Impact of laparoscopic surgical experience on the learning curve of robotic rectal cancer surgery



Robotic surgery has advantages in terms of the ergonomic design and expectations of shortening the learning curve, which may reduce the number of patients with adverse outcomes during a surgeon’s learning period. We investigated the differences in the learning curves of robotic surgery and clinical outcomes for rectal cancer among surgeons with differences in their experiences of laparoscopic rectal cancer surgery.


Patients who underwent robotic surgery for colorectal cancer were reviewed retrospectively. Patients were divided into five groups by surgeons, and their clinical outcomes were analyzed. The learning curve of each surgeon with different volumes of laparoscopic experience was analyzed using the cumulative sum technique (CUSUM) for operation times, surgical failure (open conversion or anastomosis-related complications), and local failure (positive resection margins or local recurrence within 1 year).


A total of 662 patients who underwent robotic low anterior resection (LAR) for rectal cancer were included in the analysis. Number of laparoscopic LAR cases performed by surgeon A, B, C, D, and E prior to their first case of robotic surgery were 403, 40, 15, 5, and 0 cases, respectively. Based on CUSUM for operation time, surgeon A, B, C, D, and E’s learning curve periods were 110, 39, 114, 55, and 23 cases, respectively. There were no significant differences in the surgical and oncological outcomes after robotic LAR among the surgeons.


This study demonstrated the limited impact of laparoscopic surgical experience on the learning curve of robotic rectal cancer surgery, which was greater than previously reported curves.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5


  1. 1.

    Ng SS, Lee JF, Yiu RY, Li JC, Hon SS, Mak TW, Leung WW, Leung KL (2014) Long-term oncologic outcomes of laparoscopic versus open surgery for rectal cancer: a pooled analysis of 3 randomized controlled trials. Ann Surg 259:139–147

    Article  Google Scholar 

  2. 2.

    Jayne D, Thorpe H, Copeland J, Quirke P, Brown J, Guillou P (2010) Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer. Br J Surg 97:1638–1645

    CAS  Article  Google Scholar 

  3. 3.

    Green B, Marshall H, Collinson F, Quirke P, Guillou P, Jayne D, Brown J (2013) Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer. Br J Surg 100:75–82

    CAS  Article  Google Scholar 

  4. 4.

    Group COoSTS (2004) A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004:2050–2059

    Google Scholar 

  5. 5.

    Jamali FR, Soweid AM, Dimassi H, Bailey C, Leroy J, Marescaux J (2008) Evaluating the degree of difficulty of laparoscopic colorectal surgery. Arch Surg 143:762–767

    Article  Google Scholar 

  6. 6.

    Park IJ, Choi G-S, Lim KH, Kang BM, Jun SH (2009) Multidimensional analysis of the learning curve for laparoscopic resection in rectal cancer. J Gastrointest Surg 13:275–281

    Article  Google Scholar 

  7. 7.

    Bege T, Lelong B, Esterni B, Turrini O, Guiramand J, Francon D, Mokart D, Houvenaeghel G, Giovannini M, Delpero JR (2010) The learning curve for the laparoscopic approach to conservative mesorectal excision for rectal cancer: lessons drawn from a single institution's experience. Ann Surg 251:249–253

    Article  Google Scholar 

  8. 8.

    Kayano H, Okuda J, Tanaka K, Kondo K, Tanigawa N (2011) Evaluation of the learning curve in laparoscopic low anterior resection for rectal cancer. Surg Endosc 25:2972–2979

    Article  Google Scholar 

  9. 9.

    Son G-M, Kim J-G, Lee J-C, Suh Y-J, Cho H-M, Lee Y-S, Lee I-K, Chun C-S (2010) Multidimensional analysis of the learning curve for laparoscopic rectal cancer surgery. J Laparoendosc Adv Surg Tech 20:609–617

    Article  Google Scholar 

  10. 10.

    Ito M, Sugito M, Kobayashi A, Nishizawa Y, Tsunoda Y, Saito N (2009) Influence of learning curve on short-term results after laparoscopic resection for rectal cancer. Surg Endosc 23:403–408

    Article  Google Scholar 

  11. 11.

    Jiménez-Rodríguez RM, Díaz-Pavón JM, de Juan FP, Prendes-Sillero E, Dussort HC, Padillo J (2013) Learning curve for robotic-assisted laparoscopic rectal cancer surgery. Int J Colorectal Dis 28:815–821

    Article  Google Scholar 

  12. 12.

    Park EJ, Kim CW, Cho MS, Kim DW, Min BS, Baik SH, Lee KY, Kim NK (2014) Is the learning curve of robotic low anterior resection shorter than laparoscopic low anterior resection for rectal cancer?: a comparative analysis of clinicopathologic outcomes between robotic and laparoscopic surgeries. Medicine 93:e109

    Article  Google Scholar 

  13. 13.

    Melich G, Hong YK, Kim J, Hur H, Baik SH, Kim NK, Liberman AS, Min BS (2015) Simultaneous development of laparoscopy and robotics provides acceptable perioperative outcomes and shows robotics to have a faster learning curve and to be overall faster in rectal cancer surgery: analysis of novice MIS surgeon learning curves. Surg Endosc 29:558–568

    Article  Google Scholar 

  14. 14.

    Foo CC, Law WL (2016) The learning curve of robotic-assisted low rectal resection of a novice rectal surgeon. World J Surg 40:456–462

    Article  Google Scholar 

  15. 15.

    Huang C-W, Yeh Y-S, Ma C-J, Choy T-K, Huang M-Y, Huang C-M, Tsai H-L, Hsu W-H, Wang J-Y (2015) Robotic colorectal surgery for laparoscopic surgeons with limited experience: preliminary experiences for 40 consecutive cases at a single medical center. BMC Surg 15:73

    CAS  Article  Google Scholar 

  16. 16.

    Amin MB, Edge S, Greene F, Byrd DR, Brookland RK, Washington MK, Gershenwald JE, Compton CC, Hess KR, Sullivan DC, Jessup JM, Brierley JD, Gaspar LE, Schilsky RL, Balch CM, Winchester DP, Asare EA, Madera M, Gress DM, Meyer LR (2017) AJCC cancer staging manual, 8th edn. Springer, New York

    Google Scholar 

  17. 17.

    Dinçler S, Koller MT, Steurer J, Bachmann LM, Christen D, Buchmann P (2003) Multidimensional analysis of learning curves in laparoscopic sigmoid resection. Dis Colon Rectum 46:1371–1378

    Article  Google Scholar 

  18. 18.

    Weber PA, Merola S, Wasielewski A, Ballantyne GH (2002) Telerobotic-assisted laparoscopic right and sigmoid colectomies for benign disease. Dis Colon Rectum 45:1689–1696

    Article  Google Scholar 

  19. 19.

    Pigazzi A, Ellenhorn J, Ballantyne G, Paz I (2006) Robotic-assisted laparoscopic low anterior resection with total mesorectal excision for rectal cancer. Surg Endosc Other Interv Tech 20:1521–1525

    CAS  Article  Google Scholar 

  20. 20.

    Jiménez Rodríguez R, Díaz Pavón J, la Portilla De, De Juan F, Prendes Sillero E, Cadet Dussort J, Padillo J (2011) Prospective, randomized, short-term outcome study: robotic-assisted laparoscopic surgery versus conventional laparosocpic surgery in colorectal carcinoma resection. Cir Esp 89:432–438

    Article  Google Scholar 

  21. 21.

    Kwak JM, Kim SH, Kim J, Son DN, Baek SJ, Cho JS (2011) Robotic vs laparoscopic resection of rectal cancer: short-term outcomes of a case-control study. Dis Colon Rectum 54:151–156

    Article  Google Scholar 

  22. 22.

    Rottoli M, Bona S, Rosati R, Elmore U, Bianchi PP, Spinelli A, Bartolucci C, Montorsi M (2009) Laparoscopic rectal resection for cancer: effects of conversion on short-term outcome and survival. Ann Surg Oncol 16:1279

    Article  Google Scholar 

  23. 23.

    Lee SH, Lim S, Kim JH, Lee KY (2015) Robotic versus conventional laparoscopic surgery for rectal cancer: systematic review and meta-analysis. Ann Surg Treat Res 89:190–201

    CAS  Article  Google Scholar 

  24. 24.

    Yang Y, Wang F, Zhang P, Shi C, Zou Y, Qin H, Ma Y (2012) Robot-assisted versus conventional laparoscopic surgery for colorectal disease, focusing on rectal cancer: a meta-analysis. Ann Surg Oncol 19:3727–3736

    Article  Google Scholar 

  25. 25.

    Ortiz-Oshiro E, Sánchez-Egido I, Moreno-Sierra J, Pérez CF, Díaz JS, Fernández-Represa JÁ (2012) Robotic assistance may reduce conversion to open in rectal carcinoma laparoscopic surgery: systematic review and meta-analysis. Int J Med Robot Comput Assist Surg 8:360–370

    Article  Google Scholar 

  26. 26.

    Yamaguchi T, Kinugasa Y, Shiomi A, Sato S, Yamakawa Y, Kagawa H, Tomioka H, Mori K (2015) Learning curve for robotic-assisted surgery for rectal cancer: use of the cumulative sum method. Surg Endosc 29:1679–1685

    Article  Google Scholar 

  27. 27.

    Akmal Y, Baek J-H, McKenzie S, Garcia-Aguilar J, Pigazzi A (2012) Robot-assisted total mesorectal excision: is there a learning curve? Surg Endosc 26:2471–2476

    Article  Google Scholar 

  28. 28.

    Sng KK, Hara M, Shin J-W, Yoo B-E, Yang K-S, Kim S-H (2013) The multiphasic learning curve for robot-assisted rectal surgery. Surg Endosc 27:3297–3307

    Article  Google Scholar 

  29. 29.

    Park EJ, Kim CW, Cho MS, Baik SH, Kim DW, Min BS, Lee KY, Kim NK (2014) Multidimensional analyses of the learning curve of robotic low anterior resection for rectal cancer: 3-phase learning process comparison. Surg Endosc 28:2821–2831

    Article  Google Scholar 

  30. 30.

    Kim HJ, Choi G-S, Park JS, Park SY (2014) Multidimensional analysis of the learning curve for robotic total mesorectal excision for rectal cancer: lessons from a single surgeon’s experience. Dis Colon Rectum 57:1066–1074

    Article  Google Scholar 

  31. 31.

    Tekkis PP, Senagore AJ, Delaney CP, Fazio VW (2005) Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections. Ann Surg 242:83

    Article  Google Scholar 

  32. 32.

    Jiménez-Rodríguez RM, Rubio-Dorado-Manzanares M, Díaz-Pavón JM, Reyes-Díaz ML, Vazquez-Monchul JM, Garcia-Cabrera AM, Padillo J, De la Portilla F (2016) Learning curve in robotic rectal cancer surgery: current state of affairs. Int J Colorectal Dis 31:1807–1815

    Article  Google Scholar 

  33. 33.

    Kim CW, Kim WR, Kim HY, Kang J, Hur H, Min BS, Baik SH, Lee KY, Kim NK (2015) Learning curve for single-incision laparoscopic anterior resection for sigmoid colon cancer. J Am Coll Surg 221:397–403

    Article  Google Scholar 

  34. 34.

    Park Y, Yong YG, Yun SH, Jung KU, Huh JW, Cho YB, Kim HC, Lee WY, Chun H-K (2015) Learning curves for single incision and conventional laparoscopic right hemicolectomy: a multidimensional analysis. Ann Surg Treat Res 88:269–275

    Article  Google Scholar 

  35. 35.

    Haas EM, Nieto J, Ragupathi M, Aminian A, Patel CB (2013) Critical appraisal of learning curve for single incision laparoscopic right colectomy. Surg Endosc 27:4499–4503

    Article  Google Scholar 

  36. 36.

    Hopping JR, Bardakcioglu O (2013) Single-port laparoscopic right hemicolectomy: the learning curve. JSLS: J Soc Laparoendosc Surg 17:194

    Article  Google Scholar 

  37. 37.

    Kirk KA, Boone BA, Evans L, Evans S, Bartlett DL, Holtzman MP (2015) Analysis of outcomes for single-incision laparoscopic surgery (SILS) right colectomy reveals a minimal learning curve. Surg Endosc 29:1356–1362

    Article  Google Scholar 

  38. 38.

    Kim CW, Lee KY, Lee SC, Lee S-H, Lee YS, Lim SW, Kim J-G (2017) Learning curve for single-port laparoscopic colon cancer resection: a multicenter observational study. Surg Endosc 31:1828–1835

    Article  Google Scholar 

  39. 39.

    Guend H, Widmar M, Patel S, Nash GM, Paty PB, Guillem JG, Temple LK, Garcia-Aguilar J, Weiser MR (2017) Developing a robotic colorectal cancer surgery program: understanding institutional and individual learning curves. Surg Endosc 31:2820–2828

    Article  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Byung Soh Min.

Ethics declarations


Drs. Gyoung Tae Noh, Myunghyun Han, Hyuk Hur, Seung Hyuk Baik, Kang Young Lee, Nam Kyu Kim, and Byung Soh Min have no conflict of interest or financial ties to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Noh, G.T., Han, M., Hur, H. et al. Impact of laparoscopic surgical experience on the learning curve of robotic rectal cancer surgery. Surg Endosc (2020).

Download citation


  • Learning curve
  • Robotic surgery
  • Rectal cancer
  • Laparoscopic experience