Robotic Complete Mesocolic Excision Research Articles

Comparison of Postoperative Outcomes and Long-Term Survival Rates between Patients Who Underwent Robotic and Laparoscopic Complete Mesocolic Excision for Right-Sided Colon Cancer.

Introduction: Right colon cancer often requires surgical intervention, and complete mesocolic excision (CME) has emerged as a standard procedure. The study aims to evaluate and compare the safety and efficacy of robotic and laparoscopic CME for patients with right colon cancer and 5-year survival rates examined to determine the outcomes. Materials and Methods: Patients who underwent CME for right-sided colon cancer between 2014 and 2021 were included in this study. Group differences of age, body mass index, operation time, bleeding amount, total harvested lymph nodes, and postoperative stay were analyzed by the Mann-Whitney U test. Group differences of sex, American Society of Anesthesiology, and tumor, node, and metastasis stage were analyzed by the Chi-squared test. Disease-free and overall survival were assessed using Kaplan-Meier curves with the log-rank Mantel-Cox test. Results: From 109 patients, 74 of them were 1:1 propensity score matched and used for analysis. Total harvested lymph node (P ≤ .001) and estimated blood loss (P = .031) were found to be statistically significant between the groups. We found no statistically significant difference between the groups in terms of disease-free and overall survival (P = .27, .86, respectively), and the mortality rate was 9.17%, with no deaths directly attributed to the surgery. Conclusions: Study shows that minimally invasive surgery is a feasible option for CME in right colon cancers, with acceptable overall survival rates. Although the robotic approach has a higher lymph node yield, there was no significant difference in survival rates. Further randomized trials are needed to determine the clinical significance of both approaches.

Robotic CME in 110 consecutive cases: feasibility and short-term technical and oncological outcomes.

Complete mesocolic excision (CME) has been introduced from open surgery, to compare right colon cancer surgery to total mesorectal excision for rectal cancer and it is currently being applied by robotic approach. CME concept is based on the complete removal of right mesocolon and the dissection deep at the level of the central feeding vessels. Aside the CME, intracorporeal anastomosis completes a total minimally invasive approach to the treatment of right colon cancer. This study retrospectively analyzed the feasibility and efficacy of robotic CME and intracorporeal anastomosis in a cohort of consecutive patients affected with right colon cancer. The data of 110 patients undergone a robotic CME with IA anastomosis for right colon cancer from 2018 to 2023 were prospectively collected and retrospectively analyzed. Intraoperative, postoperative, and short-middle term outcomes were considered for analysis, as well as pathologic and oncologic outcomes. A time-to-event analysis was performed using the Kaplan-Meier method for OS and DFS. All patients underwent a robotic right colectomy. Median operative time was 184 min, blood loss was negligible, no intraoperative complications occurred. Three conversions (2.7%) were experienced due to bulky lymph nodes and severe local advanced tumor. Mean postoperative stay was 6 days. Six postoperative complications occurred, 4 postoperative ileus, 1 late dehiscence of the colonic stump and an iatrogenic colonic perforation. The latter needed reintervention. Robotic CME with central vessels ligation seems feasible and safe, with acceptable morbidity and adequate short-middle term outcomes.

Developing a phantom for simulating robotic-assisted complete mesocolic excision using 3D printing and medical imaging

BackgroundRobotic-assisted complete mesocolic excision is an advanced procedure mainly because of the great variability in anatomy. Phantoms can be used for simulation-based training and assessment of competency when learning new surgical procedures. However, no phantoms for robotic complete mesocolic excision have previously been described. This study aimed to develop an anatomically true-to-life phantom, which can be used for training with a robotic system situated in the clinical setting and can be used for the assessment of surgical competency.MethodsEstablished pathology and surgical assessment tools for complete mesocolic excision and specimens were used for the phantom development. Each assessment item was translated into an engineering development task and evaluated for relevance. Anatomical realism was obtained by extracting relevant organs from preoperative patient scans and 3D printing casting moulds for each organ. Each element of the phantom was evaluated by two experienced complete mesocolic excision surgeons without influencing each other’s answers and their feedback was used in an iterative process of prototype development and testing.ResultsIt was possible to integrate 35 out of 48 procedure-specific items from the surgical assessment tool and all elements from the pathological evaluation tool. By adding fluorophores to the mesocolic tissue, we developed an easy way to assess the integrity of the mesocolon using ultraviolet light. The phantom was built using silicone, is easy to store, and can be used in robotic systems designated for patient procedures as it does not contain animal-derived parts.ConclusionsThe newly developed phantom could be used for training and competency assessment for robotic-assisted complete mesocolic excision surgery in a simulated setting.

Complete mesocolic excision versus standard resection for colon cancer: a systematic review and meta-analysis of perioperative safety and an evaluation of the use of a robotic approach.

Complete mesocolic excision (CME) has been associated with improved oncological outcomes in treatment of colon cancer. However, widespread adoption is limited partly because of the technical complexity and perceived risks of the approach. The aim of out study wasto evaluate the safety of CME compared to standard resection and to compare robotic versus laparoscopic approaches. Two parallel searches were undertaken in MEDLINE, Embase and Web of Science databases 12 December 2021. The first was to evaluate IDEAL stage3 evidence to compare complication rates as a surrogate marker of perioperative safety between CME and standard resection. The second independent search compared lymph node yield and survival outcomes between minimally invasive approaches. There were four randomized control trials (n = 1422) comparing CME to standard resection, and three studies comparing laparoscopic (n = 164) to robotic (n = 161) approaches. Compared to standard resection, CME was associated with a reduction in Clavien-Dindo grade3 or higher complication rates (3.56% vs. 7.24%, p = 0.002), reduced blood loss (113.1ml vs. 137.6ml, p < 0.0001) and greater mean lymph node harvest (25.6 vs. 20.9 nodes, p = 0.001). Between the robotic and laparoscopic groups, there were no significant differences in complication rates, blood loss, lymph node yield, 5-year disease-free survival (OR 1.05, p = 0.87) and overall survival (OR 0.83, p = 0.54). Our study demonstrated improved safety with CME. There was no difference in safety or survival outcomes between robotic and laparoscopic CME. The advantage of a robotic approach may lie in the reduced learning curve and an increased penetration of minimally invasive approach to CME. Further studies are required to explore this. CRD42021287065.

Reliability and Educational Value of YouTube Videos of Complete Meso-Colic Excision With Right Hemicolectomy in the COVID-19 Pandemic.

Aim: To investigate the reliability and educational value of YouTube videos of minimally invasive complete mesocolic excision with right hemicolectomy procedures.Materials and methods: We searched YouTube with the terms “Laparoscopic and Robotic Complete Mesocolic Excision with Right Hemicolectomy” on January 12, 2021. To assess the reliability of the videos, we evaluated nine steps in each video and scored the videos based on the key steps they contained. The videos were divided into three groups according to the source of the upload. The total number of views, length, time since upload, and the number of likes, dislikes, and comments were recorded for each video. Narration, the use of descriptive subtitles, and the upload status by an expert surgeon were also examined.Results: Sixty-eight videos were included in the study. A positive significant correlation was identified between the comprehensiveness score (CS) and the number of views (p=0.025). The CSs of the videos accessed from academic channels, as well as those accessed from journals, congress, and association channels, recorded higher CSs than those obtained from the personal channels of consultants (p=0.003). It was also found that CSs were higher in the videos of expert surgeons (p<0.001) and narrated videos (p<0.001).Conclusion: Not all YouTube videos on this subject have reliability and educational value. Surgical videos on YouTube may be evaluated by a video review commission formed by academic institutions, surgical associations, or expert surgeons, and videos suitable for education could be brought together and published via a free channel.

Robotic CME in obese patients: advantage of robotic ultrasound scan for vascular dissection

Complete mesocolic excision (CME) in right-sided colon cancers appears to confer oncological benefits compared to conventional colectomy. Identification of the superior mesenteric vein (SMV) remains challenging. We describe the novel use of intra-operative robotic ultrasound scan (rUSS) in obese patients (BMI ≥ 29). All consecutive patients having robotic CME for colon cancer between 2014 and 2017 were included in this retrospective cohort study. Data were recorded on an ethics approved prospective database and included patient demographics, clinical and oncological outcomes. Patients were divided into group 1 (BMI ≤ 28) and group 2 (BMI ≥ 29). SMV first approach was employed in all cases and SMV detection was aided using rUSS in group 2. Primary outcome was postoperative morbidity. Secondary outcomes included conversion rate, operative time and length of stay (LOS). 41 (group 1, median 66 years) were compared to 32 patients (group 2, median 63 years). There were no conversions to laparoscopy or laparotomy. Median operative times for group 2 were 30 min longer (186 vs. 216 min, p = 0.05). Overall morbidity was similar (20% vs. 19% in group 1 and 2, p = 0.26). There was no significant difference between the two groups with regard to LOS (median 7 vs. 6 days, p = 0.48), readmissions (2 vs. 5, p = 0.13), R0 resection rate (98% vs. 94%, p = 0.43) and lymph node harvest (median 31 vs. 30, p = 0.28).CME can be technically more challenging than conventional colectomy in obese patients and is associated with longer operative times. The use of rUSS in obese patients can help to identify SMV and allow safer dissection.

Report from 'ESCP 2021 Virtual': the 16th Scientific and Annual Conference of the European Society of Coloproctology, 22-24 September 2021.

Report from 'ESCP 2021 Virtual': the 16th Scientific and Annual Conference of the European Society of Coloproctology, 22-24 September 2021.

Updates on Robotic CME for Right Colon Cancer: A Qualitative Systematic Review.

Background. Complete mesocolic excision (CME) is a surgical technique introduced with the aim of ameliorating the oncologic results of colectomy. Various experiences have demonstrated favorable oncologic results of CME in comparison with standard colectomy, in which the principles of CME are not respected. The majority of the literature refers to open or laparoscopic CME. This review analyses current evidence regarding robotic CME for right colectomy. Methods. An extensive Medline (Pub Med) search for relevant case series, restricted to papers published in English, was performed, censoring video vignettes and case reports. Results. Fourteen studies (ten retrospective, four comparative series of robotic versus laparoscopic CME) were included, with patient numbers ranging from 20 to 202. Four different approaches to CME are described, which also depend on the robotic platform utilized. Intraoperative and early clinical results were good, with a low conversion and anastomotic leak rate and a majority of Clavien–Dindo complications being Grades I and II. Oncologic adequacy of the surgical specimens was found to be good, although a homogeneous histopathologic evaluation was not provided. Conclusions. Further large studies are warranted to define long-term oncologic results of robotic right colectomy with CME and its eventual benefits in comparison to laparoscopy.

Robotic complete mesocolic excision versus conventional robotic right colectomy for right-sided colon cancer: a comparative study of perioperative outcomes.

This study aims to compare the short-term outcomes of robotic complete mesocolic excision (RCME) versus conventional robotic right colectomy (RRC) for right-sided colon cancer. Consecutive patients who underwent robotic surgery for right-sided colon cancer in a public quaternary and a private tertiary healthcare centre between November 2018 and June 2020 were included. Clinical, perioperative and histopathological variables were collected and analysed. Fifty-one patients were included; 25 (49%) of them had an RCME. The groups were evenly distributed in terms of demographic characteristics and tumour location. Operative time was similar between both groups, and no patients required conversion to open surgery. There were no differences in overall complications (16% in RCME vs. 26.9% in RRC; p = 0.499) or their profile between groups. There were no anastomotic leaks recorded, and the reoperation rates were similar (0% for RCME versus 3.8% for RRC; p = 1). In addition, the median length of hospital stay was similar in between the RCME and the RRC groups (4 [4-6] days versus 5 [3-8.5] days, respectively; p = 0.891). Whilst there were no differences in the TNM staging, the mean number of lymph nodes harvested with RCME was 37.7 (±12.9) compared to 21.8 (±7.5) with RCC (p < 0.001). In our series, RCME was associated with a higher lymph node harvest and a similar morbidity profile compared to RCC. Further studies are required to validate these results and provide long-term oncologic outcomes.

Robotic complete mesocolic excision with central vascular ligation for right colonic tumours—technical notes and oncological outcomes compared to a propensity score-matched laparoscopic group

Background: Laparoscopic complete mesocolic excision (CME) of the right colon with central vascular ligation (CVL) is a technically-demanding procedure. We retrospectively evaluated the feasibility, safety and oncological outcomes of the procedure when performed using the da Vinci® robotic system.

Does Obesity Impact Surgical and Pathological Outcomes in Robotic Complete Mesocolic Excision for Colon Cancer?

Background: Obesity is one of the contributing factors to technical difficulties in minimally invasive colorectal surgery. However, there are no data regarding the outcomes for obese patients undergoing robotic complete mesocolic excision (CME) for colon cancer. In this study, we aimed to investigate whether robotic CME in obese patients can be performed with similar morbidity and pathological results compared with nonobese patients. Methods: Patients who underwent robotic CME between 2014 and 2019 were classified into obese and nonobese groups. Obesity was defined as body mass index ≥30 kg/m2. Demographic data, perioperative outcomes and pathological results were compared between the groups. Results: There were 42 and 105 patients in the obese and nonobese group, respectively. The groups were comparable regarding preoperative characteristics. There were no significant differences with respect to operative times (244 ± 64 versus 304 ± 75 minutes, P = .29), blood loss (median, 50 versus 80 mL, P = .20), intraoperative complications (0% versus 3.8%, P > .99), and conversions (0% versus 1.9%, P > .99). No differences were detected in length of hospital stay (6 ± 1 versus 6 ± 2 days, P = .73), anastomotic leak (2.4% versus 1.9%, P > .99), septic complications, reoperations (2.4% versus 3.8%), and readmissions (2.4% versus 2.9%) (P > .05). The mean number of harvested lymph nodes (33 ± 11 versus 34 ± 13, P = .79), resection margin status, and mesocolic fascia grading were similar. Conclusion: Robotic CME in obese patients can be performed with a similar morbidity and pathological profile compared with nonobese patients. The Clinical Trial Registration number is not applicable for this study.

Robotic Complete Mesocolic Excision (CME) is a safe and feasible option for right colonic cancers: short and midterm results from a single-centre experience

BackgroundComplete mesocolic excision (CME) for right colon cancers has traditionally been an open procedure. Surgical adoption of minimal access CME remains limited due to the technical challenges, training gaps and lack of level-1 data for proven benefits. Currently there is limited published data regarding the clinical results with the use of robotic CME surgery. Aim To report our experience, results and techniques, highlighting a clinical and oncological results and midterm oncological outcomes for robotic CME.AimTo report our experience, results and techniques, highlighting a clinical and oncological results and midterm oncological outcomes for robotic CME.MethodsAll patients undergoing standardised robotic CME technique with SMV first approach between January 2015 and September 2019 were included in this retrospective review of a prospectively collected database. Patient demographics, operative data and clinical and oncological outcomes were recorded.ResultsSeventy-seven robotic CME resections for right colonic cancers were performed over a 4-year period. Median operative time was 180 (128–454) min and perioperative blood loss was 10 (10–50) ml. There were 25 patients who had previous abdominal surgery. Median postoperative hospital stay was 5 (3–18) days. There was no conversion to open surgery in this series. Median lymph node count was 30 (10–60). Three (4%) patients had R1 resection. There was one (1%) local recurrence in stage III disease and 4(5%) distal recurrence in stage II and stage III. There was no 30- or 90-day mortality. Three-year disease-free survival was 100%, 91.7% and 92% for stages I, II and III, respectively. Overall survival was 94%.ConclusionsRobotic CME is feasible, effective and safe. Good oncological results and improved survival are seen in this cohort of patients with a standardised approach to robotic CME.

SMV first approach for robotic complete mesocolic excision with central vascular ligation for right colonic tumours—comparison to a propensity score-matched laparoscopic group

Background: Laparoscopic complete mesocolic excision (CME) of the right colon with central vascular ligation (CVL) is a technically demanding procedure. We retrospectively evaluated the feasibility, safety and oncological outcomes of the procedure when performed using the daVinci® robotic system.

Robotic 4 trocars modified CME with inferior approach using a da Vinci Si Platform

Mininvasive complete mesocolic excision (CME) with central vein ligation is progressively gaining a pivotal role in the multimodal management of right sided colonic cancer. Robotic CME seems to be equally safe and effective in terms of short-term morbidity, oncological radicality and 5-year survival rate as laparoscopic technique, and is commonly performed with a medial to lateral approach. A modified CME, introduced by Cho, has recently been adopted with suprapubic approach using a Da Vinci Xi platform.

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

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.

Preliminary exploration of robotic complete mesocolic excision for colon cancer with the domestically produced Chinese minimally invasive Micro Hand S surgical robot system.

To summarize our initial experience with robot-assisted complete mesocolic excision (R-CME) using a domestically produced Chinese surgical robot by a short-term evaluation. From March 2018 to December 2018, 25 patients with colon cancer underwent Micro Hand S R-CME. The operative findings, morbidities and oncological findings were analysed. The median operative duration was 210 (range, 180-235) min, and the median estimated blood loss volume was 55 (range, 25-125) ml. The median number of lymph nodes harvested was 42 (range, 21-77), and the median length of hospital stay after the operation was 7 (range, 5-9) days. There were no severe complications except for seven cases of grade I complications and five cases of grade II complications. The conversion rate was 0%. There were no cases of 30-day readmission or 30-day mortality. R-CME using a domestically produced surgical robot for selected colon cancer patients is technically feasible and safe.

Robotic complete mesocolic excision and central vascular ligation for right-sided colon cancer: short-term outcomes from a case series.

Despite conflicting data regarding oncological outcomes, studies demonstrate that complete mesocolic excision (CME) and central vascular ligation (CVL) for right-sided colon cancer removes significantly more tissue and yields higher lymph node counts when compared to conventional resection. This study aims to report the safety profile of CME and CVL in patients undergoing robotic surgery for right-sided colon cancer during the introduction of this technique across two institutions. Patients who underwent an elective robotic right colectomy with CME and CVL for right-sided colon cancer in a public quaternary and a private tertiary healthcare centre between November 2018 and April 2020 were included. Demographic, clinical, perioperative and histopathological variables were recorded and analysed. Twenty patients (13 females) with a median age of 69 (23-83) years and median body mass index of 27 (19-46) were included. All of them had a pre-operative diagnosis of right-sided colon adenocarcinoma. Median operative time and blood loss were 140 (130-300) min and 30 (20-100) mL, respectively. There were no conversions or intra-operative complications. There were two post-operative complications recorded (one ileus and one intra-abdominal collection treated with intravenous antibiotics) and no re-interventions. Median length of stay was 4 (2-8) days. All patients had an R0 resection, and the median lymph node yield was 36 (22-80) lymph nodes. This series demonstrates a safe introduction of robotic CME and CVL in patients with right-sided colon cancer. The lymph node harvest obtained with CME and CVL in this setting was high.

Robotic Complete Mesocolic Excision with Central Vascular Ligation for Right Colon Cancer: Surgical Technique and Short-term Outcomes

BackgroundMinimally invasive colorectal surgery has demonstrated to have the same oncological results as open surgery, with better clinical outcomes. Robotic assistance is an evolution of minimally invasive technique.PurposeThe study aims to present technical details and short-term oncological outcomes of robotic-assisted complete mesocolic excision (CME) with central vascular ligation (CVL) for right colon cancer.MethodologyFifty-two consecutive patients affected by right colon cancer were operated between May 2016 and February 2020 with da Vinci Xi platform. Data regarding surgical and short-term oncological outcomes were systematically collected in a colorectal specific database for statistical analysis.ResultsThirty-seven (71.15%) and 15 (28.85%) patients underwent right and extended right hemicoletomy with an extracorporeal anastomosis. Median age was 55 years. Mean operative time was 182 ± 36 min. Mean blood loss was 110 ± 90 ml. Conversion rate was 3.84% (two cases). 78.84% (41 cases) were pT3 and mean number of harvested lymph nodes was 28 ± 4. 1/52 (1.92%) had a documented anastomotic leak requiring exploratory laparotomy and diversion proximal ileostomy. Surgery-related grade IIIa–IIIb Calvien Dindo morbidity were noted in 9.61% and 1.92%, respectively.ConclusionRobotic assistance allows performance of oncological adequate dissection of the right colon with radical lymphadenectomy as in open surgery, confirming the safety and oncological adequacy of this technique, with acceptable results and short-term outcomes.

Robotic complete mesocolic excision for transverse colon cancer can be performed with a morbidity profile similar to that of conventionallaparoscopic colectomy.

In minimally invasive surgery, complete mesocolic excision (CME) for transverse colon cancer is challenging; thus, non-CME resections are commonly preferred when laparoscopy is used. Robotic technology has been developed to reduce the limitations of laparoscopy. The aim of our study was to evaluate whether robotic CME for transverse colon cancer can be performed with short-term outcomes similar to those of laparoscopic conventional colectomy (CC). A retrospective review of 118 consecutive patients having robotic CME or laparoscopic CC for transverse colon cancer in two specialized centers between May 2011 and September 2018 was performed. Perioperative 30-day outcomes of the two procedures were compared. There were 38 and 80 patients in the robotic CME group and laparoscopic CC group, respectively. The groups were comparable regarding preoperative characteristics. Intraoperative results were similar, including blood loss (median 50 vs 25ml), complications (5.3% vs 3.8%), and conversions (none vs 7.5%). The rate of intracorporeal anastomosis was significantly higher (86.8% vs 20.0%), mean operative time was longer (325.0 ± 123.2 vs 159.3 ± 56.1min (p < 0.001), and the mean number of harvested lymph nodes was higher in the robotic CME group (46.1 ± 22.2 vs 39.1 ± 17.8, p = 0.047). There were only minor differences in length of hospital stay (7.2 ± 3.1 vs 7.9 ± 4.0days), anastomotic leak (none vs 2.6%), bleeding (none vs 1.3%), surgical site infections (10.5% vs 12.5%), and reoperations (2.6% vs 6.3%). Robotic CME can be performed with a similar morbidity profile as laparoscopic CC for transverse colon cancer along with a higher rate of intracorporeal anastomosis, and higher number of lymph nodes retrieved, but longer operative times.

Superior Mesenteric Vein-First Approach for Robotic Salvage Surgery with Indocyanine Green Fluorescence Angiography

Inadequate lymphadenectomy is still a major concern in colon cancer surgery. The superior mesenteric vein (SMV)-first approach is a novel, standardized, reproducible method for robotic complete mesocolic excision surgery. Our aim was to present the application of the SMV-first approach principles to facilitate robotic salvage surgery for recurrent disease within the mesocolon. A 78-year-old female presented with a malignant lymph node deposit within residual right mesocolonic tissue, approximately 3months following a laparoscopic right hemicolectomy for colon cancer. Dissection was initiated with a transverse curvilinear incision along the inferior aspect of the remaining ileocolic pedicle to identify the SMV. Dissection continued along the ventral aspect of the SMV in a cephalad direction to identify and expose the middle colic vessels at their origin. The use of idocyanine green (ICG) confirmed the vascular anatomy, demonstrating the right branch of the middle colic artery traversing the malignant deposit in the residual mesocolon. Following ligation at the origin of the right branch of the middle colic and ileocolic vessels, the retro-mesocolic plane dissection was completed to excise the malignant deposit and the residual mesocolon. The patient was discharged home the following day. The pathological specimen confirmed metastatic poorly differentiated adenocarcinoma in one of nine lymph nodes, and the vascular pedicle resection margin was negative for tumor. Following the SMV-first approach principles provides a safe plane for dissection, and, in conjunction with ICG, facilitates the delineation of the vascular anatomy, to enable robotic salvage surgery to be performed.1-3.