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Mini-invasive Surg 2019;3:36.10.20517/2574-1225.2019.34© The Author(s) 2019.
Open AccessReview

Minimally invasive right colectomy - from conventional laparoscopic resection to robotic-assisted surgery: a narrative review

1Department of Digestive and Hepatobiliary surgery, Henri-Mondor Hospital, University Paris Est-Créteil - UPEC, Créteil 94010, France.

2Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia 46017, Spain.

3Department of Emergency and Organ Transplantation, University Aldo Moro of Bari, Bari 70121, Italy.

4Department of Hepato-Biliary-Pancreatic and Oesophago-Gastric Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK.

Correspondence Address: Dr. Paolo Moroni, Department of Digestive and Hepatobiliary surgery, Henri-Mondor Hospital, University Paris Est-Créteil - UPEC, 51 Avenue du Maréchal de Lattre de Tassigny, Créteil 94010, France. E-mail: dr.pmoroni@gmail.com

    This article belongs to the Special Issue Advances and Perspectives in Robotic Colorectal Surgery
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    © The Author(s) 2019. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, sharing, adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

    Abstract

    Robotic-assisted abdominal surgery was introduced with the aim of overcoming the drawbacks of the conventional laparoscopic approach. The present narrative review focuses on the comparison between laparoscopic and robotic-assisted approaches for right colectomy (RC) regarding short- and long-term outcomes, costs, and learning curve. The main technical aspects related to the use of robotic assistance for this specific procedure are further discussed. Minimally invasive RC is considered technically challenging due to the particularities of the right and middle colic vascular anatomy. Robotic RC is not yet widespread due to its high cost and longer operating time. However, its use may result in advantages regarding short-term clinical outcomes, and it facilitates the acquisition of basic surgical skills by speeding up the learning curve of minimally invasive colorectal surgery.

    Introduction

    Colorectal cancer (CRC) is the most common malignant disease of the gastrointestinal tract and the third most common cancer worldwide with over 1,000,000 new diagnoses and 500,000 deaths per year in the United States[1]. Approximately 40% of all CRCs are located in the right colon[2]. In recent years, several technical requirements have been established to improve the post-surgery outcomes for colon cancer. The American Joint Committee on Cancer (AJCC) has defined that, for a radical colectomy, a minimum of 12 lymph nodes must be examined to avoid understaging[3,4]. Other milestones include the introduction of the principles of complete mesocolic excision (CME)[5] and the introduction and widespread use of minimally-invasive surgery (MIS)[6]. For the resection of colon cancer, the use of conventional laparoscopy seems to reduce the length of hospital stay, postoperative pain, and the time until daily activities return to normal, as well as improve cosmetic outcomes when compared to the open approach[7-10]. Nevertheless, the adoption of laparoscopic right colectomy (LRC) might not be as widespread as expected[11-15], probably due to the high complexity of the vascular anatomy of the right and transverse colon[16].

    For minimally-invasive right colectomy (RC), the debate continues regarding whether the ileo-colonic anastomosis should be performed intra- or extra-corporeally. The majority of the published series on minimally invasive RC have reported an extra-corporeal anastomosis (EA) fashioning[16]. Few studies comparing EA with intra-corporeal anastomosis (IA) have been published recently[17]. The principles of CME require a meticulous dissection, which increases the technical challenge of LRC. In this scenario, the use of robotic assistance may overcome the limitations of the straight conventional laparoscopic instruments and allow performing a safer CME with central vascular ligation (CVL), especially in obese patients[18]. The latest da Vinci Xi® robotic system (dVXi) presents some additional advantages for colorectal procedures when compared with previous versions (da Vinci S® and Si®), such as simpler docking, possibility to position the optical system in all of its arms, which are thinner (width 1.7’ vs. 2.9’), easier to move, and allow multi-quadrant surgery. The present narrative review aims to describe the main technical aspects of robotic right colectomy (RRC) and compare the learning curve, the short- and long-term outcomes, and the costs between LRC and RRC. A literature search was performed in MEDLINE database (PubMed); articles published in English between 2000 and 2019 using the following terms were screened: “MIS”, “RC/colon resection”, “robotic surgery”, AND “laparoscopic surgery” [Tables 1-3][17,19-32].

    Table 1

    Descriptive table

    AuthorYearJournalPeriod of recruitmentType of paperNumber patientsMedian age (range)
    *Mean age ± SD
    Mean BMIASA
    1234
    Ballantyne et al.[19]2006Surg Laparosc Endosc Percutan Tech2003-2004Prosp16
    D’Annibale et al[20].2004Dis Colon Rectum2001-2009Retrosp50       73.3  24(49)5(10)31(62)13(26)1(2)
    Juo et al.[21]2015Surg Endosc2010-2013Retrosp31       60.3  26.6
    Trastulli et al.[17]2015Surg Endosc2005-2014Retrosp102       68.8  25.68 (7.8)55 (53.9)39 (38.2)0
    Formisano et al.[22]2016Updates SurgRetrosp53
    Petz et al.[23]2017EJSO2016Prosp20       69
    Lujan et al.[24]2017J Robot Surg2009-2015Retrosp89       71  28.4
    Mégevand et al[25].2019Updates Surg2010-2015Retrosp50       70.36(12)37(74)7(14)0
    Blumberg[26]2018J Robot Surg2003-2016Retrosp21       65  3006(39)15(71)0
    Cleary et al.[27]2018Surg Endosc2010-2016Retrosp588
    Scotton et al.[28]2018J Laparoendosc Adv Surg Tech A2001-2015Retrosp206       70.1  2628 (13.7)120 (58.8)52 (25.5)4 (2.0)
    Johnson et al[29]2018J Robot Surg2015-2016Retrosp113       66.4
    Spinoglio et al[30].2018Ann Surg Oncol2005-2013Prosp101       71.2  25.113 (12.8)40 (39.6)38 (37.6)10(10)
    Park et al.[31]2019Surg Endosc2009-2011Prosp35       62.8  24.415 (42.9)16 (45.7)4 (11.4)0
    Schulte et al.[32]2019BMC Surg2016-2018Retrosp31       75
    Table 2

    Table for surgical approach

    AuthorType RobotTrocar’s siteApproachMean Op. time (min)Anastomosis
    StapledHandsewnIntracorporealExtracorporealIsoperistalticAnisoperistaltic
    Ballantyne et al.[19]SMtL, LtMYYYN
    D’Annibale et al.[20]SMtL223YYYYN
    Juo et al.[21]SIRCUmbilicus
    Trastulli et al.[17]Si and XiMtL287YYYNYN
    Formisano et al.[22]XiDiagonal/SuprapubicMtL
    Petz et al.[23]XiSuprapubicMtL249YYY
    Lujan et al.[24]XiMtLYYY
    Mégevand et al.[25]XiMtL204YYY
    Blumberg[26]SiMtL330YYY
    Cleary et al.[27]Si and XiMtL-LtMY           Y (335)            Y (253)YY
    Scotton et al.[28]XiDiagonalMtL253YYY
    Johnson et al[29]Xi149YY
    Spinoglio et al.[30]S and Si279YYY
    Park et al.[31]Si195YYY
    Schulte et al.[32]XiSuprapubicMtL285
    Table 3

    Table post-operative

    AuthorConversion (%)Clavien-Dindo postoperative complicationsLeakReoperation (%)Readmission (%)
    1 (%)2 (%)3 (%)4 (%)
    Ballantyne et al.[19]        00
    D’Annibale et al.[20]        01(2)0          1(2)           0
    Juo et al.[21]        1 (3.2)0          0           0
    Trastulli et al.[17]        4 (3.9)3 (2.9)          7 (6.8)           0
    Formisano et al.[22]        1 (1.8)0          0           0
    Petz et al.[23]        0002(10)00          0           0
    Lujan et al.[24]        2 (2.3)19 (21.3)6 (6.7)1 (1.1)01 (1.1)          1 (1.1)           2 (2.2)
    Mégevand et al.[25]        02(4)
    Blumberg[26]        0
    Cleary et al.[27]
    Scotton et al.[28]        5 (2.4)1 (0.4)          6 (2.9)
    Johnson et al[29]        0          0           0
    Spinoglio et al.[30]        02(2)1 (0.9)          2(2)
    Park et al.[31]        01 (2.8)1 (2.8)          1 (2.8)           0
    Schulte et al.[32]        09(29)2 (6.4)000

    Technical aspects of RRC

    Positioning

    There is no consensus about the position of patient and robot in the operating room. In our center, we put the patient in a supine position tilted on the left side (10°-25°) with the arms tight to the body and legs closed. Generally, the table is positioned in Trendelenburg position (5°-10°)[33,34] and the robot is placed on the right side of the patient [Figure 1].

    Figure 1. ROBOTIC CONSOLE: robotic platform. SURGEON: first surgeon; ROBOTIC CART: robotic arms; ANESTHESIOLOGIST: anesthesiologist; ASSISTANT: second surgeon; SCRUB NURSE: operative nurse

    Docking

    The pneumoperitoneum is first established. Different options to position the ports have been described, some of which are similar to the conventional laparoscopic approach[35,36]. Advances in robotic systems allow variations of the port placement. Moreover, dVXi arms are thinner and have more flexibility, thus decreasing the risk of external collisions when compared to previous robot versions.

    Diagonal or oblique port placement

    Four trocars are positioned drawing an oblique line from 4 cm above the pubic symphysis (Port 1) to the left mid-clavicular line crossing over the left sub-costal margin (Port 4), separated by 7.5 cm. One assistant port can be placed at the level of the umbilicus on the middle clavicular line [Figure 2, red points][37].

    Figure 2. Robot trocar's positions. Red points: diagonal approach; blue points: suprapublic approach

    Suprapubic port placement

    This approach has been increasingly used [Figure 2, blue points]. The trocars are positioned on a horizontal line 3-4 cm above the pubic symphysis, separated by 6.5-7.5 cm[23,32,38,39]. The unconventional viewpoint is a potential barrier against its widespread use. This placement allows the extraction of the specimen using trocar’s incisions.

    Single-incision robotic colectomy

    The approach is technically challenging as surgical instruments can collide and freedom of motion may be impaired. It has been recently described that this approach should not be recommended in obese patients (BMI > 30 kg/m2)[21,40]. Further limitations for its current widespread use include the cost of multi-port access and increased incisional hernia rates[41-43].

    Medial-to-lateral vs. lateral-to-medial approaches

    Two main approaches are used for the right colonic mobilization in both LRC and RRC. Some authors suggest using the medial to lateral approach (MtL)[28] while others prefer the lateral to medial (LtM)[9,19,44] alternative. The MtL technique starts after identifying the inferior part of the duodenum and performing an incision in the mesocolon. Ileo-colic and right colic arteries are clipped close to the superior mesenteric axis in order to insure a CME. MtL mobilization continues with the dissection of Toldt-Gerota fascia from “bottom-to-up”, ending with the division of the lateral peritoneal attachments. In the LtM approach, the ligation of vascular pedicle is performed after the mesocolic dissection and the mobilization of the lateral peritoneal attachments, as in an open surgery. There is no evidence of relevant differences between the 2 approaches. MtL approach may reduce the necessary movements, therefore facilitating the use of robotic assistance[22,28]; early pedicle ligation may also prevent the tumor spreading throughout the mesentery[45].

    Complete mesocolic excision

    The surgical principles of total mesorectal excision (TME) for rectal cancer were applied in RC, resulting in the concept of CME with CVL, as described by Hohenberger et al.[5] in 2008. D3 lymphadenectomy has been performed for decades in Eastern countries when operated on colon cancer and is equivalent to CME[46]. The long-term outcomes after RC have not been improved to the same degree as those for rectal cancer after the introduction of TME[47]. Some studies showed that CME may decrease local recurrences (from 6.5% to 3.6%)[5] and improve survival rates, especially for stage III tumors[48]. The absence of data from well-powered studies, as well as the technical difficulty added by the extended dissection, has impeded the routine implementation of CME for RCC and it is nowadays far from being the “gold standard” in Western countries. Some authors suggest that robotic assistance allows overcoming the technical difficulties of CME in RCC with lower conversion rate than LRC[30].

    Intra-corporeal vs. EA

    EA has traditionally been the preferred method for intestinal reconstruction after LRC. IA may present some advantages, such as reducing the chance of twisting intestinal stumps and causing injuries by specimen traction. IA also allows choosing the location of the specimen extraction incision, reducing the possibility of incisional hernia[41,49,50]. IA application in LRC has been limited due to its technical difficulty[25,51-54], which may be mitigated by the use of robotic assistance[55,56]. EA may require an extensive mobilization of the transverse colon for reaching the specimen extraction incision[54,57]. Two recent meta-analyses in LRC have shown shorter time for first defecation, and oral liquid diet, and decreased length of hospital stay in the IA group[58,59]. Van Oostendorp et al.[59] also showed a reduction of the short-term postoperative morbidity and surgical-site infection rate in the IA group. No differences were found regarding the other short-term clinical and histopathological variables evaluated[59]. Technical advantages of robotic surgery permit performing an IA more easily. Mégevand et al.[25] reported a series of 100 cases comparing RRC and LRC with IA, and they observed faster intestinal recovery and fewer conversions in the RRC group. Solaini et al.[60], in a subgroup meta-analysis comparing only EA, found no significant differences between RRC and LRC. To date, no randomized controlled trial has been reported comparing RRC and LRC with the same type of anastomosis. Further studies are therefore needed before drawing any conclusion regarding the potential benefits of both IA and robotic assistance in decreasing the odds of anastomotic leak or improving intestinal recovery after RC.

    Three-dimensional versus two-dimensional view in LRC

    Since the first steps of minimally-invasive surgical procedures, technological research continues to improve its outcomes. In the field of surgical view, a notorious revolution is expected and it is still ongoing. The new laparoscopic platforms together with the new generation of optics allow exceeding the limits of the two-dimensional (2D) view. Abdelrahman et al.[61] reported that three-dimensional (3D) optics with ultra-high definition 4k allow a faster learning curve. This experimental evidence was confirmed by Currò et al.[62], who concluded that the 3D vision improves the depth of perception, which is especially useful in performing an IA, and it also produces less physical strain to the surgeon. However, further studies are needed before drawing any definitive conclusions regarding the potential benefits of 3D (with or without 4k) versus conventional 2D. To date, the choice between 3D and 2D systems relies only on the surgeon’s preferences and the hospital’s resources.

    Learning curve of minimally-invasive RC

    Robotic surgery, similar to all the minimally-invasive surgical procedures, requires the acquisition of specific abilities and skills. The learning curve is the number of cases required to achieve expertise with minimal procedural time and complications[63,64]. LRC requires a high degree of dexterity and technical skills which result in a learning curve of 20-30 procedures[36,65,66]; this number may increase with IA fashioning[59]. Operative time for the first cases of robotic surgery is shorter than that in laparoscopy[67]. Additionally, RRC has been proposed as an ideal procedure for the surgeon’s initial steps with robotics[68]. de’Angelis et al.[36] observed that RRC with EA was associated with a faster learning curve than LRC with EA. Only 16 procedures in the RRC group were needed to significantly reduce operative time versus 25 surgeries in the LLC group. This may be explained by the fact that robotic surgery improves the surgeon’s dexterity and depth of perception. Parisi et al.[69] concluded that the learning curve for RRC is around 44 procedures. This long curve was necessary to significantly reduce operative time and conversion to open surgery rate, as well as to significantly increase the number of harvested lymph nodes. Performing RRC can be justified in different situations depending on the type of surgical unit, for example as a training procedure for robotic colorectal surgery for young surgeons in centers that are already skilled at performing RRC. Moreover, centers aiming to incorporate complex robotic procedures could start with RRC as one of the first of them.

    Short- and long-term outcomes

    Several studies have demonstrated the safety and efficacy of RRC for both short- and long-term outcomes[31,60,70,71]. Only one randomized controlled trial found no differences in lengths of hospital stay and the surgical complications rate between RRC and LRC groups[72]. The latest meta-analysis published by Ma et al.[73] in 2019 concluded that RRC has a longer operation time, lower estimated blood loss, shorter hospital stay, and lower postoperative complication rate than LRC. Solaini et al.[60] reported that conversion to open surgery was more common during LRC, with no significant differences in mortality and postoperative complication rate. Lim et al.[70] concluded that the time for diet, first flatus, and first defecation, and the length of hospital stay were significantly decreased for RRC. Similarly, Rondelli et al.[74] showed that the time for the first flatus was significantly shorter in RRC. Such differences in recovery may also be related to the less traumatic intra-peritoneal approach provided by the use of IA, rather than purely by the use of robotic assistance. When combined, they can provide a quicker bowel recovery with less need of analgesics[17,75] and fewer post-operative complications[24,74,76-78] [Tables 4 and 5][17,24,30,54,72,76-79].

    Table 4

    Operative data table

    AuthorYearJournalNumber patientsMean Op. time (min)Mean BL (mL)Conversion (%)Harvest NodeAnastomotic Leak (%)
    RRCLRCRRCLRCRRCLRCRRCLRCRRCLRCRRCLRC
    Delaney et al.[77]2003Dis Colom Rectum22270.513810015000NRNR00
    Rawlings et al[79]2007Surg Endosc1715218.9198.24066.302 (1.3)NRNR1 (0.6)0
    Park et al.[72]2012Br J Surg353519513035.856.80029.930.81 (0.2)0
    Deutsch et al.[78]2012Surg Endosc1847219.2214.476.4123.22 (1.1)021.118.71 (5.5)1 (2.1)
    Morpurgo et al.[54]2013J Laparoendosc Adv Surg Tech A4848266223NRNRNRNR262503 (6.2)
    Lujan et al.[24]2013J Robot Surg22252511494050002415NRNR
    Casillas et al.[76]2014Am J Surg541101437963574 (7.4)11(10)282407 (6.4)
    Trastulli et al.[17]2015Surg Endosc102134287.420730404 (3.9)14 (10.4)20.3193 (2.9)2 (1.5)
    Spinoglio et al.[30]2018Ann Surg Oncol100100279236NRNR07(7)28.230.41(1)1(1)
    Table 5

    Short-term outcomes comparative table

    AuthorYearJournalNumber patientsFirst flatus (days)Major complication*Mean hospital stay (days)30 days mortality [N (%)]
    RRCLRCRRCLRCRRCLRCRRCLRCRRCLRC
    Delaney et al.[77]2003Dis Colom Rectum22NRNR003.52.500
    Rawlings AL et al[79]2007Surg Endosc1715NRNR02 (1.3)5.25.500
    Park et al.[72]2012Br J Surg35352.62.9NRNR7.98.300
    Deutsch et al.[78]2012Surg Endosc184733.6NRNR4.36.301 (2.1)
    Morpurgo et al.[54]2013J Laparoendosc Adv Surg Tech A48482.43.4NRNR7.5900
    Lujan et al.[24]2013J Robot Surg2225NRNRNRNR33NRNR
    Casillas et al.[76]2014Am J Surg54110NRNRNRNR6.25.501 (0.9)
    Trastulli et al.[17]2015Surg Endosc10213423.5NRNR46.500
    Spinoglio et al.[30]2018Ann Surg Oncol100100NRNR4(4)6(6)7.97.91(1)0

    In a recent retrospective study with 101 patients receiving RRC with CME from 2005 to 2015, Spinoglio et al.[30] showed that it is possible to perform routine RRC with CME and IA safely, with comparable long-term oncologic outcomes to laparoscopic techniques [five-year overall survival (OS) of 77% and disease-free survival (DFS) of 85%]. They also showed a non-significant improvement in DFS for AJCC/UICC stage III patients undergoing RRC. Park et al.[31] randomized 71 patients and compared robotic and LRC, and they observed that the long-term outcomes were similar between RRC and LRC with no statistically significant differences at three- and five-year DFS and OS. These findings are consistently reproduced in the contemporary literature[80][Table 6][20,30,72,80,81].

    Table 6

    Long-term outcomes comparative table

    AuthorYearJournalNumber patientsDFS 3-yearDFS 5-yearOS 3-yearOS 5-year
    RRCLRCRRCLRCRRCLRCRRCLRCRRCLRC
    D’Annibale et al.[20]2010Ann Surg Oncol50090.0%NRNRNR92.0%NRNRNR
    Cho[80]2015Ann Surg0205NRNRNR82.9%NRNRNR89.8%
    Spinoglio et al.[30]2018Ann Surg Oncol1000NRNR91.4%*NRNRNR90.3%*NR
    Kang[81]2016Surg Lap Endosc Percutan Tech2043NRNR89.5%84.0%NRNR73.1%79.2%
    Park et al.[72]2012Br J Surg353688.1%91.1%77.4%83.6%96.8%94.0%91.1%91.0%
    Spinoglio et al.[30]2018Ann Surg Oncol101101NRNR85%83%NRNR77%73%

    Costs

    Cost evaluation in robotic colorectal surgery is crucial to implementing and maintaining the new technology. Nowadays, increased costs are the most important drawback of robotic-assisted surgery and could imply a non-neglectable burden on healthcare systems. Direct costs can be divided into fixed and variable types. The fixed costs include the acquisition of the robotic system, ranging $0.6-2.5 million, and the costs of further maintenance. The variable costs depends on the consumable instruments, operating room charges, and professional fees. There is a consensus that RRC is more expensive than LRC[36,60,74,82,83]. Park et al.[72] determined that the mean direct patient payment for a robotic colectomy was about US $3600 more expensive than for a laparoscopic procedure. Cleary et al.[27] reported lower rates of conversion in RRC than in LRC; they also found that RRC was more expensive than LRC, but, when converted patients were included, the difference in cost between RRC and LRC decreased substantially. The total length of hospital stay has an impact on the costs; some of the recent meta-analyses showed that RRC is associated with shorter hospital stay, which may translate to reduced costs[73]. It is clearly difficult to assign a monetary value to measured outcomes in cost-effectiveness studies. In a recent study, laparoscopic and robotic colectomy were shown to be more cost-effective than the traditional open resection, laparoscopy being the most cost-effective approach[84]. Decreasing costs of robotic platforms and devices is mandatory for its future widespread adoption. Under careful assessment of indications for the different robotic system applications, the advantages of robotic assistance, such as higher degrees of rotation, articulation, and 3D imaging, can outweigh the existing drawbacks provided by the higher costs. The expected arrival of competitive industry players could dramatically change this situation soon.

    Conclusion

    RRC is a safe and feasible procedure with comparable outcomes to the standard laparoscopic approach. The slight benefits regarding recovery outcomes still need to be confirmed by future prospective studies. The cornerstone of those studies should be comparing the techniques with respect to the anastomotic fashioning (EA vs. IA). To date, there is no difference in terms of three- and five-year DFS and OS between laparoscopic and robotic approaches, supporting RRC as a safe and feasible technique. If CME provides better oncologic results, robotic surgery may improve the ability to assess it by decreasing the technical complexity. RRC remains much more expensive than LRC. Further studies demonstrating clinically relevant benefits over the other alternatives are still needed to determine the definitive role of robotic surgery for right colonic cancer resection. Breaking the monopoly by competitive producers of robotic systems could dramatically increase accessibility and widespread use of this approach.

    Declarations

    Authors’ contributions

    Concept and design: Moroni P, Martínez-Pérez A

    Manuscript writing: Moroni P, Payá-Llorente C

    Provision of study materials or patients, collection and assembly of data, data analysis and interpretation, and final approval of manuscript: All authors.

    Availability of data and materials

    Not applicable.

    Financial support and sponsorship

    None.

    Conflicts of interest

    All authors declared that there are no conflicts of interest.

    Ethical approval and consent to participate

    Not applicable.

    Consent for publication

    Not applicable.

    Copyright

    © The Author(s) 2019.

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    Cite This Article

    Moroni P, Payá-Llorente C, Lauka L, Reitano E, Memeo R, Gavriilidis P, Brunetti F, Martínez-Pérez A. Minimally invasive right colectomy - from conventional laparoscopic resection to robotic-assisted surgery: a narrative review. Mini-invasive Surg 2019;3:36. http://dx.doi.org/10.20517/2574-1225.2019.34

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