The Role of Robotic Surgery in Rectal Cancer: Insights from India’s Largest Multicenter Study

Rectal cancer, a prevalent form of colorectal cancer, poses significant challenges to surgeons due to its location in the pelvis and the need for precise removal of the tumor while preserving essential structures. Over the years, advancements in surgical techniques have transformed how rectal cancer is treated, with robotic-assisted surgery (RAS) emerging as a promising alternative to traditional open and laparoscopic approaches.

A recent landmark study conducted by the Indian Collaborative Group on Rectal Resections (ICGRR) has shed light on the outcomes of open, laparoscopic, and robotic-assisted rectal resections in the Indian healthcare context. This study, the largest of its kind in India, analyzed data from 829 patients across 11 centers and provides valuable insights into the short-term outcomes of these surgical techniques. As a contributor to this study, I, Dr. Sandeep Nayak, operated on many of these cases at Fortis Hospital, Bangalore. Here, I share key findings and discuss the broader implications of robotic-assisted surgery in rectal cancer care.

Rectal cancer arises in the rectum, the last segment of the large intestine. Its treatment often involves surgical resection following the principles of Total Mesorectal Excision (TME), which ensures the removal of the tumor and surrounding tissues to prevent recurrence. However, the rectum’s narrow location in the pelvis makes surgery particularly challenging. Surgeons must navigate intricate anatomy, protect critical nerves and blood vessels, and achieve clear margins to ensure the cancer is removed completely.

For decades, open surgery, which involves a large incision, was the standard approach. However, it often resulted in significant blood loss, longer recovery times, and higher complication rates. The advent of laparoscopic surgery, a minimally invasive technique using small incisions and a camera, addressed some of these challenges but had its own limitations, such as restricted visibility and reduced instrument maneuverability in the narrow pelvic cavity.

Robotic-assisted surgery (RAS) has emerged as a transformative advancement, combining the benefits of minimally invasive techniques with cutting-edge technology. With enhanced precision, 3D visualization, and superior instrument dexterity, robotic surgery allows surgeons to operate more effectively in confined spaces like the pelvis.

1. Shorter Hospital Stays:

• Patients in the RAS group had the shortest average hospital stay (7.8 days), compared to the LG (10.3 days) and OG (14 days) groups.
• At experienced centers like ours, where both robotic and laparoscopic surgeries are performed in high volumes, the average hospital stay for both approaches is approximately 4 days, reflecting the importance of expertise in achieving optimal outcomes.




2. Reduced Blood Loss and Complications:
• Robotic-assisted surgery resulted in significantly less blood loss compared to laparoscopic and open surgeries, reducing the need for transfusions and associated risks.
• Postoperative complications were lowest in the RAS group (13.7%) compared to LG (19.9%) and OG (36.6%).
  
  
  3. Better Surgical Precision:
• The RAS group had the lowest rate of positive circumferential resection margins (CRM)—a critical measure of how completely the tumor was removed—at 87%, compared to 6.8%in LG and 26.5% in OG.




4. Early Start of Adjuvant Therapy:
• Patients in the RAS group could begin adjuvant treatments like chemotherapy sooner (median 24.5 days) than those in LG (31 days) and OG (32.5 days). Early initiation of therapy is linked to better long-term outcomes.




5. Longer Operating Times:
• Robotic surgeries took longer to perform (average 326 minutes) than laparoscopic (287 minutes) and open surgeries (256 minutes). This is largely due to the time required for robotic system setup and docking.

One of the key insights from this study is the skill-dependent nature of surgery. While robotic-assisted surgery offers advanced technology that enhances precision and efficiency, its success relies heavily on the expertise of the surgeon and the surgical team.

At high-volume centers like Fortis Hospital, Bangalore, where I performed many of the robotic and laparoscopic surgeries included in this study, both techniques yield comparable outcomes in terms of hospital stay and recovery time, with most patients being discharged within four days. However, this is not uniform across all centers. The ICGRR study involved 11 hospitals, each with varying levels of expertise and case volumes. Not all centers performed both laparoscopic and robotic surgeries in high volumes, and this variability impacts the generalizability of the study’s findings.

The study highlights that while robotic surgery offers significant advantages, outcomes are closely tied to the experience and proficiency of the surgical team. Centers with extensive experience in robotic and laparoscopic techniques tend to achieve better results, whereas centers with limited experience may face challenges in replicating these outcomes.

Robotic-assisted surgery is a valuable tool in the treatment of rectal cancer, offering several advantages:

• Enhanced precision and visualization, particularly in complex pelvic anatomy.
• Reduced blood loss, postoperative complications, and shorter hospital stays.
• Improved ability to achieve clear margins, reducing the risk of recurrence.

However, robotic surgery also has limitations:

• Cost: Robotic systems are expensive, which may limit their accessibility for patients in some regions.
• Learning Curve: Surgeons require extensive training and experience to fully harness the benefits of robotic technology.
• Longer Operating Times: As seen in this study, robotic surgeries often take longer than laparoscopic or open surgeries, though this improves with experience.

The ICGRR study is a landmark effort in Indian healthcare, involving data from 11 centers and 829 patients. This collaboration between public and private institutions provides a comprehensive overview of real-world outcomes for rectal cancer surgery in India.

As a contributor to this study, I had the privilege of performing many of the robotic and laparoscopic surgeries at Fortis Hospital, Bangalore. My contribution reflects the importance of high-volume centers and skilled teams in achieving the best outcomes for patients.

The ICGRR study is a landmark effort in Indian healthcare, involving data from 11 centers and 829 patients. This collaboration between public and private institutions provides a comprehensive overview of real-world outcomes for rectal cancer surgery in India.

As a contributor to this study, I had the privilege of performing many of the robotic and laparoscopic surgeries at Fortis Hospital, Bangalore. My contribution reflects the importance of high-volume centers and skilled teams in achieving the best outcomes for patients.

Link to paper: https://link.springer.com/article/10.1007/s11701-025-02375-5