Short-term clinical outcomes of a European training programme for robotic colorectal surgery

Essential components and validation of multi-specialty robotic surgical training curricula: a systematic review

INTRODUCTION

The rapid adoption of robotic surgical systems has overtook the development of standardized training and competency assessment for surgeons, resulting in an unmet educational need in this field. This systematic review aims to identify the essential components and evaluate the validity of current robotic training curricula across all surgical specialties.

METHODS

A systematic search of MEDLINE, EMBASE, Emcare, and CINAHL databases was conducted to identify the studies reporting on multi-specialty or specialty-specific surgical robotic training curricula, between January 2000 and January 2024. We extracted the data according to Kirkpatrick's curriculum evaluation model and Messick's concept of validity. The quality of studies was assessed using the Medical Education Research Study Quality Instrument (MERSQI).

RESULTS

From the 3687 studies retrieved, 66 articles were included. The majority of studies were single-center ( n = 52, 78.8%) and observational ( n = 58, 87.9%) in nature. The most commonly reported curriculum components include didactic teaching ( n = 48, 72.7%), dry laboratory skills ( n = 46, 69.7%), and virtual reality (VR) simulation ( n = 44, 66.7%). Curriculum assessment methods varied, including direct observation ( n = 44, 66.7%), video assessment ( n = 26, 39.4%), and self-assessment (6.1%). Objective outcome measures were used in 44 studies (66.7%). None of the studies were fully evaluated according to Kirkpatrick's model, and five studies (7.6%) were fully evaluated according to Messick's framework. The studies were generally found to have moderate methodological quality with a median MERSQI of 11.

CONCLUSIONS

Essential components in robotic training curricula identified were didactic teaching, dry laboratory skills, and VR simulation. However, variability in assessment methods used and notable gaps in curricula validation remain evident. This highlights the need for standardized evidence-based development, evaluation, and reporting of robotic curricula to ensure the effective and safe adoption of robotic surgical systems.

Concurrent robotic colorectal surgical oncology training within a structured mentored international fellowship program

Robotic colorectal surgery is increasingly adopted worldwide, with mentored programs for established surgeons becoming more common. However, there is a paucity of dedicated robotic training programs for colorectal fellows. This study aims to assess the feasibility and efficacy of a structured, apprentice-based robotic colorectal training program delivered to multiple fellows concurrently. The fellowship program incorporates simulation training, dry/wet laboratory work, dedicated robotic console time in the operating room (OR) and individualised mentorship. Overall robotic proficiency was assessed using the Global Evaluative Assessment of Robotic Skills (GEARS) and procedure-specific proficiency was assessed using a modified European Academy of Robotic Colorectal Surgery (EARCS) Global Assessment Score (GAS) throughout the fellowship. A total of 59 cases (29 right hemicolectomies, 30 anterior resections) were evaluated between August 2023 and July 2024. Significant improvements were observed in GEARS scores (p = 0.0065) and modified GAS for both right hemicolectomies (p = 0.0052) and anterior resections (p = 0.0005), demonstrating a high level of competence and independence. Mean operative times were 213 min (right hemicolectomy) and 328 min (anterior resection). Median length of stay in the hospital was 2 days (right hemicolectomy) and 4 days (anterior resection). Median lymph node yield was 29 (right hemicolectomy) and 26 (anterior resection). There was 0% involved margins for both procedures. Robotic colorectal surgical oncology training delivered to multiple fellows concurrently in an apprenticeship model with dedicated console time is achievable and successful, leading to high levels of robotic competency and independence, whilst maintaining a high standard of clinical care and oncological outcome.

Key steps in exposure techniques for robotic total mesorectal excision (TME)

AIM

The use of robotic surgery is increasing significantly. Specific training is fundamental to achieve high quality and better oncological outcomes. This work defines key exposure techniques in robotic total mesorectal excision (TME). Based on a modular approach, macro- and microtractions for exposure in every step of a robotic TME are identified and described. The aim is to develop a step-by-step technical guide of the exposure techniques for a robotic TME.

METHODS

Twenty-five videos of robotic rectal resections performed at Champalimaud Foundation (Lisbon, Portugal) with the Da Vinci™ Xi robotic platform were examined. Robotic TME was divided into modules and steps. Modules are essential phases of the procedure. Steps are exposure moments of each module. Tractions are classified as macro- and microtractions. Macrotraction is the grasping of a structure to expose an area of dissection. Microtraction consists in the dynamic grip of tissue to optimize macrotraction in a defined area of dissection.

RESULTS

The procedure videos reviewed showed homogeneity concerning surgical methodology. Eight modules are outlined: abdominal cavity inspection and exposure, approach to and ligation of the inferior mesenteric vessels, medial to lateral dissection of the mesocolon, lateral colon mobilization, splenic flexure takedown, proctectomy with TME, rectal transection, and anastomosis. Each module was divided into steps, with a total of 45 steps for the entire procedure. This manuscript characterizes macrotraction and microtraction fine-tuning, detailing the large-scale macrotractions and the precision of microtractions at each step.

CONCLUSION

Tissue exposure techniques in robotic TME are key to precise dissection. This modular guide provides a functional system to reproduce this procedure safely; the addition of the exposure techniques could serve as a training method for robotic rectal cancer surgery.

Robotic colorectal surgery in Latin America: a systematic review on surgical outcomes

Background and objectives

Robotic approach in colorectal surgery is rapidly gaining interest, particularly in the context of rectal cancer resection. Despite economic barriers, substantial proliferation of robotic colorectal procedures has been observed throughout Latin America. However, there is a lack of data regarding intraoperative and early postoperative outcomes, as well as oncological and long-term results. This systematic review aims to provide an overview of the surgical outcomes of robotic-assisted colorectal approaches across Latin America.

Material and methods

A systematic literature search of electronic databases, including PubMed, LILACS, Scopus, Cochrane Library and Scielo, was performed and reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The main target of the literature search was studies that reported outcomes of colorectal robotic surgery in Latin America.

Results

A total of 9,694 published articles were identified from the initial search. Nine thousand six hundred thirty-six publications were excluded after title and abstract review and removal of duplicates. Fifty-eight articles were thoroughly reviewed, and 11 studies met the inclusion criteria. The critical appraisal of study quality (biases risk assessment) was performed according to the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis. In general, the overall study quality was poor. Of the 11 studies included in the analysis, ten addressed intraoperative and early postoperative outcomes, seven addressed oncological/pathological outcomes, and just one addressed long-term outcomes. Ten studies evaluated intraoperative and early postoperative outcomes, encompassing a total of 425 patients, the majority of whom were diagnosed with colorectal cancer. Morbidity rates exhibited a range between 0% and 45.9%, while mortality ranged from 0% to 2.5%.

Conclusion

Few studies have been published addressing intraoperative, postoperative, pathological, and oncological outcomes of robotic colorectal surgery in this region. Undoubtedly, there are unique challenges not encountered by developed countries, including economic obstacles in establishing structured training programmes and high-quality centres for the development of robotic surgery. Further studies are needed to assess the real extent of robotic surgery in the region and its results.

Systematic Review Registration

https://www.crd.york.ac.uk/, PROSPERO (CRD42023494112).

Skill progress during a dedicated societal robotic surgery training curriculum including several robotic surgery platforms

BACKGROUND

Robot-assisted procedures are increasingly common, and several systems are available for thoraco-abdominal surgery. Specific structured training is necessary, while access to these systems is still limited. This study aimed to assess surgeons' skill progress during consecutive training days of a curriculum with exposure to different robotic systems.

METHODS

This prospective observational study enrolled 47 surgeons with anonymized analysis of SimNow™ simulator performance scores and dedicated questionnaires after written consent. The primary outcome was the overall score, based on economy of motion, time to complete the exercise, and penalty for errors. Course participants in 2022-2023 had chosen 2 full hands-on days on Da Vinci® consoles with either virtual reality (VR) simulation training using the SimNow (n = 21, 44.7%) or digestive surgery procedures with a live animal model (n = 26, 55.3%). In all participants, training on Da Vinci® systems included console functions and principles of docking, camera, and instrument use for console and procedural training. They additionally had access to introductory dry-lab and VR simulator exercises on the Versius, HugoTMRAS, and Dexter systems and to VR exercises on the ROBOTiS simulator.

RESULTS

The participants (16F/31M, median age 40 years, range 29-58) from various surgical specialties (general/visceral/vascular) had no (n = 35, 74.5%) or little (n = 12, 25.5%) robotic experience including bedside assistance only and 20 (42.6%) had robotic simulator experience. The demographic variables fully completed by 44/47 participants (93.6%) and choice of module had no significant impact on the primary outcome. The considerable performance improvement from days 1 to 2 was exemplified by a significantly increased economy of motion and decreased amount of excessive force.

CONCLUSION

Robotic surgical training is increasingly complex with several systems on the market. Within a dedicated robotic surgery curriculum and based on integrated performance metrics, a significant improvement of skill levels was observed in a relatively short period of time.

Outcome of Colorectal Robotic Surgery in Newly Established Robotic Surgery Center: A Case Series

INTRODUCTION

The robotic platform compared to laparoscopy has proven to have similar postoperative outcomes, however its adoption in the Middle East has been slow and there is limited data regarding outcomes with its use in small newly established robotic colorectal programs. Our aim was to report our experience and outcomes of robotic colorectal surgery performed by fellowship-trained robotic colorectal surgeons and compare them to larger, more experienced centers.

METHODS

This is retrospective review of data collected between November 2021 and March 2023 from a tertiary health care referral center. The series included 51 patients who had elective or urgent robotic colorectal surgery. Patients who had emergency surgery were excluded. The outcomes were overall morbidity, serious morbidity, mortality, conversion to open, length of hospital stay, and quality of oncological specimen.

RESULTS

The overall morbidity was 31.4% (n = 16 patients). Only 9.8% (n = 5) had serious morbidity of which three required interventions under general anesthesia. The median length of hospital stay was 6 days (IQR = 4), and there was no mortality. Of 17 rectal cancer resections, 88% had complete mesorectal excision, 15 of them were R0 resections, median lymph node harvested was 14 (IQR = 7) and two cases were converted to open. All the colon cancer resections had R0 resection, median lymph nodes harvested was 21 (IQR = 4) and none were converted to open.

CONCLUSIONS

The implementation and integration of robotic colorectal surgery at a newly established center in a small country, when led by fellowship trained robotic colorectal surgeons, is safe and effective in terms of morbidity, mortality, conversion to open and specimen pathological quality.

Outcomes in robotic-assisted compared to laparoscopic-assisted colorectal surgery in a newly established colorectal tertiary center: a retrospective comparative cohort study

The robotic platform matches or surpasses laparoscopic surgery in postoperative results. However, limited date and slow adoption are noticed in the middle east. We aimed to report outcomes of robotic and laparoscopic colorectal surgery performed by fellowship-trained robotic colorectal surgeons and compare it to larger more experienced centers. Retrospective review of prospectively collected data between 2021 and 2023 of 107 patients who had robotic-assisted or laparoscopic-assisted colorectal surgery was included in the study. The outcomes were overall morbidity, serious morbidity, mortality, conversion to open, length of hospital stay, and the quality of oncological specimen. Of 107 patients, 57 were in the robotic and 50 were in the laparoscopic surgery groups. Overall, there were no significant differences in overall morbidity (46.8 vs. 53.2%, p = 0.9), serious morbidity (10.5 vs. 8%, p = 0.7), or mortality (0 vs. 4%, p = 0.2). Regarding oncological outcomes, there were no significant difference between the two groups regarding the number of lymph node harvested (17.7 ± 6.9 vs 19.0 ± 9.7, p = 0.5), R0 resections (92.7 vs. 87.1%, p = 0.5), and the rate of complete mesorectal excision (92.7 vs. 71.4%, p = 0.19). The study found that the robotic group had an 86% reduction in conversion rate to open surgery compared to the laparoscopic group, despite including more obese and physically dependent patients (OR = 0.14, 95% CI 0.03-0.7, p = 0.01). Robotic surgery appears to be a safe and effective as laparoscopic surgery in smaller colorectal surgery programs led by fellowship-trained robotic surgeons, with outcomes comparable to those of larger programs.

Regional variations and deprivation are linked to poorer access to laparoscopic and robotic colorectal surgery: a national study in England

BACKGROUND

Laparoscopic and now robotic colorectal surgery has rapidly increased in prevalence; however, little is known about how uptake varies by region and sociodemographics. The aim of this study was to quantify the uptake of minimally invasive colorectal surgery (MIS) over time and variations by region, sociodemographics and ethnicity.

METHODS

Retrospective analysis of routinely collected healthcare data (Clinical Practice Research Datalink linked to Hospital Episode Statistics) for all adults having elective colorectal resectional surgery in England from 1 January 2006 to 31 March 2020. Sociodemographics between modalities were compared and the association between sociodemographic factors, region and year on MIS was compared in multivariate logistic regression analysis.

RESULTS

A total of 93,735 patients were included: 52,098 open, 40,622 laparoscopic and 1015 robotic cases. Laparoscopic surgery surpassed open in 2015 but has plateaued; robotic surgery has rapidly increased since 2017, representing 3.2% of cases in 2019. Absolute differences up to 20% in MIS exist between regions, OR 1.77 (95% CI 1.68-1.86) in South Central and OR 0.75 (95% CI 0.72-0.79) in the North West compared to the largest region (West Midlands). MIS was less common in the most compared to least deprived (14.6% of MIS in the most deprived, 24.8% in the least, OR 0.85 95% CI 0.81-0.89), with a greater difference in robotic surgery (13.4% vs 30.5% respectively). Female gender, younger age, less comorbidity, Asian or 'Other/Mixed' ethnicity and cancer indication were all associated with increased MIS.

CONCLUSIONS

MIS has increased over time, with significant regional and socioeconomic variations. With rapid increases in robotic surgery, national strategies for procurement, implementation, equitable distribution and training must be created to avoid worsening health inequalities.

An Overview of Robotic Colorectal Surgery Adoption and Training in Brazil

Background and Objectives: Robotic surgical systems have rapidly become integrated into colorectal surgery practice in recent years, particularly for rectal resections, where the advantages of robotic platforms over conventional laparoscopy are more pronounced. However, as with any technological advancement, the initial high costs can be a limiting factor, leading to unequal health service access, especially in middle- and lower-income countries. Materials and Method: A narrative review was conducted with the objective of providing an overview of the escalating adoption, current training programmes, and certification process of robotic colorectal surgery in Brazil. Results: Brazil has witnessed a rapid increase in robotic platforms in recent years. Currently, there are 106 robotic systems installed nationwide. However, approximately 60% of the medical facilities which adopted robotic platforms are in the Southeast region, which is both the most populous and economically prosperous in the country. The Brazilian Society of Coloproctology recently established clear rules for the training programme and certification of colorectal surgeons in robotic surgery. The key components of the training encompass theoretical content, virtual robotic simulation, observation, assistance, and supervised procedures in colorectal surgery. Although the training parameters are well established, no colorectal surgery residency programme in Brazil has yet integrated the teaching and training of robotic surgery into its curriculum. Thus far, the training process has been led by private institutions and the industry. Conclusion: Despite the fast spread of robotic platforms across Brazil, several challenges still need to be addressed to democratise training and promote the widespread use of these platforms. It is crucial to tackle these obstacles to achieve greater integration of robotic technology in colorectal surgery throughout the country.

Textbook Oncological Outcomes for Robotic Colorectal Cancer Resections: An Observational Study of Five Robotic Colorectal Units

BACKGROUND

The quality of care of patients receiving colorectal resections has conventionally relied on individual metrics. When discussing with patients what these outcomes mean, they often find them confusing or overwhelming. Textbook oncological outcome (TOO) is a composite measure that summarises all the 'desirable' or 'ideal' postoperative clinical and oncological outcomes from both a patient's and doctor's point of view. This study aims to evaluate the incidence of TOO in patients receiving robotic colorectal cancer surgery in five robotic colorectal units and understand the risk factors associated with failure to achieve a TOO in these patients.

METHODS

We present a retrospective, multicentric study with data from a prospectively collected database. All consecutive patients receiving robotic colorectal cancer resections from five centres between 2013 and 2022 were included. Patient characteristics and short-term clinical and oncological data were collected. A TOO was achieved when all components were realized-no conversion to open, no complication with a Clavien-Dindo (CD) ≥ 3, length of hospital stay ≤ 14, no 30-day readmission, no 30-day mortality, and R0 resection. The main outcome measure was a composite measure of "ideal" practice called textbook oncological outcomes.

RESULTS

A total of 501 patients submitted to robotic colorectal cancer resection were included. Of the 501 patients included, 388 (77.4%) achieved a TOO. Four patients were converted to open (0.8%); 55 (11%) had LOS > 14 days; 46 (9.2%) had a CD ≥ 3 complication; 30-day readmission rate was 6% (30); 30-day mortality was 0.2% (1); and 480 (95.8%) had an R0 resection. Abdominoperineal resection was a risk factor for not achieving a TOO.

CONCLUSIONS

Robotic colorectal cancer surgery in robotic centres achieves a high TOO rate. Abdominoperineal resection is a risk factor for failure to achieve a TOO. This measure may be used in future audits and to inform patients clearly on success of treatment.

Short-term outcomes in robotic vs laparoscopic ileal pouch-anal anastomosis surgery: a propensity score match study

PURPOSE

Laparoscopic ileal pouch-anal anastomosis (IPAA) surgery offers improved short-term outcomes over open surgery but can be technically challenging. Robotic surgery has been increasingly used for IPAA surgery, but there is limited evidence supporting its use. This study aims to compare the short-term outcomes of laparoscopic and robotic IPAA procedures.

METHODS

All consecutive patients receiving laparoscopic and robotic IPAA surgery at 3 centres, from 3 countries, between 2008 and 2019 were identified from prospectively collated databases. Robotic surgery patients were propensity score matched with laparoscopic patients for gender, previous abdominal surgery, ASA grade (I, II vs III, IV) and procedure performed (proctocolectomy vs completion proctectomy). Their short-term outcomes were examined.

RESULTS

A total of 89 patients were identified (73 laparoscopic, 16 robotic). The 16 patients that received robotic surgery were matched with 15 laparoscopic patients. Baseline characteristics were similar between the two groups. There were no statistically significant differences in any of the investigated short-term outcomes. Length of stay trend was higher for laparoscopic surgery (9 vs 7 days, p = 0.072) CONCLUSION: Robotic IPAA surgery is safe and feasible and offers similar short-term outcomes to laparoscopic surgery. Length of stay may be lower for robotic IPAA surgery, but further larger scale studies are required in order to demonstrate this.

The current status of robotic colorectal surgery training programmes

Robotic-assisted colorectal surgery (RACS) is steadily increasing in popularity with an annual growth in the number of colorectal procedures undertaken robotically. Further upscaling of RACS requires structured and standardised robotic training to safeguard high-quality clinical outcomes. The aims of this systematic review were to assess the structure and assessment metrics of currently established RACS training programmes. A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines was performed. Searches were performed of the Ovid Medline, Embase and Web of Science databases between 2000 and 27th November 2021 to identify studies reporting on training curricula in RACS. Core components of training programmes and their relevant outcome assessment metrics were extracted. Thirteen studies were identified, with all training programmes designed for the da Vinci platform (Intuitive Surgical, Inc., Sunnyvale, CA, USA). Common elements of multimodal programmes included theoretical knowledge (76.9%), case observation (53.8%), simulation (100%) and proctored training (76.9%). Robotic skills acquisition was assessed primarily during the simulation phase (n = 4, 30.1%) and proctoring phase (n = 10, 76.9%). Performance metrics, consisting of time or assessment scores for VR simulation were only mandated in four (30.1%) studies. Objective assessment following proctored training was variably reported and employed a range of assessment metrics, including direct feedback (n = 3, 23.1%) or video feedback (n = 8, 61.5%). Five (38.4%) training programmes used the Global Assessment Score (GAS) forms. There is a broad consensus on the core multimodal components across current RACS training programmes; however, validated objective assessment is limited and needs to be appropriately standardised to ensure reproducible progression criteria and competency-based metrics are produced to robustly assess progression and competence.

Parallel, component training in robotic total mesorectal excision

There has been widespread adoption of robotic total mesorectal excision (TME) for rectal cancer in recent years. There is now increasing interest in training robotic novice surgeons in robotic TME surgery using the principles of component-based learning. The aims of our study were to assess the feasibility of delivering a structured, parallel, component-based, training curriculum to surgical trainees and fellows. A prospective pilot study was undertaken between January 2021 and May 2021. A dedicated robotic training pathway was designed with two trainees trained in parallel per each robotic case based on prior experience, training grade and skill set. Component parts of each operation were allocated by the robotic trainer prior to the start of each case. Robotic proficiency was assessed using the Global Evaluative Assessment of Robotic Skills (GEARS) and the EARCS Global Assessment Score (GAS). Three trainees participated in this pilot study, performing a combined number of 52 TME resections. Key components of all 52 TME operations were performed by the trainees. GEARS scores improved throughout the study, with a mean overall baseline score of 17.3 (95% CI 15.1-1.4) compared to an overall final assessment mean score of 23.8 (95% CI 21.6-25.9), p = 0.003. The GAS component improved incrementally for all trainees at each candidate assessment (p < 0.001). Employing a parallel, component-based approach to training in robotic TME surgery is safe and feasible and can be used to train multiple trainees of differing grades simultaneously, whilst maintaining high-quality clinical outcomes.

Diagnostic accuracy of C-reactive protein and procalcitonin in the early diagnosis of infections after laparoscopic rectal cancer surgery

BACKGROUND

We aimed to examine the diagnostic accuracy of postoperative procalcitonin (PCT) and C-reactive protein (CRP) in the detection of infectious complications in patients after laparoscopic rectal cancer surgery, as opposed to all colorectal surgery.

METHODS

Between December 2018 and December 2020, 204 patients who underwent laparoscopic rectal cancer surgery were enrolled retrospectively. The PCT, CRP and white blood cell (WBC) count were measured before surgery and on postoperative days (PODs) 3 and 5. Diagnostic accuracy was determined by the area under the receiver operating characteristic curve (AUC). Net Reclassification Index (NRI) was used to calculate the ability to correct reclassification.

RESULTS

Infectious complications occurred in 36 patients (17.6%), including 17 cases of anastomotic leakage (AL) (8.3%). The AUCs of PCT and CRP in predicting infectious complications on POD 3 were 0.690 and 0.731, respectively, which were better than those on POD 5 (AUC 0.666 and 0.697, respectively). PCT with an optimal cutoff value of 1.10 ng/mL (AUC 0.792, specificity 78.6%, negative predictive value [NPV] 96.6%), CRP with an optimal cutoff value of 109.5 mg/L (AUC 0.760, specificity 78.6%, NPV 96.1%) on POD 3 had superior diagnostic accuracy in predicting AL, both better than WBC (AUC 0.627). The AUC of combining PCT and CRP on POD 3 in predicting AL was 0.851, with a specificity of 79.7% and NPV of 97.4%, and the NRI was estimated to be 7.0%.

CONCLUSIONS

Both PCT and CRP on POD 3 are excellent negative predictors for early monitoring of infectious complications, especially AL, in patients undergoing laparoscopic rectal cancer surgery.

Surgical Complexity and Outcome During the Implementation Phase of a Robotic Colorectal Surgery Program-A Retrospective Cohort Study

Background

Robotic surgery holds particular promise for complex oncologic colorectal resections, as it can overcome many limitations of the laparoscopic approach. However, similar to the situation in laparoscopic surgery, appropriate case selection (simple vs. complex) with respect to the actual robotic expertise of the team may be a critical determinant of outcome. The present study aimed to analyze the clinical outcome after robotic colorectal surgery over time based on the complexity of the surgical procedure.

Methods

All robotic colorectal resections (n = 85) performed at the Department of Surgery, Medical University of Vienna, between the beginning of the program in April 2015 until December 2019 were retrospectively analyzed. To compare surgical outcome over time, the cohort was divided into 2 time periods based on case sequence (period 1: patients 1–43, period 2: patients 44–85). Cases were assigned a complexity level (I-IV) according to the type of resection, severity of disease, sex and body mass index (BMI). Postoperative complications were classified using the Clavien-Dindo classification.

Results

In total, 47 rectal resections (55.3%), 22 partial colectomies (25.8%), 14 abdomino-perineal resections (16.5%) and 2 proctocolectomies (2.4%) were performed. Of these, 69.4% (n = 59) were oncologic cases. The overall rate of major complications (Clavien Dindo III-V) was 16.5%. Complex cases (complexity levels III and IV) were more often followed by major complications than cases with a low to medium complexity level (I and II; 25.0 vs. 5.4%, p = 0.016). Furthermore, the rate of major complications decreased over time from 25.6% (period 1) to 7.1% (period 2, p = 0.038). Of note, the drop in major complications was associated with a learning effect, which was particularly pronounced in complex cases as well as a reduction of case complexity from 67.5% to 45.2% in the second period (p = 0.039).

Conclusions

The risk of major complications after robotic colorectal surgery increases significantly with escalating case complexity (levels III and IV), particularly during the initial phase of a new colorectal robotic surgery program. Before robotic proficiency has been achieved, it is therefore advisable to limit robotic colorectal resection to cases with complexity levels I and II in order to keep major complication rates at a minimum.