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[53]
the new approach . Tele-surgery is the latest potential advantage of robotic surgery, allowing real-time
[54]
international collaborations and mentoring .

Technical disadvantages
The loss of haptic feedback is still the main technical limitation of the available robotic platforms. A multi-
modal pneumatic feedback system offering tactile, kinesthetic, and vibrotactile feedback was incorporated
[55]
in the da Vinci® Surgical System . Other platforms, as Senhance® Surgical Robotic System and the
[56]
REVO-I® Robot Platform, also incorporated haptic feedback assistance .
Costs
Increased costs attributed to robotic surgery are the most important current impediment for the
widespread of this technology. The economic impact is an important point to assess in the setting of
increasing demands on limited health resources. To accurately measure costs has a particular difficulty at
economic evaluations. Total costs rely on direct, indirect and intangible costs. Direct costs can be divided
into fixed costs (to buy and maintain the robotic system), and variable costs (consumable instruments).
[47]
The cost of a robotic platform is $1-$2.3 million . Cost-analysis studies determined that robotic is more
[58]
expensive than open and laparoscopic surgeries [57,58] . Baek et al. in 2012, reported that robotic rectal
[58]
surgery charges were between $7,150-10,700, and $1,240 for laparoscopic surgery . The ROLARR trial
showed that health-care costs in the robotic-assisted laparoscopic group (£11 853 or $13 668) were higher
than in the conventional laparoscopic group (£10 874 or $12 556). The higher costs were attributed to longer
[59]
theater occupation and the use of specific instruments. Conversely, Ielpo et al. found that the mean
overall costs were similar between robotic and laparoscopic approach, excluding the initial purchase of the
[59]
robotic system .
Few studies have assessed the cost-effectiveness of robotic rectal surgery, it is difficult to assign a
[60]
monetary value to the measured outcomes in this particular scenario . Morelli et al. observed
[61]
that excluding fixed costs and comparing experienced phase of robotic surgery with the laparoscopic
[61]
approach, the variable operative costs were similar . Therefore, robotic expertise has a critical role
in the operative costs, similar to the procedures standardization, the surgical team’s consistency, and
the institution’s volume . Robotic surgery could mitigate increased expenditures whether provide
[62]
lesser risk of conversion and shorter hospitalization [29,63] . Indirect costs have not been deeply evaluated
for robotic rectal resections. Only Bertani et al. found a faster physical recovery after 1 month in
[57]
[57]
the robotic group compared with open surgery . The ROLARR did not found differences between
laparoscopic and robotic surgery in bladder and sexual dysfunction rates . No cost-utility study
[26]
aiming to determine indirect costs has been reported to date. Further research is needed to evaluate the
quality of life; including sexual, stool, and urinary functions, using utility measures like the disability-
adjusted life-year and the quality-adjusted life-year, to accurately compare the outcomes of the different
surgical alternatives. For the latest 20 years, da Vinci® System has dominated robotic surgery, the lack of
[42]
adversaries led to rising costs and maybe slowed the evolution of the technology . In the near future,
with the introduction of new robotic platforms, this situation is expected to change dramatically.

OUTCOMES OF ROBOTIC SURGERY FOR RECTAL CANCER
Intraoperative outcomes
Some authors suggested the potential advantage of robotic TME over conventional laparoscopy
[28]
decreasing the conversion rates to open surgery: Prete et al. [Risk Ratio (RR), 0.58; 95%CI: 0.35-0.97; P = 0.04],
[29]
Jones et al. [Odds Ratio (OR), 0.40; 95%CI: 0.29-0.55; P < 0.00001], Ohtani et al. (OR, 0.30; 95%CI: 0.19-0.46;
[64]
[65]
P < 0.00001), and Lee et al. (RR, 0.28; 95%CI: 0.15-0.54; P < 0.0001) [28,29,64,65] . The benefit has been related
to the use of three-dimensional vision and articulated instruments, facilitating the dissection during TME.