Effective implementation and adaptation of structured robotic colorectal programme in a busy tertiary unit

Abstract

Background Safety and feasibility of robotic colorectal surgery has been reported as increasing over the last decade. However safe implementation and adaptation of such a programme with comparable morbidities and acceptable oncological outcomes remains a challenge in a busy tertiary unit. We present our experience of implementation and adaptation of a structured robotic colorectal programme in a high-volume center in the United Kingdom. Methods Two colorectal surgeons underwent a structured robotic colorectal training programme consisting of time on simulation console, dry and wet laboratory courses, case observation, and initial mentoring. Data were collected on consecutive robotic colorectal cancer resections over a period of 12 months and compared with colorectal cancer resections data of the same surgeons’ record prior to the adaptation of the new technique. Patient demographics including age, gender, American Society of Anesthesiologist score (ASA), Clavien–Dindo grading, previous abdominal surgeries, and BMI were included. Short-term outcomes including conversion to open, length of stay, return to theatre, 30- and 90-days mortality, blood loss, and post-operative analgesia were recorded. Tumour site, TNM staging, diverting stoma, neo-adjuvant therapy, total mesorectal excision (TME) grading and positive resection margins (R1) were compared. p values less than or equal to 0.05 were considered statistically significant. Results Ninety colorectal cancer resections were performed with curative intent from June 2018 to June 2020. Thirty robotic colorectal cancer resections (RCcR) were performed after adaption of programme and were compared with 60 non-robotic colorectal cancer resections (N-RCcR) prior to implementation of technique. There was no conversion in the RCcR group; however, in N-RCcR group, five had open resection from start and the rest had laparoscopic surgery. In laparoscopic group, there were six (10.9%) conversions to open (two adhesions, three multi-visceral involvements, one intra-operative bleed). Male-to-female ratio was 20:09 in RCcR group and 33:20 in N-RCcR groups. No significant differences in gender (p = 0.5), median age (p = 0.47), BMI (p = 0.64) and ASA scores (p = 0.72) were present in either groups. Patient characteristics between the two groups were comparable aside from an increased proportion of rectal and sigmoid cancers in RCcR group. Mean operating time, and returns to theaters were comparable in both groups. Complications were fewer in RCcR group as compared to N-RCcR (16.6% vs 25%). RCcR group patients have reduced length of stay (5 days vs 7 days) but this is not statistically significant. Estimated blood loss and conversion to open surgery was significantly lesser in the robotic group (p < 0.01). The oncological outcomes from surgery including TNM, resection margin status, lymph node yield and circumferential resection margin (for rectal cancers) were all comparable. There was no 30-day mortality in either group. Conclusion Implementation and integration of robotic colorectal surgery is safe and effective in a busy tertiary center through a structured training programme with comparable short-term survival and oncological outcomes during learning curve.

Survey Regarding Gastrointestinal Stoma Construction and Closure in Japan

“… 24 Furthermore, these complications and risks are different in robot‐assisted surgery. 25 , 26 Robot‐assisted surgery has also been reported to have a higher rate of stoma construction than non‐robot‐assisted surgery. 25 In Japan, robotic‐assisted surgery in the lower rectum has been covered by the national health insurance since 2018.…”

“… 25 , 26 Robot‐assisted surgery has also been reported to have a higher rate of stoma construction than non‐robot‐assisted surgery. 25 In Japan, robotic‐assisted surgery in the lower rectum has been covered by the national health insurance since 2018. Therefore, future studies should consider robotic‐assisted surgery and other types of surgery.…”

RoCS: Robotic Curriculum for young Surgeons

“…The literature search of curricular programs for robotic visceral surgery provided a total of 74 results after removal of duplicates. Of these, 17 studies were identified which included description of curricular teaching structures for robotic visceral surgery [2,4,12,14,16,[31][32][33][34][35][36][37][38][39][40][41][42][43] (Table 3). The relevant studies were screened regarding authors, journal and year of publication, personnel participation, simulator training, bedside assistance, console training, referring operations or organ systems, curricular phases or time periods, connection to residents' post-graduate year or any other connection to surgical experience and evaluation methods (Table 3).…”

“…The case numbers of robotic operations have been increased exponentially over the last two decades [1][2][3] and new robotic systems emerge to the market [3]. Currently the robotic systems are designed for surgeons with advanced and/or expert surgical skills, e.g., colorectal surgeons [4]. Nevertheless, the procedures will become more and more an integral part of daily routine [5].…”

Supporting laparoscopic general surgery training with digital technology: The United Kingdom and Ireland paradigm

“…Robotic surgery additionally facilitates easy recording of intraoperative video and the publication of video datasets [93], which has supported the development of AI networks to recognise fine granularity movement of robotic instruments for surgical skills assessment [94]. In the UK and Ireland robotic UGI and colorectal surgery gains popularity, and is successfully being implemented in appropriate centres following mentored training [95,96].…”