Robotic Versus Laparoscopic Sigmoid Resection for Diverticular Disease: A Single-Center Experience of 106 Cases

Abstract

Background:

Laparoscopic sigmoid resection is the surgical standard for the treatment of diverticulitis. Robotic sigmoid resection with the da Vinci Xi^® platform may offer advantages over the laparoscopic approach.

Materials and Methods:

One hundred and six patients with uncomplicated, complicated, or recurrent diverticular disease underwent robotic (n = 60) or laparoscopic (n = 46) sigmoid resection at our institution between 2013 and 2018. Patient demographics and characteristics, perioperative measures, and complications were retrospectively analyzed.

Results:

There were no statistically significant differences between the robotic and laparoscopic group with regard to operative time (130 versus 118 minutes; P = .23), anastomotic leakage (6.7% versus 6.5%; P = 1.0), need for stoma (6.7% versus 4.3%; P = 1.0), conversion rate (1.7% versus 0%; P = .36), reoperation (8.3% versus 15.2%; P = .27), overall complications according to the Clavien-Dindo classification (30.0% versus 30.4%; P = .8), mortality (1.7% versus 0%; P = 1.0), and need for intravenous analgesics (3.0 versus 2.1 days; P = .21). The duration of postoperative ileus was significantly shorter in the robotic group (2.2 versus 2.8 days; P = .01).

Conclusion:

Robotic sigmoid resection for uncomplicated, complicated, or recurrent diverticular disease is a safe and feasible procedure. However, robotic sigmoid resection for diverticulitis is not associated with relevant clinical benefits for patients compared to laparoscopic resection except for a slightly shorter duration of postoperative ileus.

Introduction

Sigmoid resection for uncomplicated, complicated (obstruction, abscess formation, fistula, perforation), or recurrent diverticular disease is a frequently performed surgical procedure and is associated with a relevant rate of surgical complications (18.96%¹).

Compared to open sigmoid resection, laparoscopic sigmoid resection has a significantly lower rate of major complications^1–5 and is the surgical standard for the treatment of recurrent, uncomplicated, and complicated diverticulitis.^6,7 However, conversion rates from laparoscopic to open of 5.2%,⁶ 19.2%,⁸ and 26%⁹ have been reported. These depend on the severity of diverticulitis and a previous history of abdominal surgery. When it comes to laparoscopic resection for acute diverticulitis, conversion rates as high as 55% have been published.¹⁰ These are associated with bulky mesenteric tissue and ill-defined planes of dissection.¹¹

The first robotic sigmoid colectomy was published in 2002¹² (Weber PA et al., 2002). The robotic platform (da Vinci Xi^®) offers several technical advantages over the laparoscopic approach such as fine motion scaling, instruments with EndoWrist^® technology for superior dexterity, more precise dissection, tremor reduction, highly magnified 3DHD vision, and better surgeon ergonomics.^13,14

Due to the advanced capabilities of the robotic system, clinical benefits for patients undergoing robotic sigmoid resection for diverticulitis can be assumed.¹⁵ However, only about 3.7% of all colonic resections are performed robotically.¹⁶ For this reason, data on perioperative outcomes of laparoscopic versus robotic colonic resection are scarce,¹⁷ and the role of robotics specifically for sigmoid resection in patients with diverticulitis remains unclear.

The purpose of this study is to evaluate the results and outcomes of robotic sigmoid resection for diverticular disease in comparison to laparoscopic sigmoid resection for the same condition.

Materials and Methods

Study design and data collection

A retrospective analysis was conducted of all laparoscopic (group 1) and robotic (group 2) sigmoid resections for diverticular disease at our institution from October 2013 to November 2018. Indications for sigmoid resection were uncomplicated, complicated, or recurrent diverticulitis in both groups. Demographics, characteristics, operative measures, and complications of both groups were assessed.

Patient demographics and characteristics included age, body mass index, gender, American Association of Anesthesiologists (ASA) classification, smoking, diabetes mellitus type 2, previous abdominal surgery, mechanical bowel preparation (MBP), oral antibiotic bowel preparation (OABP), and type of diverticulitis according to the German Classification of Diverticular Disease (CDD; Table 1).¹⁸

Table 1.

Classification of Diverticular Disease

CDD type	Definition
0	Asymptomatic diverticulosis
1	Acute uncomplicated diverticulitis
1a	Diverticulitis without peridiverticulitis
1b	Diverticulitis with phlegmonous peridiverticulitis
2	Acute complicated diverticulitis
2a	Microabscess (≤1 cm)
2b	Macroabscess (≥1 cm)
2c	Free perforation
2c1	Purulent peritonitis
2c2	Fecal peritonitis
3	Chronic diverticular disease
3a	SUDD; localized symptoms, laboratory test (calprotectin): optional
3b	Relapsing diverticulitis without complications; signs of inflammation (laboratory tests): present, cross-sectional imaging: indicates inflammation
3c	Relapsing diverticulitis with complications (stenosis, fistula, conglomerate tumor)
4	Diverticular bleeding

CDD, Classification of Diverticular Disease; SUDD, Symptomatic uncomplicated diverticular disease.

Source: Lembcke.¹⁸

Operative measurements included conversion rate, site of bowel extraction, need for stoma, operative time, intraoperative and postoperative blood transfusion, and epidural catheter.

Postoperative complications of interest included anastomotic leakage, superficial surgical site infections (SSSI), deep surgical site infections (DSSI), reoperations within 30 days after sigmoid resection, complications according to Clavien-Dindo classification,¹⁹ need for intravenous analgesics, and length of postoperative ileus.

Preparation for surgery and operative technique

All patients received an intravenous single-shot prophylactic antibiotic consisting of 1.5 g cefuroxime and 500 mg metronidazole before skin incision. For MBP, 1000 mL of polyethylene glycol (Moviprep^®; Norgine, Amsterdam, Netherlands) was used. Patients started with MBP between 1 and 3 a.m. the day before surgery. An additional OABP consisting of 2 g paromomycin and 400 mg metronidazole was administered to all patients the evening before surgery from January 2018 onward.

All robotic procedures were performed with the da Vinci Xi Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) by two experienced colorectal surgeons. Surgery was performed in the lithotomy position, with the robot docked over the patient's right side, using a four- or five-trocar-technique (one 12 mm camera trocar, three 8 mm trocars, optionally one 12 mm assistant trocar). Robotic dissections were performed using da Vinci bipolar forceps or da Vinci Vessel Sealer Extend.

Laparoscopic operations were conducted in the lithotomy position, using four trocars (two 12 mm trocars, two 5 mm trocars). For laparoscopic dissections, Harmonic ACE^®+7 Shears with Advanced Hemostasis (Ethicon, Bridgewater, NJ) were used.

In both groups, the bowel was divided with a stapler in the upper rectum. All sigmoid specimens were extracted using an Alexis^® wound protector (Applied Medical, Rancho Santa Margarita, CA), either through a Pfannenstiel incision or an incision in the left iliac fossa. End-to-end or side-to-end anastomosis was performed using a 29 mm EES Circular Stapler^® (Ethicon).

Statistical analysis

Data analysis was performed with SPSS statistics (IBM Corp., Armonk, NY). The chi-squared test was used for group comparison of categorical variables, and the Mann–Whitney U test was used to compare differences of ordinal variables. A P value ≤.05 was considered statistically significant.

Results

A total of 106 minimally invasive sigmoid resections for diverticulitis were performed at our institution during the study period from October 2013 to November 2018. Of these, 46 were laparoscopic (43%) and 60 were robotic (57%) procedures.

Incidences of patient comorbidities and demographic characteristics were similar in the laparoscopic and the robotic group, except for the rate of OABP. OABP was more frequently administered to patients in the robotic group (43.3% versus 13.0%; P = .001). This difference was significant. There were no significant differences in types of diverticulitis according to CDD classification between the two groups (P = .387). Table 2 provides detailed data on demographics and clinical characteristics.

Table 2.

Demographics and Clinical Characteristics of Patients with Laparoscopic and Robotic Sigmoid Resections

	Laparoscopic sigmoid resection, n = 46 (43%)	Robotic sigmoid resection, n = 60 (57%)	P
Age; mean ± SD (years)	59.3 ± 11.8	60.0 ± 11.0	.92
BMI; mean ± SD (kg/m²)	26.13 ± 4.1	27.06 ± 4.5	.27
Gender; n (%)			.72
Female	20 (43.5)	24 (40)
Male	26 (26.5)	36 (60)
ASA; n (%)			.72
1	2 (4.3)	2 (3.3)
2	30 (65.2)	38 (36.3)
3	14 (30.4)	20 (33.3)
Smoking; n (%)	14 (30.4)	14 (23.3)	.66
Diabetes mellitus type 2; n (%)	2 (4.3)	5 (8.3)	.41
Previous abdominal surgery; n (%)	25 (54.3)	24 (40.0)	.17
Mechanical bowel preparation; n (%)	38 (82.6)	43 (71.7)	.19
OABP; n (%)	6 (13.0)	26 (43.3)	.001
CDD type; n (%)			.387
1a	1 (2.2)	1 (1.7)
1b	12 (26.1)	10 (16.7)
2a	11 (23.9)	13 (21.2)
2b	3 (6.5)	8 (13.3)
2c	1 (2.2)	2 (3.8)
3a	4 (8.7)	4 (6.7)
3b	7 (15.2)	5 (8.3)
3c	3 (6.5)	9 (15.0)
Not classified	3 (6.5)	8 (13.3)

ASA, American Society of Anesthesiologists; BMI, body mass index; CDD, Classification of Diverticular Disease¹⁸; OABP, oral antibiotic bowel preparation; SD, standard deviation.

When it came to operative measurements, including conversion rate, need for stoma, operative time, intraoperative/postoperative blood transfusion, and epidural catheter, there were no significant differences between the two groups (Table 3). There was a significant difference in the choice of bowel extraction site between the laparoscopic and the robotic group (Pfannenstiel incision: 17.4% laparoscopic versus 51.7% robotic; incision left iliac fossa: 82.6% laparoscopic versus 48.3% robotic; P = .002).

Table 3.

Operative Measures for Laparoscopic Versus Robotic Sigmoid Resections

	Laparoscopic sigmoid resection, n = 46 (43%)	Robotic sigmoid resection, n = 60 (57%)	P
Conversion rate; n (%)	0	1 (1.7)	.36
Bowel extraction site; n (%)			.002
Pfannenstiel incision	8 (17.4)	31 (51.7)
Incision left iliac fossa	30 (82.6)	29 (48.3)
Need for stoma; n (%)	2 (4.3)	4 (6.7)	1.0
Operative time; mean ± SD (minutes)	118 ± 36.8	130.4 ± 42.4	.23
Intraoperative and postoperative blood transfusion; n (%)	2 (4.3)	1 (1.7)	.58
Epidural catheter; n (%)	32 (69.6)	44 (73.3)	.67

SD, standard deviation.

Table 4 provides details of the incidences of postoperative complications for the laparoscopic and the robotic group. There was no significant difference between the two groups with respect to rate of anastomotic leakage, SSSI, DSSI, reoperation within 30 days after sigmoid resection, mortality, overall complications according to Clavien-Dindo classification, and the need for intravenous analgesics. In the robotic group, there were two iatrogenic injuries to the urinary bladder, which were managed with an intracorporal suture. In the laparoscopic group, there was one injury to the urinary bladder (intracorporal suture) and one ureteral injury, which was treated with a double J stent. The duration of postoperative ileus was significantly shorter in the robotic group (2.2 versus 2.8 days; P = .01).

Table 4.

Incidence of Postoperative Complications and Measures for Laparoscopic Versus Robotic Sigmoid Resections

	Laparoscopic sigmoid resection, n = 46 (43%)	Robotic sigmoid resection, n = 60 (57%)	P
Anastomotic leakage; n (%)	3 (6.5)	4 (6.7)	1.0
SSSI; n (%)	3 (6.5)	4 (6.7)	1.0
DSSI; n (%)	1 (2.2)	2 (3.3)	1.0
Reoperation <30 days; n (%)	7 (15.2)	5 (8.3)	.27
Death; n (%)	0	1 (1.7)	1.0
Clavien-Dindo			.8
I	0	1 (1.7)
II	4 (8.7)	8 (13.3)
III A	2 (6.5)	3 (5.0)
III B	7 (15.2)	5 (8.3)
IV	0	1 (1.7)
Need for intravenous analgesics; mean ± SD (days)	2.1 ± 2.8	3.0 ± 6.3	.21
Length of postoperative ileus; mean ± SD (days)	2.8 ± 1.6	2.2 ± 6.3	.01

DSSI, deep surgical site infection; SD, standard deviation; SSSI, superficial surgical site infection.

Discussion

The purpose of our study was to evaluate the role of robotic sigmoid resection in patients with diverticular disease. To do this, we retrospectively analyzed operative measurements, outcomes, and complications of robotic and laparoscopic sigmoid resections for the same indication.

Overall complications after sigmoid resection according to Clavien-Dindo were quite high for both the robotic and the laparoscopic group (robotic versus laparoscopic: 30.0% versus 30.4%; P = .8). However, a recent systematic review and meta-analysis of complications following surgery for diverticulitis showed an overall postoperative complication rate of 32.64%.¹ In our patients, most complications were managed conservatively or at least without a reoperation under general anesthesia (Clavien-Dindo ≤IIIa). Reoperations (Clavien-Dindo ≥IIIb; robotic versus laparoscopic: 8.3% versus 15.2%, P = .27) were performed in patients with anastomotic leakage and in patients with SSSI for surgical wound debridement and application of a vacuum dressing. There was no significant reduction in complications in patients with robotic sigmoid resections. The equality of the laparoscopic and robotic procedure for the surgical treatment of diverticulitis with regard to complications and outcome is confirmed by the results published by Cassini et al.²⁰ In their study, which compares robotic and laparoscopic surgical treatment of complicated diverticulitis in 156 patients, no significant differences in outcome (operative time, blood loss, postoperative morbidity) were found.

Interestingly, in our patients there was no significant difference in conversion rate between robotic and laparoscopic sigmoid resections. Although it was not statistically significant in our patients (P = .387), there was an overall higher percentage of patients with complicated diverticulitis (CDD types: 2b = diverticulitis with macroabscess; 3c = relapsing diverticulitis with complications) in the robotic group. Published data on conversion rates are very heterogeneous. Consistent with our results, a retrospective review of the National Surgical Quality Improvement Program (NSQIP) database with a comparison of 30-day postoperative outcomes after laparoscopic versus robotic colectomy could not find a difference in conversion rates for a subgroup of sigmoid resections.¹⁶ On the contrary, other studies were published with lower conversion rates for robotic resections, specifically for advanced surgical procedures such as low rectal resections (conversion rates, laparoscopic versus robotic: 17% versus 5%, P = .044).²¹ Another recent study comparing the outcomes of laparoscopic versus robotic elective colectomies was able to demonstrate a lower conversion rate in robotic resections (6.0% versus 11.5%, P < .001).²² Elliott et al. even found higher conversion rates for the robotic approach in comparison to laparoscopy in patients with sigmoid resection for diverticulitis with fistula.²³

Patients with robotic sigmoid resection showed a significantly shorter time to recovery of bowel function. This finding is in accordance with the results of a meta-analysis comparing robotic and laparoscopic colectomies by Chang et al.²⁴ and a review about the role of robotics in colorectal surgery by Mushtaq et al.²⁵ The higher rate of patients with OABP in the robotic group should be mentioned as a possible confounder with regard to postoperative ileus, as OABP was shown to be a relevant factor associated with quicker bowel recovery.²⁶

Education and training are strongly influenced by the adoption of a robotic program for colorectal surgery. With the expansion of robotic surgery to common surgical interventions with excellent laparoscopic results, laparoscopic experience will decrease for many surgeons as robotic surgery in most departments is performed exclusively by one or two designated robotic surgeons. However, a modern surgical department must provide both approaches: robotic surgery for selected surgical procedures as well as laparoscopy not least for surgical emergencies (e.g., perforated diverticulitis).

Limitations of our study are the retrospective, monocentric, not randomized, and not blinded study design and the small number of cases. These limitations must be considered when interpreting the results of this analysis.

Conclusion

The technical advantages of robotic sigmoid resection appear to be beneficial for only a few patients with complicated types of diverticulitis, as there was no significant evidence of better outcomes compared to laparoscopic sigmoid resection in our study cohort. The large number of patients who need to be treated with robotic sigmoid resection so that one patient benefits from the robotic approach has to be seen in relation to the higher costs and the adverse educational effects on laparoscopy. In our opinion, robotic surgery should be performed for highly advanced, minimally invasive procedures where there is strong evidence of better outcomes compared to laparoscopy.

Footnotes

Acknowledgment

We want to thank Mr. Paul Christensen for translation and proofreading service of the article.

Disclosure Statement

No competing financial interests exist.

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