10.3 Robotic surgery experience

Robotics overcomes many of the disadvantages of open surgery as well as those still present with laparoscopy. In a way, it embodies the natural progression in the path to MIS. The advantages include: 3D optics, wrist-like motion, tremor filtering, motion scaling, better ergonomics, and less fatigue. This translates into a lower conversion rate, decreased length of stay, easier learning curve, and the ability to operate in constricted spaces. Conversion from MIS to open has a deleterious impact on numerous patient factors, including increased transfusion rate (11.5% vs 1.9%), wound infection rate (23% vs 12%), complication rate (44% vs 21%), length of stay (+6 days vs base), and 5-year disease-free survival rate (40.2% vs 70.7%) [2426]. Recent analyses of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database comparing thousands of patients who underwent laparoscopic or robotic colorectal surgery found significantly lower conversion rates for robotics and lower length of hospital stay for both abdominal and pelvic robotic cases. There was no difference in postoperative complications when comparing the two groups and a significantly shorter length of stay for robotic procedures [27,28]. Other large database studies comparing the two groups with propensity score matching demonstrated reduced 30-day postoperative septic complications (2.3% vs 4%), hospital stay (mean: 4.8 vs 6.3 days), and discharge to another facility (3.5% vs 5.8%) in favor of robotic colectomy [29]. Analysis of the Michigan Surgical Quality Collaborative database comparing laparoscopic, hand-assisted laparoscopic, and robotic colon and rectal operations found significantly lower conversion rates for robotics in rectal resections (21.2% vs 7.8%), and approaching significance for colon resections (16.9% vs 9%) [30]. Conversion to open resulted in significantly longer length of stay for robotic (1.3 days) and laparoscopic procedures (1.7 days).

Studies have shown that the learning curve for robotic colorectal surgery ranges from 15 to 25 cases. Obtaining a learning curve which is half of that required for laparoscopy requires the surgeon to master three unique concepts of robotic surgery as outlined by Bokhari et al. [18]: (1) substituting visual cues with regard to tension and manipulation of tissues in place of tactile feedback, (2) grasping the spatial orientation of robotic instruments outside the visual field of view to maneuver safely without direct visualization, and (3) envisioning the alignment of the robotic arms and cart while operating remotely at the console, thereby minimizing external collisions [18]. A more recent study has examined whether physician factors (including time since graduation, fellowship status, and number of procedures performed) were associated with hospital stay and complications following common robotic surgery procedures in the State of New York among 1670 patients. Hospital-level factors were also analyzed, including urban versus rural setting, teaching status, hospital size, and the presence of a fellowship. After evaluating all factors in multivariable regression models and adjusting for covariates such as patients characteristics and comorbidities, neither physician- not hospital-related factors were significantly related to length of stay or complications [31]. Robotic surgery may eliminate the differences between hospitals and physicians, making outcomes independent of surgeon volume and experience.

The benefits of intracorporeal anastomosis and off-midline specimen extraction have already been demonstrated with laparoscopic colorectal surgery. This is made even easier with robotic assistance, limiting excessive handing of bowel that leads to ileus, improper orientation, and avoiding a midline extraction site. Past studies comparing laparoscopic right hemicolectomy with intracorporeal versus extracorporeal anastomosis showed decreased postoperative complications (18.7% vs 35%), infection rate (4.4% vs 14%), length of stay (mean: 5.9 vs 6.9 days), and incisional hernia rate (2.2% vs 17%) [32]. A large study examining extraction site location and incisional hernias after laparoscopic colorectal surgery has shown twice the rate of incisional hernia with midline extraction compared to off-midline (8.9% vs 2.3%4.8%) [33]. A recent multicenter retrospective study compared robotic right colectomy with intracorporeal anastomosis (RRCIA) to laparoscopic right colectomy with extracorporeal (LRCEA) and intracorporeal (LRCIA) anastomosis among 236 patients. RRCIA offers significantly better perioperative recovery outcomes compared to LRCEA, with a substantial reduction in the length of stay (4 vs 7 days). Compared with the LRCIA, the RRCIA had a shorter time to first flatus but offered no advantages in terms of the length of stay. Once again, the conversion rate was much lower for RRCIA (3.9%) versus LRCEA (8.5%) versus LRCIA (15%) [34]. This study reinforces the benefits of an intracorporeal anastomosis and the fact that it is much easier to perform robotically, leading to a decreased conversion rate.

Multiple studies have demonstrated the safety and feasibility of robotic colorectal resection with regards to short-term oncologic outcomes [35,36]. A recent retrospective study comprised of 732 patients analyzing long-term oncologic outcomes using propensity score matching showed comparable survival between robotic and laparoscopic TME. In multivariate analysis, robotic surgery was a significant prognostic factor for overall survival and cancer-specific survival [37]. The latest and largest randomized clinical trial of robotic-assisted laparoscopic surgery for patients with rectal adenocarcinoma (ROLARR) demonstrated comparable oncologic outcomes to previously published large randomized trials. The positive circumferential resection margin rate (5.7%) was lower than previous trials studying conventional laparoscopy (ACOSOG Z6051, 12.1%; ALaCaRT, 7%). Pathological grading of intact mesorectum (75.3%) was comparable to ACOSOG Z6051 (72.9%). Surprisingly, there was no statistically significant difference in the rate of conversion to open laparotomy for robotic compared with laparoscopic surgery (8.1% vs 12.2%) [38]. The authors attributed this to surgeons having varying robotic experience as compared to the expert laparoscopic group. The fact that less experienced robotic surgeons had the same conversion rate as expert laparoscopists supports the previously mentioned study by Altieri et al. which did not find surgeon robotic experience tied to outcomes or length of stay, in contrast to laparoscopy [31].

Disadvantages of robotic surgery include: increased operative time, lack of haptic feedback, surgeons remote location away from the operating room table, inability to perform multiquadrant abdominal surgery, and the cost of technology [3841]. Several metaanalyses and a most recent ACS NSQIP database analysis have compared operative times for robotic versus laparoscopic colorectal resections with a mean operative time of approximately 40minutes longer for robotic colorectal resection when compared to laparoscopic [28,42,43]. Longer operative times have been shown to improve with surgeon experience, some single-surgeon studies demonstrating a statistically significant decrease in mean operative time from 267 to 224minutes [44]. However, larger randomized studies analyzing surgeons with varying robotic experience still showed prolonged operating time when compared to laparoscopy [38]. With experience, visual cues substitute for haptic feedback, thus avoiding excessive tissue manipulation and injury. Numerous studies, previously discussed, have shown the safety and feasibility of robotic surgery with equivalent or decreased complications compared to laparoscopic surgery, thus making the lack haptic feedback a nonsafety issue. One can postulate that with haptic feedback operative time may be reduced but this will require implementation and further study of such technology. Seasoned first assists and a well-trained robotics team can provide confidence and feedback at the bedside for the surgeon while he or she is at the console, minimizing the issue of not being at the patient bedside. It behooves the surgeon to train his or her team and have an action plan in case of emergency bleeding or need to convert to open laparotomy.

Finally, the cost of new technology is offset with increased case volume, instrument use optimization, and previously touted clinical benefits. However, this remains a controversial issue since acquiring the latest robotic system costs $1.85$2.3 million and does not include ongoing instrument and maintenance costs, which can range from $0.08 to $0.17 million/year. The ROLARR randomized clinical trial comparing robotic to laparoscopic rectal surgery suggested that robotic surgery for rectal cancer is unlikely to be cost-saving. The mean difference per operation, excluding the acquisition and maintenance costs, was $1132 driven by longer operating room time and increased cost for robotic instruments [38,45]. In contrast, a recent study examining surgeons with higher experience in robotic and laparoscopic colorectal procedures (30 or more robotic procedures per year) showed no statistically significant difference in total direct cost. When comparing supply costs, robotic surgery was more expensive than laparoscopic surgery (mean: $764) due to increased costs associated with robotic reusable instruments. The total direct costs were comprised of supplies, hospital stay, and operating room costs and showed no difference ($24,473 vs $24,343) likely due to reduced length of stay and lower conversion rate [46]. Cheaper cost can be attained by decreasing operative time, limiting superfluous robotic instrument use, and improving utilization of the robotic system.

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