The robotic colorectal experience: an outcomes and learning curve analysis of 502 patients.

AIM: This study aimed to present our experience with robotic colorectal surgery since its establishment at our institution in 2009. By examining the outcomes of over 500 patients, our experience provides a basis for assessing the introduction of a robotic platform in a colorectal practice. Specific measures investigated include intraoperative data and postoperative outcomes for all operations using the robotic platform. In addition, for our most commonly performed operations we wished to analyse the learning curve to improve operative proficiency. This is the largest single-surgeon robotic database analysed to date. METHOD: A prospectively maintained database of patients who underwent robotic colorectal surgery by a single surgeon at the George Washington University Hospital was retrospectively reviewed. Demographic data and perioperative outcomes were assessed. Additionally, an operating time learning curve analysis was performed. RESULTS: Inclusion criteria identified 502 patients who underwent robotic colorectal surgery between October 2009 and December 2018. The most common indications for surgery were diverticulitis (22.9%), colon adenocarcinoma (22.1%) and rectal adenocarcinoma (19.5%). The most common operations were anterior/low anterior resection (33.9%), right hemicolectomy/ileocaecectomy (24.9%) and left hemicolectomy/sigmoidectomy (21.9%). The rate of conversion to open surgery was 4.8%. The most common postoperative complications were wound infection (5.0%), anastomotic leakage (4.0%) and abscess formation (2.8%). The operating time learning curve plateaued at 55-65 cases for anterior and low anterior resection and 35-45 cases for left hemicolectomy and sigmoidectomy. A clear learning curve was not seen in right hemicolectomy. CONCLUSION: Robotic-assisted surgery can be performed in a diverse colorectal practice with low rates of conversion and postoperative complications. Plateau performance was achieved after 65 anterior/low anterior resections and 45 left and sigmoid colectomies.

The impact of the AirSeal® valve-less trocar system in robotic colorectal surgery: a single-surgeon retrospective review.

BACKGROUND: Traditional trocar systems suffer from several innate flaws due to their silicone seal design. The AirSeal® is a valve-less trocar system that overcomes these flaws by utilizing a system of laminar flow and CO2 recirculation. The purpose of this paper is to examine the effect of the AirSeal® versus a traditional trocar system in operative time, EBL and post-operative complications. To the best of our knowledge, this is the first analysis of this system in robotic colorectal surgery. METHODS: A single surgeon's database was reviewed and all LAR and right hemicolectomy robotic cases from 2014-2015 and 2017-2018 were included for analysis. Patient demographic information was evaluated and primary outcomes examined were operative time, EBL, post-operative complications and hospital LOS. RESULTS: Ninety four patients were identified in the LAR cohort and 56 patients were identified in the right hemicolectomy cohort. Mean operative time for LAR was 293 ± 91.6 min in 2014-2015 and 232 ± 74.6 min in 2017-2018 (p = 0.001); however, this significant difference was not seen between right hemicolectomies. Mean EBL for LAR was 209 ± 189 cc in 2014-2015 and 150 ± 173.9 cc in 2017-2018 (p = 0.05); again, this significant difference was not appreciated for right hemicolectomies. There was no statistically significant difference in rates of wound infections, pneumonia, post-operative pneumonia, DVT/PE, intra-abdominal/pelvic abscesses, or unplanned 30-day readmission rate between 2014-2015 and 2017-2018. Length of stay was reduced in both populations between 2014-2015 and 2017-2018; however, it neither reached statistical significance. CONCLUSION: In patients undergoing low anterior resections, the AirSeal® trocar system demonstrated a statistically significant reduction in mean operative time and EBL compared to the traditional trocar system. There was also a trend towards decreased length of stay and post-operative complications with AirSeal® use in low anterior resections and right hemicolectomies. In patients undergoing distal colorectal procedures, the AirSeal® trocar system should be considered.

Robotic-assisted surgery for complicated and uncomplicated diverticulitis: A single-surgeon case-series comparison.

BACKGROUND: Robotic-assisted techniques in colorectal surgery have dramatically increased. Comparative data on the management of uncomplicated and complicated diverticulitis using robotics is lacking. The purpose of this study is to examine outcomes of patients who underwent robotic-assisted resection in diverticulitis. METHODS: A prospectively maintained database performed by a single surgeon was retrospectively reviewed to identify patients who underwent robotic-assisted surgery (RAS) for diverticulitis from October 2009 to November 2018. Demographic data, preoperative and intraoperative parameters and postoperative outcomes were assessed using χ2 or Fisher exact test with p values <0.05 considered significant. IRB approval was obtained for this study, #NCR190935. RESULTS: Comparison revealed significant differences in operative times (222 vs. 291 min, p < 0.00001), mean estimated blood loss (130 vs. 304 cc, p = 0.0003) and mean length of stay (3.9 vs. 5.0 days, p = 0.006). Low rates of postoperative complications were observed, with no significant differences noted for conversion to laparoscopy, surgical site infection, leak, intra-abdominal abscess, 30-day unplanned readmission or recurrence. CONCLUSION: Patients with complicated diverticulitis required longer operative time, had increased estimated blood loss and more often converted to an open procedure; however, overall rates of post-operative complications were low in both groups. RAS shows promise for use in complicated diverticulitis.

The outcomes of two robotic platforms performing transanal minimally invasive surgery for rectal neoplasia: a case series of 21 patients.

Colorectal cancer remains the third most common cancer effecting adults. Surgical guidelines recommend transanal excision of early rectal neoplasia up to 8 cm from the anal verge. A retrospective review of two novel approaches for transanal robotic local excision with R0 resections of rectal cancers which was, on average, higher than 8 cm. Twenty-one cases of robotic assisted transanal surgery for early stage disease (T0-T1, N0) were reviewed. The first 10 cases performed with the da Vinci® Si robotic platform between 2013 and 2016, and the first 11 cases performed using the Flex® Medrobotics platform between August 2017 and August 2018. The average distance from the anal verge was 11.1 cm and 9.5 cm for the da Vinci® Si and Flex® Colorectal Drive, respectively. The average operative time was 167.6 min for the da Vinci® Si and 110.1 min for the Flex® Colorectal Drive; the average EBL was 37.5 cc and 9.1 cc for the da Vinci® Si and Flex® Colorectal Drive. In the da Vinci® series, four cases required intraoperative conversion. In the Flex® series, one case was aborted due to unfavorable robotic positioning. All margins were histologically negative when surgically complete with no recurrences to date. Transanal robotic surgery may provide a method to address rectal lesions farther from the anal verge than previously described. The Flex® Colorectal Drive platform may provide superior ability to navigate the nonlinear anatomy of the rectum and distal sigmoid colon.