Published online Jun 27, 2021. doi: 10.4240/wjgs.v13.i6.597
Peer-review started: March 15, 2021
First decision: May 4, 2021
Revised: May 4, 2021
Accepted: May 19, 2021
Article in press: May 19, 2021
Published online: June 27, 2021
Processing time: 95 Days and 3.4 Hours
The benefits of laparoscopic approach for right colectomy have been well reported. However, there are some critical surgical steps that are still debated such as intracorporeal anastomosis, central vein ligation (CVL) and complete mesocolic excision (CME). The introduction of the three-dimensional (3D) vision in laparoscopic systems provided some of the advantages of robotic platform; thus, 3D laparoscopic surgery has emerged as a competitive alternative to the robotic one in order to overcome the technical issues of the two-dimensional laparoscopic right colectomy.
In a recent paper, we compare robotic surgery and 3D laparoscopy for right colectomy with CME and intra-corporeal anastomosis. Given our experience in minimally invasive colorectal surgery and driven to such previous effort, we wanted to undertake the present study with the aim to critically appraise our whole experience in the use of 3D laparoscopic system in right colectomy making a comparison with the 2D one. Moreover, we decided to carry out a meta-analysis of available data in order to compare our results to the literature ones in the attempt to increase the statistical power and level of evidence.
The aim of this study is to analyze the results of 3D and 2D laparoscopic right colectomy and to compare it to the published series through a systematic review and meta-analysis.
Personal series: A retrospective study with propensity score matching analysis of patients undergoing laparoscopic right colectomy at Umbria2 Hospitals from January 2014 to March 2020 was performed. Inclusion criteria were adenocarcinoma or neuroendocrine tumour (NET) confirmed by pathological examination limited to the following tumour locations: cecum, ascending colon and hepatic flexure. Exclusion criteria were: malignant lymphoma or other non-cancer cases, and emergency procedures. Locally advanced tumor as well as hepatic metastases or concomitant conditions requiring surgical treatment were not considered exclusion criteria. Propensity scores were calculated by bivariate logistic regression, including the following variables: sex, age, BMI, size of tumor, CME yes or not, complexity grade of concomitant procedure. We matched propensity scores 1:1 with the use of the nearest neighbor methods without replacement. The caliper width was set at 0.2. A CME subgroups analysis was also performed. Meta-analysis: A systematic review was carried out through MEDLINE (PubMed), Embase, Web of Science, Scopus, and The Cochrane Library from January 1980 to 31 October 2020. The following keywords and/or medical subject heading (MeSH) terms were used in combination: “2D”, “two-dimensional”, “3D”, “three-dimensional”, “laparoscopy”, “colon”, “colorectal surgery”, and “right colectomy”. At least one peri-operative outcome of interest should be reported. Studies comparing 3D robotic vision to 2D laparoscopic vision were excluded.
Forty-seven patients of the 2D group were matched to 47 patients of the 3D group. The 3D group showed a favorable trend in terms of mean operative time (170.7 ± 32.9 min vs 183.8 ± 35.4 min; P = 0.053) and a significant lower anastomotic time (16.9 ± 2.3 min vs 19.6 ± 2.9 min, P < 0.001). The CME subgroups analysis showed a shorter anastomotic time (16.5 ± 1.8 min vs 19.9 ± 3.0 min; P < 0.001) and operative time (175.0 ± 38.5 vs 193.7 ± 37.1 min; P = 0.063) in the 3D group. Six studies and our series were included in the meta-analysis with 551 patients (2D group: 291; 3D group: 260).The pooled analysis demonstrated a significant difference in favour of the 3D group regarding the operative time (P < 0.001) and the anastomotic time (P < 0.001) while no differences were identified between groups in terms of blood loss (P = 0.827), LNH yield (P = 0.243), time to first flatus (P = 0.333), postoperative complications (P = 0.718) and length of stay (P = 0.835).
The advantage of the 3D system becomes evident when CME and/or more complex associated procedure are requested significantly reducing both the total operative and the anastomotic time. 3D laparoscopic right colectomy has shorter operative and anastomotic time without affecting the standard lymphadenectomy.
The 3D system seems to allow to shorten the learning curve and to overcome some technical issues of the classic 2D laparosocpy. The value of the 3D laparoscopy becomes better evident when CME has been carried out and/or when more complex associated procedures are requested. Further researches are needed to validate those results.