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COMPARATIVE OUTCOMES OF ROBOTIC, LAPAROSCOPIC, AND OPEN COMPLETION PROCTECTOMY WITH ILEOANAL POUCH ANASTOMOSIS IN ULCERATIVE COLITIS: ANALYSIS FROM 2015 TO 2023
Attila Ulkucu
*, Imran Khan, Hermann Kessler
Colorectal Surgery, Cleveland Clinic, Cleveland, OH
Background: Optimal surgical approach for completion proctectomy with ileoanal pouch anastomosis (IPAA) as stage two in three-staged restorative proctocolectomy for ulcerative colitis (UC) remains uncertain.
This study compares robotic, laparoscopic, and open surgeries to identify the safest and most efficient technique.
Methods: A retrospective analysis was conducted on 365 UC patients who underwent completion proctectomy with IPAA between 2015 and 2023. Surgical approaches included laparoscopic (n = 240), open (n = 101), and robotic surgeries (n = 24). Patient demographics, perioperative variables, and postoperative outcomes were collected and analyzed.
Results: Of the cohort, 47% were women, mean age was 42 (±15.8) years, and mean BMI was 26.5 kg/m
2 (±5.5). Patients who had open surgery tended to be older (average age: 46.7 years) than those receiving laparoscopic (39.2 years) and robotic surgeries (38.5 years) (p=0.0001). Open surgery group also had a higher BMI (28 kg/m
2) than laparoscopic (26 kg/m
2) and robotic groups (27 kg/m
2) (p=0.04). Robotic surgery, primarily employed for medically refractory cases (79%), demonstrated the highest mean operative duration (303 minutes) compared to laparoscopic (254 minutes) and open approaches (269 minutes) (p=0.01). Open surgery exhibited the highest postoperative complication (29%) and surgical site infection (SSI) rates (16%), surpassing laparoscopic (15% complications; 7% SSIs) and robotic procedures (13% complications; 4% SSIs) (p=0.008 and p = 0.01, respectively). Unplanned readmissions were significantly linked to surgical approach (p=0.02), predominantly following laparoscopic procedures (Table). Pouch failure just occurred in one patient following an open operation, but not in other types of surgeries. Multivariate analysis showed a moderate correlation between higher BMI and extended operative times in robotic surgeries (r=0.54), with outpatients` office visit inversely related to BMI in all types of surgeries (r=-0.56) (Figure). Male gender is observed to be associated with higher postoperative complications in laparoscopic surgery (OR: 3.37) but lower risk in open surgery (OR: 0.5). The median clinical follow-up period was comparable across surgical types, averaging 58 months for laparoscopic, 61 months for open, and 62 months for robotic surgery.
Conclusion: In a selected cohort of patients, robotic completion proctectomy with IPAA in UC may have less postoperative complications and infections compared to open and laparoscopic surgery, despite longer operative times. Laparoscopic and robotic approach may both be applied with favorable morbidity. It must be taken into consideration that this study is limited by the small number of robotic cases and potential selection bias, as the surgical approach was influenced by preoperative patient conditions, surgeon’s expertise and patient preference.
Figure: Correlation Matrices and Scatterplot Analysis of Key Continuous Variables Across Surgical Approaches in Completion Proctectomy with IPAAThis figure presents the correlation matrices and scatterplot analyses of BMI, age at surgery, surgical duration, and follow-up period (FUP) stratified by surgical approach (laparoscopic, open, robotic). The correlation coefficients, estimated using a row-wise method, reveal distinct patterns across surgical modalities. Notable findings include a stronger correlation between BMI and surgical duration in robotic surgeries compared to laparoscopic or open procedures, and the inverse association between FUP and surgical duration in open cases.
Table: Comparison of Completion Proctectomy with IPAA Across Types of Surgery
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