EAES consensus statement on the use of robotics in general surgery

In the last issue of Surgical Endoscopy, and important consensus document appeared form the European Association of Endoscopic Surgeons (yet the study group is highly international). It is in line with the initiatives of the Fundamentals of Robotic Surgery, presented last week.
The document passes through techniques, components and procedures of robotic surgery, and makes the following statements (each supported by peer reviewed papers cited):

• Robotics can enhance dexterity compared to manual laparoscopic surgery if 6 degrees of freedom are provided
• Robotics did not show added value in single-incision laparoscopic surgery
• Current robotic systems lack haptic feedback making tissue manipulation more difficult
• There is a trade-off between speed and precision. The higher the speed the lower the precision, this holds true for robotics and humans
• Complex tasks in endoscopic surgery are performed better and faster with robotics in an experimental setting
• Surgeon ergonomics of robot-assisted surgery are better than ergonomics of standard endoscopic techniques, and can be improved further with optimal design of the workstation
• Robotic surgery is a specific surgical field that requires a new set of skills. Training for robotic surgery should be done using a formal curriculum for basic skills and for specific procedures
• Robotic cholecystectomy has comparable clinical outcomes to standard laparoscopic cholecystectomy
• Robotic single-site cholecystectomy has comparable outcomes to laparoscopic singleincision cholecystectomy in selected cases of uncomplicated gallbladder disease. There are reports of device malfunction and technique related complications
• Robotic Single-Site Cholecystectomy may potentially overcome some of the technical limitations encountered in Single-Site Laparoscopic Cholecystectomy
• Additional dedicated training and education are necessary prior to using the robotic single-site access port and system
• Robotic assistance may facilitate complex biliary surgery, particularly bilio-enteric bypass
• Robotic hepatectomy shows comparable clinical outcomes to laparoscopic hepatectomy. The use of robotic assistance may increase the rate of minimally invasive major hepatic resections
• Spleen-preserving distal pancreatectomy may be facilitated by robotic assistance and conversion to open surgery may be reduced
• Robotic pancreatico-duodenectomy shows comparable results to both open and laparoscopic equivalents in selected patients, with a tendency of reduced operative blood loss.
• Robot-assisted fundoplication provides comparable clinical outcomes to laparoscopic fundoplication in the treatment of reflux disease
• Robotic repair of large hiatal hernias appears to be safe. Comparative studies are not currently available
• Robot-assisted Heller myotomy for achalasia may result in less perioperative perforations and better quality of life compared to standard endoscopic techniques
• Robotic gastric resection has comparable clinical outcomes to standard laparoscopic gastrectomy for cancer. It may reduce intraoperative blood loss and postoperative length of stay as compared with laparoscopic gastrectomy, but is associated with longer operative time and higher cost
• Robot-assisted thoracoscopic esophagectomy with total mediastinal lymphadenectomy has comparable clinical results
• to standard minimally invasive techniques. There may be a reduced rate of recurrent laryngeal nerve palsy
• The definition of robotic-assisted surgery for rectal cancer is currently not standardized
• Robotic-assisted surgery for rectal cancer has comparable clinical outcomes compared to standard laparoscopic surgery
• Robotic and laparoscopic-assisted surgery for rectal cancer, are equally safe except for lowvolume surgeons
• Studies on the learning curve for robotic proctectomy for rectal cancer are focused on operating time
• Robotic-assisted proctectomy does not provide significant differences in postoperative recovery compared to laparoscopic-assisted surgery for rectal cancer
• Robotic rectopexy for rectal prolapse shows comparable clinical outcomes to the standard laparoscopic counterpart
• Robotic-assisted proctectomy for rectal cancer shows no significant differences in quality of histopathology metrics and survival rates compared with the laparoscopic counterpart
• Robotic rectopexy for rectal prolapse shows comparable clinical outcomes to the standard laparoscopic counterpart
• Robotic-assisted colectomy shows comparable clinical outcomes to standard laparoscopic colectomy
• Robotic-assisted colectomy performed by low-volume surgeons may result in increased rates of postoperative complications when comparedto the rates following high-volume expert surgeons
• There is limited literature assessing the histological extent of robotic-assisted segmental colectomy for colon cancer
• Robotic-assisted bariatric surgery shows comparable clinical outcomes to standard laparoscopic bariatric surgery
• Robotic splenectomy and partial splenectomy have comparable clinical outcomes to standard laparoscopic splenectomy
• Robotic splenectomy and subtotal splenectomy have longer operative time and higher costs compared to standard laparoscopic ones
• Robotic adrenalectomy has comparable clinical outcomes compared to standard laparoscopic adrenalecotmy
• Robotic-assisted transaxillary thyroidectomy has comparative clinical outcome to endoscopic transaxillary thyroidectomy
• Robotic and endoscopic thyroidectomy showed comparable operative time and postoperative outcomes with the exception of a higher risk of transient hypocalcemia in the robotic approach
• Robotic-assisted transaxillary thyroidectomy achieves same quality of histopathology metrics when compared to endoscopic approach
• Robotic-assisted donor nephrectomy has comparable clinical outcomes when compared to standard laparoscopic donor nephrectomy, even when a right nephrectomy is performed with a less favorable vascular anatomy
• Robotic general surgery is more expensive than conventional laparoscopic surgery with comparable clinical outcomes

Read more in the article! (The authors' draft version is available here.)