Introduction: The robotic platform compared to laparoscopy has proven to have similar postoperative outcomes; however, its adoption in the Middle East has been slow and there are limited data regarding outcomes with its use in small newly established robotic colorectal programs. Our aim was to report our experience and outcomes of robotic colorectal surgery performed by fellowship-trained robotic colorectal surgeons and compare them to larger, more experienced centers. Methods: This is retrospective review of data collected between November 2021 and March 2023 from a tertiary health care referral center. The series included 51 patients who had elective or urgent robotic colorectal surgery. Patients who had emergency surgery were excluded. The outcomes were overall morbidity, serious morbidity, mortality, conversion to open, length of hospital stay, and quality of oncological specimen. Results: The overall morbidity was 31.4% (n = 16 patients). Only 9.8% (n = 5) had serious morbidity of which three required interventions under general anesthesia. The median length of hospital stay was 6 days (IQR = 4), and there was no mortality. Of 17 rectal cancer resections, 88% had complete mesorectal excision, 15 of them were R0 resections, median lymph node harvested was 14 (IQR = 7) and two cases were converted to open. All the colon cancer resections had R0 resection, median lymph nodes harvested was 21 (IQR = 4) and none were converted to open. Conclusions: The implementation and integration of robotic colorectal surgery at a newly established center in a small country, when led by fellowship-trained robotic colorectal surgeons, is safe and effective in terms of morbidity, mortality, conversion to open and specimen pathological quality.

Highlights of the Study

  • Low morbidity, no mortality, and excellent pathological specimen quality were recorded in 51 robotic colorectal surgeries.

  • Low conversion to open, low readmission, affirmed the safety and efficacy of robotic colorectal surgery.

  • Robotic colorectal surgery, led by fellowship-trained surgeons, is safe and effective in terms of morbidity, mortality, and specimen quality.

In recent years, minimally invasive colorectal resection adoption has been in the rise for both malignant and benign disease processes [1]. Compared to open surgery, minimally invasive surgery offers faster patient recovery, shorter length of hospital stay (LOS), fewer perioperative morbidities, with no compromise of oncological outcomes [1]. It has less traumatic impact on the abdominal wall (due to small incisions), minimal exposure of internal organs to the external environment, minimal tissue manipulation, less tissue trauma and easier precise dissection within the confinement of the narrow pelvis [1]. However, laparoscopic surgery has its limitations such as high conversion rate, arguably higher positive CRM rates (in locally advanced cancer), more difficult visualization due to poor stability of the assistant-controlled camera, poor ergonomics of the straight tip instruments which have been associated with enhanced tremor effect; moreover, the camera provides only two-dimensional views of the deep surgical field [2, 3]. The da Vinci surgical system (Intuitive Surgical, CA, USA) was the first robotic surgical system to be approved by the Food and Drug Administration (FDA) in 2000. It was introduced as an innovative device that could overcome many of the limitations of laparoscopic surgery. This robotic platform demonstrated that it could alleviate the anatomical limitation of the bony pelvis and provide precise stable dissection in a confined pelvic space, facilitated by efficient third-arm retraction, fine instrument movement with flexible EndoWrist instruments that allowed 7 degrees of freedom and a magnified three-dimensional view [4, 5]. According to available data, the use of the robotic platform demonstrates a favorable safety profile and is associated with promising oncological outcomes [6‒10]. Compared to laparoscopy, robotic surgery has proven to have similar postoperative morbidity and oncological outcomes, with data showing trends toward lower conversion rates when performed by experienced robotic surgeon [11].

Adoption of robotic surgery in the Middle East has been slow, and there are very limited data regarding outcomes in newly established programs. Our aim was to report our experience and short-term outcomes of robotic colorectal surgery performed by fellowship-trained robotic colorectal surgeons.

A retrospective review of a prospectively collected data from 2021 to 2022 was performed. All operations were performed at Jaber Al-Ahmad Hospital, Kuwait; this is a newly established tertiary care center. Our Robotic Colorectal Surgery program was initiated in 2021.

Ethical Approval

This study was approved by Kuwait Ministry of Health Ethical Review Board (ethical approval number: 2228/2023).

Surgeons’ Experience

Our program had four fellowship-trained colorectal surgeons, of whom two had robotic training in their fellowship program. All surgeons had at least 3 years of independent practice following fellowships. One surgeon did the American Board of Colon & Rectal Surgery (ABCRS) accredited 1-year fellowship followed by 1-year Fellowship Council Accredited Minimally Invasive & Robotic Colorectal Fellowship in the USA. His robotics fellowship included 30–40% colorectal robotic exposure and a “Certificate of Da Vinci System Training as a Fellow” accreditation certificate. One surgeon received his training in the UK where his fellowship incorporated both colorectal oncology and robotic training in the same 1-year fellowship and his robotic case volume was just under 25% of overall cases. Further, he holds the “Certificate of da Vici System Training as a Console Surgeon” accreditation certificate from Intuitive Surgical. The other two colorectal surgeons had no previous robotic training, though they had extensive minimally invasive training; one did an ABCRS accredited fellowship and the other did a Fellowship Council accredited fellowship.

Study Population, Settings, and Perioperative Variables

We included all patients ≥18 years of age who underwent an inpatient elective or urgent robotic colorectal procedure. We did not include patients who had emergency procedures. Colorectal procedures were identified using Current Procedural Terminology codes. Cases were selected consecutively based on the availability of the robotic platform. All patients who were candidates for minimal invasive surgery were offered robotic surgery. Reasons for not performing robotic surgery were either patient refusal or due to the unavailability of the robot or its consumables. Elective setting was defined as procedures that were performed when the patient was brought from their home on the day before the surgery for a non-emergency/nonurgent scheduled surgical procedure. Non-elective setting indicated procedures that were performed when the patient was an inpatient at an acute care hospital, transferred from an emergency department, transferred from a clinic, preadmitted for “tuning,” or who had undergone an urgent surgical procedure. We used the Da Vinci SI robot for all cases. The case was counted as robotic if for right colectomy, the ileocolic vessel ligation, medial dissection and lateral dissection and part of the hepatic flexure was performed by the robot. For the left colon, the splenic flexure mobilization and dissection of left colic and or inferior mesenteric arteries (IMA) must be performed by the robot. For anterior resection and low anterior resection (LAR), the IMA and the total mesorectal excision (TME) dissection must be performed by the robot. With regard to the robotic port configuration, for anterior resection, LAR, abdominoperineal resection (APR) and rectopexy, the right lower quadrant, umbilical, left upper quadrant and left lateral (level of anterior axillary line), robotic ports and right upper quadrant assistant port were used. For left colectomy cases, a right lower quadrant, umbilical, epigastric and left lateral (level of anterior axillary line) robotic ports, and right upper quadrant, assistant port were used. For right colectomy, an epigastric, umbilical, left lower quadrant, and right lower quadrant, robotic ports with left upper quadrant assistant port were used. All anastomoses were done intracorporeally, though when an end-to-end anastomosis stapler was used, the anvil was applied extracorporeally. We followed the enhanced recovery after surgery (ERAS) program which incorporated mechanical bowel preparation with oral antibiotics, pre/postoperative anticoagulation, same day oral intake, same day ambulation and patient-controlled analgesia. Patient demographics, clinical characteristics, American Society of Anesthesiology (ASA) class, history of smoking, dependency status using the Eastern Cooperative Oncology Group (ECOG) scale, and medical comorbidities were recorded. Use of drains was also noted. Pathological specimen quality data including R0 resection, number of lymph nodes harvested, circumferential resection margin (CRM) positivity, and completeness of TME were recorded and collected. Thirty days morbidity and mortality were collected as well. Staging for colon cancer was by computerized tomography (CT) chest abdomen and pelvis, CEA, CA 19-9, and positron emission tomography (PET) CT scan of stage IV. In the case of rectal cancer, in addition to the modalities used for stage colon cancer, a magnetic resonance imaging (MRI) pelvis was also performed.

Outcomes

Primary outcomes assessed included overall 30 days morbidity, serious morbidity, mortality, reoperation, and unplanned readmission. Overall morbidity included minor (Clavien–Dindo score 1 or 2) and serious morbidity (Clavien–Dindo score 3 or 4). Oncological outcomes including quality of resection and number of lymph nodes harvested were reported. In addition, LOS was also noted. Anastomotic leak was defined as the presence of contrast extravasation on a CT scan of the abdomen of pelvis and/or evidence of anastomotic dehiscence on imaging, endoscopically or operatively. Conversion to open was defined as the inability to complete the IMA and TME dissection in rectal resection robotically. In left partial colectomy, the inability to mobilize the splenic flexure, and dissection of the left colic and left branch of middle colic robotically. For right colectomy, the inability to complete the ileocolic vessels, right colic, right branch of middle colic, and hepatic flexure mobilization robotically.

Statistical Analysis

Statistical analysis was performed using SPSS version 23.0 (SPSS, Chicago, USA). Continuous variables were described as mean (SD) and median (IQR), while categorical variables were described using frequencies and percentages.

Patients and Procedures Characteristics

Fifty-one consecutive patients were included in the study. The mean age was 53.9 years (SD: 14.7), and the mean body mass index was 29.05 kg/m2 (SD: 6.07). Most patients (64.8%) were ASA with hypertensive (n = 15, 30%) and diabetic (n = 13, 26%) being the most common reported comorbidities (Table 1). Forty-seven procedures were done electively (92.1%), while four procedures were done on an urgent basis (7.8%); of these, two urgent procedures were for symptomatic colovesical fistulas secondary to recurrent sigmoid diverticulitis, one for sigmoid stricture complicated by diverticular disease, and one for obstructed upper rectal cancer. The median operative timing of these surgeries was 320 min. Colon cancer (n = 20, 35.3%) was the most common indication for robotic resection, followed by rectal cancer (n = 17, 33.3%), and sigmoid diverticular disease (n = 5, 9.8%). Other indications are depicted in Table 2.

Table 1.

Baseline characteristics of patients

CharacteristicsValue
Age, years, mean (SD) 53.9 (14.7) 
Male gender, n (%) 34 (66.7) 
Female gender, n (%) 17 (33.3) 
BMI, kg/m2, mean (SD) 29.07 (6.07) 
ECOG, n (%) 
 0–1 35 (68.6) 
 2 15 (29.4) 
 3 0 (0) 
 4 1 (1.9) 
 5 0 (0) 
Smoking status, n (%) 
 Smoker 44 (86.3) 
 Non-smoker 7 (13.7) 
ASA status, n (%) 
 ASA 1 8 (15.7) 
 ASA 2 35 (68.6) 
 ASA 3 8 (15.7) 
 ASA 4 0 (0) 
Medical comorbidities, n (%) 
 Hypertensive requiring medication 15 (30) 
 None 13 (32) 
 Diabetic requiring medication 13 (26) 
 Asthmatic or COPD 4 (8) 
 CVS 2 (5) 
CharacteristicsValue
Age, years, mean (SD) 53.9 (14.7) 
Male gender, n (%) 34 (66.7) 
Female gender, n (%) 17 (33.3) 
BMI, kg/m2, mean (SD) 29.07 (6.07) 
ECOG, n (%) 
 0–1 35 (68.6) 
 2 15 (29.4) 
 3 0 (0) 
 4 1 (1.9) 
 5 0 (0) 
Smoking status, n (%) 
 Smoker 44 (86.3) 
 Non-smoker 7 (13.7) 
ASA status, n (%) 
 ASA 1 8 (15.7) 
 ASA 2 35 (68.6) 
 ASA 3 8 (15.7) 
 ASA 4 0 (0) 
Medical comorbidities, n (%) 
 Hypertensive requiring medication 15 (30) 
 None 13 (32) 
 Diabetic requiring medication 13 (26) 
 Asthmatic or COPD 4 (8) 
 CVS 2 (5) 

SD, standard deviation; BMI, body mass index; ASA, American Society of Anesthesiologists Classification; COPD, chronic obstructive pulmonary disease; CVS, cardiovascular diseases.

Table 2.

Robotic procedures performed, with indication and length of hospital stay per procedure type

Procedure typeIndication (n)n (%)Median LOS
Anterior resection Colon adenocarcinoma (n = 12) 17 (33.3) 5 days 
Diverticular disease (n = 5) 
Low anterior resection (LAR) Rectal cancer (n = 12) 12 (23.5) 7 days 
Abdominoperineal resection (APR) Rectal cancer (5) 5 (9.8) 8 days 
Left colectomy Colon adenocarcinoma (4) 4 (7.8) 6.5 days 
Rectopexy Rectal prolapse (3) 3 (5.9) 4 days 
Right hemicolectomy Colon adenocarcinoma (4) 4 (7.8) 6.5 days 
Total colectomy Ulcerative colitis (1), colonic inertia (1) 2 (3.9) 20.5 days 
Hartman’s reversal Previous perforated colon adenocarcinoma (1) 1 (1.9) 5 days 
Procedure typeIndication (n)n (%)Median LOS
Anterior resection Colon adenocarcinoma (n = 12) 17 (33.3) 5 days 
Diverticular disease (n = 5) 
Low anterior resection (LAR) Rectal cancer (n = 12) 12 (23.5) 7 days 
Abdominoperineal resection (APR) Rectal cancer (5) 5 (9.8) 8 days 
Left colectomy Colon adenocarcinoma (4) 4 (7.8) 6.5 days 
Rectopexy Rectal prolapse (3) 3 (5.9) 4 days 
Right hemicolectomy Colon adenocarcinoma (4) 4 (7.8) 6.5 days 
Total colectomy Ulcerative colitis (1), colonic inertia (1) 2 (3.9) 20.5 days 
Hartman’s reversal Previous perforated colon adenocarcinoma (1) 1 (1.9) 5 days 

Anterior resection (n = 17, 33.3%) followed by LAR (n = 12, 23.5%) were the most common procedures performed (Table 2). Of all proctectomy cases, 15 patients had neoadjuvant treatment. All of them except one received neoadjuvant radiation therapy. Drains were used in 58.8% of cases (n = 30). Indications for drain placement included APR, ultra-low colorectal anastomosis, and concerns about an infected environment due to complicated diverticular disease.

Conversion to Open

Two cases were converted to open in our population. The conversion in the first case was due to cardiac hemodynamic instability that did not allow sustained pneumoperitoneum. The second conversion was in a rectal cancer case where the operating surgeon could not establish a clear dissection plane safely robotically due to radiation effect.

Oncology

Of 17 rectal resections, 15 were R0 resections (88%), while 2 patients had R1 resection (11.8%). Regarding TME status, 15 had complete TME (88%) except two which were incomplete (11.8%). One of the patients with incomplete TME was the one we converted to open due to radiation effect. Median lymph nodes harvested was 14 (IQR: 7). We had 20 colonic adenocarcinomas. All resections were R0, and median lymph nodes harvested was 21 (IQR: 4).

Morbidity and Mortality

Our overall complication rate was 31.4% (n = 16 patients). Acute kidney injury (n = 7, 13.7%) was the most reported complication (Table 3). Serious morbidity (Calvien-Dino ≥ III) occurred in 5 patients (9.8%). We had one anastomotic leak requiring reoperation, and one diverting loop ileostomy retraction and ischemia requiring reoperation with local revision. Furthermore, we had one case who underwent LAR complicated by bowel ischemia of the colonic conduit requiring reoperation. This patient also had pelvic fluid collection with CT guided drainage by IR. We had two organ space infections; one was managed with interventional radiology drainage and intravenous antibiotics and one with only intravenous antibiotics. In addition, gracilis flap necrosis occurred in one APR patient and the plastic team managed it with wound care and bedside serial debridement. There was no reported mortality.

Table 3.

Total complication rate

Post-operative complication within 30 daysn (%)Calvien-Dindo classification
Acute kidney injury 7 (13.7)  
 2 patients with colostomies 
 4 patients with iloestomies 
 1 patient with resection without stoma 
Surgical site infection 3 (5.9)  
 Pelvic collection (organ space) II, IIIa 
Hematoma 2 (3.9) 
 Left rectus muscle hematoma II 
 Abdominal hematoma   
Urinary tract infection (UTI) 2 (3.9) II 
Bowel ischemia 1 (1.9) IV 
Anastomotic leak 1 (1.9) IV 
Pulmonary embolism (PE) 1 (1.9) II 
Gracilis flap necrosis and failure 1 (1.9) IIIa 
Local ischemia in proximal loop ileostomy 1 (1.9) IIIb 
Post-operative complication within 30 daysn (%)Calvien-Dindo classification
Acute kidney injury 7 (13.7)  
 2 patients with colostomies 
 4 patients with iloestomies 
 1 patient with resection without stoma 
Surgical site infection 3 (5.9)  
 Pelvic collection (organ space) II, IIIa 
Hematoma 2 (3.9) 
 Left rectus muscle hematoma II 
 Abdominal hematoma   
Urinary tract infection (UTI) 2 (3.9) II 
Bowel ischemia 1 (1.9) IV 
Anastomotic leak 1 (1.9) IV 
Pulmonary embolism (PE) 1 (1.9) II 
Gracilis flap necrosis and failure 1 (1.9) IIIa 
Local ischemia in proximal loop ileostomy 1 (1.9) IIIb 

Length of Hospital Stay

Median LOS was 6 days (IQR: 4).

Readmission Rate within 30 Days

Two patients were readmitted to our center within 30 days of surgery. These cases were secondary to partial ileus which was managed conservatively with 48-h hospital admission for rehydration.

Colorectal Procedures

In our center, the most performed robotic colorectal surgery procedures were for sigmoid and rectal pathologies. This theme appeared to be the dominant indication for the use of the robot in other colorectal robotic programs as well [11‒14]. The Chang et al. [12] series of 1,145 cases used the robot for only sigmoid and rectal pathologies (24.2% were APR, 75.5% were anterior resections, and 0.3% were Hartmann). The RoLARR multicenter randomized controlled trial included only rectal cancer resections [11]. This trend toward prioritizing the use of the robotic in left colon and pelvic pathologies is not surprising because the robot as an innovative tool was created to overcome the limitations of laparoscopy, which is more marked in the confined narrow pelvis; this was also the case with us. In addition, in our center, our referral pattern was for mostly left-side and pelvic pathologies, so in our series, it was driven by disease prevalence as well, and we suspect it is the case with other series too.

Conversion to Open

Our conversion rate was low at 3.9%. Chang et al. [12] reported a conversion rate of 5.9%. In the ROLARR multicenter randomized controlled trial their overall conversion to open rate was 11.1%. A report on a series of 18 robotic rectal cancer resections reported a conversion rate of 22.2% (reasons included bulky tumor, insufficient exposure due to elongated sigmoid, and T4 tumor) [13]. A NSQIP review of robotic elective colectomy for left sided diverticulitis reported a 7.5% conversion rate [14]. Conversion rates in other series ranged from 1.7% to 17.1% [15‒20].

Oncology

Our series included 37 cases of malignancies (72.5%) of which 39% and 33.3% were colon and rectal cancer, respectively. With regard to colon cancer cases, we had 100% R0 resection rate and our median lymph node harvesting rate was 21. For rectal cancer, we had 88% R0 resection and our median lymph node harvesting was 14. Only two cases had incomplete TME (11.8%). Chang et al. [12] reported their positive CRM to be 1.3% while another study on a robotic case series of 58 patients ≥80 years old, mostly left-sided pathologies, reported 91.3% R0 resection and 22 median lymph node harvesting [20]. The ROLARR study had 6.3% positive CRM [11, 20]. They reported 100% R0 resections and a mean of 20 lymph node harvesting. Galata et al. [13] published a series of 18 robotic rectal cancer resections and reported that their positive CRM was 5.5%, 94.5% R0 resection, and a mean of 14 lymph node harvesting. A study of 136 robotic rectal resections for rectal cancer reported 2.3% CRM positivity, complete TME in 96.2% of specimens, near complete 3%, and incomplete 0.8% [21]. The Merola et al. [22] study of 94 patients who had robotic right hemicolectomy reported mean lymph node harvesting of 21 lymph nodes. In their 46 robotic right colectomy and anterior resection cases, Grosek et al. [23] reported that their median number of lymph node harvesting was 24. It appears that our oncological specimen quality is within the same range as other larger and more established programs.

Morbidity and Mortality

Our overall morbidity, type of morbidities, serious morbidities and mortality appeared to be on level with larger, more established programs. Our overall complication rate was 31.4%, acute kidney injury was the most common complication. We had one medical intraoperative complication; serious complications (Calvien-Dino ≥III) occurred in only 5 patients (9.8%). The other series had overall complication rates between 13% and 38% and serious complications rates between 3.2% and 14%. The Asklid et al. [19] cohort study of 72 patients who had robotic proctectomy reported a 25% overall complications rate. The ROLARR 30 days postoperative complication rate was 25% and their intraoperative complication rate was 14.8% [11]. Galata et al. [13] reported an overall complication rate of 33.3%. A study by Merola et al. [22] on 94 patients who had robotic right hemicolectomy reported an overall complication rate of 19% and serious complication rate of 3.19%. The NSQIP review of Al-Temimi et al. [14] reported an overall complication rate of 14.4%, of which 2.05% was anastomotic leak, and 3.42% complications requiring return to the operating room [14]. Rencuzogullari et al. [24] investigated robotic proctectomy in inflammatory bowel disease and reported a 38% overall complications rate, of which 23.5% were serious. Opoku et al. [25] review of NSQIP data of 341 robotic proctectomy with ileal anal pouch related outcome. The overall complication rate was 24.6%, of which 8.2% were organ space infection, 3.8% were sepsis, 4.1% were anastomotic leak, 7.9% required reoperation.

The mortality rate in our study was 0. Mortality rates in other studies were 0.8% within 30 days [12], 1.7% in 90 days [20], 3.4% [26] and 0.3% [25]. The mortality rate in the ROLARR study was 0.9%. All deaths were related to septic complications [11, 20].

Length of Hospital Stay

Our median length of hospital stay was 6 days which was similar to the study of Chang et al. [12]. Westrich et al. [20] reported 7 days median length of hospital (range: 3–46). The ROLARR median LOS was 3 days [11]. Kethman et al. [27] NSQIP data review of 192 patients reported mean LOS of 8.6 days. Al-Temimi et al. [14] NSQIP left sided diverticulitis review reported a mean LOS of 3.89 days. Other studies report a range between 4 and 7 days [19, 21‒23, 26, 28].

Readmission

We had a low readmission rate (3.9%) compared to other series, without having disproportionately longer LOS. Wilkie et al. [26] reported a 5.3% readmission rate. The Opoku et al. [25] series on inflammatory bowel disease reported a readmission rate of 19.4%.

Implications regarding Fellowship Training

This study indicates that our outcomes are on par with larger, more established robotic colorectal programs. We believe this has been largely achieved because our surgeons received fellowship training in robotic surgery. Panteleimonitis et al. [29] reviewed 1,130 robotic colorectal surgery cases performed by 26 international robotic colorectal surgery training programs (the European Academy of Robotic Colorectal Surgery, EARCS). When independent surgeries performed by fellowship graduates were compared to their proctors, except for operative time, blood loss, and LOS, all other outcomes including conversion rate, reoperation, readmission, anastomotic leak, other complications, R1 resection and lymph node harvested were similar. Panteleimonitis et al. [30] compared the outcomes of the same surgeons during their robotic training under expert supervision and subsequent cases as independent robotic colorectal surgeons and found no difference in postoperative outcomes. Aradaib et al. [31] reported the outcomes of 4 colorectal surgeons trained in robotic surgery, who underwent previous training as per the EARCS program, each at the beginning of their independent robotic surgery experience. Analyzing the outcomes of 55 consecutive cases performed by the 4 surgeons, they reported their median LOS was 6 days, they had no mortality, had no intraoperative complications, no conversion to open, overall postoperative complication rate was 14.5%, serious complication was 3.6%, and readmission rate was 7.3%. Their R0 resection was achieved in 95% of patients and their median lymph node harvested in non-neoadjuvant cases was 15 and in neoadjuvant cases was 8. Their results mirrored ours.

Strength and Limitations

This is a retrospective review of prospectively collected data and the first case series of robotic colorectal surgery in Kuwait. It is also the first in the Middle East Gulf region. It is unique because it details the outcomes to expect if a new robotic program, led by fellowship-trained robotic surgeons, was to be established in a small country with a relatively small population. Our results are limited by the small sample size and lack of long-term outcomes. Furthermore, the present quality of our surgical specimens would likely translate to acceptable long-term outcomes such as disease recurrence, disease free survival and overall survival. Moreover, we are optimistic about reducing the length of hospital stay as our robotic program expands and the enhanced recovery after surgery (ERAS) program is applied more rigorously.

In colorectal surgery, the safety and effectiveness of the robotic platform compared to other minimally invasive techniques has been established in large and experienced centers. However, data are limited regarding whether these outcomes can be replicated in smaller newly established centers. In our study, population morbidity, mortality, conversion rates and quality of pathological specimens are comparable to larger centers with more experience. This appears to be attributed to our program being led by fellowship-trained robotic colorectal surgeons.

We thank the College of Medicine, Kuwait University for their help in providing support for conducting various aspects of this study. We thank the following physicians who were essential in conducting sample collection and supervising data collection: Dr. Mahdi Abdulrasoul, Dr. Zeinab Chamkha, Dr. Sabri Hammoud, Dr. Fanan Alsaihan, Dr. Hussein Alzaid, and Dr. Fares Alfaraj.

This study was approved by the Kuwait Ministry of Health Ethical Review Board (ethical approval number: 2228/2023). All methods were carried out in accordance with relevant guidelines and regulations. The Ethics Committee approved the research project as informed consent was not required due to the effective de-identification of patient data.

The authors declare that they have no conflicts of interests.

No funding was obtained for this study.

Ahmed A. Alkhamis: conception and design of the study, data acquisition, analysis, interpretation of the results, and manuscript drafting and revision. Diaa M. Soliman: manuscript drafting, initial clinical audit, study design, data acquisition, analysis, and interpretation. Khaled A. Alsadder: data collection, analysis, interpretation, and manuscript revision. Hashem M. Busalha and Ahmad S. Alrashed: data collection, analysis, interpretation, and manuscript preparation. Bader H. Alshaban: data interpretation and manuscript editing. Salman K. Alsafran and Sulaiman M. Almazeedi: data collection, analysis, interpretation, and manuscript preparation and revision.

The datasets used and/or analyzed in this study are available from the corresponding author on reasonable request.

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