Robotic-assisted intracorporeal versus extracorporeal techniques in sigmoidectomy: a propensity score- matched analysis

doi:10.21203/rs.3.rs-3125154/v1

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Research Article

Robotic-assisted intracorporeal versus extracorporeal techniques in sigmoidectomy: a propensity score- matched analysis

https://doi.org/10.21203/rs.3.rs-3125154/v1

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Journal Publication

published 29 Jul, 2023

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Background

Scarce research has been performed to assess the safety and efficacy of anastomosis technique on robotic-assisted sigmoidectomy. This study was designed to evaluate the difference between intracorporeal and extracorporeal techniques during robotic-assisted sigmoidectomy.

Methods

Clinical data of 193 cases who received robotic-assisted sigmoidectomy were retrospectively collected and analyzed. Only 116 cases were available for analysis (intracorporeal group = 58, extracorporeal group = 58) after propensity score matching. Independent sample t-test was conducted to evaluate the continuous variables. Moreover, the statistical significance of categorical variables was tested using Chi-square or Fisher exact tests.

Results

Statistical analysis showed that the intracorporeal group demonstrated greater superiorities in pain scale on the first and second postoperative day (P < 0.05), time of catheter indwelling (P = 0.009) and length of hospital stay (P = 0.019). Additionally, the intracorporeal technique contributed to fewer complications including urinary retention (P = 0.027) and hernia (P = 0.037) than the extracorporeal group.

Conclusions

Our analysis revealed that intracorporeal technique was safe and feasible due to the shorter time of catheter indwelling and length of hospital stay and fewer post-operation complications.

Robotic

Sigmoidectomy

Intracorporeal anastomosis

Extracorporeal anastomosis

Since Philip A[1] performed the first robotic-assisted laparoscopic sigmoidectomy in 2002, the application of robotics in colorectal surgery has evolved rapidly. Additionally, the robotic systems, especially the Vinci Ⅰ version in performing abdominal surgery, are considered as a substitute alternative to standard laparoscopic surgery[2, 3]. Kim et al.[4] suggested that robot-assisted may provide a better therapeutic effect than laparoscopy in total mesorectal excision, especially in middle and low rectum cancer.

In colorectal surgery, intracorporeal anastomosis (IA) and extracorporeal anastomosis (EA) are implemented to reconstruct intestinal tract[5]. Compared to the IA technique, the EA requires mobilizing the small intestine and colon and pulling on the mesentery as the bowel is withdrawn, which theoretically leads to more surgical injury[6–8]. Recent studies have demonstrated that the robotic-assisted intracorporeal anastomosis technique offers distinct advantages over the robotic-assisted intracorporeal anastomosis technique in right hemicolectomy[9–12]. Patients who underwent IA approach had shorter recovery time in gastrointestinal function, shorter length of hospital stay, and fewer complications compared to those who received EA technique [11, 12]. Regrettably, limited literature focused on the difference between IA and EA approaches in robotic-assisted sigmoidectomy. This study is aim to evaluate the difference between the two techniques in safety and efficacy during robotic-assisted sigmoidectomy.

Patient Selection

This study was a retrospective study that summarized perioperative data between January 2020 to May 2023. Patients were diagnosed with sigmoid colon cancer by colonoscopy biopsy before undergoing robotic-assisted sigmoidectomy. Patients were enrolled according to the following criteria: (1) The preoperative pathology confirmed the diagnosis of sigmoid colon cancer. (2) Patients did not undergo preoperative radiotherapy or chemotherapy. (3) The operation was robotic sigmoidectomy without conversion to laparotomy or open. Overall, 193 patients were enrolled in, of which 58 cases were treated with the intracorporeal anastomosis technique and 58 cases were treated with the extracorporeal anastomosis technique. The choice of surgical method depends on the preference and experience of surgeon and the comprehensive condition of the tumor and patient. The emotional consent was required from each patient before surgery. This study was approved by the Ethics Committee of Northern Jiangsu People's Hospital.

Surgical technique

All patients underwent robotic-assisted sigmoidectomy and selective splenic flexure mobilization, followed by tension-free anastomosis. IA technique: Robot was applied to mobilize the sigmoid colon and the upper segment of rectum, and dissect the D3 lymph node simultaneously. Robotic motion arms were used to depart the descending colon with 10–15 cm away from the proximal end of the tumor, and the upper rectum with 5cm away from the distal end of the tumor using a linear stapler. Then, an incision was cut for extracting the specimen near the left middle abdomen. The anastomosis was constructed in the anastomosis way of side-of-the-colon to side-of-the-upper rectum with a 60 mm linear linear stapler, after drilling a 5mm hole in the proximal colon 5cm away from the closure line. The specimen was then extracted from the incision near the left middle abdomen. Finally, all incisions were sutured after the anastomotic stoma was confirmed free of anastomotic leakage and bleeding.

EA technique: Robot was applied to mobilize the sigmoid colon and the upper rectum, and dissect the D3 lymph node simultaneously. An incision was cut near the left middle abdomen, removing the sigmoid colon from the abdominal cavity. Robotic motion arms were used to depart the descending colon with 10–15 cm away from the proximal end of the tumor, and the upper rectum with 5cm away from the distal end of the tumor using a closure line. The anastomosis was then constructed in the anastomosis way of end-of-the-proximal colon to side-of-the-distal colon. Next, the colon was placed back into the abdominal cavity after closing the colonic stump and getting the anastomotic stoma checked free of anastomotic leakage and bleeding. Finally, all incisions were sutured.

Data collection

For each case, baseline characteristics include age, sex, BMI (body mass index), ASA class (American Society of Anesthesiologists), diabetes, hypertension, and history of abdominal surgery. Intraoperative data contain dissection of lymph node, TNM stage, distance between the tumor and the anus, maximum diameter of tumor, operative time, incision size and intraoperative blood loss. Postoperative outcomes covered pain scale based on a numeric rating scale (NRS), time to first stool, time to first diet, catheter, abdominal drainage tube, postoperative hemoglobin, postoperative leukocytes and hospital stay. Complications were compared between two groups in terms of incorporated ileus, anastomotic leak, bleeding, urinary retention, hernia, deep space infection, wound infection, reoperation, readmission and pulmonary infection.

Statistical analysis

All quantitative data were analyzed using SPSS version 26 (IBM Corporation, Armonk, NY). Continuous and categorical variables were respectively reported as mean ± SD and number (%). Continuous variables were tested using independent sample t-test. Statistical significance was tested via Chi-square or Fisher exact tests for categorical variables. Propensity score matching was performed using sex, age, BMI, ASA, history of diabetes, history of hypertension and history of abdominal surgery as predictors in the propensity score models. The matching algorithm was nearest neighbor with a caliper 0.2 standard deviations. Statistical significance was defined using P value 0.05 with two-tailed analysis.

A total of 193 patients (IA = 61, EA = 132) who underwent robotic-assisted sigmoidectomy met the criteria for inclusion and 116 cases (IA = 58, EA = 58) were available after propensity score matching. Results showed no obvious difference in patient characteristics between the IA and EA groups after propensity score matching (Table 1). Operation characteristics are presented in Table 1. There was no distinct difference in operative time and intraoperative blood loss before and after propensity score matching. Compared to the EA group, the size of incision and distance between the tumor and the anus were markedly smaller in the IA group (P < 0.001).

Table 1

Patient and operative characteristics
	Unadjusted			Propensity score matched
Variable	Intracorporeal (N = 61)	Extracorporeal (N = 132)	P value	Intracorporeal (N = 58)	Extracorporeal (N = 58)	P value
Age (years), mean (SD)	61. (7.20)	65.44 (10.73)	0.001	61.44 (6.91)	61.00 (11.23)	0.796
Gender number (%)
Femal	12(19.7%)	25 (18.9%)		12 (20.7%)	12 (20.7%)
Male	49 (80.3%)	107 (81.8%)	0.904	46 (79.3%)	46 (79.3%)	> 0.999
BMI (kg/m²), mean (SD)	23.96 (2.76)	24.50 (1.53)	0.160	24.15 (2.69)	24.25 (1.44)	0.800
ASA class, N (%)
Ⅰ/Ⅱ	31 (50.8%)	79 (59.8%)		31 (53.4%)	32 (55.2%)
Ⅲ/Ⅳ	30 (49.2%)	53 (40.2%)	0.239	27 (46.6%)	26 (44.8%)	0.852
Diabetes, N (%)	13 (21.3%)	23 (17.4%)	0.519	13 (22.4%)	12 (20.7%)	0.821
Hypertension, N (%)	22 (36.1%)	49 (37.1%)	0.888	21 (36.2%)	22 (37.9%)	0.848
History of abdominal surgery, N (%)	15 (24.6%)	35 (26.5%)	0.777	15 (25.9%)	12 (20.7%)	0.510
Dissection of lymph node	13.75 (4.09)	14.49 (4.47)	0.275	13.81 (4.14)	14.60 (4.36)	0.317
TNM stage
Ⅰ/Ⅱ	43 (70.5%)	91 (68.9%)		17 (29.3%)	12 (20.7%)
Ⅲ/Ⅳ	18 (29.5%)	41 (31.1%)	0.828	41 (70.7%)	46 (79.3%)	0.284
Distance between the tumor and the anus
(cm), mean (SD)	19.75 (1.50)	21.50 (1.47)	< 0.001	19.78 (1.52)	21.67 (1.50)	< 0.001
Maximum diameter of tumor (cm), mean (SD)	5.65 (1.28)	5.60 (1.54)	0.801	5.64 (1.31)	5.48 (1.69)	0.569
Operative time (min), mean (SD)	138.50 (28.80)	136.20 (21.90)	0.539	138.95 (29.35)	133.91 (20.64)	0.288
Incision size (cm), mean (SD)	6.25 (0.649)	8.64 (0.51)	< 0.001	6.25 (0.66)	8.62 (0.52)	< 0.001
Intraoperative blood loss(ml), mean (SD)	55.43 (12.1)	54.05 (17.56)	0.581	54.86 (11.49)	52.91 (16.77)	0.467

Postoperative outcomes are showed in Table 2. In the IA group, the levels of pain scale on the first and second postoperative day were obviously slighter than the EA group (P < 0.05). On the third postoperative days, the lower level of pain scale was also found in the IA group, but did not display significant difference between the two groups. Similarly, the outcomes of time to first stool (P = 0.110), time to first diet (P = 0.084) and abdominal drainage tube (P = 0.373) revealed no significant difference between the two groups. Additionally, catheter indwelling time (IA 4.34 days vs EA 4.93 days, P = 0.009) and length of hospital stay (IA 8.37 days vs. 9.81 days, P = 0.019) were markedly shorter in the IA group.

Table 2

Postoperative outcomes
	Unadjusted			Propensity score matched
Variable	Intracorporeal (N = 61)	Extracorporeal (N = 132)	P value	Intracorporeal (N = 58)	Extracorporeal (N = 58)	P value
Pain scale, mean (SD)
POD 1	4.67 (1.43)	5.96 (1.27)	< 0.001	4.60 (1.43)	6.00 (1.31)	< 0.001
POD 2	4.52 (0.99)	5.05 (1.10)	0.002	4.48 (0.99)	5.03 (1.09)	0.005
POD 3	2.60 (0.97)	2.79 (1.36)	0.272	2.59 (0.93)	2.81 (1.34)	0.300
Time to first stool (days), mean (SD)	4.85 (1.18)	5.13 (1.34)	0.170	4.83 (1.20)	5.21 (1.33)	0.110
Time to first diet (days), mean (SD)	4.74 (1.15)	5.32 (1.67)	0.005	4.78 (1.15)	5.24 (1.67)	0.084
Catheter (days), mean (SD)	4.32 (0.96)	4.84 (1.35)	0.003	4.34 (0.96)	4.93 (1.37)	0.009
Abdominal drainage tube (days), mean (SD)	9 (1.22)	9.32 (2.88)	0.271	8.98 (1.25)	9.36 (2.98)	0.373
Postoperative hemoglobin (g/L), mean (SD)	123.41 (15.61)	124.08 (18.53)	0.808	123.57 (15.84)	124.60 (18.59)	0.748
Postoperative leukocytes (*10^9/L), mean (SD)
(*10^9/L), mean (SD)	9.75 (3.07)	9.65 (2.09)	0.831	9.76 (3.10)	9.66 (1.97)	0.838
Hospital stay (days), mean (SD)	8.36 (2.89)	9.90 (3.00)	0.001	8.37 (2.91)	9.81 (3.75)	0.019

Postoperative complications are presented in Table 3. There were 12 cases suffered from urinary retention in the EA group, more than the IA group (P = 0.027). In the IA group, the number of cases who diagnosed with the complication of hernia was much less than the EA group (1.7% vs. 13.8%, P = 0.037). There was no significant difference in ileus (P > 0.999), anastomotic leak (P = 0.675), bleeding (P > 0.999), deep space infection (P = 0.675), wound infection (P = 0.611), reoperation (P > 0.999), readmission (P > 0.999) and pulmonary infection (P = 0.611).

Table 3

Postoperative complications
	Unadjusted			Propensity score matched
Variable	Intracorporeal (N = 61)	Extracorporeal (N = 132)	P value	Intracorporeal (N = 58)	Extracorporeal (N = 58)	P value
Ileus, N (%)	4 (6.6%)	6 (4.7%)	0.85	3 (3.4%)	4 (6.9%)	> 0.999
Anastomotic leak, N (%)	3 (4.9%)	8 (6.1%)	> 0.999	2 (3.4%)	4 (6.9%)	0.675
Bleeding, N (%)	2 (3.3%)	6 (4.7%)	0.949	5 (8.6%)	4 (6.9%)	> 0.999
Urinary retention, N (%)	3 (4.9%)	19 (14.4%)	0.054	3 (5.2%)	12 (20.7%)	0.027
Hernia, N (%)	2 (3.3%)	17 (12.9%)	0.037	1 (1.7%)	8 (13.8%)	0.037
Deep space infection, N (%)	4 (6.6%)	6 (4.7%)	0.85	4 (6.9%)	2 (3.4%)	0.675
Wound infection, N (%)	3 (4.9%)	6 (4.7%)	> 0.999	1 (1.7%)	3 (5.2%)	0.611
Reoperation, N (%)	3 (4.9%)	8 (6.1%)	> 0.999	3 (3.4%)	3 (3.4%)	> 0.999
Readmission, N (%)	1 (1.6%)	5 (3.8%)	0.724	1(3.8%)	2 (15.4%)	> 0.999
Pulmonary infection, N (%)	1 (1.6%)	4 (3.0%)	0.938	1 (1.7%)	3 (5.2%)	0.611

Colorectal surgery is evolving towards more minimally invasive techniques including the application of robots and developing novel anastomosis technologies. Recent studies have indicated that robotic-assisted intracorporeal techniques have great advantages in boosting patient recovery and reducing postoperative complications in right hemicolectomy, left hemicolectomy, and rectal resection[9, 13]. We suspect that the superiorities of robotic-assisted colectomy could be extended to patients with sigmoidectomy. Riad et al.[14] also demonstrated that intracorporeal techniques can markedly reduce the incidence of conversion and incisional hernia, increase the duration of surgery though. Therefore, we designed this propensity score matching to compare the difference between the two approaches in sigmoidectomy. Consequently, the results revealed that intracorporeal technique has obvious advantages in surgical incision, pain scale, catheter indwelling time and hospital stay in robotic-assisted sigmoidectomy. Moreover, the intracorporeal technique exhibited significant advantages in reducing complications such as urinary retention and incisional hernia.

Compared with the EA group, the IA group has certain advantages in minimizing the size of surgical incision (P < 0.001) and reducing the occurrence of incisional hernia (P = 0.037). It was assumed that the incision size produced by intracorporeal approach is mainly determined by the lesion size, and it is not necessary to be expanded for reaching the sigmoid colon to the site of removal. Especially in obese patients, utilizing of extracorporeal technique is more challenging and requires an enlarged surgical incision or a midline incision to remove the tumor. However, the increased surgical incision could increase the probability of injury to abdominal muscles, blood vessels and nerves, and consequently increases the risk of abdominal incisional hernia. Moreover, it was indicated in the study of Samia et al.[15] that patients received midline incisions had a significantly higher probability of developing incisional hernia than that who received incision at other sites, including muscle-splitting, pfannenstiel and ostomy site. Nevertheless, incision hernia is considered to have a long-term morbidity related to complex mesh repairs and multiply recurrent hernia repairs[16–18]. Hereby, above analyses still need to be supported and verified by more researches.

How to alleviate postoperative pain in patients has been a critical topic in medical research for long time. This study revealed that the level of postoperative pain scale in patients is significantly milder after using the IA approach, although it only showed a significant difference on the first and second days after surgery. The reason for this result is closely related to the choice of IA approach with less intestinal traction and shorter incision length during surgery. In laparoscopic surgery, Li et al.[19] demonstrated that the lower level of pain scale appeared in the IA group in the analysis of 117 patients, which may be a result from the procedure that the bowel stump was pulled out of the small laparotomy wound onto the body surface of the abdominal wall and generated more extensive incisional wounds. In the study of Shinsuke et al[20], they analyzed the relative data of 81 patients underwent surgery and found that the intracorporeal group had milder postoperative pain especially in obese patients. The superiorities of IA in postoperative pain scale can reduce the frequency and dosage of postoperative analgesic and increase the patient satisfaction with surgery, which worth more widely applied.

Urinary system injury is one of the severest complications in sigmoidectomy. Our results indicated that the extracorporeal method have distinctly longer time of catheter indwelling than the intracorporeal approach (P = 0.009). Moreover, the proportion of postoperative urine retention was 5.2% in the IA group, while it rose to 20.7% in the EA group (P = 0.027). The reason for this result may be related to the increased probability of damage to the urinary system, because there could be more severe traction of the intestinal tract during operation.

Furthermore, shorter hospital stay is a distinct advantage in the IA technique (P = 0.019). EA approach requires pulling the sigmoid colon to the incision site, which may affect the recovery of intestinal peristalsis after surgery, so as to affect the digestive function of the intestine. Interestingly, our results showed that the time to first diet and defecation was longer in the EA group, which suggests that the EA technique has a greater impact on intestinal function and could lead to longer recovery time. Additionally, IA group have a lower level of postoperative pain, which is beneficial for patients to earlier mobilize, so as to accelerate the rehabilitation of patients. Martin et al.[21] also suggested that the factors affecting the length of hospital stay may include the type of surgery, opioid use, early feeding, early mobilization, and other key components of the enhanced recovery pathway. Riad et al.[14] found that the length of hospital stay was markedly shorter after receiving the intracorporeal technique in a study of 169 patients with robotic-assisted sigmoidectomy. Other similar studies indicated that the length of hospital stay was obviously shorter in patients underwent laparoscopic and robotic right hemicolectomy with intracorporeal technique[11, 22, 23]. Thus, the above studies demonstrated that intracorporeal technique has a clear advantage in the length of hospital stay.

There are still several limitations in this study. First of all, it is a retrospective study conducted by a single center rather than a randomized controlled study. Furthermore, the research scale is limited and requires much number of patients to support the outcomes of the study. This study mainly focused on short-term and medium-term results, but lacked follow-up on long-term results.

In conclusion, this study revealed that IA technique can significantly reduce the length of the surgical incision, time of catheter indwelling, level of postoperative pain and length of hospital stay. Moreover, the occurrence of postoperative complications using IA approach is also significantly reduced. Consequently, IA technique is superior to EA approach in terms of safety and efficacy.

Funding：This work was supported by [Galectin-1 and GRP78 interact in the endoplasmic reticulum to activate mesenchymal CAFs and promote the invasion and metastasis of gastric cancer through ATF4-SHH pathway] (81972269) and [Key Laboratory of Basic and Clinical Translation of Digestive/Metabolic Diseases] (YZ2020159).

Competing Interests: The authors have no relevant financial or non-financial interests to disclose.

Author Contributions: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by [Qing Yao], [Qian-Nan Sun] and [Jia-Jie Zhou]. The first draft of the manuscript was written by [Qing Yao] and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.”.

Ethics approval: This is an observational study. The Ethics Committee of Northern Jiangsu People's Hospital has confirmed that no ethical approval is required.

Consent to participate: Informed consent was obtained from all individual participants included in the study.

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No competing interests reported.

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Robotic-assisted intracorporeal versus extracorporeal techniques in sigmoidectomy: a propensity score- matched analysis

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