Out of the 60 websites identified from the initial search, only 14 websites contained patient information on robotic colorectal surgery (Table 1). Of these, only three (21%) of the sites clearly stated the date of the last update, two of which were in the last year and the third was ten years ago (Figure 1). The remaining eleven (79%) only had information on copyright and although the copyright year was not earlier than 2022 indicating that the content is less than two years old, there was nothing to suggest the timeline of their last review.
Table 1 Classification of the sixty websites that were obtained from the initial search on Google, Yahoo and Firefox
Content
|
Number of websites
|
Patient information
|
14
|
Scientific articles
|
10
|
Duplicates
|
27
|
Advert
|
3
|
Resources for surgeons
|
5
|
Video Links
|
1
|
Total
|
60
|
Ten (71%) of the sites were affiliated with hospitals, and the other four (29%) were associated with a university, clinic, non-governmental organization (NGO) and an individual surgeon. Twelve (86%) of these websites were in the United States while two (14%) were in the United Kingdom, both of which were affiliated with hospitals (Figure 2).
In relation to content (Figure 3), eleven (79%) websites clearly defined what robotic surgery was and a similar number explained its mechanism of action. One site did neither of the two. All of them mentioned the types of medical conditions that can be treated using robotic surgery but only half (50%) outlined other surgical techniques (open and laparoscopic surgery). No website mentioned the options of transanal endoscopic microsurgery (TEMS) or transanal minimally invasive surgery (TAMIS). The common conditions highlighted were rectal cancer (100%) colon cancer (12, 86%), inflammatory bowel disease (10, 71%) and diverticulitis (9, 64%) while the less common ones included rectal prolapse (5, 36%), colorectal fistula (2, 14%), rectal polyp (2, 14%), hemorrhoids (1, 7%) and colorectal endometriosis (1, 7%).
Similarly, every website discussed some aspect of potential benefits associated with robotic colorectal surgery, mainly reduced chance of bleeding (10, 71%), less pain (13, 93%), improved wound cosmesis (11, 79%), reduced hospital stay (100%), shorter recovery or return to work (9, 64%), reduced incidence of post-operative hernias or adhesions (5, 36%), improved surgical precision (5, 36%), better surgical dexterity (4, 29%), faster return of bowel function (3, 21%) and less chances of conversion to open surgery (2, 15%). However, only three websites (21%) highlighted the risks or complications involved (short and long-term). Some of the risks mentioned included failure of the robot, damage to neurovascular structures, traction injury with increased risk of major bleeding and potentially longer operating time.
Six (43%) of the sites had pictures or videos to support patient information giving, while eight (57%) contained text only. Most of the websites (12, 86%) explained that their own surgical team were trained in robotic surgery. No website mentioned the possibility of being on a waiting list if robotic surgery was offered, how much it will cost and that research on robotic colorectal surgery is still ongoing. Twelve websites (86%) failed to mention what to expect after surgery with regards to quality of life and return to work.
Analysis of the quality of the website contents using the instrument revealed specific deficiencies (Figure 4). Five websites clearly stated their aims but in nine cases (64%) the aims were implied. Nine websites (64%) fully achieved the stated aims. Only five (36%) had information that was relevant and easily understood by the public (a non-scientific audience). The sources of information were obvious for all websites analysed. Sites fared poorly in stating when their content was last updated with 11 of them (79%) scoring 1. Balanced information was only seen on three websites (21%) while the rest either focused more on the positive aspects of robotic surgery and only mentioned the negatives briefly or not at all.
There were more websites which signposted avenues for additional patient support (13, 93%) than those without, although it was considered to be most robust in just three cases (21%). Only one site (7%) attempted to comment on areas on uncertainty in robotic surgery and even this was not in detail. Most websites tried to explain how this treatment option worked with six of them (43%) scoring well by using easy to understand language and illustrations (pictures and animations). In relation to benefits and risks, a comprehensive description was done on only one occasion (7%) with up to 11 sites (79%) omitting to mention risks or complications and 10 (72%) discussing mainly generic and a few specific advantages.
Robotic colorectal surgery is a treatment option for several medical conditions and hence it is not expected that websites would discuss the effect of no treatment for each condition. From our study, all the websites stated that not all patients would be suitable candidates for this treatment (option of no treatment). Discussions on how the surgery will affect a patient's quality of life were mostly poor (12, 86%). Seven sites (50%) made no mention of other surgical options (open and laparoscopic approaches), and a similar number did not explain that the choice of robotic surgery was a joint decision made between the patient and their healthcare team. No website mentioned the option of TEMS or TAMIS as an alternative to robotic colorectal surgery.
The Cohen Kappa analysis of inter-assessor reliability (Figure 5) showed almost perfect agreement in one area (7%), substantial agreement in four areas (27%), moderate agreement in three areas (20%), fair level of agreement in four areas (27%), slight agreement in two areas (13%) and no agreement in one area (7%). The degree of agreement was statistically significant in four areas (27%) – relevance, risks, unbiased and shared decision-making.
In the overall DISCERN rating agreed by both assessors, two websites scored 1, four sites had a score of 2, five websites scored 3, three sites scored 4 and no website had a score of 5 (Figure 6).