Surg Endosc DOI 10.1007/s00464-014-3835-9

and Other Interventional Techniques

Robotic right colectomy with intracorporeal anastomosis compared with laparoscopic right colectomy with extracorporeal and intracorporeal anastomosis: a retrospective multicentre study Stefano Trastulli • Andrea Coratti • Salvatore Guarino • Riccardo Piagnerelli • Mario Annecchiarico • Francesco Coratti • Michele Di Marino • Francesco Ricci Jacopo Desiderio • Roberto Cirocchi • Amilcare Parisi



Received: 11 February 2014 / Accepted: 15 August 2014 Ó Springer Science+Business Media New York 2014

Abstract Background Growing evidence suggests that the intracorporeal fashioning of an anastomosis after a laparoscopic right colectomy may offer several advantages. However, due to the difficulty of the intracorporeal technique, laparoscopic extracorporeal confectioning of the anastomosis remains the most widely adopted technique. Although the purpose of the robotic approach was to overcome the limitations of the laparoscopic technique and to simplify the most demanding surgical procedures, such as performing an intracorporeal anastomosis, evidence is lacking that compares the robotic right colectomy with intracorporeal anastomosis (RRCIA) technique with both the conventional laparoscopic right colectomy with extracorporeal anastomosis (LRCEA) and the laparoscopic right colectomy with intracorporeal anastomosis confectioning (LRCIA) techniques. This study aims to compare the intraoperative and postoperative outcomes of the RRCIA to those of both the LRCEA and the LRCIA.

S. Trastulli (&)  F. Ricci  J. Desiderio  R. Cirocchi  A. Parisi Department of Digestive Surgery and Liver Unit, Santa Maria Hospital, Terni, Italy e-mail: [email protected] A. Coratti  M. Annecchiarico  M. Di Marino Department of Oncology, Division of Oncological and Robotic Surgery, Careggi University Hospital, Florence, Italy S. Guarino Department of Surgical Science, ‘‘Sapienza’’ University of Rome, Rome, Italy R. Piagnerelli  F. Coratti Department of General Surgery, Misericordia Hospital, Grosseto, Italy

Methods A retrospective review of a prospectively maintained database of two Italian centres was performed on the data on patients undergoing an RRCIA, LRCEA or LRCIA for cancer or adenomas. Results Two hundred and thirty-six patients (RRCIA = 102, LRCEA = 94, LRCIA = 40) met the criteria for inclusion in the study. The three groups were comparable in their demographic and baseline characteristics. No significant differences were found in the conversion to open rates, intraoperative blood loss, 30-day morbidity and mortality, number of lymphnodes harvested and other pathological characteristics. Compared with the LRCEA, the RRCIA required a longer operative time (P \ 0.0001) but had better recovery outcomes, such as a shorter length of hospital stay (P \ 0.0001). Compared with the LRCIA, the RRCIA had a shorter time to first flatus (P \ 0.0001) but offered no advantages in terms of the length of the hospital stay. Conclusion Performing the RRCIA offers significantly better perioperative recovery outcomes compared with the LRCEA, with a substantial reduction in the length of the hospital stay. The RRCIA does not offer the same advantages compared with the LRCIA. Keywords Robotic surgery  Laparoscopic surgery  Right colectomy  Colorectal surgery  Colectomy  Ileocolic anastomosis

Laparoscopy represents the gold standard approach for right colon resections, providing better recovery in the return to normal bowel function, a shorter length of hospital stay and lower postoperative morbidity compared with open surgery, with similar oncological outcomes [1, 2]. Nevertheless, standardisation of the surgical technique for laparoscopic right colectomy (LRC), in particular regarding the

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performance of the intracorporeal or extracorporeal ileocolic anastomosis, is lacking [3, 4]. This is primarily because performing a laparoscopic right colectomy with intracorporeal anastomosis (LRCIA) is considered one of the most challenging laparoscopic colorectal manoeuvres [5]. In fact, the laparoscopic right colectomy with extracorporeal anastomosis (LRCEA) remains the most widely adopted technique [6], despite growing evidence suggesting that fashioning the anastomosis with the intracorporeal technique offers several benefits, such as a faster return to normal bowel function, shorter hospital stay and decreased need for analgesic drugs [7]. Theoretically, the same clinical advantages postulated for the LRCIA over the LRCEA could be obtained performing the right colectomy with an intracorporeal anastomosis with the use of a robot. The use of robotic technology is intended to overcome the technical limitations of laparoscopic surgery by simplifying the most demanding of the surgical manoeuvres, such as intracorporeal anastomosis confectioning, thereby improving surgical outcomes. To date, evidence on the translation of the presumed technical robotic advantages to the actual clinical scenario for RRCIA over the LRCEA, the most widely adopted technique for a LRC, or in respect to the LRCIA are scarce and do not allow firm conclusions to be drawn [8]. In fact, to our knowledge, only a few studies in the literature compare the robotic right colectomy with intracorporeal anastomosis (RRCIA) with the LRCEA [9–12], and there are no studies specifically comparing the RRCIA with the LRCIA. Moreover, in some of these comparative studies, heterogeneous anastomotic techniques (intracorporeal and extracorporeal) were used, potentially jeopardising the reliability of the results. Only two studies [9, 10] to date specifically compared the RRCIA with the LRCEA, drawing contrasting conclusions: Morpurgo et al. reported a shorter time to first flatus, shorter length of hospital stay and lower anastomotic complication rates in the RRCIA group [9], while Rawlings found no differences in all of the examined outcomes between the RRCIA and LRCEA [10]. The only published randomised clinical trial comparing the robotic with the LRC found no objective advantages in the robotic use, but both the laparoscopic and robotic cases were performed with a mixed anastomotic technique (intraand extracorporeal) [12]. Based on this background, the aim of this study was to evaluate the possible clinical advantages of performing right colectomies with intracorporeal anastomosis using a robotic approach (RRCIA) in respect to both the LRCIA and the most commonly practiced laparoscopic technique with extracorporeal anastomosis confectioning (LRCEA).

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Methods The aim of this bi-centric retrospective comparative study was to analyse the results from patients undergoing a robotic right colectomy with an intracorporeal ileocolic anastomosis and comparing them to a first group of patients undergoing a right colectomy with a traditional laparoscopic approach with extracorporeal ileocolic anastomosis and to a second group of patients undergoing a right colectomy with intracorporeal anastomosis in two mini-invasive surgery centres in Italy. The two Italian centres participating in this study were the Department of Digestive Surgery and Liver Unit at the Santa Maria Hospital in Terni and the Department of General Surgery at the Misericordia Hospital in Grosseto. In the Grosseto centre, the Da Vinci robot was introduced in 2000, whereas it became available in Terni in 2011. In both institutions, the Da Vinci Robot, after its introduction, was offered to all patients who needed a right colectomy and were suitable for a mini-invasive approach. The data of interest for this study were collected by retrospectively reviewing the prospectively collected databases of the two centres to identify the robotic and LRC procedures performed in the period between June 2005 and May 2014 on the basis of the pre-specified inclusion and exclusion criteria. In particular, the time frame considered for retrieving the data on the robotic and laparoscopic procedures in the Grosseto Hospital ranged from February 2008 to May 2011 and from June 2005 to December 2010, respectively, whereas in the Terni institution, data are from the robotic and laparoscopic procedures performed between June 2011 and May 2014 and from November 2005 to May 2014, respectively (only four laparoscopic right colectomies were performed in the period between June 2011 and May 2014 at the Terni institution). The inclusion criteria for this study included the following: – – – –

age C 18 histological diagnosis of adenoma or carcinoma of the right colon (caecum, ascending, right flexure) undergoing robotic right colectomy (full robotic or hybrid technique) with intracorporeal anastomosis undergoing traditional LRC with intracorporeal or extracorporeal anastomosis The exclusion criteria included the following:

– – –

perforated, obstructing or locally invasive neoplasm emergency procedures right colectomies associated with other major surgical procedures (i.e. major hepatectomies, other major intestinal resections).

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In both centres, the procedures were performed by three senior surgeons who were experienced with minimally invasive surgery (Andrea Coratti and Pier Cristoforo Giulianotti from the Grosseto institution and Amilcare Parisi from the Terni institution). Each of the participating surgeons had extensive experience in laparoscopic colorectal surgery and had received specific training for robotic surgery. In the Terni institution, the robotic procedures were performed by surgeons at the beginning of their learning curve in robotic right colectomies; on the contrary, in the Grosseto centre where the robot had already been introduced few years before, each of the participating surgeons had already performed at least 25 [13] robotic colorectal procedures. The decision to perform the ileocolic anastomosis either with the intracorporeal or extracorporeal technique was exclusively based on the operator’s preference in both centres. In the present study, there were no predefined criteria for selecting patients for either the intracorporeal anastomosis or extracorporeal anastomosis confectioning in the laparoscopic procedures, though it was common practice in both institutions to consider overweight or obese patients to be better candidates for intracorporeal anastomosis, thereby avoiding the challenges of exteriorising a large specimen through a small incision in a thick abdominal wall. In both institutions, preoperative investigations were performed in the pre-assessment clinic with the anaesthetist’s evaluation, surgical assessment, colonoscopy, staging CT of the abdomen, pelvis and chest and blood tests. On the day before the operation, all of the patients underwent bowel preparation with a sodium phosphate enema or an oral mechanical bowel preparation. Short-term prophylactic antibiotics were administered 30 min before starting the surgery. A true fast-track surgery protocol was not followed for the groups undergoing right colectomies, as the hospital committees were still in the process of agreeing on the implementation of a fast-track protocol. In the absence of specific contraindications, the naso-gastric tube was removed at the end of the surgical procedure, and patients were allowed free fluid oral intake from day 1 after surgery. A semisolid diet followed immediately if fluids were well tolerated. The urinary catheter was routinely removed on the first postoperative day. The discharge criteria in both of the centres included the uncomplicated oral intake of semisolid food, apyrexia, bowel opened to gas, normal urinary function and pain control not requiring parenteral analgesia. The age, gender, body mass index (BMI), American Society of Anaesthesiologists (ASA) score, history of previous abdominal surgery, tumour/adenoma location (caecum/ascending colon or hepatic flexure) for each included patient were retrieved to compare the baseline characteristics of the included groups.

The outcomes of interest used to compare the RRCIA to both the LRCEA and LRCIA were the intraoperative outcomes (operative time, estimated blood loss and conversion to open rate), recovery outcomes (time to first flatus and length of hospital stay), postoperative 30-day surgical and medical complications and mortality, reoperation rate, number of postoperative units of blood transfused and pathological outcomes (number of harvested lymphnodes, specimen length and tumour stage). The number of harvested lymphnodes and specimen length outcomes were analysed considering only the subgroup of patients with cancer. The anastomotic leaks were considered as such only after radiological confirmation (contrast radiograph or computed tomographic scan) or after re-intervention revealing leakage. A paralytic ileus was considered to be present in the absence of bowel sounds and the bowel not opening for more than 3 days following surgery. We considered a conversion to laparotomy for all of those cases in which any unplanned abdominal incision was performed and in the event of the performance of any unplanned step of the procedures in the extracorporeal site. In these cases, requiring the performance of any extracorporeal steps of the procedure other than the specimen extraction, the procedures were not considered LRCIA. The laparoscopic procedures converted to open surgery were included in the statistical analysis for the laparoscopic treatment group (LRCEA or LRCIA) on the basis of the type of intervention planned by the surgeon (LRCEA or LRCIA) before starting the surgical procedure. The same also applies to the robotic group. The operative time was calculated as the time between the establishment of the pneumoperitoneum and the skin closure, including the robot docking time and all of the laparoscopic steps (such as the abdominal cavity exploration and hepatic flexure mobilisation); the aspirated and introduced fluids were measured to estimate the blood loss. After discharge, the patients were followed up with outpatient surgical visits on a weekly basis, at least during the first postoperative month. Two robotic right hemicolectomy techniques were performed: the full robotic right colectomy and the hybrid technique.

Surgical procedures Hybrid robotic right colectomy with intracorporeal anastomosis The procedural steps for performing a hybrid RRCIA and the positioning of ports have been reported previously in our recently published paper [14]. In brief, the exploration of the abdominal cavity, the gastrocolic ligament separation and the colo-epiploic

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detachment is performed with an initial traditional laparoscopic approach. In the same way, the greater omentum is transacted, and the point of the intestinal division is identified. The procedure is then continued with the Da Vinci SiHD Robot (Intuitive Surgical, Mountain View, Sunnyvale, CA, USA) positioned cranially on the right side of the patient. The initial configuration of the four arms is as follows: the cautery hook is positioned in arm #1, the camera in arm #2, the fenestrated bipolar forceps in arm #3 and the double fenestrated grasper on arm #4. A traditional right colectomy is performed with a medial-to-lateral approach by incising the parietal peritoneum below the ileo-colic vessels identifying the Gerota and Toldt’s Fascias posteriorly and anteriorly up to the third part of the duodenum (D3). The ileo-colic vascular pedicle is then divided. The next step is the section of the mesocolon cranio-caudally along the superior mesenteric pedicle with ligation of the vessels encountered (right colic if present and right branch of the mid-colic artery) at their origin. If an extended right colectomy is required due to the position of the neoplastic lesion, then the entire mid-colic pedicle is also divided. For a neoplasm of the hepatic flexure or proximal transverse colon, an extended lymphadenectomy is performed by also including the subpyloric lymphnodes. After the medial-to-lateral dissection, the parietal peritoneal incision is continued in the right colonic gutter along the Toldt fascia next to the caecum and ascending colon up to the previous posterior dissection. Once the specimen is totally dissected, a mechanical stapler is used to divide the transverse colon. Thus, the distal ileal loop is identified and divided using the mechanical stapler. The resected colon segment is then completely detached. The intracorporeal anastomosis is performed after the insertion of a needle holder through robotic arm #1. Using two sero-serosal stitches, the ileal loop and the transverse colon are hooked together to facilitate a side-to-side stapled or hand-sewn anastomosis. The distal point was kept in tension by robotic arm #3 to make the two bowel segments parallel. Enterotomies were created with the cautery hook on robotic arm #1. Therefore, the anastomosis was confectioned either completely hand-sewn using a needle holder through robotic arm #2 or with the use of a mechanical stapler. Double layer side-to-side ileocolic isoperistaltic anastomoses were performed in the hand-sewn group. In the mechanical anastomosis, the assistant surgeon first introduced the larger part of the stapler into the colotomy and then the smaller part through the small bowel loop to complete a latero-lateral isoperistaltic anastomosis. The enterotomies were closed with stitches passed in a second needle holder through robotic arm #1: a first layer of continuous absorbable 2/0 monofilament suture and a

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second layer of interrupted sero-serosal suture. The mesenteric defect was not closed. The surgical specimen was retrieved through a McBurney or midline supraumbilical incision. A Redon drainage tube was positioned in the right paracolic gutter through the incision used for port #3. Full robotic right colectomy with intracorporeal anastomosis The full robotic right hemicolectomy technique is quite similar to the hybrid technique, and the only difference is that the hepatic flexure mobilisation and the omental partition are performed with the robot; however, an initial laparoscopic abdominal cavity exploration is still routinely performed. Moreover, the port’s position is similar. In the full robotic technique, both the hand-sewn intracorporeal anastomosis and the closure of the enterotomy in the stapled anastomosis are performed with a single layer absorbable 3/0 monofilament suture. A drainage tube is not routinely positioned. Laparoscopic right colectomy with intracorporeal and extracorporeal anastomosis The procedural steps of the LRC with both the extracorporeal and intracorporeal ileo-colic anastomoses are comparable to the steps described for the robotic approach except for the use of laparoscopic instruments and for the different techniques used to perform the extracorporeal ileocolic anastomosis. In patients undergoing a LRC with an extracorporeal anastomosis, the vessel ligation and division is performed intracorporeally, but the colon transection is performed extracorporeally. The extracorporeal anastomosis is performed by exteriorising the two stumps of the bowel after having resected the ileum through a midline mini-laparotomy or through a subcostal incision using a mechanical stapler in a side-to-side antiperistaltic fashion. The enterotomies are then closed with a continuous monofilament absorbable suture and covered by a second layer of interrupted stitches. The mesenteric gap was not routinely repaired in either of the two groups. Statistical analysis The data on the baseline characteristics and on the outcomes of interest were analysed to compare the robotic approach with the laparoscopic approach considering the outcomes from both the LRCEA and LRCIA approaches. A comparison of the outcomes between the LRCEA and LRCIA groups was not performed, as this was not the aim of this study. The statistical analysis was performed using Prism version 6.00, GraphPad Software (La Jolla California, USA). When necessary, the v2 test or Fischer’s exact test was used to compare the data for the dichotomous

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outcomes of interest. Continuous data were presented as the means and the standard deviation (SD) or as the median and range of values. For the comparison of the means, we performed a one-way analysis of variance (ANOVA) with a post hoc analysis to compare the pairs of samples of interest (RRCIA vs LRCEA and RRCIA vs LRCIA). If necessary, the Kruskal–Wallis test was performed. A P value \ 0.05 was considered statistically significant.

Results Overall, a total of 236 patients undergoing a robotic or LRC (overall period from June 2005 to May 2014) in the two participating centres were eligible for inclusion in this study: 102 of the patients underwent RRCIA, 94 underwent LRCEA and 40 underwent LRCIA. As shown in Table 1, we found no significant differences in the comparison of the baseline characteristics of age, gender, BMI, ASA score, previous abdominal surgery and the tumour/adenoma locations of the patients in the RRCIA group with those of the patients included in the LRCEA and LRCIA groups. The results for the intraoperative outcomes are shown in Table 2. The RRCIA results demonstrated a significantly longer operative time (mean 287.4 min, P \ 0.0001) compared with both the LRCEA (mean 208 min) and the LRCIA (mean 204.3 min) results. The intraoperative estimated blood loss was not significantly different between the RRCIA (median 30 ml, P = 0.168) compared with either Table 1 Baseline patients characteristics

the LRCEA (median 45 ml) or LRCIA (median 10 ml). Four conversions to open surgery were recorded in the RRCIA group, eight in the LRCEA group and six in the LRCIA group; these conversions were due to the presence of extensive intra-abdominal adhesions or to the local extension of the neoplasm. No significant differences in the conversions to open surgery rates were found (P = 0.072). None of the laparoscopic or robotic procedures that were planned to be performed with intracorporeal anastomoses before the start of the intervention were converted to an LRCEA or to robotic right colectomy with extracorporeal anastomosis. Compared with the LRCEA, the RRCIA was found to provide a significantly shorter time to first flatus (median 2 vs 3 days, 0.001 \ P \ 0.01) and length of hospital stay (median 4 vs 7 days, P \ 0.0001, respectively). On the contrary, the RRCIA showed advantages compared with the LRCIA only in the time to first flatus (median 2 vs 4 days, respectively, P \ 0.0001), though no significant difference was found in the length of the hospital stay, as shown in Table 3. No 30-day mortality occurred in any of the three groups. The overall 30-day complication rate did not significantly differ between the RRCIA group (22.5 %, P = 0.955) compared with either the LRCEA (22.3 %) group or the LRCIA group (20 %). Moreover, the anastomotic leakage rate was not different (P = 0.845) between the RRCIA group (2.9 %) and the LRCEA (2.1 %) and LRCIA (0 %) groups. Similarly, the rate of wound infections (P = 0.467), paralytic ileus (P = 0.866), wound bleeding (P = 0.999), intra-abdominal abscesses (P = 0.999) and other postoperative complications were similar between the RRCIA and either the LRCEA or LRCIA, as shown in Table 4. The reoperation rate was similar as well (P = 0.146).

RRCIA n = 102

LRCEA n = 94

LRCIA n = 40

P value

68.8 (11.6)

70.8 (10.2)

71.5 (10.3)

0.282

56/46

52/42

25/15

0.689

25.6 (3.8)

25.4 (3.5)

26.6 (4)

0.260

(RRCIA vs LRCEA****)

8/55/39

10/45/39

2/24/14

0.677

(RRCIA vs LRCIA****)

Table 2 Intraoperative outcomes RRCIA n = 102

Age Mean (SD) Gender (m/f) (n)

LRCIA n = 40

P value (Post hoc analysis)

208 (61)

204.3 (51.9)

P \ 0.0001

Operative Time (min)

BMI Mean (SD)

LRCEA n = 94

Mean (SD)

287.4 (76.4)

ASA score 1/2/3, (n)

Estimated blood loss (ml)

Previous abdominal surgery n (%)

47 (46.7)

51 (54.2)

16 (40)

0.267

77/17

35/5

0.606

Tumour/Adenoma location Caecum and ascending/ flexure (n)

88/14

RRCIA robotic right colectomy with intracorporeal anastomosis, LRCEA laparoscopic right colectomy with extracorporeal anastomosis, LRCIA laparoscopic right colectomy with intracorporeal anastomosis, SD standard deviation, BMI body mass index, ASA American Society of Anesthesiologist, n number

Median (range)

30 (10–250)

45 (10–500)

10 (10–350)

0.168

6 (15 %)

0.072

Conversion to open surgery n (%)

4 (3.9 %)

8 (8.5 %)

RRCIA robotic right colectomy with intracorporeal anastomosis, LRCEA laparoscopic right colectomy with extracorporeal anastomosis, LRCIA laparoscopic right colectomy with intracorporeal anastomosis, SD standard deviation, min minutes, ml millilitres, n number **** P \ 0.0001, *** 0.0001 \ P \ 0.001, ** 0.001 \ P \ 0.01, * 0.01 \ P \ 0.05

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LRCEA n = 94

Table 4 Postoperative 30-day morbidity and mortality LRCIA n = 40

P value (post hoc analysis)

Complications n (%)

RRCIA n = 102

LRCEA n = 94

LRCIA n = 40

P value

Anastomotic leak

3 (2.9)

2 (2.1)

0

0.845

\0.0001

Wound infection

5 (4.9)

5 (5.3)

4 (10)

0.467

(RRCIA vs LRCEA**) (RRCIA vs LRCIA****)

Wound bleeding

1 (1)

0

0

0.999

Time to first flatus (days) Median (range)

2 (1–8)

3 (1–6)

4 (1–7)

Length of hospital stay (days) Median (range)

4 (3–22)

7 (4–21)

5.5 (3–14)

\0.0001 (RRCIA vs LRCEA****)

RRCIA robotic right colectomy with intracorporeal anastomosis, LRCEA laparoscopic right colectomy with extracorporeal anastomosis, LRCIA laparoscopic right colectomy with intracorporeal anastomosis **** P \ 0.0001, *** 0.0001 \ P \ 0.001, ** 0.001 \ P \ 0.01, * 0.01 \ P \ 0.05

Table 5 shows the results of the analysed pathological outcomes, for which we found no significant differences among the three compared groups. In particular, considering the subgroup of patients with cancer (88 in the RRCIA, 88 in the LRCEA and 32 in the LRCIA group), the number of harvested lymphnodes was similar (P = 0.659) in the RRCIA (mean 20.3), LRCEA (mean 19.5) and LRCIA (mean 19) groups. In addition, the specimen length and the stage of the lesions were similar between the RRCIA patients and those in the LRCEA and LRCIA groups.

Paralytic ileus

2 (2)

3 (3.2)

1 (2.5)

0.866

Intestinal obstruction

4 (3.9)

3 (3.2)

1 (2.5)

0.999

Intra-abdominal abscess

2 (2)

1 (1)

0

0.999

Intra-abdominal bleeding Gastrointestinal bleeding

2 (2) 3 (2.9)

0 4 (4.2)

0 1 (2.5)

0.654 0.892

Subcutaneous emphysema

2 (2)

0

0

0.654

Pneumonia

1 (1)

3 (3.2)

0

0.397

Pulmonary embolism

1 (1)

1 (1)

0

0.999

Urinary infection/retention

0

2 (2.1)

0

0.468

Atrial fibrillation

0

3 (3.2)

0

0.137

Myocardial infarction

1 (1)

0

1 (2.5)

0.310

Total complications

27

27

8



Total patients with complications

23 (22.5)

21 (22.3)

8 (20)

0.955

Postoperative blood transfusions

4

8

4

0.237

Reoperations

7 (6.8)

2 (2.1)

0

0.146

Death

0

0

0

1.000

RRCIA robotic right colectomy with intracorporeal anastomosis, LRCEA laparoscopic right colectomy with extracorporeal anastomosis, LRCIA laparoscopic right colectomy with intracorporeal anastomosis, n number Table 5 Postoperative pathological characteristics RRCIA

LRCEA

LRCIA

P value

285.4 (95.2)

296.5 (103.3)

0.081

19.5 (7.7)

19 (10.1)

Specimen length (mm)* Mean, (SD)

315.2 (74)

Discussion

N of retrieved lymphnodes*

The present multicentre retrospective study analysing 236 minimally invasive right colectomies appears to confirm that performing a right colectomy with an intracorporeal anastomosis, as well as with the robotic approach, is feasible and safe. Moreover, the approach results in better postoperative recovery outcomes, such as a significantly shorter time to first flatus with a significant reduction of the length of hospital stay, compared with the LRCEA, without any significant differences in the conversion to open surgery rate, postoperative 30-day morbidity and mortality and pathological outcomes, such as the number of harvested lymphnodes. On the contrary, when comparing the RRCIA with the LRCIA, no significant differences in the evaluated outcomes were found, except for a shorter time to first flatus in the robotic group. The median duration of the length of the hospital stay for the RRCIA group in our study was 4 days, and this value is with in the range of the

Postoperative staging, n

Mean, (SD)

123

20.3 (7.7)

0.659 0.318

Adenoma

14

6

8

In situ I

7 23

5 26

2 7

II

26

26

10

III

30

27

9

IV

2

4

4

RRCIA robotic right colectomy with intracorporeal anastomosis, LRCEA laparoscopic right colectomy with extracorporeal anastomosis, LRCIA laparoscopic right colectomy with intracorporeal anastomosis, n number, mm millimetres * Analysis performed only considering the patients with cancer (RRCIA n = 88; LRCEA n = 88; LRCIA n = 32)

previous studies on RRCIA (mean 3.9–7.9 days) [9–12]. We hypothesise that the shorter time to the first flatus and the shorter length of the hospital stay evident in the

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comparison between the robotic approach and the LRCEA and not the LRCIA may be primarily due to the technique used for the anastomosis formation (intracorporeal vs extracorporeal) rather than to the use of the robot itself. In fact, we believe, as some other authors have claimed [9, 11, 15], that the intracorporeal confectioning of the anastomosis causes less visceral trauma, less tissue-stretching, especially of the mesentery pedicle, and less dissection of the distal transverse colon compared with the extracorporeal technique after a right colectomy. These benefits contribute to a better recovery of the bowel function and to the consequently shorter hospital stay in the RRCIA compared with the LRCEA group. Moreover, we found that the median length of the hospital stay for the LRCEA (median 7 days) was within the range demonstrated in the results of previous studies on the LRCEA [2]. However, it should be emphasised that although patients undergoing robotic surgery showed a significantly shorter time to first flatus compared with the patients undergoing both LRCEA and LRCIA, we found no significant differences in the length of the hospital stay between the RRCIA and LRCIA groups, but significant differences were found between the RRCIA and LRCEA groups. This finding emphasises the fact that the recovery of bowel function after surgery is not the only factor determining a patient’s suitability for hospital discharge, which is notably affected by a wide range of additional factors, such as postoperative pain severity, the number and type of complications, operative time, blood loss, number and types of comorbidities and the functional status of the patients. In a nonrandomised study such as this one, selection bias and confounding factors make it impossible to ascribe with certainty the differences found in the analysed outcomes, including the recovery outcomes, to the effects of the treatments under investigation. The effects of the confounding factors and the selection and performance biases could justify the median duration of the length of stay of 7 days in the LRCEA group despite the median time to first flatus of 3 days that we use as a surrogate measure of recovery of bowel function. Such confounding factors and bias are not likely to be measurable and may also explain the differences in the recovery time between the RRCIA and LRCEA found in this study. In the present study, performance bias existed because neither the patients nor the surgeons were blinded to the treatment received by the patients. The knowledge of the treatments may unconsciously affect the clinical decisions regarding hospital discharge as well as others soft endpoints (time to peristalsis or to the resumption of diet). Despite this bias, the potential advantages of performing an intracorporeal anastomosis also include the possibility of performing a smaller abdominal incision for specimen extraction and in more convenient sites (such as McBurney

or Pfannenstiel incision) [16], with better cosmetic results [17], decreased incisional hernia rates [18, 19] and less postoperative pain. The problem is that performing a laparoscopic intracorporeal anastomosis is technically challenging, and also if performed totally stapled, it requires a longer operative time and additional training in laparoscopic suturing [6, 20]. For these reasons, its use to date is not widespread. A systematic review of the laparoscopic vs the open right colectomy published in 2012 confirmed this trend, showing that among the 17 included comparative studies, 14 reported the fashioning of an extracorporeal anastomosis, and the remaining three did not report this information [2]. Notably, using the robot allows some of the technical limitations of the laparoscopy to be overcome, such as by facilitating the process of intracorporeal suturing [21]. It has been estimated that to complete a reasonable learning curve for performing laparoscopic right colectomies approximately 56 procedures are needed [22], and between 18 and 250 procedures are needed for rectal resections [23]. To date, there are no studies that have specifically estimated the learning curve for robotic right colectomies with appropriate methods; however, the learning curve estimated for robotic rectal resections ranges between approximately 15 and 25 procedures [13, 23]. These data, together with the fact that some of the surgeons who have routinely performed the LRCEA have described a rapid and natural adaptation to a robotic intracorporeal anastomosis [11], suggest that the robot may be a useful tool for increasing the use of the intracorporeal confectioning of the anastomosis after a right colectomy. Because only a minority of colorectal surgeons manage routinely to complete laparoscopic right colectomies with intracorporeal anastomoses due to the procedure’s technical difficulties, the robotic method may facilitate the adoption of the intracorporeal anastomosis technique, allowing a larger number of patients the benefit of its advantages. To date, the ‘‘conventional’’ laparoscopic technique for right colectomies, at least from a diffusion point of view, should be considered to be those performed with an extracorporeal anastomosis (LRCEA). Then, a new technique, such as the robotic right colectomy with an intracorporeal anastomosis, must be compared with the LRC with an extracorporeal anastomosis to enable a hypothetical comparative study to achieve an acceptable generalisability and external validity and to avoid the potential for jeopardised that is possible if mixed (intra and extracorporeal) anastomotic techniques are used [14]. The latter concept assumes increasing importance in view of the growing evidence suggesting that there is a significant impact of the anastomosis confectioning site (intra- or extracorporeal) after a right colectomy in improving postoperative outcomes [7, 24, 25], such as the length of the

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hospital stay, which also have a relevant impact in the overall costs. By comparing the results of our study with the present literature, we found that, as previously reported, only four comparative studies exist that report data from the comparison between the RRCIA with the LRCEA [9–12], and surprisingly, there are no studies that compare the RRCIA with the LRCIA. Moreover, some of these studies [11, 12] reported a number of cases in which an extracorporeal anastomosis was performed in the robotic group and an intracorporeal anastomosis in the laparoscopic group. In particular, the RCT by Park and colleagues [12] represents the best source of evidence to date on the comparison between robotic and laparoscopic right colectomies. If we consider the intracorporeal anastomosis as a key factor in obtaining a faster bowel recovery and therefore a shorter length of hospital stay, the performance of mixed anastomotic techniques in each study arm may have strongly biased the results of this study, in which the sample size calculation was based on length of hospital stay [12]. Only the study by Morpurgo and coworkers [9] found both a significantly shorter time to first flatus (2.4 vs 3.4 days, P \ 0.05) and shorter length of postoperative hospital stay (7.5 vs 9 days, P \ 0.05) in the RRCIA compared with the LRCEA procedures. In this study, all robotic procedures were completed with an intracorporeal anastomosis, and all laparoscopic procedures were completed with an extracorporeal anastomosis. The significantly shorter hospital stay obtained in the RRCIA group represents an interesting finding that could potentially counterbalance the higher costs of the robot. If this counterbalance was confirmed, surgeons that routinely perform an extracorporeal anastomosis after a LRC that are not as familiar with laparoscopic intracorporeal suturing could maximise the advantages of using the robot. For these surgeons, it would be easier and quicker to learn how to perform an intracorporeal anastomosis with the robot than laparoscopically. On the contrary, the surgeons who already perform the LRCIA may receive less obvious benefits from the use of the robot; in actuality, for a well-trained laparoscopic surgeon, the confectioning of a laparoscopic intracorporeal anastomosis is as easy as robotic intracorporeal anastomosis confectioning. In our study, we found no differences in either the overall complication rate or in the single complication rates (see Table 4) between the RRCIA and each of the laparoscopic groups. Recently, the observational study by Morpurgo et al. [9] found a significantly lower anastomosis complication rate by comparing the RRCIA versus the LRCEA groups, but the small sample size of the study may have precluded any meaningful conclusion about the anastomotic complications outcomes. The mean operative time in our study for the robotic procedures was significantly longer than the operative

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times required for both the LRCEA and LRCIA procedures. Our results are in agreement with the means reported in the literature for the RRCIA, ranging between 195 and 266 min [9–12]. The operative time was significantly longer than the times required to perform the LRCEA in all of the published comparative studies [9–12]. The surgeons who participated in the present study have different levels of expertise in general robotic and colonic surgery, and this represents a limitation, though all of them did have extensive experience in laparoscopic colorectal surgery. This lack of robotic experience on the part of some of the surgeons strongly influences the robotic operative time in the early period of the learning curve, such as in the case of the Terni experience, for which the data come from procedures performed at the beginning of the surgeon’s experience with robotic right colectomies. Although this study involved only two institutions, the differences in the surgeons’ experience with robotic right colectomies may have contributed to generalisability of the results that is, in general, one of the advantages of performing an observational multicentre study [26]. Some authors have supported the idea that the use of robot may provide a higher comfort level and more accuracy in performing a complete mesocolic excision [27], in particular a lymphadenectomy with true high vessels’ ligation. In our opinion, this is particularly true in cases of obese patients or when an extended lymphadenectomy is required, such as for neoplasms of the hepatic colonic flexure or in the proximal transverse colon. In particular, the robotic approach also provides, in our opinion, the potential for the better control of any bleeding that occurs during lymphnode dissection, especially when it is performed in anatomically challenging sites, such as in the proximity of the superior mesenteric vein, the cephalopancreatic area or the sub-pyloric region. However, evidence that demonstrates better oncological outcomes in terms of recurrence rates or survival rates with the use of robotics is lacking. Although this study is the only one in the literature to specifically compare the robotic right colectomy with the LRC with both intracorporeal and extracorporeal anastomoses, it does have some limitations. Primarily, the retrospective nature of the analysis exposes to bias and confounding factors, especially in the selection phase, as previously described. The effect of both the bias (primarily selection and performance biases) and the confounding factors are not likely to be measurable and may explain the differences in recovery time or in other measured outcomes in this study. Therefore, the findings of this study should be interpreted with caution because of the well-known potential for retrospective studies to produce misleading results and because cause-and-effect relationships cannot be inferred from observational studies.

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An additional limitation of this study is that a cost analysis was not performed, and this remains a crucial issue in the adoption of robotics for right colectomies Moreover, in view of the results of the present study, the robotic right colectomy with an intracorporeal anastomosis requires a further higher level of evidence for the cost analysis in studies with an appropriate design that includes treatment arms with homogeneous anastomotic techniques. In particular, based on our experience, we believe that it is mandatory to better investigate the potential advantages of the RRCIA in respect both to the LRCEA and LRCIA in terms of the recovery outcomes and length of hospital stay and in terms of the cost-effectiveness ratio, by performing RCTs with adequate, homogeneous interventions arms (only RRCIA vs LRCEA or LRCIA procedures) and statistical power. Additionally, an investigation of the potential advantages, in terms of the long-term oncological outcomes, conversion or postoperative morbidity rates, such as a reduction in anastomotic leak rates, in particular between the RRCIA and the LRCIA, would also require RCTs with a sufficient sample size to make it possible to detect the small but still clinically relevant, hypothesised differences in these outcomes. For these reasons, it is necessary to plan and to perform a multicentre randomised trial enrolling a large number of patients similar to the ongoing multicentre randomised clinical trial on robotic vs laparoscopic rectal cancer resection known as ‘‘ROLARR’’ [28].

Disclosures Drs. Stefano Trastulli, Andrea Coratti, Salvatore Guarino, Riccardo Piagnerelli, Mario Annecchiarico, Francesco Coratti, Michele Di Marino, Francesco Ricci, Jacopo Desiderio, Roberto Cirocchi, Amilcare Parisi have no conflicts of interest or financial ties to disclose.

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Robotic right colectomy with intracorporeal anastomosis compared with laparoscopic right colectomy with extracorporeal and intracorporeal anastomosis: a retrospective multicentre study.

Growing evidence suggests that the intracorporeal fashioning of an anastomosis after a laparoscopic right colectomy may offer several advantages. Howe...
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