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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1369_Библиотеки_им_академика_М_И_Перельмана.pdf
198
Table 15.5 Operating time/LOS: colon [1]
N
robotN lap
Delaney [26] 6 6 165 108 3 2.5 NS
D’Annibale
[27]
Rawlings [29] 30 27 219 right 169 right 0.002 5.2 5.5 0.86
Spinoglio [30] 50 161 384 266 <0.001 7.7 8.3 0.928
deSousa [31] 40 135 159 118 <0.001 5 5 0.86
Bertani [71] 34 30 194 210 NS 5 5 NS
Luca [72] 33 102 192 136 <0.001 5 8 <0.001
Deutsch [32] 79 92 219 right 214 right 0.75 4.3
Table 15.6 Operating time/LOS: colon [2]
Morpurgo
[35]
Lim [36] 34 146 253 218 0.016 5.5 6.2 0.005
Casillas [37] 146 200 143
Trastulli
[38]
Trinh [39] 15 25 258 191 0.183 9.6 6.5 0.091
Tam [89] 409 1511CL 168 136 <0.0001 4 4.44 0.04
Bhama [90] 299 7790 211 167 <0.001 4.3 5.3 <0.001
CL conventional laparoscopy, HAL hand-assist laparoscopy
53 53 240 222 NS 10 10 NS
N
robot N lap
48 48 266 223 <0.05 7.5 9 <0.05
102 94 287 208 <0.0001 4 7 <0.0001
40 287 204 <0.0001 4 5.5 NS
815HAL 168 135 <0.0001 4 4.41 0.008
OR time
robot
225
sigmoid
290 left 255 left 0.0006 4.1
OR time
lap P value
199
sigmoid
OR
time
robot
right
188
left
0.128 6.0 6.6 0.85
OR
time
lap P value
79
right
109
left
<0.01 6.2
<0.01 3.6
LOS
robot
right
left
LOS
robot
right
left
R.K. Cleary
LOS
lap P value
6.3
0.13
right
4.2
0.71
left
LOS
lap P value
5.5
0.47
right
6.5
0.01
left
Single Institution Studies for Robotic Colectomy
Several single site reports have demonstrated the safety and feasibility of the robotic
platform for colectomies [17–25].
DeNoto et al. reported no complications and no conversions for 11 patients who
had robotic sigmoid colectomies [17]. D’Annibale described 50 consecutive robotic
right colectomies for cancer. This study showed no conversions and reasonable oncologic outcomes to include a disease-free survival of 85 % in stage III patients. This
15 Completed and Ongoing Trials in Robotic Colorectal Surgery
Table 15.7 Circumferential margins: rectum
N robot N lap + CRM robot + CRM lap P value
Hellan [40] 39 0.0 %
Patriti [54] 29 27 0.0 % 0 NS
Baik [55] 56 57 7.1 % 8.8 % NS
Park [56] 41 82 4.9 % 3.7 % NS
Pigazzi [46] 143 0.7 %
Bianchi [57] 25 25 0.0 % 4 NS
Kim NK [62] 100 100 3 2 NS
Baek [63] 41 41 2.4 4.9 NS
deSousa [61] 36 51 0 6.5 NS
Kwak [66] 59 59 1.7 % 0 NS
Park [68] 52 123 4.5 5.8 NS
Kim YW [64] 62 147 3.2 2.7 NS
Kang [60] 104 97 4.2 % 6.7 NS
Park SY [59] 40 40 7.5 5 NS
D’Annibale [58] 50 50 0.0 % 12 0.02
Kim [85] 48 0.0 %
Ielpo [69] 56 87 3.6 2.3 NS
Kuo [70] 36 28 12.5 16.7 NS
Table 15.8 Complications: rectum
N
robotN lap
Patriti [54] 29 37 29.2 18.7 NS 6.8 2.7 NS
Baik [55] 56 57 5.4 19.3 0.025 1.8 7
Park [56] 41 82 29.3 23.2 NS 9.7 7.3 NS
Bianchi [57] 25 25 16 24 NS 4 8
Baek [63] 41 41 8.6 2.9 0.616
Kwak [66] 58 59 13.6 10.2 0.609
Park [68] 52 123 19.2 12.2 0.229 9.6 5.6 NS
Kim YW [64] 62 147 12.9 17.7 0.4 6.6 10.9 NS
Kang [60] 104 97 20.6 27.9 0.3 7.3 10.8 NS
Park SY [59] 40 40 15 12.5 0.745 7.5 5.0 NS
D’Annibale
[58]
Kuo [70] 36 28 25 32 NS
Ielpo [69] 56 87 26.8 23 0.61 9.7 4.5 0.35
50 50 10 22 0.104 10 14 0.998
Morbidity
robot
Morbidity
lap
P
value
Leak
robot
Leak
lap P value
199
study also demonstrated the feasibility of the intracorporeal anastomosis [18].
Abodeely et al. evaluated 48 patients with various colorectal diseases to include ten
with low rectal cancers and 22 with diverticulitis. There were no conversions and one
anastomotic leak. Mean hospital LOS was 5.4 days. Oncologic margins were acceptable and short-term outcomes were reasonable [19]. Luca et al. studied 55 consecu-
200
Table 15.9 Complications: colon
N
robot N lap
D’Annibale
[27]
deSousa [31] 40 135 20 20.7 0.919
Bertani [71] 34 30 18 13 NS 3 3 NS
Luca [72] 33 102 8
Tyler [33] 160 2423 21.7 21.6 0.992
Lim [36] 34 146 10.3 5.9 0.281 0 1.4 NS
Casillas [37] 146 200 14 29 0.03 0 5 0.1
Trastulli [38] 102 94 EC22.5 22.3 0.955 2.9 2.1 0.845
Trinh [39] 15 25 20 36 0.457 1 0 NS
Tam [89] 409 1511 14.8 10.7 0.22 2.1 1.0 0.26
Ielpo [69] 56 87 26.8 23 0.61 9.7 4.5 0.35
53 53 7.5 17
409 815 14.8 9.8 0.12 2.1 2.4 0.86
Morbidity
robot
40 IC 22.5 20 NS 2.9 0 NS
Morbidity
lap
P
value
Leak
robot
R.K. Cleary
Leak
lap P value
tive robotic procedures for rectal and left colon cancer. Complication rates and
oncologic outcomes were acceptable. Anastomotic leak rate was 12.7 % [20]. Huettner
et al. reported on 102 consecutive colectomies for benign and malignant neoplasia
and diverticulitis. There were 59 right colectomies and 43 sigmoid resections.
Conversion rate was 8.8 %. Mean hospital LOS was 3 days. Anastomotic leak rate
was 0.98 % [21]. Ragupathi et al. presented 24 patients with diverticulitis who had
anterior resection. There were no conversions and the complication rate was 12.5 %
with no anastomotic leaks. Mean hospital LOS was 3.4 days [22].
Park et al. published their experience with robotic right colectomy with intracorporeal anastomosis for 15 patients with colon cancer. There were no conversions and oncologic results were acceptable [23]. Trastulli et al. also reported on the feasibility of
robotic right colectomy with intracorporeal anastomosis for colon cancer in 20 consecutive patients. There were no conversions and margins were good [24]. Eriksen et al.
performed a retrospective review of 223 robotic colon and rectal procedures for a variety of diagnoses. Conversion to open was required in 9 % of patients. Complication rates
were acceptable. They found that operative time decreased with experience [25].
Retrospective and Comparative Studies for Robotic Colectomy
With some exceptions, retrospective and case-matched comparison trials have demonstrated that robotic colectomy outcomes are similar to the laparoscopic approach
for diseases of the colon [26–39]. Several studies have shown no difference in estimated blood loss (EBL), R0 resection, lymph node harvest, complications,
15 Completed and Ongoing Trials in Robotic Colorectal Surgery
201
reoperation, LOS, and operative mortality. Operative time is longer and institutional
costs are higher for the robotic approach. Incisional hernia rates are less for robotic
right colectomies because when compared to the extracorporeal anastomosis, the
technically less demanding robotic intracorporeal anastomosis allows the specimen
extraction site to be away from the midline where the incisional hernia rate is highest [34, 35]. Three studies showed shorter recovery times as measured by quicker
return of gastrointestinal activity or shorter hospital LOS for the robotic group and
one study showed fewer conversions for robotic right colectomies [35–38].
In one of the earliest robotic colorectal surgery reports, Delaney et al. compared
six robotic and six laparoscopic procedures for various benign and malignant diagnoses. Though the robotic approach was safe in their experience, they expressed
concerns about the added cost of the robotic approach [26]. D’Annibale compared
53 robotic with 53 laparoscopic colorectal procedures for various indications and
found the robotic approach to be particularly advantageous for splenic flexure mobilization, dissection in a narrow pelvis, identification of the pelvic nerves, and in the
construction of handsewn anastomoses. There were no differences between robotic
and laparoscopic groups with respect to operative time, lymph node harvest, and
hospital LOS [27]. Anvari et al. compared ten patients who had robotic colorectal
surgery with the Zeus system with ten laparoscopic colorectal procedures for similar indications. There were no intraoperative complications or conversions in the
robotic group. Morbidity and hospital LOS for the robotic group were comparable
to the laparoscopic group. Operative times for the robotic group decreased after the
first four cases [28].
Rawlings et al. compared 30 robotic and 27 laparoscopic colectomies and performed subgroup analysis of right- and left-sided procedures. Robotic right colectomies were longer because these procedures included an intracorporeal anastomosis,
whereas the laparoscopic counterparts were all extracorporeal anastomoses.
Operative times and costs were higher for the robotic group [29]. Spinoglio et al.
compared their first 50 robotic colorectal procedures with 161 laparoscopic procedures, mostly for malignant neoplasia. Oncologic results were comparable and
operative time was increased for the robot group [30]. deSousa et al. compared 40
robotic and 135 laparoscopic right hemicolectomies for various benign and malignant diagnoses. All anastomoses were done extracorporeal. Conversion rates and
outcomes were similar for both procedures. Operative time and institutional costs
were higher with the robotic approach [31].
Deutsch et al. conducted a retrospective review of 79 robotic and 171 laparoscopic colectomies for benign and malignant disease with subgroup analysis of the
right and left side. Hospital LOS and other outcome measures were similar. Robotic
operative times were longer for the left colectomy group but not for the right colectomy group [32]. In a review of the 2008–2009 National Inpatient Sample, Tyler
et al. compared 160 robotic cases with 2423 laparoscopic cases of diverse benign
and malignant indications. Complication rates and hospital LOS were similar for
both groups. Robotic surgery was associated with more postoperative infections,
fistulas, and thromboembolic events, and less pneumonia, ileus, and anastomotic
complications. The robotic option was associated with higher institutional costs [33].
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R.K. Cleary
Morpurgo et al. compared 48 robotic right hemicolectomies with intracorporeal
anastomosis to 48 laparoscopic right hemicolectomies with extracorporeal anastomosis. Operative results were similar in both groups while the robotic approach
took longer. Hospital LOS was shorter for the robotic group. Anastomotic complications and incisional hernias were more common in the laparoscopic group [35].
Lim compared 30 robotic and 146 laparoscopic colectomies for sigmoid colon cancer. Clinical and oncologic outcomes were similar in both groups. The robotic mean
operative time was longer [36].
Casillas et al. compared 200 laparoscopic and 146 robotic colorectal operations
for benign and malignant disease. Robotic surgery was associated with longer operating times but shorter LOS for left colectomies and fewer conversions to open for
right colectomies. There were also fewer postoperative complications for robotic
abdominal operations to include ileus and anastomotic leaks [37]. Trastulli et al. did
a retrospective review of patients who had robotic right colectomy with intracorporeal anastomosis (n = 102), laparoscopic right colectomy with extracorporeal anastomosis (n = 94), and laparoscopic right colectomy with intracorporeal anastomosis
(n = 40). There were no differences in conversion rates, 30-day morbidity and mortality, lymph node harvest, and other oncologic parameters. Robotic right colectomy had better recovery outcomes than laparoscopic right colectomy with
extracorporeal anastomosis, and shorter time to first flatus without a difference in
hospital LOS when compared to laparoscopic right colectomy with intracorporeal
anastomosis. These authors concluded that the robotic advantage is due to the intracorporeal anastomosis [38]. Trinh et al. compared 15 robotic with 25 laparoscopic
colorectal cases in a small series. There was no difference in blood loss, operative
times, lymph node harvest, and hospital LOS between groups [39].
Studies Evaluating the Robotic Approach for Rectal Resection
Several single institution and multicenter studies evaluating the role of robotic surgery for cancer of the rectum have demonstrated safety and feasibility of the robotic
approach [40–52].
Hellan et al. analyzed 39 consecutive patients who had robotic total mesorectal
excision (TME) for rectal cancer. The conversion rate was 2.6 % and the anastomotic leak rate was 12.1 %. All had negative circumferential margins. The authors
concluded that the robotic approach was safe and could be conducted according to
sound oncologic principles [40]. Choi et al. reported 13 patients who underwent
robotic colorectal surgery with transanal or transvaginal retrieval of specimens.
Eleven patients had low anterior resection and two patients had high anterior resection. Their outcomes were reasonable with a completely intracorporeal resection
and anastomosis, and without a transabdominal specimen extraction site [41]. Baek
et al. analyzed 64 consecutive patients with stage I–III rectal cancer. The conversion
rate was 9.4 % and oncologic parameters to include lymph node harvest, distal margins, and circumferential margins were all adequate. Early oncologic outcomes at 3
15 Completed and Ongoing Trials in Robotic Colorectal Surgery
203
years were similar to open TME [42]. Choi et al. reviewed 50 consecutive robotic
TME for rectal cancer. Mean operative time was 5 h. Complication rate was 18 %,
and 8.3 % had anastomotic leaks. Mean lymph node harvest was 20.6 lymph nodes
[43]. deSousa et al. performed a retrospective review of 44 robotic TME for rectal
cancer. Most patients were obese and 89 % of these neoplasms were in the low or
mid rectum. The conversion rate was 4.5 % and outcomes were favorable [44]. Park
et al. reviewed 45 patients who had a totally robotic technique for rectal cancer. The
conversion rate was 2.2 % and the complication rate was 11.1 % [45]. Pigazzi et al.
reviewed 143 robotic procedures for rectal cancer in three centers. The conversion
rate was 4.9 %. They concluded that oncologic outcomes compared favorably with
open resection [46].
Koh reported 21 patients who underwent robotic rectal resection for cancer.
Postoperative morbidity occurred in 14.3 %. There were no conversions and average
LOS was 6.4 days. Mean lymph node harvest was 17.8 [47]. Leong et al. evaluated
29 patients with rectal cancer who underwent robotic TME with intersphincteric
resection. Median distance of the tumor from the anal verge was 3 cm. Lymph node
harvest and oncologic margins were acceptable. There were no conversions [48]. In
a study evaluating the robotic surgery learning curve, Bokhari et al. assessed 50
patients who had robotic procedures for benign and malignant rectosigmoid disease. Utilizing the cumulative sum technique, they determined that the learning
curve for robotic surgery was 15–25 cases [49]. Zawadzid et al. evaluated 77 consecutive robotic rectal resections for cancer using the hybrid approach, characterized by laparoscopic mobilization of the proximal colon and robotic TME. Sixty-eight
were low anterior resections and nine had coloanal anastomoses. A total of 3.9 %
had positive circumferential margins. The anastomotic leak rate was 6.4 %. The
authors concluded that the hybrid robotic-laparoscopic technique for rectal cancer
is a viable method to incorporate robotic training into colorectal practice [50]. In a
review of 182 patients who had robotic TME for rectal cancer, Baek et al. separated
patients into easy, moderate, and difficult groups based on preoperative MRI pelvimetry. There were no differences between groups with respect to operative time,
complications, or oncologic outcomes. The authors concluded that robotic surgery
offers comfort for the surgeon and may overcome the challenges with difficult pelvic anatomy [51]. Shiomi et al. described 113 consecutive robotic rectal resections
for patients with rectal cancer. There were 82 anterior resections, 23 intersphincteric
resections, and eight abdominoperineal resections. Median operative time was
302 min. There were no conversions and outcomes were reasonable [52].
Retrospective and Comparative Studies for Rectal Resection
Case-matched comparisons of robotic and laparoscopic TME for cancer of the rectum have demonstrated results at least comparable to the laparoscopic approach
[53–57] with some studies showing an advantage to the robotic platform with
respect to conversion [54, 55, 58], recovery time [58, 59], hospital LOS [55, 59, 60],
204
R.K. Cleary
and oncologic parameters [54, 55, 59, 61]. Operative times are longer for the robot
in some studies but this difference is not as apparent for TME for low and mid rectal
cancers, a lengthy operation by any approach. Minimally invasive surgeons with
considerable laparoscopic experience conducted many of the early comparisons of
laparoscopic and robotic surgery. The inconsistencies in results and conclusions
may be a reflection of this variation in minimally invasive expertise.
Pigazzi et al. compared six consecutive patients who had total mesorectal excision (TME) for rectal cancer with six patients who had TME by the conventional
laparoscopic approach. There were no conversions in either group. Operative time
and hospital LOS were the same in both groups [53]. Patriti et al. compared 29
patients who had TME for rectal cancer with 37 patients who had the laparoscopic
approach. Operative time was shorter for the robotic approach in this study.
Conversion rates were lower for the robotic group (0 vs. 18.9 %) and there was a
trend in this group toward better disease-free survival [54]. Baik et al. compared 56
robotic low anterior resections for rectal neoplasia with 57 done by conventional
laparoscopy. Operative times were the same in both groups. Conversion rates, major
complications, and hospital LOS were more favorable in the robotic group when
compared to the laparoscopic group. Pathologic mesorectal grading, a reflection of
the adequacy of TME and circumferential margins, was better in the robotic group
(p = 0.03) [55]. Park et al. compared 41 patients who had TME for low rectal cancer
with 82 matched patients who underwent laparoscopic TME. A higher percentage
of patients had specimen extraction either by transanal or transvaginal techniques in
the robotic group (48.4 % robotic vs. 13.4 % laparoscopic). Complication rates were
similar between groups as was lymph node harvest, distal margins, and circumferential margins [56]. Bianchi et al. compared 25 robotic TME and 25 laparoscopic
TME for low and mid rectal cancers. Median operating time, first bowel movement,
median hospital LOS, postoperative complications, median lymph node harvest,
distal margins, circumferential margins, and conversions were all similar between
the two groups [57].
Kim et al. performed a case-matched comparison of 100 open, 100 laparoscopic,
and 100 robotic TME for rectal cancer. The conversion rate was 2 % in the robotic
group and 3 % in the laparoscopic group. Operative time was longer for the robotic
group. Oncologic margins were the same in all groups, but lymph node harvest was
higher in the open than in the laparoscopic and robotic groups. The robotic group
was better than laparoscopic and open groups with respect to first flatus, tolerating
a soft diet, and hospital LOS. There was no difference in anastomotic leak rates
among groups [62]. deSousa et al. compared 36 consecutive robotic rectal resections with 51 consecutive laparoscopic rectal resections. Hand-assisted laparoscopy
was used for splenic flexure mobilization in all cases. There were more abdominoperineal resections and more low and mid rectal neoplasms in the robotic group.
Operative time was longer for the robotic group. Complications, lymph node harvest, and hospital LOS were comparable. The robotic group had fewer positive circumferential margins but this did not reach statistical significance [61]. Baek et al.
compared 41 robotic TME and 41 laparoscopic TME for rectal cancer from a
prospectively maintained database. Operative time, conversion rates, and the
15 Completed and Ongoing Trials in Robotic Colorectal Surgery
205
number of anastomotic leaks were similar, as were oncologic outcomes.
Hospitalization costs were higher for the robotic approach but did not reach statistical significance [63].
In another learning curve study of 62 patients who had robotic surgery for rectal
cancer, Kim et al. showed that the operative and console times decreased after 20
cases. When comparing these robotic procedures with 147 laparoscopic cases, there
was no difference in complications including anastomotic leaks, and no difference
in lymph node harvest and oncologic margins during the learning curve period.
These authors concluded that an open surgeon may be trained on robotic technology
without a long learning curve, even without previous laparoscopic experience [64].
Baek et al. compared 154 robotic and 150 laparoscopic rectal resections for cancer.
There were more patients with low rectal neoplasms who had preoperative chemoradiation in the robotic group. Nevertheless, postoperative course and complication
rates were similar between the two groups. The robotic approach was associated
with higher institutional costs [65].
Kwak et al. retrospectively analyzed 117 robotic and 102 laparoscopic rectal
cancer resections over a 2-year period. Lymph node harvest, resection margins, and
conversion rates were similar for both groups. Operative time was longer for the
robotic group. Short-term local recurrence rates and distant metastases were similar
between groups [66]. Patel et al. performed a 3-arm case-matched analysis to
include 30 robotic, 30 hand-assisted laparoscopic, and 30 conventional laparoscopic
resections of the rectum and rectosigmoid. Complication rates, lymph node harvest,
and hospital LOS were similar among all three groups. Operative time for low rectal
cancers was comparable for all three groups [67]. Park et al. compared 52 patients
who had robotic procedures for rectal cancer with 123 laparoscopic and 88 open
procedures. The operative time for the robotic approach was longer. The proportion
of patients who had natural orifice (transanal or transvaginal) extraction with intracorporeal anastomosis was higher in the robotic group. Complication rates, lymph
node harvest, and margins were the same among the three groups [68].
Kang et al. conducted a case-matched analysis comparing open (n = 165), laparoscopic (n = 165), and robotic (n = 165) rectal resections for rectal cancer. They
applied propensity scores to adjust for patient and tumor characteristics and found
that some outcomes (time to soft diet and hospital LOS) were more favorable with
the robot. Short-term disease-free survival was the same among the three groups.
The authors concluded that the robotic approach has advantages over open and laparoscopic surgery for low and mid rectal neoplasms [60]. Park et al. did a study comparing 40 robotic TME with intersphincteric dissection and 40 laparoscopic TME
with intersphincteric dissection in patients with rectal cancer. Transabdominal intersphincteric dissection was performed more often with the robotic than the laparoscopic approach. There was no difference in postoperative morbidity and pathologic
outcomes. There was a trend toward less blood loss and quicker functional recovery
in the robotic group [59]. D’Annibale et al. compared 50 consecutive robotic TME
to 50 consecutive laparoscopic TME for rectal cancer. Median operative time was
the same in both groups. There were more favorable outcomes with the robotic
approach with respect to conversions (0 % vs. 14 %), circumferential margins (5 vs.
206
12 %), hospital LOS, and voiding and sexual function [58]. Ielpo et al. compared 56
robotic with 87 laparoscopic rectal resections for cancer. The conversion rate was
significantly better for the robotic approach for lower rectal cancers (1.8 % vs. 9.2 %,
p = 0.04). Operative time was longer in the robotic group. There was no difference in
hospital LOS, complications, or oncologic outcomes between groups [69]. Kuo
et al. retrospectively evaluated the feasibility of robotic intersphincteric resection in
36 patients with low rectal cancer and compared them with 28 patients who had the
laparoscopic approach. They found the robotic approach to be safe and feasible and
that operating times decreased with experience [70].
R.K. Cleary
Comparisons Between Robotic and Open Colectomy
Bertani et al. compared 45 open, 30 laparoscopic, and 34 robotic colectomies and
rectal resections for colorectal cancer. Laparoscopic and robotic approaches had
several advantages compared to open groups. The robotic approach was associated
with higher institutional costs [71]. Luca et al. compared 33 robotic and 102 open
right colectomies for cancer. The robotic anastomoses were constructed in an extracorporeal fashion. Lymph node retrieval and hospital LOS were better with the
robotic approach (5 days vs. 8 days) [72].
Comparisons Between Robotic and Open for Rectal Resection
The results of the ACOSOG randomized study comparing open and laparoscopic
TME for rectal cancer that showed inferior oncologic parameters for the laparoscopic approach raise the question of the possible need for a randomized trial comparing robotic and open approaches for rectal cancer [6]. However, a proposal for a
randomized trial comparing robotic and open TME is unlikely. There are some
small case series and comparisons between robotic and open procedures.
Kim et al. did a case-matched comparison of 100 robotic procedures and 100
open procedures for rectal cancer. The distal margin was longer in the robotic group.
Complication rates and functional results were comparable between groups [73].
Kim et al. compared 108 patients with rectal cancer who underwent a completely
transabdominal robotic intersphincteric resection with 114 patients with rectal cancer who underwent the same procedure by an open approach. Abdominal intersphincteric resection was completed more often in the robotic group than the open
group (82.6 % vs. 67.9 %, p = 0.008). The two groups had equivalent morbidity,
oncologic margins, and lymph node harvest. The robotic group had 2.7-fold less
frequent moderate to severe sexual dysfunction when compared to the open group.
Fecal incontinence scores were better in the robotic group at 6 and 12 months
(p < 0.05) [74]. In another study, this same group compared 21 patients who underwent curative abdominoperineal resection for rectal cancer with 27 patients who
15 Completed and Ongoing Trials in Robotic Colorectal Surgery
207
had the open approach. The robotic group had a similar percentage of cylindrical
excision (76 % vs. 70 %, p = 0.75), better lymph node harvest (20 vs. 16, p = 0.3),
and fewer positive circumferential margins than the open group (0 % vs. 15 %,
p = 0.12). The circumferential margins were also significantly wider in the robotic
group (76 mm vs. 25 mm, p = 0.02) [75].
Meta-analyses and Reviews
Several meta-analyses have now been conducted comparing robotic and laparoscopic colorectal surgery. Most of these studies show advantages for the robotic
approach with respect to conversion rates [76, 87–88].
Lin et al. conducted a meta-analysis of eight studies comparing 268 robotic and
393 laparoscopic resections for rectal cancer. The robotic approach resulted in less
conversion to open. All other outcomes were the same including operative time
[76]. A meta-analysis by Memon et al. assessed seven studies comparing robotic
(n = 353) and laparoscopic (n = 401) proctectomy for rectal cancer. Again, the
robotic approach resulted in fewer conversions. There were no differences in hospital LOS, complications, lymph node harvest, and oncologic margins [77]. In a
review and meta-analysis that included 203 robotic and 283 laparoscopic surgeries
for rectal cancer, Ortiz-Oshiro et al. found that conversion rates were more favorable for the robotic approach. There was no difference in complications between
groups including anastomotic leaks. There were no differences in hospital LOS and
oncologic outcomes [78]. In another meta-analysis of 16 studies for benign and
malignant colorectal disease, Yang et al. found that the robotic approach to rectal
cancer was associated with less blood loss, fewer conversions, longer operating
time, and higher costs when compared to the laparoscopic approach [79]. In a comprehensive literature review that included 39 case series or comparative nonrandomized studies of patients undergoing robotic resections for benign and malignant
colorectal disease, Antoniou et al. found that robotic right and left colectomies had
low conversion rates (1.1 % and 3.8 %, respectively) and acceptable operative morbidity (13.4 % and 15.1 %, respectively). Robotic anterior resection was associated
with a low conversion rate (0.4 %), low morbidity (9.7 %), and adequate lymph node
harvest (mean 14.3) [80].
In a systematic review of short-term outcomes that included 351 robotic colorectal procedures, Fung et al. found that complication rates were similar, and that operative time and cost were higher for the robotic approach when compared to the
laparoscopic approach [81]. Liao et al. performed a meta-analysis of four randomized trials comparing 110 robotic and 116 laparoscopic colorectal surgeries. The
robotic approach was associated with significant reduction in estimated blood loss,
conversion to open (1.8 % vs. 9.5 %, p = 0.04), and more favorable time to bowel
function recovery. There were no differences in complications rates, hospital LOS,
oncologic margins, and lymph node harvest [82]. In a systematic review and metaanalysis of eight nonrandomized studies to include 344 robotic and 510 laparoscopic