Robotic vs. Laparoscopic Stapling in Robotic Total Mesorectal Excision: A Prospective Cohort Study

Anastomotic leak remains a major complication following total mesorectal excision (TME). While multiple stapler firings during rectal transection are associated with an increased risk of leaks, robotic stapling platforms offer enhanced articulation and precision that may reduce the number of required firings. This study aimed to compare the clinical outcomes and technical efficiency of robotic vs. conventional laparoscopic stapling for rectal transection during robotic TME.

We conducted a prospective cohort study of 57 adult patients who underwent robotic TME for rectal adenocarcinoma in 2025. We stratified patients by the rectal transection device used: robotic stapling (n = 27) or laparoscopic stapling (n = 30). All patients were enrolled in an ileostomy omission protocol, avoiding routine protective diversion and utilizing postoperative C-reactive protein (CRP) and procalcitonin surveillance to screen for anastomotic leakage. The primary outcome was the proportion of stoma-free patients at 30 days. Secondary outcomes included the number of stapler loads fired, incidence of anastomotic leak, total operative time, and length of in-hospital stay.

Baseline demographic and clinical characteristics were comparable between both cohorts. The 30-day stoma-free rate was significantly higher in the robotic stapling cohort (100%) compared with the laparoscopic cohort (86.6%) (adjusted relative risk (RR): 1.16, 95% confidence interval (CI): 1.03-1.33, p = 0.049). Furthermore, robotic stapling required significantly fewer stapler firings (mean: 1.85 ± 0.45 vs. 2.65 ± 0.67; p < 0.001). The incidence of anastomotic leak was 3.7% in the robotic group vs. 16.6% in the laparoscopic group; however, this trend did not reach statistical significance (RR: 0.22, 95% CI: 0.03-1.78; p = 0.113). Operative time and length of stay did not differ significantly between the groups.

Utilizing a robotic stapler during robotic TME significantly reduces the number of firings required for rectal transection and is associated with a higher success rate of safe ileostomy omission when combined with postoperative biomarker surveillance. Larger randomized trials are warranted to definitively establish whether these technical advantages translate to a statistically significant reduction in anastomotic leak rates.