JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Volume 23, Number 5, 2013 ª Mary Ann Liebert, Inc. DOI: 10.1089/lap.2012.0404
Robotic-Assisted Intracorporeal Anastomosis Versus Extracorporeal Anastomosis in Laparoscopic Right Hemicolectomy for Cancer: A Case Control Study Emilio Morpurgo, MD, Tania Contardo, MD, Roberta Molaro, MD, Antonio Zerbinati, MD, Camillo Orsini, MD, and Annibale D’Annibale, MD
Abstract
Introduction: Extracorporeal ileocolic anastomosis in laparoscopic right hemicolectomy for cancer has a significant risk of complications. The aim of this study is to evaluate the operative and postoperative results of hybrid right hemicolectomy with intracorporeal robotic-assisted anastomosis for adenocarcinoma of the ascending colon compared with the standard extracorporeal anastomosis in a case control study. Patients and Methods: Forty-eight right hemicolectomies for cancer (2009–2012) with laparoscopic medial to lateral dissection, vascular ligation, bowel transection, and robotic-assisted intracorporeal anastomosis with specimen extraction through a Pfannestiel incision (robotic group [RG]) were compared with 48 laparoscopic hemicolectomies (2009–2011) with extracorporeal anastomosis (laparoscopic group [LG]). Results: The two groups were comparable with respect to age, gender, stage of cancer, and body mass index. Surgery time was significantly longer in RG patients (RG, 266 – 41 minutes; LG, 223 – 51 minutes; P < .05). Operative results were similar in the two groups. Recovery of bowel function (day of first bowel movement: RG, 3.0 – 1.0 days; LG, 4.0 – 1.2 days; P < .05) and hospital stay (RG, 7.5 – 2.0 days; LG, 9.0 – 3.2 days; P < .05) were quicker and shorter, respectively, in RG. There were four anastomotic complications and four incisional hernias in LG and none in RG (P < .05). Conclusions: There are fewer anastomotic and wound complications in RG patients. Intracorporeal roboticassisted ileocolic anastomosis allows a faster recovery compared with extracorporeal anastomosis.
Introduction
I
n laparoscopic right colectomy the extracorporeal anastomosis is the technique preferred by several authors.1–3 This technique requires an extensive and unnecessary mobilization of the colon in order to exteriorize the bowel through the minilaparotomy. Laparoscopic intracorporeal anastomosis has been proposed in order to overcome these disadvantages in selected patients: it is technically challenging with straight, nonarticulated instruments, it requires an adequate training, and the rate of anastomotic complications may be as high as 5%.4,5 The robotic technique is now widely used in minimally invasive abdominal surgery.6–10 In colorectal surgery it is used for anterior resections, left colectomies, and
right colectomies, although its advantages when compared with standard laparoscopy are not yet fully defined. In particular, the literature available concludes that robotic right colectomy is feasible and safe11–13 and oncologically adequate,12 but clear advantages able to justify a longer operation11,13 and the higher costs of the procedure9,11,14 compared with standard laparoscopy are not yet fully demonstrated. Literature is still lacking in randomized or case control studies with homogeneous, well-matched groups. The indications (benign disease or malignancy), dissection technique (medial to lateral or lateral to medial approach), and ileocolic anastomosis technique are all too heterogeneous to enable firm conclusions to be drawn.11–15 The aim of this case control study is to evaluate whether a hybrid standardized right
Department of Surgery, Regional Specialized Center for Robotic and Laparoscopic Surgery, P. Cosma Hospital, Camposampiero (Padova), Italy.
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INTRACORPOREAL ROBOTIC-ASSISTED ANASTOMOSIS hemicolectomy for cancer with intracorporeal robotic-assisted ileocolic anastomosis has any advantages over standard laparoscopy with extracorporeal anastomosis.
415 were discharged when fully functional. The local Ethics Committee was notified according to the Italian law. Surgical technique
Patients and Methods At the Department of Surgery, Regional Specialized Center for Videolaparoscopic Robotic Surgery, Hospital of Camposampiero, Padova, Italy, since June 2009 the hybrid technique of right hemicolectomy for cancer of the ascending colon with laparoscopic medial to lateral dissection, laparoscopic vascular control, laparoscopic bowel division, and roboticassisted intracorporeal ileocolic anastomosis has been standardized and used. From January 2008 to May 2012 96 consecutive patients underwent a minimally invasive right colectomy for cancer: 48 patients (between 2008 and June 2011) underwent a laparoscopic resection with extracorporeal anastomosis, and 48 patients (between June 2009 and May 2012) underwent a hybrid procedure with robotic-assisted intracorporeal anastomosis using the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA). From June 2011 the latter is the technique of choice at our institution. During the overlap interval 18 patients were operated with standard extracorporeal anastomosis and 27 with intracorporeal roboticassisted suture. During this overlap interval, the decision on which technique to use was based on the availability of the da Vinci Surgical System. Since June 2011 all right hemicolectomies are scheduled only when the robotic system is available to our Department. Demographic data are shown in Table 1. All demographic, pathology (size of specimen, number of lymph nodes retrieved, tumor stage), operative (time of operation, intraoperative complications), and postoperative (recovery of bowel function, hospital stay, postoperative complications) data were entered into the institutional prospectively maintained database and analyzed using chisquared and t tests when appropriate. Incisional hernias were recorded at office follow-up or phone interviews, if needed. Data were then compared with the last 48 consecutive standard laparoscopic right hemicolectomies for cancer with extracorporeal anastomosis performed at the same institution. Postoperative protocol includes nothing peroral until the first passage of flatus followed by advancement to regular diet as tolerated. Patients
Table 1. Demographic Data
Male/female Age (years) BMI (kg/m2) ASA score I II III IV Cancer stage I II III IV
Robotic-assisted anastomosis
Extracorporeal anastomosis
27/21 68 – 8 25 – 3.5
16/32 74 – 11 28 – 4
8 28 12 0
4 26 17 1
20 18 7 3
11 15 18 4
ASA, American Society of Anesthesiologists; BMI, body mass index.
A left paraumbilical Hasson camera port (or a 12-mm trocar in robotic cases) is inserted, and a 12 mm Hg pneumoperitoneum is created. Two operative trocars (robotic or laparoscopic) are inserted in the left lower and upper quadrant; a 3.5-mm trocar is positioned in the right flank if needed to lift the transverse colon. In the robotic group (RG) a 12-mm trocar is positioned in the right flank and is used by the bedside assistant. The ileocolic vessels are identified, isolated, clipped, and divided at the origin. The right colon and its mesentery are sharply dissected from the duodenum, the head of the pancreas, and the fascia of Gerota. The right branches of the right middle colic vessels (or the right middle colic vessels in cases of cancers located distally) are divided. The omentum is divided, starting from the middle third of the transverse colon. The gastrocolic ligament is divided along the gastroepiploic arcade. The hepatic flexure is taken down, and the right abdominal gutter is dissected. In the laparoscopic group (LG) the transverse colon needs to be further mobilized in order to be exteriorized through a periumbilical incision. The size of the incision is modulated according to the size of the specimen and the tumor and the thickness of the mesentery and the mesocolon and may vary from 4 to 7 cm. The terminal ileum and the tranvserse colon are divided extracorporeally with a GIA stapler (Covidien, Norwalk, CT), the bowel stumps are oversewn, and a hand-sewn double-layer lateral anastomosis is made. The mesentery defect is sutured only if its base can be exposed and is visible from the incision. In the robotic-assisted group the terminal ileum and transverse colon are divided with a laparoscopic 6.5-cm endoscopic stapler. The specimen is extracted through a muscle-splitting Pfannestiel incision. The laparotomy is sutured, and the da Vinci Surgical System cart is docked to the patient. The two bowel stumps are oversewn. The orientation of the mesentery of the small bowel is checked, and the small bowel and the transverse colon are brought together with a robotic stay suture. Two enterotomies are performed with the robotic hook. Using the articulated robotic instruments the terminal ileum and transverse colon are easily pulled into the endo-GIA jaws (the jaw with the staple reloaded into the transverse colon), and the anastomosis is performed. The enterotomies are then sutured with a double-layer running robotic suture. The mesentery defect is sutured at its base. Results Operative results are shown in Table 2. Operative time (that includes the docking time of the robot) was significantly longer in RG; specimen size and number of lymph nodes retrieved are similar and adequate in both groups. Follow-up was 13 – 8 months (range, 1–34 months) in RG and 35 – 13 months (range, 8–42 months) in LG. Postoperative complications are listed in Table 3. Anastomotic complications (leaks and twist) were significantly more frequent in LG than in RG. Additionally, the incidence of incisional hernia was also significantly higher in LG. One of the 4 patients in LG with incisional hernia underwent laparoscopic repair. Postoperative results (Table 4) show that the group with intracorporeal robotic-assisted anastomosis recovered bowel
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MORPURGO ET AL. Table 2. Operative Results Robotic-assisted Extracorporeal anastomosis anastomosis
Operative time (minutes) Length of specimen (cm) Lymph nodes retrieved
266 – 41 26 – 7 26 – 13
223 – 51 24 – 3 25 – 13
Table 4. Postoperative Results P < .05 NS NS
NS, not significant.
function significantly more quickly and had a shorter hospital stay than the standard laparoscopy group. Discussion In laparoscopic right colectomy, extracorporeal anastomosis is the preferred technique by several authors.1–3 Significant percentages of anastomotic complications (leak and twist) have been described with a such technique16–18; the twist of the mesentery is a well-known and well-described event that can occur when extracorporeal anastomosis is performed,12,17 without the direct vision of the orientation of the bowel. These complications (particularly leaks) can be explained by the difficulty of performing the anastomosis through a small minilaparotomy: in particular, in patients with a bulky and short mesentery of the transverse colon, it is difficult to exteriorize the bowel adequately in order to perform an ideal tension-free anastomosis without traction, especially in the presence of a thick abdominal wall. Additionally, a very small minilaparotomy may not suffice to accommodate the terminal ileum and the transverse colon, especially in obese patients, and this may explain the high incidence of incisional hernias described in the literature,17,19 which may exceed 17%. We have reviewed the historical data of all right laparoscopic colectomies with extracorporeal anastomosis performed at our Department of Surgery in the Regional Specialized Center for Videolaparoscopic Robotic Surgery (authors’ unpublished data). Of 126 right colectomies, which are not included in the present study, 7 patients had an anastomotic complication: 5 had leaks, and 2 had twists of the mesentery. Laparoscopic intracorporeal anastomosis has been proposed, but laparoscopic intracorporeal suturing with straight nonarticulated instruments is challenging,
Table 3. Postoperative Complications Robotic-assisted anastomosis Anastomotic complications Leak 0 Twist 0 Total 0 Wound infection 5 Incisional hernia 0 Nonsurgical 3 complications Early mortality 0 a
Extracorporeal anastomosis
P
3a 1b 4 7 4 3
< .05 NS < .05 NS
0
Two conservative treatment, one redo anastomosis. Immediate redo anastomosis. NS, not significant. b
Robotic-assisted Extracorporeal anastomosis anastomosis Recovery of bowel function Gas Stools Postoperative stay (day)
(day) 2.4 – 0.8 3.0 – 1.0 7.5 – 2.0
3.4 – 1.2 4.0 – 1.2 9.0 – 3.2
P < .05 < .05 < .05
especially if a watertight, delicate suture is required and complications of the anastomosis are described.4,5 The use and the potential benefits of the robotic da Vinci Surgical System in right hemicolectomy are far from being fully understood. The literature is mostly limited to analysis of series and case reports.9–13,20,21 Additionally, the majority of the series are nonhomogeneous because they include both patients with benign diseases and malignancies.11,13 Only one report includes an analysis of a large series of patients with malignancies.12 Most series describe a technique that is not yet standardized with a medial to lateral or lateral to medial approach and intracorporeal or extracorporeal anastomosis. The conclusion that can be drawn from the literature is that robotic right colectomy is both feasible and safe,11–13 but at a higher cost and with longer operating room time than standard laparoscopy.9,11,14 The major advantages of robotics are the three-dimensional view and the endowrist movements that facilitate intra-abdominal suturing: in this study robotic-assisted intra-abdominal ileocolic anastomosis has been compared with extracorporeal anastomosis. Four anastomotic complications were observed in the LG with extracorporeal anastomosis and none in the RG, and the difference is statistically significant. The three-dimensional view and the endowrist movements of the robotic arms make anastomosis easy, fast, and intuitive. Additionally, the suture is made under the direct vision of the mesentery, thereby reducing the risk of twisting the bowel and the anastomosis, which is a well-known and well-described complication. One of the disadvantages of using the da Vinci Surgical System is that operative time (that includes the docking time) is longer than in laparoscopy.11,13 In order to minimize this problem, maneuvers that are easily performed using standard laparoscopic instrumentation (dissection of the bowel, vascular isolation and division, division of the mesentery and of the omentum, division of the bowel) are carried out in laparoscopy. The da Vinci Surgical System is used to perform the anastomosis. Our results show that patients who underwent intracorporeal robotic-assisted anastomosis had a significantly faster recovery of bowel function and a shorter hospital stay. This may be explained by the fact that when the anastomosis intracorporeally is performed, bowel manipulation is minimized, and the transverse colon does not have to be unnecessarily mobilized, freed, and stretched in order to be exteriorized and anastomosed. The results of our study have also shown that patients in the extracorporeal anastomosis group have a significantly higher risk of incisional hernia than the those in the robotic-assisted group. Performing the anastomosis intracorporeally has the advantage of removing the specimen through a Pfannestiel muscle-sparing laparotomy, which not only gives better esthetic results but has also been
INTRACORPOREAL ROBOTIC-ASSISTED ANASTOMOSIS shown to have a lower risk of hernia formation compared with midline laparotomy.19 The disadvantage of robotics lies in cost, which may not fully justify its use in colorectal surgery. Our results, even with all disadvantages of a case control study, show that patients suffering from cancer of the right colon who undergo an intracorporeal robotic-assisted ilecolic anastomosis have a faster recovery of bowel function, a shorter hospital stay, and fewer anastomotic complications than patients operated on with standard extracorporeal anastomosis. This may reduce the overall hospital costs, especially if the results will be confirmed by larger randomized studies. Disclosure Statement Each author certifies that he or she has no competing financial or commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) or other relationships with commercial parties that might pose a conflict of interest in connection with the submitted article. References 1. Kaiser AM, Kang JC, Chan LS, Vukasin P, Beart RW. Laparoscopic-assisted vs open colectomy for colon cancer: A prospective randomised trial. J Laparoendosc Adv Surg Tech A 2004;14:329–334. 2. Lezoche F, Feliciotti F, Paganini AM, Guerrieri D, De SA, Minervini S, Campagnacci R. Laparoscopic vs open hemicolectomy for colon cancer. Surg Endosc 2002;16:596–603. 3. Senagore, AJ, Delaney CP. A critical analysis of laparoscopic colectomy at a single institution: Lessons learned after 1000 cases. Am J Surg 2006;191:377–380. 4. Casciola L, Ceccarelli G, Di Zitti L, Valeri R, Bellochi R, et al. Laparoscopic right hemicolectomy with intracorporeal anastomosis. Technical aspects and personal experience. Minerva Chir 2003;58:621–627. 5. Lacy AM, Garcia-Valdecasas JC, Delgado S, Castells A, Taura` P, Pique´ JM, Visa J. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: A randomised trial. Lancet 2002;359:2224–2229. 6. Zimmern A, Prasad L, De Souza A, Marecik S, Park J, Abcarian H. Robotic colon and rectal surgery: A series of 131 cases. World J Surg 2010;34:1954–1958. 7. D’ Annibale A, Orsini C, Morpurgo E, Sovernigo G. Robotic surgery: Considerations after 250 procedures. Chir Ital 2006;58:5–14. 8. D’ Annibale A, Morpurgo E, Fiscon V, Sovernigo G, Orsini C, Guidolin D. Robotic and laparoscopic surgery for the treatment of colorectal diseases. Dis Colon Rectum 2004;47:2162–2168. 9. Delaney CP, Lynch AC, Senagore A, Fazio V. Comparison of robotically performed and traditional laparoscopic colorectal surgery. Dis Colon Rectum 2003;46:1633–1639.
417 10. Weber PA, Merola S, Wasiliewsky A, Ballanthyne GH. Telerobotic-assisted laparoscopic right and sigmoid colectomiesforbenigndisease.DisColonRectum2002;45:1689–1696. 11. De Souza AL, Prasad L, Park JJ, Marecik SJ, Blumetti J, Abcarian H. Robotic assistance in right hemicolectomy: Is there a role? Dis Colon Rectum 2010;53:1000–1006. 12. D’ Annibale A, Pernazza G, Morpurgo E, Monsellato I, Pende V, Lucandri G, Termini B, Orsini C, Sovernigo G. Robotic right colon resection: Evaluation of first 50 consecutive cases for malignant disease. Ann Surg Oncol 2010;17:2856–2862. 13. Rawlings AL, Woodland JH, Crawford DL. Telerobotic surgery for right and sigmoid colectomies: 30 consecutive cases. Surg Endosc 2006;20:1713–1718. 14. Rawlings AL, Woodland JH, Vegunta RK, Crawford DL. Robotic versus laparoscopic colectomy. Surg Endosc 2007;21: 1701–1708. 15. Ballanthyne GH, Ewing D, Pigazzi A, Wasiliewski A. Telerobotic-assisted laparoscopic right hemicolectomy: Lateral to medial or medial to lateral dissection? Surg Laparosc Endosc Percutan Tech 2006;16:406–410. 16. Waters JA, Guzman MJ, Fajardo AD, Selzer DJ, Wiebke EA, Robb BW. Single-port laparoscopic right hemicolectomy: A safe alternative to conventional laparoscopy. Dis Colon Rectum 2010;53:1467–1472. 17. Hellan M, Anderson C, Pigazzi A. Extracorporeal versus intracorporeal anastomosis for laparoscopic right hemicolectomy. JSLS 2009;13:312–317. 18. Feroci F, Lenzi E, Kro¨nig KG, Morali L, Contagio S, Borrelli A, Giaconi G, Statizzi M. Feasibility and effectiveness of laparoscopic right colectomy with extracorporeal anastomosis. Minerva Chir 2011;66:41–48. 19. Winslow ER, Fleshman JW, Birnbaum E, Brunt LM. Wound complications of laparoscopic vs open colectomy. Surg Endosc 2002;16:1420–1425. 20. Antoniou SA, Antoniou GA, Koch OO, Pointner R, Granderath FA. Robot-assisted laparoscopic surgery of the colon and rectum. Surg Endosc 2012;26:1–11. 21. Buchs NC, Pugin F, Bucher P, Morel P. Totally robotic right colectomy: A preliminary case series and an overview of the literature. Int J Med Robot 2011 June 15 [Epub ahead of print]. doi: 10.1002/rcs.404.
Address correspondence to: Roberta Molaro, MD Department of Surgery Regional Specialized Center for Robotic and Laparoscopic Surgery P. Cosma Hospital via P. Cosma 1 Camposampiero (Padova) Italy E-mail:
[email protected]
