**10. Discussions**

Colorectal laparoscopic surgery after the 1990s when viewed with considerable skepticism had a period of growth between 2000 and 2015 all over the world. According to studies published at that time, laparoscopy has a number of certain advantages over the open approach [11, 13]. However, it is obvious that it becomes extremely difficult to perform when there is relatively low visibility in a narrow pelvis or in different quadrants [14]. The learning curve for colorectal

surgery is not small, on average a minimum of 90 interventions are required to overcome this learning curve. Miskovic et al. published in 2012 a meta-analysis related to the learning curve in laparoscopic surgery and shows that if we refer to the time of operation or blood loss more than 90 interventions are needed, but if we refer to the complication rate or conversion rate more than 150 procedures are needed [44].

After the publication of the ALaCaRT and ACOSOGZ6051 studies, the controversies resurfaced [20, 21]. There has been some delimitation between colon surgery and rectal surgery. For colon surgery, the laparoscopic approach is very good, with a clear distinction in terms of difficulty between right hemicolectomy and left colectomy. For rectal surgery, however, there have been controversies about the honesty of the laparoscopic approach compared to the open approach. Here rectal robotic surgery comes to replace all the disadvantages of laparoscopic surgery. The advantages of robotic surgery are obvious in terms of standard three-dimensional visibility, the ability to perform fine dissections in small spaces, difficult to access with tools with 7 degrees of freedom [45–48].

Although the first robotic operation for rectal cancer was performed in 2002 [49], published studies have been quite poor in comparing this approach to the laparoscopic or classical approach. Y. Cui et al. publishes in 2017 a meta-analysis which compares the robotic approach compared to the laparoscopic approach and which discusses only 9 studies that meet the eligibility conditions [50]. The following conclusions can be drawn from this meta-analysis. The robotic approach is superior to the laparoscopic approach in terms of intraoperative blood loss, length of hospital stays and postoperative morbidity rate. Only the time of the intervention was in favor of the laparoscopic approach. Another published meta-analysis which takes into account 5 eligible studies comparing 334 robotic interventions with 337 laparoscopic ones and which demonstrates the superiority of the robotic approach only in the lower conversion rate, but with a higher intervention time [51].

The findings of another study related to the robotic approach in rectal cancer published by Z. Azman highlight the benefits of this approach compared to the laparoscopic or open approach. Superior visualization, shorter learning curve, ergonomic position of the surgeon, lower conversion rate, lower blood loss, shorter hospitalization, lower morbidity rate and better preservation of sexual and urinary function are these robotic advantages [52].

The first randomized clinical trial (ROLARR Study) does not show statistically significant differences between the robotic and laparoscopic approach in any of the 8 end points studied [24]. Subsequent studies have shown a number of advantages of the robotic approach. Fleming et al. performs a meta-analysis comparing the robotic approach with the laparoscopic approach in terms of preserving urogenital function in men and concluding that urinary and erectile function is better in men undergoing the robot compared to conventional laparoscopic surgery for rectal cancer. The results in women did not identify a consistently more favorable result in any of the groups [53]. Another advantage of the robotic approach is found in obese patients, in whom hospitalization is lower and a re-admission to 30 days is rarer, with a faster recovery and a lower rate of postoperative complications, but with a longer duration of operation than the laparoscopic approach [54].

With the advent of novelties in robot instruments, vascular sealing instruments or robotic staplers bring obvious advantages in the easier and more precise development of interventions. In the future, with the advent of other robotic platforms with reusable tools, they will reduce costs and then this disadvantage of robotic surgery will disappear [55].
