Stapled Anastomosis Versus Hand-Sewn Anastomosis With Mucosectomy for Ileal Pouch-Anal Anastomosis: A Systematic Review and Meta-analysis of Postoperative Outcomes, Functional Outcomes, and Oncological Safety.

PURPOSE: This systematic review and meta-analysis aimed to compare outcomes between stapled ileal pouch-anal anastomosis (IPAA) and hand-sewn IPAA with mucosectomy in cases of ulcerative colitis and familial adenomatous polyposis. METHODS: This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis) guidelines 2020 and AMSTAR 2 (Assessing the methodological quality of systematic reviews) guidelines. We included randomized clinical trials (RCTs) and controlled clinical trials (CCTs). Subgroup analysis was performed according to the indication for surgery. RESULTS: The bibliographic research yielded 31 trials: 3 RCTs, 5 prospective clinical trials, and 24 CCTs including 8872 patients: 4871 patients in the stapled group and 4038 in the hand-sewn group. Regarding postoperative outcomes, the stapled group had a lower rate of anastomotic stricture, small bowel obstruction, and ileal pouch failure. There were no differences between the 2 groups in terms of operative time, anastomotic leak, pelvic sepsis, pouchitis, or hospital stay. For functional outcomes, the stapled group was associated with greater outcomes in terms of seepage per day and by night, pad use, night incontinence, resting pressure, and squeeze pressure. There were no differences in stool Frequency per 24h, stool frequency at night, antidiarrheal medication, sexual impotence, or length of the high-pressure zone. There was no difference between the 2 groups in terms of dysplasia and neoplasia. CONCLUSIONS: Compared to hand-sewn anastomosis, stapled ileoanal anastomosis leads to a large reduction in anastomotic stricture, small bowel obstruction, ileal pouch failure, seepage by day and night, pad use, and night incontinence. This may ensure a higher resting pressure and squeeze pressure in manometry evaluation. PROTOCOL REGISTRATION: The protocol was registered at PROSPERO under CRD 42022379880.

The Impact of a Modular Robotic Total Mesorectal Excision Training Program on Perioperative and Oncological Outcomes in Robotic Rectal Cancer Surgery.

BACKGROUND: Structured training programs for robotic colorectal surgery are limited, and there are concerns about surgical outcomes and operating times. OBJECTIVE: To compare perioperative and oncological outcomes of robotic total mesorectal excision for rectal cancer performed by expert consultants and surgical trainees in a modular surgical training program. DESIGN: Retrospective cohort study. SETTINGS: Conducted at a colorectal training referral center for robotic surgery. PATIENTS: Consecutive robotic total mesorectal excision cases between May 2013 and December 2017 were evaluated retrospectively from a prospectively maintained institutional database and divided into 2 groups: group I comprised expert surgeons and group II comprised supervised trainees. Robotic total mesorectal excision training modules (5 modules) were performed stepwise with increasing complexity. Patients' demographic, perioperative, and oncological data were collected. INTERVENTIONS: Modular robotic training. MAIN OUTCOME MEASURES: Comparable R0 resection rate, lymph node harvest, and oncological outcomes between experts and trainees, suggesting good quality in oncological resection. RESULTS: A total of 177 robotic total mesorectal excision resections were performed (group I: n = 80, group II: n = 97). Four trainees completed 37.5 modules each. Patients' age, sex, and BMI were similar between groups. Group II had a higher ASA III score (6.3% vs 25.8%, p = 0.002). Clinical TNM and neoadjuvant chemoradiotherapy rates were similar. Group II had a longer operative time (225 [197.5-297.5] vs 250 [230-300] minutes, p = 0.004). No conversion occurred. There were no differences in intra- or postoperative outcomes between groups. The rate of R0 resection and the number of harvested lymph nodes were also similar between groups. The median follow-up was 75 (64.0-81.7) and 47 (38.0-55.0) months, respectively. Local and distant recurrence rates, 5-year overall survival (81.1% group I vs 81.3% group II, p = 0.832), and 5-year disease-free survival (79.7% group I vs 80.7% group II, p = 0.725) were similar between groups. LIMITATIONS: The groups operated in 2 consecutive periods. CONCLUSIONS: The robotic total mesorectal excision modular surgical training program maximizes training experience without significantly affecting the perioperative and oncological outcomes of patients with rectal cancer. See Video Abstract. EL IMPACTO DEL PROGRAMA MODULAR DE ENTRENAMIENTO EN ESCISIN MESORRECTAL TOTAL ROBTICA EN LOS RESULTADOS PERIOPERATORIOS Y ONCOLGICOS EN LA CIRUGA ROBTICA DEL CNCER DE RECTO: ANTECEDENTES:Los programas de entrenamiento estructurados para la cirugía colorrectal robótica están limitados debido a preocupaciones sobre los resultados quirúrgicos y los tiempos de operación.OBJETIVO:Comparar los resultados perioperatorios y oncológicos de la escisión mesorrectal total robótica para el cáncer de recto realizada por consultores expertos y aprendices de cirugía en un programa modular de entrenamiento quirúrgica.DISEÑO:Estudio de cohorte retrospectivo.AJUSTES:Realizado en un centro de referencia de entrenamiento colorrectal para cirugía robótica.PACIENTES:Se evaluaron retrospectivamente casos consecutivos de escisión mesorrectal total robótica entre mayo de 2013 y diciembre de 2017 a partir de una base de datos institucional mantenida prospectivamente y se dividieron en dos grupos: Grupo I: cirujanos expertos; Grupo II: aprendices supervisados. Los módulos de entrenamiento robótico de escisión mesorrectal total (cinco módulos) se realizaron paso a paso con complejidad creciente. Se recogieron datos demográficos, perioperatorios y oncológicos.INTERVENCIONES:Entrenamiento modular en robótica.PRINCIPALES MEDIDAS DE RESULTADO:Tasa de resección R0 comparable, extracción de ganglios linfáticos y resultados oncológicos entre expertos y aprendices que sugieren buena calidad en la resección oncológica.RESULTADOS:Se realizaron un total de 177 resecciones por escisión mesorrectal total robótica (Grupo I: n = 80, Grupo II: n = 97). Cuatro alumnos completaron 37,5 módulos cada uno. La edad, el sexo y el IMC fueron similares entre los grupos. El grupo II tuvo una puntuación más alta de la Sociedad Americana de Anestesiólogos III (6,3% frente a 25,8%, p = 0,002). Las tasas clínicas de TNM y quimiorradioterapia neoadyuvante fueron similares. El grupo II tuvo mayor tiempo operatorio (225 (197,5-297,5) vs 250 (230-300) minutos, p = 0,004). No se produjo ninguna conversión. No hubo diferencias en los resultados intra o posoperatorios entre los grupos. La tasa de resección R0 y el número de ganglios linfáticos extraídos también fueron similares entre los grupos. La mediana de seguimiento fue de 75 (64,0-81,7) y 47 (38,0-55,0) meses, respectivamente. Tasas de recurrencia local y a distancia, supervivencia general a 5 años (81,1% Grupo I vs. 81,3% Grupo II, p = 0,832) y supervivencia libre de enfermedad a 5 años (79,7% Grupo I vs. 80,7% Grupo II, p = 0,725) fueron similares entre los grupos.LIMITACIONES:Los grupos operaron en dos períodos consecutivos.CONCLUSIONES:El programa de entrenamiento quirúrgico modular para la escisión mesorrectal total robótica maximiza la experiencia de capacitación sin afectar significativamente los resultados perioperatorios y oncológicos de los pacientes con cáncer de recto. (Traducción-Dr. Aurian Garcia Gonzalez).

Robotic approach to colonic resection: For some or for all patients?

The robotic approach is rapidly gaining momentum in colorectal surgery. Its benefits in pelvic surgery have been extensively discussed and are well established amongst those who perform minimally invasive surgery. However, the same cannot be said for the robotic approach for colonic resection, where its role is still debated. Here we aim to provide an extensive debate between selective and absolute use of the robotic approach for colonic resection by combining the thoughts of experts in the field of robotic and minimally invasive colorectal surgery, dissecting all key aspects for a critical view on this exciting new paradigm in colorectal surgery.

Robotic versus laparoscopic right colectomy for nonmetastatic pT4 colon cancer: A European multicentre propensity score-matched analysis.

AIM: Minimally invasive surgery has been increasingly adopted for locally advanced colon cancer. However, evidence comparing robotic (RRC) versus laparoscopic right colectomy (LRC) for nonmetastatic pT4 cancers is lacking. METHODS: This was a multicentre propensity score-matched (PSM) study of a cohort of consecutive patients with pT4 right colon cancer treated with RRC or LRC. The two surgical approaches were compared in terms of R0, number of lymph nodes harvested, intra- and postoperative complication rates, overall (OS), and disease-free survival (DFS). RESULTS: Among a total of 200 patients, 39 RRC were compared with 78 PS-matched LRC patients. The R0 rate was similar between RRC and LRC (92.3% vs. 96.2%, respectively; p = 0.399), as was the odds of retrieving 12 or more lymph nodes (97.4% vs. 96.2%; p = 1). No significant difference was noted for the mean operating time (192.9 min vs. 198.3 min; p = 0.750). However, RRC was associated with fewer conversions to laparotomy (5.1% vs. 20.5%; p = 0.032), less blood loss (36.9 vs. 95.2 mL; p < 0.0001), fewer postoperative complications (17.9% vs. 41%; p = 0.013), a shorter time to flatus (2 vs. 2.8 days; p = 0.009), and a shorter hospital stay (6.4 vs. 9.5 days; p < 0.0001) compared with LRC. These results were confirmed even when converted procedures were excluded from the analysis. The 1-, 3- and 5-year OS (p = 0.757) and DFS (p = 0.321) did not significantly differ between RRC and LRC. CONCLUSION: Adequate oncological outcomes are observed for RRC and LRC performed for pT4 right colon cancer. However, RRC is associated with lower conversion rates and improved short-term postoperative outcomes.

Robotic transanal minimally invasive surgery (r-TAMIS): perioperative and short-term outcomes for local excision of rectal cancers.

BACKGROUND: Transanal minimally invasive surgery (TAMIS) is an advanced technique for excision of early rectal cancers. Robotic TAMIS (r-TAMIS) has been introduced as technical improvement and potential alternative to total mesorectal excision (TME) in early rectal cancers and in frail patients. This study reports the perioperative and short-term oncological outcomes of r-TAMIS for local excision of early-stage rectal cancers. METHODS: Retrospective analysis of a prospectively collected r-TAMIS database (July 2021-July 2023). Demographics, clinicopathological features, short-term outcomes, recurrences, and survival were investigated. RESULTS: Twenty patients were included. Median age and body mass index were 69.5 (62.0-77.7) years and 31.0 (21.0-36.5) kg/m2. Male sex was prevalent (n = 12, 60.0%). ASA III accounted for 66.7%. Median distance from anal verge was 7.5 (5.0-11.7) cm. Median operation time was 90.0 (60.0-112.5) minutes. Blood loss was minimal. There were no conversions. Median postoperative stay was 2.0 (1.0-3.0) days. Minor and major complication rates were 25.0% and 0%, respectively. Seventeen (85.0%) patients had an adenocarcinoma whilst three patients had an adenoma. R0 rate was 90.0%. Most tumours were pT1 (55.0%), followed by pT2 (25.0%). One patient (5.0%) had a pT3 tumour. Specimen and tumour maximal median diameter were 51.0 (41.0-62.0) mm and 21.5 (17.2-42.0) mm, respectively. Median specimen area was 193.1 (134.3-323.3) cm2. Median follow-up was 15.5 (10.0-24.0) months. One patient developed local recurrence (5.0%). CONCLUSIONS: r-TAMIS, with strict postoperative surveillance, is a safe and feasible approach for local excision of early rectal cancer and may have a role in surgically unfit and elderly patients who refuse or cannot undergo TME surgery. Future prospective multicentre large-scale studies are needed to report the long-term oncological outcomes.

Ambulatory laparoscopic colectomies: a systematic review.

AIM: Ambulatory laparoscopic colectomy (ALC), meaning discharge within 24 h of surgical colonic resection, has recently been proposed in a few, selected patients. This systematic review was performed with the aim of reviewing protocols for ALC and assessing feasibility, safety and outcomes after ALC. METHOD: A PRISMA-compliant systematic review and pooled analysis was performed searching all English studies published until October 2022 in PubMed, Cochrane Library, Web of Science (PROSPERO, CRD42022334463). Inclusion criteria were original articles including patients undergoing ALC, specifying at least one outcome of interest. Exclusion criteria were articles reporting a robotic-assisted procedure; unable to retrieve patient data from articles; the same patient series included in different studies. Primary outcomes were success, overall complications and readmission rates. Secondary outcomes included mortality and specific complications such us surgical site infection, anastomotic leak, ileus, bleeding, rate of ALC acceptance, and unscheduled consultation and reoperation rate. RESULTS: Among 1087 studies imported for screening, 11 were included (1296 patients). The success rate was 47% with an overall morbidity of 14%. Readmission and reoperation rates were 5% and 1%, respectively. No mortality was recorded. Protocols of ALC differ significantly among published studies. CONCLUSIONS: Overall, ALC appears to be safe and feasible in selected cases with an acceptable success rate and a low risk of readmission after hospital discharge. Future studies should evaluate patients' benefits and discharge criteria, as well as uniformity and standardization of eligibility criteria. This systematic review may help inform on ALC adoption in clinical practice.

International standardization and optimization group for intersphincteric resection (ISOG-ISR): modified Delphi consensus on anatomy, definition, indication, surgical technique, specimen description and functional outcome.

AIM: Intersphincteric resection (ISR) is an oncologically complex operation for very low-lying rectal cancers. Yet, definition, anatomical description, operative indications and operative approaches to ISR are not standardized. The aim of this study was to standardize the definition of ISR by reaching international consensus from the experts in the field. This standardization will allow meaningful comparison in the literature in the future. METHOD: A modified Delphi approach with three rounds of questionnaire was adopted. A total of 29 international experts from 11 countries were recruited for this study. Six domains with a total of 37 statements were examined, including anatomical definition; definition of intersphincteric dissection, intersphincteric resection (ISR) and ultra-low anterior resection (uLAR); indication for ISR; surgical technique of ISR; specimen description of ISR; and functional outcome assessment protocol. RESULTS: Three rounds of questionnaire were performed (response rate 100%, 89.6%, 89.6%). Agreement (≥80%) reached standardization on 36 statements. CONCLUSION: This study provides an international expert consensus-based definition and standardization of ISR. This is the first study standardizing terminology and definition of deep pelvis/anal canal anatomy from a surgical point of view. Intersphincteric dissection, ISR and uLAR were specifically defined for precise surgical description. Indication for ISR was determined by the rectal tumour's maximal radial infiltration (T stage) below the levator ani. A new surgical definition of T3isp was reached by consensus to define T3 low rectal tumours infiltrating the intersphincteric plane. A practical flowchart for surgical indication for uLAR/ISR/abdominoperineal resection was developed. A standardized ISR surgical technique and functional outcome assessment protocol was defined.

Trends in emergency colorectal surgery: a 7-year retrospective single-centre cohort study.

BACKGROUND: Emergency colorectal resections carry a higher morbidity and mortality than elective surgery. The use of minimally invasive surgery has now become widespread in elective colorectal surgery, with improved patient outcomes. Laparoscopy is being increasingly used for emergency colorectal resections, but its role is still being defined. Our aim was to observe the uptake of laparoscopy for emergency colorectal surgery in our centre. METHOD: A retrospective single-centre cohort study was performed using local National Emergency Laparotomy Audit data from January 2014-December 2020. All patients who had a colorectal resection were included. Trends in the number and type of resections were recorded. Primary outcome was the proportion of cases started and completed laparoscopically. Secondary outcomes included rate of conversion to open, length of stay and 30-day mortality. RESULTS: A total 523 colorectal resections were performed. The number of cases attempted and completed laparoscopically steadily increased over the study period (28.3% to 63.3% and 16.3% to 35.4%, respectively). The mean rate of conversion to open was 43.8%. The greatest expansion in laparoscopy was for cases of intestinal obstruction, perforation and peritonitis, and for those undergoing Hartmann's procedure and right hemicolectomy. 30­day mortality for cases completed laparoscopically was much lower than those converted or started with open surgery (2.1% vs 11.7% and 17.5%, respectively). Laparoscopic approach was independently associated with reduced length of stay. CONCLUSION: Laparoscopy has been successfully adopted for emergency colorectal resections in our centre, with half of cases felt to be suitable for minimally invasive surgery.

Best practice considerations on the assessment of robotic assisted surgical systems: results from an international consensus expert panel.

BACKGROUND: Health technology assessments (HTAs) of robotic assisted surgery (RAS) face several challenges in assessing the value of robotic surgical platforms. As a result of using different assessment methods, previous HTAs have reached different conclusions when evaluating RAS. While the number of available systems and surgical procedures is rapidly growing, existing frameworks for assessing MedTech provide a starting point, but specific considerations are needed for HTAs of RAS to ensure consistent results. This work aimed to discuss different approaches and produce guidance on evaluating RAS. METHODS: A consensus conference research methodology was adopted. A panel of 14 experts was assembled with international experience and representing relevant stakeholders: clinicians, health economists, HTA practitioners, policy makers, and industry. A review of previous HTAs was performed and seven key themes were extracted from the literature for consideration. Over five meetings, the panel discussed the key themes and formulated consensus statements. RESULTS: A total of ninety-eight previous HTAs were identified from twenty-five total countries. The seven key themes were evidence inclusion and exclusion, patient- and clinician-reported outcomes, the learning curve, allocation of costs, appropriate time horizons, economic analysis methods, and robotic ecosystem/wider benefits. CONCLUSIONS: Robotic surgical platforms are tools, not therapies. Their value varies according to context and should be considered across therapeutic areas and stakeholders. The principles set out in this paper should help HTA bodies at all levels to evaluate RAS. This work may serve as a case study for rapidly developing areas in MedTech that require particular consideration for HTAs.

Early Experience of Undertaking Robotic Assisted Total Mesorectal Excision in Rectal Resections, Avoiding a Diverting Stoma: Key eHancement of the Anastomosis for No Stoma Technique - A Case Series.

Background. Anastomotic leak is a feared complication in rectal cancer surgery, and a proximal diverting stoma to protect the rectal anastomosis is used to minimize its impact. We evaluated a novel technique that uses the da Vinci® robotic platform (Intuitive Surgical) to reinforce the colorectal anastomosis and rectal staple line with sutures, and rectal resection and assessment of the anastomotic perfusion, using our Portsmouth protocol. Methods. During robotic rectal cancer surgery, we used indocyanine green to determine the level of transection and check the vascularity of the circular anastomosis. The distal transverse staple line and circular staple line of the colorectal anastomosis were reinforced with absorbable interrupted stitches (KHANS technique - Key enHancement of the Anastomosis for No Stoma). The integrity of the colorectal/anal anastomosis was also checked using the underwater air-water leak test, with concomitant flexible sigmoidoscopy to visualize the circular staple line. Results. Fifty patients underwent total mesorectal excision for cancer. Using the KHANS technique, we avoided a diverting stoma in all cases. One patient had a radiological leak, leading to a pelvic abscess. In 56% of cases, the anastomosis was within 5 cm of the anal verge. Median length of stay was 5 (3-34) days, with two 30-day readmissions. No 90-day mortality or 30-day reoperations were observed. Conclusion. The KHANS technique appears feasible, successful, and safe in decreasing the incidence of diverting stomas in rectal resections.

Consensus statements on complete mesocolic excision for right-sided colon cancer-technical steps and training implications.

BACKGROUND: CME is a radical resection for colon cancer, but the procedure is technically demanding with significant variation in its practice. A standardised approach to the optimal technique and training is, therefore, desirable to minimise technical hazards and facilitate safe dissemination. The aim is to develop an expert consensus on the optimal technique for Complete Mesocolic Excision (CME) for right-sided and transverse colon cancer to guide safe implementation and training pathways. METHODS: Guidance was developed following a modified Delphi process to draw consensus from 55 international experts in CME and surgical education representing 18 countries. Domain topics were formulated and subdivided into questions pertinent to different aspects of CME practice. A three-round Delphi voting on 25 statements based on the specific questions and 70% agreement was considered as consensus. RESULTS: Twenty-three recommendations for CME procedure were agreed on, describing the technique and optimal training pathway. CME is recommended as the standard of care resection for locally advanced colon cancer. The essential components are central vascular ligation, exposure of the superior mesenteric vein and excision of an intact mesocolon. Key anatomical landmarks to perform a safe CME dissection include identification of the ileocolic pedicle, superior mesenteric vein and root of the mesocolon. A proficiency-based multimodal training curriculum for CME was proposed including a formal proctorship programme. CONCLUSIONS: Consensus on standardisation of technique and training framework for complete mesocolic excision was agreed upon by a panel of experts to guide current practice and provide a quality control framework for future studies.

Supervised training of laparoscopic colorectal cancer resections does not adversely affect short- and long-term outcomes: a Propensity-score-matched cohort study.

BACKGROUND: Supervised training of laparoscopic colorectal cancer surgery to fellows and consultants (trainees) may raise doubts regarding safety and oncological adequacy. This study investigated these concerns by comparing the short- and long-term outcomes of matched supervised training cases to cases performed by the trainer himself. METHODS: A prospective database was analysed retrospectively. All elective laparoscopic colorectal cancer resections in curative intent of adult patients (≥ 18 years) which were performed (non-training cases) or supervised to trainees (training cases) by a single laparoscopic expert surgeon (trainer) were identified. All trainees were specialist surgeons in training for laparoscopic colorectal surgery. Supervised training was standardised. Training cases were 1:1 propensity-score matched to non-training cases using age, American Society of Anesthesiologists (ASA) grade, tumour site (rectum, left and right colon) and American Joint Committee on Cancer (AJCC) tumour stage. The resulting groups were analysed for both short- (operative, oncological, complications) and long-term (time to recurrence, overall and disease-free survival) outcomes. RESULTS: From 10/2006 to 2/2016, a total of 675 resections met the inclusion criteria, of which 95 were training cases. These resections were matched to 95 non-training cases. None of the matched covariates exhibited an imbalance greater than 0.25 (│d│>0.25). There were no significant differences in short- (length of procedure, conversion rate, blood loss, postoperative complications, R0 resections, lymph node harvest) and long-term outcomes. When comparing training cases to non-training cases, 5-year overall and disease-free survival rates were 71.6% (62.4-82.2) versus 81.9% (74.2-90.4) and 70.0% (60.8-80.6) versus 73.6% (64.9-83.3), respectively (not significant). The corresponding hazard ratios (95% confidence intervals, p) were 0.57 (0.32-1.02, p = 0.057) and 0.87 (0.51-1.48, p = 0.61), respectively (univariate Cox proportional hazard model). CONCLUSIONS: Standardised supervised training of laparoscopic colorectal cancer procedures to specialist surgeons may not adversely impact short- and long-term outcomes. This result may also apply to newer surgical techniques as long as standardised teaching methods are followed.

Early salvage total mesorectal excision (sTME) after organ preservation failure in rectal cancer does not worsen postoperative outcomes compared to primary TME: systematic review and meta-analysis.

IMPORTANCE: While oncological outcomes of early salvage total mesorectal excision (sTME) after local excision (LE) have been well studied, the impact of LE before TME on postoperative outcomes remains unclear. We aimed to compare early sTME with a primary TME for rectal cancer. METHODS: Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines with the random-effects model were adopted using Review Manager Version 5.3 for pooled estimates. RESULTS: We retrieved eleven relevant articles including 1728 patients (350 patients in the sTME group and 1438 patients in the TME group). There was no significant difference between the two groups in terms of mortality (OR = 0.90, 95%CI [0.21 to 3.77], p = 0.88), morbidity (OR = 1.19, 95%CI [0.59 to 2.38], p = 0.63), conversion to open surgery (OR = 1.34, 95%CI [0.61 to 2.94], p = 0.47), anastomotic leak (OR = 1.38, 95%CI [0.50 to 3.83], p = 0.53), hospital stay (MD = 0.23 day, 95%CI [- 1.63 to 2.10], p < 0.81), diverting stoma rate (OR = 0.69, 95%CI [0.44 to 1.09], p = 0.11), abdominoperineal resection rate (OR = 1.47, 95%CI [0.91 to 2.37], p = 0.11), local recurrence (OR = 0.94, 95%CI [0.44 to 2.04], p = 0.88), and distant recurrence (OR = 0.88, 95%CI [0.52 to 1.48], p = 0.62). sTME was associated with significantly longer operative time (MD = 25.62 min, 95%CI[11.92 to 39.32], p < 0.001) lower number of harvested lymph nodes (MD = - 2.25 lymph node, 95%CI [- 3.86 to - 0.65], p = 0.006), and higher proportion of incomplete TME (OR = 0.25, 95%CI [0.11 to 0.61], p = 0.002). CONCLUSIONS: sTME is not associated with increased postoperative morbidity, mortality, or local recurrence. However, the operative times are longer and yield a poor specimen quality.

Robotic Complete Mesocolic Excision (CME) is a safe and feasible option for right colonic cancers: short and midterm results from a single-centre experience.

BACKGROUND: Complete mesocolic excision (CME) for right colon cancers has traditionally been an open procedure. Surgical adoption of minimal access CME remains limited due to the technical challenges, training gaps and lack of level-1 data for proven benefits. Currently there is limited published data regarding the clinical results with the use of robotic CME surgery. Aim To report our experience, results and techniques, highlighting a clinical and oncological results and midterm oncological outcomes for robotic CME. AIM: To report our experience, results and techniques, highlighting a clinical and oncological results and midterm oncological outcomes for robotic CME. METHODS: All patients undergoing standardised robotic CME technique with SMV first approach between January 2015 and September 2019 were included in this retrospective review of a prospectively collected database. Patient demographics, operative data and clinical and oncological outcomes were recorded. RESULTS: Seventy-seven robotic CME resections for right colonic cancers were performed over a 4-year period. Median operative time was 180 (128-454) min and perioperative blood loss was 10 (10-50) ml. There were 25 patients who had previous abdominal surgery. Median postoperative hospital stay was 5 (3-18) days. There was no conversion to open surgery in this series. Median lymph node count was 30 (10-60). Three (4%) patients had R1 resection. There was one (1%) local recurrence in stage III disease and 4(5%) distal recurrence in stage II and stage III. There was no 30- or 90-day mortality. Three-year disease-free survival was 100%, 91.7% and 92% for stages I, II and III, respectively. Overall survival was 94%. CONCLUSIONS: Robotic CME is feasible, effective and safe. Good oncological results and improved survival are seen in this cohort of patients with a standardised approach to robotic CME.

A meta-analysis comparing hand-assisted laparoscopic right hemicolectomy and open right hemicolectomy for right-sided colon cancer.

BACKGROUND: Mini-invasive colorectal cancer surgery was adopted widely in recent years. This meta-analysis aimed to compare hand-assisted laparoscopic surgery (HALS) with open right hemicolectomy (OS) for malignant disease. METHODS: PRISMA guidelines with random effects model were adopted using Review Manager Version 5.3 for pooled estimates. RESULTS: Seven studies that involved 506 patients were included. Compared to OS, HALS improved results in terms of blood loss (MD = 53.67, 95% CI 10.67 to 96.67, p = 0.01), time to first flatus (MD = 21.11, 95% CI 14.99 to 27.23, p < 0.00001), postoperative pain score, and overall hospital stay (MD = 3.47, 95% CI 2.12 to 4.82, p < 0.00001). There was no difference as concerns post-operative mortality, morbidity (OR = 1.55, 95% CI 0.89 to 2.7, p = 0.12), wound infection (OR = 1.69, 95% CI 0.60 to 4.76, p = 0.32), operative time (MD = - 16.10, 95% CI [- 36.57 to 4.36], p = 0.12), harvested lymph nodes (MD = 0.59, 95% CI - 0.18 to 1.36, p = 0.13), and recurrence (OR = 0.97, 95% CI 0.30 to 3.15, p = 0.96). CONCLUSIONS: HALS is an efficient alternative to OS in right colectomy which combines the advantages of OS with the mini-invasive surgery.

Minimally invasive right colectomy anastomosis study (MIRCAST): protocol for an observational cohort study of surgical complications using four surgical techniques for anastomosis in patients with a right colon tumor.

BACKGROUND: Right colectomy is the standard surgical treatment for tumors in the right colon and surgical complications are reduced with minimally-invasive laparoscopy compared with open surgery, with potential further benefits achieved with robotic assistance. The anastomotic technique used can also have an impact on patient outcomes. However, there are no large, prospective studies that have compared all techniques. METHODS/DESIGN: MIRCAST is the Minimally-Invasive Right Colectomy Anastomosis Study that will compare laparoscopy with robot-assisted surgery, using either intracorporeal or extracorporeal anastomosis, in a large prospective, observational, multicenter, parallel, four-cohort study in patients with a benign or malignant, non-metastatic tumor of the right colon. Over 2 years of follow-up, the study will prospectively evaluate peri- and postoperative complications, postoperative recovery, hospital stay, and mid-term results including survival, local recurrence, metastases rate, and conversion rate. The primary composite endpoint will be the efficacy of the surgical method regarding surgical wound infections and postoperative complications (Clavien-Dindo grade III-IV complications at 30 days post-surgery). Secondary endpoints include long-term oncologic results, conversion rate, operative time, length of stay, and quality of life. DISCUSSION: This will be the first large, international study to prospectively evaluate the use of minimally-invasive laparoscopy or robot-assisted surgery during right hemicolectomy and to control for the impact of the anastomotic technique. The research will contribute to current knowledge regarding the medical care of patients with malignant or benign tumors of the right colon, and enable physicians to determine which technique may be the most appropriate for their patients. TRIAL REGISTRATION: This study was registered on Clinicaltrials.gov (clinicaltrials.gov identifier: NCT03650517 ) on August 28th 2018 (study protocol version CI18/02 revision A, 21 February 2018).

The Use of Enhanced Technologies in Robotic Surgery and Its Impact on Outcomes in Rectal Cancer: A Systematic Review.

The main advantage of the robotic approach is the surgical precision that the technology offers. It is particularly useful in rectal cancer as this is a technically challenging procedure. The technological advantage of the robot leads to better postoperative outcomes. Apart from the 3D vision and endowrist instrumentation in comparison to laparoscopy, the options of using fluorescence imaging, endowrist stapler, and table motion have revolutionised the way of performing an anterior resection. Thus, the true benefit of these advances will be the quality of the surgery, which leads to better postoperative outcomes. This article focuses on the current status of applications of new modalities and technology development in robotic rectal surgery. A systematic literature search was performed using PubMed, MEDLINE, and cochrane database. The studies included were considered based on the following (1) articles written in English, (2) full text is available, (3) whether the topic is related to the use of novel technologies during robotic rectal surgery, and (4) sample: adult patients and malignant rectal disease. The primary end point was to analyse the current use of technological advances in robotic rectal surgery. Only a few studies are currently available on the use of these different technologies in robotic colorectal surgery. Many of these reports describe promising results, although with short-term outcomes. The use of technologies in robotic colorectal surgery is safe and feasible and can be used together to improve short-term outcomes. Intraoperative fluorescence angiography has demonstrated to reduce the rate of anastomotic leak, whereas the robotic stapler and the table motion simplify anatomic resection.

The impact of robotic total mesorectal excision on survival of patients with rectal cancer-a propensity matched analysis.

INTRODUCTION: Robotic surgery can overcome some limitations of laparoscopic total mesorectal excision (L-TME), improving the quality of the surgery. We aim to compare the medium-term oncological outcomes of L-TME vs. robotic total mesorectal excision (R-TME) for rectal cancer. METHODS: A retrospective analysis was performed including patients who underwent L-TME or R-TME between 2011 and 2017. Patients presenting with metastatic disease or R1 resection were excluded. From a total of 680 patients, 136 cases of R-TME were matched based on age, gender, stage and time of follow-up with an equal number of patients who underwent L-TME. We compared 3-year disease-free survival (DFS) and overall survival (OS). RESULTS: Major complications were lower in the robotic group (13.2% vs. 22.8%, p = 0.04), highlighting the anastomotic leakage rate (7.4% vs. 16.9%, p = 0.01). The 3-year DFS rate for all stages was 69% for L-TME and 84% for R-TME (p = 0.02). For disease stage III, the 3-year DFS was significantly higher in the R-TME group. OS was also significantly superior in the robotic group for every stage, reaching 86% in stage III. In the multivariate analysis, R-TME was a significant positive prognostic factor for distant metastasis (OR 0.2 95% CI 0.1, 0.6, p = 0.001) and OS (OR 0.2 95% CI 0.07, 0.4, p = 0.000). Moreover, major complications were also found to have a negative impact on OS (OR 8.3 95% CI 3.2, 21.6, p = 0.000). CONCLUSION: R-TME for rectal cancer can achieve better oncological outcomes compared with L-TME, especially in stage III rectal cancers. However, a longer follow-up period is needed to confirm these findings.