|Ahead of print
Robotic-assisted versus conventional laparoscopic surgery for colorectal cancer: Short-term outcomes at a single center
Dong-ping Hu1, Xiao-long Zhu2, He Wang2, Wen-han Liu2, Yao-chun Lv1, Xin-long Shi1, Li-li Feng1, Wei-sheng Zhang1, Xiong-Fei Yang1
1 Department of Anorectal Surgery, Gansu Provincial Hospital, Lanzhou, P.R. China
2 Department of Anorectal Surgery, Gansu Provincial Hospital; Department of Clinical Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou, P.R. China
|Date of Submission||26-Jan-2019|
|Date of Decision||04-May-2019|
|Date of Acceptance||16-May-2019|
|Date of Web Publication||28-Jan-2021|
Department of Anorectal Surgery, Gansu Provincial Hospital, Lanzhou
Source of Support: None, Conflict of Interest: None
Background: The robotic technique has been established as an alternative approach to laparoscopy for colorectal surgery. The aim of this study was to compare the short-term outcomes of robot-assisted and laparoscopic surgery in colorectal cancer.
Methods: The cases of robot-assisted or laparoscopic colorectal resection were collected retrospectively between July 2015 and September 2018. We evaluated patient demographics, perioperative characteristics, and pathologic examinations. Short-term outcomes included time to passage of flatus and length of postoperative hospital stay.
Results: A total of 580 patients were included in the study. There were 271 patients in the robotic colorectal surgery (RCS) group and 309 in the laparoscopic colorectal surgery (LCS) group. The time to passage of flatus in the RCS group was 3.62 days shorter than the LCS group. The total costs were increased by 2,258.8 USD in the RCS group compared to the LCS group (P < 0.001).
Conclusion: The present study suggests that colorectal cancer robotic surgery was more beneficial to patients because of a shorter postoperative recovery time of bowel function and shorter hospital stays
Keywords: Colon, rectum, colorectal cancer, laparoscopy, rectal cancer, robotic surgery
Key Message The Da Vinci Surgical System is an advanced robotic platform designed to perform complex surgical operations by using minimally invasive methods.
|How to cite this URL:|
Hu Dp, Zhu Xl, Wang H, Liu Wh, Lv Yc, Shi Xl, Feng Ll, Zhang Ws, Yang XF. Robotic-assisted versus conventional laparoscopic surgery for colorectal cancer: Short-term outcomes at a single center. Indian J Cancer [Epub ahead of print] [cited 2021 May 5]. Available from: https://www.indianjcancer.com/preprintarticle.asp?id=308289
Dong.Ping Hu and Xiao.Long Zhu are co.first authors and contributed equally to this work.
| » Introduction|| |
According to the Global Cancer Data Report of 2018, colorectal cancer is the third most common cancer, and it accounts for 10.0% of all cancers. Additionally, colorectal cancer ranks second in cancer-related deaths, and it accounts for 9.2% of deaths.
Surgery is one of the most effective ways to treat colorectal cancer. Since the field of colorectal cancer surgery was introduced, the laparoscopic technique has been widely used. Clinical studies have shown that laparoscopic surgery is significantly better than open surgery for colorectal cancer in terms of short-term efficacy, but there is no significant difference in long-term survival rates.,, However, laparoscopic techniques have the disadvantage of unstable image, especially in patients with a narrow pelvis.
There are several advantages of the da Vinci robotic system that include free-moving multi-joint forceps, high-quality three-dimensional imaging, stable camera work by an operator, an image stabilizer, a motion-scaling function, and greatly improved ergonomics.,, In 2002, Professor Weber first reported two cases of benign diseases in which the da Vinci robot was used for a right colon and sigmoid resection. Pigazzi et al. first described robotic-assisted laparoscopic resection with total mesorectal excision for rectal cancer in 2006. Robotic-assisted surgery using the da Vinci surgical system has been gaining popularity in colorectal surgery. Previous studies have shown that robotic surgery has a faster recovery rate for postoperative gastrointestinal function, better protection for pelvic autonomic function, less intraoperative bleeding, lower transit open surgery rates, and similar postoperative complications and hospital stays compared to laparoscopic surgery.,,
Therefore, the robot may be an alternative approach to laparoscopy for colorectal surgery.,,16], However, the true benefits of robotic-assisted surgery over laparoscopic surgery remain undefined, and there is particularly a lack of studies with large sample sizes.
Thus, we conducted the present study to clarify the advantages of robotic-assisted surgery for colorectal cancer by comparing its short-term outcomes with those of laparoscopic surgery in the first large series of cases from a single center in China.
| » Methods|| |
The aim of this study was to assess the safety and effectiveness of robotic-assisted surgery versus laparoscopic surgery in patients with colorectal cancer. This study was approved by the Ethics Committee of the Gansu Provincial Hospital. All consecutive cases of robot-assisted and laparoscopic colorectal resection were collected in this retrospective study between July 2015 and September 2018. Two researchers (ZX, WH) independently collected the following information from medical records at the study center: patient demographics, perioperative characteristics, and pathological examination of the outcomes. Discrepancies between the two authors were resolved by discussion and a consensus. The robotic system was introduced for the first time in our center in June 2016, and 300 cases of robotic surgery were performed between that date and September 2018. The inclusion into this study required a confirmed histological diagnosis of colorectal malignant tumor. The exclusion criteria included patients with synchronous tumors, benign diseases, emergency admissions, or clinical T4 stage tumors that did not respond to neoadjuvant treatment.
A total of 271 robotic cases met the inclusion criteria. Data were collected from 350 cases of laparoscopic surgery from June 2016 to September 2018. A total of 309 laparoscopic cases met the inclusion criteria.
Pathologic examination outcome, demographics, and perioperative characteristics of the patients were analyzed. Preoperative tumor assessment and clinical staging included digital rectal examination, rigid proctoscopy with tumor biopsy, colonoscopy, carcinoembryonic antigen blood level, chest X-ray and/or chest computed tomography scan, contrast-enhanced abdominopelvic computed tomography, pelvic magnetic resonance imaging, and anesthesiologist assessment.
Body mass index (BMI) was categorized according to the Chinese adult BMI classification proposed by the Working Group on Obesity in China in 2001. Patients were divided into four groups according to quartiles of age: <54, 54–61, 62–67, >67. Staging was determined using The American Joint Committee on Cancer (AJCC) tumor-node-metastasis (TNM) classification and staging system for colon cancer (7th Edition).
The perioperative results included operative time, estimated blood loss amount, time to passage of flatus, liquid diet duration, retrieved lymph node number, postoperative hospital stay length, and total cost. The operative time was defined as the time length between skin incision and its closure, and it included the docking and undocking time of robotic surgery. The liquid diet was started when patients reported their first flatulence. The postoperative hospital stay was defined as the time length between the date of surgery and the date of discharge. The total cost included surgery, anesthesia, medicines, and care.
Robotic surgical technique
Surgeries were performed by surgeons in our center with an experience of more than 2600 laparoscopic-assisted colorectal cases. All patients selected the procedures of their own free will. All patients underwent standard mechanical bowel preparation, antibiotic and antithrombotic prophylaxis, orogastric tube, and a urinary catheter placement. The procedures for performing the robot-assisted surgery are the same as the procedures for the standard laparoscopic surgery. The principle of surgery states that the margin should be at least 10 cm away from the tumor. The blood vessels and non-contact tumors were treated from the inside to the outside and in a distal to proximal manner. The procedure is summarized as follows: (1) Mirror exploration: observe if there are ascites in the abdominal cavity. Observe if there is tumor infiltration, implantation, and metastasis on the surface of organs, such as the liver and peritoneal retina. Observe the location and size of the tumor and the swelling of the surrounding lymph nodes. (2) Exposure of the field: the sigmoid colon is stretched to the front to tighten the mesentery or the vestige of the ileum. If the patient is female, the uterus is suspended during the operation. (3) Free blood vessels: use a robotic ultrasonic scalpel to skeletal blood vessels, which are then clipped and disconnected with a Hemolok hemostasis clip. During this process, the surgeon should pay special attention to protecting the nerve. (4) Free side peritoneum and corresponding resection of the intestine: ultrasonic scalpel or electric scissors are primarily used for the sharp separation to avoid bleeding caused by violent tearing. In the radical operation of sigmoid colon and rectal cancer, the nerve and ureter should be protected during the process of freeing the bowel. (5) Anastomosis: a small incision was made in the abdomen. The purse was sutured with purse pliers 15 cm above the mass. The intestine was broken, and the specimen was removed. According to the abdominoperineal resection for rectal surgery, perineal surgery, and intestinal fistula are the same as open surgery. (6) Evacuation: evacuate the robot arm and the robot system. Exit each puncture cannula and suture each puncture hole and incision.
However, a port in a different location can be found in previous studies. There is a different port position for laparoscopic and robot-assisted surgery to accommodate the robotic arm and to provide the surgeon's assistant with additional ports. As previously reported, the port location is the standard location for this type of procedure and the standard method used (laparoscopic versus robotic assistance).,,,,,,,
Stata software version 12.0 (Stata Corp) was used for statistical analysis. Data were compared using the χ2 test or Fisher's exact test for categorical variables, and the t-test or the Mann–Whitney U-test were used for continuous variables. P values ≤0.05 were considered statistically significant.
| » Results|| |
[Table 1] summarizes the characteristics of the 580 patients in the robotic colorectal surgery (RCS) and laparoscopic colorectal surgery (LCS) groups. There were 271 patients included in the RCS group and 309 in the LCS group. There were no significant differences in age, sex, BMI, or blood type between the two groups. There were also no significant differences found for other characteristics, such as the distance from the anal media, preoperative serum carcinoembryonic antigen, and surgery method. Surgeries included low and high anterior resection, abdominoperineal resection, left hemicolectomy, right hemicolectomy, and sigmoidectomy.
Perioperative outcomes and postoperative complications
Mean operative times were 190.6 minutes for LCS and 205.9 minutes for RCS, and there was no significant difference between the two groups (P = 0.846). However, there was significantly more blood loss in the RCS group than in the LCS group (P < 0.001).
There was also a significant difference in the time to passage of flatus between the two groups. Compared to patients in the LCS group, patients in the RCS group had a shorter time to passage of flatus [mean, 3.62 versus 6.9 days, P < 0.001]. The mean length of hospital stay for all patients that underwent RCS was shorter than that of those that underwent LCS (P < 0.001) [Table 2]. Conversion to open surgery was not significantly different between the two groups (P = 0.598).
There was no operative mortality in either group. [Table 3] lists the postoperative complications. No significant differences were identified between the groups for the frequencies of ileus, anastomotic leakage, anastomotic bleeding, incisional obstruction, urinary infections, urinary retention, venous thrombosis of the lower extremities, cardiac failure, and respiratory infections.
Patients who underwent an operation for bowel malignancy also underwent the appropriate oncological procedures. Of these bowel malignancies, 564 were adenocarcinomas of the colon and rectum, and 16 were mucinous adenocarcinoma of the colon and rectum. There were no significant differences observed between the two groups in tumor size, lymph node yield, positive lymph node, postoperative pathologic TNM stage, histology, or pathological diagnosis. Positivity of circumferential resection margin (CRM) were not significantly different [Table 4].
The total number of lymph nodes harvested was 12.4 in the RCS group and 12.6 in the LCS group (P = 0.608).
The total cost of the RCS group was 11,332.6 USD, and it was 9,073.7 USD for the LCS group (P < 0.001). The mean operation cost of the RCS group was 1,908.7 USD, and it was 1,194.5 USD (P = 0.028) for the LCS group [Table 2].
| » Discussion|| |
To evaluate the feasibility and short-term outcomes of RCS and LCS, we compared the operative time, the amount of estimated blood loss, the time to passage of flatus, the duration of liquid diet, the number of retrieved lymph nodes, the total cost, and the length of postoperative hospital stay. We found no significant differences in the operative time between the RCS group and the LCS group. However, there was significantly more blood loss in the RCS group than in the LCS group. Compared to the patients in the LCS group, the patients in the RCS group had a shorter time to passage of flatus, and patients who underwent RCS had a shorter hospital stay length. Furthermore, the total cost in the RCS group was higher than in the LCS group. To date, there have been 300 cases of colorectal cancer undergoing the da Vinci robotic surgery in our center. According to our experience, the surgical techniques are feasible, and the clinical efficacy is acceptable.
In the present study, RCS exhibited a trend of longer operation times than LCS, but this difference was not significant. However, several retrospective studies,, have shown longer operative times for RCS than for LCS. The longer operative times for RCS may be influenced by the learning curve period that was neglected in those previous analyses. Moreover, a systematic review determined that operative times for robotic surgery improved rapidly, and after 41 cases, it became faster than laparoscopy. Tomohiro et al. reported similar results to ours.
The intraoperative estimated blood loss was higher during RCS than LCS. This result was consistent with a previous study  that reported less blood loss in pelvic resections using LCS. This increase in intraoperative estimated blood loss might be related to the initial experience with RCS and newer technology devices. Devices based on newer energy that are used to control bleeding are often used in LCS but not in RCS.
There were no significant differences observed between the two groups in lymph node yield, and the mean number of lymph nodes removed was 12.4 in the RCS group. In 1990, the World Congress of gastroenterology in Sydney recommended that 12 lymph nodes should be removed. Nevertheless, a long-term follow-up is essential for a reliable evaluation of oncological outcomes associated with RCS.
Our results indicate that patients who underwent RCS had a significantly faster recovery of bowel function and a shorter hospital stay, which is similar to previous reports. One possible reason is that there are potential advantages to using robots in colorectal surgery that may effectively reduce intraoperative gastrointestinal stimulation and promote the recovery of gastrointestinal function, which would truncate the recovery of intestinal function. Moreover, a faster recovery of intestinal function prevents water and electrolyte balance disorders, reduces postoperative intestinal adhesion and other complications, promotes patient rehabilitation, and shortens the length of hospital stay. This explanation corresponds with our findings that the RCS group had a shorter hospital length of stay compared to the LCS group.
This study revealed that the overall hospital costs were higher for RCS than LCS. Numerous studies have reported that the cost of RCS is higher than LCS.,, Robotics is a new technique for colorectal surgery, and there has been increasing attention given to the high cost that is associated with it.
However, our analysis had its limitations. These limitations include its retrospective nature and the potential for selection bias in a single-surgeon case series. In addition, this study provides an initial comparison between RCS and LCS for colorectal cancer, but a prospective study is needed to thoroughly further explore and determine the short-term prognosis of robotic and laparoscopy surgeries.
| » Conclusions|| |
The present study suggests that colorectal cancer robotic surgery was more beneficial to patients because it had a shorter postoperative recovery time of bowel function and shorter hospital stays. However, further randomized controlled trials are needed to determine if there is a significant benefit of robotic surgery compared to laparoscopic surgery.
We thank members of the colorectal team for their contribution of patient data for this paper. The writers acknowledge the editors and the reviewers for their valuable comments and suggestions, which have greatly improved the article.
Financial support and sponsorship
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Natural Science Foundation of Gansu Province (Grant No. 18JR3RA055) and Lanzhou Science and Technology Development Guiding Plan (2017-zd-42).
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]