Control Comparison of the New EndoWrist and Traditional Laparoscopic Staplers for Anterior Rectal Resection with the Da Vinci Xi: A Case Study.

Background: A new robotic stapler for the da Vinci Xi® is directly controlled by the surgeon at the console and equipped with EndoWrist® technology. We evaluated operative and short-term results of the first patients who underwent anterior rectal resection for cancer with the da Vinci Xi and new staplers, and compared the results with those of a comparable group treated with traditional laparoscopic staplers. Methods: From December 2015 to December 2017, 25 patients underwent anterior rectal resection for cancer with robotic EndoWrist staplers (EndoWrist group). Using a case-control method, we compared the results with those of a similar group of patients treated with the same system and a traditional laparoscopic endostapler, controlled by a bedside assistant (Control group). Results: No conversions to laparoscopy or laparotomy were observed, in either group. The mean number of charges was 2.1 ± 0.2 in the EndoWrist group versus 2.7 ± 0.7 in the Control group (P = .0004). The other perioperative results were comparable. During follow-up, the incidence of anastomotic fistula in a contrast enema study was higher in the Control group, although the difference was not statistically significant (two leaks versus two leaks in EndoWrist group; P = .8). The interval between rectal resection and stoma closure was shorter in the EndoWrist group (3.4 ± 2.5 versus 4.2 ± 2.9 months in the Control group; P = .2), although the difference was not significant. Conclusions: Our experience suggests that the new robotic staplers simplify transection, which could reduce the average number of stapler firings used during rectal resection and could decrease the incidence of anastomotic leakage. These findings require confirmation in larger studies.

Robot-assisted total mesorectal excision for rectal cancer: case-matched comparison of short-term surgical and functional outcomes between the da Vinci Xi and Si.

BACKGROUND: Robotic rectal resection with da Vinci Si has some technical limitations, which could be overcome by the new da Vinci Xi. We compare short-term surgical and functional outcomes following robotic rectal resection with total mesorectal excision for cancer, with the da Vinci Xi (Xi-RobTME group) and the da Vinci Si (Si-RobTME group). METHODS: The first consecutive 30 Xi-RobTME were compared with a Si-RobTME control group of 30 patients, selected using a one-to-one case-matched methodology from our prospectively collected Institutional database, comprising all cases performed between April 2010 and September 2016 by a single surgeon. Perioperative outcomes were compared. The impact of minimally invasive TME on autonomic function and quality of life was analyzed with specific questionnaires. RESULTS: The docking and overall operative time were shorter in the Xi-RobTME group (p < 0.001 and p < 0.05 respectively). The mean differences of overall operative time and docking time were -33.8 min (95% CI -5.1 to -64.5) and -6 min (95% CI -4.1 to -7.9), respectively. A fully-robotic approach with complete splenic flexure mobilization was used in 30/30 (100%) of the Xi-RobTME cases and in 7/30 (23%) of the Si-RobTME group (p < 0.001). The hybrid approach in males and patients with BMI > 25 kg/m2 was necessary in ten patients (45 vs. 0%, p < 0.001) and in six patients (37 vs. 0%, p < 0.05), in the Si-RobTME and Xi-RobTME groups, respectively. There were no differences in conversion rate, mean hospital stay, pathological data, and in functional outcomes between the two groups before and at 1 year after surgery. CONCLUSION: The technical advantages offered by the da Vinci Xi seem to be mainly associated with a shorter docking and operative time and with superior ability to perform a fully-robotic approach. Clinical and functional outcomes seem not to be improved, with the introduction of the new Xi platform.

Full Robotic Colorectal Resections for Cancer Combined With Other Major Surgical Procedures: Early Experience With the da Vinci Xi.

BACKGROUND: The da Vinci Xi has been developed to overcome some of the limitations of the previous platform, thereby increasing the acceptance of its use in robotic multiorgan surgery. METHODS: Between January 2015 and October 2015, 10 patients with synchronous tumors of the colorectum and others abdominal organs underwent robotic combined resections with the da Vinci Xi. Trocar positions respected the Universal Port Placement Guidelines provided by Intuitive Surgical for "left lower quadrant," with trocars centered on the umbilical area, or shifted 2 to 3 cm to the right or to the left, depending on the type of combined surgical procedure. RESULTS: All procedures were completed with the full robotic technique. Simultaneous procedures in same quadrant or left quadrant and pelvis, or left/right and upper, were performed with a single docking/single targeting approach; in cases of left/right quadrant or right quadrant/pelvis, we performed a dual-targeting operation. No external collisions or problems related to trocar positions were noted. No patient experienced postoperative surgical complications and the mean hospital stay was 6 days. CONCLUSIONS: The high success rate of full robotic colorectal resection combined with other surgical interventions for synchronous tumors, suggest the efficacy of the da Vinci Xi in this setting.

Use of the new da Vinci Xi® during robotic rectal resection for cancer: a pilot matched-case comparison with the da Vinci Si®.

BACKGROUND: The aim of this study was to compare the short-term outcomes of robotic rectal resection with total mesorectal excision (TME) for rectal cancer, with the use of the new da Vinci Xi® (Xi-RobTME group) and the da Vinci Si® (Si-RobTME group). METHODS: Ten patients with histologically confirmed rectal cancer underwent robot-assisted TME with the use of the new da Vinci Xi. The outcomes of Xi-RobTME group were compared with a Si-RobTME group selected using a case-matched methodology. RESULTS: Overall operative times and mean hospital stays were shorter in the Xi-RobTME group. Surgeries were fully robotic with a complete take-down of the splenic flexure in all Xi-RobTME cases, while only four cases of the Si-RobTME group were fully robotic, with two cases of complete take-down of the splenic flexure. CONCLUSIONS: The new da Vinci Xi could offer some advantages with respect to the da Vinci Si in rectal resection for cancer. Copyright © 2016 John Wiley & Sons, Ltd.

Robot-assisted versus laparoscopic rectal resection for cancer in a single surgeon's experience: a cost analysis covering the initial 50 robotic cases with the da Vinci Si.

PURPOSE: The aim of this study is to compare surgical parameters and the costs of robotic surgery with those of laparoscopic approach in rectal cancer based on a single surgeon's early robotic experience. METHODS: Data from 25 laparoscopic (LapTME) and the first 50 robotic (RobTME) rectal resections performed at our institution by an experienced laparoscopic surgeon (>100 procedures) between 2009 and 2014 were retrospectively analyzed and compared. Patient demographic, procedure, and outcome data were gathered. Costs of the two procedures were collected, differentiated into fixed and variable costs, and analyzed against the robotic learning curve according to the cumulative sum (CUSUM) method. RESULTS: Based on CUSUM analysis, RobTME group was divided into three phases (Rob1: 1-19; Rob2: 20-40; Rob3: 41-50). Overall median operative time (OT) was significantly lower in LapTME than in RobTME (270 vs 312.5 min, p = 0.006). A statistically significant change in OT by phase of robotic experience was detected in the RobTME group (p = 0.010). Overall mean costs associated with LapTME procedures were significantly lower than with RobTME (p < 0.001). Statistically significant reductions in variable and overall costs were found between robotic phases (p < 0.009 for both). With fixed costs excluded, the difference between laparoscopic and Rob3 was no longer statistically significant. CONCLUSIONS: Our results suggest a significant optimization of robotic rectal surgery's costs with experience. Efforts to reduce the dominant fixed cost are recommended to maintain the sustainability of the system and benefit from the technical advantages offered by the robot.

Use of a novel multi-purpose sponge for laparoscopic surgery: Does it have special relevance to robotically-assisted laparoscopic surgery?

BACKGROUND: The STAR System (Ekymed SpA) is a novel multipurpose sponge developed for conventional manual laparoscopic surgery. MATERIALS AND METHODS: Between December 2012 and December 2014, we successfully used the sponge in ten robot-assisted and ten direct manual laparoscopic operations to achieve haemostasis, for blunt dissections, for atraumatic lifting of solid organs, to check for bile leaks, for cleaning the surgical field thus avoiding frequent use of suction or the application of haemostatic agents. The reason of the insertion (RI), the main use (MU) and any further use (FU), once inserted, were registered for each operation and compared between the two groups. RESULTS: The principal RI was haemostasis for minor bleeding, without differences between the two groups (P = not significant). Regard to MU, in the robotic group cleaning the surgical field was utilised more than laparoscopic group (100% vs. 60%; P = 0.03). About FU, atraumatic solid organs lifting was more frequent during robotically assisted surgery than with laparoscopy (50% vs. 0%; P = 0.01). A statistically more frequent use of the sponge was registered during standard laparoscopy for the blunt dissection (30% vs. 80%; P = 0.03). CONCLUSIONS: The STAR System was beneficial in both approaches, but it imparts added benefit during robotically-assisted laparoscopic surgery organs because of the lack of tactile feedback and because the operating surgeon is remote from the patient, and has to rely on the assisting surgeon in the sterile field for dealing with bleeding episodes, cleansing/mopping the operative field when necessary, who may not be experienced or completely proficient.

Robotic surgery and hemostatic agents in partial nephrectomy: a high rate of success without vascular clamping.

Robot-assisted partial nephrectomy has been proposed as a technique to overcome technical challenges of laparoscopic partial nephrectomy. We prospectively collected and analyzed data from 31 patients who underwent robotic partial nephrectomy with systematic use of hemostatic agents, between February 2009 and October 2014. Thirty-three renal tumors were treated in 31 patients. There were no conversions to open surgery, intraoperative complications, or blood transfusions. The mean size of the resected tumors was 27 mm (median 20 mm, range 5-40 mm). Twenty-seven of 33 lesions (82%) did not require vascular clamping and therefore were treated in the absence of ischemia. All margins were negative. The high partial nephrectomy success rate without vascular clamping suggests that robotic nephron-sparing surgery with systematic use of hemostatic agents may be a safe, effective method to completely avoid ischemia in the treatment of selected renal masses.

Hand-assisted hybrid laparoscopic-robotic total proctocolectomy with ileal pouch--anal anastomosis.

PURPOSE: Few studies have reported minimally invasive total proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). We herein report a novel hand-assisted hybrid laparoscopic-robotic technique for patients with FAP and UC. METHODS: Between February 2010 and March 2014, six patients underwent hand-assisted hybrid laparoscopic-robotic total proctocolectomy with IPAA. The abdominal colectomy was performed laparoscopically with hand assistance through a transverse suprapubic incision, also used to fashion the ileal pouch. The proctectomy was carried out with the da Vinci Surgical System. The IPAA was hand-sewn through a trans-anal approach. The procedure was complemented by a temporary diverting loop ileostomy. RESULTS: The mean hand-assisted laparoscopic surgery (HALS) time was 154.6 (±12.8) min whereas the mean robotic time was 93.6 (±8.1) min. In all cases, a nerve-sparing proctectomy was performed, and no conversion to traditional laparotomy was required. The mean postoperative hospital stay was 13.2 (±7.4) days. No anastomotic leakage was observed. To date, no autonomic neurological disorders have been observed with a mean of 5.8 (±1.3) bowel movements per day. CONCLUSIONS: The hand-assisted hybrid laparoscopic-robotic approach to total proctocolectomy with IPAA has not been previously described. Our report shows the feasibility of this hybrid approach, which surpasses most of the limitations of pure laparoscopic and robotic techniques. Further experience is necessary to refine the technique and fully assess its potential advantages.

Robotic giant hiatal hernia repair: 3 year prospective evaluation and review of the literature.

BACKGROUND: While conventional laparoscopic repair for giant hiatal hernias is considered difficult, robotic technology is likely to result in an improved postoperative course. METHODS: We prospectively analysed patients with giant hiatal hernias who underwent robotic repair during a 3 year period. Preoperative data, operative variables, complications, clinical outcomes and anatomical recurrence after 1 year were evaluated. RESULTS: Six patients with giant hiatal hernias underwent robotic repair using the Da Vinci surgical system. The mean operative time was 182 min. The mean hospital stay was 6 days. No patients required reoperation for disease recurrence, and all claimed the absence of postoperative symptoms. CONCLUSIONS: Robotic approaches can minimize surgical trauma in patients with giant hiatal hernias and result in favourable outcomes in terms of anatomical recurrence and quality of life. With the availability of the da Vinci System, all patients with giant hiatal hernias can be offered a minimally invasive surgical option.