Meta analysis of robot-assisted versus conventional laparoscopic fundoplication in children

Background

Minimally invasive fundoplication may be performed using either a robot-assisted (RF) or conventional laparoscopic (LF) technique. Evidence comparing RF and LF in children remains unclear. This study aims to elucidate the comparative safety and efficacy of RF versus LF by systematic review and meta-analysis.

Methods

Comparative studies investigating RF versus LF in children were identified from multiple electronic literature databases. Meta-analysis was performed using random effects modeling. Safety parameters investigated were post-operative morbidity and intra-operative conversions. Efficacy outcomes of interest were operative success, re-operation, post-operative complications, length of hospital stay (LOS), total operating time (OT), analgesia requirement, and cost.

Results

Six observational studies met inclusion criteria, reporting outcomes of 297 children. No randomized controlled trials were identified. Pooled analysis determined no statistically significant differences between RF and LF for conversions, OT, LOS, and post-operative complications. There was no standardized follow up beyond the early post-operative period to enable data synthesis for remaining outcomes of interest. Limited evidence indicates higher costs with RF.

Conclusions

Safety and short-term efficacy seem comparable between RF and LF in children. There is insufficient evidence to assess comparative effectiveness for many important procedure specific outcome measures. Higher quality and longer follow-up studies are required.     

Learning curves of robot-assisted laparoscopic surgery compared with conventional laparoscopic surgery: an experimental study evaluating skill acquisition of robot-assisted laparoscopic tasks compared with conventional laparoscopic tasks in inexperienced users

BACKGROUND: Laparoscopic surgery can be demanding, resulting in longer operating time and a longer time before reaching proficiency compared with open surgery. Robotic assistance allows stereoscopic vision and improves dexterity, potentially leading to faster and safer laparoscopic surgery and a shortening of the learning curve. METHODS: Duration and accuracy were measured in inexperienced participants, performing basic and advanced laparoscopic tasks using both conventional laparoscopy and the daVinci Surgical System. RESULTS: Eight participants performed 176 laparoscopic tasks. Robotic assistance resulted in faster and more accurate performance of laparoscopic tasks. However, conventional laparoscopy showed faster skill acquisition. CONCLUSIONS: Robotic assistance resulted in faster and more accurate performance of laparoscopic tasks. However, learning curves favored conventional laparoscopy. These data suggest robotic assistance might be most beneficial in inexperienced subjects. The relatively flat learning curve in robot-assisted laparoscopy suggests robotic assistance might be less (or marginally) beneficial in experienced surgeons. This could explain why robotic assistance has failed to show clear benefit in several clinical studies. Extensive conventional laparoscopic training might lead to faster, safer, and less expensive surgery, further marginalizing the role for robotic assistance in laparoscopic surgery.     

机器人辅助与传统腹腔镜行肝切除术效果比较的Meta分析

目的 通过系统评价,比较机器人辅助与传统腹腔镜肝切除术治疗肝脏肿瘤的效果.方法 计算机检索PubMed、Elsevier、Springer、Cochrane图书馆、CNKI、重庆维普和万方数据库,收集手术机器人与腹腔镜行肝脏切除术的随机或非随机对照研究,由两名研究者根据纳入与排除标准进行筛选文献、提取资料并评价质量后,采用RevMan5.3软件进行Meta分析.结果 最终纳入11个非随机对照研究,共890例病人.其中,行机器人辅助腹腔镜肝切除术268例,传统腹腔镜肝切除术622例.Meta分析结果显示:机器人辅助组较传统腹腔镜组手术时间更长[MD=46.40,95％CI(18.17,74.63),P=0.001],术中出血量更多[MD=78.70,95％CI(19.18,138.22),P=0.01],但两组病人的平均住院日、中转开腹率、并发症发生率、3个月生存率及3年生存率差异均无统计学意义.结论 机器人系统在肝脏手术中是安全可行的,与传统腹腔镜相比,虽然其手术时间更长,术中出血量更多,但是在平均住院日、中转开腹率、并发症发生率、3个月生存率及3年生存率等方面两者无明显差异.鉴于纳入研究较少,样本量小,且文献质量受限,各研究评价方法变异性较大,所以上述结论仍需多中心、大样本量并且高质量的随机对照研究进一步验证.     

Stapled versus hand-sewn vascular anastomoses. An experimental study in the rabbit

OBJECTIVE: Narrowing of vascular anastomoses is a frequently encountered surgical problem, with intimal hyperplasia being one of its most important causes. The aim of the present study was to compare in a rabbit model 'manual' (hand-sewn) with 'stapled' anastomoses (using a staple device) with respect to occurrence and severity of intimal hyperplasia. MATERIALS AND METHODS: Twenty-four male rabbits (mean weight 2,849 g) were randomly allocated to one of two groups (n = 12). An end-to-end anastomosis of the left femoral artery was performed in all animals under general anesthesia. The anastomosis was hand sewn in group 1, while a vascular closure stapler (VCS) was used in group 2. Both anastomotic time and total operation time were recorded. After 28 days, the rabbits were sacrificed. The femoral artery of operated and nonoperated sides were removed and prepared for anatomopathological examination. The I/M ratio (= difference between tunica intima and tunica media) was determined on hematoxylin-eosin stained slides. All results were analyzed using Student's t test. RESULTS: Mean anastomotic times were 25 +/- 7 min for the 'manual' group and 17 +/- 9 min for the 'stapled' group (p = 0.02). There was no significant difference in the total operation time (55 +/- 15 vs. 41 +/- 18 min, p = 0.057). All animals survived the anastomosis procedure. In the group of 'manual' anastomosis, morbidity was significantly higher. At the moment of sacrifice, all anastomoses were patent. There was no difference in the I/M ratio between the groups. CONCLUSIONS: The use of VCS is a promising alternative to hand-sewn anastomoses. It takes less time to perform a stapled anastomosis, the technique has a shorter learning period and morbidity seems to be lower when vascular anastomoses are applied with the VCS in this rabbit model.     

Meta-analysis of robot-assisted versus conventional laparoscopic Nissen fundoplication for gastro-oesophageal reflux disease

Background: Conventional laparoscopic Nissen fundoplication (CLF) is generally considered the surgical approach of choice for gastro‐oesophageal reflux disease. Robotic‐assisted laparoscopic fundoplication (RALF) has recently been introduced into laparoscopic clinical practice with the aim of improving surgical performance by eliminating tremors and fatigue. A meta‐analysis of randomized clinical trials (RCTs) was performed to compare RALF and CLF. Methods: Medline, Embase, ISI Web of Knowledge CPCI‐S and The Cochrane Library were searched and the methodological quality of included trials was evaluated. Outcomes evaluated were intraoperative, dysphagia, flatulence, antisecretory medication, satisfaction with intervention, operation time, hospital stay and total cost. Results were pooled in meta‐analyses as risk ratios and weighted mean differences (WMD). Results: Of 221 patients in six RCTs, 111 were allocated to CLF and 110 to RALF. RALF prolonged total time necessary to carry out fundoplication (WMD 3.17 (95% confidence interval. 2.33–4.00) min; P < 0.00001, χ²P = 0.25, I² = 24%). Operation complication, antisecretory medication, satisfaction with intervention, the time needed for hiatal dissection, the time from incision to completion of sutures, the total operation time and total cost were similar in both groups. Conclusion: Clinical outcomes from RALF were comparable to CLF approach, but RALF prolonged the operation time. Currently, CLF should be routinely used as costs are lower.     

Comparison of endovascular and conventional vascular prostheses in an experimental infection model

Introduction: The causes and management of prosthetic graft infections have been extensively studied for conventional bypass grafts; however, the infectivity and therapy for endovascular graft infections are completely unknown. The aim of this study was to compare the biologic properties of infected aortic grafts when inserted by endoluminal or standard transabdominal techniques.Methods: Eighteen dogs underwent placement of polytetrafluoroethylene grafts in their infrarenal aortas either by an endovascular technique (8) or a standard interposition technique (10). Endovascular grafts were constructed from polytetrafluoroethylene (3 cm) and two balloon-expandable stents coaxially mounted onto a balloon catheter delivery system. The grafts were inserted through a left carotid arteriotomy under fluoroscopic control. Initially, seven grafts were infected with decreasing inocula of Staphylococcus aureus, starting at 10⁷ organisms per ml for 30 minutes and then rinsed briefly (10 seconds) in normal saline solution, until a 50% infective dose for the standard grafts was determined to be 10² organisms per ml. After this initial experiment, a second group of 11 dogs were compared at a concentration of 10² S. aureus per ml. Five dogs underwent endovascular repair, and six dogs had standard graft interpositions after an identical period of bacterial exposure. All grafts were removed at 2 weeks under sterile conditions and were submitted for quantitative culture analysis.Results: Three of the six dogs (50%) with standard grafts appeared to clear their infections, whereas only one of the five dogs (20%) with an endovascular graft was free of organisms at 14 days. This result was further manifested by statistically significant lower postmortem colony counts in the standard grafts (p < 0.01).Conclusions: The endoluminal position of the graft and its proximity to the arterial wall do not appear to provide protection against infection. These data suggest that if endovascular grafts become infected, they may be in a disadvantaged position for host defense mechanisms to be effective. (J Vasc Surg 1996;24;920-6.)     

Evaluation of conventional laparoscopic versus robot-assisted laparoscopic redo hiatal hernia and antireflux surgery: a cohort study

Surgery for refractory gastroesophageal reflux disease (GERD) and hiatal hernia leads to recurrence or persisting dysphagia in a minority of patients. Redo antireflux surgery in GERD and hiatal hernia is known for higher morbidity and mortality. This study aims to evaluate conventional versus robot-assisted laparoscopic redo antireflux surgery, with the objective to detect possible advantages for the robot-assisted approach. A single institute cohort of 75 patients who underwent either conventional laparoscopic or robot-assisted laparoscopic redo surgery for recurrent GERD or severe dysphagia between 2008 and 2013 were included in the study. Baseline characteristics, symptoms, medical history, procedural data, hospital stay, complications and outcome were prospectively gathered. The main indications for redo surgery were dysphagia, pyrosis or a combination of both in combination with a proven anatomic abnormality. The mean time to redo surgery was 1.9 and 2.0 years after primary surgery for the conventional and robot-assisted groups, respectively. The number of conversions was lower in the robot-assisted group compared to conventional laparoscopy (1/45 vs. 5/30, p = 0.035) despite a higher proportion of patients with previous surgery by laparotomy (9/45 vs. 1/30, p = 0.038). Median hospital stay was reduced by 1 day (3 vs. 4, p = 0.042). There were no differences in mortality, complications or outcome. Robotic support, when available, can be regarded beneficial in redo surgery for GERD and hiatal hernia. Results of this observational study suggest technical feasibility for minimal-invasive robot-assisted redo surgery after open primary antireflux surgery, a reduced number of conversions and shorter hospital stay.     

Esophagogastric anastomoses in rats--an experimental model.

Esophagectomy with esophagogastric anastomosis is not uncommonly complicated by anastomotic dehiscence. Although this is a major problem in clinical esophageal surgery, laboratory investigation of esophagogastric anastomotic wound healing has been hampered by the lack of a practical rodent model. Researchers have turned to large-animal experiments, or used various upper gastrointestinal pseudo-anastomotic techniques in rodents. None of these approaches has proved to be satisfactory. We report our technique of side-to-side esophagogastric anastomosis in the rat. Using this technique we have overcome the problems encountered in our earlier studies of esophagogastric anastomotic wound healing in the rat.     

30-day outcomes of robot-assisted versus conventional laparoscopic sleeve gastrectomy: First analysis based on MBSAQIP

Background

Sleeve gastrectomy (SG) is the most popular bariatric procedure in the United States. Although standardized, variation exists in how the staple line is managed. Robotic approaches to SG (RSG) are increasing, though benefits compared with the conventional laparoscopic approach (LSG) remain controversial.

机器人辅助和腹腔镜保留幽门胃切除术的初步对比

目的 观察机器人辅助和腹腔镜保留幽门胃切除术的手术安全性.方法 回顾性收集2019年1月至2021年6月在南京大学医学院附属鼓楼医院胃肠中心接受保留幽门胃切除术的13例病人的临床资料.按手术方式分为机器人手术组(4例)和腹腔镜手术组(9例),对病人的手术时间、术中失血、术后恢复情况、围手术期检验指标、术后并发症及手术病...     

Feasibility of robot-assisted laparoscopic surgery: an evaluation of 35 robot-assisted laparoscopic cholecystectomies

Laparoscopic surgery offers patients distinct benefits but is not without its disadvantages to surgeons in terms of maneuverability and visualization. Robotic telemanipulation systems were introduced with the objective of providing a solution to the problems in this field of surgery. The feasibility of robot-assisted surgery was assessed by performing 35 laparoscopic cholecystectomies with the da Vinci robotic system. Time necessary for system setup and operation was recorded, as were complications, technical problems, postoperative hospital stay, morbidity, and mortality. Thirty-four of 35 cholecystectomy procedures were completed laparoscopically with the da Vinci system. Technical problems occurred in three cases, resulting in one intraoperative complication (a minilaparotomy caused by the loss of an instrument part). Median hospitalization was 2 days. There were no postoperative deaths or morbidity within 30 days after surgery. System setup time decreased as the experience of the operating team increased. Operating times were comparable with those reported for standard laparoscopic cholecystectomy. Robot-assisted surgery was repeatedly proven as a safe and feasible approach to laparoscopic cholecystectomy.     

Comparative effectiveness of laparoscopic versus robot-assisted colorectal resection

Background

During the past 20 years, laparoscopy has revolutionized colorectal surgery. With proven benefits in patient outcomes and healthcare utilization, laparoscopic colorectal surgery has steadily increased in use. Robotic surgery, a new addition to colorectal surgery, has been suggested to facilitate and overcome limitations of laparoscopic surgery. Our objective was to compare the outcomes of robot-assisted laparoscopic resection (RALR) to laparoscopic resections (LAP) in colorectal surgery.

Methods

A national inpatient database was evaluated for colorectal resections performed over a 30-month period. Cases were divided into traditional LAP and RALR resection groups. Cost of robot acquisition and servicing were not measured. Main outcome measures were hospital length of stay (LOS), operative time, complications, and costs between groups.

Results

A total of 17,265 LAP and 744 RARL procedures were identified. The RALR cases had significantly higher total cost ($5,272 increase, p < 0.001) and direct cost ($4,432 increase, p < 0.001), significantly longer operating time (39 min, p < 0.001), and were more likely to develop postoperative bleeding (odds ratio 1.6; p = 0.014) than traditional laparoscopic patients. LOS, complications, and discharge disposition were comparable. Similar findings were noted for both laparoscopic colonic and rectal surgery.

Conclusions

RALR had significantly higher costs and operative time than traditional LAP without a measurable benefit.     

机器人辅助腹腔镜小儿肾盂成形术的护理模式探讨

目的:总结机器人辅助腹腔镜小儿肾盂成形术的护理流程,探讨机器人小儿泌尿手术的围手术期模式.方法:回顾性分析2014年5月～2017年7月于海军军医大学第一附属医院行机器人辅助腹腔镜肾盂成形术的26例患儿(男23例,女3例)的围手术期资料和护理管理情况,包括患者基本资料、手术时间、术中出血、术后住院时间和术后并发症等.结果:26例患儿机器人辅助腹腔镜手术均经腹腔顺利完成,无中转开腹手术,患儿年龄为(6.69±3.35)岁,手术时间为(183.19±81.463)min,术中出血量为(9.62±5.643)ml.术后平均住院时间为(4.85±?1.056)d.机器人摆放就位时间由30min缩短为15min,术后未发生任何因护理配合不当而出现的并发症.结论:机器人手术系统在小儿泌尿手术中具有创伤小、出血少、疗效好等优点.在机器人手术中护理人员应充分完善护理准备、提升护理配合质量、总结经验,确保形成系统、有效的可行护理管理模式.     

Randomized clinical trial of robot-assisted versus laparoscopic Nissen fundoplication

BACKGROUND: Several studies have shown the safety and feasibility of robot-assisted antireflux surgery but comparative data are lacking. METHODS: Fifty consecutive patients scheduled for laparoscopic antireflux surgery were randomized into two groups. Twenty-five patients underwent robot-assisted surgery and 25 standard laparoscopic fundoplication. All robot-assisted procedures were performed with the da Vinci Surgical System. RESULTS: There were no significant differences in age, sex, body mass or preoperative reflux pattern between the groups. Operating times were significantly longer for robot-assisted than standard laparoscopic operations (mean total operating time 131.3 versus 91.1 min, P < 0.001; skin-to-skin time 78.0 versus 63.5 min, P = 0.001). There was no conversion to open surgery. Conversion to standard laparoscopy was necessary in one of 25 robot-assisted procedures. The length of hospital stay was similar in both groups. Robot-assisted surgery was associated with significantly higher mean total costs (euro 3157 versus euro 1527; P < 0.001). There were no significant differences in clinical, endoscopic and functional outcomes between groups. There was no procedure-related mortality. CONCLUSION: Robot-assisted laparoscopic fundoplication is comparable to the standard laparoscopic procedure in terms of feasibility and outcome, but costs are higher owing to longer operating times and the use of more expensive instruments.     

经肛门拖出式腹腔镜与传统腹腔镜手术治疗直肠癌近期疗效差异的meta分析

目的比较经肛门拖出式腹腔镜手术与传统腹腔镜手术治疗直肠癌患者的近期疗效。方法检索2009年1月至2019年7月期间PubMed、Cochrane Library、Embase、中国知网、中国生物医学、万方、维普科技期刊等国内外数据库中发表的有关经肛门拖出式腹腔镜与传统腹腔镜手术治疗直肠癌疗效比较的文献,并严格按照纳入排除标准筛选合格的文献,利用Stata12.0软件进行统计学分析。结果共纳入文献19篇,包含直肠癌患者2 683例。meta分析结果显示,与传统腹腔镜组比较,经肛门拖出式腹腔镜组的手术时间缩短[WMD=–6.78,95%CI为(–11.96,–1.60),P<0.01]、术中出血量降低[WMD=–14.94,95%CI为(–23.48,–6.40),P<0.01]、术后肠道功能恢复时间提前[WMD=–13.55,95%CI为(–18.24,–8.85),P<0.01]、术后住院时间缩短[WMD=–1.60,95%CI为(–2.00,–1.21),P<0.01]、总并发症发生率降低[OR=0.50,95%CI为(0.38,0.67),P<0.01]且术后切口感染发生率降低[OR=0.19,95%CI为(0.08,0.45),P<0.01],而在淋巴结清扫数目[WMD=–0.02,95%CI为(–0.44,0.40),P=0.92]、切缘距肿瘤距离[WMD=0.13,95%CI为(–0.30,0.55),P=0.56]和吻合口漏发生率[OR=0.97,95%CI为(0.62,1.50),P=0.87]方面两者的差异无统计学意义。结论经肛门拖出式腹腔镜较传统腹腔镜手术对直肠癌的治疗更具低创性、安全性和可靠性,具有进一步推广及研究价值,但由于本研究纳入文献可能存在不可避免的偏倚等影响,故未来还需要更多的临床随机对照研究进一步探索。     

Imaging of experimental end-to-side anastomoses in a cast model.

OBJECTIVE: To evaluate cast models in the imaging of experimental end-to-side anastomoses. DESIGN: Experimental study. SETTING: Teaching hospital, Finland. INTERVENTIONS: 20 non-stenosed and 10 stenosed end-to-side anastomoses were constructed using a Dacron prosthesis 8 mm in diameter. Cast models were made of all anastomoses, and anteroposterior and oblique projection radiographs were taken of them. Cross-sectional radiographs were also taken of the stenosed anastomoses. MAIN OUTCOME MEASUREMENTS: The diameters and areas of anastomoses were measured on the radiographs and compared with the corresponding measurements of the casts. RESULTS: No filling defects were observed in any of the cast models and only minor differences were found between the corresponding measurements of the anteroposterior and oblique projection radiographs and casts. The lower density of the contrast medium in the stenotic anastomoses indicated a stenosis. In the cross-sectional radiographs of the stenotic anastomoses there was a significant reduction (p < 0.001) both in the diameter and the area, the mean of which was 63% and the median 61%. CONCLUSIONS: Radiographs of cast models look promising in imaging of experimental end-to-side anastomoses when cross-sectional projections are also used.