Robotic approach to rectal cancer

Rectal cancer surgery is subject to oncological requirements that induce technical difficulties for an organ located in a narrow volume basin in contact with vascular and nervous structures that must be respected. This technical act must also meet the criteria of minimally invasive surgery. The robotic tool facilitating laparoscopy aims to achieve all these objectives.
To date, the literature is full of publications concerning the use of the robot in the surgical treatment of rectal cancer with more than 2000 publications to date. There are many prospective cohort studies, meta-analyses, but few trials.
The first randomized trial comparing laparoscopy to robotics, entitled ROLARR, conducted in 2012 (29 centers, 10 countries, 471 patients), whose primary endpoint was the conversion rate, did not show any difference between the two groups, with however a slight benefit in favor of the robot for male, obese and large prostate patients. This trial was burdened by numerous methodological biases. The analysis of these same groups carried out in 2018 and showed however that the conversion rate was significantly lower in the robot group according to the operator's experience. The Chinese trial comparing two groups in 2022 (586 robots vs 585 laparoscopies) showed significantly fewer invaded lateral margins in the robot group (4 vs 7.2%), fewer intraoperative complications (5.5 vs 8.7%), less blood loss (40.0 vs 50.0 ml), fewer conversions (1.7 vs 3.9%) and fewer serious postoperative complications (Clavien Dindo >2) (16.2 vs 23.1%). However, the low rate of anastomotic fistulas of between 5 and 8% in this trial is surprising. The Korean multicenter trial published in 2023 (robot 165 vs lap 155) had as its primary endpoint the rate of complete mesorectal excision. In the subgroup of patients who received neoadjuvant radio-chemotherapy, the rate of invaded margins was significantly lower in the robot group (0 vs 8.2% p < 0.034). However, this trial was interrupted early in 2016 for economic reasons, the additional cost of the robot being borne by the patient. There is no recommendation concerning the use of the robot in rectal cancer. However, the critical analysis of the literature clearly shows the technical benefit of the robot over laparoscopy and justifies its common use in expert centers.

JAMA. 2017 ;318(16) :1569-1580. Doi :10.1001/jama.2017.7219 October 24/31 – 2017
Effect of Robotic-Assisted vs Conventional Laparoscopic Surgery on Risk of Conversion to Open Laparotomy Among Patients Undergoing Resection for Rectal Cancer The ROLARR Randomized Clinical Trial
David Jayne, MD ; Alessio Pigazzi, PhD ; Helen Marshall, MSc ; Julie Croft, BSc ; Neil Corrigan, MSc ; Joanne Copeland, BSc ; Phil Quirke, FmedSci ; NickWest, PhD ; Tero Rautio, PhD ; Niels Thomassen, MD ; Henry Tilney, MD ; Mark Gudgeon, MS ; Paolo Pietro Bianchi, MD ; Richard Edlin, PhD ; Claire Hulme, PhD ; Julia Brown, MSc

Lancet Gastroenterol Hepatol 2022 Nov ;7(11) :991-1004.
Doi : 10.1016/S2468-1253(22)00248-5. Epub 2022 Sep 8.
Robotic versus laparoscopic surgery for middle and low rectal cancer (REAL) : short-term outcomes of a multicentre randomised controlled trial
Qingyang Feng 1, Weitang Yuan 2, Taiyuan Li 3, Bo Tang 4, Baoqing Jia 5, Yanbing Zhou 6, Wei Zhang 7, Ren Zhao 8, Cheng Zhang 9, Longwei Cheng 10, Xiaoqiao Zhang 11, Fei Liang 12, Guodong He 1, Ye Wei 1, Jianmin Xu 13 ; REAL Study Group
Annals of Surgery 278(1) :p 31-38, July 2023. DOI : 10.1097/SLA.0000000000005788
Comparison of Laparoscopic Versus Robot-Assisted Surgery for Rectal Cancers
The COLRAR Randomized Controlled Trial
Park, Jun Seok MD, PhD* ; Lee, Sung Min MD* ; Choi, Gyu-Seog MD, PhD* ; Park, Soo Yeun MD* ; Kim, Hye Jin MD* ; Song, Seung Ho MD* ; Min, Byung Soh MD, PhD† ; Kim, Nam Kyu MD, PhD† ; Kim, Seon Hahn MD, PhD‡ ; Lee, Kang Young MD, PhD†