OBJECTIVE:To compare the quality of surgical resection of transanal total mesorectal excision (TA-TME) and robotic total mesorectal excision (R-TME).
BACKGROUND:Both TA-TME and R-TME have been ...advocated to improve the quality of surgery for rectal cancer below 10 cm from the anal verge, but there are little data comparing TA-TME and R-TME.
METHODS:Data of patients undergoing TA-TME or R-TME for rectal cancer below 10 cm from the anal verge and a sphincter-saving procedure from 5 high-volume rectal cancer referral centers between 2011 and 2017 were obtained. Coarsened exact matching was used to create balanced cohorts of TA-TME and R-TME. The main outcome was the incidence of poor-quality surgical resection, defined as a composite measure including incomplete quality of TME, or positive circumferential resection margin (CRM) or distal resection margin (DRM).
RESULTS:Out of a total of 730 patients (277 TA-TME, 453 R-TME), matched groups of 226 TA-TME and 370 R-TME patients were created. These groups were well-balanced. The mean tumor height from the anal verge was 5.6 cm (SD 2.5), and 70% received preoperative radiotherapy. The incidence of poor-quality resection was similar in both groups (TA-TME 6.9% vs R-TME 6.8%; P = 0.954). There were no differences in TME specimen quality (complete or near-complete TA-TME 99.1% vs R-TME 99.2%; P = 0.923) and CRM (5.6% vs 6.0%; P = 0.839). DRM involvement may be higher after TA-TME (1.8% vs 0.3%; P = 0.051).
CONCLUSIONS:High-quality TME for patients with rectal adenocarcinoma of the mid and low rectum can be equally achieved by transanal or robotic approaches in skilled hands, but attention should be paid to the distal margin.
Laparoscopic distal pancreatectomy (LDP) has been adopted relatively slowly despite the benefits of minimally invasive approach. The robotic approach can overcome the limitations of LDP, thus ...increasing the acceptance of minimally invasive distal pancreatectomy.
We performed a 1:1 retrospective case-matched comparison among 2 groups of 35 patients who underwent robotic-assisted distal pancreatectomy (RDP) or LDP from August 2014 to April 2017.
The operative time was similar in both groups (230 RDP vs. 205 LDP min, p = 0.382). The robotic group had a lower estimated blood loss (95 vs. 275 mL, p = 0.035). The spleen preservation rate was higher in the RDP group (100 vs. 66.7%, p = 0.027), while the conversion rate to open surgery was higher in the laparoscopic group (14.3 vs. 2.9%, p = 0.048). The overall complication rate was lower in the robotic group (25.7 vs. 37.1%, p = 0.044). There was no statistically significant difference in oncologic outcomes between the groups in terms of R0 resection rate (100% RDP vs. 85% LDP, p = 0.233) and number of harvested lymph nodes (14.4 RDP vs. 10.8 LDP, p = 0.678).
The RDP showed a lower estimated blood loss, conversion, and morbidity rate. It offered a higher spleen preservation rate in comparison to LDP while maintaining comparable oncologic outcomes.
Abstract
Aim
The complete mesocolic excision competency assessment tool (CMECAT) is a novel tool designed to assess technical skills in minimally invasive complete mesocolic excision (CME) surgery. ...The aim of this study was to assess construct validity and reliability of CMECAT in a clinical context.
Method
Colorectal surgeons were asked to submit video recorded laparoscopic CME resections for independent assessment of their technical abilities. The videos were grouped by surgeons' training level, and four established CME experts were recruited as CMECAT assessors. Extended reliability analysis (G‐theory) was applied to describe assessor agreement.
Results
A total of 19 videos and 72 assessments were included in the analysis. Overall, technical skills assessed by CMECAT improved with increased training level: the experts scored significantly better than the untrained surgeons (3.3 vs. 2.5 points;
p
< 0.01). On right‐sided resections, significantly higher scores were reported with increased training level for all categories and sections, while for left‐sided resections, the variance across groups was smaller and significantly higher scores were only reported for oncological safety describing items. Overall, assessor agreement was high (G‐coefficient: 0.81).
Conclusion
This study confirms that CMECAT can be applied to video recorded CME cases for technical skill assessment. Further, it can reliably assess technical performance in right sided CME surgery, where construct validity has now been established. More videos are required to evaluate its validity on left colonic CME. In the future, we hope CMECAT can improve feedback during CME training, serve as a tool in certification processes and contribute to distinguishing CME from conventional surgery in future research.
Robotic surgery for colorectal cancer Gómez Ruiz, Marcos; Lainez Escribano, Mario; Cagigas Fernández, Carmen ...
Annals of gastroenterological surgery,
November 2020, Letnik:
4, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Minimally invasive surgery has demonstrated many benefits in general surgery, particularly in colon and rectal procedures. On the other hand, it has some limitations that must be taken into account, ...especially technical drawback. Robotic surgery has incorporated many improvements to overcome this disadvantage, such as 3D visualization, articulating instruments assisting complex and precise movements. As a result, robotic colorectal surgery shows less intraoperative blood loss, shorter time to oral tolerance and initial flatus (particularly associated with “Enhanced Recovery After Surgery” protocol), less conversion rate to open surgery, shortened hospital stay, and longer distal margins compared to laparoscopic and open surgery. This approach also shows a shorter learning curve. Some studies suggest that it could decrease perioperatively or 30 days after the intervention's mortality, raise overall survival, reduce wound infection, and improve functional results, while others show no significant difference. However, it lengthens surgical time. Otherwise, the studies included do not show statistically significant changes in the number of resected lymph nodes and anastomotic leaks. Economic costs remain one of the major concerns, although to date there are no large‐scale studies that have evaluated this aspect from a global point of view. Robotic surgery represents a qualitative leap in surgical instruments and, although there is no strong evidence in favor of the use of robotic surgery over laparoscopic or open surgery, there is enough evidence to support its use in colorectal surgery, with potential advantages for patients.
Robotic resections for colorectal cancer are becoming the standard approach in many colorectal surgery units worldwide. A good number of uncertainties still exist regarding its benefits when compared to other options. After a comprehensive search of the available literature, our group presents a review of those studies. Besides, this article provides a personal point of view given our experience of more than 1000 colorectal robotic resections for cancer.
BACKGROUND:We performed a prospective pilot study of robotic-assisted laparoscopic transanal proctectomy with total mesorectal excision for the surgical treatment of rectal cancer. This study was to ...assess the feasibility and safety of robotic-assisted laparoscopic transanal total mesorectal excision.
TECHNIQUE:All patients underwent robotic-assisted laparoscopic left colon mobilization, robotic-assisted laparoscopic transanal total mesorectal excision, ultralow mechanical colorectal or handsewn coloanal anastomosis, and a diverting loop ileostomy. Four patients with stage III disease received long-course preoperative chemoradiation before surgery.
MAIN OUTCOME MEASURES:Primary and secondary end points included the assessment of pathological examination and postoperative morbidity.
RESULTS:Between August 2013 and January 2014, 4 men and 1 woman underwent robotic-assisted laparoscopic transanal total mesorectal excision. Patient age and BMI were 57 ± 13.9 years and 25.8 ± 2,7 kg/m. Tumors were located an average of 5 ± 1 cm from the anal verge and were preoperatively staged as T2N0M0 (1 patient) and T2N1M0 (4 patients). Mean operative time was 398 ± 88 minutes with no intraoperative complications. Mean length of hospital stay was 6 ± 1 days. A Clavien II, grade B anastomotic leakage developed in 1 patient postoperatively. In all cases, pathological examination of the total mesorectal excision specimens showed complete mesorectal excision with negative proximal, distal, and circumferential margins. All patients were disease-free at their initial 3-month follow-up.
CONCLUSIONS:Robotic-assisted laparoscopic transanal total mesorectal excision is a feasible and safe option for the surgical management of early-stage rectal cancers. Robotic technology with endowristed instruments and 3-dimensional high-definition imaging are of great help in overcoming the limitations of traditional laparoscopic transanal surgery. Long-term functional and oncological assessments of outcome are needed.
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