ROBOTIC VERSUS LAPAROSCOPIC INTRACORPOREAL ANASTOMOSIS IN RIGHT COLON CANCER SURGERY: ANALYSIS OF PATIENTS’ OPERATIVE OUTCOMES AND OPERATORS’ CURRENT ATTITUDES BY MEANS OF A MONOCENTRIC CLINICAL PROSPECTIVE STUDY AND A EUROPEAN MULTICENTRIC RETROSPECTIVE STUDY

Background. Whereas laparoscopy proved to have better operative outcomes than open surgery over the years, robotic surgery provided no clear advantages over laparoscopy despite its more advanced technical features. However, robotic technology might help to achieve some advantageous procedures which are generally regarded as challenging, such as performing an intracorporeal anastomosis during a right colectomy. The objectives of this research project were: 1) to compare the outcomes of laparoscopic and robotic surgery in the case of a right colectomy with intracorporeal anastomosis for colon cancer; 2) to find any factors influencing surgical decisions and outcomes. Methods. First, we conducted a meta-analysis comparing the outcomes of laparoscopic and robotic right colectomy, providing subgroup analyses for both extracorporeal and intracorporeal anastomosis. Second, we conducted a monocentric prospective clinical study comparing laparoscopic and robotic right colectomy with intracorporeal anastomosis only. Thereby, we participated in the European mul-ticentric retrospective study MERCY (Minimally invasivE surgery for oncologic Right ColectomY). This study investigated the most relevant issues of minimally invasive right colectomy, such as the comparison between extracorporeal and intracorporeal anastomosis, the search for predictors of surgical outcomes and factors influencing the choice of surgical approach and type of anastomosis, the description of current trends in the minimally invasive surgery of right colon cancer, and the comparison between robotic and laparoscopic right colectomy with intracorporeal anastomosis. Results. We performed the largest meta-analysis on laparoscopic vs robotic right colectomy currently available, providing the first subgroup analysis for intracorporeal anastomosis only. In the pooled data analysis, the better results of robotic surgery are presumably attributable to the clear prevalence of the intracorporeal anastomosis in the robotic group rather than to the surgical approach itself. The subgroup analysis for intracorporeal anastomosis found a shorter hospital stay after robotic right colectomy, but the retrospective nature of almost all included studies cannot be excluded as an explanation. However no higher rate of anastomotic leak was found after laparoscopic surgery, suggesting that laparoscopy is as effective and safe as robotic surgery in fashioning an intracorporeal anastomosis. Our clinical research found no differences comparing 24 laparoscopic vs 40 robotic right colectomies with intracor-poreal anastomosis, except a longer operative time in the robotic group. Thereby, the MERCY study found that age, male gender, BMI, ASA score, robotic surgery, and intracorporeal anastomosis were significant predictors of surgical outcomes when performing a right colectomy for cancer. Moreover, the intracorporeal anastomosis has become increasingly widespread over the years. In this regard, age > 90 years, ASA IV, stage cT4, multivisceral resection and intraoperative hemodynamic instability were identified as factors influencing the choice of the type of anastomosis to perform. The comparison between robotic and laparoscopic right colectomy with intracorporeal anastomosis did not find any difference in terms of short-term outcomes and survivals supporting robotic surgery over laparoscopy. Conclusions. The robotic surgery is not superior to laparoscopy in performing a right colectomy with intracorporeal anastomosis for cancer. However, the debate should be directed towards the definition of ever more effective criteria for selecting patients for a specific minimally invasive approach and a specific type of anastomosis. Finally, the evidence collected throughout our research was summarized and formalized in the elaboration of the 2021 guidelines for robotic right colectomy of the Association Française de Chirurgie (AFC), in which we have taken an active part.