The marginal gains of robotic surgery in colorectal cancer

Robotic surgery was introduced to enhance surgical performance; however, evidence of superiority over conventional laparoscopy remains inconsistent in colorectal cancer treatment. Inspired by Sir Dave Brailsford's concept of marginal gains, we hypothesized that small improvements of robotic platforms might be associated with improved surgical outcomes. This study aimed to evaluate whether robotic surgery was associated with a higher probability of achieving a 'perfect' operation for colorectal cancer.

Two consecutive periods were compared, laparoscopic surgery from January 2019 to February 2021 and robotic surgery from March 2021 to February 2025. The primary outcome was a composite measure termed 'perfect' operation defined as; no conversion, complications, reoperation, readmittance, mortality, R0 resection and mesocolic/rectal surgical plane. Multivariable logistic regression and propensity score matching were used to adjust for confounding.

A total of 916 patients were included (500 robotic, 416 laparoscopic). Baseline characteristics were comparable. The rate of 'perfect' operations was higher after robotic surgery (63.6% vs. 43.8%, p < 0.001). After multivariable adjustment, robotic surgery remained independently associated with a higher likelihood of a 'perfect' operation (adjusted OR 2.60, 95% CI: 1.96-3.46; p < 0.001). Findings were consistent across colonic and rectal subgroups and after propensity score matching. In addition, length of stay (LOS) was reduced in robotic rectal cancer surgery from an average of 5-4 days.

Robotic surgery was associated with a 2.5-fold increased rate of a 'perfect' operation for colorectal cancer and reduced LOS after rectal resection, supporting the concept of cumulative marginal gains associated with robotic surgery.