P402 - Morbid Obesity And The Robot: Does Surgical Approach Impact Textbook Outcomes For Right Colectomy?

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Purpose/Background: Patients with obesity present anatomic challenges during surgery for colorectal cancer that predispose them to excess morbidity. The time-sensitive nature of malignancy often does not allow for prolonged periods of optimization. Because of this, minimally invasive approaches can become less effective and may result in conversion to open surgery. In the setting of obesity, robotic right colectomy (RRC) can improve visualization, alter extraction excision location, and increase the accessibility of intracorporeal anastomosis to a broader number of surgeons to overcome some of the challenges of traditional laparoscopic (LAP) approaches. We hypothesized that RRC for right-sided colon cancers improves the rate of conversion to open surgery, reduces total hospitalization (LOS), and globally increases the number of patients who achieve textbook outcome (TBO) as compared to LAP in patients with BMI > 35.

Methods/Interventions: The NSQIP colectomy database was reviewed from 2018 – 2021. Patients were included if they underwent a partial colectomy with anastomosis for a malignant neoplasm of the cecum, ascending colon, or hepatic flexure. Exclusion criteria included preoperative sepsis, concurrent abdominopelvic organ resection, and BMI < 35. Individual demographics and 30-day perioperative outcomes were compared between the LAP and RRC. To provide a global evaluation of performance, the ability of each platform to achieve a TBO was also compared (defined a priori as freedom from NSQIP-defined perioperative complications, conversion to open, length of stay > 5 days, death, readmission, reoperation, anastomotic leak, or nodal harvest < 12).

Results/Outcomes: A total of 1982 patients meeting all study criteria were identified: LAP 1586 (80.0%); RRC 396 (20.0%). LAP patients were on average older and RRC patients had higher BMI. Other demographics, comorbidities, and pathologic stage at surgery were similar (Table 1). Less than 2% of patients received perioperative chemotherapy. RRC had a higher proportion of patients who achieved TBO (64.8% vs 55.4%, p< 0.001). Operative time was greater for RRC (208 vs. 162 minutes, p< 0.001) while LOS and rate of conversion to open were reduced (4.1 vs 5.4 days, and 5.3% vs 10.2% respectively, p < 0.01 for all). RRC Patients who did not achieve TBO were more likely to require reoperation, readmission, or blood transfusion while LAP patients were more likely to have LOS > 5 days or need to convert to open at the index operation (Table 1).

Conclusion/Discussion: The study is limited by the biases inherent to large databases and its retrospective design. This study also is not able to account for institutional practice patterns and individual surgeon level of training, experience, and annual colectomy volume which have been demonstrated to affect perioperative outcomes after colectomy.
RRC may improve the proportion of patients who can achieve TBO as opposed to LAP in patients with BMI > 35. From a surgical outcomes perspective, future studies are needed investigate the oncologic safety of long-term optimization strategies prior to surgery for colon cancer and what role if any neoadjuvant chemotherapy has in this high risk cohort.