Laparoscopic Surgery Systematic Review

This assignment requires the development of a systematic review and research proposal investigating laparoscopic surgery outcomes. The focus is on comparing laparoscopic procedures with open surgeries, analyzing patient-reported outcomes like pain scores, recovery times, and surgical site complications. The assignment involves formulating research questions, conducting a comprehensive literature search using databases like PubMed and Embase, critically appraising studies for methodological quality, synthesizing findings through meta-analysis if appropriate, and presenting the results in a structured report.

1Running head: MEDICINE AND HEALTH
Medicine and Health
Name of student:
Name of university:
Author note:

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Table of Contents
Abstract......................................................................................................................................4
Introduction................................................................................................................................5
Aims............................................................................................................................................6
Objective....................................................................................................................................6
Research question......................................................................................................................7
Background literature review....................................................................................................7
Methodology.............................................................................................................................12
Research protocol....................................................................................................................19
PICOS framework................................................................................................................19
Materials and methods.........................................................................................................20
Search strategy.....................................................................................................................20
Key terms.............................................................................................................................20
Study selection.....................................................................................................................22
Quality assessment...............................................................................................................22
Appraisal of rigor.................................................................................................................23
Ethical appraisal..................................................................................................................23
Data extraction.....................................................................................................................24
Data analysis........................................................................................................................26
Limitations................................................................................................................................26
Dissemination and sharing of the research findings................................................................28

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References................................................................................................................................29
Appendices...............................................................................................................................37

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Is the surgical outcome and costs of robotic-assisted surgery more effective than
Laparoscopic surgery for colorectal cancer surgery?
Abstract
Colorectal cancer refers to the presence of a tumor or lump in the colon and the rectum. It is
the second most prevalent cancer among humans, after lung cancer. Although, traditional
laparoscopic surgical techniques have been used since decades to treat colorectal cancer, this
surgical procedure has certain limitations. One major limitation related to the use of
laparoscopy is associated with the poor ergonomic postioninig of the surgeons who
participate in the surgery. Other limitations are related to the restricited movements of the
surgical instruments and 2-dimensional imaging of the body organs. To overcome thrse
limitations, recently surgeons have started promoting the use of robotic assisted surgery for
treatment of colorectal cancer. This technique is an emerging one and has several technical
advantages over the conventional laparoscopic procedure. Some of the advantages that
robotic assisted surgery has includes, presence of 3 dimensional imaging, improved
visualisation, tremor filter and well articulated instruments. The procedure involves the
sitting of a surgeon at the robotic console. This is followed by placing the fingers of the
surgeon on the robotic control system. The robotic system thereby translates the movement of
the surgeons' fingers and wrists and operatres the tumor. Thus, it allows better dexterity than
the conventional laparoscopic instruments. Therefore, this systematic review aims to
critically evaluate articles that compare the effects of robotic surgery with those of
laparoscopy, on the benefits that patients may gain. Hence, the research proposal will search
for relevant articles and determine the immediate effects of robotic assisted surgery on
discomfort and pain, length of hospitalisation, patient recovey time and amount of blood loss.
keywords- laparoscopy, robotic assisted surgery, colorectal cancer, benefits

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Introduction
Among the most prevalent forms of cancer is colorectal cancer, which again might be
of different forms such as adenocarcinoma, carcinoid tumors and lymphoma. The incidence
of colorectal cancer in the UK is noteworthy, as well as the mortality rate, drawing the
attention of health care professionals to come up with suitable treatment strategies (Siegel et
al. 2017). Colorectal cancer is the fourth most common form of cancer in the country. In both
females and males, it is the third most common form of cancer. There were 41,300 new cases
of colorectal cancer being reported in the year 2014. This implied diagnosis o around 110
cases each day. Around 15,903 deaths occurred in the year 2014 due to this form of cancer.
Colorectal cancer is the second most common cause of cancer in the country and accounts for
10% of all cancer deaths (Stewart and Wild 2017).
Surgery has been denoted as the primary treatment option for a patient suffering from
early-stage colorectal cancer. The form of surgery that is to be undertaken is dependent on the
cancer stage and the primary goal of the surgery. There are certain side effects and risks
associated with colorectal surgery, and these are dependent on diverse factors such as
patient’s general health, the extent of the operation and healthcare environment
(Karayiannakis 2016). According to Niitsu et al. (2016), laparoscopic colorectal cancer
surgery is the most widely used form of treatment and healthcare data points out its
advantageous in comparison to open surgery approach. The benefits that this method has to
include the shorter duration of hospital stay, negligible blood loss due to operation ad less
pain suffered by patients. Though initial concerns regarding the adequacy of the extent of
resection and port-site recurrence had been dismissed, different groups of scholars have
pointed out that laparoscopic surgery is not universally accepted. As opined by Yasui et al.
(2017) laparoscopic surgery is much challenging, and there is a number of concerns

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remaining integrated to this process. These are confined space in the pelvis, maintenance of
resection margin and inability to convert to open surgery.
Research is constantly going on in the area of surgery of colorectal cancer surgery and
scientists are attempting to find advanced and novice methods by which the surgical
procedure can be effective and safe as well (Gamagami, Kozak and Kakarla 2017). Robotic
surgery has gained attention in the recent past as a new and advanced method of treating
colorectal cancer. Such form of surgery can be performed with the hep of different techniques
which might include laparoscopic surgery. Research has highlighted that there are different
advantages of using this mode of surgery such as steadiness and 3D surgical view. However,
cost effectiveness is a crucial barrier to implementing robotic surgery method on a larger
scale (Guend et al. 2017).
Against this background there is a need for understanding the relative benefits and
challenges of using robotic-assisted surgery and Laparoscopic surgery for colorectal cancer.
A rigorous comparison and analysis of the two methods are entailed at present. Whether the
surgical outcome and costs of robotic-assisted surgery are better than Laparoscopic surgery
for colorectal cancer surgery would be a praiseworthy topic for research.
Aims
The primary aim of the proposed systematic review is to undertake an evaluation of
costs and surgical outcomes of robotic-assissted surgery in comparison to laproscopic surgery
to understand which is better for colorectal cancer.
Objective
The key objectives of the systematic review proposal are as follows-

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 To understand the cost effectiveness of robotic-assissted surgery in comparison to
laproscopic surgery for colorectal cancer
 To evaluate the surgical outcomes of robotic-assissted surgery in comparison to
laproscopic surgery for colorectal cancer
 To highlight among robotic-assissted surgery and laproscopic surgery can be applied
at large scale in the near future
Research question
The research question that would be addressed in the proposed systematic reviewis as
follows-
Is the surgical outcome and cost of robotic-assisted surgery more effective than
Laparoscopic surgery for colorectal cancer?
Background literature review
Multiple trials have been conducted in the past 5 years in order to prove the cost
effectiveness and safety of robotic-assisted surgery when compared to laproscopic surgical
procedures for colorectal cancer. 9 studies have been compared in this literature review in
order to illustrate the cost effectiveness of robotic surgery and its possible role in improving
clinical outcomes.
Throughout the literature, while making a comparsion between the two surgical
approaches, typical and consistent arguments have been presented by the author in order to
prove which method is more cost effective and feasible regarding colorectal cancer surgery in
recent medical practice. The reviews published till date are of moderate to high quality in
terms of the scientific methodology that has been followed and the hierarchy of evidence
presented in the literature. Nevertheless, the authors failed to provide an universal statement

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or consensus regarding the implementation of robotic-assisted surgery as the best surgical
practice.
Sawada et al. (2015) used the method of propensity score matching and conducted a
matched case-control study in order to evaluate the short-term benefits of robotic-assisted
surgery in case of colorectal cancer. The scores were compared with those of the
conventional laparoscopic surgerical procedures. The study recruited 10 patients with left-
sided colon and rectal cancer, who underwent robotic surgery, and compared them to the
outcomes observed among 20 patients receiving conventional laparoscopic surgery, after
propensity score matching. The results did not show any significant difference in
clinicopathologic outcomes between the two groups. However, the robotic-assisted surgery
took longer operation time than the conventional surgery method. Thus, the study indicated
that apart from operative time no changrs were observed among the two methods and robotic
surgery is a promising tool that can be used for treating colorectal cancer patients.
Taggarshe et al. (2014) argued that robotic surgery is a safe, suitable and feasible
technique for colorectal cancer. The study conducted an extensive literature search and
extracted data related to the operation details, clinical outcomes, blood loss and intraoperative
complications. The review identified that the mean operative time for robotic colonic surgery
was 224 minutes. Furthermore, the mean estimated blood loss was found to be 47.67 mls, and
the post-operative mean morbidity rate was 23%. Thus,the study concluded that although
robotic-assisted surgety was associated with sexual and urinary dysfunction and longer
operation time, it was related to lower blood loss, lower conversions and better visualisation.
Therefore, it was considered to be a feasible technique.
This study was supported by a review that gave a general overview regarding the
potential advantages of robotic surgery over laproscopic surgical approach and also provided

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information on the clinical outcomes (Ielpo et al. 2017). The review also compared 120
robotic colorectal resections with laproscopic rectal surgeries and found that the operative
time was longer for the robotic surgery. The complication rates were found to be less for
robotic surgery (5.4%-43.2%). The review also suggested the presence of higher resection
costs in case of robotic surgery. Thus, it confirmed the excellence of clinical outcomes
following robotic surgey. However, it failed to prove superiority of this procedure over the
conventional laproscopic methods.
The cost-effectiveness of robotic surgery for colorectal cancer were also analysed by a
study that recruited colorectal cancer patients from a large-volume Korean institution (Kim et
al. 2015). The study analysed the costs that had accumulated during robotic and laproscopic
surgeries and found that operation fees, hospital charges and anesthesia fees were higher in
robotic surgery. However, no changes were observed in the fees for pre-operative and post-
operative management. Comparison of the short term outcomes displayed longer operation
time and higher hospital charges in the robotic surgety group. Therefore, the study failed to
provide evidence for the cost-effectiveness of robotic surgery in case of colorectal cancer and
suggested that a well-desgined randomised controlled trial was required to investigate its
effectiveness.
The view that robotic surgery fails to offer any clinical or oncological benefits when
compared to laproscopic surgery was supported by a study that evaluated the long-term
oncological outcomes of the two surgical procedures (Park et al. 2015). It recruited 217
patients with stage I-III rectal cancer and analysed the pre-operative clinicopathological
outcomes. A median follow-up was carried for 58 months. These outcomes failed to show
any significant differences except in the length of hospitalisation and conversion rates.
Robotric surgery showed a 92.8% 5-year survival rate compared to 93.5% in the other
surgical method. Furthermore, no differences were observed in the disease-free survival rates

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and local recurrence rates. Therefore, despite an increased cost, it could not be concluded
that robotic surgery provides a better clinical benefit compared to laproscopy.
The fact that robotic surgery confers a better clinical outcome was argues by a
randomised clinical trial that compared it to conventional laproscopic surgery (Jayne et al.
2017). 471 patients with rectal adenocarcinoma fit for resection were selected from 29 sites,
across 10 countries and a follow-up was conducted. Conversion to open laparotomy was
considered as the primary outcome. The overall rate of conversion was found to be around
10.1% and the overall CRM+ rate was around 5.7%. No statistical difference was observed
between the 2 groups with respect to sexual dysfunction, bladder dysfunction, post-operative
complications and mortality. Thus, the findings suggested that when surgeons with different
experiences perfrom robotic surgery, no advantage is conferred on resection of rectal cancer.
Another study compared the costs and surgical parameters between 25 laproscopic
and 50 robotic surgeries and gathered information on demographic features, surgical
procedures and outcomes (Morelli et al. 2016). On collecting and differentiating the costs
into fixed and variable units, the robotic learning curve was found. This showed a significant
lowering of median operative time and mean costs in laproscopic procedures. The findings
suggested that reduction in operation time and optimisation of instruments contributed to the
improvement in hospitalisation costs in the long run. Thus, the study suggested that although,
robotic surgery is more expensive, efforts to reduce fixed costs are required in order to
mantain the sustainability of the procedure.
The findings were further supported by Tyler et al. (2013) in a restrospective review
that compared the costs and in-hospital outcomes between patients undergoing the two kinds
of surgeries. On using a regression model to compae the procedural outcome differences
while controlling the baseline difference it was found that there was no significant difference

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in the rates of intraoperative or postoperative complications and length of hospitalisation
between the two surgical procedures. However, significantly higher costs were found
associated with colectomy that underwent robotic surgery. Thus, the study provided evidence
to suggest that despite increasing the cost of care, robotic-assisted surgery does not provide
any reduction in morbidity or length of hospital stay.
Zhang et al. (2016) conducted a meta-analysis and opined that robotic-assisted
surgery is a promising approach owing to its safety and efficacy when compared to the
conventional laproscopic approach in case of colorectal surgery. On analysing 24 studies the
meta-analysis concluded that robotic surgery showed lower conversion rates, estimated blood
loss and length of hospital stay. However, the study focused on a need to further evaluate the
cost-efficiency and oncological outcomes for robotic surgery.
Robotic surgery showed an imporovement in short-term outocome in patients during
initial use in another study (Shin 2012). The study compared 30 patients who were treated
with robotic surgery with a similar number of patients treated with laproscopy for colorectal
cancer, followed by an analysis of short-term outcomes and perioperative variables. No
significant differences were found between any peri-operative measures apart from the mean
operating time. Robotic surgery showed an increased operation time and therefore, the study
suggested that this longer operation time might create problems in clinical outcomes among
patients. Therefore, on thorough analysis of the literature review it can be suggested that
although it is well established that robotic surgery is not cost-effective when compared to the
laproscopic methods, there is lack of evidence that can prove its superiority over the
convetional surgical method regarding improvement of clinical outcomes among patients.

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Methodology
A research paradigm refers to the series of agreements and common beliefs that are
shared between researchers and scientists in order to address and understand specific research
problems (Meerwald 2013). They encompass practices that are associated with first principles
of research. The research paradigms are characterised through their ontology, epistemology
and methodology. While ontology focuses on what exists and helps to observe the nature of
reality, epistemology illustrates the perceived relationship of the researcher with the question
that is being discovered (Arghode 2012). This systematic review will follow an ontological
approach an will describe a world view on reality. It will question the presence of reality and
will question the exisitece of multiple realities and single identified reality. The systematic
review will evaluate the clinical efficacy of robotic assisted surgery in colorectal cancer and
will provide evidences to determine whether this surgical method is superior to thew
conventional laparoscopic technique.
The epistemological approach will focus on the sources from which the findings are
obtained, and the reliability of the information source. My ontological view in this context is
that colorectal cancer can be treated by adopting surgical resection, laparoscopic surgery,
colostomy or robotic assited surgery. While removing the tumour, some parts of the adjacent
lymph nodes and the healthy colon often gets removed in these surgical operations. However,
my epistemological approach focuses on the fact that both laparoscopic and robotic assisted
surgery have several adverse health outcomes and also influence some associaited factors
such as, length of stay in hospitals, and healthcare costs. Therefore, epistemology for this
research proposal is principally based on correlating the outcomes with the two surgical
approaches and comparing them to determine which surgery is feasible and safe for patients.
The systematic review will also contain an axiological approach that will question the notions
of worth and will deal with the nature and ethics of the research value.

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I intended to perform this systematic review owing to the fact that robotic assisted surgery
and laparoscopic surgery have revolutionised surgical practices in colorectal cancer, over the
past decades. Laparoscopic surgery has shown several drawbacks that have resulted in
adverse patient outcomes. Technical disadvantages of this surgical approach led to the
adoption of surgical robotrs in rectal surgery. However, the presence of single institution
designs and small sample population have acted as major limitations in exhibited the effects
of the new surgical technique. This systematic review was conducted to overcome these
limitations, and for determining the relative mertis of robotic assisted surgery over
conventional laparoscopic surgery.
On the other hand, methodology refers to the strategic approach that researchers employ
to carry out their research while discovering new knowledge. These three characteristics
work towards creating a holistic view of the way by which researchers view scientific
knowledge. In other words, paradigm encompasses a network of coherent ideas on the
function of researchers and the nature of the world. These paradigms are adhered to by all
researchers and help in conditioning their thinking (Goldkuhl 2012). They underpin the entire
research activity (Goertz and Mahoney 2012). Thus, they are a set of perceptions and beliefs
utilising which all research theories operate. The paradigms are classified into distinct
categories based on the view of reality. The four categories are as follows:
1. Positivism- Positivism is associated with French philosopher, Auguste Comte.
According to positivists, all methods of natural sciences can be applied on social
science practices. The procedures that are followed by natural scientists are applied in
the social context by positivist scientists in order to understand and control the natural
world. These scientists work towards valuing neutrality, performing statistical
measurements, quantifying and observing events that help them in establishing causal
laws (Taylor and Medina 2013). In such a paradigm, the findings remain the same

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irrespective of the methods of data collection and analysis. Thus, it is possible to
generalise the findings beyond the specific sample. This common paradigm is adopted
by researchers in cases where statistical methods are used to establish relationships
between theories, frameworks and models. This paradigm results in the formation of
the most systematic reviews, which address transparency, rigour and bias elimination.
Replicability becomes possible (Houghton, Hunter and Meskell 2012).
2. Interpretative paradigm- Interpretativism or constructivism are related concepts,
which are used as a paradigm in order to understand the world as it is experienced by
others. Positivists differ from constructivists on making assumptions regarding the
nature of realit, the basis of knowledge, its value, source and the role of knowledge in
a research process. The constructivist approach can be traced back to The philosophy
of phenomenology proposed by Edmund Husserl had made the first mention of this
approach (Chan, Fung and Chien 2013).
Therefore, interpretivists state that there lie a multi-layered concept of reality,
which is quite complex. They believe in the power of creativity of people and mention
that people are actively involved in constructing their social reality. The paradigm
further mentions studying of the social world in a natural context, through the eyes of
the respondent. It does not believe in the intervention of the researchers. The findings
depend on the interaction between the research respondents/participants and the
researchers (Reiners 2012). Inductive researchers commonly utilise this paradigm as
they aim to develop certain hypothesis rather than testing the efficacy of an already
existing theory. However, the limitation of this paradigm lies in its failure to
discriminate between fundamental patterns. This results in loss of objectivity.
3. Post-positivism- A philosophy of critical realism influences the paradigm of post-
positivism. This approach is generally differentiated from positivism based on the

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presence of focus on theory falsification (post-positivism) or theory verification
(positivism) (Wahyuni 2012). This can be proved by an example that the presence of
a single black swan proves that the rest of the million swans are white in colour. The
million swans fail to prove that all of them are white (Henderson 2011). Showing
consistency with the positivists, the post-positivists also believe on the presence of an
independent reality that is not influenced by our thoughts, and that such reality can be
studied by the application of scientific methods. However, critical realismalso takes
into account the fact that errors may occur in the observations and that theories can be
modified (Aliyu et al. 2014).
The observations of this approach are generally theory laden. The worldview
and bias of the researcher influence the observations. Multiple measures are used and
the data is triangulated in order to achieve objectivity. This helps in providing a clear
insight into the events that occur in reality. There exist several similarities between
the positivists and the post-positivists. However, the post-postivist paradigm better
caters to the research approaches that are used in social science. The principal purpose
of research, in this paradigm is prediction of results, testing a theory and discovering
associations and the strength of relationship between different variables (Hall,
Griffiths and McKenna 2013). Thus, it can be stated that ontologically the theory
believes in a fixed and static realtiy. Epistemologically, the approach states that
complete access is unavailable for the objective knowledge existing in the world
(critical realism). Furthermore, this paradigm can also be utilised to measure several
variables that remain unobserved such as, anxiety. Thus, it can be stated that this
paradigm helps in designing a powerful research and attracts funding.
4. Critical theory- The critical theory is associated with the Institute for Social Research
and is influenced by Habermas. This paradigm helps in raising the awareness among

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participants and also interrogates discrimination and accepted injustice. The critical
theorists believe in action rather than new discoveries (Scotland 2012). They work
towards briniging about changes that would directly improve the situations and lives
of the oppressed people. The research process using this approach involves complete
participation of the participants and the researchers. The participants work in
designing the questions related to the research (Petty, Thomson and Stew 2012).
They help in collecting data and analysing them, thereby reaping the results of the
research. The ontological aspect states that social, political, historical and cultural
factors continuously contest the truth. On the other hand, the epistemological factor
mentions the co-construction of knowledge between groups and individuals. Thus,
this paradigm helps in establishing the mediation of knowledge by power relations.
The approach methodology focuses on emancipation of research (Chandler 2012).
Both qualitative and quantitive methods are sed by this paradigm in iterative research
plans that involve focus groups, case studies and participant observations.
Parameters Positivism Interpretivism Post-positivism Critical
approach
Reason for the
research
Discovering
laws that govern
universe
Understanding
and describing
human nature
Discovering
laws that are
generalizable
Empowering
people and
changing society
Philosophy Realism Phenomenology Critical realism Critical theory
Ontology One reality Multiple realties
that are socially
constructed
One reality with
multiple
perspectives
Multiple
realities
influenced by
social, political,

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and other values
Knowledge
nature
Objective Subjective Objective Relational
Methodology Quantitative Qualitative Casual
comparitive
Participatory
Data collection
techniques
Questionnaires Interviews,
participant’s
observations
Observations,
Experiments
Philosophic
sagacity
Table 1- Comparison between the different paradigms (Kitchin 2014)
This systematic review is based on quantitative studies that will evaluate and compare the
operation time, postoperative outcome of laparoscopic surgery and robotic assisted surgery
and also will also assess the associated hospital costs. Therefore, this systematic review will
encompass a well defined research question, objectives, data collection from elctornic
databases and the outcomes will be used to generalise the concepts for expecting good future
results.
The systematic review will follow the research paradigm of positivism. It will focus only
on factual knowledge that will be obtained through the measurements and observations of the
research findings from the studies that will be included in the systematic review. My role
will only be restricted to collection and interpretation of data from the research studies and
the corresponding research findings that will be obtained will be usually quantifiable and
observable. The quantifiable observations will lead the research proposal to a statistical
analysis.
This systematic review will be based on close ended or pre-coded questionnaires and
official statistics for discovering the facts related to the research question. Once this method

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has been completed, the findings will be summarised from the obtained valid data to reach a
conclusion. The data that will be produced by this approach as ought to be valid and reliable
and will create provisions for other researchers to replicate the findings in future. Statistical
data in the form of charts and graphs will help in easy categorisation and will facilitate better
comparison between the two surgical approaches.
Furthermore, the research will also adopt a deductive approach as it will test and compare
the effectiveness of the two surgical approaches for treatment of colorectal cancer. This will
creare provisions for using already existing data from the literature, to set assumptions about
the outcomes. The data that will be collected from the published articles will therefore be
used to address the research question of this systematic review. Therefore, the deductive
approach will narrow down the research and will focus more on desigining a research
strategy based on the research question. On the other hand, inductive research approaches are
usually associated with qualitative research. The data is collected and analysed by researchers
who intend to discover new principles and theories related to the research question.

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Research protocol
A research protocol is defined as a plan that contains description of the background
rational purpose design method, statistical analysis and organisation of a clinical research
(Chan et al. 2013). The research protocol for this review will differentiate it from critical
literature review and will include details of the different studies that will be searched
critically appraise and the results of which will be synthesized.
PICOS framework
Conduction of a systematic review is a time consuming process and it is imperative to
the research that enough time must be given while writing and preparing the research
proposal. This research proposal is based on a gantt chart which acts like a time table and
keeps a track of the time span during which certain activities are intended to be
accomplished. The Research question for this particular study is kept as specific and
comprehensive as possible. AP core question Framework is considered while framing the
Research question. This Framework helps in identification of proper therapeutic interventions
and positive health outcomes (Smith et al. 2011). The research question for this proposal is
there food broken down into several components that are mentioned below:
P stands for the problem statement or the population that is be considered. In this
case, the problem is colorectal cancer. I refers to the intervention that is applied on patients
suffering from the problem. The research proposal focuses on two kinds of intervention,
laparoscopic surgery and robotic assisted surgery, respectively. C stands for comparison
between the two proposed surgical interventions. O refers to the outcomes which include
pre-determined benefits that will be obtained from the surgery. Lastly, S refers to the entire

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study design based on which, the research proposal has been framed. The study design will
focus on quantitative studies of meta-analysis of randomised control trials.
PICOS Framework Question concepts
P (population or disease of
interest)
colorectal cancer
I (intervention) robotic assisted surgery and laparoscopic surgery
C (comparison) comparison between the two surgeries
O (outcome) safety feasibility, cost and health benefits
S (study design) quantitative study of meta analysis and randomised
control trials
Table 2- PICOS franmework used for the systematic review
Materials and methods
The research will follow methodology from the Christmas 2009 checklist and
cochrane handbook for systematic review version 5.1.0
Search strategy
Electronic data bases success medline, scopus and the cochrane library was used to
search for articles that were peer reviewed and published in English. Research articles
published prior to 2011 were not included in the study.
Key terms
The search terms which were used to narrow down the literature research work
"robotic assisted", "laparoscopy", "cancer", "benign colorectal cancer", "feasibility",
"safety", "cost effectiveness", "adult patients", "conventional", "traditional laparoscopic",
"robotic surgery" in combination with certain Boolean operators such as or and and. The not
Boolean operator was also utilised to exclude studies that word unpublished or have been

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conducted on patients suffering from other cva medical disorders in addition to colorectal
cancer.
It was ensured that there are no already existing systematic reviews that focus on the
research question by performing a scoping review through common websites.
Database Date
searched
Initial
hits
Results after screening
MEDLINE (24/11)2017 170 27
SCOPUS (24/11)2017 95 19
Cochrane
Library
(24/11)2017 787 33
TOTAL 1052 79
Table 3- Template for searching the electronic databases
Search group1 Search group 2 Search group 3
“Benign Colorectal cancer”,
“cancer”, “adult patients”
*Adolescent or paediatric
patients were not considered
“Laparoscopy”,“conventional”,
“robotic assisted”, “traditional
laparoscopic”, “robotic
surgery”
"Cost effectiveness",
"benefits", "comparing",
"assessing", "safety" ,
"feasibility"
Table 4- Search terms for the systematic review
Notes: Words were combined together using the Boolean operators OR and AND. NOT
was used to exclude studies conducted on patients below 18 years of age.
Limits: 2011 to date.

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English language articles
Quantitative study design- Meta analysis of randomised controlled trials
Table 5- Narrowing down the search

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Study selection
It is imperative for a good quality systematic review to have a rigorous inclusion and
exclusion criteria before beginning the review (Costantino, Montano and Casazza 2015). The
inclusion criteria were as follows. Randomised control trials that were published in English
were considered irrespective of their blinding status. Studies that were conducted on
colorectal cancer patients agent above 18 years were included. All research articles that
compared robotic assisted surgery to laparoscopic surgery after 2011 were selected for the
systematic review. It was ensured that the selected articles contain data on at least one of the
pre-determined health outcomes.
Owing to the fact that this systematic review was based on comparing quantitative
data for the two proposed surgical interventions, all randomised control trials that contained
qualitative data were excluded from the study. Articles published in language other than
English and prior to 2011 word also excluded.
Quality assessment
Critical appraisal refers to the procedure of evaluating and interpreting evidences by a
systematic consideration of data validity, completeness of the report. Methods and
procedures that have been applied, observed conclusions, and compliance with the ethical
codes of practice. Internal validity, on the other hand, refers to the extent to which the results
of a particular study will approximate the truth (Singh 2013). Quality of systematic reviews
therefore encompasses the methodological quality and internal and external validity of the
selected quantitative studies. The following aspects were considered while evaluating the
quality of the research proposal:
 Relevance of the studies to the research question
 The internal validity to avoid biases

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 External validity
 Appropriateness of the data presentation
 Ethical considerations and implications of the two surgical interventions that the
research question intends to evaluate
Appraisal of rigor
The effective Public Health Practice Project Quality Assessment Tool for quantitative
studies was adopted to investigate the quality of all the randomised controlled trials that was
included in the systematic review (Needleman, Clarkson, and Worthington 2013). The
following 8 components were used for this evaluation:
1. Selection bias
2. Confounders
3. Study design
4. Blending
5. Data collection
6. Drop out or withdrawal
7. Intervention
8. Result analysis
Ethical appraisal
The decision making procedure within research context is based on several ethical
principles. These principles help in providing a structured framework that assists in
formulating answers to several questions which arise during the study. The principles also
help in solving different ethical issues faced by the researcher (Zeng et al. 2015).

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Generally, 7 ethical principles based on nonmaleficene, beneficence, justice, fidelity,
confidentiality, veracity and autonomy are taken into consideration (Duckworth
2016). Ethical approval was not required for conduction of this systematic review. During
conduction of the systematic review it wasn ensured that all the meta analysis and
randomised controlled trials that were included in the review had received approval from
recognised ethical committees (Fletcher 2015).
Data extraction
The aim of the review was to assess the feasibility of robotic asssited surgery and
compare it to traditional laparoscopic surgeruy among people with colorectal cancer. The
data that was extracted included the following information:
 Name of the first author
 Year of publication
 Country of publication
 The surgical intervention that was applied
 Type of operation
 Basic characteristics of the patients
 Age, Body mass index (BMI) and number of patients
 The diagnostic procedure that was followed
A thorough analysis of the prospective research articles that were selected from the
databases, it was found that there are certain pre-defined clinicopathologic and cost related
outcomes that facilitate the comparsion between the two surgical methods. Most of the
perioperative and cost outcomes that were used for data extraction are mentioned below-
1) Intraoperative operating time.

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2) Estimated blood loss.
3) Surgical failure
4) Peri-operative and postoperative spontaneous pain score
5) Wound related, biliary and other health complications
6) Length of hospitalisation
7) Patient satisfaction and quality of life
Pain perception was measured by most of the included articles by uitilising the Modified
Early Warning Score (MEWS) van (Galen et al. 2016). This score helps in standardising the
level of the pain that is perceived by patients and adds reliability to the data. Furthermore, a
Surgical Outcomes Measurement System (SOMS) instrument was used by the selected
articles to determine the quality of life and patient satisfaction (Zapf et al. 2013).
All the essential data were extracted from relevant tables, texts, charts and figures present
in the selected articles. No additional reviewer was included as there was no conflict or
disagreemt regarding the inclusion of the data.
Stud
author
country of
origin
Patients’
demograp
hics
(age,
gender,BM
I,numbers)
Procedural
details (failure
or success of
instruments,
operation
time)
Intraopera
tive and
postoperat
vie
omplicatio
ns
Pain,
length
of
hospital
isation
and
QoL
scores,
Total
hospital
charges

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A
B
C
D
E
Table 6- Data extraction table
Data analysis
All the data that have been collected for the research proposal are of quantitative type.
Therefore, inferential statistics is the preferred method that will be used for comparing tbe
results from the different articles. A Student t test (parametric data), Statistical Package for
the Social Science (SPSS Version 20) or Mann-Whitney U test (non-parametric) will be used
to compare the patient data on demographics that include the age and BMI. On the other
hand, a Chi-squared χ2 test will be used for comparing categorical data on the gender of the
patients, length of hospital stays, complication rates, and hospital charges for both the
surgical procedures (Ghasemi and Zahediasl 2012).
A regression analysis will be used for determining the operative time for both the
proposed interventions for colorectal cancer. Heterogeneity in the collected data will be
evaluated using the Q-test and I2 value. In addition, inspecting funnel plots will help in
identifying publication biases. These methods of analysis will help in drawing a definite
conclusion on the feasibility of robotic surgery over laparoscopic surgery.
Limitations
Time constraint is one of the most potential limitations for this research proposal.
Owing to this fact, only articles that were published in Englih were searched and included in

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the systematic review. There are several problems associated with searhing for relevant
articles while performing a systematic review. These problems include language and
publication bias. Language bias generally refers to the fact that research findings are
published in a particular language cdepending on the direction and nature of their results.
Thus, positive research findings are likely to be published in English (Morrison et al. 2012).
This increases the likelihood of researchers obtaining statistically significant results to
publish the randomised controlled trials in an English journal.
On the other hand, publication bias refers to the publication or non-publication of all
research findings based on the direction and nature of their results. Therefore, positive
research results tend to get frequently published than research that obtained negative results
(Dwan et al. 2013). In addition, appropriate key words should also be used for obtaining an
effective research result. In this context, only ‘Index Terms’ were used gor the search of
relevant articles that were included in the review. Furthermore, the presence of a single
researcher and defined selections of quantitative studies increased the risk of potential
selection biases (Armijo‐Olivo et al. 2012). This is due to the fact that several aspects of
quality assessment such as, data extraction and data selection depend on the evaluation by
two or more researchers that helps them reach a consensus to eliminate all kind sof conflicts
that arise between the major authors. This is considered as an essential prerequisite in the
PRISMA checklist and often affects the reliability and validity of the results that are obtained
later on. Other limitations of this systematic review are as follows-
 Exclusion of unpublished data
 Limitations of the individual meta-analysis and studies
 Failure to adjust the drawbacks of the randomised controlled trials

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Dissemination and sharing of the research findings
This proposal was conducted with the aim of meeting the learning outcomes and the
for understanding the basic steps of research methodology. It was done for meeting the
eligibility standards for qualifying the Research Studies Module. I intend to purse this
research in real-time after obtaining a confirmation from the examiner. The findings of the
research will thereby be disseminated and shared with the Uiversity Newsletter and will also
be sent to other reputed journals for publication. The research findings will hopefully be able
to address the knowledge gap related to the use of robotic assisted surgery for colorectal
cancers.
It will encourage, promote and facilitate the development of minimally invasive
surgical techniques in less developed parts of the world, where robotic surgry is still at its
infancy. The research findings will further support the use of evidence based research for
improving the quality of life of patients. This is based on the fact that systematic research
reviews form a basis for an appropriate research evidence source and assist in easy decision-
making rather than unearthing original research reports.

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Appendices
Appendix 1- Gantt chart tool for setting the timetable for the systematic review and research
proposal

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Appendix 2- PRISMA 2009 Checklist of items for systematic review and meta-analysis

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Pain score
Point 0 No pain at rest No pain on movement
Point 1 No pain at rest Slight pain on movement
Point 2 Intermittent pain at rest Moderate pain on movement
Point 3 Continuous pain at rest Severe pain on movement
Appendix 3- Pain score from MEWS (Modified Early Warning Score)

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Appendix 4- Quality Assessment Tool for Quantitative Studies from Effective Public Health
Practice Project (EPHPP)

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Appendix 5- Data extraction form

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Appendix 6- Quality Assessment Tool for Quantitative Studies Dictionary from EPHPP
(Effective Public Health Practice Project).

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