Background In the right colon surgery, there is a growing literature comparing the safety of robotic right colectomy (RRC) to that of laparoscopic right colectomy (LRC). With this paper we aim to systematically revise and meta-analyze the latest comparative studies on these two minimally invasive procedures. Methods A systematic review of studies published from 2000 to 2017 in the PubMed, Scopus, and Embase databases was performed. Primary endpoints were postoperative morbidity and mortality. Secondary endpoints were blood loss, conversion to open surgery, harvested lymph node anastomotic leak, postoperative hemorrhage, abdominal abscess, postoperative ileus, time to first flatus, non-surgical complications, wound infections, hospital stay, and incisional hernia and costs. A subgroup analysis was performed on those series presenting only extracorporeal anastomosis in both arms. Results After screening 355 articles, 11 articles with a total of 8257 patients were eligible for inclusion. Operative time was found to be significantly shorter for the laparoscopic procedures in the pooled analysis (SMD - 0.99 95% CI - 1.4 to - 0.6, p Conclusions RRC can be regarded as a feasible and safe technique. Its superiority in terms of postoperative recovery must be confirmed by further large prospective series comparing RRC and LRC performed with the same anastomotic technique. RRC seemed to be associated with higher costs than LRC.

Robotic versus laparoscopic right colectomy: an updated systematic review and meta-analysis

The aim of this study was to compare the long-term outcomes of robot-assisted right colectomy (RAC) with those for conventional laparoscopy-assisted right surgery (LAC) for treating right-sided colon cancer. The enthusiasm for the robotic techniques has gained increasing interest in colorectal malignancies. However, the role of robotic surgery in the oncologic safety has not yet been defined. From September 2009 to July 2011, 71 patients with right-sided colonic cancer were randomized in the study. Adjuvant therapy and postoperative follow-up were similar in both groups. The primary and secondary endpoints of the study were hospital stay and survival, respectively. Data were analyzed by intention-to-treat principle. The RAC and LAC groups did not differ significantly in terms of baseline clinical characteristics. Compared with the LAC group, RAC was associated with longer operation times (195 min vs. 129 min, P < 0.001) and higher cost ($12,235 vs. $10,319, P = 0.013). The median follow-up was 49.23 months (interquartile range 40.63–56.20). The combined 5-year disease-free rate for all tumor stages was 77.4% (95% confidence interval [CI], 60.6–92.1%) in the RAC group and 83.6% (95% CI 72.1–0.97.0%) in the LAC group (P = 0.442). The combined 5-year overall survival rates for all stages were 91.1% (95% CI 78.8–100%) in the RAC group and 91.0% (95% CI 81.3–100%) in the LAC group (P = 0.678). Using multivariate analysis, RAC was not a predictor of recurrence. RAC appears to similar long-term survival as compared with LAC. However, we did not observe any clinical benefits of RAC which could translate to a decrease in expenditures. Trial registry: http://www.ClinicalTrials.gov
 , number NCT00470951.

Long-term oncologic after robotic versus laparoscopic right colectomy: a prospective randomized study

Minimally invasive colectomy has become the standard for treatment of colonic disease in many centers. Restoration of bowel continuity following resection can be achieved by intracorporeal (IC) or extracorporeal (EC) anastomosis. The aim of this systematic review was to assess the outcomes of IC compared to EC anastomosis in minimally invasive right colectomy. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant systematic literature search for studies assessing the outcome of IC and EC anastomosis in laparoscopic and robot-assisted right colectomy was conducted. The primary outcome of this review was postoperative complications. Secondary outcomes included operative time, blood loss, length of stay, conversion to open surgery, and bowel recovery. Twenty-five studies including 4450 patients were evaluated. 47.7% of patients had IC anastomosis and 52.3% had EC anastomosis. The weighted mean length of extraction site incision in the IC group was shorter than the EC group. The EC group had significantly higher odds of conversion to open surgery (OR 1.87, 95% CI 1–3.45, p = 0.046), total complications (OR 1.54, 95% CI 1.05–2.11, p = 0.007), anastomotic leakage (AL) (OR 1.95, 95% CI 1.4–2.7, p = 0.003), surgical site infection (SSI) (OR 1.69, 95% CI 1.4–2.6, p = 0.002), and incisional hernia (OR 3.14, 95% CI 1.85–5.33, p < 0.001) compared to the IC group. Both groups had similar rates of ileus, small bowel obstruction, bleeding, and intra-abdominal infection. IC anastomosis was associated with significantly shorter extraction site incisions, earlier bowel recovery, fewer complications, and lower rates of conversion, AL, SSI, and incisional hernia than has the EC anastomosis.

Intracorporeal versus extracorporeal anastomosis in minimally invasive right colectomy: an updated systematic review and meta-analysis

Purpose Surgeons tend to view the robotic right colectomy (RRC) as an ideal beginning procedure to gain proficiency in robotic general and colorectal surgery. Nevertheless, oncological RRC, especially if performed with intracorporeal ileocolic anastomosis confectioning, cannot be considered a technically easier procedure. The aim of this study was to assess the learning curve of the RRC performed for oncological purposes and to evaluate its safety and efficacy investigating the perioperative and pathology outcomes in the different learning phases. Methods Data on a consecutive series of 108 patients undergoing RRC with intracorporeal anastomosis between June 2011 and September 2015 at our institution were prospectively collected to evaluate surgical and short-term oncological outcomes. CUSUM (Cumulative Sum) and Risk-Adjusted (RA) CUSUM analysis were performed in order to perform a multidimensional assessment of the learning curve for the RRC surgical procedure. Intraoperative, postoperative and pathological outcomes were compared among the learning curve phases. Results Based on the CUSUM and RA-CUSUM analyses, the learning curve for RRC could be divided into 3 different phases: phase 1, the initial learning period (1st–44th case); phase 2, the consolidation period (45th–90th case); and phase 3, the mastery period (91th–108th case). Operation time, conversion to open surgery rate and the number of harvested lymph nodes significantly improve through the three learning phases. Conclusions The learning curve for oncological RRC with intracorporeal anastomosis is composed of 3 phases. Our data indicate that the performance of RRC is safe from an oncological point of view in all of the three phases of the learning curve. However, the technical skills necessary to significantly reduce operative time, conversion to open surgery rate and to significantly improve the number of harvested lymph nodes were achieved after 44 procedures. These data suggest that it might be prudent to start the RRC learning curve by treating only benign diseases and to reserve the performance of oncological resection to when at least the initial learning phase has been completed.

Robotic right hemicolectomy: Analysis of 108 consecutive procedures and multidimensional assessment of the learning curve

Through retrospective review of consecutive charts, we compare the short-term and long-term clinical outcomes after robotic-assisted right colectomy with intracorporeal anastomosis (RIA) (n=89) and laparoscopic right colectomy with extracorporeal anastomosis (LEA) (n=135). Cohorts were similar in demographic characteristics, comorbidities, pathology, and perioperative outcomes (conversion, days to flatus and bowel movement, and length of hospitalization). The RIA cohort experienced statistically significant: less blood loss, shorter incision lengths, and longer specimen lengths than the LEA cohort. Operative times were significantly longer for the RIA group. No incisional hernias occurred in the RIA group, whereas the LEA group had 5 incisional hernias; mean follow-up was 33 and 30 months, respectively. RIA is effective and safe and provides some clinical advantages. Future studies may show that, in obese and other technically challenging patients, RIA facilitates resection of a longer, consistent specimen with less mesentery trauma that can be extracted through smaller incisions.

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Advantages of Robotic Right Colectomy With Intracorporeal Anastomosis.

Background: In laparoscopic right hemicolectomy (LRC), extracorporeal or intracorporeal (ICA) anastomosis can be performed. Several authors have suggested advantages to ICA. This study rep...

Robotic right colectomy with intracorporeal anastomosis: experience with 52 consecutive cases.

Laparoscopic colectomy has been shown to have significant advantages over open colectomy. Yet, the widespread adoption of laparoscopic techniques has been slower than expected. The enhanced visualization and dexterity afforded by the robotic system platform may facilitate the adoption of a minimally invasive approach to colectomies. Robotic right colectomy (RRC) is safe and feasible and may be an ideal case for a surgeon’s initial experience with robotic techniques. Operative times and perioperative complications are comparable to laparoscopic colectomy, and limited studies suggest oncologic outcomes to be equivalent as well. One of the obvious advantages of the robotic approach is the facilitation of an intracorporeal anastomosis (ICA). If future studies confirm that ICA is advantageous, the role of RRC may gain importance. Finally, single-incision robotic techniques are being investigated and have been shown to be feasible. With advancing technology, application of this platform may become more widespread.

Brian X. Rivera

Papers

Advantages of Robotic Right Colectomy With Intracorporeal Anastomosis.

Robotic right colectomy with intracorporeal anastomosis: experience with 52 consecutive cases.

Robotic Right Hemicolectomy