PURPOSE:The objective of the current study was to assess the therapeutic benefit of lymphadenectomy according to the extent of lymphadenectomy. METHODS:Patients undergoing colectomy for right-sided colon cancer were identified. Distribution of lymph node metastases (DLNM) of 1, 2 and 3 were defined as lymph node metastasis (LNM) in the pericolic nodes, the intermediate nodes and the front of the SMV near the origin of the major artery, respectively. The therapeutic index (TI) was calculated based on the frequency of LNM and the 5 year overall survival (OS) rate of patients with LNM. RESULTS:Among 344 patients who met the inclusion criteria, roughly half had LNM (n = 150, 43.7%). While 107 (31.1%) and 30 (8.7%) patients had DLNM1 and DLNM2, respectively, only 13 patients (3.8%) were defined as DLNM3. However, there was no significant difference in 5 year OS by DLNM (DLNM1 71.1%, DLNM2 78.7%, DLNM3 50.4%, p = 0.61). Overall, the TI of lymphadenectomy for D3 area was approximately 1/10 of the TI for D1 (1.9 vs.22.1), given the low frequency of LNM (3.8%) and poor 5 year OS of patients with LNM (50.4%). This trend was consistent irrespective of primary tumor locations. CONCLUSION:The survival benefit from central lymphadenectomy namely D3 was low among patients with right-sided colon cancers.

PURPOSE:Surgeons tend to view the robotic right colectomy (RRC) as an ideal beginning procedure to gain proficiency in robotic general and colorectal surgery. Nevertheless, oncological RRC, especially if performed with intracorporeal ileocolic anastomosis confectioning, cannot be considered a technically easier procedure. The aim of this study was to assess the learning curve of the RRC performed for oncological purposes and to evaluate its safety and efficacy investigating the perioperative and pathology outcomes in the different learning phases. METHODS:Data on a consecutive series of 108 patients undergoing RRC with intracorporeal anastomosis between June 2011 and September 2015 at our institution were prospectively collected to evaluate surgical and short-term oncological outcomes. CUSUM (Cumulative Sum) and Risk-Adjusted (RA) CUSUM analysis were performed in order to perform a multidimensional assessment of the learning curve for the RRC surgical procedure. Intraoperative, postoperative and pathological outcomes were compared among the learning curve phases. RESULTS:Based on the CUSUM and RA-CUSUM analyses, the learning curve for RRC could be divided into 3 different phases: phase 1, the initial learning period (1st-44th case); phase 2, the consolidation period (45th-90th case); and phase 3, the mastery period (91th-108th case). Operation time, conversion to open surgery rate and the number of harvested lymph nodes significantly improve through the three learning phases. CONCLUSIONS:The learning curve for oncological RRC with intracorporeal anastomosis is composed of 3 phases. Our data indicate that the performance of RRC is safe from an oncological point of view in all of the three phases of the learning curve. However, the technical skills necessary to significantly reduce operative time, conversion to open surgery rate and to significantly improve the number of harvested lymph nodes were achieved after 44 procedures. These data suggest that it might be prudent to start the RRC learning curve by treating only benign diseases and to reserve the performance of oncological resection to when at least the initial learning phase has been completed.

Totally robotic right hemicolectomy (TRRH) is a novel alternative surgical method used for the treatment of colon cancer. The aim of this study was to compare both the short-and long-term outcomes of TRRH and robotic-assisted right hemicolectomy (RARH) for the treatment of colon cancer.We performed a 1:2 matched propensity score analysis. We then retrospectively analyzed all procedures (64 cases TRRH and 128 cases RARH) carried out by a single surgeon between December 4, 2014 and June 20, 2018 at a large center. Both short-and long-term surgical outcomes were compared between 2 different groups.Based on the propensity score matching, we selected 64 patients that had undergone TRRH treatment and 128 patients who had undergone RARH treatment. The preoperative clinical-pathological characteristics were well matched between the 2 groups. We observed no significant differences between the 2 groups in postoperative pathological outcomes. The mean operative time was found to be significantly longer in the TRRH group compared to the RARH group (168.2 ± 9.1 minutes vs 153.4 ± 7.4 minutes, P = .034). The mean operative incision length was found to be significantly longer in the TRRH group than in the RARH group (4.5 ± 0.6 cm vs 6.9 ± 1.1 cm, P = .023). Postoperative pain score (visual analog scale at day 1) was found to be significantly lower in the TRRH group than in the RARH group (2.9 ± 1.3 vs 4.1 ± 2.1, P = .005). The time to pass flatus was observed to be statistically lower in the TRRH group (P = .042). We observed 3 twists of mesentery in the RARH group, while none were observed in the TRRH group (P < .050). Both the 3-year overall survival (TRRH [91.6%] vs RARH [89.2%], P = .467) and the 3-year disease-free survival (TRRH [81.4%] vs RARH [78.2%], P = .551) were determined to be comparable between the 2 groups studied here.We show that TRRH is a safe and feasible treatment option for colon cancer patients in terms of both short- and long-term outcomes. High-volume, randomized, controlled trials with sufficient follow-up studies will need to be carried out in order to confirm this rationale.

Outcomes advantages for the minimally invasive approach to colon and rectal surgery have been clearly described since the original report of a laparoscopic colectomy in 1991. Advancements in minimally invasive options for colon and rectal surgery have produced the need for critical evaluation of alternative and evolving techniques. The evolution and increased adoption of the minimally invasive robotic platform has allowed the intracorporeal anastomosis, previously described with the laparoscopic approach, to be more widely available to surgeon skill sets because of robotic articulating instruments and ergonomic advantages. Studies comparing intra- and extracorporeal techniques for laparoscopic right colectomy have demonstrated some outcomes advantages for the intracorporeal approach that include fewer conversions-to-open, fewer postoperative complications, and shorter hospital length of stay. Recent robotic-assisted comparisons have also shown an intracorporeal advantage and have extended the analysis to left-sided colorectal resections. Further upgrades in minimally invasive options and techniques warrant further evidence-based considerations for surgeons choosing between these options and techniques.

Complete mesocolic excision (CME) with central vascular ligation for right-sided colon cancer has been proven to provide superior oncologic outcomes and survival advantage when compared to standard lymphadenectomy [1]. A number of studies comparing conventional laparoscopic versus open CME have shown feasibility and safety of the laparoscopic approach with acceptable oncological profile and postoperative outcomes [2, 3]. The introduction of robotic systems with its technical advantages, including improved vision, better ergonomics and precise dissection, has further revolutionized minimally invasive approach in colorectal surgery. However, there seems to be a relatively slow adoption of robotic approach in the CME technique for right-sided colon cancer. This video demonstrates our detailed operative technique and feasibility for performing right-sided CME robotically. The surgical procedure is performed with a medial-to-lateral approach through four 8-mm robotic and one assistant ports. First, the ileocolic vessels are isolated, clipped and transected near their origins. Cephalad dissection continues along the ventral aspect of the superior mesenteric vein. Staying in the embryological planes between the mesocolon and retroperitoneal structures, mesenteric dissection is extended up to the root of the right colic vessels, if present, and the middle colic vessels, which are clipped and divided individually near their origins. After the terminal ileum is transected using an endolinear staple, the colon is mobilized fully from gastrocolic tissue and then from its lateral attachments. The transverse colon is transected under the guidance of near-infrared fluorescence imaging. Creation of an intracorporeal side-to-side ileotransversostomy anastomosis and extraction of the specimen complete the operation. We consider robotic CME to be feasible, safe and oncologically adequate for the treatment of right-sided colon cancer. Its technical advantages may lead to further dissemination of the robotic approach and better standardization of this surgical technique.

Background Minimally invasive approach has gained interest in the treatment of patients with colorectal cancer. The purpose of this study is to analyze the differences between laparoscopy and robotics for colorectal cancer in terms of oncologic and clinical outcomes in an initial experience of a single center. Materials and Methods Clinico-pathological data of 100 patients surgically treated for colorectal cancer from March 2008 to April 2014 with laparoscopy and robotics were analyzed. The procedures were right colonic, left colonic, and rectal resections. A comparison between the laparoscopic and robotic resections was made and an analysis of the first and the last procedures in the 2 groups was performed. Results Forty-two patients underwent robotic resection and 58 underwent laparoscopic resection. The postoperative mortality was 1%. The number of harvested lymph nodes was higher in robotics. The conversion rate was 7.1% for robotics and 3.4% for laparoscopy. The operative time was lower in laparoscopy for all the procedures. No differences were found between the first and the last procedures in the 2 groups. Conclusions This initial experience has shown that robotic surgery for the treatment of colorectal adenocarcinoma is a feasible and safe procedure in terms of oncologic and clinical outcomes, although an appropriate learning curve is necessary. Further investigation is needed to demonstrate real advantages of robotics over laparoscopy.

The purpose of this study is to compare the early postoperative and pathological outcomes of robotic right colectomy (RRC) to those of laparoscopic right colectomy (LRC) with intracorporeal anastomosis (IA) within the systematic application of an enhanced recovery after surgery (ERAS) program. A single-institution prospective database of patients who underwent elective RRC or LRC with IA for neoplastic lesions between April 2010 and June 2018 was retrospectively reviewed. The patients' demographic characteristics, and perioperative and pathological outcomes were analyzed. Propensity-weighted analysis was employed to address potential selection biases of treatment allocation. A total of 216 patients (46 RRC, 170 LRC) were included. RRC demonstrated a significantly longer operative time (mean 242.43 min, SD 47.51) compared to LRC (mean 187.60 min, SD 56.60) (p = 0.001), confirmed by the propensity-weighted analysis (Coefficient 50.65; p < 0.001). Conversion rate between the two groups was comparable (p = 0.99). Median length of hospital stay (LOS) was the same in the RRC and the LRC group (4 days, p = 0.35). Readmission rate within 30 days in the RRC and LRC group was 2.2% and 2.4%, respectively (p = 0.99). Overall 30-day morbidity and 30-day mortality was 32.6% versus 27.1% (p = 0.46), and 0% versus 1.2% (p = 0.99) in the robotic and laparoscopic groups, respectively. No difference was found in the number of harvested lymph nodes (p = 0.75). In an ERAS environment, without the bias of mixed techniques of anastomosis, RRC had similar postoperative and pathological outcomes compared to the laparoscopic approach, but was associated with a longer operative time.

AIM:The aim of this study is to compare clinical and oncological outcomes of robot-assisted right colectomy with those of conventional laparoscopy-assisted right colectomy, reporting for the first time in literature, a cost-effectiveness analysis. METHODS:This is a case-matched prospective non-randomized study conducted from October 2013 to October 2017 at Sanchinarro University Hospital, Madrid. Patients with right-sided colonic adenocarcinoma or adenoma, not suitable endoscopic resection were treated with robot-assisted right colectomy and a propensity score-matched (1:1) was used to balance preoperative characteristics of a laparoscopic control group. Perioperative, postoperative, long-term oncological results and costs were analysed, and quality-adjusted life years (QALY), and the cost-effectiveness ratio (ICER) were calculated. The primary end point was to compare the cost-effectiveness differences between both groups. A willingness-to-pay of 20,000 and 30,000 per QALY was used as a threshold to recognize which treatment was most cost effective. RESULTS:Thirty-five robot-assisted right colectomies were included and a group of 35 laparoscopy-assisted right colectomy was selected. Compared with the laparoscopic group, the robotic group was associated with longer operation times (243 min vs. 179 min, p < 0.001). No significant difference was observed in terms of total costs between the robotic and laparoscopic groups (9455.14 vs 8227.50 respectively, p = 0.21). At a willingness-to-pay threshold of 20,000 and 30,000, there was a 78.78-95.04% probability that the robotic group was cost effective relative to laparoscopic group. CONCLUSION:Robot-assisted right colectomy is a safe and feasible technique and is a cost-effective procedure.

OBJECTIVE:Analysis of various parameters related to the patient, the disease, and the needed surgical maneuvers to develop guidance for preoperative selection of the appropriate and the best approach for a given patient. Rapid advances in minimally invasive surgical technology are fascinating and challenging alike. It can be difficult for surgeons to keep up with new modalities that come on to the market place and to assess their true value, i.e., distinguish between fashionable trends versus scientific evidence. Laparoscopy established minimally invasive surgery and has revolutionized surgical concepts and approaches to diseases since its advent in the early 1990s. Now, with robotic surgery rapidly gaining traction in this high-tech surgical landscape, it remains to be seen how the long-term surgical landscape will be affected. METHODS:Review of the surgical evolution, published data and cost factors to reflect on advantages and disadvantages in order to develop a broader perspective on the role of various technology platforms. RESULTS:Advocates for robotic technology tout its advantages of 3D views, articulating wrists, lack of hand tremor, and surgeon comfort, which may extend the scope of minimally invasive surgery by allowing for operations in places that are more difficult to access for laparoscopic surgery (e.g., the deep pelvis), for complex tasks (e.g., intracorporeal suturing), and by decreasing the learning curve. But conventional laparoscopy has also evolved and offers high-definition 3D vision to all team members. It remains to be seen whether all together the robot features outweigh the downsides of higher cost, operative times, lack of tactile feedback, possibly unusual complications, inability to move the operative table with ease, and the difficulty to work in different quadrants. CONCLUSIONS:While technical and design developments will likely address some shortcomings, the value-based impact of the various approaches will have to be examined in general and on a case-by-case basis. Value as the ratio of quality over cost depends on numerous parameters (disease, complications, patient, efficiency, finances).

BACKGROUND:Laparoscopic colorectal surgery has become a mainstay in the treatment of benign and malignant colorectal diseases. There are inherent limitations to conventional laparoscopy which can be overcome by the robot. Here we present our experience with 131 cases of robotic and robot-assisted colon and rectal resections. METHODS:This is a retrospective review of a prospectively maintained database. From August 2005 through June 2009, we performed a total of 131 totally robotic and robot-assisted colorectal resections. These included 42 right colectomies (RC), 16 anterior resections (AR) for benign disease, 8 AR with rectopexy for prolapse, 7 total proctocolectomies (TPC), 47 low and ultralow anterior resections (LAR) for rectal cancer, and 11 abdominal perineal resections (APR). All LARs were done as a hybrid procedure (laparoscopic splenic flexure mobilization followed by robotic rectal dissection), and all APR specimens were extracted through the perineal incision. All coloanal anastomoses were diverted with a loop ileostomy. RESULTS:There were no intraoperative complications in this series. Postoperative complications included 10 patients with ileus or small bowel obstruction (SBO), 2 patients with anastomotic leaks, 1 patient with an abscess, and 3 patients with temporary peripheral neuropathy that resolved spontaneously. Five patients required reoperation and there were a total of 4 conversions (3.7%) across all case types. CONCLUSIONS:Robotic colon and rectal resections are safe and feasible options for the treatment of both benign and malignant disease processes. Further studies comparing oncologic and perioperative outcomes of robotic, laparoscopic, and open techniques are needed to determine the utility and efficacy of this technology in the field of colorectal surgery.

BACKGROUND AND OBJECTIVES:The number of robotic colorectal procedures performed has rapidly increased, but there are only sparse data available about the robotic learning curve of expert laparoscopic colorectal surgeons. METHODS:In this retrospective study, we reviewed 101 minimally invasive right colectomies consecutively performed by a single surgeon with 20 years of clinical practice fully dedicated to laparoscopic surgery. Thus, the last 59 laparoscopic resections were compared with the first 42 robotic resections. RESULTS:The duration of the procedure was longer in the robotic group, but the conversion rate was the same in both groups. There was no difference between groups in rates of overall and severe postoperative complications, reoperation, hospital length of stay, and readmission. Number of harvested lymph nodes and oncological quality of resection defined by the pathologist were the same. CONCLUSIONS:This study suggests that the transition from the right laparoscopic colectomy with extracorporeal anastomosis to the robot-assisted right colectomy with intracorporeal anastomosis when performed by a surgeon with experience in laparoscopic colorectal surgery may not entail any increase on the morbidity rate or reduce the oncologic quality of the resection.

BACKGROUND:Minimally invasive surgery for colorectal cancer has been demonstrated to have the same oncological results as open surgery, with better clinical outcomes. Robotic surgery is an evolution of minimally invasive technique. This study aims to evaluate surgical and oncological short-term outcomes of robotic right colon resection in comparison with the laparoscopic approach. METHODS:Between January 2014 and May 2017, fifteen laparoscopic right hemicolectomies were compared to seven robotic ones. The primary data points included operation time, length of hospital stay, extraction site incision length, complications, and conversions. When malignancy was the indication for surgery, additional data points have been added. RESULTS:The study showed no difference in parameters between the two groups, but estimated blood loss was significantly smaller for Robotic arm. We found a prolonged total operative room time in the robotic arm, while the surgical time is similar in two groups. The data collected about specimen length and number of lymph nodes suggest that robotic procedure is oncologically similar to laparoscopic one. CONCLUSIONS:Robotic approach allows performance of adequate dissection of the right colon with radical lymphadenectomy as in laparoscopic surgery, confirming the safety and oncological efficacy of this technique, with acceptable results and short-term outcomes. KEY WORDS:Da Vinci surgery, XI, Laparoscopic colorectal surgery, Right hemicolectomy, Robot.

OBJECTIVE:The aim of this study was to compare the long-term outcomes of robot-assisted right colectomy (RAC) with those for conventional laparoscopy-assisted right surgery (LAC) for treating right-sided colon cancer. BACKGROUND:The enthusiasm for the robotic techniques has gained increasing interest in colorectal malignancies. However, the role of robotic surgery in the oncologic safety has not yet been defined. METHODS:From September 2009 to July 2011, 71 patients with right-sided colonic cancer were randomized in the study. Adjuvant therapy and postoperative follow-up were similar in both groups. The primary and secondary endpoints of the study were hospital stay and survival, respectively. Data were analyzed by intention-to-treat principle. RESULTS:The RAC and LAC groups did not differ significantly in terms of baseline clinical characteristics. Compared with the LAC group, RAC was associated with longer operation times (195 min vs. 129 min, P < 0.001) and higher cost ($12,235 vs. $10,319, P = 0.013). The median follow-up was 49.23 months (interquartile range 40.63-56.20). The combined 5-year disease-free rate for all tumor stages was 77.4% (95% confidence interval [CI], 60.6-92.1%) in the RAC group and 83.6% (95% CI 72.1-0.97.0%) in the LAC group (P = 0.442). The combined 5-year overall survival rates for all stages were 91.1% (95% CI 78.8-100%) in the RAC group and 91.0% (95% CI 81.3-100%) in the LAC group (P = 0.678). Using multivariate analysis, RAC was not a predictor of recurrence. CONCLUSIONS:RAC appears to similar long-term survival as compared with LAC. However, we did not observe any clinical benefits of RAC which could translate to a decrease in expenditures. TRIAL REGISTRY:http://www.ClinicalTrials.gov , number NCT00470951.

BACKGROUND:Minimally invasive colectomy has become the standard for treatment of colonic disease in many centers. Restoration of bowel continuity following resection can be achieved by intracorporeal (IC) or extracorporeal (EC) anastomosis. The aim of this systematic review was to assess the outcomes of IC compared to EC anastomosis in minimally invasive right colectomy. METHODS:A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant systematic literature search for studies assessing the outcome of IC and EC anastomosis in laparoscopic and robot-assisted right colectomy was conducted. The primary outcome of this review was postoperative complications. Secondary outcomes included operative time, blood loss, length of stay, conversion to open surgery, and bowel recovery. RESULTS:Twenty-five studies including 4450 patients were evaluated. 47.7% of patients had IC anastomosis and 52.3% had EC anastomosis. The weighted mean length of extraction site incision in the IC group was shorter than the EC group. The EC group had significantly higher odds of conversion to open surgery (OR 1.87, 95% CI 1-3.45, p = 0.046), total complications (OR 1.54, 95% CI 1.05-2.11, p = 0.007), anastomotic leakage (AL) (OR 1.95, 95% CI 1.4-2.7, p = 0.003), surgical site infection (SSI) (OR 1.69, 95% CI 1.4-2.6, p = 0.002), and incisional hernia (OR 3.14, 95% CI 1.85-5.33, p < 0.001) compared to the IC group. Both groups had similar rates of ileus, small bowel obstruction, bleeding, and intra-abdominal infection. CONCLUSION:IC anastomosis was associated with significantly shorter extraction site incisions, earlier bowel recovery, fewer complications, and lower rates of conversion, AL, SSI, and incisional hernia than has the EC anastomosis.

PURPOSE:Laparoscopic surgery for colon cancer has widely accepted as safe and effective. However, few studies report outcomes on robotic right colon resection with confectioning of the intracorporeal ileocolic anastomosis. This study aims to evaluate the feasibility and safety of robotic right colon resection with intracorporeal ileocolic anastomosis (RRCIA) in patients with cancer. METHODS:Data of consecutive series of 20 patients undergoing RRCIA between June 2011 and May 2012 at our institution were prospectively collected in order to evaluate surgical and oncological short-term outcomes. RESULTS:Seven males and 13 females were operated of RRCIA during the study period. Mean age is 66.7 years. The mean overall operative time was 327.5 min (255-485), and the robot time was 286 min (range 225-440 min). No conversion to open or laparoscopy occurred. The mean specimen length was 32.7 cm (range 26-44 cm), and the mean number of harvested lymph nodes was 17.6 (range 14-21). During the 30 postoperative days, only one complication occurred, consisting in an infection of surgical specimen extraction wound. CONCLUSION:The RRCIA is a feasible and safe for patients with right colon cancer, also in terms of intraoperative oncological outcomes.

INTRODUCTION:Implementation of robotic technology in surgery is challenging in many ways. The aim of this study was to present the implementation process and results of the first two years of consecutive robot-assisted laparoscopic (RAL) colorectal procedures. MATERIAL AND METHODS:The study was a retrospective study of a consecutive, unselected patient population. All outcome parameters were predefined and all patients completed 30-day follow-up. All parameters were reported, including complication rate, reoperation rate and mortality. RESULTS:From April 2010 to April 2012, a total of 223 elective RAL colorectal procedures were performed. The procedures were grouped as follows: left colectomy/sigmoid resection (n = 65), low anterior resection (n = 50), abdominoperineal resection (n = 10), right colectomy (n = 56), rectopexia (n = 21), colectomy (n = 8), palliative procedure (n = 8) and stoma reversal (n = 8). The overall mortality rate was 0.4%; intra- and post-operative complication rates were 5.4% and 16%, respectively; and the reoperation rate was 9%. Conversion to open surgery was necessary in 9% of cases. A positive learning curve was found for low anterior resections with a significant decrease in duration of surgery over the course of the study period. CONCLUSION:RAL colorectal surgery can be performed as a standard procedure for most colorectal procedures. Appropriate staff education, surgical plan and quality assessment are necessary and we recommend a credentialing system for robotic surgery certification. Future randomized clinical trials should be performed to evaluate the short- and long-term results in these patients. FUNDING:not relevant. TRIAL REGISTRATION:not relevant.

INTRODUCTION:Multidimensional comparison between open, laparoscopy, and robotic surgery in the management of right-sided colon cancer are lacking. The aim of this study was to compare the early perioperative results and oncologic outcomes among the 3 different methods. PATIENTS AND METHODS:Between June 2007 and 2011, a total of 96 patients who underwent right hemicolectomy in a single institution were classified into the open surgery (OS; n=33), the laparoscopy surgery (LS; n=43), and the robot surgery (RS; n=20) groups. Perioperative and oncologic outcomes were compared among the 3 groups. RESULTS:Patient demographics were comparable. Operation time was significantly longer in the RS and LS than the OS (P<0.001). There was 1 OS conversion in LS. There was no difference of total retrieved lymph node numbers among the 3 groups. Postoperative recovery was faster and hospital stay was shorter in RS than OS. However, there was no difference between LS and RS. After the median 40 months' follow-up, 5-year disease-free survival was similar among the OS, LS, and RS (87.7%, 84%, and 89.5%, respectively). Total charge and total patient charge were significantly higher in RS than the others. CONCLUSIONS:Our comparative study demonstrates that the RS have better short-term outcomes in reducing hospital stay compared with the OS, but similar to the LS. Although the oncologic outcomes are similar, the benefit of RS in right hemicolectomy is unclear considering a high cost of RS.

PURPOSE:We developed a technique of totally-robotic right colectomy with D3 lymphadenectomy and intracorporeal anastomosis via a suprapubic transverse linear port. This article aimed to introduce our novel robotic surgical technique and assess the short-term outcomes in a series of five patients. METHODS:All colectomies were performed using the da Vinci Xi system. Four robot trocars were placed transversely in the supra pubic area. Totally-robotic right colectomy was performed, including colonic mobilization, D3 lymphadenectomy, and intra corporeal stapled functional anastomosis. The 2 middle suprapubic trocar incisions were then extended to retrieve the specimen. RESULTS:Five robotic right colectomies via the suprapubic approach were performed between August 2015 and February 2016. The mean operation time was 183 ± 29.37 minutes, and the mean estimated blood loss was 27 ± 9.75 mL. The time to clear liquid intake was 3 days in all patients, and the mean length of stay after surgery was 6.2 ± 0.55 days. No patient required conversion to conventional laparoscopic surgery. There were no perioperative complications. According to the pathology report, the mean number of harvested lymph nodes was 36.6 ± 4.45. Four patients were stage III, and 1 patient was stage II according to the 7th edition of the American Joint Committee on Cancer system. CONCLUSION:Totally-robotic right colectomy via the suprapubic approach can be performed successfully in selected patients. Further comparative studies are required to verify the clinical advantages of our technique over conventional robotic surgery.

INTRODUCTION:Laparoscopic techniques have induced a tremendous revolution in the field of general surgery. Recent multicenter trials have demonstrated similar patient-oriented and oncologic outcomes for laparoscopic colon and rectal resections compared with their open counterparts. Meanwhile, robotic technology has gradually entered the field of general surgery, allowing increased dexterity, improved operative view, and optimal ergonomics. The objective of this study was to review the current status of clinical robotic applications in colorectal surgery. METHODS:A systematic review of the literature using the PubMed search engine was undertaken to identify relevant articles. The keywords used in all possible combinations were: surgical robotics, robotic surgery, computer-assisted surgery, colectomy, sigmoid resection, sigmoidectomy, and rectal resection. RESULTS:Thirty-nine case series or comparative nonrandomized studies were identified. A specific interest for robot-assisted rectal surgery during the past few years was recorded in the literature. The retrieved articles included 13 ileocecal resections, 220 right colectomies, 190 left colectomies/sigmoid resections, 440 anterior resections, 149 abdominoperineal/intersphincteric resections, and 11 total/subtotal colectomies. The clinical application of the da Vinci robotic system in right and left/sigmoid colectomies yielded satisfactory results in terms of open conversion (1.1 and 3.8%, respectively) and operative morbidity (13.4 and 15.1%, respectively). Robot-assisted anterior resection was accompanied by a considerably low conversion rate (0.4%), morbidity (9.7%), and adequate number of harvested lymph nodes (14.3, mean). CONCLUSIONS:Robotic applications in colorectal surgery are feasible with low conversion rates and favorable morbidity. Further studies are required to evaluate its oncologic and patient-oriented outcomes.

Right colon cancer rarely presents as an emergency, in which bowel occlusion and massive bleeding are the most common clinical presentations. Although there are no definite guidelines, the first line treatment for massive right colon cancer bleeding should ideally stop the bleeding using endoscopy or interventional radiology, subsequently allowing proper tumor staging and planning of a definite treatment strategy. Minimally invasive approaches for right and left colectomy have progressively increased and are widely performed in elective settings, with laparoscopy chosen in the majority of cases. Conversely, in emergent and urgent surgeries, minimally invasive techniques are rarely performed. We report a case of an 86-year-old woman who was successfully treated for massive rectal bleeding in an urgent setting by robotic surgery (da Vinci Intuitive Surgical System®). At admission, the patient had severe anemia (Hb 6 g/dL) and hemodynamic stability. A computer tomography scanner with contrast enhancement showed a right colon cancer with active bleeding; no distant metastases were found. A colonoscopy did not show any other bowel lesion, while a constant bleeding from the right pre-stenotic colon mass was temporarily arrested by endoscopic argon coagulation. A robotic right colectomy in urgent setting (within 24 hours from admission) was indicated. A three-armed robot was used with docking in the right side of the patient and a fourth trocar for the assistant surgeon. Because of the patient's poor nutritional status, a double-barreled ileocolostomy was performed. The post-operative period was uneventful. As the neoplasia was a pT3N0 adenocarcinoma, surveillance was decided after a multidisciplinary meeting, and restoration of the intestinal continuity was performed 3 months later, once good nutritional status was achieved. In addition, we reviewed the current literature on minimally invasive colectomy performed for colon carcinoma in emergent or urgent setting. No study on robotic approach was found. Seven studies evaluating the role of laparoscopic colectomy concluded that this technique is a safe and feasible option associated with lower blood loss and shorter hospital stay. It may require longer operative time, but morbidity and mortality rates appeared comparable to open colectomy. However, the surgeon's experience and the right selection of candidate patients cannot be understated.

Complexity and operative risks of complete mesocolic excision (CME) seem to be important drawbacks to generalize this procedure in the surgical treatment of right colon cancer. Robotic systems have been developed to improve quality and outcomes of minimal invasive surgery. The aim of this study was to evaluate the feasibility of robotic right-sided CME and present our initial experience. A retrospective review of 37 patients undergoing totally robotic right-sided CME between February 2015 and November 2017 was performed. All the operations were carried out using the key principles of both CME with intracorporeal anastomosis and no-touch technique. Data on perioperative clinical findings and short-term outcomes were analyzed. There were 20 men and 17 women with a mean age of 64.4 ± 13.5 years and a body mass index of 26.8 ± 5.7 kg/m. The mean operative time and estimated blood loss were 289.8 ± 85.3 min and 77.4 ± 70.5 ml, respectively. Conversion to laparoscopy occurred in one patient (2.7%). All the surgical margins were clear and the mesocolic plane surgery was achieved in 27 (72.9%) of the cases. The mean number of harvested lymph nodes was 41.8 ± 11.9 (median, 40; range 22-65). The mean length of hospital stay was 6.6 ± 3.7 days. The intraoperative and postoperative complication rates were 5.4 and 21.6%, respectively. We believe that use of robot for right-sided CME is feasible and appears to provide remarkably a high number of harvested lymph nodes with good specimen quality.

Following the successful introduction of robotic surgery to the field of urology and gynecology, its use gained even more interest among those in the field of colorectal surgery. Rectal resection is believed to be among the best suited for robotic assistance. In particular, the right hemicolectomy procedure has been proposed as a training tool in order to gain clinical experience with the robot. This article and attached video demonstrates, in detail, the robot-assisted right hemicolectomy, including key landmarks of the procedure. The case presented involved a 58-year-old man with an advanced cecal adenocarcinoma. In our opinionrobot-assisted right colon resection is a procedure that offers particular value for the novice robotic team who is in the beginning stages of their colorectal surgery experience. Although no concrete advantages for use of the robot in this particular procedure have been demonstrated in the literature, because it is a relatively straightforward and simple procedure, it can serve as a valuable training tool for the novice robotic surgeon.

BACKGROUND:Surgical resection with curative intent remains the standard of care for colon cancer. This study aims to compare the 30-day outcomes and oncologic results following open, laparoscopic, and robot-assisted right colon resection for colon cancer using the Targeted Colectomy American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. MATERIALS AND METHODS:All patients undergoing elective, right colon resection with primary anastomosis were identified within the targeted colectomy ACS-NSQIP database. Only patients with stage I, II, or III colon cancer were included. The association of surgical approach with oncologic results and 30-day morbidity and mortality outcomes was investigated using a variety of statistical tests. RESULTS:A total of 3518 patients met inclusion criteria; 1024 (29.1%) underwent open surgery (OS), 2405 (63.4%) underwent laparoscopic surgery, and 89 (2.5%) underwent robotic surgery. Patients undergoing OS were significantly more likely to have positive resection margins (P < .001). Patients undergoing OS were significantly more likely to experience prolonged intubation (P = .02), deep wound infections (P = .001), wound dehiscence (P = .005), deep venous thrombosis (P = .04), bleeding requiring a blood transfusion (P < .001), a prolonged postoperative ileus (P < .001), and longer length of hospital stay (P < .001), and were more likely to die (P = .02). CONCLUSION:The laparoscopic approach to colon resection for colon cancer has lower 30-day morbidity compared to OS. The robotic approach is equivalent to the laparoscopic approach, and its utilization may increase in the future.

BACKGROUND:Right colectomy is the standard surgical treatment for tumors in the right colon and surgical complications are reduced with minimally-invasive laparoscopy compared with open surgery, with potential further benefits achieved with robotic assistance. The anastomotic technique used can also have an impact on patient outcomes. However, there are no large, prospective studies that have compared all techniques. METHODS/DESIGN:MIRCAST is the Minimally-Invasive Right Colectomy Anastomosis Study that will compare laparoscopy with robot-assisted surgery, using either intracorporeal or extracorporeal anastomosis, in a large prospective, observational, multicenter, parallel, four-cohort study in patients with a benign or malignant, non-metastatic tumor of the right colon. Over 2 years of follow-up, the study will prospectively evaluate peri- and postoperative complications, postoperative recovery, hospital stay, and mid-term results including survival, local recurrence, metastases rate, and conversion rate. The primary composite endpoint will be the efficacy of the surgical method regarding surgical wound infections and postoperative complications (Clavien-Dindo grade III-IV complications at 30 days post-surgery). Secondary endpoints include long-term oncologic results, conversion rate, operative time, length of stay, and quality of life. DISCUSSION:This will be the first large, international study to prospectively evaluate the use of minimally-invasive laparoscopy or robot-assisted surgery during right hemicolectomy and to control for the impact of the anastomotic technique. The research will contribute to current knowledge regarding the medical care of patients with malignant or benign tumors of the right colon, and enable physicians to determine which technique may be the most appropriate for their patients. TRIAL REGISTRATION:This study was registered on Clinicaltrials.gov (clinicaltrials.gov identifier: NCT03650517 ) on August 28th 2018 (study protocol version CI18/02 revision A, 21 February 2018).

BACKGROUND:A surgical robot (the da Vinci system) was developed to overcome the disadvantages of laparoscopic surgery, and applications of this system have been widely used. In this study, we present our standardized technique of robotic right colectomy with lymphadenectomy and intracorporeal anastomosis, with an assessment of feasibility in a series of 15 patients. METHODS:All robotic right colectomies with lymphadenectomy were performed by a single surgeon between April 2009 and March 2010. Robotic assistance was used for the colonic mobilization, lymphadenectomy, and bowel reconstruction. Patient demographics, perioperative clinical outcomes, and pathologic results were reviewed. RESULTS:Robotic-assisted right colectomy was successfully performed on 15 patients with colon cancer. The total operative time was 201.4 ± 8.1 minutes, with a mean robotic time of 114.4 ± 7.5 minutes. No patient required conversion to conventional surgery. The median time to clear liquid intake was 3 days, and the median length of stay after surgery was 8 days. The mean tumor diameter was 3.0 ± 0.3 cm, and the mean number of harvested lymph nodes was 24.2 ± 15.5. Tumors were diagnosed as stage I in 7 patients, stage II in 5, and stage III in 3. CONCLUSIONS:Robotic right colectomy with lymphadenectomy can be performed successfully and safely. The robotic system was safe and feasible for the following steps: accurate node dissection, suturing for intracorporeal anastomosis, and natural orifice specimen extraction. Further comparative studies must be performed to verify the advantages of robotic surgery over conventional laparoscopic surgery.

This work is a topic highlight on the surgical treatment of the right colon pathologies, focusing on the literature state of art and comparing the open surgery to the different laparoscopic and robotic procedures. Different laparoscopic procedures have been described for the treatment of right colon tumors: Totally laparoscopic right colectomy, laparoscopic assisted right colectomy, laparoscopic facilitated right colectomy, hand-assisted right colectomy, single incision laparoscopic surgery colectomy, robotic right colectomy. Two main characteristics of these techniques are the different type of anastomosis: Intracorporeal (for totally laparoscopic right colectomy, single incision laparoscopic surgery colectomy, laparoscopic assisted right colectomy and robotic technique) or extracorporeal (for laparoscopic assisted right colectomy, laparoscopic facilitated right colectomy, hand-assisted right colectomy and open right colectomy) and the different incision (suprapubic, median or transverse on the right side of abdomen). The different laparoscopic techniques meet the same oncological criteria of radicalism as the open surgery for the right colon. The totally laparoscopic right colectomy with intracorporeal anastomosis and even more the single incision laparoscopic surgery colectomy, remain a technical challenge due to the complexity of procedures (especially for the single incision laparoscopic surgery colectomy) and the particular right colon vascular anatomy but they seem to have some theoretical advantages compared to the other laparoscopic and open procedures. Data reported in literature while confirming the advantages of laparoscopic approach, do not allow to solve controversies about which is the best laparoscopic technique (Intracorporeal vs Extracorporeal Anastomosis) to treat the right colon cancer. However, the laparoscopic techniques with intracorporeal anastomosis for the right colon seem to show some theoretical advantages (functional, technical, oncological and cosmetic advantages) even if all studies conclude that further prospective randomized trials are necessary. Robotic technique may be useful to overcome the problems related to inexperience in laparoscopy in some surgical centers.