title: Robot-assisted surgery in elderly and very elderly population: our experience in oncologic and general surgery with literature review.
abstract: BACKGROUND
  Although there is no agreement on a definition of elderly, commonly an age cutoff of ≥65 or 75 years is used. Nowadays most of malignancies requiring surgical treatment are diagnosed in old population. Comorbidities and frailty represent well-known problems during and after surgery in elderly patients. Minimally invasive surgery offers earlier postoperative mobilization, less blood loss, lower morbidity as well as reduction in hospital stay and as such represents an interesting and validated option for elderly population. Robot-assisted surgery is a recent improvement of conventional minimally invasive surgery.
  
  
  OBJECTIVE
  We provided a complete review of old and very old patients undergoing robot-assisted surgery for oncologic and general surgery interventions.
  
  
  METHODS
  A retrospective review of all patients undergoing robot-assisted surgery in our General Surgery Unit from September 2012 to June 2016 was conducted. Analysis was performed for the entire cohort and in particular for three of the most performed surgeries (gastric resections, right colectomy, and liver resections) classifying patients into three age groups: ≤64, 65-79, and ≥80. Data from these three different age groups were compared and examined in respect of different outcomes: ASA score, comorbidities, oncologic outcomes, conversion rate, estimated blood loss, hospital stay, geriatric events, mortality, etc.
  
  
  RESULTS
  Using our in-patient robotic surgery database, we retrospectively examined 363 patients, who underwent robot-assisted surgery for different diseases (402 different robotic procedures): colorectal surgery, upper GI, HPB, etc.; the oncologic procedures were 81%. Male were 56%. The mean age was 65.63 years (18-89). Patients aged ≥65 years represented 61% and ≥80 years 13%. Overall conversion rate was of 6%, most in the group 65-79 years (59% of all conversions). The more frequent diseases treated were colorectal surgery 43%, followed by hepatobilopancreatic surgery 23.4%, upper gastro-intestinal 23.2%, and others 10.4%.
  
  
  CONCLUSIONS
  Robot-assisted surgery is a safe and effective technique in aging patient population too. There was no increased risk of death or morbidity compared to younger patients in the three groups examined. A higher conversion rate was observed in our experience for patients aged 65-79. Prolonged operative time and in any cases steep positions (Trendelenburg) have not represented a problem for the majority of patients.
  
  
  CONCLUSIONS
  In any case, considering the high direct costs, minimally invasive robot-assisted surgery should be performed on a case-by-case basis, tailored to each patient with their specific histories and comorbidities.
authors.affiliation: Department of Surgery, Division of General Surgery, Hospital of Arezzo, Arezzo, Italy.
authors.forename: Graziano
authors.initials: G
authors.lastname: Ceccarelli
authors.affiliation: Department of Surgery, Division of General Surgery, Hospital of Arezzo, Arezzo, Italy.
authors.forename: Enrico
authors.initials: E
authors.lastname: Andolfi
authors.affiliation: Department of Surgery, Division of General Surgery, Hospital of Arezzo, Arezzo, Italy.
authors.forename: Alessia
authors.initials: A
authors.lastname: Biancafarina
authors.affiliation: Department of Surgery, Division of General Surgery, Hospital of Arezzo, Arezzo, Italy. aldorocca@hotmail.it.|Department of Clinical Medicine and Surgery, University of Naples "Federico II", Via Sergio Pansini, 80131, Naples, Italy. aldorocca@hotmail.it.
authors.forename: Aldo
authors.initials: A
authors.lastname: Rocca
authors.affiliation: Department of Surgical Specialities and Nephrology, University of Naples "Federico II", Naples, Italy.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Amato
authors.affiliation: Department of Surgical Specialities and Nephrology, University of Naples "Federico II", Naples, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Milone
authors.affiliation: Department of Surgery, Division of General Surgery, Hospital of Arezzo, Arezzo, Italy.
authors.forename: Marta
authors.initials: M
authors.lastname: Scricciolo
authors.affiliation: Department of Surgery, Division of General Surgery, Hospital of Arezzo, Arezzo, Italy.
authors.forename: Barbara
authors.initials: B
authors.lastname: Frezza
authors.affiliation: Department of Surgery, Division of General Surgery, Hospital of Arezzo, Arezzo, Italy.
authors.forename: Egidio
authors.initials: E
authors.lastname: Miranda
authors.affiliation: Department of Surgery, Division of General Surgery, Hospital of Arezzo, Arezzo, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: De Prizio
authors.affiliation: Department of Surgery, Division of General Surgery, Hospital of Arezzo, Arezzo, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Fontani
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D016330:Frail Elderly; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D009369:Neoplasms / Q000601:surgery*; D061646:Operative Time; D012189:Retrospective Studies; D012306:Risk; D065287:Robotic Surgical Procedures / Q000706:statistics & numerical data*; D013514:Surgical Procedures, Operative / Q000379:methods
keywords: Aging population; Cancer; Elderly; Geriatric; Minimal invasive surgery; Robotic surgery