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Page 6 of 12 Moroni et al. Mini-invasive Surg 2019;3:36 I http://dx.doi.org/10.20517/2574-1225.2019.34

Figure 1. ROBOTIC CONSOLE: robotic platform. SURGEON: first surgeon; ROBOTIC CART: robotic arms; ANESTHESIOLOGIST:
anesthesiologist; ASSISTANT: second surgeon; SCRUB NURSE: operative nurse

[68]
Additionally, RRC has been proposed as an ideal procedure for the surgeon’s initial steps with robotics .
[36]
de’Angelis et al. observed that RRC with EA was associated with a faster learning curve than LRC with
EA. Only 16 procedures in the RRC group were needed to significantly reduce operative time versus 25
surgeries in the LLC group. This may be explained by the fact that robotic surgery improves the surgeon’s
[69]
dexterity and depth of perception. Parisi et al. concluded that the learning curve for RRC is around
44 procedures. This long curve was necessary to significantly reduce operative time and conversion to
open surgery rate, as well as to significantly increase the number of harvested lymph nodes. Performing
RRC can be justified in different situations depending on the type of surgical unit, for example as a
training procedure for robotic colorectal surgery for young surgeons in centers that are already skilled at
performing RRC. Moreover, centers aiming to incorporate complex robotic procedures could start with
RRC as one of the first of them.

SHORT- AND LONG-TERM OUTCOMES
Several studies have demonstrated the safety and efficacy of RRC for both short- and long-term
outcomes [31,60,70,71] . Only one randomized controlled trial found no differences in lengths of hospital stay
[72]
and the surgical complications rate between RRC and LRC groups . The latest meta-analysis published
[73]
by Ma et al. in 2019 concluded that RRC has a longer operation time, lower estimated blood loss,
[60]
shorter hospital stay, and lower postoperative complication rate than LRC. Solaini et al. reported that
conversion to open surgery was more common during LRC, with no significant differences in mortality
[70]
and postoperative complication rate. Lim et al. concluded that the time for diet, first flatus, and first
defecation, and the length of hospital stay were significantly decreased for RRC. Similarly, Rondelli et al.
[74]
showed that the time for the first flatus was significantly shorter in RRC. Such differences in recovery may
also be related to the less traumatic intra-peritoneal approach provided by the use of IA, rather than purely
by the use of robotic assistance. When combined, they can provide a quicker bowel recovery with less need
of analgesics [17,75] and fewer post-operative complications [24,74,76-78] [Tables 4 and 5] [17,24,30,54,72,76-79] .

In a recent retrospective study with 101 patients receiving RRC with CME from 2005 to 2015, Spinoglio et al.
[30]
showed that it is possible to perform routine RRC with CME and IA safely, with comparable long-term
oncologic outcomes to laparoscopic techniques [five-year overall survival (OS) of 77% and disease-free
survival (DFS) of 85%]. They also showed a non-significant improvement in DFS for AJCC/UICC stage