Robotic Colorectal Surgery Learning Curve and Case Complexity

Shaw, Darcy; Wright, Moriah E; Taylor, Lindsay; Bertelson, Noelle L.; Shashidharan, Maniamparampil; Menon, Prem Haridas; Menon, Vijay; Wood, Samuel; Ternent, Charles A.

doi:10.1089/lap.2016.0411

Cited by 42 publications

(39 citation statements)

References 20 publications

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“…To overcome increased complication rates in the learning phase, a complexity score was proposed for laparoscopic colorectal resection to minimize surgical risk in the beginning ( 10 ). The situation in robotic surgery could be similar: Even though complex cases may especially benefit from robotic surgery, appropriate case selection with respect to the actual experience in robotic surgery may still be a critical determinant of outcome, especially in the implementation phase of this new operation technique ( 11 ).…”

Section: Introductionmentioning

confidence: 99%

Surgical Complexity and Outcome During the Implementation Phase of a Robotic Colorectal Surgery Program—A Retrospective Cohort Study

et al. 2021

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BackgroundRobotic surgery holds particular promise for complex oncologic colorectal resections, as it can overcome many limitations of the laparoscopic approach. However, similar to the situation in laparoscopic surgery, appropriate case selection (simple vs. complex) with respect to the actual robotic expertise of the team may be a critical determinant of outcome. The present study aimed to analyze the clinical outcome after robotic colorectal surgery over time based on the complexity of the surgical procedure.MethodsAll robotic colorectal resections (n = 85) performed at the Department of Surgery, Medical University of Vienna, between the beginning of the program in April 2015 until December 2019 were retrospectively analyzed. To compare surgical outcome over time, the cohort was divided into 2 time periods based on case sequence (period 1: patients 1–43, period 2: patients 44–85). Cases were assigned a complexity level (I-IV) according to the type of resection, severity of disease, sex and body mass index (BMI). Postoperative complications were classified using the Clavien-Dindo classification.ResultsIn total, 47 rectal resections (55.3%), 22 partial colectomies (25.8%), 14 abdomino-perineal resections (16.5%) and 2 proctocolectomies (2.4%) were performed. Of these, 69.4% (n = 59) were oncologic cases. The overall rate of major complications (Clavien Dindo III-V) was 16.5%. Complex cases (complexity levels III and IV) were more often followed by major complications than cases with a low to medium complexity level (I and II; 25.0 vs. 5.4%, p = 0.016). Furthermore, the rate of major complications decreased over time from 25.6% (period 1) to 7.1% (period 2, p = 0.038). Of note, the drop in major complications was associated with a learning effect, which was particularly pronounced in complex cases as well as a reduction of case complexity from 67.5% to 45.2% in the second period (p = 0.039).ConclusionsThe risk of major complications after robotic colorectal surgery increases significantly with escalating case complexity (levels III and IV), particularly during the initial phase of a new colorectal robotic surgery program. Before robotic proficiency has been achieved, it is therefore advisable to limit robotic colorectal resection to cases with complexity levels I and II in order to keep major complication rates at a minimum.

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Section: Introductionmentioning

confidence: 99%

Surgical Complexity and Outcome During the Implementation Phase of a Robotic Colorectal Surgery Program—A Retrospective Cohort Study

et al. 2021

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“…As expected, robotic operative times decreased over the course of the study and without any detriment on the primary outcome. While the robotic platform is generally accepted to have a quicker learning curve than laparoscopic surgery, [11][12][13] our data suggest that laparoscopic skilled surgeons can transition to the robotic platform without compromising perioperative outcomes.…”

Section: Discussionmentioning

confidence: 77%

Sigmoidectomy for Diverticulitis—A Propensity-Matched Comparison of Minimally Invasive Approaches

Ogilvie

Saunders

Parker

et al. 2019

Journal of Surgical Research

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a b s t r a c tBackground: As the availability and use of robotic surgery increases, current data suggest comparable outcomes to laparoscopic surgery but at an increased cost. Elective sigmoid resection for diverticular disease is the most common colorectal application of robotic surgery and there is limited comparative data specifically for this indication. Methods:We identified all elective cases of laparoscopic-and robot-assisted surgery for diverticular disease among a practice of 7 colorectal surgeons within an established enhanced recovery protocol. We performed propensity matching based on surgical indications (recurrent disease, ongoing symptoms, or fistula), stoma creation, and body mass index to create a matched cohort. Our primary outcomes were return of bowel function, length of stay, opioid use, and pain scores during the first 72 h postoperatively. Secondary outcomes were operative room and hospital charges.Results: From 2011 to 2016, 69 robotic cases were propensity matched from a group of 222 laparoscopic cases to create a 1:1 case ratio that was equivalent in terms of patient demographics and operative indications. Time to first bowel movement was slightly quicker in the robotic group (1 [1] versus 2 [1.5], P ¼ 0.09), while length of stay (3.5 [1.6] versus 3.6 [1.4] d, P ¼ 0.64) was equivalent. Pain scores were lower in the robotic group on day 0 (4.6 versus 6.1, P ¼ 0.0001), but similar on day 1 and day 2 (4.3 versus 4.1, P ¼ 0.62 and 3.8 versus 3.3, P ¼ 0.19). There was no difference in postoperative 72-h opioid use between groups (110.8 MME [144.5] versus 97.4 MME [101.5], P ¼ 0.70). In the robotic arm operating room charges were slightly more ($2835 AE $394 versus $2196 AE $359, P < 0.0001), but total hospital charges were over significantly increased ($41,159 [$7840] versus $25,761 [$11,689], P < 0.0001).Conclusions: Via a carefully matched cohort of elective sigmoid resection for diverticular disease at a single community institution, we have demonstrated that laparoscopic-and robotic-assisted surgery result in clinically equivalent return of bowel function, length of stay, postoperative pain, and opioid use. ª

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“…Although performance increased rapidly in both techniques, the learning curve favored robotic surgery clearly, which thus turned out to be easier to learn. Other studies, as from Shaw [40], Blumberg [41], and Parisi [42], support this suggestion. Accordingly, and although not implicated by the available literature, one can assume that a larger patient cohort will be treated by a minimally invasive mesocolic approach when robotic surgery is used.…”

Section: Learning Curvementioning

confidence: 73%

Complete mesocolic excision in minimally invasive surgery of colonic cancer: do we need the robot?

et al. 2020

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Summary Background Robotic surgery offers favorable prerequisites for complex minimally invasive surgeries which are delivered by higher degrees of freedom, improved instrument stability, and a perfect visualization in 3D which is fully surgeon controlled. In this article we aim to assess its impact on complete mesocolic excision (CME) in colon cancer and to answer the question of whether the current evidence expresses a need for robotic surgery for this indication. Methods Retrospective analysis and review of the current literature on complete mesocolic excision for colon cancer comparing the outcome after open, laparoscopic, and robotic approaches. Results Complete mesocolic excision results in improved disease-free survival and reduced local recurrence, but turns out to be complex and prone to complications. Introduced in open surgery, the transfer to minimally invasive surgery resulted in comparable results, however, with high conversion rates. In comparison, robotic surgery shows a reduced conversion rate and a tendency toward higher lymph node yield. Data, however, are insufficient and no high-quality studies have been published to date. Almost no oncologic follow-up data are available in the literature. Conclusion The current data do not allow for a reliable conclusion on the need of robotic surgery for CME, but show results which hypothesize an equivalence if not superiority to laparoscopy. Due to recently published technical improvements for robotic CME and supplementary features of this method, we suppose that this approach will gain in importance in the future.

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Robotic Colorectal Surgery Learning Curve and Case Complexity

Cited by 42 publications

References 20 publications

Surgical Complexity and Outcome During the Implementation Phase of a Robotic Colorectal Surgery Program—A Retrospective Cohort Study

Surgical Complexity and Outcome During the Implementation Phase of a Robotic Colorectal Surgery Program—A Retrospective Cohort Study

Sigmoidectomy for Diverticulitis—A Propensity-Matched Comparison of Minimally Invasive Approaches

Complete mesocolic excision in minimally invasive surgery of colonic cancer: do we need the robot?

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