Comparison of Robot-Assisted Surgery Versus Laparoscopic Surgery in Colorectal Surgery: A Systematic Review of Operative and Postoperative Outcomes
Keywords:
rectal cancer, operative outcomes, rectal resection, costs, laparoscopic surgery, robotic surgery, systematic reviewAbstract
Background: Along with the increasing trend of robotic surgery adoption, various healthcare centers are beginning to consider transitioning from open or laparoscopic approaches to robot-assisted surgical techniques for the management of rectal cancer.
Methods: A literature search was conducted on the Medline (via PubMed), Google Scholar, and ResearchGate databases to find relevant articles from early 2014 to January. All randomized clinical trials (RCTs) and prospective studies comparing robotic surgery with open or laparoscopic rectal resection were included.
Results: A total of 15 RCTs and 11 prospective studies with a total of 6,922 patients were included. The review results showed that robotic surgery was associated with less blood loss, lower surgical site infection rates, shorter hospital stays, and higher rates of negative resection margins compared to open surgery. Compared to laparoscopy, robotic surgery showed lower conversion rates, less blood loss, lower reoperation rates, and lower mortality. However, operative time and procedure costs for robotic surgery were higher compared to both approaches.
Conclusion: The robotic approach is a safe and effective option for rectal resection, with clear advantages over open surgery. For centers transitioning from laparoscopic techniques, cost considerations need to be carefully calculated.
References
Hossain, M.S.; Karuniawati, H.; Jairoun, A.A.; Urbi, Z.; Ooi, J.; John, A.; Lim, Y.C.; Kibria, K.M.K.; Mohiuddin, A.K.M.; Ming, L.C.; et al. Colorectal Cancer: A Review of Carcinogenesis, Global Epidemiology, Current Challenges, Risk Factors, Preventive and Treatment Strategies. Cancers 2022, 14, 1732. [CrossRef]
Sung, H.; Ferlay, J.; Siegel, R.L.; Laversanne, M.; Soerjomataram, I.; Jemal, A.; Bray, F. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. Cancer J. Clin. 2021, 71, 209–249. [CrossRef] [PubMed]
Fazeli, M.S.; Keramati, M.R. Rectal cancer: A review. Med. J. Islam. Repub. Iran 2015, 29, 171. [PubMed]
Glynne-Jones, R.; Wyrwicz, L.; Tiret, E.; Brown, G.; Rödel, C.; Cervantes, A.; Arnold, D. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann. Oncol. 2017, 28, iv22–iv40. [CrossRef] [PubMed]
Senagore, A.J. Adoption of Laparoscopic Colorectal Surgery: It Was Quite a Journey. Clin. Colon Rectal Surg. 2015, 28, 131–134. [CrossRef]
Baik, S.H.; Ko, Y.T.; Kang, C.M.; Lee, W.J.; Kim, N.K.; Sohn, S.K.; Chi, H.S.; Cho, C.H. Robotic tumor-specific mesorectal excision of rectal cancer: Short-term outcome of a pilot randomized trial. Surg. Endosc. 2008, 22, 1601–1608. [CrossRef]
Denost, Q.; Adam, J.P.; Rullier, A.; Buscail, E.; Laurent, C.; Rullier, E. Perineal transanal approach: A new standard for laparoscopic sphincter-saving resection in low rectal cancer, a randomized trial. Ann. Surg. 2014, 260, 993–999. [CrossRef]
Martel, G.; Boushey, R.P. Laparoscopic colon surgery: Past, present and future. Surg. Clin. N. Am. 2006, 86, 867–897. [CrossRef]
Van der Pas, M.H.; Haglind, E.; Cuesta, M.A.; Fürst, A.; Lacy, A.M.; Hop, W.C.; Bonjer, H.J. Laparoscopic versus open surgery for rectal cancer (COLOR II): Short-term outcomes of a randomised, phase 3 trial. Lancet Oncol. 2013, 14, 210–218. [CrossRef]
Jeong, S.Y.; Park, J.W.; Nam, B.H.; Kim, S.; Kang, S.B.; Lim, S.B.; Choi, H.S.; Kim, D.W.; Chang, H.J.; Kim, D.Y.; et al. Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): Survival outcomes of an open-label, non-inferiority, randomised controlled trial. Lancet Oncol. 2014, 15, 767–774. [CrossRef]
Bege, T.; Lelong, B.; Esterni, B.; Turrini, O.; Guiramand, J.; Francon, D.; Mokart, D.; Houvenaeghel, G.; Giovannini, M.; Delpero, J.R. The learning curve for the laparoscopic approach to conservative mesorectal excision for rectal cancer: Lessons drawn from a single institution’s experience. Ann. Surg. 2010, 251, 249–253. [CrossRef] [PubMed]
Fleshman, J.; Branda, M.; Sargent, D.J.; Boller, A.M.; George, V.; Abbas, M.; Peters, W.R., Jr.; Maun, D.; Chang, G.; Herline, A.; et al. Effect of Laparoscopic-Assisted Resection vs. Open Resection of Stage II or III Rectal Cancer on Pathologic Outcomes: The ACOSOG Z6051 Randomized Clinical Trial. JAMA 2015, 314, 1346–1355. [CrossRef] [PubMed]
Stevenson, A.R.; Solomon, M.J.; Lumley, J.W.; Hewett, P.; Clouston, A.D.; Gebski, V.J.; Davies, L.; Wilson, K.; Hague, W.; Simes, J. Effect of Laparoscopic-Assisted Resection vs. Open Resection on Pathological Outcomes in Rectal Cancer: The ALaCaRT Randomized Clinical Trial. JAMA 2015, 314, 1356–1363. [CrossRef]
Weber, P.A.; Merola, S.; Wasielewski, A.; Ballantyne, G.H. Telerobotic-assisted laparoscopic right and sigmoid colectomies for benign disease. Dis. Colon Rectum 2002, 45, 1689–1694. [CrossRef] [PubMed]
Stefanidis, D.; Wang, F.; Korndorffer, J.R., Jr.; Dunne, J.B.; Scott, D.J. Robotic assistance improves intracorporeal suturing performance and safety in the operating room while decreasing operator workload. Surg. Endosc. 2010, 24, 377–382. [CrossRef]
Stefanidis, D.; Hope, W.W.; Scott, D.J. Robotic suturing on the FLS model possesses construct validity, is less physically demanding, and is favored by more surgeons compared with laparoscopy. Surg. Endosc. 2011, 25, 2141–2146. [CrossRef]
Kim, M.J.; Park, S.C.; Park, J.W.; Chang, H.J.; Kim, D.Y.; Nam, B.H.; Sohn, D.K.; Oh, J.H. Robot-assisted Versus Laparoscopic Surgery for Rectal Cancer: A Phase II Open Label Prospective Randomized Controlled Trial. Ann. Surg. 2018, 267, 243–251. [CrossRef]
Corbellini, C.; Biffi, R.; Luca, F.; Chiappa, A.; Costa, S.; Bertani, E.; Bona, S.; Lombardi, D.; Tamayo, D.; Botteri, E.; et al. Open, laparoscopic, and robotic surgery for rectal cancer: Medium-term comparative outcomes from a multicenter study. Tumori 2016, 102, 414–421. [CrossRef]
Jayne, D.; Pigazzi, A.; Marshall, H.; Croft, J.; Corrigan, N.; Copeland, J.; Quirke, P.; West, N.; Rautio, T.; Thomassen, N.; et al. 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. JAMA 2017, 318, 1569–1580. [CrossRef]
Somashekhar, S.P.; Ashwin, K.R.; Rajashekhar, J.; Zaveri, S. Prospective Randomized Study Comparing Robotic-Assisted Surgery with Traditional Laparotomy for Rectal Cancer-Indian Study. Indian J. Surg. 2015, 77, 788–794. [CrossRef]
Prete, F.P.; Pezzolla, A.; Prete, F.; Testini, M.; Marzaioli, R.; Patriti, A.; Jimenez-Rodriguez, R.M.; Gurrado, A.; Strippoli, G.F.M. Robotic Versus Laparoscopic Minimally Invasive Surgery for Rectal Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Ann. Surg. 2018, 267, 1034–1046. [CrossRef]
Qiu, H.; Yu, D.; Ye, S.; Shan, R.; Ai, J.; Shi, J. Long-term oncological outcomes in robotic versus laparoscopic approach for rectal cancer: A systematic review and meta-analysis. Int. J. Surg. 2020, 80, 225–230. [CrossRef] [PubMed]
Tang, B.; Lei, X.; Ai, J.; Huang, Z.; Shi, J.; Li, T. Comparison of robotic and laparoscopic rectal cancer surgery: A meta-analysis of randomized controlled trials. World J. Surg. Oncol. 2021, 19, 38. [CrossRef] [PubMed] Cancers 2023, 15, 839 32 of 34
Han, C.; Yan, P.; Jing, W.; Li, M.; Du, B.; Si, M.; Yang, J.; Yang, K.; Cai, H.; Guo, T. Clinical, pathological, and oncologic outcomes of robotic-assisted versus laparoscopic proctectomy for rectal cancer: A meta-analysis of randomized controlled studies. Asian J. Surg. 2020, 43, 880–890. [CrossRef] [PubMed]
Ryan, O.K.; Ryan, É.J.; Creavin, B.; Rausa, E.; Kelly, M.E.; Petrelli, F.; Bonitta, G.; Kennelly, R.; Hanly, A.; Martin, S.T.; et al. Surgical approach for rectal cancer: A network meta-analysis comparing open, laparoscopic, robotic and transanal TME approaches. Eur. J. Surg. Oncol. 2021, 47, 285–295. [CrossRef]
Simillis, C.; Lal, N.; Thoukididou, S.N.; Kontovounisios, C.; Smith, J.J.; Hompes, R.; Adamina, M.; Tekkis, P.P. Open Versus Laparoscopic Versus Robotic Versus Transanal Mesorectal Excision for Rectal Cancer: A Systematic Review and Network Meta-analysis. Ann. Surg. 2019, 270, 59–68. [CrossRef]
Guo, Y.; Guo, Y.; Luo, Y.; Song, X.; Zhao, H.; Li, L. Comparison of pathologic outcomes of robotic and open resections for rectal cancer: A systematic review and meta-analysis. PLoS ONE 2021, 16, e0245154. [CrossRef]
Liao, G.; Li, Y.B.; Zhao, Z.; Li, X.; Deng, H.; Li, G. Robotic-assisted surgery versus open surgery in the treatment of rectal cancer: The current evidence. Sci. Rep. 2016, 6, 26981. [CrossRef]
Moher, D.; Liberati, A.; Tetzlaff, J.; Altman, D.G. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Int. J. Surg. 2010, 8, 336–341. [CrossRef]
Kalkum, E.; Klotz, R.; Seide, S.; Hüttner, F.J.; Kowalewski, K.F.; Nickel, F.; Khajeh, E.; Knebel, P.; Diener, M.K.; Probst, P. Systematic reviews in surgery-recommendations from the Study Center of the German Society of Surgery. Langenbecks Arch. Surg. 2021, 406, 1723–1731. [CrossRef]
Sterne, J.A.C.; Savovi´c, J.; Page, M.J.; Elbers, R.G.; Blencowe, N.S.; Boutron, I.; Cates, C.J.; Cheng, H.Y.; Corbett, M.S.; Eldridge, S.M.; et al. RoB 2: A revised tool for assessing risk of bias in randomised trials. BMJ 2019, 366, l4898. [CrossRef] [PubMed]
Sterne, J.A.; Hernán, M.A.; Reeves, B.C.; Savovi´c, J.; Berkman, N.D.; Viswanathan, M.; Henry, D.; Altman, D.G.; Ansari, M.T.; Boutron, I.; et al. ROBINS-I: A tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016, 355, i4919. [CrossRef] [PubMed]
Atkins, D.; Best, D.; Briss, P.A.; Eccles, M.; Falck-Ytter, Y.; Flottorp, S.; Guyatt, G.H.; Harbour, R.T.; Haugh, M.C.; Henry, D.; et al. Grading quality of evidence and strength of recommendations. BMJ 2004, 328, 1490. [CrossRef] [PubMed]
Corrigan, N.; Marshall, H.; Croft, J.; Copeland, J.; Jayne, D.; Brown, J. Exploring and adjusting for potential learning effects in ROLARR: A randomised controlled trial comparing robotic-assisted vs. standard laparoscopic surgery for rectal cancer resection. Trials 2018, 19, 339. [CrossRef]
Debakey, Y.; Zaghloul, A.; Farag, A.; Mahmoud, A.; Elattar, I. Robotic-Assisted versus Conventional Laparoscopic Approach for Rectal Cancer Surgery, First Egyptian Academic Center Experience, RCT. Minim. Invasive Surg. 2018, 2018, 5836562. [CrossRef]
Jiménez Rodríguez, R.M.; Díaz Pavón, J.M.; De La Portilla de Juan, F.; Prendes Sillero, E.; Hisnard Cadet Dussort, J.M.; Padillo, J. Prospective randomised study: Robotic-assisted versus conventional laparoscopic surgery in colorectal cancer resection. Cir. Esp. 2011, 89, 432–438. [CrossRef]
Patriti, A.; Ceccarelli, G.; Bartoli, A.; Spaziani, A.; Biancafarina, A.; Casciola, L. Short- and medium-term outcome of robot-assisted and traditional laparoscopic rectal resection. J. Soc. Laparoendosc. Surg. 2009, 13, 176–183.
Tolstrup, R.; Funder, J.A.; Lundbech, L.; Thomassen, N.; Iversen, L.H. Perioperative pain after robot-assisted versus laparoscopic rectal resection. Int. J. Colorectal. Dis. 2018, 33, 285–289. [CrossRef]
Wang, G.; Wang, Z.; Jiang, Z.; Liu, J.; Zhao, J.; Li, J. Male urinary and sexual function after robotic pelvic autonomic nervepreserving surgery for rectal cancer. Int. J. Med. Robot. Comput. Assist. Surg. 2017, 13, e1725. [CrossRef]
Xu, J.; Wei, Y.; Ren, L.; Feng, Q.; Chen, J.; Zhu, D.; Chang, W.; Yi, T.; Yang, L.; Qin, X. Robot-assisted vs. laparoscopic vs open abdominoperineal resections for low rectal cancer: Short-term outcomes of a single-center prospective randomized controlled trial. Ann. Oncol. 2017, 28, v161–v162. [CrossRef]
Feng, Q.; Yuan, W.; Li, T.; Tang, B.; Jia, B.; Zhou, Y.; Zhang, W.; Zhao, R.; Zhang, C.; Cheng, L.; et al. Robotic versus laparoscopic surgery for middle and low rectal cancer (REAL): Short-term outcomes of a multicentre randomised controlled trial. Lancet. Gastroenterol. Hepatol. 2022, 7, 991–1004. [CrossRef] [PubMed]
Feng, Q.; Tang, W.; Zhang, Z.; Wei, Y.; Ren, L.; Chang, W.; Zhu, D.; Liang, F.; He, G.; Xu, J. Robotic versus laparoscopic abdominoperineal resections for low rectal cancer: A single-center randomized controlled trial. J. Surg. Oncol. 2022, 126, 1481–1493. [CrossRef] [PubMed]
Liu, Y.; Liu, M.; Lei, Y.; Zhang, H.; Xie, J.; Zhu, S.; Jiang, J.; Li, J.; Yi, B. Evaluation of effect of robotic versus laparoscopic surgical technology on genitourinary function after total mesorectal excision for rectal cancer. Int. J. Surg. 2022, 104, 106800. [CrossRef]
European Society of Coloproctology collaborating group. An international multicentre prospective audit of elective rectal cancer surgery; operative approach versus outcome, including transanal total mesorectal excision (TaTME). Color. Dis. 2018, 20, 33–46. [CrossRef]
Asklid, D.; Gerjy, R.; Hjern, F.; Pekkari, K.; Gustafsson, U.O. Robotic vs. laparoscopic rectal tumour surgery: A cohort study. Color. Dis. 2019, 21, 191–199. [CrossRef] [PubMed]
Bertani, E.; Chiappa, A.; Biffi, R.; Bianchi, P.P.; Radice, D.; Branchi, V.; Cenderelli, E.; Vetrano, I.; Cenciarelli, S.; Andreoni, B. Assessing appropriateness for elective colorectal cancer surgery: Clinical, oncological, and quality-of-life short-term outcomes employing different treatment approaches. Int. J. Color. Dis. 2011, 26, 1317–1327. [CrossRef] Cancers 2023, 15, 839 33 of 34
Dulskas, A.; Albandar, M.; Samalavicius, N.E.; Han, Y.D.; Kim, N.K. Laparoscopic and Robotic Surgery for Rectal Cancer— Comparative Study Between Two Centres. Indian J. Surg. 2021, 83, 48–54. [CrossRef]
Galata, C.; Vassilev, G.; Haas, F.; Kienle, P.; Büttner, S.; Reißfelder, C.; Hardt, J. Clinical, oncological, and functional outcomes of Da Vinci (Xi)-assisted versus conventional laparoscopic resection for rectal cancer: A prospective, controlled cohort study of 51 consecutive cases. Int. J. Color. Dis. 2019, 34, 1907–1914. [CrossRef]
Kim, H.J.; Choi, G.S.; Park, J.S.; Park, S.Y.; Yang, C.S.; Lee, H.J. The impact of robotic surgery on quality of life, urinary and sexual function following total mesorectal excision for rectal cancer: A propensity score-matched analysis with laparoscopic surgery. Color. Dis. 2018, 20, O103–O113. [CrossRef]
Kim, J.Y.; Kim, N.K.; Lee, K.Y.; Hur, H.; Min, B.S.; Kim, J.H. A comparative study of voiding and sexual function after total mesorectal excision with autonomic nerve preservation for rectal cancer: Laparoscopic versus robotic surgery. Ann. Surg. Oncol. 2012, 19, 2485–2493. [CrossRef]
Miura, T.; Sakamoto, Y.; Morohashi, H.; Suto, A.; Kubota, S.; Ichisawa, A.; Kuwata, D.; Yamada, T.; Tamba, H.; Matsumoto, S.; et al. Robotic surgery contributes to the preservation of bowel and urinary function after total mesorectal excision: Comparisons with transanal and conventional laparoscopic surgery. BMC Surg. 2022, 22, 147. [CrossRef] [PubMed]
Polat, F.; Willems, L.H.; Dogan, K.; Rosman, C. The oncological and surgical safety of robot-assisted surgery in colorectal cancer: Outcomes of a longitudinal prospective cohort study. Surg. Endosc. 2019, 33, 3644–3655. [CrossRef]
Quijano, Y.; Nuñez-Alfonsel, J.; Ielpo, B.; Ferri, V.; Caruso, R.; Durán, H.; Díaz, E.; Malavé, L.; Fabra, I.; Pinna, E.; et al. Robotic versus laparoscopic surgery for rectal cancer: A comparative cost-effectiveness study. Tech. Coloproctol. 2020, 24, 247–254. [CrossRef] [PubMed]
Park, J.S.; Choi, G.S.; Lim, K.H.; Jang, Y.S.; Jun, S.H. Robotic-assisted versus laparoscopic surgery for low rectal cancer: Casematched analysis of short-term outcomes. Ann. Surg. Oncol. 2010, 17, 3195–3202. [CrossRef] [PubMed]
Martínez-Pérez, A.; Carra, M.C.; Brunetti, F.; De’Angelis, N. Pathologic Outcomes of Laparoscopic vs Open Mesorectal Excision for Rectal Cancer: A Systematic Review and Meta-analysis. JAMA Surg. 2017, 152, e165665. [CrossRef] [PubMed]
Stevenson, A.R.L.; Solomon, M.J.; Brown, C.S.B.; Lumley, J.W.; Hewett, P.; Clouston, A.D.; Gebski, V.J.; Wilson, K.; Hague, W.; Simes, J. Disease-free Survival and Local Recurrence After Laparoscopic-assisted Resection or Open Resection for Rectal Cancer: The Australasian Laparoscopic Cancer of the Rectum Randomized Clinical Trial. Ann. Surg. 2019, 269, 596–602. [CrossRef]
Liu, G.; Zhang, S.; Zhang, Y.; Fu, X.; Liu, X. Robotic Surgery in Rectal Cancer: Potential, Challenges, and Opportunities. Curr. Treat. Options Oncol. 2022, 23, 961–979. [CrossRef]
Wee, I.J.Y.; Kuo, L.J.; Ngu, J.C. Urological and sexual function after robotic and laparoscopic surgery for rectal cancer: A systematic review, meta-analysis and meta-regression. Int. J. Med. Robot. Comput. Assist. Surg. 2021, 17, 1–8. [CrossRef]
Kowalewski, K.F.; Seifert, L.; Ali, S.; Schmidt, M.W.; Seide, S.; Haney, C.; Tapking, C.; Shamiyeh, A.; Kulu, Y.; Hackert, T.; et al. Functional outcomes after laparoscopic versus robotic-assisted rectal resection: A systematic review and meta-analysis. Surg. Endosc. 2021, 35, 81–95. [CrossRef]
Clancy, C.; O’Leary, D.P.; Burke, J.P.; Redmond, H.P.; Coffey, J.C.; Kerin, M.J.; Myers, E. A meta-analysis to determine the oncological implications of conversion in laparoscopic colorectal cancer surgery. Color. Dis. 2015, 17, 482–490. [CrossRef]
Guillou, P.J.; Quirke, P.; Thorpe, H.; Walker, J.; Jayne, D.G.; Smith, A.M.; Heath, R.M.; Brown, J.M. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): Multicentre, randomised controlled trial. Lancet 2005, 365, 1718–1726. [CrossRef] [PubMed]
Rottoli, M.; Bona, S.; Rosati, R.; Elmore, U.; Bianchi, P.P.; Spinelli, A.; Bartolucci, C.; Montorsi, M. Laparoscopic rectal resection for cancer: Effects of conversion on short-term outcome and survival. Ann. Surg. Oncol. 2009, 16, 1279–1286. [CrossRef] [PubMed]
Bianchi, P.P.; Ceriani, C.; Locatelli, A.; Spinoglio, G.; Zampino, M.G.; Sonzogni, A.; Crosta, C.; Andreoni, B. Robotic versus laparoscopic total mesorectal excision for rectal cancer: A comparative analysis of oncological safety and short-term outcomes. Surg. Endosc. 2010, 24, 2888–2894. [CrossRef] [PubMed]
Mörner, M.E.; Gunnarsson, U.; Jestin, P.; Svanfeldt, M. The importance of blood loss during colon cancer surgery for long-term survival: An epidemiological study based on a population based register. Ann. Surg. 2012, 255, 1126–1128. [CrossRef] [PubMed]
Basilico, V.; Griffa, B.; Radaelli, F.; Zanardo, M.; Rossi, F.; Caizzone, A.; Vannelli, A. Anastomotic leakage following colorectal resection for cancer: How to define, manage and treat it. Minerva Chir. 2014, 69, 245–252. [PubMed]
Memon, S.; Heriot, A.G.; Murphy, D.G.; Bressel, M.; Lynch, A.C. Robotic versus laparoscopic proctectomy for rectal cancer: A meta-analysis. Ann. Surg. Oncol. 2012, 19, 2095–2101. [CrossRef] [PubMed]
Park, J.S.; Choi, G.S.; Lim, K.H.; Jang, Y.S.; Jun, S.H. S052: A comparison of robot-assisted, laparoscopic, and open surgery in the treatment of rectal cancer. Surg. Endosc. 2011, 25, 240–248. [CrossRef]
Flynn, J.; Larach, J.T.; Kong, J.C.H.; Waters, P.S.; Warrier, S.K.; Heriot, A. The learning curve in robotic colorectal surgery compared with laparoscopic colorectal surgery: A systematic review. Color. Dis. 2021, 23, 2806–2820. [CrossRef]
Brodie, A.; Vasdev, N. The future of robotic surgery. Ann. R. Coll. Surg. Engl. 2018, 100, 4–13. [CrossRef]
Son, G.M.; Kim, J.G.; Lee, J.C.; Suh, Y.J.; Cho, H.M.; Lee, Y.S.; Lee, I.K.; Chun, C.S. Multidimensional analysis of the learning curve for laparoscopic rectal cancer surgery. J. Laparoendosc. Adv. Surg. Tech. Part A 2010, 20, 609–617. [CrossRef] Cancers 2023, 15, 839 34 of 34
Jiménez-Rodríguez, R.M.; Díaz-Pavón, J.M.; De la Portilla de Juan, F.; Prendes-Sillero, E.; Dussort, H.C.; Padillo, J. Learning curve for robotic-assisted laparoscopic rectal cancer surgery. Int. J. Color. Dis. 2013, 28, 815–821. [CrossRef] [PubMed]
Yamaguchi, T.; Kinugasa, Y.; Shiomi, A.; Sato, S.; Yamakawa, Y.; Kagawa, H.; Tomioka, H.; Mori, K. Learning curve for robotic-assisted surgery for rectal cancer: Use of the cumulative sum method. Surg. Endosc. 2015, 29, 1679–1685. [CrossRef] [PubMed]
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