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

Abstract

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.

Robotic colon surgery in obese patients: a systematic review and meta‐analysis

“…As the learning curve and efficiency of robotic colorectal surgery improves with increasing usage and technological advances, it is probable that operative time will also decrease. In fact, Müller et al 41 . found that in robotic colorectal surgery patients, operative time and major complications significantly decreased between two time periods of consecutive patients.…”

Learning curve and surgical outcome of robotic assisted colorectal surgery with ERAS program

“…Bencini et al 13 suggested beginning robotic right hemicolectomy (RRH) to reduce the learning curve for more challenging procedures, such as robotic rectal resection (RRR). However, the development of robot systems in simple surgery regarding the standard laparoscopic approach is less evident compared to complex cases 14 . Surgeon A performed standard surgery in the initial step, and surgeon B chose complex surgery in the initial step.…”

A Review of Robotic Surgery in Colorectal Surgery

“…Muller shows that the Miskovic complexity score correlates with the rate of major complications in robotic colorectal surgery, especially if the surgeon is not proficient in robotic surgery [ 33 ]. Therefore, the learning curve should be used and taken as an important factor, when selecting complex cases to be perfomed via robotic approach [ 33 ]. This will lead to a significant reduction in major complications over time [ 33 ].…”