Purpose Minimally invasive surgery offers reduced trauma, accelerated recovery, and shorter hospital stays. Robotic technology further enhances laparoscopic precision, particularly in colorectal procedures. This study investigated the safety and effectiveness of robotic natural orifice transluminal extraction colectomy (R-NOTEC) and robotic no-incision colectomy (R-NIC), comparing these techniques to the conventional robotic colectomy.
Methods Outcomes of patients undergoing robotic-assisted colorectal resection—either conventional robotic colectomy or R-NOTEC/R-NIC—using a single docking technique at a tertiary hospital over 3 years were analyzed. All patients were managed according to established Enhanced Recovery After Surgery protocols.
Results In total, 100 patients were included, with 25 receiving R-NOTEC or R-NIC. The median age was 65 years (range, 30–82 years), and the median body mass index was 31.0 kg/m2 (range, 20.1–43.0 kg/m2). The median length of stay was significantly shorter in the R-NOTEC/R-NIC group than in the conventional robotic group (2.0 days vs. 3.4 days, P=0.021). Other outcomes, such as circumferential resection margin status, lymph node yield, and mortality, were similar between groups. The R-NOTEC/R-NIC group exhibited a slightly lower complication rate, as well as less opioid use. No conversions to open surgery occurred in either group.
Conclusion R-NOTEC/R-NIC offer significant promise in colorectal surgery by minimizing trauma, expediting recovery, and maintaining oncologic safety. Nevertheless, these procedures require specialized surgical expertise and careful patient selection. Further research should focus on long-term outcomes and standardization of these techniques.
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Purpose The hinotori Surgical Robot System (hereafter “hinotori”) is a novel platform for robot-assisted surgery, while the da Vinci Surgical System (“da Vinci”) remains the field standard. This study compared short-term surgical outcomes of rectal cancer surgery between these systems using propensity score–matched analysis.
Methods A retrospective analysis was conducted of 209 consecutive patients who underwent robot-assisted surgery with the da Vinci and 58 patients with the hinotori system. After 2:1 propensity score matching, 108 da Vinci and 54 hinotori cases were included. Surgical outcomes, including operative time, blood loss, postoperative complications, length of hospital stay, and pathological findings, were compared.
Results After matching, the baseline demographics were well balanced between groups. The hinotori system was associated with significantly longer operative time (266 minutes vs. 227 minutes, P=0.014) and console time (156 minutes vs. 110 minutes, P=0.001). However, estimated blood loss and postoperative complication rate did not differ significantly. Pathological findings, including the number of lymph nodes retrieved and the incidence of positive surgical margins, were comparable between systems.
Conclusion In rectal surgery, the hinotori system demonstrates comparable short-term safety outcomes to da Vinci. Despite longer operative times and limited integrated instrumentation, hinotori‐assisted procedures may be feasible in selected patients. Further research should address long-term oncological outcomes and strategies to improve procedural efficiency.
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Purpose Robot-assisted surgery is readily applied to every type of colorectal surgeries. However, studies showing the safety and feasibility of robotic surgery (RS) have dealt with rectal cancer more than colon cancer. This study aimed to investigate how technical advantages of RS can translate into actual clinical outcomes that represent postoperative systemic response.
Methods This study retrospectively reviewed consecutive cases in a single tertiary medical center in Korea. Patients with primary colon cancer who underwent curative resection between 2006 and 2012 were included. Propensity score matching was done to adjust baseline patient characteristics (age, sex, body mass index, American Society of Anesthesiologists physical status, tumor profile, pathologic stage, operating surgeon, surgery extent) between open surgery (OS), laparoscopic surgery (LS), and RS groups.
Results After propensity score matching, there were 66 patients in each group for analysis, and there was no significant differences in baseline patient characteristics. Maximal postoperative leukocyte count was lowest in the RS group and highest in the OS group (P=0.021). Similar results were observed for postoperative neutrophil count (P=0.024). Postoperative prognostic nutritional index was highest in the RS group and lowest in the OS group (P<0.001). The time taken to first flatus and soft diet resumption was longest in the OS group and shortest in the RS group (P=0.001 and P<0.001, respectively). Among all groups, other short-term postoperative outcomes such as hospital stay and complications did not show significant difference, and oncological survival results were similar.
Conclusion Better postoperative inflammatory indices in the RS group may correlate with their faster recovery of bowel motility and diet resumption compared to LS and OS groups.
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The benefits of minimally invasive approaches in colorectal surgery have been well demonstrated. However, some hesitancy remains with regards to the utilization of the robotic platform for total colectomies, mostly due to the perceived need for multiple re-dockings in multiquadrant surgery. This video aims to demonstrate how the robotic platform can be efficiently utilized in multiquadrant surgery without the need for multiple re-dockings, as well as some tips on how to overcome the potential challenges that may be encountered during this procedure.
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Lateral pelvic node dissection can be challenging. In addition to detailed anatomical knowledge of the pelvic side wall, surgeons also need to be proficient in performing fine dissection within the confines of this limited operative field. While the incorporation of robotics can facilitate the safe completion of this technically demanding procedure, this is nonetheless dependent on the way the robotic system is used. This video aims to demonstrate several tips and tricks for performing robotic lateral pelvic node dissection.
Minimally invasive colorectal surgery is currently well-accepted, with open techniques being reserved for very difficult cases. Laparoscopic colectomy has been proven to have lower mortality, complication, and ostomy rates; a shorter median length of stay; and lower overall costs when compared to its open counterpart. This trend is seen in both benign and malignant indications. Natural orifice specimen extraction surgery (NOSES) in colorectal surgery was first described in the early 1990s. Three recent meta-analyses comparing transabdominal extraction against NOSES concluded that NOSES was superior in terms of overall postoperative complications, recovery of gastrointestinal function, postoperative pain, aesthetics, and hospital stay. However, NOSES was associated with a longer operative time. Herein, we present our technique of robotic NOSES anterior resection using the da Vinci Xi platform in diverticular disease and sigmoid colon cancers.
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Intersphincteric resection (ISR) with coloanal anastomosis is an oncologically safe anus-preserving technique for very low-lying rectal cancers. Most studies focused on oncological and functional outcomes of ISR with very few evaluating long-term postoperative anorectal complications. Full-thickness prolapse of the neorectum is a relatively rare complication. This report presents the case of a 70-year-old woman presenting with full-thickness prolapse of the side limb of the side-to-end coloanal anastomosis occurring 2 weeks after the stoma closure and 2 months after a robotic partial ISR performed with the Da Vinci single-port platform. The anastomosis was revised through resection of the side limb and conversion of the side-to-end anastomosis into an end-to-end handsewn anastomosis with interrupted stitches. This study describes the first case of full-thickness prolapse of the side limb of the side-to-end handsewn coloanal anastomosis following ISR. Moreover, a revision of all reported cases of post-ISR full-thickness and mucosal prolapse was performed.
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International standardization and optimization group for intersphincteric resection (ISOG‐ISR): modified Delphi consensus on anatomy, definition, indication, surgical technique, specimen description and functional outcome Guglielmo Niccolò Piozzi, Krunal Khobragade, Vusal Aliyev, Oktar Asoglu, Paolo Pietro Bianchi, Vlad‐Olimpiu Butiurca, William Tzu‐Liang Chen, Ju Yong Cheong, Gyu‐Seog Choi, Andrea Coratti, Quentin Denost, Yosuke Fukunaga, Emre Gorgun, Francesco Guerra, Ma Colorectal Disease.2023; 25(9): 1896. CrossRef
Purpose The use of robot-assisted surgery for rectal cancer is increasing, but the pathological outcomes have not been fully clarified. We compared the surgical and pathological outcomes between robot-assisted and open surgery in specimens from patients operated on for rectal cancer.
Methods All patients who underwent resection for rectal cancer from 2016 to 2018 were included (n=137). Specimens were divided into 3 sections to analyze the pathology of the lymph nodes.
Results The total specimen lengths were shorter in the robot-assisted group than in the open surgery group (mean±standard deviation: 29.1±8.6 cm vs. 33.8±9.9 cm, P=0.004) because of a shorter proximal resection margin (21.7±8.7 cm vs. 26.4±10.6 cm, P=0.006). The number of recruited lymph nodes (35.8±21.8 vs. 39.6±16.5, P=0.604) and arterial vessel length (8.84±2.6 cm vs. 8.78±2.4 cm, P=0.891) did not differ significantly between the 2 surgical approaches. Lymph node metastases were found in 33 of 137 samples (24.1%), but the numbers did not differ significantly between the procedures. Among these 33 cases, metastatic lymph nodes were located in the mesorectum (75.8%), in the sigmoid colon mesentery (33.3%), and at the arterial ligation site of the inferior mesenteric artery (12.1%). The circumferential resection margin and the proportion of complete mesorectal fascia were comparable between the groups.
Conclusion There were no significant differences between the 2 surgical approaches regarding arterial vessel length, recruitment of lymph node metastases, and resection margins.
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Purpose Since the introduction of robotic surgery, robots for colorectal cancer have replaced laparoscopic surgery, and a single-port robot (SPR) platform has been launched and is being used to treat patients. We analyzed the learning curve and initial complications of using an SPR platform in colorectal cancer surgery.
Methods We reviewed 39 patients who underwent SPR colectomy from April to October 2019. All surgeries were performed by the same surgeon using an SPR device. A learning curve was generated using the cumulative sum methodology to assess changes in total operation time, docking time, and surgeon console time. We grouped the patients into 3 groups according to the time period: the first 11 were phase 1, the next 11 were phase 2, and the last 17 were phase 3.
Results The mean age of the patients was 61.28±13.03 years, and they had a mean body mass index of 23.79±2.86 kg/m2. Among the patients, 23 (59.0%) were male, and 16 (41.0%) were female. The average operation time was 186.59±51.30 minutes, the average surgeon console time was 95.49±35.33 minutes, and the average docking time (time from skin incision to robot docking) was 14.87±10.38 minutes. The surgeon console time differed significantly among the different phases (P<0.001). Complications occurred in 8 patients: 2 ileus, 2 postoperation hemoglobin changes, 3 urinary retentions, and 1 complicated fluid collection.
Conclusion In our experience, the learning curve for SPR colectomy was achieved after the 18th case.
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Review
Malignant disease, Rectal cancer ,Functional outcomes,Colorectal cancer,Minimally invasive surgery
Intersphincteric resection (ISR) is the ultimate anus-sparing technique for low rectal cancer and is considered an oncologically safe alternative to abdominoperineal resection. The application of the robotic approach to ISR (RISR) has been described by few specialized surgical teams with several differences regarding approach and technique. This review aims to discuss the technical aspects of RISR by evaluating point by point each surgical controversy. Moreover, a systematic review was performed to report the perioperative, oncological, and functional outcomes of RISR. Postoperative morbidities after RISR are acceptable. RISR allows adequate surgical margins and adequate oncological outcomes. RISR may result in severe bowel and genitourinary dysfunction affecting the quality of life in a portion of patients.
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Technical Note
Malignant disease, Rectal cancer,Minimally invasive surgery
Recently, abdominoperineal resection (APR) using a robot has been demonstrated in other studies. However, there has been no report on APR for rectal cancer using the single-port robot (SPR) platform. In response to this research gap, we described the clinical experience of APR using a SPR. From April 2019 to March 2020, APR using a SPR platform was performed in a total of 4 patients. Three patients had a transumbilical approach, and 1 patient had a transstoma site approach. The average operation time was 307 minutes, and the patient docking time to the SPR platform was 133.5 minutes. There were no complications during the operation, and no laparoscopy or open conversion. No reoperation occurred within 30 days. Mild postoperative complications occurred in 2 patients. We found that APR has safety and feasibility in surgery using an SPR platform. There was no intraoperative event and severe postoperative complications.
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Despite the technical limitations of minimally invasive surgery, laparoscopic total mesorectal excision (LTME) for rectal cancer has short-term advantages over open surgery, but the pathological outcomes reported in randomized clinical trials are still in controversy. Minimally invasive robotic total mesorectal excision (RTME) has recently been gaining popularity as robotic surgical systems potentially provide greater benefits than LTME. Compared to LTME, RTME is associated with lower conversion rates and similar or better genitourinary functions, but its long-term oncological outcomes have not been established. Although the operating time of RTME is longer than that of LTME, RTME has a shorter learning curve, is more convenient for surgeons, and is better for sphincter-preserving operations than LTME. The robotic surgical system is a good technical tool for minimally invasive surgery for rectal cancer, especially in male patients with narrow deep pelvises. Robotic systems and robotic surgical techniques are still improving, and the contribution of RTME to the treatment of rectal cancer will continue to increase in the future.
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We aimed to show that a standardized step-by-step robotic approach using surgical landmarks could make lateral pelvic lymph node dissection (LPND) less complicated. We performed robot-assisted LPND consisting of 4 steps using surgical landmarks. The first step is a dissection of uretero-hypogastric fascia, which envelopes the ureter and the hypogastric nerve. The second step is a dissection of the medial side of the external iliac vein located at the lateral border of the obturator lymph nodes (LNs) group. The third step is a dissection of the vesico-hypogastric fascia, which is at the medial border of the obturator LNs group. The final step is a dissection of the internal iliac artery until the Alcock’s canal. Indocyanine green was injected just before surgery around the dentate line to identify the lateral pelvic LNs. Standardization using a robotic approach for LPND guided by surgical landmarks allows a safer and more effective surgery.
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