancer. Realist evaluation provides an overall framework for the study. The study will be in three phases. In Phase I, grey literature will be reviewed to identify stakeholders' theories concerning how robotic surgery becomes embedded into surgical practice and its impacts. These theories will be refined and added to through interviews conducted across English hospitals that are using robotic surgery for rectal cancer resection with staff at different levels of the organisation, along with a review of documentation associated with the introduction of robotic surgery. In Phase II, a multi-site case study will be conducted across four English hospitals to test and refine the candidate theories. Data will be collected using multiple methods: the structured observation tool OTAS (Observational Teamwork Assessment for Surgery); video recordings of operations; ethnographic observation; and interviews. In Phase III, interviews will be conducted at the four case sites with staff representing a range of surgical disciplines, to assess the extent to which the results of Phase II are generalisable and to refine the resulting theories to reflect the experience of a broader range of surgical disciplines. The study will provide (i) guidance to healthcare organisations on factors likely to facilitate successful implementation and integration of robotic surgery, and (ii) guidance on how to ensure effective communication and teamwork when undertaking robotic surgery.