BACKGROUND: We aimed to compare outcomes and cost effectiveness of extra-corporeal anastomosis (ECA) versus intra-corporeal anastomosis (ICA) for laparoscopic right hemicolectomy using the National Surgical Quality Improvement Programme data.
METHODS: Patients who underwent elective laparoscopic right hemicolectomy for colon cancer from January 2018 to December 2022 were identified. Non-cancer diagnoses, emergency procedures or synchronous resection of other organs were excluded. Surgical characteristics, peri-operative outcomes, long-term survival and hospitalisation costs were compared. Incremental cost-effectiveness ratio (ICER) was used to evaluate cost-effectiveness.
RESULTS: A total of 223 patients (175 ECA, 48 ICA) were included in the analysis. Both cohorts exhibited comparable baseline patient, comorbidity, and tumour characteristics. Distribution of pathological TMN stage, tumour largest dimension, total lymph node harvest and resection margin lengths were statistically similar. ICA was associated with a longer median operative duration compared with ECA (255 min vs. 220 min, P < 0.001). There was a quicker time to gastrointestinal recovery, with a shorter median hospital stay in the ICA group (4.0 versus 5.0 days, P = 0.001). Overall complication rates were comparable. ICA was associated with a higher surgical procedure cost (£6301.57 versus £4998.52, P < 0.001), but lower costs for ward accommodation (£1679.05 versus £2420.15, P = 0.001) and treatment (£3774.55 versus £4895.14, P = 0.009), with a 4.5% reduced overall cost compared with ECA. The ICER of -£3323.58 showed ICA to be more cost effective than ECA, across a range of willingness-to-pay thresholds.
CONCLUSIONS: ICA in laparoscopic right hemicolectomy is associated with quicker post-operative recovery and may be more cost effective compared with ECA, despite increased operative costs.

OBJECTIVE: Restoring bowel continuity after laparoscopic right hemicolectomy with an intra-corporeal (IC) rather than an extra-corporeal (EC) ileocolic anastomosis may offer advantages in post-operative recovery. The aim of this study was to compare bowel function recovery between these two techniques, in a context of complete mesocolic excision within an enhanced recovery after surgery (ERAS) protocol.
METHODS: All consecutive patients who underwent oncologic laparoscopic right hemicolectomy from January 2012 to February 2021 in our institution were included in the study. Data were gathered from the prospectively maintained official ERAS (EIAS) database and completed through our institution\'s electronic health records. The primary endpoint was prolonged post-operative ileus (PPOI), defined as the need to insert a nasogastric tube, or refractory nausea VAS > 4, on or after the third post-operative day. Secondary endpoints were post-operative pain, morbidity and length of hospital stay (LoS). Groups were compared before and after propensity score matching based on age, gender, ASA score, use of epidural analgesia and post-operative complications.
RESULTS: A total of 108 patients met the inclusion criteria, 36 (30%) had IC and 72 (70%) EC anastomosis. In the unmatched population, baseline characteristics were similar except for more frequent use of epidural analgesia in the EC group (62 (72.9%) vs. 17 (47.2), p = 0.007). PSM analysis was carried out. Operative time was longer in the IC group (197 min (176-223) vs. 160 (140-189), p < 0.001). The rate of PPOI was similar (2 (5.6%) patients in the IC group vs. 10 (11.6%) in the EC group (p = 0.306)), but time to frist passage of flatus and stool was shorter in the IC group. There was no difference in morbidity but patients after IC anastomosis had lower pain VAS scores at 24 h (p = 0.004) and a trend for a shorter LoS (6 (5-8) days vs 7 (5-10) in the EC group, p = 0.054). After PSM, there were 36 patients in each group. PPOI, time to first flatus and stool, morbidity and LoS were not significantly different although there was a trend for better recovery outcomes in the IC group. Patients in the IC group had significantly longer operative times but less pain at 24 h.
CONCLUSIONS: Although IC anastomosis was not significantly associated to lower rates of PPOI, it showed trends of faster recovery and significantly less post-operative pain at the expense of longer operating times.

OBJECTIVE: Robotic assistance could increase the rate of ileo-colic intra-corporeal anastomosis (ICA) during robotic right colectomy (RRC). However, although robotic ICA can be accomplished with several different technical variants, it is not clear whether some of these technical details should be preferred. An evaluation of the possible advantage of one respect to another would be useful.
METHODS: We conducted a systematic review of literature on technical details of robotic ileo-colic ICA, from which we performed a meta-analysis of clinical outcomes. The extracted data allowed a comparative analysis regarding the outcome of overall complication (OC), bleeding rate (BR) and leakage rate (LR), between (1) mechanical anastomosis with robotic stapler, versus laparoscopic stapler, versus totally hand-sewn anastomosis and (2) closure of enterocolotomy with manual double layer, versus single layer, versus stapled.
RESULTS: A total of 30 studies including 2066 patients were selected. Globally, the side-to-side, isoperistaltic anastomosis, realized with laparoscopic staplers, and double-layer closure for enterocolotomy, is the most common technique used. According to the meta-analysis, the use of robotic stapler was significantly associated with a reduction of the BR with respect to mechanical anastomosis with laparoscopic stapler or totally hand-sewn anastomosis. None of the other technical aspects significantly influenced the outcomes.
CONCLUSIONS: ICA fashioning during RRC can be accomplished with several technical variants without evidence of a clear superiority of anyone of these techniques. Although the use of robotic staplers could be associated with some benefits, further studies are necessary to draw conclusions.

OBJECTIVE: The aim of the present systematic review and meta-analysis is to compare laparoscopic right colectomy (LRC) versus robotic right colectomy (RRC) using homogeneous subgroup analyses for extra-corporeal anastomosis (EA) and intra-corporeal anastomosis (IA).
METHODS: MEDLINE, Scopus, and Web of Science databases were searched up to April 2020 for prospective or retrospective studies comparing LRC versus RRC on at least one short- or long-term outcome. The primary outcome was the length of hospital stay (LOS). The secondary outcomes included operative and pathological results, survival, and total costs. LRC and RRC were compared using three homogeneous subgroups: without distinction by the type of anastomosis, EA only, and IA only. Pooled data analyses were performed using mean difference (MD) and random effects model.
RESULTS: Thirty-seven of 448 studies were selected. The included patients were 21,397 for the LRC group and 2796 for the RRC group. Regardless for the type of anastomosis, RRC showed shorter LOS, lower blood loss, lower conversion rate, shorter time to flatus, and lower overall complication rate compared with LRC, but longer operative time and higher total costs. In the EA subgroup, RRC showed similar LOS, longer operative time, and higher costs compared with LRC, the other outcomes being similar. In the IA subgroup, RRC showed shorter LOS and longer operative time compared with LRC, with no difference for the remaining outcomes.
CONCLUSIONS: Most included articles are retrospective, providing low-quality evidence and limiting conclusions. The more frequent use of the IA seems to explain the advantages of RRC over LRC.

The objective of the study was to review the technical and peri-operative outcomes using the da Vinci Xi (dVXi) and da Vinci Si (dVSi) models with suprapubic port placement (SPPP) or traditional port placements (TPP) during a robotic right hemicolectomy (RRHC). A retrospective review was undertaken of prospectively maintained databases of RRHC performed by two senior colorectal surgeons in the USA and Australia. Data were prospectively collected for patient demographics, intra-operative technical outcomes and peri-operative clinical outcomes. A cohort of 138 patients underwent RRHC between 2013 and 2017: 134 (97%) had intra-corporeal anastomoses (ICA), 50% for polyp disease and 38% for cancer. 16 (12%) patients had post-operative complications, 11 (8%) of whom had only one complication. There were five (4%) anaemias requiring transfusion; five (4%) anastomotic bleeds; one (1%) leucocytosis/sepsis; two (1%) paralytic ileus; and two (1%) delayed readmissions. There were no conversions to open operations, anastomotic leaks, 30-day readmissions, or 30-day mortalities. With dVSi compared to dVXi, median (IQR) total operation time (TOT) reduced by 16% [134 (118-169) min versus 113 (90-132), p < 0.001]. dVXi had shorter console times (CST) [75 (62-97) min vs 94 (77-108), p = 0.004]. SPPP seemed more advantageous than TPP with less CST [75 (60-98) min versus 85 (70-106), p = 0.02]; less TOT [110 (90-130) min versus 130 (108-167), p < 0.001]; and shorter LOS [2 (2-3) days versus 3(2-3), p = 0.03]. There are operative technical improvements and peri-operative patient clinical benefits during RRHC with ICA using either da Vinci models or port placement configurations. It appears more advantageous to use dVXi with SPPP configuration as our preferred setup for RHHC. Many gastrointestinal surgeons foresee potential benefits of robotic surgery (RS) over conventional laparoscopic surgery, hence evaluation of RS in both routine and more complex operations is needed (Kwak and Kim in J Robot Surg 5:65-72, 2011).

UNASSIGNED: Intra-corporeal delta-shaped anastomosis (IDA) is an important development in laparoscopic digestive-tract reconstruction. We applied it in laparoscopic right hemicolectomy for right colon cancer and compared the short-term outcomes between the patients treated with IDA and conventional extracorporeal anastomosis (EA).
UNASSIGNED: Between 1 January 2016 and 1 October 2017, 36 and 50 patients who underwent IDA and EA, respectively, were included. Data on clinicopathological characteristics, surgical outcomes, post-operative recovery and complications were collected and compared between the two groups.
UNASSIGNED: Surgical outcomes and clinicopathological characteristics were similar between the two groups except the length of incision, which was significantly shorter in the IDA group than in the EA group (4.6 ± 0.6 vs 5.6 ± 0.7 cm, P < 0.001). The time to ground activities, fluid diet intake and post-operative hospitalization did not differ between the groups; however, the time to first flatus was significantly shorter in the IDA group than in the EA group (2.8 ± 0.5 vs 3.2 ± 0.8 days, P = 0.004). The post-operative visual analogue scale for pain was lower in the IDA group than in the EA group on post-operative Day 1 (4.0 ± 0.7 vs 4.5 ± 1.0, P = 0.002) and post-operative Day 3 (2.7 ± 0.6 vs 3.4 ± 0.6, P < 0.001). The surgical complication rates were 8.3 and 16.0% in the IDA and EA groups (P = 0.470), respectively. No complications such as anastomotic bleeding, stenosis and leakage occurred in any patient.
UNASSIGNED: IDA is safe and feasible and shows more satisfactory short-term outcomes than EA.

The role of laparoscopy for right colectomy remains controversial - largely because of a lack of standardization of the operative procedure, including a diversity of techniques including laparoscopy-assisted cases with extra-corporeal anastomosis and totally laparoscopic procedures with intra-corporeal anastomosis.
METHODS: The charts of all patients who underwent right colectomy by a totally laparoscopic approach in our service since 2004 were reviewed and pre-, intra-, and postoperative data were collected.
RESULTS: Eighty-two patients underwent totally laparoscopic right colectomy; of these, 32 had a BMI greater than 20 kg/m2 (39%). The mean operative duration was 113 minutes. In most cases, the operative specimen was extracted through a supra-pubic Pfannenstiel incision measuring 4-6 cm in length. Three cases were converted to a laparoscopy-assisted technique (in order to control the ileo-cecal vascular pedicle because of extensive nodal invasion in two cases, and to evaluate a hepatic flexure polyp in the third case). Overall morbidity was 29.3% and parietal morbidity was only 9.8%; there was no difference in morbidity between obese patients (BMI>30 kg/m2) and non-obese patients (BMI<30 kg/m2). The mean duration of hospitalization was 9 days and two patients developed ventral hernia in the extraction incision in long-term follow-up.
CONCLUSIONS: These satisfactory results show that the totally laparoscopic approach to right colectomy is technically feasible and safe, even in obese patients. In addition, the very low rate of parietal complications is an argument in favor of this approach.

OBJECTIVE: In laparoscopic distal gastrectomy for gastric cancer, most surgeons prefer extra-corporeal anastomosis because of technical challenges and unfamiliarity with intra-corporeal anastomosis. Herein, we report the feasibility and safety of intra-corporeal Billroth-II anastomosis in gastric cancer.
METHODS: From April 2004 to March 2011, 130 underwent totally laparoscopic distal gastrectomy with intra-corporeal Billroth-II reconstruction, and 269 patients underwent laparoscopy-assisted distal gastrectomy with extra-corporeal Billroth-II reconstruction. Surgical efficacies and outcomes between two groups were compared.
RESULTS: There were no differences in demographics and clinicopathological characteristics. The mean operation and reconstruction times of totally laparoscopic distal gastrectomy were statistically shorter than laparoscopy-assisted distal gastrectomy (P = 0.019; P < 0.001). Anastomosis-related complications were observed in 11 (8.5%) totally laparoscopic distal gastrectomy and 21 (7.8%) laparoscopy-assisted distal gastrectomy patients, and the incidence of these events was not significantly different. Post-operative hospital stays for totally laparoscopic distal gastrectomy were shorter than laparoscopy-assisted distal gastrectomy patients (8.3 ± 3.2 days vs. 9.9 ± 5.3 days, respectively; P = 0.016), and the number of times parenteral analgesic administration was required in laparoscopy-assisted distal gastrectomy patients was more frequent after surgery.
CONCLUSIONS: Intra-corporeal Billroth-II anastomosis is a feasible procedure and can be safely performed with the proper experience for laparoscopic distal gastrectomy. This method may be less time consuming and may produce a more cosmetic result.