Robotic-assisted colorectal surgery in obese patients: a case-matched series.

BACKGROUND: Reports demonstrate laparoscopic colorectal surgery in obese patients is associated with higher conversion to laparotomy and complication rates. While several advantages of robotic-assisted surgery have been reported, outcomes in obese patients have not been adequately studied. Therefore, this study compares outcomes of robotic-assisted surgery in non-obese and obese patients. METHODS: A retrospective review of 331 consecutive robotic procedures performed at a single institution between 2009 and 2015 was performed. Patients were divided into non-obese (BMI <30 kg/m2) and obese (BMI ≥30 kg/m2) groups, and were clinically matched by gender, age, and procedure performed. Intraoperative and postoperative complications, operative time, estimated blood loss, and length of stay were examined. RESULTS: Following matching, each group included 108 patients comprised of 50 men and 58 women. Mean BMI was 24.6 ± 3.15 and 36.2 ± 5.67 kg/m2 (p < 0.0001), and the mean age was 59.2 ± 11.28 years for non-obese patients and 57.1 ± 12.44 for obese patients (p = 0.18). Surgeries included low anterior resection, right colectomy, left colectomy, sigmoid colectomy, excision of rectal endometriosis, total proctocolectomy, APR, subtotal colectomy, ileocecectomy, proctectomy, rectopexy, transanal excision of rectal mass, and colostomy site hernia repair. The mean operative time was 272.69 ± 115.43 and 282.42 ± 120.51 min (p = 0.55), estimated blood loss 195.23 ± 230.37 and 289.19 ± 509.27 mL (p = 0.08), conversion to laparotomy 6.48 and 9.26 % (p = 0.45), and length of stay 5.38 ± 4.94 and 4.56 ± 4.04 days (p = 0.18) for the non-obese and obese groups, respectively. Twenty of the non-obese patients had postoperative complications as compared to 27 of the obese patients (p = 0.30). However, the prevalence of wound complications was higher in obese patients (1.9 vs 9.3 %; p = 0.03). CONCLUSION: There is no difference in conversion to laparotomy and overall complication rates in non-obese and obese patients undergoing robotic-assisted colorectal surgery. However, obesity is associated with a higher prevalence of wound complications. Robotic-assisted surgery may minimize conversion to laparotomy and complications typically seen in obese patients due to improved visualization, instrumentation, and ergonomics.

Incisional and port-site hernias following robotic colorectal surgery.

BACKGROUND: The association between extraction site location, robotic trocar size, and the incidence of incisional hernias in robotic colorectal surgery remain unclear. Laparoscopic literature reports variable rates of incisional hernias versus open surgery, and variable rates of trocar site hernias. However, conclusions from these studies are confusing due to heterogeneity in closure techniques and may not be generalized to robotic cases. This study evaluates the effect of extraction site location on incisional hernia rates, as well as trocar hernia rates in robotic colorectal surgery. MATERIALS AND METHODS: A retrospective review of multiport and single incision robotic colorectal surgeries from a single institution was performed. Patients underwent subtotal, segmental, or proctocolectomies, and were compared based on the extraction site through either a muscle-splitting (MS) or midline (ML) incision. Hernias were identified by imaging and/or physical exam. Demographics and risk factors for hernias were assessed. Groups were compared using a multivariate logistic regression analysis. RESULTS: The study included 259 colorectal surgery patients comprising 146 with MS and 113 with ML extraction sites. Postoperative computed tomograms were performed on 155 patients (59.8 %) with a mean follow-up of 16.5 months. The overall incisional hernia rate was 5.8 %. A significantly higher hernia rate was found among the ML group compared to the MS group (12.4 vs. 0.68 %, p < 0.0001). Of the known risk factors assessed, only increased BMI was associated with incisional hernias (OR 1.18). No trocar site hernias were found. CONCLUSION: Midline extraction sites are associated with a significantly increased rate of incisional hernias compared to muscle-splitting extraction sites. There is little evidence to recommend fascia closure of 8-mm trocar sites.

Single-incision robotic colectomy (SIRC): Current status and future directions.

By combining laparo-endoscopic single-site surgery (LESS) techniques with the da Vinci robotic platform, single-incision robotic colectomy (SIRC) aims to further minimize incision-related complications and improve cosmetic outcomes from the current standard of care, laparoscopic colectomy. While there is limited literature on SIRC, all available reports suggest SIRC to be a safe and feasible procedure in terms of perioperative outcomes. Future research should focus on further clarification of proposed benefits of SIRC such as cosmetics, ergonomics, incidence of incision-related complications, and long-term oncologic outcomes.

Single-Incision Robotic Colectomy (SIRC) case series: initial experience at a single center.

BACKGROUND: Laparoscopic colectomy has been associated with favorable outcomes when compared to open colectomy. Single-Incision Robotic Colectomy (SIRC) is a novel procedure hypothesized to improve upon conventional three-port laparoscopic colectomy. We hereby present and analyze our institution's initial experience with SIRC. METHODS: We performed a retrospective review of 59 patients who underwent SIRC between May 2010 and September 2013, attempting to identify factors associated with conversion rate and postoperative complication rate. RESULTS: Our study included 34 males (57.6%) and 25 females (42.4%). The mean age was 60.3 years (range 29-92 years), and the mean BMI was 26.6 kg/m(2) (range 14.9-39.7 kg/m(2)). We identified 31 right hemicolectomies (53.4%), 20 sigmoid colectomies (34.5%), 5 left hemicolectomies (1.7%), 2 low anterior resections (3.5%), and 1 total colectomy (1.7%). The overall median operative time was 188 min with an interquartile range of 79 min. Surgical indications included diverticulitis (n = 23, 39.0%), benign colonic mass (n = 18, 30.5%), colon cancer (n = 16, 27.1%), familial adenomatous polyposis (n = 1, 1.7%), and Crohn's disease (n = 1, 1.7%). There were four conversions to open procedure (6.8%), three conversions to multiport robotic procedure (5.1%), and one conversion to single-port laparoscopic procedure (1.7%). Reasons for conversions include difficulty mobilizing the colon and robotic equipment malfunction. Conversions were associated with both higher complication rates (62.5 vs 25.5%, p = 0.035) and longer LOS (7.4 vs 4.0 days, p = 0.0003). Postoperative complications occurred in 16 of the 59 cases (27.1%). Higher BMI was the only significant risk factor for postoperative complications. The overall median LOS was 4 ± 2 days, while the median estimated blood loss was 100 ± 90 ml. CONCLUSIONS: Our experience has shown that SIRC can be a safe and feasible procedure for both benign and malignant disease. Patient selection is the key to improving surgical outcomes in SIRC.

The Use of Robotic and Laparoscopic Surgical Stapling Devices During Minimally Invasive Colon and Rectal Surgery: A Comparison.

PURPOSE: To date there exists no published study examining the safety and efficacy of the EndoWrist 45 (Intuitive Surgical, Inc.) robotic stapler. We compared outcomes between the robotic and comparable laparoscopic stapler in robotic-assisted colorectal procedures. MATERIALS AND METHODS: We conducted a retrospective review of 93 patients who underwent robotic-assisted colorectal surgery at our institution from 2012 to 2014. Surgeries included left, sigmoid, subtotal and total colectomies, and low anterior rectal resections. Indications were malignancy and diverticular and inflammatory bowel disease. Preoperative demographics, intraoperative data, and postoperative outcomes were examined. Student's t-test and Fischer's exact used were appropriate. RESULTS: Forty-five millimeters laparoscopic staplers were used in 58 cases, while the 45 mm robotic stapler was used in 35 cases. There was no difference in age (P = .651), gender (P = .832), or body mass index (P = .204) between groups. There was no difference in estimated blood loss (P = .524), operative time (P = .769), length of stay (P = .895), or complication rate (P = .778). The robotic stapler group had one anastomotic leak, while the laparoscopic stapler group had six (P = .705). There were more laparoscopic stapler fires (2.69) per patient than robotic stapler fires (1.86) (P = .001). The cost per patient for the laparoscopic group was $631.45 versus $473.28 for the robotic group (P = .001). CONCLUSION: This is the first study to evaluate the robotic stapler. Advantages of the robotic stapler include large range of motion and 90° of articulation, which may provide a benefit when using the stapler in difficult areas like the pelvis. The robotic stapler has a comparable level of safety as a 45 mm laparoscopic stapler and is more cost effective.

Microscopic margins and patterns of treatment failure in resected pancreatic adenocarcinoma.

OBJECTIVE: To correlate microscopic margin status with survival and local control in a large cohort of patients from a high-volume pancreatic cancer center. DESIGN: Retrospective database review. A uniform procedure for margin analysis was used with 4-color inking (neck, portal vein groove, uncinate, and posterior pancreatic margin) by the surgeon in the operating room. SETTING: A tertiary care hospital. PATIENTS: We reviewed patients who underwent pancreaticoduodenectomy between September 1, 1997, and December 31, 2008, from a prospective, institutional database. MAIN OUTCOME MEASURES: Using Cox regression models, we identified pathologic characteristics associated with local recurrence (LR) after controlling for potential confounding variables. Overall and LR-free survival curves were generated by the Kaplan-Meier method. RESULTS: Of 285 patients who underwent pancreaticoduodenectomy for pancreatic adenocarcinoma, 97 (34.0%) had 1 or more positive microscopic margins (uncinate, 16.5%; portal vein groove, 8.8%; neck, 7.7%; and posterior, 10.5%). A total of 198 patients (69.5%) recurred, with the first site of failure being LR only in 47 (23.7%), local plus distant recurrence in 42 (21.2%), and distant recurrence only in 109 (55.1%). Patients with LR only were significantly more likely to have lymph node involvement (adjusted hazard ratio, 2.66; 95% CI, 1.25-5.63) or a positive posterior margin (adjusted hazard ratio, 4.27; 95% CI, 2.07-8.81). Patients with a positive posterior margin had significantly poorer LR-free survival with (P < .001) or without (P = .01) lymph node involvement. CONCLUSIONS: When systematically assessed, the incidence of positive microscopic margins is high. Positive posterior margins and lymph node involvement were each independently and significantly associated with LR.