A comparison between Open, Laparoscopic, and Robotic Techniques in General Surgery with a particular focus on Colorectal and Hepatobiliary surgery

Introduction. Colorectal cancer (CRC) is a common tumour and a leading cause of death. Up to 70% of the patients present with or will develop distant metastasis being the liver the most common site of disease recurrence. Surgery is one of the mainstays within the multimodal treatment of CRC. In rectal surgery, the total mesorectal excision (TME) is a crucial step while in liver surgery, accurate planning of the resection is required to allow the complete tumour removal preserving an adequate liver remnant. Minimally invasive surgery (MIS) is still far from being considered a gold standard but its use is in progressive expansion in both colorectal and liver surgery owing to the better short-term outcomes and the at least non-inferiority of MIS over open surgery. However, within the minimally invasive techniques, no clear benefits of the robotic platform have been demonstrated yet. The aims of this study are to compare laparoscopic and robotic surgery for lower rectum cancer and to compare open and MIS for the treatment of the first occurrence of liver metastasis from colorectal adenocarcinoma in terms of short and long-term outcomes. Material and Methods. During the study period, from November 2018 to August 2021, all the patients undergoing anterior resection of the rectum with a colorectal anastomosis for lower rectum cancer and all the patients undergoing liver rection for the first occurrence of metastasis from colorectal adenocarcinoma were prospectively entered into a dedicated database. Demographic aspects, tumour characteristics, perioperative data, pathological results, and long-term outcomes were evaluated and retrospectively analysed. Results. Fifteen patients underwent anterior resection of the rectum, 8 were treated with laparoscopy and 7 with the robotic technique. No differences were found in the preoperative data. However, the great majority of the patients receiving neoadjuvant therapies were treated with the robotic technique. A significantly longer surgery time was associated with the robotic technique while postoperative course and morbidity rates were similar. The specimens from the patients treated with the robotic technique presented with significantly smaller tumours, lower T stage, lower number of nodes harvested (but with a mean above the required number of 12), wider CMR, and similar quality of mesorectum excision. All the patients are actually alive but 3 of them experienced disease recurrence. No differences in DFS were found (p=0.165). Fifty-one patients underwent liver resection, 41 were treated with open surgery and 10 with MIS. One patient in the open group died within 15 days after surgery (postoperative mortality rate of 2%) and she was excluded from the analysis. No significant differences were found in patient characteristics while patients with a significantly higher number of lesions were treated with the open technique. Operative results were similar except for the Pringle maneuver which was more frequently used in open surgery. Postoperative morbidity rate and length of hospital stay were significantly higher in the open group. No differences were found in the pathological specimen, in particular in the resection margin and KRAS status. The estimated mean OS was 46 months (95% CI 42-50). All the dead patients were treated with an open technique, thus precluding further comparative analysis. Sixty percent of the patients experienced recurrence. The estimated mean and median DFS was 22 months (95% CI 15,6-29) and 8 months. No differences were found for the techniques in DFS (p=0.164) even stratifying the analysis for several factors including the number of lesions, the technique used to treat primary cancer (p=0.148), and margin status (p=0.153), KRAS mutation (p=0.735). Conclusions. For difficult cases of rectal surgery, including patients with higher BMI and those who received neoadjuvant treatment, the robotic technique may allow at least similar or better oncological results compared to laparoscopy. For liver surgery, MIS and parenchymal sparing resections should be preferred whenever technically feasible providing better short-term outcomes and similar oncologic results compared to open surgery and more extended resections. The expertise and the multidisciplinary evaluation are of paramount importance to provide the patients with the best treatment.