EP463 - Comparative Outcomes of Robotic Versus Laparoscopic Total Proctocolectomy

Purpose/Background: Total proctocolectomy (TPC) with ileostomy is a standard operative option for patients with inflammatory bowel disease (IBD), inherited polyposis syndromes, and synchronous or diffuse colorectal malignancy. While laparoscopic TPC is associated with improved postoperative outcomes relative to open surgery, the benefits of the robotic approach-considered technically challenging due to the potential need for re-docking-is unclear. We hypothesized that robotic TPC is associated with lower rates of conversion to open surgery compared with a laparoscopic approach.

Methods/Interventions: We performed a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database and proctectomy participant use files (2016-2023). We identified all patients undergoing an elective TPC for IBD or malignancy and stratified by planned surgical approach (laparoscopic versus robotic). The primary outcome was conversion to open surgery. Secondary outcomes included operative time and rates of postoperative organ space infection, ileus, acute kidney injury (AKI), transfusion, deep venous thrombosis or pulmonary embolism, reoperation, and 30-day readmission. Covariates included patient demographics and comorbidities, indication, preoperative chemotherapy and radiation, and chronic steroid use. The nonparametric test of trend was used to evaluate change in robotic TPC utilization over time. Kruskal-Wallis and chi-squared tests were used for continuous and categorical variables, respectively, with multivariable regressions for outcome associations.

Results/Outcomes: Among 1,995 patients, 1,465 (73%) underwent laparoscopic and 530 (27%) robotic TPC. Robotic utilization for elective, minimally invasive TPC increased from 13% in 2016 to 44% in 2023 (p < 0.001). Patients undergoing a robotic approach were more frequently male (59.1 vs. 50.0%, p< 0.001) and less likely to have IBD (52.6 vs. 67.9%, p< 0.001) or chronic steroid use (36.2 vs. 46.6%, p< 0.001). On univariate analysis, robotic TPC was associated with lower conversion rates (5.5% vs. 9.1%, p=0.01) but longer operative time (398 vs. 310 minutes, p< 0.001) and higher rates of organ space infection (12.1 vs. 7.4%, p< 0.001), AKI (3.8 vs. 1.3%, p< 0.001), and 30-day readmission (19.8 vs. 15.5%, p=0.02). Multivariable analysis demonstrated that robotic TPC was associated with a 45% reduction in the conversion rate (OR=0.55 [95% Confidence Interval (CI) 0.36-0.85]) but increased operative time (β=79 minutes [95%CI 67-91]) and higher rates of organ space infection (OR=1.68 [95%CI 1.19-2.35]) and AKI (OR = 2.82 [95%CI 1.45-5.50]). The robotic approach trended toward higher rates of 30-day readmission (OR=1.28 [95%CI 0.98-1.67]) but not reoperation. Among those readmitted, the robotic approach was associated with more wound and organ space infections (36.0 vs. 29.3%, p=0.01).

Conclusion/Discussion: Utilization of robotic total proctocolectomy has increased significantly across NSQIP institutions. Compared to laparoscopic TPC, the robotic approach is associated with significantly lower conversion rates but longer operative time and higher rates of postoperative AKI and organ space infections. Further study is needed to identify drivers of organ space infection and strategies to mitigate this risk.

Figure 1. Perioperative outcomes following multivariable logistic regression
Figure 1 demonstrates the odds ratios reflecting the effect of a robotic approach to total proctocolectomy relative to a laparoscopic approach, following multivariable regression controlling for patient demographics, comorbidities, and indication for surgery. Error bars represent 95% confidence intervals, and * indicates significance at the p<0.05 level.