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      Robot-assisted laparoscopic surgery versus conventional laparoscopic surgery in randomized controlled trials: A systematic review and meta-analysis

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          Abstract

          Importance

          This review provides a comprehensive comparison of treatment outcomes between robot-assisted laparoscopic surgery (RLS) and conventional laparoscopic surgery (CLS) based on randomly-controlled trials (RCTs).

          Objectives

          We employed RCTs to provide a systematic review that will enable the relevant community to weigh the effectiveness and efficacy of surgical robotics in controversial fields on surgical procedures both overall and on each individual surgical procedure.

          Evidence review

          A search was conducted for RCTs in PubMed, EMBASE, and Cochrane databases from 1981 to 2016. Among a total of 1,517 articles, 27 clinical reports with a mean sample size of 65 patients per report (32.7 patients who underwent RLS and 32.5 who underwent CLS), met the inclusion criteria.

          Findings

          CLS shows significant advantages in total operative time, net operative time, total complication rate, and operative cost ( p < 0.05 in all cases), whereas the estimated blood loss was less in RLS ( p < 0.05). As subgroup analyses, conversion rate on colectomy and length of hospital stay on hysterectomy statistically favors RLS ( p < 0.05).

          Conclusions

          Despite higher operative cost, RLS does not result in statistically better treatment outcomes, with the exception of lower estimated blood loss. Operative time and total complication rate are significantly more favorable with CLS.

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          Most cited references52

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          Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections.

          To provide a multidimensional analysis of the learning curve in major laparoscopic colonic and rectal surgery and compare outcomes between right-sided versus left-sided resections. The laparoscopic learning curve is known to vary between surgeons, may be influenced by the patient selection and operative complexity, and requires appropriate case-mix adjustment. This is a descriptive single-center study using routinely collected clinical data from 900 patients undergoing laparoscopic surgery between November 1991 and April 2003. Outcome measures included operation time, conversion rate (CR), and readmission and postoperative complication rates. Multifactorial logistic regression analysis was used to identify patient-, surgeon-, and procedure-related factors associated with conversion of laparoscopic to open surgery. A risk-adjusted Cumulative Sum (CUSUM) model was used for evaluating the learning curve for right and left-sided resections. The conversion rate for right-sided colonic resections was 8.1% (n = 457) compared with 15.3% for left-sided colorectal resections (n = 443). Independent predictors of conversion of laparoscopic to open surgery were the body mass index (BMI) (odds ratio [OR] = 1.07 per unit increase), ASA grade (OR = 1.63 per unit increase), type of resection (left colorectal versus right colonic procedures, OR = 1.5), presence of intra-abdominal abscess (OR = 5.0) or enteric fistula (OR = 4.6), and surgeon's experience (OR 0.9 per 10 additional cases performed). Having adjusted for case-mix, the CUSUM analysis demonstrated a learning curve of 55 cases for right-sided colonic resections versus 62 cases for left-sided resections. Median operative time declined with operative experience (P<0.001). Readmission rates and postoperative complications remained unchanged throughout the series and were not dependent on operative experience. Conversion rates for laparoscopic colectomy are dependent on a multitude of factors that require appropriate adjustment including the learning curve (operative experience) for individual surgeons. The laparoscopic model described can be used as the basis for performance monitoring between or within institutions.
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            Randomized clinical trial of robot-assisted versus standard laparoscopic right colectomy.

            Robotic surgery was invented to overcome the demerits of laparoscopic technique. However, it is unclear whether robot-assisted colectomy (RAC) has significant clinical advantages over laparoscopically assisted colectomy (LAC) in treating colonic cancer. The aim of this study was to compare the surgical outcomes of RAC versus LAC for right-sided colonic cancer. Patients with right-sided colonic cancer were randomized to receive RAC or LAC. The primary outcome measure was length of hospital stay. Secondary outcomes were duration of operation, morbidity, postoperative pain, hospital costs and pathological quality of the specimen. Of 71 patients randomized, 70 (35 in each group) were included in the analysis. Hospital stay, surgical complications, postoperative pain score, resection margin clearance and number of lymph nodes harvested were similar in both groups. The duration of surgery was longer in the RAC group (195 versus 130 min; P < 0·001). No conversion to open surgery was needed in either group. Overall hospital costs were significantly higher for RAC (US $ 12,235 versus $ 10,320; P = 0·013); the higher costs were attributed primarily to the costs of surgery, including consumables. Robotic-assisted laparoscopic right colectomy was feasible but provided no benefit to justify the greater cost. NCT01042743 (http://www.clinicaltrials.gov). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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              Robotic tumor-specific mesorectal excision of rectal cancer: short-term outcome of a pilot randomized trial.

              Laparoscopic colorectal resection has become popular. The recently developed da Vinci Surgical System promises to facilitate endoscopic surgery and overcome its disadvantages. This study therefore aimed to compare the short-term results between robotic tumor-specific mesorectal excision (R-TSME) using the da Vinci Surgical System and conventional laparoscopic tumor-specific mesorectal excision (L-TSME) in rectal cancer patients. Between April 2006 and February 2007, 36 patients were randomly assigned to receive R-TSME or L-TSME. During the study, 18 patients underwent robotic low anterior resection using the da Vinci Surgical System, and 18 patients had conventional laparoscopic low anterior resection. Patient characteristics, perioperative clinical results, complications, and pathologic details were compared between the two groups. The patient characteristics were not significantly different between the two groups. The mean operating time, hemoglobin change, and conversion rate were not significantly different between the groups. Complications were treated conservatively and did not require surgical intervention in the R-TSME group. The average length of stay was 6.9 +/- 1.3 days in the R-TSME group and 8.7 +/- 1.3 days in the L-TSME group (p < 0.001). The specimen quality of the R-TSME group was acceptable. Tumor-specific mesorectal excision was performed safely and effectively using the da Vinci Surgical System and the perioperative outcomes were acceptable.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: ResourcesRole: SoftwareRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: Project administrationRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                23 January 2018
                2018
                : 13
                : 1
                : e0191628
                Affiliations
                [1 ] Department of Biomedical Science, Hanyang University College of Medicine and Graduate School of Biomedical Science and Engineering, Seoul, Korea
                [2 ] Department of Thoracic and Cardiovascular Surgery, Hanyang University Guri Hospital, Guri, Gyunggi, Korea
                [3 ] Department of Microbiology and Biomedical Science, Hanyang University College of Medicine and Graduate School of Biomedical Science and Engineering, Seoul, Korea
                National Academy of Medical Sciences, NEPAL
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0002-6506-7519
                Article
                PONE-D-17-24232
                10.1371/journal.pone.0191628
                5779699
                29360840
                db56a856-5853-40d2-8554-5f65255a7635
                © 2018 Roh et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 27 June 2017
                : 14 December 2017
                Page count
                Figures: 3, Tables: 0, Pages: 12
                Funding
                Funded by: The Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (MEST), Republic of Korea.
                Award ID: NRF-2015R1D1A1A01058565
                Award Recipient :
                We state that the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Please note that this research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (MEST) (NRF-2015R1D1A1A01058565), Republic of Korea. The role of the National Research Foundation ( http://www.nrf.re.kr/eng/main) is to promote an independent research to benefit basic science research. In this regard, we state that any individual, other than the three authors, and the funder had no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript.
                Categories
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                Surgical and Invasive Medical Procedures
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                Engineering and Technology
                Mechanical Engineering
                Robotics
                Medicine and Health Sciences
                Surgical and Invasive Medical Procedures
                Laparoscopy
                Medicine and Health Sciences
                Surgical and Invasive Medical Procedures
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                All relevant data can be found in the paper, its supplemental files, and protocol.io ( http://dx.doi.org/10.17504/protocols.io.k7ucznw).

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