Role of robotic approach in ileal pouch–anal anastomosis (IPAA): A systematic review of the literature

Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) has become standard surgical treatment of choice in patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP) in which the medical management fails. Despite the wide use of laparoscopic method, the enhanced and innovative features that come with the robotic platform, such as endo-wrist technology, 3D visualization, surgeon-controlled camera and motion scaling, make it an appealing choice. This study aims to investigate the feasibility and safety of robotic approach for proctectomy or proctocolectomy with IPAA as compared to conventional laparoscopic approach. A systematic review was completed for studies done between 2010 and 2022 comparing the robotic approach with the laparoscopic approach. Nine studies were found to be feasible to be included in this review. In terms of the outcomes, although the mean operating time was slightly higher than the laparoscopic approach, the other outcomes, such as mean blood loss, return of the bowel movement, mean hospital stay, and conversion to open, were found to be significantly lower in the robotic approach as compared to both laparoscopic and conventional open techniques. Despite the overall increased rate of complications combined from all the studies, the rate of significant complications such as anastomotic leaks requiring readmission and return to theater was also found to be substantially less. This study concludes that although robotic approach is in its initial stages for pelvic surgeries, it can be safely employed due to improved dexterity and visibility.


Introduction
In patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP) refractory to medical management, restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become standard surgical treatment of choice [1,2]. It is not only an effectively curative procedure, without requiring the need for permanent stoma but also limits cancer in these patients.
Despite the fact that the laparoscopic method is widely used for IPAA, with the advent of innovative technologies and techniques, robotic platform is now becoming a potentially new technique for minimal-invasive surgery. Endowrist technology, surgeon-controlled camera equipped with three-dimensional visualization and motion scaling with tremor reduction leading to better dexterity during operation are some of the enhanced features that can make robotic surgery an attractive option [3]. The typically younger group of patients undergoing proctectomy and IPAA may gain the most from developments in minimally invasive surgery, such as quicker recuperation and thus return to work, decreased morbidity and lower healthcare costs. The other advantage is better visualization in the pelvis due to 3D technology to avoid damage to pelvic nerves which leads to urogenital dysfunction [4]. Despite this, there are just a few accounts 1 3 of robotic IPAA operations in the literature. The purpose of this study is to perform a systematic review of the published literature to assess the safety and feasibility of robotic restorative proctocolectomy.
This literature review investigates proctectomy or proctocolectomy with IPAA utilizing the robotic platform and identifies the safety of robotic approach in terms of primary outcomes which include mortality, anastomotic leakage, ileus, operating times, estimated blood loss, conversion to open, postoperative stay in the hospital and rates of readmission, first bowel motion after the surgery, re-procedure and quality of life.

Results
Forty-three studies were selected for screening after an initial search revealed 112 papers and after duplicates were removed as an additional 20 papers were excluded in the screening and 23 papers were found to be eligible for a complete review. Nine papers met inclusion criteria.
The papers were excluded on the basis of following reasons: case reports, case series containing less than 4 patients, video vignettes, and review articles mainly related to open and laparoscopic surgeries for inflammatory bowel disease. These findings have been summarized in the PRISMA flow chart in Fig. 1.
In total, 271 patients underwent a robotic proctectomy + /− colectomy and IPAA. The indication for operation in majority of the patients was ulcerative colitis and indeterminate colitis, except for Crohn's disease in 4 patients, familial adenomatous polyposis in 11 patients and reasons unspecified in 2 patients. The study characteristics have been summarized in Table 1.

Discussion
This systematic analysis included 9 papers that evaluated findings in 271 individuals with inflammatory bowel disease after robotic IPAA. Although all the studies were non-randomized trials, one of the studies included also evaluated the significance of robotic approach in the children [5].
The main outcomes are summarized in Table 2. The mean operation timing ranged from 235 to 380 min across various studies. Compared to a mean timing range of 234-316 min for laparoscopic, and a mean of 130 min for open procedures, as concluded by a systematic analysis put forth by Flynn et al. in 2021, this statistically significant higher average time for robotic technique could be attributed to it being a relatively 'initial' evolving experience for many of surgeons and time required during the docking and undocking of the robots [14,23].
The range of estimated mean blood loss for robotic cases was 50.3 to 360 ml, with two studies reporting median blood loss of 65 ml and 75 ml. Lightner et al. found that the median figure for estimated blood loss for robotic surgery in his comparative study (75 ml) was lower compared to a median of 100 ml for laparoscopic surgery, with the difference being statistically significant [7]. A similar statistically significant comparison was made by Marino et al. who also reported the reduction of estimated blood loss (179 vs. 288 ml) [9]. However, Rencuzogallari et al. reported a higher estimated blood loss as compared to the laparoscopic group [10].
In the three papers where return of bowel motion was reported, a range of 1 to 3 days was noted. Rencuzogallari et al.'s comparative study showed that a similar value (mean of 2.79 days) for laparoscopic was calculated, and thus, the difference was not found out to be statistically significant [11].
Estimated hospital stay was noted for all these studies. The range for means was 7.85 to 9.1 days, whereas smaller medians were recorded for most studies as depicted in Table 2  9.5% and 11% of the cases had to be converted to open for two of such studies. 0% conversion rates were recorded for the rest while one paper did not record this outcome.
The complications related to the robotics approach have been summarized in Table 3. Although the overall complication rate found in this literature review was more than some of the studies reporting laparoscopic rectal dissection in patients with IBD, the rate of reported significant complications such as anastomotic leaks requiring readmission and return to theater was significantly lower than all of the studies [15][16][17][18][19][20][21][22]. One literature review comparing the robotic versus laparoscopic ileal pouch-anal anastomosis showed a leak/pelvic sepsis rate of 20% and a readmission rate of 18% for the laparoscopic cases and Mark-Christensen et al. reported a readmission rate of 26% for the open cases which is far higher than the findings in this analysis [23].

Conclusion
This study concludes that overall better dexterity and visualization specifically in the narrow space of pelvis render the procedure safe and without any significant complications. As compared to the conventional open and laparoscopic approaches, robotic approach is in its infancy and therefore, has a lot of room for improvement in terms of techniques and technology.