Robot-assisted versus conventional laparoscopic surgery for colorectal disease, focusing on rectal cancer: a meta-analysis

Case report: A clinical report of photodynamic neoadjuvant combined with fluorescent laparoscopic localization robotic surgery for the treatment of patients with advanced colorectal cancer combined with obstruction

The incidence of colorectal cancer is relatively high in our country, with the majority of patients being diagnosed at an advanced stage. For individuals with advanced-stage colorectal cancer, conversion or neoadjuvant therapy is frequently necessitated to facilitate surgical intervention and achieve a curative effect. And about 10% to 30% of colon cancer patients are complicated with intestinal obstruction. Surgical intervention remains the primary treatment for managing intestinal obstructions, albeit with a considerable risk of perioperative mortality and an increased likelihood of postoperative complications. PDT, as a neoadjuvant treatment for colon cancer, can shrink the local tumor and relieve obstruction, and is effective in colon cancer combined with obstruction. Robotic surgery has the advantages of high stability and low trauma, and compared with laparoscopic colon cancer surgery, robotic surgery can achieve better results. Fluorescent laparoscopic clarifies the location and size of the tumor lesion, allowing for greater precision when removing colon cancer lesions in robotic surgery. Therefore, in the treatment of colon cancer, PDT can offer an opportunity for surgery after relieving obstruction in patients with obstructive colon cancer. Additionally, when combined with fluorescent laparoscopic robotic colon cancer surgery, it provides a novel treatment approach for patients with obstructive colon cancer. Preoperative photodynamic neoadjuvant therapy combined with robotic colon cancer surgery has not yet been reported. Here, we report a case of colon cancer with obstruction, preoperative TNM stage was T4N1, and the lesion had caused intestinal stenosis. After four sessions of PDT, the patient's intestinal lumen was unobstructed and the lesion had regressed. After evaluation, fluorescent laparoscopic localization and visualization of lymph nodes combined with robotic colon cancer resection were performed. Postoperative pathology showed that the patient's tumor regression grade was grade 1. The patient's tumor was completely resected with good resection effect. No tumor invasion was found on both sides of the resection margin, and the patient did not relapse after surgery.

Low ligation of the inferior mesenteric artery in robotic mid-low rectal cancer surgery: a comparative study from a single-center

Laparoscopic total mesorectal excision is the main surgical approach for treating rectal cancer, but there is still no clear consensus on the issue of low ligation of the inferior mesenteric artery during the procedure. Robotic surgery has been shown to have certain advantages over laparoscopic surgery in multiple studies, but further research is needed to better understand the outcomes of robotic surgery in the context of low ligation procedures. In this study, we included 1590 patients with mid-low rectal cancer. Among them, 942 patients underwent low ligation surgery (LL), divided into 138 in the robotic group and 804 in the laparoscopic group. The high ligation surgery (HL) group consisted of 648 patients. The results of LL vs HL showed that the LL group had faster bowel movement recovery (P = 0.003), lower anastomotic leak rate (P = 0.032), and lower International Prostate Symptom Score (IPSS) at 6 months postoperatively (P < 0.001). The results of Rob-LL vs Lap-LL showed that the Rob-LL group had longer operative time (P < 0.001), less blood loss (P = 0.001), more lymph nodes retrieved (P = 0.045), and lower Wexner score at 2 weeks postoperatively (P = 0.029). The concept of low ligation of the inferior mesenteric artery is a promising surgical approach that can accelerate the patient's functional recovery. When combined with robotic technology, it may offer more benefits than laparoscopic techniques.

Comparison of short-term outcomes of laparoscopic surgery, robot-assisted laparoscopic surgery, and open surgery for lateral lymph-node dissection for rectal cancer: a network meta-analysis

This study attempted to compare short-term outcomes of laparoscopic surgery (LS), robot-assisted laparoscopic surgery (RS), and open surgery (OS) for lateral lymph-node dissection (LLND) in treatment of rectal cancer through network meta-analysis. Embase, Web of Science, PubMed, and The Cochrane Library databases were searched to collect cohort studies on outcomes of LS, RS, and OS for LLND for rectal cancer. Newcastle-Ottawa Scale (NOS) was utilized to evaluate the quality of cohort studies. Primary outcomes should at least include one of the following clinical outcome measures: operative time, blood loss, total lymph-node harvest, positive resection margin rate, postoperative complications, and postoperative hospital stay. A network meta-analysis was conducted using STATA software. Fourteen cohort studies including 8612 patients were eligible for inclusion. The network meta-analysis results showed that, in terms of intraoperative outcomes, the RS group had the longest operative time, while the OS group had the shortest; the LS and RS groups had significantly less blood loss than the OS group. In terms of histological outcomes, there were no significant differences in the total number of lymph nodes harvested and the positive margin rate among the LS, RS, and OS groups (P > 0.05). Regarding postoperative outcomes, the OS group had the highest probability of postoperative complications and the longest hospital stay, followed by the LS group, with the RS group being the lowest. RS was the best method in blood loss, postoperative complication rate, and postoperative hospital stay, followed by LS. OS had the shortest operative time and the highest blood loss.

Robotic colorectal surgery and future directions

As the adoption of robotic-assisted procedures expands across various surgical specialties, colorectal surgery stands out as a prominent beneficiary. This rise in usage can be traced back to the increased accessibility of robotic platforms and a growing institutional shift towards cutting-edge surgical methods. When compared with traditional laparoscopic methods, robotic techniques offer distinct advantages. Their true potential shines in surgeries involving complex anatomical regions, where the robot's enhanced dexterity and range of motion prove invaluable. The three-dimensional, magnified view provided by robotic systems further boosts surgical precision and clarity. These advantages render robotic assistance especially suitable for colorectal surgeries, notably in intricate areas such as the rectum and endoluminal spaces. As the medical world emphasizes minimally invasive surgical methods, there's a pressing need to evolve and optimize robotic techniques in colorectal surgery. This article traces the evolution of robotic interventions in colorectal surgeries, highlighting both its historical milestones and anticipated future trends. We'll also explore emerging robotic tools and systems set to reshape the colorectal surgical arena.

The current application and evidence for robotic approach in abdominal surgery: A narrative literature review

The current application of robotic surgery is evolving at a high pace in the current years. The technical advantages enable several abdominal surgical procedures to be performed minimally invasive instead of open surgery. Furthermore, procedures previously performed successfully using standard laparoscopy are now performed with a robotic approach, with conflicting results. The present narrative review reports the current literature on the robotic surgical procedures typically performed in a typical Scandinavian surgical department: colorectal, hernia, hepato-biliary, and esophagogastric surgery.

Streamlining robotic-assisted abdominoperineal resection

BACKGROUND

Robot-assisted surgery has proven to be a safe and feasible approach for the management of rectal cancer, including abdominoperineal resection (APR). However, it often incurs longer operative times and higher costs. This study aimed to overcome these limitations by adopting a synchronous approach utilizing an optimized team composition.

METHODS

Data on patients who underwent robot-assisted APR at our facility between June 2022 and June 2023 were analyzed. The key points of the optimized approach included the following: At the start of the surgery, the surgeon performed an anococcygeal ligament resection from the perineal side while the bedside assistants set up the ports. Then, through console manipulation, the presacral fascia, elevated by previously placed gauze, was easily and safely incised, providing access to the perineal region.

RESULTS

A total of nine patients were included in this study. The median operation time was 231 min, and the intraoperative blood loss was 170 ml. The operation time was reduced to 167.5 min, and the blood loss was 80.5 ml in cases without a trainee. Surgical site infections, classified as Clavien-Dindo grade II complications, were observed in two cases, but no obvious urinary or erectile dysfunction was observed.

CONCLUSION

The study results indicate that the challenges associated with APR can be efficiently addressed without requiring additional personnel by streamlining team composition and the synchronous approach. This optimization strategy minimizes the need for a larger surgical team, while maximizing the utilization of surgical time and resources.

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.

Robotic-assisted colectomy in children: a comparative study with laparoscopic surgery

The aim of this study was to compare outcomes of laparoscopic and robotic-assisted colectomy in children. All children who underwent a colectomy with a laparoscopic (LapC) or robotic-assisted (RobC) approach in our institution (January 2010-March 2023) were included. Demographics, surgical data, and post-operative outcomes within 30 days were collected. Additional cost related to the robotic approach was calculated. Comparisons were performed using Fisher tests for categorical variables and Mann-Whitney tests for continuous variables. A total of 55 colectomies were performed: 31 LapC and 24 RobC (median age: 14.9 years). Main indications included: inflammatory bowel disease (n = 36, 65%), familial adenomatous polyposis (n = 6, 11%), sigmoid volvulus (n = 5, 9%), chronic intestinal pseudo-obstruction (n = 3, 5%). LapC included 22 right, 4 left, and 5 total colectomies. RobC included 15 right, 4 left, and 5 total colectomies. Robotic-assisted surgery was associated with increased operative time (3 h vs 2.5 h, p = 0.02), with a median increase in operative time of 36 min. There were no conversions. Post-operative complications occurred in 35% of LapC and 38% of RobC (p = 0.99). Complications requiring treatment under general anesthesia (Clavien-Dindo 3) occurred in similar rates (23% in LapC vs 13% in RobC, p = 0.49). Length of hospitalization was 10 days in LapC and 8.5 days in RobC (p = 0.39). The robotic approach was associated with a median additional cost of 2156€ per surgery. Robotic-assisted colectomy is as safe and feasible as laparoscopic colectomy in children, with similar complication rates but increased operative times and cost.

Robotic versus laparoscopic left colectomy with complete mesocolic excision for left-sided colon cancer: a multicentre study with propensity score matching analysis

PURPOSE

Robotic surgery for right-sided colon and rectal cancer has rapidly increased; however, there is limited evidence in the literature of advantages of robotic left colectomy (RLC) for left-sided colon cancer. The purpose of this study was to compare the outcomes of RLC versus laparoscopic left colectomy (LLC) with complete mesocolic excision (CME) for left-sided colon cancer.

METHODS

Patients who had RLC or LLC with CME for left-sided colon cancer at five hospitals in China between January 2014 and April 2022 were included. A one-to-one propensity score matched analysis was performed to decrease confounding. The primary outcome was postoperative complications occurring within 30 days of surgery. Secondary outcomes were disease-free survival, overall survival and the number of harvested lymph nodes.

RESULTS

A total of 292 patients (187 male; median age 61.0 [20.0-85.0] years) were eligible for this study, and propensity score matching yielded 102 patients in each group. The clinicopathological characteristics were well-matched between groups. The two groups did not differ in estimated blood loss, conversion to open rate, time to first flatus, reoperation rate, or postoperative length of hospital stay (p > 0.05). RLC was associated with a longer operation time (192.9 ± 53.2 vs. 168.9 ± 52.8 min, p = 0.001). The incidence of postoperative complications did not differ between the RLC and LLC groups (18.6% vs. 17.6%, p = 0.856). The total number of lymph nodes harvested in the RLC group was higher than that in the LLC group (15.7 ± 8.3 vs. 12.1 ± 5.9, p < 0.001). There were no significant differences in 3-year and 5-year overall survival or 3-year and 5-year disease-free survival.

CONCLUSION

Compared to laparoscopic surgery, RLC with CME for left-sided colon cancer was found to be associated with higher numbers of lymph nodes harvested and similar postoperative complications and long-term survival outcomes.

Robotic versus laparoscopic left colectomy with complete mesocolic excision for left-sided colon cancer: a multicentre study with propensity score matching analysis

BACKGROUND

Robotic surgery for right-sided colon and rectal cancer has rapidly increased; however, there is limited evidence in the literature of advantages of robotic left colectomy (RLC) for left-sided colon cancer. The purpose of this study was to compare the outcomes of RLC versus laparoscopic left colectomy (LLC) with complete mesocolic excision (CME) for left-sided colon cancer.

METHODS

Patients who had RLC or LLC with CME for left-sided colon cancer at 5 hospitals in China between January 2014 and April 2022 were included. A one-to-one propensity score matched analysis was performed to decrease confounding. The primary outcome was postoperative complications occurring within 30 days of surgery. Secondary outcomes were disease-free survival, overall survival and the number of harvested lymph nodes.

RESULTS

A total of 292 patients (187 males; median age 61.0 [20.0-85.0] years) were eligible for this study, and propensity score matching yielded 102 patients in each group. The clinical-pathological characteristics were well-matched between groups. The two groups did not differ in estimated blood loss, conversion to open rate, time to first flatus, reoperation rate, or postoperative length of hospital stay (p > 0.05). RLC was associated with a longer operation time (192.9 ± 53.2 vs. 168.9 ± 52.8 minutes, p=0.001). The incidence of postoperative complications did not differ between the RLC and LLC groups (18.6% vs. 17.6%, p = 0.856). The total number of lymph nodes harvested in the RLC group was higher than that in the LLC group (15.7 ± 8.3 vs. 12.1 ± 5.9, p< 0.001). There were no significant differences in 3-year and 5-year overall survival or 3-year and 5-year disease-free survival.

CONCLUSIONS

Compared to laparoscopic surgery, RLC with CME for left-sided colon cancer was found to be associated with higher numbers of lymph nodes harvested and similar postoperative complications and long-term survival outcomes.

Can CT Pelvimetry Be Used to Predict Circumferential Resection Margin Positivity in Laparoscopic Resection of Middle and Lower Rectum Cancer?

Background Previous studies have shown that pelvimetry can be valuable in predicting surgical difficulties in rectal cancer operations. However, its usability in predicting circumferential resection margin (CRM) involvement remains debatable. This study investigated the factors affecting CRM status and the importance of computed tomography (CT) pelvimetry in predicting CRM involvement in laparoscopic resection of middle and lower rectal cancer. Methodology In this study, we retrospectively investigated the data of 111 patients who underwent a laparoscopic operation for middle and lower rectum cancer at Ankara University Faculty of Medicine, Department of Surgical Oncology between January 2014 and January 2020. The predictive value of CT pelvimetry and other variables on the CRM status was analyzed. Results The following four pelvic parameters differed significantly between the genders: transverse diameter of the pelvic inlet (p = 0.024), anteroposterior diameter of the pelvic outlet (p = 0.003), transverse diameter of the pelvic outlet (p < 0.001), and pelvic depth (p < 0.001). The effect of pelvic anatomic parameters on CRM involvement was not found to be significant. It was found that tumor height from the anal verge (p = 0.004), tumor size (p < 0.001), and gender (p = 0.033) were significant risk factors for CRM involvement. Survival was poor in patients with male gender (p = 0.032), perineural invasion (p < 0.001), and grade 3 tumor. Conclusions In this study, no benefit was found in predicting CRM positivity from CT pelvimetry in the laparoscopic resection of middle and lower rectal cancer. Besides, tumor height from the anal verge, tumor size, and gender were important factors for CRM positivity. Although our study sheds light on this issue, prospective randomized studies with larger sample sizes are needed.

Robotic versus laparoscopic low anterior resection following neoadjuvant chemoradiation therapy for stage II-III locally advanced rectal cancer: a single-centre cohort study

Neoadjuvant chemo-radiotherapy (nCRT) of locally advanced rectal cancer is associated with challenging surgical treatment and increased postoperative morbidity. Robotic technology overcomes laparoscopy limitations by enlarged 3D view, improved anatomical transection accuracy, and physiologic tremor reduction. Patients with UICC stage II-III rectal cancer, consecutively referred to our institution between March 2015 and June 2020 (n = 102) were treated with robotic (Rob-G, n = 38) or laparoscopic (Lap-G, n = 64) low anterior resection (LAR) for total meso-rectal excision (TME) following highly standardized and successful nCRT treatment. Feasibility, conversion rates, stoma creation, morbidity and clinical/pathological outcome were comparatively analysed. Sex, age, BMI, ASA scores, cTN stages and tumour distance from dentate line were comparable in the two groups. Robotic resection was always feasible without conversion to open surgery, which was necessary in 11/64 (17%) Lap-G operations (p = 0.006). Primary or secondary stomata were created in 17/38 (45%) Rob-G and 52/64 (81%) Lap-G patients (p < 0.001). Major morbidity occurred in 7/38 (18.4%) Rob-G and 6/64 (9.3%) Lap-G patients (p = 0.225). Although median operation time was longer in Rob-G compared with Lap-G (376; IQR: 330-417 min vs. 300; IQR: 270-358 min; p < 0.001), the difference was not significant in patients (Rob-G, n = 6; Lap-G, n = 10) with ≥30 BMI (p = 0.106). Number of resected lymph nodes, ypTN staging and circumferential resection margins (CRM) were comparable. Resection was complete in 87% of Rob-G and 89% of Lap-G patients (p = 0.750). Robotic LAR is not inferior to laparoscopic LAR following nCRT. Larger, randomized studies are needed to confirm lower conversion in robotic, compared to laparoscopic resection.

Short- and Long-Term Outcome of Laparoscopic- versus Robotic-Assisted Right Colectomy: A Systematic Review and Meta-Analysis

Background: There is a rapidly growing literature available on right hemicolectomy comparing the short- and long-term outcomes of robotic right colectomy (RRC) to that of laparoscopic right colectomy (LRC). The aim of this meta-analysis is to revise current comparative literature systematically. Methods: A systematic review of comparative studies published between 2000 to 2021 in PubMed, Scopus and Embase was performed. The primary endpoint was postoperative morbidity, mortality and long-term oncological results. Secondary endpoints consist of blood loss, conversion rates, complications, time to first flatus, hospital stay and incisional hernia rate. Results: 25 of 322 studies were considered for data extraction. A total of 16,099 individual patients who underwent RRC (n = 1842) or LRC (n = 14,257) between 2002 and 2020 were identified. Operative time was significantly shorter in the LRC group (LRC 165.31 min ± 43.08 vs. RRC 207.38 min ± 189.13, MD: −42.01 (95% CI: −51.06−32.96), p < 0.001). Blood loss was significantly lower in the RRC group (LRC 63.57 ± 35.21 vs. RRC 53.62 ± 34.02, MD: 10.03 (95% CI: 1.61−18.45), p = 0.02) as well as conversion rate (LRC 1155/11,629 vs. RRC 94/1534, OR: 1.65 (1.28−2.13), p < 0.001) and hospital stay (LRC 6.15 ± 31.77 vs. RRC 5.31 ± 1.65, MD: 0.84 (95% CI: 0.29−1.38), p = 0.003). Oncological long-term results did not differ between both groups. Conclusion: The advantages of robotic colorectal procedures were clearly demonstrated. RRC can be regarded as safe and feasible. Most of the included studies were retrospective with a limited level of evidence. Further randomized trials would be suitable.

National differences in implementation of minimally invasive surgery for colorectal cancer and the influence on short-term outcomes

Background

The timing and degree of implementation of minimally invasive surgery (MIS) for colorectal cancer vary among countries. Insights in national differences regarding implementation of new surgical techniques and the effect on postoperative outcomes are important for quality assurance, can show potential areas for country-specific improvement, and might be illustrative and supportive for similar implementation programs in other countries. Therefore, this study aimed to evaluate differences in patient selection, applied techniques, and results of minimal invasive surgery for colorectal cancer between the Netherlands and Sweden.

Methods

Patients who underwent elective minimally invasive surgery for T1-3 colon or rectal cancer (2012–2018) registered in the Dutch ColoRectal Audit or Swedish ColoRectal Cancer Registry were included. Time trends in the application of MIS were determined. Outcomes were compared for time periods with a similar level of MIS implementation (Netherlands 2012–2013 versus Sweden 2017–2018). Multilevel analyses were performed to identify factors associated with adverse short-term outcomes.

Results

A total of 46,095 Dutch and 8,819 Swedish patients undergoing MIS for colorectal cancer were included. In Sweden, MIS implementation was approximately 5 years later than in the Netherlands, with more robotic surgery and lower volumes per hospital. Although conversion rates were higher in Sweden, oncological and surgical outcomes were comparable. MIS in the Netherlands for the years 2012–2013 resulted in a higher reoperation rate for colon cancer and a higher readmission rate but lower non-surgical complication rates for rectal cancer if compared with MIS in Sweden during 2017–2018.

Conclusion

This study showed that the implementation of MIS for colorectal cancer occurred later in Sweden than the Netherlands, with comparable outcomes despite lower volumes. Our study demonstrates that new surgical techniques can be implemented at a national level in a controlled and safe way, with thorough quality assurance.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08974-1.

Robotic versus laparoscopic colorectal surgery in elderly patients in terms of recovery time: a monocentric experience

Colorectal cancer has a great socio-sanitary relevance. It represents the third cancer by incidence and mortality. Ageing plays a major role in the development of colorectal cancer and this tumour, in patients aged 65 and older, has gradually increased over the past decade. The robotic technique is considered the evolution of conventional laparoscopy. Few studies evaluate the effects of robotic surgery in elderly patient, and even fewer are those that compare it with laparoscopic surgery in this population. The aim of this study was to evaluate the perioperative outcomes of robotic colorectal surgery compared to laparoscopic colorectal surgery in patients older than 65 years. We conducted a retrospective study enrolling 83 elderly patients (age > 65) undergoing robotic and laparoscopic colectomy (32 and 51, respectively) between January 2019 and January 2021. For statistical analysis, p values were calculated using t test and chi-square test. p < 0.05 is the criterion for statistical significance. Statistical analyses were performed with the Number Cruncher Statistical System (NCSS) 2020 data analysis version 20.0.1 (Utah, USA). The operation time was higher in robotic left (p = 0.003, mean time 249.6 vs 211.7 min) and right (p = 0.004, mean time 238.5 vs 183.5 min) hemicolectomy and similar for procedures on rectosigmoid and rectum when compared to laparoscopic technique. In terms of length of hospital stay and recovery of bowel function, these values were significantly lower for robotic group in left hemicolectomy (p = 0.004), rectum (p = 0.003) and rectosigmoid (p = 0.003), while right hemicolectomy was similar in two groups (p = 0.26). There was no statistically significant difference between the groups regarding conversion rate, postoperative complications, length of specimen, number of lymph nodes encountered and oncological results. Colorectal robotic surgery in elderly patients appears as a feasible and safe surgical approach when compared to the laparoscopic one, showing a shorter recovery and a reduction of length of stay with similar oncological outcomes even if with an increase of operating times.

Single-Port Robot-Assisted Abdominoperineal Resection: A Case Review of the Fi rst Four Experiences

Recently, abdominoperineal resection (APR) using a robot has been demonstrated in other studies. However, there has been no report on APR for rectal cancer using the single-port robot (SPR) platform. In response to this research gap, we described the clinical experience of APR using a SPR. From April 2019 to March 2020, APR using a SPR platform was performed in a total of 4 patients. Three patients had a transumbilical approach, and 1 patient had a transstoma site approach. The average operation time was 307 minutes, and the patient docking time to the SPR platform was 133.5 minutes. There were no complications during the operation, and no laparoscopy or open conversion. No reoperation occurred within 30 days. Mild postoperative complications occurred in 2 patients. We found that APR has safety and feasibility in surgery using an SPR platform. There was no intraoperative event and severe postoperative complications.

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.

Postoperative complications observed with robotic versus laparoscopic surgery for the treatment of rectal cancer: An updated meta-analysis of recently published studies

BACKGROUND

This is an updated meta-analysis comparing the postoperative complications observed with robotic versus laparoscopic surgery (LS) for the treatment of rectal cancer.

METHODS

Cochrane central, MEDLNE (Medical Literature Analysis and Retrieval System Online), EMBASE (Excerpta Medica dataBASE), Google Scholar, Web of Science and http://www.ClinicalTrials.gov were searched for studies (published after the year 2015), comparing robotic versus LS for the treatment of rectal cancer. The postoperative outcomes were considered as the endpoints in this analysis. RevMan 5.4 was used to carry out the statistical analysis. Risk ratio (RR) with 95% confidence intervals (CI) were used to represent the results following data analysis.

RESULTS

A total number of 22,744 participants were included in this study whereby 9178 participants were assigned to the robotic surgery and 13,566 participants were assigned to the LS group. The time period of patients' enrollment varied from years 2007 to 2017. Our results showed that overall complications (RR: 0.91, 95% CI: 0.71-1.17; P = .45), wound complications (RR: 0.81, 95% CI: 0.64-1.04; P = .09), anastomotic leak (RR: 1.12, 95% CI: 0.88-1.42; P = .37), anastomotic bleeding (RR: 0.88, 95% CI: 0.29-2.64; P = .82), stoma-related complications (RR: 0.88, 95% CI: 0.24-3.21; P = .85), intra-abdominal abscess (RR: 0.53. 95% CI: 0.22-1.31; P = .17), urinary tract infection (RR: 0.94, 95% CI: 0.53-1.66; P = .83), enterocolitis (RR: 1.35, 95% CI: 0.38-4.71; P = .64), reoperation (RR: 0.85, 95% CI: 0.46-1.54; P = .58), and mortality (RR: 0.75, 95% CI: 0.34-1.62; P = .46) were not significantly different between robotic-assisted versus LS for rectal cancer. Postoperative ileus (RR: 1.21, 95% CI: 0.81-1.81; P = .34), readmission (RR: 1.17, 95% CI: 0.75-1.83; P = .48), and urinary retention (RR: 0.51, 95% CI: 0.21-1.23; P = .14) were also similarly manifested.

CONCLUSIONS

In this updated meta-analysis, both robotic and laparoscopic surgeries were equally effective for the treatment of rectal cancer. Similar postoperative complications were observed. However, our analysis was restricted only to postoperative outcomes, parameters such as duration of surgery were not taken into consideration.

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.

Implementation of an enhanced recovery after surgery program with robotic surgery in high-risk patients obtains optimal results after colorectal resections

Enhanced recovery after surgery programs reduce postoperative complications and length of stay after laparoscopic colorectal surgery, but are still under evaluation after robotic colorectal surgery. To evaluate potential benefits in terms of length of stay and complications of an Enhanced recovery after surgery program in colorectal surgery. A subanalysis was performed to assess what combination of surgical approach and perioperative care had better outcomes. Prospective observational cohort study. 300 consecutive colorectal surgery patients: 150 were prospectively included in the enhanced recovery after Surgery program group and 150 retrospectively in the traditional care group, and subdivided according to the type of surgery, in Hospital Marques de Valdecilla, between 2013 and 2016. Postoperative complications decreased significantly (p = 0.002) from 46 to 28% (traditional care vs program group). The length of stay was decreased by 2 days (p < 0.001). Multivariate analysis indicated similar effect sizes after adjusting for age, gender, Charlson score, and type of surgery. Type of surgery was an independent predictive factor for postoperative complications and length of stay. Compared to open surgery, postoperative complications decreased by 50% (p < 0.001) after robotic surgery and by 40% (p = 0.01) after laparoscopic surgery, while the median length of stay decreased by three days (p < 0.001) after minimally invasive surgery. Enhanced recovery after surgery program and minimally invasive surgery were associated with decreased morbidity and length of stay after colorectal surgery compared to open surgery and traditional care. An enhanced recovery after surgery program with robotic surgery in high-risk patients might be beneficial.

Perioperative Outcomes and Trends in the Use of Robotic Colectomy for Medicare Beneficiaries From 2010 Through 2016

Importance

The use of robotic surgery for common operations like colectomy is increasing rapidly in the United States, but evidence for its effectiveness is limited and may not reflect real-world practice.

Objective

To evaluate outcomes of and trends in the use of robotic, laparoscopic, and open colectomy across diverse practice settings.

Design, Setting, and Participants

This population-based study of Medicare beneficiaries undergoing elective colectomy was conducted between January 2010 and December 2016. We used an instrumental variable analysis to account for both measured and unmeasured differences in patient characteristics between robotic, open, and laparoscopic colectomy procedures. Data were analyzed from January 21, 2019, to March 1, 2019.

Exposures

Receipt of robotic colectomy.

Main Outcomes and Measures

Incidence of postoperative medical and surgical complications and length of stay.

Results

A total of 191 292 procedures (23 022 robotic procedures [12.0%], 87 639 open procedures [45.8%], and 80 631 laparoscopic colectomy procedures [42.0%]) were included. Robotic colectomy was associated with a lower adjusted rate of overall complications than open colectomy (17.6% [95% CI, 16.9%-18.2%] vs 18.6% [95% CI, 18.4%-18.7%]; relative risk [RR], 0.94 [95% CI, 0.91-0.98]). This difference was driven by lower rates of medical complications (15.5% [95% CI, 14.8%-16.2%] vs 16.9% [95% CI, 16.7%-17.1%]; RR, 0.92 [95% CI, 0.87-0.96]) because surgical complications were higher with the robotic approach (3.0% [95% CI, 2.8%-3.2%] vs 2.4% [95% CI, 2.3%-2.5%]; RR, 1.18 [95% CI, 1.04-1.35]). There were no differences in complications between robotic and laparoscopic colectomy (11.1% [95% CI, 10.5%-11.6%] vs 11.0% [95% CI, 10.8%-11.2%]; RR, 1.00 [95% CI, 0.95-1.05]). There was an overall shift toward greater proportional use of robotic colectomy from 0.7% (457 of 65 332 patients) in 2010 to 10.9% (8274 of 75 909 patients) in 2016. In hospitals with the highest adoption of robotic colectomy between 2010 and 2016, increasing use of robotic colectomy (0.8% [100 of 12 522 patients] to 32.8% [5416 of 16 511 patients]) was associated with a greater replacement of laparoscopic operations (43.8% [5485 of 12 522 patients] to 25.2% [4161 of 16 511 patients]) than open operations (55.4% [6937 of 12 522 patients] to 41.9% [6918 of 16 511 patients]).

Conclusions and Relevance

While robotic colectomy was associated with minimal safety benefit over open colectomy and had comparable outcomes with laparoscopic colectomy, population-based trends suggest that it replaced a greater proportion of laparoscopic rather than open colectomy, especially in hospitals with the highest adoption of robotics.

Fellowship training in robotic colorectal surgery within the current hospital setting: an achievable goal?

BACKGROUND

Although currently limited, the requirement for colorectal trainees to attain skills in robotic surgery is likely to increase due to further utilization of robotic platforms globally. The aim of the study is to describe the training programme utilized and assess outcomes of fellowship training in robotic colorectal surgery.

METHODS

A structured robotic training programme was generated across a tertiary hospital setting. Review of four prospectively maintained fellow operative logbooks was performed to assess caseload and skill acquisition. Operative and patient-related outcomes were compared with consultant trainer performed cases. Data were analysed using R with a P < 0.05 considered significant.

RESULTS

The structured robotic training scheme is a two-tiered system over a 12-month period. The trainer-directed pathway comprised of a robotic console safety course followed by cart-side assisting, a wet lab animal course, dual-console accreditation training course and onsite proctoring, prior to becoming an independent console surgeon. Over 2 years, 265 robotic (n = 143 primary/component surgeon) cases were undertaken with fellows A, B, C and D involved in 63, 77, 75 and 50 robotic colorectal cases, respectively. Individual learning curves revealed independent procedure competency at cases 11, 14, 15 and 12, respectively, for robotic anterior resection. There was no significant difference observed in operative time (P = 0.39), blood loss (P = 0.41), lymph node harvest (P = 0.35), conversion rates (2% versus 4%), anastomotic leaks (1% versus 3%) and R0 resection rates (100% versus 98% colonic, 96% versus 96% rectal, P = 0.48) between surgical fellows and consultant trainers. Clavien-Dindo(III-IV) complications were similar (10% versus 6%,P = 0.25) with no mortalities encountered.

CONCLUSION

It is feasible and safe to train fellows in robotic colorectal surgery without compromise of operative- and patient-related outcomes.

Intraureteral indocyanine green augments ureteral identification and avoidance during complex robotic-assisted colorectal surgery

AIM

Up to 10% of patients who undergo nonurological abdominopelvic operations suffer a ureteral injury. While preoperative ureteral stenting to facilitate identification of the ureter is common, it does not reduce the incidence of intraoperative ureteral injury and is not without risk. As we continue to broaden the application of minimally invasive surgical techniques, a new form of ureteral identification and avoidance that does not rely on tactile feedback is needed. We report our initial experience with intraureteral indocyanine green (ICG) for ureteral identification and avoidance during complex robotic-assisted colorectal surgery.

METHOD

Patients undergoing adjunctive ureteral identification during robotic-assisted colorectal surgery were prospectively identified. Each patient underwent intraureteral ICG administration using rigid cystoscopy (22 Fr). A 5-Fr open-ended ureteral catheter was inserted up to 20 cm and used to inject 5 ml of 2.5 mg/ml ICG as the catheter was withdrawn to the ureteral orifice. Intraureteral ICG was then detected using near-infrared laser fluorescence technology (Firefly®).

RESULTS

Successful ICG-enhanced ureteral identification and avoidance was performed in 15 of 16 (94%) patients undergoing robotic-assisted colorectal surgery. The median ICG instillation time was 11.5 min (range 4-21 min) and the median operative time with ICG visualization was 489 min (8 h 9 min) [range 268-738 min (4 h 28 min-12 h 18 min)]. No patient experienced intraoperative ureteral injury and there were no adverse sequelae or complications associated with intraureteral ICG administration.

CONCLUSION

Intraureteral ICG is a safe and effective method of intraoperative ureteral identification and avoidance during complex robotic-assisted colorectal surgery. Precise and prolonged ureteral visualization was achieved, allowing for long operative times compatible with complex robotic-assisted operations.

Robotic-assisted cholecystectomy is superior to laparoscopic cholecystectomy in the initial training for surgical novices in an ex vivo porcine model: a randomized crossover study

Background

Robotic-assisted surgery (RAS) potentially reduces workload and shortens the surgical learning curve compared to conventional laparoscopy (CL). The present study aimed to compare robotic-assisted cholecystectomy (RAC) to laparoscopic cholecystectomy (LC) in the initial learning phase for novices.

Methods

In a randomized crossover study, medical students (n = 40) in their clinical years performed both LC and RAC on a cadaveric porcine model. After standardized instructions and basic skill training, group 1 started with RAC and then performed LC, while group 2 started with LC and then performed RAC. The primary endpoint was surgical performance measured with Objective Structured Assessment of Technical Skills (OSATS) score, secondary endpoints included operating time, complications (liver damage, gallbladder perforations, vessel damage), force applied to tissue, and subjective workload assessment.

Results

Surgical performance was better for RAC than for LC for total OSATS (RAC = 77.4 ± 7.9 vs. LC = 73.8 ± 9.4; p = 0.025, global OSATS (RAC = 27.2 ± 1.0 vs. LC = 26.5 ± 1.6; p = 0.012, and task specific OSATS score (RAC = 50.5 ± 7.5 vs. LC = 47.1 ± 8.5; p = 0.037). There were less complications with RAC than with LC (10 (25.6%) vs. 26 (65.0%), p = 0.006) but no difference in operating times (RAC = 77.0 ± 15.3 vs. LC = 75.5 ± 15.3 min; p = 0.517). Force applied to tissue was similar. Students found RAC less physical demanding and less frustrating than LC.

Conclusions

Novices performed their first cholecystectomies with better performance and less complications with RAS than with CL, while operating time showed no differences. Students perceived less subjective workload for RAS than for CL. Unlike our expectations, the lack of haptic feedback on the robotic system did not lead to higher force application during RAC than LC and did not increase tissue damage. These results show potential advantages for RAS over CL for surgical novices while performing their first RAC and LC using an ex vivo cadaveric porcine model.

Registration number

researchregistry6029

Graphic abstract

Robotic Surgery for Rectal Cancer: Hype or Hope? (Indian Experience)

The primary goal to achieve cure in oncology is to reduce recurrence, maximize disease-free survival, maintain function, and optimize quality of life. Surgery remains the mainstay treatment modality in rectal cancer. The current trend is to perform least invasive method of doing complex surgeries while not compromising in the oncological of functional outcomes of patients. Total mesorectal excision (TME) for rectal cancer surgery entails removal of the rectum with its fascia as an intact unit while preserving surrounding vital structures. The procedure is technically challenging because of the narrow and deep pelvic cavity housing the rectum encased by fatty lymph vascular tissue within the perirectal fascia, distally the anal sphincter complex, and an intimate surrounded by vital structures like ureter, vessels, and nerves. Robotic technology enables overcoming these difficulties caused by complex pelvic anatomy. This system can facilitate better preservation of the pelvic autonomic nerve and thereby achieve favorable postoperative sexual and voiding functions after rectal cancer surgery. The nerve-preserving TME technique includes identification and preservation of the superior hypogastric plexus nerve, bilateral hypogastric nerves, pelvic plexus, and neurovascular bundles.

Short-term outcomes of pelvic floor peritoneum closure in endoscopic low anterior resection of rectal cancer: A propensity score matching analysis

BACKGROUND

The efficacy of pelvic floor peritoneum closure (PC) during endoscopic low anterior resection (E-LAR) of rectal cancer remains unclear. This study aimed to clarify whether pelvic floor PC affected short-term outcomes.

METHODS

The study group comprised patients with the pathologically confirmed diagnosis of rectal cancer who underwent E-LAR with pelvic floor PC or with no PC (NPC) between January 2013 and December 2018 in Southwest Hospital. After propensity score matching (PSM), 584 patients (292 who underwent PC and 292 who underwent NPC) were evaluated. Postoperative indicators, including the rates of complications, anastomotic leakage (AL), reoperation, and inflammation, were observed in the two groups.

RESULTS

No significant difference was observed in the rates of postoperative complications between the PC and NPC groups. The rates of AL were similar (11.3% vs. 9.2%, p = .414). However, the reoperation rate of patients in the PC group was significantly lower than that of patients in the NPC group after AL (36.4% vs. 11.1%, p = .025). The hospital costs were higher in the NPC leakage subgroup (p = .001). Additionally, the serum C-reactive protein levels were lower in the PC group on postoperative days (PODs) 1, 3, and 5, whereas procalcitonin levels on POD 1 and 3 were lower in the PC group but did not differ significantly on POD 5.

CONCLUSION

Pelvic peritonization did not affect the rate of complications, especially AL; however, it effectively reduced the reoperation and inflammation rates and reduced hospitalization costs. Other short-term outcomes were similar, which warrant the increased use of pelvic peritonization in endoscopic surgery.

Impact of laparoscopic surgical experience on the learning curve of robotic rectal cancer surgery

BACKGROUND

Robotic surgery has advantages in terms of the ergonomic design and expectations of shortening the learning curve, which may reduce the number of patients with adverse outcomes during a surgeon's learning period. We investigated the differences in the learning curves of robotic surgery and clinical outcomes for rectal cancer among surgeons with differences in their experiences of laparoscopic rectal cancer surgery.

METHODS

Patients who underwent robotic surgery for colorectal cancer were reviewed retrospectively. Patients were divided into five groups by surgeons, and their clinical outcomes were analyzed. The learning curve of each surgeon with different volumes of laparoscopic experience was analyzed using the cumulative sum technique (CUSUM) for operation times, surgical failure (open conversion or anastomosis-related complications), and local failure (positive resection margins or local recurrence within 1 year).

RESULTS

A total of 662 patients who underwent robotic low anterior resection (LAR) for rectal cancer were included in the analysis. Number of laparoscopic LAR cases performed by surgeon A, B, C, D, and E prior to their first case of robotic surgery were 403, 40, 15, 5, and 0 cases, respectively. Based on CUSUM for operation time, surgeon A, B, C, D, and E's learning curve periods were 110, 39, 114, 55, and 23 cases, respectively. There were no significant differences in the surgical and oncological outcomes after robotic LAR among the surgeons.

CONCLUSIONS

This study demonstrated the limited impact of laparoscopic surgical experience on the learning curve of robotic rectal cancer surgery, which was greater than previously reported curves.

Transoral Robotic Surgical Proficiency Via Real-Time Tactile Collision Awareness System

OBJECTIVES

In 2009, the Food and Drug Administration approved the use of the surgical robotic system for removal of benign and malignant conditions of the upper aerodigestive tract. This novel application of robotic-assisted surgery, termed transoral robotic surgery (TORS), places robotic instruments and camera system through the mouth to reach recessed areas of the pharynx and larynx. Over the successive decade, there was a rapid adoption of TORS with a surgical growth rate that continues to increase. Despite the rapid clinical acceptance, the field of TORS has not yet seen substantive changes or advances in the technical shortcomings, the lack of which has restricted objective TORS-specific surgical skills assessment as well as subsequent skills improvement efforts. One of the primary technical challenges of TORS is operating in a confined space, where the robotic system is maneuvered within the restrictive boundaries of the mouth and throat. Due to these confined boundaries of the pharynx, instruments can frequently collide with anatomic structures such as teeth and bone, producing anatomic collisions. Therefore, we hypothesized that anatomic collisions negatively impact TORS surgical performance. Secondarily, we hypothesized that avoidance of unwanted anatomic collisions could improve TORS surgical proficiency.

METHODS

Design and fidelity testing for a custom TORS training platform with an integrated anatomic collision-sensing system providing real-time tactile feedback is described. Following successful platform assembly and testing, validation study using the platform was carried through prospective surgical training with trial randomization. Twenty otolaryngology-head and neck surgery residents, each trainee performing three discrete mock surgical trials (n = 60), performed the initial system validation. Ten of the 20 residents were randomized to perform the surgical trials utilizing the real-time feedback system. The remaining 10 residents were randomized to perform the surgical trials without the feedback system, although the system still could record collision data. Surgical proficiency was measured by Global Evaluative Assessment of Robotic Skills (GEARS) score, time to completion, and tumor resection scores (categorical scale ranging 0-3, describing the adequacy of resection).

RESULTS

Major anatomic collisions (greater than 5N of force) negatively affected GEARS robotic skills. A mixed model analysis demonstrated that for every additional occurrence of a major collision, GEARS robotic skills assessment score would decrease by 0.29 points (P = .04). Real-time collision awareness created significantly fewer major (> 5 N) anatomic collisions with the tactile feedback system active (n = 30, mean collisions = 2.9 ± 4.2) as compared with trials without tactile feedback (n = 30, mean collisions = 12.53 ± 23.23) (P < .001). The second assessment measure of time to completion was unaffected by the presence of collisions or by the use of tactile feedback system. The third proficiency assessment was measured with tumor resection grading. Tumor resection scores was significantly (P = .02) improved with collision awareness system activated than trials without collision awareness.

CONCLUSION

In order to test our primary hypothesis, a novel TORS training platform was successfully developed that provides collision force measurements including frequency, severity, and duration of anatomic collisions. Additionally, the platform was modulated to provide real-time tactile feedback of the occurrence of out-of-field collisions. Utilizing this custom platform, our hypothesis that anatomic collisions during TORS diminishes surgical performance was supported. Additionally, our secondary hypothesis that subsequent reduction of anatomic collisions improves TORS proficiency was supported by the surgical trial. Dedicated investigation to characterize the effect size and clinical impact is required in order to translate this finding into training curriculums and into clinical utilization.

LEVEL OF EVIDENCE

II (Randomized trial) Laryngoscope, 130:S1-S17, 2020.

Laparoscopic Versus Robotic Proctectomy Outcomes: An ACS-NSQIP Analysis

BACKGROUND

The robotic platform is increasingly used in colorectal surgery. Recent upgrades in the robotic platform and introduction of proctectomy-specific reports from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) warrant updated evaluation of minimally invasive proctectomy outcomes. The aim of this study was to compare outcomes in robotic versus laparoscopic proctectomy using ACS-NSQIP data.

MATERIALS AND METHODS

The ACS-NSQIP data set was used to identify adult patients undergoing elective robotic and laparoscopic proctectomy in 2016 and 2017. Demographics, preoperative and intraoperative data, and postoperative outcomes were collected. Propensity-weighted analysis was used to estimate the effect of robotic versus laparoscopic surgery on outcomes.

RESULTS

Of 3845 patients meeting inclusion criteria, 2681 (70%) underwent a laparoscopic approach and 1164 (30%) underwent a robotic approach. Patients undergoing a robotic procedure were more likely to be older, have higher American Society of Anesthesiologists scores, low rectal tumors, and have undergone chemotherapy or radiation before surgery. After propensity adjustment, a robotic approach was associated with a decrease in conversion to open operation (estimated mean difference, -6.7%; P < 0.01), length of stay (-0.6 d; P = 0.01), occurrence of postoperative ileus (-3.7%; P = 0.01), and an increase in operative time (20.3 min; P < 0.01).

CONCLUSIONS

Using data from a national cohort, we found that compared with laparoscopy, robotic proctectomy is associated with decreased conversion to open operation, longer operation time, decreased length of stay, and decreased postoperative ileus. Our study identified several advantages to a robotic approach; however, further work is needed to assess cost-effectiveness in conjunction with clinical outcomes.

Trends of robotic-assisted surgery for thyroid, colorectal, stomach and hepatopancreaticobiliary cancer: 10 year Korea trend investigation

BACKGROUND

The current position of robotic surgery in the field of minimally invasive surgery remains ambiguous. We evaluated long-term trends of robotic general surgery and the future direction of its development.

METHODS

Data on robotic cancer surgeries between 2005 and 2014 were retrospectively collected by volunteer institutions in the Republic of Korea. Spearman's correlation and logistic regression analyses were used to compare robotic and laparoscopic surgery trends in general surgery.

RESULTS

The odds that robotic surgery was performed instead of laparoscopic surgery significantly decreased in the fields of colorectal, stomach, and hepato-biliary-pancreatic surgery (odds ratio [OR]: 0.95, 95% confidence interval [CI]: 0.93-0.97; OR: 0.90, 95% CI: 0.88-0.92; and OR: 0.71, 95% CI: 0.65-0.78, respectively), except for thyroid surgery (OR: 1.28, 95% CI: 1.25-1.30). Of the total numbers of each procedure, proportions of robotic intersphincteric resections, abdominoperineal resections, and pylorus-preserving surgery performed significantly increased (r = 0.98, P < .001; r = 0.78, P = .01; and r = 0.86, P = .007, respectively).

CONCLUSIONS

The use of robotic surgery failed to preponderate that of laparoscopic surgery, except for thyroid surgery. Robotic surgery is increasingly preferred for limited fields or complex surgeries, but the use of robotics in simple surgeries has decreased.

Long-term oncological outcomes in robotic versus laparoscopic approach for rectal cancer: A systematic review and meta-analysis

BACKGROUND

Short-term outcomes of robotic mesorectal excision for rectal cancer resection seem comparable to those of conventional laparoscopic mesorectal excision. However, the long-term oncological outcomes of robot mesorectal excision require further investigation.

MATERIALS AND METHODS

The PubMed, EMBASE, Medline, and Cochrane Library databases were searched from the date of database inception to March 31, 2019 for all available trials; the results of robotic and laparoscopic mesorectal excision for rectal cancer surgery were compared. Survival parameters, including overall survival (OS) and disease-free survival (DFS), were independently extracted by two investigators. Hazard ratios (HRs) were calculated using random- or fixed-effects models. The presence of heterogeneity was assessed using Q test, and the extent of heterogeneity was quantified by I² index. The meta-analysis was performed using Review Manager software, version 5.3.

RESULTS

A total of seven studies including 2593 patients (1362 treated by robotic mesorectal excision and 1231 by laparoscopic mesorectal excision) were included. Pooled analyses showed no significant difference in OS (HR = 0.94, 95% confidence interval [CI]: 0.63 to 1.39, P = 0.75) or DFS (HR = 0.93, 95% CI: 0.79 to 1.10, P = 0.85) between the robotic and laparoscopic mesorectal excision for treatment of rectal cancer.

CONCLUSION

Regarding long-term survival, robotic mesorectal excision for rectal cancer is comparable to laparoscopic mesorectal excision. More prospective, multicenter randomized trials with longer follow-up periods are needed to determine the long-term outcomes of patients undergoing robotic mesorectal excision.

Development of a Transoral Robotic Surgery Training Platform

Transoral robotic surgery (TORS) presents unique challenges due to difficulty manipulating surgical instruments within the tight confines of the oral cavity. Collisions between the end effectors and anatomical structures can be visualized through the endoscope; however, instrument shaft collisions are outside of the field-of-view. Acquiring the requisite skill set to minimize these collisions is challenging due to the lack of an appropriate training platform. In this paper, we present a TORS training platform with an integrated collision sensing system and real-time haptic feedback. Preliminary testing involved the recruitment of 10 Otolaryngology residents assigned to `feedback' (N=5) and `no feedback' (N=5) groups. Each trainee performed three mock surgical procedures involving the resection of a tumor from the base of the tongue. Superior surgical performance was observed in the feedback group suggesting that haptic feedback will enhance the acquisition of surgical skills.

Robotic simultaneous resection for colorectal liver metastasis: feasibility for all types of liver resection

BACKGROUND

A laparoscopic approach is increasingly being utilized in simultaneous colorectal and liver resection (SCLR) for colorectal cancer with liver metastasis. However, this approach is technically challenging and hence has not been widely adopted. Robotic surgical systems could potentially overcome this problem. We aim to describe the feasibility and outcomes of robotic SCLR for colorectal carcinoma with liver metastasis.

METHODS

The medical records of 12 patients who underwent robotic SCLR for colorectal cancer with liver metastasis between January 2008 and September 2018 were reviewed retrospectively.

RESULTS

The mean age was 59 years (range, 37-77 years). The liver resections were comprised of two right hepatectomies, one left hepatectomy, one left lateral sectionectomy, one segmentectomy of S3 and wedge resection (segment 7), one caudate lobectomy, one associated liver partition and portal vein ligation for staged hepatectomy, and five wedge resections involving segments 4, 5, 6, 7, or 8. The colorectal procedures involved seven low-anterior resections, two anterior resections, two right hemicolectomies, and one left hemicolectomy. The mean operative time was 449 min (range, 135-682 min) with a mean estimated blood loss of 274.3 mL (range, 40-780 mL). The mean length of hospital stay was 12 days (range, 5-28 days). No patients required conversion to laparotomy. Liver resection-related complications were two liver abscesses (Clavien-Dindo classification, one grade II and one grade III) and one case of ascites (grade I), whereas colorectal resection-related complications included one anastomosis leak (grade III) and one superficial wound infection (grade II). There were no deaths reported within 30 days of the procedure. With a mean follow-up duration of 31.5 ± 26.1 months, the overall survival and disease-free survival values were 75.2 and 47.1 months, respectively.

CONCLUSION

Robotic SCLR for colorectal neoplasm with liver metastasis can be performed safely even in cases requiring major liver resections, especially in a specialized center with a well-trained team.

Oncological Outcomes and Quality of Life After Rectal Cancer Surgery

Surgery for rectal cancer has been completely revolutionized thanks to the adoption of new technologies and up-to-date surgical procedures that have been applied to the traditional milestone represented by Total Mesorectal Excision (TME).

The multimodal and multidisciplinary approach, with new technologies increased the patients’ life expectancies; nevertheless, they have placed the surgeon in front of newer issues, represented by both oncological outcomes and the patients’ need of a less destructive surgery and improved quality of life.

In this review we will go through laparoscopic, robotic and transanal TME surgery, to show how the correct choice of the most appropriate technique, together with a deep knowledge of oncological principles and pelvic anatomy, is crucial to pursue an optimal cancer treatment. Novel technologies might also help to decrease the patients’ fear of surgery and address important issues such as cosmesis and improved preservation of postoperative functionality.

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.

Robotic Surgery for Malignant Liver Disease: a Systematic Review of Oncological and Surgical Outcomes

Robot-assisted laparoscopic surgery is yet another modification of minimally invasive liver surgery. It is described as feasible and safe from the surgical point of view; however, oncological outcomes need to be adequately analysed to justify the use of this technique when resecting malignant liver tumours. We reviewed existing English medical literature on robot-assisted laparoscopic liver surgery. We analysed surgical outcomes and oncological outcomes. We analysed operative parameters including operative time, type of hepatectomy, blood loss, conversion rate, morbidity and mortality rates and length of stay. We also analysed oncological outcomes including completeness of resection (R status), recurrence, survival and follow-up data. A total of 582 patients undergoing robot-assisted laparoscopic liver surgery were analysed from 17 eligible publications. Only 5 publications reported survival data. The overall morbidity was 19% with 0.2% reported mortality. R0 resection was achieved in 96% of patients. Robotic liver surgery is feasible and safe with acceptable morbidity and oncological outcomes including resection margins. However, well-designed trials are required to provide evidence in terms of survival and disease-free intervals when performed for malignancy.

Robotic Versus Laparoscopic Rectal Surgery for Rectal Cancer: A Meta-Analysis of 7 Randomized Controlled Trials

Background. Robotic surgery has been recently used as a novel tool for rectal surgery. This study assessed the current evidence regarding the efficiency, safety, and potential advantages of robotic rectal surgery (RRS) compared with laparoscopic rectal surgery (LRS). Methods. We comprehensively searched PubMed, Embase, and the Cochrane Library databases and performed a systematic review and cumulative meta-analysis of all randomized controlled trials (RCTs) assessing the 2 approaches. Results. Seven RCTs including a total of 1022 cases were identified. The conversion rate is significantly lower for RRS (odds ratio: 0.29; 95% confidence interval: 0.09 to 0.96; P = .04). The length of the distal margin was significantly shorter in the LRS group than in the RRS group (weighted mean difference: 0.60; 95% confidence interval: 0.09 to 1.10; P = .02). Perioperative complication rates, harvested lymph nodes, positive circumferential resection margins, complete total mesorectal excision, first flatus, and length of stay did not differ significantly between approaches ( P > .05). Conclusions. This meta-analysis indicates that RRS is a safe and effective approach. It is not inferior to LRS in terms of oncologic outcomes and postoperative complications. Future large-volume, well-designed RCTs with extensive follow-up are awaited to confirm and update the findings of this analysis.

Rectal Surgery Evaluation Trial: protocol for a parallel cohort trial of outcomes using surgical techniques for total mesorectal excision with low anterior resection in high-risk rectal cancer patients

AIM

Total mesorectal excision (TME) is the standard of care for rectal cancer, which can be combined with low anterior resection (LAR) in patients with mid-to-low rectal cancer. The narrow pelvic space and difficulties in obtaining adequate exposure make surgery technically challenging. Four techniques are used to perform the surgery: open laparotomy, laparoscopy, robot-assisted surgery and transanal surgery. Comparative data for these techniques are required to provide clinical data on the surgical management of rectal cancers.

METHODS

The Rectal Surgery Evaluation Trial will be a prospective, observational, case-matched, four-cohort, multicentre trial designed to study TME with LAR using open laparotomy, laparoscopy, robot-assisted surgery or transanal surgery in high-surgical-risk patients with mid-to-low non-metastatic rectal cancer. All surgeries will be performed by surgeons experienced in at least one of the techniques. Oncological, morbidity and functional outcomes will be assessed in a composite primary outcome, with success defined as circumferential resection margin ≥ 1 mm, TME Grade III and minimal postoperative morbidity (absence of Clavien-Dindo Grade III-IV complications within 30 days after surgery). Secondary end-points will include the co-primary end-points over the long term (2 years), quality of surgery, quality of life, length of hospital stay, operative time and rate of unplanned conversions.

DISCUSSION

This will be the first trial to study all four surgical techniques currently used for TME with LAR in a specific group of high-risk patients. The knowledge obtained will contribute towards helping physicians determine the advantages of each technique and which may be the most appropriate for their patients.

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.

Short-term postoperative outcomes following robotic versus laparoscopic ileal pouch-anal anastomosis are equivalent

BACKGROUND

Minimally invasive approaches have become the standard of care for ileal pouch-anal anastomoses (IPAA). There are few reports comparing outcomes following a laparoscopic versus robotic approach. Our aim was to determine if there were any differences in the 30-day postoperative outcomes following IPAA performed laparoscopically versus robotically.

METHODS

A retrospective chart review of all laparoscopic and robotic IPAA performed between January 1, 2015 and June 30, 2018 was carried out. Patients included were adult patients who underwent a proctectomy and IPAA utilizing either a laparoscopic or robotic approach. Data collected included patient demographics, operative variables, and 30-day postoperative outcomes.

RESULTS

A total of 132 patients had a minimally invasive IPAA; 58 were performed laparoscopically and 74 robotically. Less than half the patients were female (n = 55; 41.7%) with a median age of 37 years (range 18-68 years). The majority of patients had a diagnosis of ulcerative colitis (n = 103; 78.0%) with medically refractory disease (n = 87; 65.9%). A greater proportion of patients in the laparoscopic cohort had a prolonged length of stay (n = 27; 46.6% versus n = 18; 24.3%; p < 0.001) and a two-stage approach (n = 56; 96.6% versus n = 37; 50%; p < 0.001), but there were no differences in the rates between the laparoscopic versus robotic cohorts of superficial surgical site infection (6.9% versus 6.8%; p = 0.99), peripouch abscess (15.5% versus 6.8%; p = 0.11), anastomotic leak (6.9% versus 2.7%; p = 0.21), pelvic abscess (15.5% versus 6.8%; p = 0.11), and pelvic sepsis (15.5% versus 6.8%; p = 0.11), readmission (24.1% versus 17.6%; p = 0.35) or reoperation (6.9% versus 5.4%; p = 0.72). On multivariable analysis, only male sex remained predictive of prolonged length of stay, and a robotic approach trended toward a decreased rate of prolonged length of stay.

CONCLUSIONS

Laparoscopic and robotic IPAA have equivalent postoperative morbidity underscoring the safety of the continued expansion of the robotic platform for pouch surgery.

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.

Short-Term Outcomes of Robotic versus Laparoscopic Total Mesorectal Excision for Rectal Cancer: A Cohort Study

The aim of this study was to evaluate and compare the intestinal function recovery time and other short-term outcomes between robotic-assisted total mesorectal excision (R-TME) and laparoscopic total mesorectal excision (L-TME) for rectal cancer. This is a retrospective study using a prospectively collected database. Patients’ records were obtained from Gansu Provincial Hospital between July 2015 and October 2017. Eighty patients underwent R-TME, and 116 with the same histopathological stage of the tumor underwent an L-TME. Both operations were performed by the same surgeon, comparing intra- and postoperative outcomes intergroups. The time to the first passage of flatus ( P < 0.001), the time to the first postoperative oral fluid intake ( P < 0.001), and the length of hospital stay ( P < 0.01) of the R-TME group were about three days faster than those in the L-TME group. The rate of conversion to open laparotomy ( P = 0.038) and postoperative urinary retention ( P = 0.016) were significantly lower in the R-TME group than in the L-TME group. Intraoperative blood loss of the R-TME group was more than that of the L-TME group ( P < 0.01).The operation time, number of lymph nodes harvested, and rate of positive circumferential resection margin were similar intergroup. The total cost of the R-TME group was higher than that of the L-TME group, but with a lack of statistical significance (85,623.91 ± 13,310.50 vs 67,356.79 ± 17,107.68 CNY, P = 0.084). The R-TME is safe and effective and has better postoperative short-term outcomes and faster intestinal function recovery time, contrasting with the L-TME. The large, multicenter, prospective studies were needed to validate the advantages of robotic surgery system used in rectal cancer.

Robotic versus laparoscopic rectal resection surgery: Short-term outcomes and complications: A retrospective comparative study

BACKGROUND

The safety of robotic-assisted surgery (RAS) remains a concern. This study aimed to compare the complications after RAS versus laparoscopic-assisted surgery (LAS) for rectal cancer using the Clavien-Dindo classification and to identify risk factors related to the complications.

METHOD

Between March 2010 and June 2016, 556 rectal cancer patients who underwent successful RAS and 1029 patients who received LAS were enrolled in this study. The complications were graded according to the Clavien-Dindo classification, and the possible risk factors related to the complications were analyzed.

RESULTS

The overall postoperative complication rate was 14.9%, with a 5% rate of severe complications that were classified as grade III or above in RAS group compared with 17.1% and 4.4% in LAS group. However, no significant difference was found (P = 0.608). A high ASA score was identified as an independent risk factor for overall and severe complications in both groups. The use of more than 3 staples in each operation and the anastomotic site of the anal verge at less than 5 cm were independent risk factors for complications.

CONCLUSIONS

RAS for rectal cancer is technically safe and it does not significantly improve the complication rate. The incidence of overall complications is still related to tumor location, the general condition of the patients, and the surgical approach.