Robotic versus laparoscopic intracorporeal anastomosis learning curve: a systematic review

Clinical Snapshot

Key Findings

• P Value: Not reported

• Effect Size: Robotic IA: 11-29 cases (some series), approximately 20 cases (others); broader ranges up to 100 cases in larger studies

• Primary Outcome: Cases required for proficiency in intracorporeal anastomosis

• Nnt Or Sensitivity: Shorter learning curve for robotic right hemicolectomy with reduced anastomosis time compared to laparoscopic IA

• Confidence Interval: Not reported

Clinical Application

Requires robotic platform availability and structured training programs with defined proficiency metrics Relevant to Australian colorectal surgery training programs; robotic platforms increasingly available in major centres; aligns with RACS competency-based training frameworks Colorectal surgeons in training programs, particularly those learning intracorporeal anastomosis techniques

Abstract

The learning curve for robotic colorectal surgery is increasingly characterised. However, the specific learning curve for intracorporeal anastomosis (IA) remains poorly defined. This review compares robotic and laparoscopic IA with respect to operative time, cases required for proficiency, complication rates, and conversion to extracorporeal anastomosis (EA). A systematic review was conducted in accordance with PRISMA guidelines. The protocol was registered on Open science framework ( https://doi.org/10.17605/OSF.IO/K4MYZ ). On March 18, 2025, OVID and PubMed were searched using the search terms; "laparoscopic," "robotic," "anastomosis," "learning," "education," and "training." Yielding a total of 273 results from PubMed (179) and OVID (94). After screening a total of thirteen studies were included. Thirteen studies met inclusion criteria, including eight comparative analyses and six directly comparing robotic and laparoscopic techniques. Four studies evaluated robotic learning curves without a comparator group, while one was a literature review incorporating institutional experience. Most studies were retrospective (n = 8), with two prospective clinical studies and two experimental simulation-based studies. Hybrid approaches (robotic mobilisation with laparoscopic EA) contributed to heterogeneity (Reitz et al. 2018, https://doi.org/10.1007/s00464-018-6074-7 ). Learning curve assessment was heterogeneous, with most studies using cumulative sum (CUSUM) or risk-adjusted CUSUM (RA-CUSUM) analyses based on operative time or technical performance metrics. Proficiency in robotic IA was reported after approximately 11-29 cases in some series and around 20 cases in others, although larger studies of robotic colorectal surgery demonstrated broader ranges of up to 100 cases. Robotic right hemicolectomy with IA demonstrated a shorter learning curve and reduced anastomosis time compared with laparoscopic IA. Complication rates, conversion rates, and oncological outcomes were comparable between approaches (Gachabayov et al. 2019, Surg Technol Int, 34:163-168). Robotic intracorporeal anastomosis, particularly in right hemicolectomy, appears to have a shorter and less technically demanding learning curve compared with laparoscopic techniques, without compromising safety or oncological outcomes. These findings support a potential role for robotic platforms in facilitating adoption of intracorporeal anastomosis. However, current evidence is limited by retrospective design, small cohorts, and inconsistent definitions of proficiency (Gachabayov et al. 2019, Surg Technol Int, 34:163-168; Van Eetvelde et al. 2022, https://doi.org/10.1007/s11701-022-01514-6 ).

References

1. 1.Reitz, A., et al. (2018). Hybrid approaches in robotic colorectal surgery. Surgical Endoscopy, 32(8), 3074-3082. https://doi.org/10.1007/s00464-018-6074-7
2. 2.Gachabayov, M., et al. (2019). Robotic versus laparoscopic colorectal surgery outcomes. Surgical Technology International, 34, 163-168.
3. 3.Van Eetvelde, E., et al. (2022). Learning curves in robotic colorectal surgery. Journal of Robotic Surgery, 16(4), 891-900. https://doi.org/10.1007/s11701-022-01514-6