Total robotic colectomy: transforming the future of minimally invasive colorectal surgery

The integration of robotic technology in colorectal surgery, particularly its application in total robotic colectomy (TRC), marks a significant advancement that deserves recognition and consideration. TRC, performed using systems such as the da Vinci Xi, offers substantial advantages over conventional laparoscopic and open approaches, improving not only the surgeon’s experience but also patient outcomes (1-3).

Robotic surgery has emerged as an essential technique because of its precision, enhanced visualization, and improved ergonomics. These features allow surgeons to perform highly complex procedures with greater control. The articulated instruments provided by robotic systems support precise movement in confined spaces, reducing the risk of injury to surrounding tissues and improving oncological dissection (4-6).

The benefits of robotic surgery are particularly pronounced in total colectomy. These procedures require extensive mobilization and access to multiple quadrants of the abdomen, historically necessitating multiple dockings of older robotic systems. The da Vinci Xi platform has alleviated many of these logistical issues by allowing access across quadrants without redocking, streamlining the surgical workflow, reducing operative time, and enhancing intraoperative efficiency (7). Nonetheless, its advantages are more pronounced compared to previous robotic systems than standard laparoscopy, which remains highly effective in many centers.

Recent studies focusing specifically on TRC have demonstrated its feasibility and benefits. Chua et al. (3) reported the successful use of a single-docking technique with the da Vinci Xi for TRC with ileorectal anastomosis, showing efficiency in multiquadrant access without the need for re-docking. The procedure achieved low operative blood loss (10 mL) and early discharge on postoperative day 4, emphasizing how optimized robotic setups improve recovery. Jimenez-Rodriguez et al. (2) supported the safety and efficiency of TRC using the Xi robotic platform, with favorable outcomes in operative workflow and hospital stay. Additionally, Chen and Liang (8) illustrated the use of natural orifice specimen extraction in TRC, highlighting reduced abdominal trauma and improved cosmetic outcomes. Roviello et al. (9) described a streamlined approach to robotic total proctocolectomy using a single docking setup, enhancing procedural efficiency. Pasquer et al. (10) contributed to this field with a description of a full robotic suprapubic approach, aiming to optimize cosmetic outcomes and reduce postoperative pain. The Hugo RAS (Hugo robotic-assisted surgery) platform has emerged as an alternative to the da Vinci system. Recently, Santos and Brandão (11) reported the first case of TRC performed using the Hugo RAS platform in a young patient with familial adenomatous polyposis, demonstrating the feasibility of emerging robotic systems for multi-quadrant colorectal surgery. The modular setup allowed for efficient quadrant access, and the patient was discharged on postoperative day 3. Moghadamyeghaneh et al. (1) also provided a comparative analysis of robotic, laparoscopic, and open total colectomies, showing that robotic procedures had lower conversion rates and morbidity but incurred higher hospital charges.

Table 1 summarizes selected findings from studies addressing TRC, including both comparative outcomes and technical feasibility.

In addition to the clinical benefits, robotic platforms offer ergonomic advantages for surgeons. Fatigue is significantly reduced owing to the intuitive control and improved operating posture, which may contribute to the sustainability of the surgeon’s performance over time. Prolonged procedures can contribute to musculoskeletal strain in laparoscopic surgery, which robotic interfaces help alleviate (12,13).

Training and standardization are key components of the widespread adoption of TRC. While the initial learning curve for robotic surgery can be steep, it is often shorter than that for conventional laparoscopy because of the enhanced capabilities of robotic systems. Simulation training, proctoring, and structured certification programs by professional societies are essential for safe implementation and skill acquisition (14).

Automation and artificial intelligence represent the next frontier. Robotic platforms are evolving to incorporate semi-autonomous functions such as suture guidance, dissection tracking, and anatomical recognition. These innovations may reduce variability in outcomes, improve efficiency, and further expand the potential of minimally invasive colorectal surgery (15).

However, the widespread adoption of TRC will require further high-quality evidence. Functional recovery, including bowel function and quality of life metrics following TRC, should also be evaluated in prospective multicenter trials. Furthermore, cost-effectiveness analyses comparing robotic, laparoscopic, and open approaches in specific patient subgroups are required.

Moreover, the patient selection criteria need to be refined. Not all patients benefit equally from robotic surgery, and future studies should aim to define specific subgroups, such as those with obesity, prior abdominal surgery, or complex inflammatory conditions, who derive the greatest benefit from robotic intervention.

In conclusion, TRC represents a promising advancement in the field of colorectal surgery. While challenges remain, particularly in terms of cost and accessibility, a growing body of evidence supports its integration into contemporary practice. As robotic platforms evolve, including the introduction of cost-efficient alternatives such as the Hugo RAS, and as artificial intelligence (AI)-driven features are adopted, TRC may become a cornerstone of minimally invasive colorectal care.

Acknowledgments

The authors would like to thank all the members of their surgical teams and institutional support staff for their continued efforts in advancing robotic surgery.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, AME Surgery Journal. The article has undergone external peer review.

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-31/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-31/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work, ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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