Experiences in Robotic Colorectal Surgery: Comprehensive Insights from a Multi-center Analysis Using the Senhance Robotic System

doi:10.21203/rs.3.rs-4615466/v1

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Research Article

Experiences in Robotic Colorectal Surgery: Comprehensive Insights from a Multi-center Analysis Using the Senhance Robotic System

https://doi.org/10.21203/rs.3.rs-4615466/v1

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Introduction: Robotic-assisted surgery has revolutionised minimally invasive approaches, particularly in colorectal surgery. While many single-center studies on colorectal surgeries exist in present literature, including experiences with Senhance® Robotic Systems, comprehensive multi-center studies are lacking. This study, conducted through the TransEnterix European Patient Registry ("TRUST"), aims to assess the safety and feasibility in this context.

Methods: The present study explored procedural times, complications, robotic malfunction and limitations, adverse events and pain management outcomes for colorectal procedures, including sigmoid resection, right hemicolectomy and rectal surgery collected in two European centers.

Results: Data from 355 colorectal surgeries showed that the median duration of surgery was 147.2 minutes (IQR: 124.3–183.0), the docking time was reported with a median of 3.4 minutes (IQR: 2.0–5.4) and the console time was found at a mean of 84.4 minutes (SD: 33.6). Despite minimal blood loss, pain scores, and robotic malfunction, 2,9% of the cases (10 instances) required conversions to either an open or laparoscopic approach. Further, most robotic limitations were attributed to limited motion (18.9%, 67 cases) and collisions (11.5%, 41 cases). Adverse events (24 cases, 6.8%) were effectively managed, with 23 instances judged completely unrelated to the robotic system.

Conclusion: This study underscores the positive outcomes and safety profile of Senhance® Robotic Systems in colorectal surgery, contributing valuable insights for future research and clinical practice.

Robotic Surgery

Colorectal Surgery

Senhance Robotic System

Minimally Invasive

Multi-center Analysis

Robotic-assisted surgery is one of the fastest-growing minimally invasive approaches, drastically substantially transforming medicine, particularly surgical disciplines. Its initial groundbreaking applications in urology [1] have paved the way for cutting-edge advancements such as single port approaches [2] and even procedures in neurosurgery [3], showcasing its potential implications across various specialities. The continuous evolution of robotic-assisted surgery underscores its versatility and promises transformative impacts on diverse medical domains. Colorectal surgery has quickly embraced robotic technology, leading to abundant literature on detailed outcomes compared to other approaches, including laparoscopic and open approaches based on different robotic systems. As the Da Vinci System (Intuitive Surgical, Inc., Sunnyvale, CA, USA) was the first robotic system introduced to the market, most centers worldwide conduct surgeries and report results using this system. The robotic surgery industry constantly continues to develop, introducing various new systems to the market. The Senhance® Robotic System (Asensus Surgical US, Inc., Durham, NC, USA) is an example. The system was previously known as TELELAP ALF-X by TransEnterix and made its market debut in 2014. It is now FDA and Conformité Européenne (Englisch: European conformity, CE) mark approved. The Senhance® Robotic System offers several advantages that potentially surpass those of other surgical systems. First, and in contrast to the Da Vinci System, the system uses mostly reusable and sterilisable instruments, contributing to lower procedural costs and the potential of an eco-friendly image. Furthermore, various groundbreaking highlights emerge from the robotic console and equipment. On the one hand, haptic feedback enhances safety by allowing the perception, assessment, and analysis of forces between the instrument and the patient’s tissue. On the other hand, glasses with eye-tracking and 3D visualisation empower the surgeon to control the view intuitively. The ergonomics are worth mentioning, as the surgeon operating the Senhance® console benefits from an ergonomically optimised seat with an angled footrest. The independently positionable robotic arms are controlled through an open console, ensuring secure communication with the nurses and assistants and heightened safety for both the team and the patient. Lastly, trocar placements align with typical laparoscopic positions, facilitating efficient hybrid interventions or fast conversions. Given its outstanding features, various reports on experiences with the Senhance® Robotic System in colorectal surgery have been published. The first colorectal series was published in 2017 by Spinelli and colleagues [4], followed by other patient series [5–9, 4]. A recent systematic review [10] with six studies exploring the Senhance® Robotic System meta-analysed various parameters (e.g., duration of surgery, docking times, conversions, postoperative morbidities). It concluded that an acceptable safety profile, reasonable docking times, low conversion rates, and affordable case costs for colorectal surgeries. Recently, the first series using augmented intelligence (AI) with this robotic system was published, marking the inaugural report in the literature concerning the application of AI in robotic surgery (Samalavicius NE, Dulskas (in press). First Clinical experience using augmented intelligence in robotic colorectal cancer surgery with Senhance robotic platform. Ann Coloproctol 2024;1:00–00).

However, there is still a lack of multi-center experiences that exceed single-site reports. Certainly, a multi-center study can achieve more accurate findings through increased sample sizes, improved external validity and possibly reduce bias. Therefore, the present study aims to explore the safety and feasibility of colorectal surgeries with the Senhance® Robotic System at two European centers.

Patients

For the present report, the data used represent excerpts from the “TRUST” (The TransEnterix European Patient Registry for Robotic-assisted Laparoscopic Procedures in Urology, Abdominal Surgery, Thoracic and Gynecologic Surgery), which represents an international study group. For robotic-assisted colorectal surgery, adult patients were included from two European study centers (Klaipeda University Hospital, Lithuania and Evangelisches Hospital, Wesel, Germany). Patients were screened for eligibility for laparoscopic surgery. They were included when the indication for colorectal surgery and no absolute contraindications for laparoscopic surgery (e.g., severe cardiopulmonary diseases) or exclusion criteria such as life-threatening diseases, limiting the participant’s life expectation to less than 12 months or inability to give consent applied. Indications for robotic colorectal surgery mirrored the indications for laparoscopic surgery.

Procedure

Robotic-assisted colorectal surgeries were categorised into sigmoid resection, right hemicolectomy and rectal surgery. All procedures were entirely performed with the help of the Senhance® Robotic System. Various papers on procedural details, including our own, are published [11–18, 6, 19, 20]. In general, three robotic arms were utilized alongside five trocar placements, with a preference for the combination of 12mm and 5mm trocars. The surgical teams conducting surgeries varied across locations. In Wesel, three surgeons and fourteen assistants formed 34 distinct constellations. In Klaipeda, the surgical teams comprised three surgeons and seven assistants, leading to three unique surgical constellations. After completing the procedure, “docking time“ (in minutes), “console time”, and“duration of surgery” (in minutes) were documented in a database. "Docking time" is the period between initiating and concluding the robot's docking to the trocars, while “console time” represents the time the cockpit surgeon operates through the robotic system. At the same time, "duration of surgery" refers to the time from the initial skin incision to the completion of suturing. Perioperative complications and adverse events (AE) were documented in detail when they occurred. Intraoperative complications included AEs involving visceral or vascular injury, cardiopulmonary events, major blood loss (> 500 mL), or the need for blood transfusion. Postoperative complications included AEs that are related to the procedure, such as infections (e.g. wound infection), insufficient anastomosis, sepsis, ileus, bowel obstruction, and venous thromboembolic events and occurred within 30 days postoperative. The recorded data on AEs and complications in the registry followed the Clavien Dindo Classifications for each event (Dindo et al. 2004). Severe AEs were identified when readmission, repeated surgery, or death occurred. In the event of any complication, the association with the robotic procedure and the Senhance® Robotic System was determined, and an international safety committee reassessed the link to the robotic procedure and system. Additionally, conversions to standard laparoscopy or open surgery were protocolled in the database. Finally, blood loss during the procedure was recorded by estimation and patient medication usage (according to the World Health Organisation (WHO) analgesic ladder [21]) as well as pain scores (on a 0–10 visual pain scale) were collected on a 0–10 visual pain scale (at one day postoperative and discharge).

Each patient provided written informed consent for the robotic procedure. Demographic data such as age, sex, BMI, relevant diseases and previous abdominal surgery were gathered before the procedure. Study Initiation started in October 2017, and the database registry ended in November 2023. Confidentiality and patients’ anonymity were ensured. The study received approval from the Ethics Committee of the Medical Association of Westphalia-Lippe and the University of Münster (Approval Number: 2017-463-f-S) and was subsequently confirmed by multiple local approvals.

Statistical analysis

We used “statistical software SAS® 9.4 (TS1M6) for Microsoft Windows” [22] for statistical analysis. No imputation or replacement of missing values was undertaken. Continuous data were expressed using either the median with interquartile ranges (IQR) or mean ± standard deviation (SD). Categorical variables were presented in terms of frequencies and percentages.

Demographic data and procedure details

Three hundred fifty-five robotic-assisted colorectal surgeries (sigmoid resection, right hemicolectomy and rectal surgery) were recorded at both our centers (Wesel: 192 cases, 54% and Klaipeda: 163 cases, 46%). Sigmoid resection emerged as the most often performed, with 169 cases (47.6%) reported. Data was provided from 123 patients (34.7%) for rectal surgery data, and right hemicolectomy was predated in 63 cases (17.7%). Table 1 displays a breakdown of the colorectal procedures.

The average age of the overall cohort was 64.8 years (SD: 12 years), with 56.9% female and 43.1% male patients. The patients' BMI averaged 26.3 kg/m² (SD: 4.5 kg/m²). Most of the study population did not present a smoking history (82.0%). However, a fairly large population was diagnosed with relevant comorbidities (37.7%) and reported a history of previous abdominal surgery (30.4%). For a comprehensive overview of demographic data, see Table 2.

Table 1

Colorectal Procedures
Center	Sigmoid Resection	Rectal Surgery	Right Hemicolectomy	Total
Klaipeda	23	92	48	163
Wesel	146	31	15	192
Total	169	123	63	355

Table 2

Demographic Data and Medical History
		Wesel	Klaipeda	Total
	N	192	163	355
Age (years)	mean ± SD	64.8 ± 11.7	64.8 ± 12.4	64.8 ± 12.0
Gender	Male	75 (39.1%)	78 (47.9%)	153 (43.1%)
Gender	Female	117 (60.9%)	85 (52.1%)	202 (56.9%)
BMI (kg/m²)	mean ± SD	27.6 ± 5.1	24.8 ± 3.1	26.3 ± 4.5
History of smoking	No	165 (85.9%)	126 (77.3%)	291 (82.0%)
History of smoking	Yes	27 (14.1%)	37 (22.7%)	64 (18.0%)
Relevant comorbidity	No	63 (32.8%)	158 (96.9%)	221 (62.2%)
Relevant comorbidity	Yes	129 (67.2%)	5 (3.1%)	134 (37.7%)
Type of relevant comorbidity (multiple entries)	Diabetes	14 (7.3%)	1 (0.6%)	15 (4.2%)
	Hypertension	83 (43.2%)	3 (1.8%)	86 (24.2%)
	Cardiovascular Co-morbidity	20 (10.4%)	1 (0.6%)	21 (5.9%)
	COPD or Impaired Respiratory Function	18 (9.4%)	-	18 (5.1%)
	Impaired Renal Function	15 (7.8%)	-	15 (4.2%)
	Liver Disease	2 (1.0%)	-	2 (0.5%)
	Stroke	-	1 (0.6%)	1 (0.3%)
	Sleep Apnea	2 (1.0%)	-	2 (0.5%)
	GERD	10 (5.2%)	-	10 (2.8%)
	Depression	5 (2.6%)	-	5 (1.4%)
	Osteoarthritis	2 (1.0%)	-	2 (0.5%)
	Chronic pain	2 (1.0%)	-	2 (0.5%)
	Others	41 (21.4%)	2 (1.2%)	43 (12.1%)
Previous relevant abdominal surgery	No	91 (47.4%)	156 (95.7%)	247 (69.6%)
Previous relevant abdominal surgery	Yes	101 (52.6%)	7 (4.3%)	108 (30.4)
Type of relevant abdominal surgery (multiple entries)	Open surgery	29 (15.1%)	1 (0.6%)	30 (8.5%)
Type of relevant abdominal surgery (multiple entries)	Laparoscopic surgery	78 (40.6%)	6 (3.7%)	84 (23.7%)

Procedure time and blood loss

Based on 355 robotic-assisted colorectal surgeries performed with the Senhance® Robotic System at our two European centers, the duration of surgery was found at a median of 147.2 minutes (IQR: 124.3–183.0, see Table 3). The docking time was reported with a median of 3.4 minutes (IQR: 2.0–5.4). Results for console time were found at a mean of 83.4 minutes (SD: 33.6). By investigating both centers individually, we can notice a reduction in times [(duration of surgery: Klaipeda: 165 minutes (IQR: 140.0–200.0) vs. Wesel: 132 minutes (IQR: 111.0–168.5), docking time: Klaipeda: 4 minutes (IQR: 2.0–7.0) vs. Wesel: 3 minutes (IQR: 2.0–4.0), console time: Klaipeda: 77.7 minutes (SD: 34.3) vs. Wesel: 90.2 minutes (SD:32.7)] with an increased caseload (Klaipeda: 163 vs. Wesel: 192).

Blood loss was minimal (e.g. 0 ml or not measurable) in 71.8% (255 cases). If more than 0 ml were reported, a median of 96 ml (IQR: 62.1–173.0) was measured.

Table 3

Procedure times. All values are stated in minutes
		Wesel	Klaipeda	Total
	N	192	163	355
Duration of surgery	median	132	165	147.2
Duration of surgery	P25%-P75%	111.0-168.5	140.0-200.0	124.3–183.0
Docking time	median	3	4	3.4
Docking time	P25%-P75%	2.0–4.0	2.0–7.0	2.0-5.4
Console time	mean	77.7	90.2	83.4
Console time	SD	34.3	32.7	33.6

Conversions and Malfunctions

All procedures were finished successfully, with no mortality related to the procedure or robotic system. Nevertheless, conversions were required in 2,9% of cases (10 instances), signalling a shift away from the utilisation of Senhance® Robotic Systems in favour of standard laparoscopic and open surgery. One case (0.3%) needed continuation via laparoscopic surgery. Eight cases (2.3%) required continuation via open surgery, with three initially planned conversions. Another case (0.3%) was first attempted with a laparoscopic approach and was then converted to open surgery (see Table 4). In most cases, the reasons for conversions were limitations due to difficult anatomy, e.g., multiple adhesions, unexpected localisation of cancer, T4 tumors requiring multi-visceral resections, or intraoperative bleeding.

Of 355 robotic-assisted colorectal surgeries, robotic malfunctions were documented as a rarity in one case (0.3%). This incident was defined as “other malfunction” and thus was not related to the robotic system's console, monitor, or camera. Additionally, the recorded event was fixable and did not require stopping the procedure or switching to another approach. Further, most robotic limitations were attributed to limited motion (18.9%, 67 cases) and collisions (11.5%, 41 cases). Of note, only single entries were allowed for robotic malfunction count, while multiple entries were permitted for the malfunction type and limitations. Detailed results are presented in Table 4.

Table 4

Conversion and malfunctions
		Wesel	Klaipeda	Total
	N	192	163	355
Conversion	None	185 (96.4%)	160 (98.2%)	345 (97.1%)
	Laparscopic	1 (0.5%)	-	1 (0.3%)
	Open	5 (2.6%)	3 (1.8%)	8 (2.3%)
	Laparoscopic + Open	1 (0.5%)	-	1 (0.3%)
Robot malfunctions	No	191 (99.5%)	163 (100%)	354 (99%)
Robot malfunctions	Yes	1 (0.5%)	--	1 (0.3%)
Type of Robot malfunction (multiple entries)	Other malfunction	1 (0.5%)	-	1 ( 0.3%)
Robotic limitations (multiple entries)	Collision	2 (1.0%)	39 (23.9%)	41 (11.9%)
Robotic limitations (multiple entries)	Limited motion	5 (2.6%)	62 (38.0%)	67 (19.4%)
Open: open surgery, laparoscopic: laparoscopic surgery

Adverse events

Twenty-four intra- and postoperative AEs (6.8%) were documented throughout the study at both our centers, with twelve events reports at each center. Only one complication happened during surgery (non-robot-associated intraoperative bladder incision), which demanded conversion to open with no other consequences. The AEs included most often complications such as haemorrhage, hernia, anastomotic leakage, postoperative ileus, urinary retention, and stenosis. A detailed overview of all events can be found in Supplementary Table 1. In total, ten reports (2.8%) were categorised as serious adverse events (SAE). They included occurrences such as haemorrhage, haematoma, anastomotic leak, postoperative ileus, colon descendens perforation and necrosis of the colon. Seven cases (2%) of the overall recorded AEs were judged with mild severity, 12 cases (3.4%) were evaluated as moderate severity, and five cases (1.4%) were referred to as SAEs. Twenty-three cases (6.5%, 95.8% of all AEs) were unrelated to the robotic system. Only one report (0.3%) is judged as possibly related to the Senhance® Robotic System. In this case, the patient experienced incontinence following primary rectal resection, possibly due to injury to surrounding nerve structures. All AEs were unexpected and were effectively treated with appropriate interventions. All patients were discharged in good health.

Pain

Across both centers, WHO medication types 1 (349 cases, 98.3%) and 3 (307 cases, 86.5%) were the most frequently administered (Aabha A. Anekar et al.). The overall pain scores indicated a minimal pain level of 3.1 (± 1.7) on a 0–10 visual pain scale one day postoperative. By discharge, the pain score had successfully decreased to an average of 1.2 (± 1.1), representing a more than 50% reduction. Results per center can be found in Table 5.

Table 5

Pain perception
		Wesel	Klaipeda	Total
	N	192	163	355
One day postoperative	mean ± SD	3.1 ± 2.2	3.1 ± 0.8	3.1 ± 1.7
At discharge	mean ± SD	1.2 ± 1.5	1.1 ± 0.4	1.2 ± 1.1

An important aspect of robotic surgery is that it is inevitably done by and through a robot. This robot is thus prone to face malfunctions. However, we found minimal malfunctions with the Senhance® Robotic System. Only limited motion and potential collisions were likely to occur. Typically, surgical operating rooms (ORs) do not have a separate dedicated room for the robot. Instead, they share the OR with procedures using open or laparoscopic approaches. Accordingly, the OR might not be optimised for the robotic procedures. Nevertheless, the collision, usually involving the robotic arms, can be easily resolved by the assistant or nurse. While limited motion is often indicated as a warning on the screen and can typically be addressed by those familiar with the system, it's worth noting that approximately one-third of patients in the recorded demographic data had previous abdominal surgery. Previous abdominal surgery is an important factor likely to result in adhesions. Furthermore, the average BMI was 26.3 kg/m², categorised as overweight and the average age was 64.8 (SD: 12.0) [23]. Elevated chances of adhesion and being overweight are likely attributed to limited motion. In addition to the complexity of procedures and their higher likelihood of conversion, AEs and SAEs, it is important to acknowledge that factors such as being overweight, older aged and adhesions can significantly increase the occurrence of AEs and SAEs. A thorough examination revealed that the Wesel center included significantly more patients with documented previous surgeries (Wesel: 52.6% vs. Klaipeda: 4.3%). However, conversions (7 cases), as well as AEs and SAEs (24 cases), were relatively low at the Wesel center, suggesting that this factor is of limited significance when operating with the Senhance® Robotic System. This highlights an overall limitation of the present study: some departments, such as the Klaipeda center, are still rather selective in applying robotic surgery, likely opting for patients who are most suitable for these procedures.

The comparison with laparoscopic surgery is particularly intriguing and warrants further exploration. In Farah et al.’s recent comprehensive research [24] on 53.209 patients, robotic-assisted colorectal surgery demonstrated significantly lower conversion rates (4.3% vs 9.2%, p-value < 0.001) but longer duration of surgery (225 minutes vs 177 minutes, p-value < 0.001) compared to laparoscopy. Our current findings in a large cohort show a duration of surgery with a median of 147.2 minutes and are, thus, even lower than laparoscopic surgery. An explanation for this could be that regardless of whether surgeons perform laparoscopic surgery using monopolar/bipolar instruments and clips, or advanced bipolar/ultrasonic instruments for tasks such as vessel sealing, the Senhance™ Robotic System allows the preferred surgical technique to be maintained. For instance, at the Wesel center, vessels are prepared robotically and sealed with an ultracision device, whereas, in Klaipeda, stapling is the standard practice. Despite these variations in technique, the result remains consistent and the duration of surgery is low. This flexibility highlights a significant advantage of the Senhance™ system: established operating methods can be continued without necessitating a change in technique. Ultimately, this emphasises the safety and feasibility of the robotic system.

Our conversion rate was reported at 2.3% for transitioning to an open approach, significantly higher than 0.3% for switching to laparoscopic approaches and 0.3% for initially attempting laparoscopic and open procedures. In consequence, the majority of procedures (97.1%) were performed robotically and rarely resorted to a shift to open or laparoscopic surgery. In this context, we can further highlight that simpler standard procedures are typically initiated at the beginning of robotic surgery integration. In contrast, more complex procedures are approached with greater experience, as exemplified especially at the Wesel center. At this center, three conversions to open surgery were initially planned due to the complex case or patient characteristics. Furthermore, the team constellations differed notably in Wesel and were drastically higher. This indicates that, despite not always having an expert team, robotic surgery integrates effectively and seamlessly even into smaller peripheral hospitals, resulting in positive outcomes and hardly any conversions. Overall, our results show that surgery was rarely converted or negatively influenced by the Senhance® Robotic System.

Another feature of the Senhance® Robotic System is the ergonomic seating position. No standing or banding is involved in robotic surgery for the cockpit surgeon controlling the robotic console. This could reduce fatigue and enhance focus, especially compared to laparoscopic surgery. Our observed operating time of 147.2 minutes could reflect this. Based on the documented duration of surgery and docking time, we observe a decreasing trend as the number of cases increases across our two centers, indicating a reduction in times with increased experience. Even with constantly changing team constellations, Menke and colleagues previously identified and discussed this trend with the Senhance® Robotic System [25].

Exploring the highlights of the Senhance® Robotic System, the eye-tracking 3D visualisation is specific to the system, allowing surgeons to have a detailed, self-managed view of the surgical site. This enhanced visualisation helps in precise manoeuvring and better identification of anatomical structures. This becomes crucial when the surgical site might face an unclear situation and an AE. The Senhance® Robotic System further offers surgeons great agility and range of motion, as the robotic arms can mimic the movements of the surgeon's hands with increased precision. This is particularly advantageous in complex procedures involving delicate tissues. Lastly, the Senhance® Robotic System provides haptic feedback, allowing surgeons to feel a sense of touch during the procedure. This feature enhances the surgeon's ability to assess tissue characteristics and manipulate instruments more effectively. These factors collectively suggest that ambiguous situations are more effectively managed, and the surgeon maintains greater control throughout the procedure. Therefore, discussing AEs, especially intraoperative ones, is important in this context. Overall, 6.8% of the cases reported AEs. 95.8% were postoperative complications, while only one complication occurred during surgery (bladder rupture). This significantly emphasises the precise control maintained throughout the procedure. Important to emphasise is that the AEs were, in the majority of cases (23 cases, 6.5%, 95,6% of all AEs), unrelated to the robotic system and thus general AEs in the context of colorectal surgery but not for the Senhance® Robotic System. Only a minority (0.3%) were judged, possibly related to the system. These results are showing big improvement as initial findings with the Senhance® Robotic System by Spinelli and colleagues report a postoperative AEs rate of 35.5% [4]. The Da Vinci System (Intuitive Surgical, Inc., Sunnyvale, CA, USA) has also been investigated multiple times for adverse events. A study by Kim and colleagues reported an adverse event rate of 12% (6 cases) [26]. Meanwhile, a large-scale study by Huang and colleagues found a postoperative complication rate of 8.8% over five years [27]. Since we included both intraoperative and postoperative adverse events in our overall complication rate, the results are very favorable for demonstrating safey with the Senhance® Robotic System.

Finally, Robotic-assisted surgery is a minimally invasive approach involving small incisions through which the robotic arms are inserted with surgical instruments and a camera. Typically, this method yields smaller scars, decreased blood loss, diminished pain, and faster recovery times when contrasted with open surgery [28]. This can be underlined by our results presenting minimal pain on the postoperative day one and a significant reduction of pain on the day of discharge. The reported pain was adequately managed with standard WHO pain medication and did not differ between our study centers. Regarding blood loss, respective recordings further support the minimal blood loss during robotic surgery. These aspects are, however, not specific to the Senhance® Robotic System but could also be found similarly in laparoscopic surgery [29].

The study provides comprehensive insights into the outcomes and challenges of robotic-assisted colorectal surgeries with the Senhance® Robotic System across multiple centers. The detailed breakdown of our findings enhances our understanding of the nuances and variations in outcomes across different aspects of colorectal surgery. In conclusion, safety and feasibility are demonstrated with the Senhance® Robotic System, and its application across various surgeries in colorectal surgery is approved.

Author Contribution

All authors contributed to the study's conception and design. Material preparation, data collection and analysis were performed by N.E.S., R.K., V.N., F.W., O.M.H., V.M. . The first draft of the manuscript was written by N.E.S. and V.M. and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Acknowledgement

Asensus Surgical US, Inc., Durham, NC, USA, and the TransEnterix European Patient Registry (TRUST) study group supported this study.

Data Availability

Data is available upon request.

Competing Interests: The authors state that they have no conflicts of interest.

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Experiences in Robotic Colorectal Surgery: Comprehensive Insights from a Multi-center Analysis Using the Senhance Robotic System

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