Robotic Versus Laparoscopic Surgery for Colorectal Cancer: A Trial Sequential Meta-Analysis of Randomized Trials

Abstract

Background: Laparoscopic surgery (LS) is widely recognized as the standard minimally invasive method for colorectal cancer. Although robotic surgery (RS) has seen increased adoption, its clinical and economic advantages over LS remain uncertain. Methods: A systematic search was carried out across PubMed, Scopus, and the Cochrane Central Register up to March 2025. Only randomized controlled trials (RCTs) directly comparing RS and LS were included. Pooled risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated using random-effects models. Heterogeneity was assessed via the I 2 statistic. Trial sequential analysis (TSA) was applied to assess the robustness of the cumulative evidence. Results: Fourteen RCTs encompassing 2867 patients were included. Compared with LS, RS significantly lowered the conversion rate to open surgery (RR = 0.54; 95% CI: 0.36–0.80; P = .002), time to first stool (MD = −0.33 days; 95% CI: −0.60 to −0.06; P = .016), and positive circumferential resection margin (CRM) (RR = 0.65; 95% CI: 0.46–0.93; P = .017). Sensitivity analysis revealed a slight benefit for RS in time to first flatus (MD = −0.13 days; P = .03). RS was associated with a longer surgery duration (MD = +49.4 minutes; 95% CI: 18.0–80.7; P = .002). No significant differences were observed for intraoperative blood loss, postoperative complications, or cancer recurrence. TSA confirmed definitive findings for selected outcomes, while others remained underpowered. Conclusions: RS and LS showed equivalent results for postoperative complications and cancer-related outcomes. RS was advantageous in reducing conversion and CRM positivity, despite longer operative time.