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Page 6 of 8 Genova et al. Mini-invasive Surg 2020;4:2 I http://dx.doi.org/10.20517/2574-1225.2019.30

conventional laparoscopy in terms of all-cause mortality, incidence of surgical site infection, intraoperative
blood loss, length of hospital stay, and time to oral diet, but inferior in terms of operative time. No
significant difference was found in terms of anastomotic leak and disease recurrence. However, regarding
the RCTs subgroup of the same study, no significant difference was found except for operative time, which
confirms the current absence of evident advantages in favor of one approach or the other in colon cancer
surgery.

Robotic surgery of the rectum
[23]
In 2001, Cadière et al. first described the use of robotic technology in rectal surgery, reporting three
transanal rectal resections performed by introducing through the anus two robotic arms for manipulations
[24]
and a standard laparoscope held by an assistant for viewing. In 2003, Delaney at al. reported the first case
[25]
of transabdominal robot-assisted rectopexy for rectal prolapse, while Giulianotti et al. reported the first
[17]
cases (six) of robot-assisted rectal anterior resection for rectal cancer . Notably, both types of operations
[26]
mentioned above were performed with Intuitive Surgical systems. In the same year, Hildebrandt et al. also
reported the implementation of an AESOP 3000 robotic arm in the surgical treatment of rectal cancer to
perform two laparoscopic rectal anterior resections.

The advantages provided by the robotic systems in terms of view and manipulations seemed even more
evident in the case of rectal surgery because of the narrow, deep, and fixed operating field represented by
the pelvis. Therefore, a growing number of robot-assisted procedures in rectal surgery, especially for cancer,
has been reported, with many authors trying to compare the outcomes of robotic surgery and conventional
laparoscopy.

Focusing on oncological surgery and setting aside the numerous retrospective studies available, seven
RCTs [27-33] comparing robotic and laparoscopic surgery of the rectum were carried out to present, and
[34]
their results were summarized by Liao et al. in a systematic review with meta-analysis published in
2019. Notably, these authors did not find any significant difference in terms of circumferential resection
margins and quality of mesorectal excision, as well as in terms of proximal resection margins and number
of retrieved lymph nodes, even if a significant heterogeneity of data was found for these two latter issues.
On the contrary, distal resection margins were significantly longer in patients undergoing robotic surgery,
although the heterogeneity of data was still considered high.

Particular attention must be paid to the Robotic vs. Laparoscopic Resection for Rectal Cancer (ROLARR)
[31]
study , the largest and highest quality trial currently available. In particular, it concluded there was no
significant difference between robotic and conventional laparoscopic surgery in terms of conversion rate,
circumferential resection margins, mesorectal resection quality, and postoperative complications within 30 days
and 6 months after operation. In addition, the authors performed a costs analysis showing significantly higher
costs for robotic surgery, but the absolute difference was just slightly in favor of conventional laparoscopy
among the patients with complete data.

[28]
Moreover, among the trials cited above, only Patriti et al. reported overall survival and disease-free
survival, showing no significant differences, but stressing a trend towards better disease-free survival in
robotic surgery and concluding in favor of the latter in the case of total mesorectal excision but not in case
of partial mesorectal excision.

Limitations of robotic technology to present
Even if robotic technology provides several objective advantages in terms of working conditions and offers a
faster adaptation compared to conventional laparoscopy, it also presents some limitations, the most relevant