Restorative resection in robot-assisted versus laparoscopic total mesorectal excision: systematic review and meta-analysis

Abstract Background The surgical treatment of rectal cancer is based on the principle of total mesorectal excision (TME). Owing to its technological advantages, robot-assisted total mesorectal excision (R-TME) is hypothesized to facilitate primary anastomosis more frequently than laparoscopic total mesorectal excision (L-TME). This systematic review and meta-analysis aimed to investigate whether R-TME is associated with a higher likelihood of restorative surgery compared with L-TME. Methods This systematic review and meta-analysis was conducted in accordance with PRISMA guidelines. The protocol was prospectively registered in PROSPERO, the international prospective register of systematic reviews (registration number: 1106767). PubMed/MEDLINE, Embase, the Web of Science, and the Cochrane Library were searched for studies from January 2010 to January 2026. Pooled ORs and mean differences were calculated using a random-effects model. Results Twenty studies were included, reporting on 7133 patients. The pooled analysis demonstrated a significantly higher likelihood of restorative surgery with R-TME compared with L-TME (OR 1.43 (95% c.i. 1.04 to 1.98)). In a subgroup analysis of studies including patients after 2020, a stronger effect was observed (OR 2.86 (95% c.i. 1.80 to 4.53)). No significant differences were observed in anastomotic leakage, postoperative complications, reoperations, and readmissions. R-TME was associated with a lower conversion rate compared with L-TME (OR 0.37 (95% c.i. 0.28 to 0.49)). Conclusion R-TME is associated with a higher likelihood of primary anastomosis formation while maintaining a comparable safety profile. The more pronounced effect in recent studies likely reflects increasing surgical expertise. Future research should determine whether these advantages translate into measurable improvements in patient quality of life.