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Page 4 of 6 Ghuman et al. Mini-invasive Surg 2020;4:84 I http://dx.doi.org/10.20517/2574-1225.2020.88

status was available for 235, and 234 to laparoscopic with CRM status available for 224 patients. The CRM
[11]
positivity rate was 6.3% in laparoscopic vs. 5.1% in the robotic group (P = 0.56). Kim et al. also found
similar CRM positivity rates in their RCT with no difference in robotic (6.1%) compared to laparoscopic
[13]
(5.5%) (P = 0.999). Eltair et al. also confirmed no difference in positive CRM in their pooled analysis
2
of three RCTs in their meta-analysis, but high heterogeneity was noted (I = 57%). Several meta-analyses
that included retrospective studies along with the available RCTs have also shown no difference in positive
CRM [14,24-26] .

Proximal Resection Margin: Adequate mobilization of the colon, including splenic flexure mobilization,
should allow for sufficient proximal resection margins in rectal cancer surgery. The advantages of
laparoscopic and robotic rectal cancer resection with this regard pertain to the smaller incisions required for
sufficient mobilization compared to open surgery. The three RCTs examined in this review by Jayne et al. ,
[10]
[11]
[12]
Kim et al. , and Baik et al. reported no difference in proximal resection margins when comparing
robotic to laparoscopic rectal cancer operations. None of the meta-analyses examined in this review
reported a difference in proximal margins [13,14,27,28] .

Distal Resection Margin: The ROLARR RCT did not compare length of distal margin between the two
surgical groups but did note one patient had a positive distal margin in the laparoscopic group . Kim et al.
[10]
[11]
reported median distal resection margins and noted no statistical difference between robotic (1.5 cm)
and laparoscopic (0.7 cm) (P = 0.11). Baik et al. also noted no difference in mean or median distal
[12]
[13]
resection margins in their groups (P = 0.467). Eltair et al. examined five RCTs, which included 455
patients, in their meta-analysis for distal resection margins and found slightly longer distal margins in the
robotic group compared to the laparoscopic one with a mean difference of 0.8 cm (P = 0.004). There was
significantly high heterogeneity (I = 75%) observed in this pooled analysis. A meta-analysis by Liao et al.
2
[27]
included five RCTs, with 340 patients, and also found longer distal margin in the robotic group compared
to the laparoscopic one (P = 0.003), but again high heterogeneity was noted (I = 75%). Simillis et al. also
[14]
2
found the robotic surgical approach to have higher distal resection margins when compared to open (7.6
mm), laparoscopic (6.8 mm), and transanal (6.8 mm) techniques. There were no reported data on positive
distal margins for any of these groups.

CONCLUSION
Introduction of new surgical techniques to further surgical innovation and improve patient outcomes
should be judiciously undertaken to ensure patient care, most notably that oncologic outcomes are not
compromised. The majority of the high-level available evidence has found no differences between the
two surgical approaches relative to TME completeness, lymph node harvest, positive CRM, or proximal
resection margin. A longer distal resection margin has been found with robotic compared to laparoscopic
approaches in meta-analyses, but not in RCTs. However, there is no evidence that a longer distal margin
translates to better oncological outcomes.

Based on the current literature, either approach, laparoscopic or robotic, is safe and effective from a
pathology standpoint. Since the two techniques are comparable, other outcomes and factors need to be
considered when recommending one versus the other to our patients. The non-pathology outcomes are
discussed in a separate review and should be strongly considered .
[29]
Scrutinizing ones’ own rectal cancer resection outcomes is even more important than reviewing the
literature. The Commission on Cancer’s National Accreditation Program for Rectal Cancer was established
to ensure the highest quality metrics based on the highest level of evidence available are followed . The
[30]
NAPRC requires data collection and monitoring, which should help the provision of optimal care. A
national program of this caliber allows for further tracking of current care processes to better evaluate