Right colectomy from open to robotic - a single-center experience with functional outcomes in a learning-curve setting

Abstract

Purpose: Right colectomy (RC) is a frequently performed procedure. Beneath standard conventional open surgery (COS), various minimally invasive techniques had been introduced. Several advantages had recently been described for robotic approaches over COS or conventional laparoscopy. Nevertheless, novel minimally invasive techniques require continuous benchmarking against standard COS to gain maximum patient safety. Bowel dysfunction is a frequent problem after RC. Together with general complication rates postoperative bowel recovery are used as surrogate parameters for postoperative patient outcome in this study.

Methods: Retrospective, 10-year single-center analysis of consecutive patients who underwent sequentially either COS (n = 22), robotic-assisted (ECA: n = 39), or total robotic surgery (ICA: n = 56) for oncologic RC was performed.

Results: The conversion from robotic to open surgery rate was low (overall: 3.2%). Slightly longer duration of surgery had been observed during the early phase after introduction of the robotic program to RC (ECA versus COS, p = 0.044), but not anymore thereafter (versus ICA). No differences were observed in oncologic parameters including rates of tumor-negative margins, lymph node-positive patients, and lymph node yield during mesocolic excision. Both robotic approaches are beneficial regarding postoperative complication rates, especially wound infections, and shorter length of in-hospital stay compared with COS. The duration until first postoperative stool is the shortest after ICA (COS: 4 [2-8] days, ECA: 3 [1-6] days, ICA: 3 [1-5] days, p = 0.0004). Regression analyses reveal neither a longer duration of surgery nor the extent of mesocolic excision, but the degree of minimally invasiveness and postoperative systemic inflammation contribute to postoperative bowel dysfunction, which prolongs postoperative in-hospital stay significantly.

Conclusion: The current study reflects the institutional learning curve of oncologic RC during implementation of robotic surgery from robotic-assisted to total robotic approach without compromises in oncologic results and patient safety. However, the total robotic approach is beneficial regarding postoperative bowel recovery and general patient outcome.

Keywords: Bowel dysfunction; Complete mesocolic excision; Ileus; Intracorporal anastomosis; Right colectomy; Robot.

Fig. 1

Port placement for right colectomy with the Da Vinci ® Xi system (Intuitive Surgical, Sunnyvale, CA, USA). Three robotic ports and one assistant port (*) were used. a The 12-mm assistant port (*) is placed in the left lower abdomen by means of a minilaparotomy. Thereafter, the three robotic ports are introduced under vision on a line between the symphysis (#) and the left costal arch (§) on the midclavicular line (two 8-mm ports and one 12-mm port [→]). Care has to be taken on the assistant port, which should be placed in a triangle between the two lower robotic ports to have optimal access. For the later Pfannenstiel minilaparotomy the access of the lowest robotic port above the symphysis is used. b The lowest robotic port above the symphysis is used for bipolar instrument. The middle robotic port is used for the camera and the upper port in the left upper abdomen beneath the costal arch (→) is used for monopolar scissors, stapler devices, and in case of intracorporal anastomosis for the needle holder

Fig. 2

Surrogate outcomes of the surgical procedure. a Numbers of harvested lymph nodes during oncological right colectomy with complete mesocolic excision (p [Kruskal–Wallis test] = 0.570) and b duration of surgery (p [Kruskal–Wallis test] = 0.047). COS conventional open surgery; ECA hybrid minimally invasive, robotic-assisted right colectomy with extracorporal hand-sewn anastomosis; ICA total minimally invasive, robotic right colectomy with intracorporal hand-sewn anastomosis

Fig. 3

Perioperative markers for systemic inflammation. a Preoperative leukocyte counts in peripheral blood (p [Kruskal–Wallis test] = 0.411) and b highest leukocyte counts in peripheral blood during postoperative days 1–3 (p [Kruskal–Wallis test] = 0.014). c Preoperative C-reactive protein values in peripheral blood (p [Kruskal–Wallis test] = 0.408) and d highest C-reactive protein values in peripheral blood during postoperative days 1–3 (p [Kruskal–Wallis test]  < 0.0001). COS conventional open surgery; ECA hybrid minimally invasive, robotic-assisted right colectomy with extracorporal hand-sewn anastomosis; ICA total minimally invasive, robotic right colectomy with intracorporal hand-sewn anastomosis

Fig. 4

Surrogate parameters of postoperative patient outcome. a Postoperative comprehensive complication index summarizes postoperative complications classified by the Clavien-Dindo classification of surgical complications [60, 61] (p [Kruskal–Wallis test] < 0.0001). b Postoperative day of first stool (p [Kruskal–Wallis test] = 0.0004). c Initial postoperative length of stay at the intensive care unit (p [Kruskal–Wallis test] = 0.0006). d Postoperative length of total in-hospital stay (p [Kruskal–Wallis test] < 0.0001). COS conventional open surgery; ECA hybrid minimally invasive, robotic-assisted right colectomy with extracorporal hand-sewn anastomosis; ICA total minimally invasive, robotic right colectomy with intracorporal hand-sewn anastomosis

Fig. 5

Linear regression analysis in response to the surgical approach. a Linear regression of highest C-reactive protein values in peripheral blood during postoperative days 1–3 (left Y-axis, black line and dots) and highest leukocyte counts in peripheral blood during postoperative days 1–3 (right Y-axis, grey line and dots) against the surgical approach. b Linear regression of postoperative bowel dysfunction, i.e. duration until first postoperative stool (left Y-axis, black line and dots) and postoperative length of total in-hospital stay (right Y-axis, grey line and dots) against the surgical approach. c and d Linear regression of the length of postoperative total in-hospital stay against postoperative day of first stool and comprehensive complication index differentiated by the three surgical approaches. COS conventional open surgery; ECA hybrid minimally invasive, robotic-assisted right colectomy with extracorporal hand-sewn anastomosis; ICA total minimally invasive, robotic right colectomy with intracorporal hand-sewn anastomosis

Fig. 6

Evaluation of factors that might influence on postoperative bowel dysfunction independently from the surgical approach by linear regression analysis