624789

research-article2015
SRIXXX10.1177/1553350615624789Surgical InnovationFerrara et al

Original Article
Surgical Innovation

Laparoscopy Versus Robotic Surgery for

1­–7
© The Author(s) 2015
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DOI: 10.1177/1553350615624789

Experience sri.sagepub.com

Francesco Ferrara, MD1, Riccardo Piagnerelli, MD2,

Maximilian Scheiterle, MD1, Giulio Di Mare, MD1, Pasquale Gnoni, MD1,
Daniele Marrelli, MD1, and Franco Roviello, MD1,2

Abstract
Background. Minimally invasive approach has gained interest in the treatment of patients with colorectal cancer. The
purpose of this study is to analyze the differences between laparoscopy and robotics for colorectal cancer in terms of
oncologic and clinical outcomes in an initial experience of a single center. Materials and Methods. Clinico-pathological
data of 100 patients surgically treated for colorectal cancer from March 2008 to April 2014 with laparoscopy and
robotics were analyzed. The procedures were right colonic, left colonic, and rectal resections. A comparison between
the laparoscopic and robotic resections was made and an analysis of the first and the last procedures in the 2
groups was performed. Results. Forty-two patients underwent robotic resection and 58 underwent laparoscopic
resection. The postoperative mortality was 1%. The number of harvested lymph nodes was higher in robotics. The
conversion rate was 7.1% for robotics and 3.4% for laparoscopy. The operative time was lower in laparoscopy for all
the procedures. No differences were found between the first and the last procedures in the 2 groups. Conclusions. This
initial experience has shown that robotic surgery for the treatment of colorectal adenocarcinoma is a feasible and safe
procedure in terms of oncologic and clinical outcomes, although an appropriate learning curve is necessary. Further
investigation is needed to demonstrate real advantages of robotics over laparoscopy.

Keywords
colorectal surgery, robotic surgery, surgical oncology

Introduction invasive fashion without the limitations of laparoscopy.9

Minimally invasive surgery has gained influence over the
past two decades. The first colorectal laparoscopic proce-
dure was performed by Jacobs et al1 in 1991. Ten years
later, in 2001, the robotic system was applied to colorectal
surgery.2 Many authors have given further evidence on the
noninferiority of laparoscopy over open surgery, focusing
on morbidity and mortality3,4 and on the effectiveness of
this approaches in terms of oncologic outcomes.5 However,
this approach has some critical issues, like the lack of dex-
terity, unstable images brought about by intentional camera
panning, and a difficult learning curve. Therefore, mini-
mally invasive colorectal surgery has been adopted very
slowly, especially for rectal cancer resections, maybe
because of the difficulty of the laparoscopic approach in
narrow anatomic fields such as the pelvis.6-8 To overcome
these limitations, robotic surgical systems have been intro-
duced and quickly adopted in colorectal surgery.
Nevertheless this technique has some advantages, which
allow to perform colorectal procedures in minimally
The main advantages are the tremor filtering, the 3-dimen-
sional high-definition imaging system, and the motion
scaling, which permit a meticulous dissection. In addition,
the learning curve of the robotic system seems to be much
more simple and intuitive than laparoscopy.10 On the other
hand, the robotic approach has some drawbacks, like, for
example, the lack of tactile sense, bulky robotic cart, lon-
ger operative time, and high costs.11 These are the main
1
Department of Medicine, Surgery and Neurosciences, Unit of
Surgical Oncology, Azienda Ospedaliera Universitaria Senese,
University of Siena, Italy
2
Department of Medicine, Surgery and Neurosciences, Unit of
Minimally Invasive Surgery, Azienda Ospedaliera Universitaria Senese,
University of Siena, Italy
Corresponding Author:
Francesco Ferrara, Department of Medicine, Surgery and
Neurosciences, Unit of Surgical Oncology, Azienda Ospedaliera
Universitaria Senese, University of Siena, Strada delle Scotte, 14,
53100 Siena, Italy.
Email: frr.fra@gmail.com

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2 Surgical Innovation 
reasons why the use of robotic systems in surgery is not
widespread and not always used in place of standard lapa-
roscopic techniques. Moreover, there is no evidence
regarding the superiority of robotics over laparoscopy in
terms of oncologic outcomes.12 Several studies, which
have come to the same conclusions, are always limited by
their retrospective design and the evidence of noninferior-
ity of the robotic approach compared with laparoscopy or
open surgery.13,14 The minimally invasive approach for
colorectal surgery has been adopted by our Surgical Unit
since 2008, and the DaVinci Si HD Surgical System
(Intuitive Surgical, Inc, Sunnyvale, CA, USA) was
acquired by our hospital in April 2011. At first, we began to
treat patients suitable for minimally invasive surgery with
the robotic system, selecting easier cases with less comor-
bidities. Later, we decided to treat more complex cases as
well, and the choice of the two approaches was mainly
linked to the availability of the robotic system in our hospi-
tal, which is usually used by different surgical teams.
Subsequently, in this study there was no randomized
selection of patients who underwent laparoscopic or
robotic resection. We present a retrospective study with
prospectively collected data to compare the short-term
outcomes of robotic and laparoscopic colorectal resec-
tions performed in our institution by a single surgeon.
This is an initial experience of minimally invasive sur-
gery procedures performed at our open surgery experi-
enced center.
Materials and Methods
Between March 2008 and April 2014, 100 patients
affected by colorectal cancer underwent to minimally
invasive surgical resection (laparoscopic or robotic) at
the Surgical Oncology and Minimally Invasive Surgery
Units, University of Siena, Italy. Data were collected in a
database and they were extracted for statistical analysis.
The criteria for patients selection were the following: his-
tological diagnosis of adenocarcinoma of the colon or
rectum, no anesthesiological contraindications to mini-
mally invasive surgery, procedures performed by the
same surgical team, absence of metastatic diseases, pre-
operative workup analysis (endoscopy with biopsies,
radiological imaging and routine examinations) per-
formed at our institution. Data were extracted from the
medical records of each patient; in particular we have
considered the following: demographic data, discharge
paper, surgical operation descriptions (to extract tumor
location data, type of intervention, perioperative mortal-
ity, operative time from incision to closure and conver-
sion to open surgery), and the histopathologic report (to
get data on histotype, tumor staging and grading, tumor
size, number of lymph nodes harvested and involved,
resection’s margins involvement). Comorbidities were
classified according to Charlson Comorbidity Index.15
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Tumor staging was classified according to Union for
International Cancer Control–American Joint Committee
on Cancer (UICC-AJCC) TNM 7th edition classification
system. Lymphadenectomy was considered adequate
when a number of 12 or more lymph nodes has been har-
vested, according to the last UICC-AJCC guidelines.16
The lymph node ratio (LNR) has also been considered, as
the ratio between the number of lymph nodes involved
and the number of lymph nodes harvested. Grade III-IV
postoperative complications, according to Clavien-Dindo
classification, were considered.
The first comparison was made between the 2 groups
of robotic and laparoscopic resections. Then a second
comparison was carried out among the first and the last
20 robotic and laparoscopic procedures, respectively, to
analyze their differences between these 2 approaches in
the first and in the last period of our experience. Finally,
we divided the single procedures (right hemicolectomy,
left hemicolectomy, and rectal resection) in order to ana-
lyze the differences between the 2 approaches.
Clinicopathologic data and surgical outcomes were con-
sidered till their discharge or till 30 days after the
operation.
Surgical Procedures
For both laparoscopic and robotic operations the same
standardized approach was adopted for each type of pro-
cedure, by means of an extracorporeal anastomosis tech-
nique for right and left colonic resections and a trans-anal
end-to-end mechanical anastomosis for rectal resections,
when performed. The specimen was always extracted
through a small epigastric incision in the event of right-
sided colonic resections and through a left side incision in
case of left-sided or rectal resections. Total mesorectal
excision was performed in all cases of rectal cancer.
Data Analysis
Data were analyzed using IBM SPSS Statistics v.20 soft-
ware for Windows (IBM Corp, Armonk, NY, USA).
Between-group tests were performed using Fisher’s exact
test for dichotomous data, chi-square test for categorical
data and Student’s t test for continuous data. A P value
<.05 was chosen for the statistical significance level.
Results
From March 2008 to April 2014, 100 consecutive patients
have been operated on for histologically proven colorectal
adenocarcinoma by the same surgeon with minimally
invasive technique at the Oncologic and Minimally
Invasive Surgery Unit, University of Siena, Italy. Of these,
42 patients underwent robotic colorectal resection (RCR)
and 58 underwent laparoscopic colorectal resection
Ferrara et al 3
(LCR). Demographic and clinicopathologic data are
shown in Table 1. The 2 groups were comparable with
respect to gender, age, comorbidities, tumor location,
pTNM, and Dukes staging. In the RCR group the mean
number of lymph nodes harvested was significantly
higher than in the LCR group (18.8 vs 14.6, P < .001). No
statistically significant differences were found in the
mean number of positive lymph nodes (0.7 vs 0.9, P = .28)
and in the mean operative time, although it was higher
in the RCR than in the LCR group (293.6 vs 223.0, P >
.99). No significant differences were observed for post-
operative stay, even though it was lower in the RCR
group (7.3 vs 8.9, P = .18). The LNR was 0.036 and 0.061
for RCR and LCR groups respectively. The number of
conversions to open surgery was 3 (7.1%) in the RCR
group and 2 (3.4%) in the LCR group (Table 1). In all
cases, no neoplastic infiltration of the resection margins
was retrieved.
Major complications (grade III-IV Clavien-Dindo)
occurred in 5 cases: 3 for anastomotic leakage (2 in LCR
right hemicolectomies and 1 in RCR rectal resection), 1
for intestinal occlusion (RCR left hemicolectomy), and 1
for abdominal bleeding (LCR left hemicolectomy).
The postoperative mortality (30-day mortality) was
1% (1 LCR left hemicolectomy patient died on 11th post-
operative day for aspiration pneumonia).
The RCR and LCR groups were also divided into 2
parts respectively, part A for the first 20 procedures
(RCR-A and LCR-A) and part B for the last 20 proce-
dures (RCR-B and LCR-B). A comparison was made
between RCR-A and RCR-B and between LCR-A and
LCR-B.
No significant differences were found among the
RCR-A and RCR-B with regard to the mean number of
harvested and positive lymph nodes and the mean opera-
tive time. The LNR was 0.075 and 0.025 for RCR-A and
RCR-B, respectively. The number of conversions was 2
for the RCR-A and 1 for RCR-B. Postoperative stay was
significantly lower in RCR-B (8.8 vs 5.8, P < .01). No
differences were observed in terms of complications
between the 2 groups (Table 2).
In the comparison between the LCR-A and LCR-B, no
statistically significant differences were found between
the mean number of harvested nodes, the mean number of
positive nodes, the LNR, the mean operative time, the
conversion rate, and the postoperative stay, though it was
lower in LCR-B. The postoperative complications were 2
for LCR-A and 1 for LCR-B, not statistically comparable
(Table 3).
The analysis of single procedures (right hemicolec-
tomy, left hemicolectomy, and rectal resection) showed
no significant differences in terms of mean number of
harvested and positive lymph nodes and mean hospital
stay in RCR and LCR groups. The mean operative time
resulted significantly lower in the LCR group for the 3
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types of procedures (Table 4). This analysis also showed
that the only conversions to open surgery were for rectal
resections.
Discussion
During the past decades, colorectal surgery has devel-
oped its minimally invasive approach with the increasing
use of laparoscopic and robotic techniques.17 The contin-
uous evolution of medical and surgical fields has opened
the door to this kind of innovation. The use of minimally
invasive approach in colorectal surgery has been reported
by several authors in the literature.13,14,18-21 These studies
have confirmed that minimally invasive colorectal sur-
gery provides similar results as “traditional” open
approach, especially in terms of operative and oncologic
outcomes, although there is no consensus on the best
therapeutic option.22 There are several limitations affect-
ing laparoscopic surgery, including the high conversion
rate to open surgery.23 The introduction of robot-
assisted surgery has overcome some of the limitations
of laparoscopy and has been successfully applied to sev-
eral surgical fields, such as urology, general surgery, and
gynecology.24
Robotic surgery has certain technical advantages that
could overcome the drawbacks of laparoscopy, like assis-
tant-dependent unstable 2-dimensional view, inability to
perform high-precision suturing, poor ergonomics, and
fixed tips with limited dexterity of surgical instruments
inside the patient.22 In the past years, there has been a con-
sistent trend of increase in the number of colorectal surger-
ies using the robotic approach. Although this kind of
approach has been mainly used in rectal surgery,25 its imple-
mentation has been slow in colonic surgery.26 Our initial
experience, comparing the laparoscopic and the robotic
approaches in colorectal surgery for oncologic disease, con-
firms the advantages of robotic surgery in terms of ade-
quacy of lymphadenectomy. In 2002, Weber et al21 were the
first authors to publish the results on robotic colorectal
resections for tumors of the sigmoid colon and of the rec-
tum. Subsequent studies have demonstrated the feasibility
of this type of procedure for colorectal resections, increas-
ing the number of patients treated with this approach.13 One
of the most important factors that defines adequate resec-
tion of the colon-rectum is the number of harvested lymph
nodes, which should be at least 12, as established by the last
guidelines of the AJCC.16 In our study, this target was
always respected, both in the laparoscopic and in the robotic
group. There was a significant difference in the lymph
nodal yield, achieving better results in the robotic group
(18.8 vs 14.6 in the LCR group, P < .001). These results,
which have shown a more accurate lymphadenectomy in
robotic surgery, can be justified by the use of the high-defi-
nition 3-dimensional vision system of the DaVinci SiHD
(InSite Vision System), which allows a real-time
4 Surgical Innovation 

Table 1.  Demographic Data and Outcomes of the Patients. Table 2.  Comparison Between Group A and Group B of
Robotic Surgery.
RCR (n = 42), LCR (n = 58),
n (%) n (%) P
RCR-A RCR-B
Age, years, mean ± SD 66.1 ± 12.6 65.4 ± 11.2 .40a (n = 20) (n = 20) Pa
Sex (male:female) 24:18 34:24 .88b
Procedures .37b No. of harvested 16.5 ± 10.5 21.6 ± 13.8 .09
  Right hemicolectomy 13 (31) 15 (25.9)   nodes, mean ± SD
  Left hemicolectomy 11 (26.1) 23 (39.6)   No. of positive nodes 0.9 ± 2.3 0.6 ± 1 .27
  Rectal resection 18 (42.9) 20 (34.5)   mean ± SD
No. of harvested nodes, mean 18.8 ± 12.2 14.6 ± 7.5 .01a LNR 0.075 0.025  
± SD
No. of positive nodes mean 0.7 ± 1.7 0.9 ± 1.8 .28a Postoperative stay, 8.8 ± 4.30 5.8 ± 1.00 <.01
± SD days, mean ± SD
LNR 0.036 0.061   Operative time, 312.8 ± 88.4 273.3 ± 68.4 .06
Operative time, minutes, 293.6 ± 83.0 223.0 ± 69.9 >.99a minutes, mean ±
mean ± SD
SD
Hospital stay, days, mean 7.3 ± 3.4 8.9 ± 11.3 .18a
± SD No. of conversions 2 1  
No. of conversions to open 3 (7.1) 2 (3.4) .94b No. of major 1 1  
surgery complications
Major complications (grade 2 (4.8) 3 (5.2) .99b
III-IV) Abbreviations: LNR, lymph node ratio; RCR, robotic colorectal
  Anastomotic leakage 1 (2.4) 2 (3.4)   resection.
  Intestinal occlusion 1 (2.4) 0   a
Student’s t test.
  Abdominal bleeding 0 1 (1.7)  
Postoperative mortality 0 1 (1.7)   Table 3.  Comparison Between Group A and Group B of
CCI (number of patients):  
Laparoscopic Surgery.
 0 13 (31) 28 (48.3)  
 1 16 (38.1) 14 (24.1) .34b LCR-A LCR-B
 2 8 (19) 10 (17.2)  
(n = 20) (n = 20) Pa
 3 4 (9.5) 3 (5.2)  
 4 1 (2.4) 4 (6.9)   No. of harvested 14.5 ± 9.5 14.5 ± 7.7 .49
Mean tumor size, cm 3.6 3.3 .13a
nodes, mean ± SD
Grading (number of patients):
 G2 21 (50) 34 (58.6) .39b
No. of positive nodes 1.2 ± 2.3 0.5 ± 1.6 .15
 G3 21 (50) 24 (41.4)   mean ± SD
Dukes stage (number of patients): LNR 0.079 0.034  
 A 15 (35.7) 26 (44.8)   Postoperative stay, 12.9 ± 18.66 6.9 ± 2.23 .08
 B 16 (38.1) 14 (24.1) .32b days, mean ± SD
 C 11 (26.2) 18 (31.1)  
Operative time, 226.5 ± 77.6 233.3 ± 74.2 .42
Stage (number of patients):
 I 15 (35.7) 26 (44.8)  
minutes, mean ± SD
 IIa 15 (35.7) 14 (24.1)   No. of conversions 1 1  
 IIb 0 0 .61b No. of major 2 1  
 IIc 1 (2.4) 0   complications
 IIIa 2 (4.8) 5 (8.6)  
 IIIb 8 (19) 11 (19)   Abbreviations: LCR, laparoscopic colorectal resection; LNR, lymph
 IIIc 1 (2.4) 2 (3.4)   node ratio.
a
pT (number of patients): Student’s t test.
 pT1 9 (21.4) 16 (27.6)  
 pT2 8 (19) 15 (25.9)  
 pT3 23 (54.8) 27 (4.7) .41b magnification with a considerable advantage over regular
 pT4a 1 (2.4) 0   surgery. This system provides more than a thousand frames
 pT4b 1 (2.4) 0   of the instrument position per second and filters each image
pN (number of patients):
 pN0 31 (73.8) 40 (69)  
through a video processor that eliminates background noise.
 pN1a 5 (11.9) 8 (13.8)   The endoscope is automatically programmed to regulate the
 pN1b 5 (11.9) 5 (8.6) .61b temperature of the endoscope in order to prevent fogging
 pN2a 0 3 (5.2)   during the operation.27 The mean number of lymph nodes
 pN2b 1 (2.4) 2 (3.4)  
Infiltrated resection margins 0 0  
harvested reported in our article is also superior to the value
described by other authors in robotic surgery. For example,
Abbreviations: CCI, Charlson Comorbidity Index; LCR, laparoscopic colorectal Lim et al,28 in a study on 180 patients who underwent mini-
resection; LNR, lymph node ratio; RCR, robotic colorectal resection.
a
Student’s t test. mally invasive surgery, described a mean number of lymph
b
Chi-square test. nodes harvested of 12. Park et al29 reported a mean number of

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Ferrara et al 5

Table 4.  Analysis of Single Procedures for Robotic and malignant tumor. This value is comparable to our findings.
Laparoscopic Surgery. These results could appear in contrast with the mean values
Procedure Variables RCR LCR Pa of positive lymph nodes, which, in our study, seems to be
superior in patients treated with laparoscopy than of those
RH No. of 24.2 ± 13.4 18.0 ± 6.4 .13 treated with robotics (0.9 vs 0.7, P = .28) and also superior
harvested to the lymph node ratio (0.061 vs 0.036). Although these
nodes, mean
results are not statistically significant, the superior value of
± SD
  No. of 0.92 ± 1.3 1.3 ± 2.4 .59
the mean of positive lymph nodes harvested with laparos-
positive copy can be ascribed to the different composition of the 2
nodes, mean groups of patients, with more “early” stages in the robotic
± SD group, and not to the different approaches used. The robotic
  Operative 230.0 ± 34.9 167.7 ± 35.7 <.01 approach has several advantages over the traditional laparo-
time, scopic surgery, that is, the possibility for the surgeon of
minutes, using an endoscope with a more easily visualization of the
mean ± SD
anatomic structures or the more powerful manipulation
  Hospital stay, 7.1 ± 1.5 8.5 ± 4.3 .26
guaranteed by the Endowrist system, which allows to
days, mean
± SD maneuver the structures in a way that simulates fine human
LH No. of 19.1 ± 16.3 12.9 ± 4.5 .09 movements. These and other features allow the surgeon to
harvested perform fine operations such as nerve sparing, the identifi-
nodes, mean cations of ureters or gonadic vessels, and sutures in general.
± SD For these reasons, the sexual and urinary functionalities
  No. of 0.2 ± 0.4 0.5 ± 0.9 .24 seem to be better after being treated with robotic surgery
positive than after laparoscopy.30 In our study, the number of con-
nodes, mean versions to open surgery has been shown only for patients
± SD
undergoing rectal resection, because in these cases the oper-
  Operative 273.2 ± 66.9 213.5 ± 60.9 .01
time,
ation is technically more difficult than colonic resections.
minutes, Our experience has pointed out a comparable rate of con-
mean ± SD version and, in some cases, inferior to those reported by
  Hospital stay, 6.1 ± 2.1 10.7 ± 17.6 .39 other authors.31-33 The causes of the conversions were more
days, mean frequently due to massive bleedings or, sometimes, to the
± SD presence of diffuse and tenacious adhesions. The decision
RR No. of 14.8 ± 5.8 14.0 ± 10.1 .38 to convert to open surgery has been taken in order to guar-
harvested antee an adequate oncologic radicality and to avoid a pro-
nodes, mean longed operative time as well as to carry on the procedure
± SD
safely. Although these results are not statistically signifi-
  No. of 0.8 ± 2.4 1.0 ± 2.1 .41
cant, it seems evident that the laparoscopic approach
positive
nodes, mean requires less time than robotics (293.6 vs 223.0 minutes in
± SD LCR group, P > .99). These data acquired statistical signifi-
  Operative 351.9 ± 78.4 275.5 ± 59.8 <.01 cance when we analyzed the single procedures separately,
time, showing that robotic procedures are more time consuming.
minutes, This result is comparable to that reported in a recent review
mean ± SD by Mirnezami et al.34 It describes a more extended opera-
  Hospital stay, 7.1 ± 1.4 8.11 ± 4.6 .35 tive time for robotic cases, specifying that this finding is
days, mean less evident in case of rectal resections.34 These results are
± SD
justified by the time used to dock and undock the robotic
Abbreviations: LCR, laparoscopic colorectal resection; LH, left system, even in presence of an experienced surgical team. It
hemicolectomy; RCR, robotic colorectal resection; RH, right frequently happens that patients on the surgical table require
hemicolectomy; RR, rectal resection. different positions, so the robotic cart needs to be undocked
a
Student’s t test.
and redocked several times during the same procedure. This
extends the operative time. Only the standardization of the
lymph nodes of 12.9 in a study on 80 patients divided into 2 surgical procedures together with the continuous training of
groups, 40 laparoscopies and 40 robotics. A recent review by the whole surgical team (surgeons, nurses, anesthesiolo-
Kim et al12 reported a mean of 17.8 harvested lymph nodes, gists, and operation room staff) can improve the quality of
analyzing 19 studies for a total of 955 patients who under- the operations and lead to a progressive reduction of the
went colorectal resection in minimally invasive surgery for operative time. The low rate of postoperative mortality

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6 Surgical Innovation 
(only 1 patient died in the LCR group for nonsurgical com-
plication) showed the safety of these approaches. Our study
also shows a low rate of major complications, with no sub-
stantial differences in the 2 groups.
We have also compared the procedures performed at
the beginning and in the last period of our experience,
analyzing the first 20 operations and the last 20 for each
group. In all surgical operations, the principles of onco-
logic radicality were always respected, the number of
lymph nodes removed were in all cases superior to 12, in
line with the international guidelines.16 Moreover, pathol-
ogy showed no involvement of margins in all cases, so R0
surgery was always achieved. A low conversion rate was
observed. This confirms that the technique was ade-
quately acquired and improved. In the robotic group, we
have reached extremely favorable results. Both in the first
and in the last 20 procedures, the number of lymph nodes
removed was higher than the minimum number of 12
stated by the AJCC,16 with a mean number of nodes of
21.6, improved respect to the first experience. The con-
version rate decreased from 2 to 1 conversion in the sec-
ond group, and the mean operative time, from 312.8 to
273.3 minutes (P = .06), has demonstrated how the sur-
geon and all the components of the surgical team have
acquired more skills in the utilization of the robotic sys-
tem. We also significantly shortened the hospital stay,
from 8.8 to 5.8 days (P < .01), reducing the costs of hos-
pitalization for these patients. Another factor improved in
our experience was the ability to perform some opera-
tions with a single docking approach, especially for left
colonic resections. It has consequently allowed us to
reduce significantly the duration of these procedures. For
the laparoscopic experience, the oncologic radicality in
terms of lymph nodal harvest was always respected, with
no differences, both in the first and in the last part of our
experience. Even in this group we have reduced the hos-
pital stay, from 12.9 to 6.9 days (P = .08), not significant,
but important to mention, because it is one of the benefits
of minimally invasive surgery. Moreover, the number of
complications was the same for RCR-A and RCR-B and
decreased from 2 to 1 for LCR-A and LCR-B.
When we analyzed separately the single procedures,
the RCR and LCR groups were homogenous in terms of
lymph nodes removed in rectal resections. In right and
left hemicolectomy we found more lymph nodes har-
vested for RCR groups, but with no statistically signifi-
cant difference. There were significant results for the
operative time, shorter in the LCR groups, for the reasons
already discussed; these data are also confirmed in litera-
ture.12,35,36 Another important factor, even though not sig-
nificant, was the lower number of postoperative stay for
the RCR groups, highlighting again that the robotic
approach gives advantages in terms of hospitalization.
In conclusion, robotic surgery for the treatment of
colorectal adenocarcinoma is a feasible and safe procedure.
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It is not inferior to standard laparoscopy in terms of onco-
logic radicality and surgical complications. This retrospec-
tive study on 100 patients operated consecutively by the
same surgeon at a single center has demonstrated that har-
vesting lymph nodes with the robotic system is better than
laparoscopy, in particular when the learning curve is
achieved. Oncologic results were comparable for the 2
techniques, with several advantages for the surgeon per-
forming robotic operations, especially in terms of ergonom-
ics. The robotic approach has also shown its superiority in
terms of postoperative stay, reducing the costs of
hospitalization.
We have also to mention about the weakness of this
study: certainly the number of cases is small to achieve
proper conclusions, especially for each type of procedure.
Other data are necessary to make a stronger comparison
between the 2 approaches, for instance, functional results
and pelvic nerve damage for rectal resections, or surgical
site infection rate and postoperative pain for all the proce-
dures. Other limitations of this study are its retrospective
nature and the lack of selection of the patients to the dif-
ferent approaches. During the past years in our experi-
ence, we have been increasing the surgical robotic activity
as against laparoscopy, performing more and more robotic
operations in order to achieve better results in this field
and to progressively reduce operative times. Moreover, in
our opinion, the costs of the robotic system could be com-
pensated by the reduction of hospitalization. Further
investigation is certainly needed to demonstrate real
advantages of robotics over laparoscopy, maybe with a
clinical trial, in order to properly select patients for the 2
types of approach.
Author Contributions
Study concept and design: Franco Roviello, Riccardo Piagnerelli
Acquisition of data: Maximilian Scheiterle, Pasquale Gnoni
Analysis and interpretation: Francesco Ferrara, Giulio Di Mare
Study supervision: Franco Roviello, Daniele Marrelli
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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