Lymph node yield in right colectomy for cancer: a comparison of open, laparoscopic and robotic approaches

Widmar, Maria; Keskin, Metin; Strombom, Paul; Beltran, Pedro; Chow, Oliver; Smith, J. Joshua; Nash, Garrett M.; Shia, Jinru; Russell, David; Garcia‐Aguilar, Julio

doi:10.1111/codi.13786

Cited by 53 publications

(50 citation statements)

References 30 publications

(31 reference statements)

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“…The mean lymph node retrieval in the BTU-cohort of 40.2 is superior to the range of levels reported for classic laparoscopic as well as for open techniques. The improved lymph node yield in robotic RC if compared to historic laparoscopic and open techniques is in accordance with other reports [29, 30]. Our levels of lymph node harvest were comparable to very recent early series of BTU-RRC [31].…”

Section: Discussionsupporting

confidence: 91%

A standardized suprapubic bottom-to-up approach in robotic right colectomy: technical and oncological advances for complete mesocolic excision (CME)

et al. 2019

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Backround Several studies have demonstrated a direct correlation between lymph node yield and survival after colectomy for cancer. Complete mesocolic excision (CME) in right colectomy (RC) reduces local recurrence but is technically demanding. Here we report our early single center experience with robotic right colectomy comparing our standardized bottom-to-up (BTU) approach of robotic RC with CME and central vessel ligation (CVL) facilitated by a suprapubic access with the “classical” medial-to-lateral (MTL) strategy. Methods A 4-step BTU approach of robotic RC guided by embryonal planes in the process of retrocolic mobilization with suprapubic port placement was performed in the BTU-group ( n = 24; all with intention to treat cancer). In step 1 CME was initiated with caudolateral mobilization of the right colon guided by the fascia of Toldt across the duodenum and up to the Trunk of Henle. Subsequently, dissection was performed BTU right of the middle supramesenteric vessels with central ileocolic vessel ligation in step 2. Subsequent to separation of the transverse retromesenteric space and completion of mobilization the hepatic flexure in step 3, the transverse mesocolon was then transected right of the middle colic vessels in step 4. An extracorporeal side to side anastomosis was performed. We compared the outcome of the BTU-group with a MTL-group ( n = 7). Results Patient characteristics like age, gender, BMI, comorbidity (ASA) and M-status were comparable among groups. There was no conversion. Overall complication rate was 35.5%. We experienced no anastomoses insufficiency, grade Dindo/Clavien III/IV complication or mortality in this study. Type I and II complications and surgical characteristics incl. OR-time, ICU- and hospital-stay were comparable between the two groups. However, the lymph node yield was superior in the BTU-group (mean 40.2 ± 17.1) when compared with the MTL-group (16,3 nodes ±8.5; p < 0,001). Conclusions Compared to the classical MTL approach, robotic suprapubic BTU RC changes from a search of the layers bordering the oncological dissection to a consequent utilization of the planes as a retro-mesocolic guide during CME. The BTU strategy could bear the potential to increase the lymph node yield. Robotic systems may provide the technical requirements to combine advantages of both open and minimally invasive RC.

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Section: Discussionsupporting

confidence: 91%

A standardized suprapubic bottom-to-up approach in robotic right colectomy: technical and oncological advances for complete mesocolic excision (CME)

et al. 2019

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“…A similar retrospective study compared the costs of a single surgeon's first 50 robotic versus laparoscopic rectal resections. 58 The study also compared operative times and costs as a function of experience within the robotic group, separating the 50 cases into three phases: the initial learning curve (cases [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19], competent period (cases 20-40), and experienced phase (cases 41-50). On average, the operative times and overall costs were significantly higher in the robotic group than in the laparoscopic group.…”

Section: Costs Of Robotic Colorectal Surgerymentioning

confidence: 99%

“…These findings supported the idea that robotic ''gateway'' procedures can be used to bypass the steep learning curve for minimally invasive rectal surgery. 8 In addition, in a recent study by Widmar et al 9 the authors retrospectively reviewed 181 open, 163 laparoscopic, and 119 robotic right colectomies performed at the Memorial Sloan Kettering Cancer Center in New York. They found that robotic right colectomy improves LN yield and the LN to length of surgical specimen ratio, which may reflect a better and more precise mesocolic excision.…”

Section: Introductionmentioning

confidence: 99%

“…They found that robotic right colectomy improves LN yield and the LN to length of surgical specimen ratio, which may reflect a better and more precise mesocolic excision. 9 Left colectomy is a more challenging procedure when compared with right colectomy. Other than being more technically demanding, left colectomy requires a colo-colonic or colorectal anastomosis and has a significantly higher incidence of anastomotic leak, wound infection, overall complication rate (ureteral injury, conversion, etc.…”

Section: Introductionmentioning

confidence: 99%

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Appraisal and Current Considerations of Robotics in Colon and Rectal Surgery

Andolfi

Umanskiy

2019

Journal of Laparoendoscopic & Advanced Surgical Techniques

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Background: Robotic technology aims to obviate some of the limitations of conventional laparoscopic surgery, yet the role of robotics in colorectal surgery is still largely undefined and varies with respect to its application in abdominal versus pelvic surgery. Methods: With this review, we aimed to highlight current developments in colorectal robotic surgery. We systematically searched the following databases: PubMed, EMBASE, and Cochrane Library. We critically reviewed the available literature on the use of robotic technology in colon and rectal surgery. Results: Robotic colorectal surgery is oncologically safe and has short-term outcomes comparable to conventional laparoscopy, with potential benefits in rectal surgery. It has a shorter learning curve but increased operative times and costs. It offers potential advantages in the resection of rectal cancer, due to lower conversion rates. There is also a trend toward better outcomes in anastomotic leak rates, circumferential margin positivity, and perseveration of autonomic function. Conclusion: Laparoscopy remains technically challenging and conversion rates are still high. Therefore, most cases of colorectal surgery are still performed open. Robotic surgery aims to overcome the limits of the laparoscopic technique. This new technology has many advantages in terms of articulating instruments, advanced three-dimensional optics, surgeon ergonomics, and improved accessibility to narrow spaces, such as the pelvis. However, further studies are needed to assess long-term results and benefits.The first report on laparoscopic right colectomy was published by Jacobs et al. 1 ; shortly following that Fowler performed the first laparoscopic left colectomy. Since these initial reports, several large studies found that the oncologic outcomes of laparoscopic colectomy were equivalent to open surgery. Despite the growing evidence supporting the use of laparoscopic colectomy for colon cancer, the adoption of this technique was relatively slow due to some limitations: loss of stereoscopic vision and depth perception, paradoxical motion of the instruments, amplified movements, parallel instrumentation, and suboptimal ergonomics. To overcome these shortfalls, the use of hand-assisted laparoscopy was introduced as a bridge between open and laparoscopic surgery. 2,3 Robotic colectomy was first reported in 2002 and since that time adoption of robotic surgery has steadily increased, as evidenced by the number of publications in both medical and lay press. The da Vinci robotic system, the only currently available robotic system in the market approved by the FDA for colorectal surgery, provides several advantages over traditional laparoscopic surgery including a stable camera platform, threedimensional (3D) imaging, improved ergonomics, tremor elimination, ambidextrous capability, motion scaling, and

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“…Lymph node yield in right colectomies for cancer: a comparison of open, laparoscopic and robotic approaches. Widmar M, Keskin M, Strombom P, Beltran P, Chow OS, Smith JJ, Nash GM, Shia J, Russell D, García‐Aguilar J …”

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confidence: 99%

Editor's Choice

Pera

2017

Colorectal Disease

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The association between the number of lymph nodes retrieved during colectomy in non-metastatic colorectal cancer and survival has been demonstrated in multiple studies. In this issue, Widmar et al. hypothesized that, with its increased dexterity and visualization, robotic right colectomy would lead to higher lymph node yield and improved mesocolic excision. The authors performed a retrospective study comparing open, laparoscopic and robotic colectomy for cancer. The two primary endpoints for this study were total lymph node yield and the lymph node to length of surgical especimen, the latter as an indirect marker of the completeness of the mesocolic excision. Pathologic examination showed that the lymph node yield was highest among patients undergoing robotic colectomy compared to the other groups. In multivariable analysis, robotic right colectomy was associated with higher lymph node yield and lower lymph node to length of surgical specimen. Although the present analysis has several confounding factors which are difficult to eliminate, these results suggest that robotic surgery might facilitate a more complete mesocolic excision with low morbidity. Before this approach can be recommended, these findings should be validated in a prospective study with a more complete pathologic evaluation investigating also its influence on tumor recurrence and survival. Miguel PeraAssociate Editor, Colorectal Disease

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Lymph node yield in right colectomy for cancer: a comparison of open, laparoscopic and robotic approaches

Cited by 53 publications

References 30 publications

A standardized suprapubic bottom-to-up approach in robotic right colectomy: technical and oncological advances for complete mesocolic excision (CME)

A standardized suprapubic bottom-to-up approach in robotic right colectomy: technical and oncological advances for complete mesocolic excision (CME)

Appraisal and Current Considerations of Robotics in Colon and Rectal Surgery

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