Totally robotic vs 3D laparoscopic colectomy: A single centers preliminary experience

Abstract

AIM: To compare robotic and three-dimensional (3D) laparoscopic colectomy based on the literature and our preliminary experience.

METHODS: This retrospective observational study compared operative measures and postoperative outcomes between laparoscopic 3D and robotic colectomy for cancer. From September 2013 to September 2014, 24 robotic colectomies and 23 3D laparoscopic colectomy were performed at our Department. Data were analyzed and reported both by approach and by colectomy side. Robotic left colectomy (RL) vs laparoscopic 3D left colectomy (LL 3D) and Robotic right colectomy (RR) vs laparoscopic 3D (LR 3D). Rectal cancer procedures were not included.

RESULTS: There were 18 RR and 11 LR 3D, 6 RL and 12 LL 3D. As regards LR 3D, extracorporeal anastomosis (EA) was performed in 7 patients and intracorporeal anastomosis (IA) in 4; the RR group included 14 IA and 4 EA. There was no mortality. Median operative time was higher for the robotic group while conversion rate (12.5% vs 13%) and lymph nodes removed (14 vs 13) were similar for both. First flatus time was 1 d for RR and 2 d the other patient groups. Oral intake was resumed in 1 d by LR and in 2 d by the other patients (P = 0.012). Overall cost was €4950 and €1950 for RL and LL 3D, and €4450 and €1450 for RR and LR 3D, respectively.

CONCLUSION: There were no differences between RR and LR 3D, except that IA was easier with RR, and probably contributed with the learning curve to the longer operative time recorded. Both techniques offer similar advantages for the patient with significantly different costs. In left colectomies robotic colectomy provided better outcomes, especially in resections approaching the rectum.

Key Words: Three-dimensional vision systems; Robotic surgery; Laparoscopic surgery; Colectomy; Costs; Short-term outcomes

Core tip: Three-dimensional (3D) vision systems (Robotic and 3D laparoscopy) have been applied recently in the field of general colorectal surgery. They have brought a lot of benefits not only for the surgeon but also for the patient. However the robotic technique is very expensive, and no study has been published comparing these two techniques. Here, we compared robotic colorectal surgery to 3D laparoscopic with respect to short term outcomes and costs.

INTRODUCTION

Laparoscopy has been a reliable approach for colon cancer surgery for a number of years[1,2]. Technological advances have introduced significant improvements. Currently available technologies include robotically assisted surgery, three-dimensional (3D) vision, computer graphics, 4k laparoscopic systems, and other methods[3]. 3D surgical imaging systems provide stereoscopic depth information that conventional 2D display systems cannot supply. Stereoscopic projection technology improves the performance, proficiency, as well as teaching of minimally invasive surgery[4,5]. Robotic systems derive from military medical research directed at improving procedure feasibility, safety and efficacy[6,7]. Since their introduction they have been applied to several surgical specialties, to overcome the inherent limitations of laparoscopy[6]. The main advantages of robotic systems include high-definition 3D vision, magnification up to 10 ×, and an endo-wrist with 360° range of movement. However, reports of robotic colectomy (RC) involve small series[7-10], and there are no studies comparing laparoscopic colectomy (3DLC) to RC. According to the literature, either approach enhances surgeon performance; however, it is still unclear whether they also involve advantages for the patient. The aim of this study was to compare the benefits, short-term outcomes, and cost of 3DLC and RC.

MATERIALS AND METHODS

Study population

From June 2013 to September 2014, 47 of the colon cancer procedures performed at our Department used a minimally invasive 3D vision technique. For all patients, demographics, pathological examination, operative details and postoperative outcomes were retrospectively collected and analyzed.

Surgical procedure

Patient assignation to robotic colectomy or 3D laparoscopic colectomy depended exclusively on equipment availability. All procedures were performed by two skilled laparoscopic surgeons, that performs almost 200 laparoscopic operations per year, who had performed at least 100 3D laparoscopic procedures and who had recently begun using the robotic equipment. Right colectomy was defined as the procedure that involves removing the cecum, the ascending colon, the hepatic flexure, the first one third of the transverse colon and part of the terminal ileum along with fat and lymph nodes. Left colectomy was defined as the procedure that involves removing of the distal transverse colon, descending colon and sigmoid colon with colorectal anastomosis. Rectal cancer procedures were excluded because of their complexity while surgeons are in their learning curve.

Perioperative management

Post-operative management of patients included a specific fast track protocol. An early mobilization and an early re alimentation was guaranteed as soon as possible according to patients condition and co-operation. No patient was discharged earlier than 5 d as the local health care system does not provide home assistance.

Statistical analysis

The benefits, short-term outcomes, and cost of 3D laparoscopic colectomy and robotic colectomy were examined and compared. A retrospective analysis of all data was performed. Since right and left colectomy are technically different procedures, data were analyzed both in terms of approach used and of colectomy side (Figure 1). For the quantitative values the median was calculated as a measure of centrality and the 1^st and 3^rd quartiles as a measure of variability. The qualitative values were expressed as actual values and percentage. Data were divided into right and left colectomies. The Wilcoxon test for independent samples was applied to the quantitative values and the χ² test and Fisher’s test to the qualitative values. Statistical significance was set at α < 0.05. The IBM SPSS Statistics program was used for all analyses.

Figure 1 Study design. RL: Robotic left colectomy; LL: Laparoscopic left colectomy.

RESULTS

Patients were 24 men and 23 women with a mean age of 68 years. There were 24 robotic colectomy and 23 3D laparoscopic colectomy. The robotic colectomy and laparoscopic 3D groups were of comparable age and body mass index and were not significantly different in terms of disease stage, ASA class, or previous surgery. Patients underwent 18 right robotic colectomy (RR), 11 right 3D laparoscopic colectomy (LR 3D), 6 left robotic colectomy (RL), and 12 left laparoscopic colectomy (LL 3D) (Figure 1). As regards LR 3D, extracorporeal anastomosis (EA) was performed in 7 patients and intracorporeal anastomosis (IA) in 4; the RR group included 14 IA and 4 EA. The benefits, short-term outcomes, and cost of laparoscopic 3D colectomy and robotic colectomy are analyzed and reported by side and technique.

Left colectomy

Operative results: As regards the 18 left colectomies - 6 RL and 12 LL 3D - there were no significant differences between patients in terms of operative results such as operative time, intraoperative blood loss, complications and number of lymph nodes removed. These data are reported in Table 1 and Figure 2. The conversion rate was higher in RC, albeit without significant differences: 2 RC were converted to 2D laparoscopy and one 3DLC to open surgery. EA was performed in 4 LL and 1 RL patient; in the other cases the Knight Griffen method was adopted. Median operative time was 100 min for RL and 167 min for LL.

Table 1 Qualitative and quantitative characteristics of left colectomies n (%).

	RL (n = 6)	LL 3D (n = 12)	P value
Gender
Male	1 (16.7)	5 (41.7)	0.600
Female	5 (83.3)	7 (58.3)
Anastomosis
Extracorporeal	1 (16.7)	4 (33.3)	0.615
Intracorporeal	5 (83.3)	8 (66.7)
Conversions	2 (33.3)	1 (8.3)	0.245
Complications	1 (16.7)	1 (8.0)	1.000
Pain medications	5 (83.3)	9 (75.0)	1.000
Age1	65 (63-72)	66 (57-74)	0.708
BMI1	26 (23-28)	27 (26-29)	0.353
Overall time1 (min)	175 (146-196)	167 (144-186)	0.672
Surgical time1 (min)	114 (99-149)	113 (94-130)	0.707
Anesthesia time1 (min)	159 (133-176)	153 (118-166)	0.605
Hospital stay1 (d)	6 (6-9)	6 (6-9)	0.526
Solid food1 (d)	1 (1-2)	2 (2-2)	0.012
First flatus1 (d)	2 (1-5)	2 (1-4)	0.567
Mobilization1 (d)	2 (1-2)	1 (1-2)	0.610
Lymph nodes removed1	13 (9-15)	13 (9-16)	0.189
Duration of pain medications1 (d)	3 (2-4)	2 (1-2)	0.316
DRG1	7326 (7326-10570)	7326 (7326-11660)	0.911

¹Median (1^st-3^rd quartile). RL: Robotic left colectomy; LL: Laparoscopic left colectomy; BMI: Body mass index; DRG: Disease related group.

Figure 2 Left colectomy: Surgical time, oral intake, complications, and disease related group.

Postoperative results and complications: Postoperative results were comparable in terms of amount of pain medications, first passage of flatus, mobilization, hospital stay or disease-related group (DRG). The 6 RL patients began to eat solid food significantly earlier (P = 0.012) than the 12 LL patients (median 1 d vs 2 d). The only complication in RL was an anastomotic leakage that was treated with re-intervention; the sole complication in the LL group was an abdominal abscess that was treated with percutaneous drainage.

Costs: The two left colectomies fall under the same DRG despite the fact that their cost at discharge may vary due to possible complications and hospital stay. The cost of RC was higher. In fact, even excluding equipment purchase and maintenance costs, RL cost €4950 and LL cost €1950.

Right colectomy

Operative results: As regards the right colectomies, there were 18 RR and 11 LR. There were no significant differences between these patients in terms of operative results such as intraoperative blood loss and number of lymph nodes removed. These data are reported in Table 2 and Figure 3. Median operative time was 173 min for RR and 145 min for LR; the difference was significant (P = 0.006). One RR and 2 LR required conversion to open procedures, and the difference was not significant. All conversions involved patients with previous abdominal surgery. IA were 14 in RR and 4 in LR; the remaining 11 patients had EA performed with a mechanical suture technique.

Table 2 Qualitative and quantitative characteristics of right colectomies n (%).

	RR (n = 18)	LR 3D (n = 11)	P value
Sex
Male	9 (50)	9 (81.8)	0.187
Female	9 (50)	2 (18.2)
Anastomosis
Extracorporeal	4 (22.2)	7 (63.6)	0.070
Intracorporeal	14 (77.8)	4 (36.4)
Conversions	1 (5.6)	2 (18.2)	0.649
Complications	3 (16.7)	4 (36.4)	0.449
Pain medication	11 (61.1)	6 (54.5)	0.449
Age1	74 (57-80)	65 (59-75)	0.559
BMI1	26 (24-28)	26 (23-28)	0.654
Overall time1 (min)	173 (156-189)	145 (130-155)	0.006
Surgical time1 (min)	130 (106-139)	100 (95-120)	0.033
Anesthesia time1 (min)	155 (134-164)	125 (118-140)	0.008
Hospital stay1 (d)	5 (5-7)	5 (5-10)	0.723
Solid food1 (d)	2 (2-3)	2 (2-2)	0.137
First flatus1 (d)	1 (1-3)	2 (2-4)	0.927
Mobilization1 (d)	2 (1-2)	1 (1-2)	0.345
Lymph nodes removed1	14 (8-20)	14 (9-20)	0.829
Duration of pain medication1 (d)	1 (0-2)	1 (0-2)	0.832
DRG1	7326 (7326-7326)	7326 (7326-9492)	0.588

¹Median (1^st-3^rd quartile). RL: Robotic left colectomy; LL: Laparoscopic left colectomy; BMI: Body mass index; DRG: Disease related group.

Figure 3 Right colectomy: Surgical time, oral intake, complications, and disease related group, and type of anastomosis.

Postoperative results and complications: Postoperative results were comparable in terms of hospital stay, complications, amount of pain medications, first flatus time, mobilization and time until tolerance of solid food. Three RR patients had anastomosis bleeding that was managed with transfusion, since all had roughly 10 g/dL hemoglobin before surgery. As regards LR, one patient had postoperative bleeding that required transfusion and another had wound dehiscence.

Costs: These two operations also fall under the same DRG, despite their different final cost at discharge. The cost of the procedure was €4450 for RR and €1450 for LR.

DISCUSSION

Since its introduction, robotics surgery has been proved to be a safe and effective technique for various procedures, including complex ones[8,10,11]. The first RC for colorectal cancer was performed almost 14 years ago[12]. Since then the technology has spread widely, and results have been published by several groups[10,13-15]. However, most of the studies assessing the benefits of robotic surgery have compared it to open surgery, not to laparoscopy[16-18]. The main advantages of robotic surgery have been documented in gastrectomy and colorectal resections[7]. The few studies comparing robotic and (2D) laparoscopy found similar benefits, but a higher cost and longer operative time for the former technique. Finally, there are no studies comparing robotic and 3D laparoscopy. Two ongoing randomized trials, the ACOSOG Z6051 and the ROLARR (Robotic vs Laparoscopic Resection for Rectal cancer) are evaluating RC and 3DLC. While awaiting their findings, laparoscopy remains the optimal approach in terms of patient outcomes and use of healthcare resources[19]. Where the oncological results are concerned, the robot likely performs superior total mesorectal excisions (TME) in a narrow and deep space[20]. With regard to surgeon benefits, a multicenter study by Pigazzi et al[21] found an interesting 97% survival rate 3 years after robotic TME. The literature suggests that there are no significant differences in the other oncological measures between the two techniques, thus confirming the safety of robotic surgery[22]. The majority of studies refer mainly to rectal cancer or colorectal cancer and there is poor evidence in the literature concerning colon cancer alone.

Despite the small sample, our data agree with the above reports; for instance the number of lymph nodes removed was similar for both approaches in all resections. None of the short-term outcomes evaluated in our study were significantly different, except the interval until solid oral intake, which was 1 d for RL and 2 d for all the other procedures (P = 0.012). Operating time was significantly longer between RR and LR 3D (P = 0.006) (median 173 min vs 145 min). This is easily explained by the higher rate of IA in the RR compared with the LR 3D group (14 vs 4).

Some studies have suggested that in RR patients IA may result in superior postoperative outcomes and lower extraction site morbidity, such as herniation[23,24]. Moreover, a hand-sewn laparoscopic IA is quite complex to perform: this part of the procedure is enhanced by the robot, which provides considerable benefits, especially in the case of obese patients with a short and heavy mesentery[24]. The shorter RC incision is also an advantage, especially to the extent that it reduces the risk of wound infection[25]. Nevertheless, the feasibility of robotic surgery needs further evaluation.

Despite these advantages, the price of robotic equipment is a problem for stressed western economies. Previous publications have described the poor cost-effectiveness of RC. Other studies have stressed that the steep purchase cost is accompanied by expensive dedicated disposable instruments and tools[19]. In our experience and according to the literature, RC costs almost three times as much as 3DLC procedure even without factoring in the purchase cost[26,27]. Our study provides no clear evidence of postoperative benefits that would help offset such greater cost[19]. 3D vision is one of the main advantages of robotics technology, but based on our data 3DLC provided similar short-term outcomes at a lower cost.

However, the present study refers to a preliminary experience and has several limitations. Most importantly, this was a retrospective study and with a small sample size. In addition, results can be influenced by surgeon being in their learning curve of robotic surgery. The lack of high quality data in literature in this field demonstrates the need for randomized clinical trials.

Why then should we invest in this new technology? For example, the United Kingdom has adopted an integrated national teaching program to extend laparoscopic surgery, including 3D laparoscopy, instead of RC technology, to achieve a more efficient and effective use of healthcare resources[28]. Yet robotic should be viewed as the natural evolution of laparoscopy, even though its indications are still to be defined. Robotics surgery overcomes the limitations of laparoscopy, also by reducing the conversion rate[29,30] and improving nerve function[19]. The current state of healthcare resources suggests that 3D laparoscopy should be extended to treat the majority of patients with colon cancer, but it should be stressed that RC provides an opportunity to develop the technology further with the same safety profile and efficiency of treatment. Finally, a Dutch study[31] suggests that evaluation of a new technology should take into account its affordance. The Affordances approach “can capture empirically the contextual dynamics of technology adoption in health care by exploring in depth actor’s interaction with the technology while considering the interpretative spaces created in situation of use. This is the best way to elicit real-life values of innovations, values as defined through the eyes of the (potential) users”[31]. According to this approach, robotics surgery is both rational and inevitable.

Further evaluation is required to establish the clinical benefits and real cost of RC before its introduction into routine practice. The two techniques fall under the same DRG despite the fact that RC is more expensive. This currently limits its use to cases where laparoscopy is least effective and RC provides real advantages to patients, but this requires further comparative studies. Robotics should be considered as the logical evolution of laparoscopy. The only way to develop it is to use it.

COMMENTS

Background

Colorectal cancer is one of the most common cancers worldwide. Surgery is the only potentially curative therapeutic option. Laparoscopy has been a reliable approach for colon cancer surgery for a number of years. Three-dimensional (3D) laparoscopy represents the latest evolution of this technique. Recently, robotics has been introduced in general surgery. Robotics surgery has been proved to be a safe and effective technique for various procedures, including complex ones. The first robotic colectomy for colorectal cancer was performed almost 14 years ago.

Research frontiers

Technological advances have introduced significant improvements in general surgery. 3D vision systems have brought many benefits to the surgeon. Robotic surgery remains the latest challenge for the surgeon. Actually the hot topic in literature is how much these new technologies can bring benefits not only for the surgeon, but also for the patient with acceptable costs.

Innovations and breakthroughs

Various studies in the literature have compared robotic surgery to open surgery, and only a few have compared it with other types of mini-invasive surgery. No study has compared 3D laparoscopic surgery with Robotics in the field of colorectal surgery. This study evaluate the short outcomes of Robotic vs laparoscopic 3D surgery in colorectal cancer, as well as its economic feasibility.

Applications

The data in this study suggested that there are no significant advantages for the patient performing robotic vs 3D laparoscopic resections for colon cancer. Furthermore, this study also provided readers with important information regarding the economic obstacles. This study did not evaluate rectal cancer, where significant advantages exist according to the literature and robotics should be adopted. The authors suggest that economic resources should be more properly invested to extend laparoscopic surgery, especially 3D rather than robotics, in the field of colon cancer. Nowadays robotic colectomy provides an opportunity to develop the technology further with the same safety profile and efficiency of treatment.

Terminology

Currently available technologies include robotically assisted surgery, 3D vision, computer graphics, 4k laparoscopic systems, and other methods. 3D surgical imaging systems provide stereoscopic depth information that conventional 2D display systems cannot supply. Stereoscopic projection technology improves the performance, proficiency, as well as teaching of minimally invasive surgery.

Peer-review

To date, no study has compared 3D laparoscopic surgery with Robotics in the field of colorectal surgery. This study evaluated the short outcomes of Robotic vs laparoscopic 3D surgery in colorectal cancer checking, as well as its economic feasibility. These findings could be applied in clinical practice right away. They are likely to be of great interest to the vision of surgeons, researchers, clinicians, and trainees.