Robotic Versus Conventional Laparoscopic Surgery for Colorectal Cancer: A Systematic Review and Meta-Analysis with Trial Sequential Analysis

Abstract

Background: Minimally invasive surgery has been considered as an alternative to open surgery by surgeons for colorectal cancer. However, the efficacy and safety profiles of robotic and conventional laparoscopic surgery for colorectal cancer remain unclear in the literature. The primary aim of this review was to determine whether robotic-assisted laparoscopic surgery (RAS) has better clinical outcomes for colorectal cancer patients than conventional laparoscopic surgery (CLS). Methods: All randomized clinical trials (RCTs) and observational studies were systematically searched in the databases of CENTRAL, EMBASE and PubMed from their inception until January 2018. Case reports, case series and non-systematic reviews were excluded. Results: Seventy-three studies (6 RCTs and 67 observational studies) were eligible (n = 169,236) for inclusion in the data synthesis. In comparison with the CLS arm, RAS cohort was associated with a significant reduction in the incidence of conversion to open surgery (ρ < 0.001, I 2 = 65%; REM: OR 0.40; 95% CI 0.30,0.53), all-cause mortality (ρ < 0.001, I 2 = 7%; FEM: OR 0.48; 95% CI 0.36,0.64) and wound infection (ρ < 0.001, I 2 = 0%; FEM: OR 1.24; 95% CI 1.11,1.39). Patients who received RAS had a significantly shorter duration of hospitalization (ρ < 0.001, I 2 = 94%; REM: MD − 0.77; 95% CI 1.12, − 0.41; day), time to oral diet (ρ < 0.001, I 2 = 60%; REM: MD − 0.43; 95% CI − 0.64, − 0.21; day) and lesser intraoperative blood loss (ρ = 0.01, I 2 = 88%; REM: MD − 18.05; 95% CI − 32.24, − 3.85; ml). However, RAS cohort was noted to require a significant longer duration of operative time (ρ < 0.001, I 2 = 93%; REM: MD 38.19; 95% CI 28.78,47.60; min). Conclusions: This meta-analysis suggests that RAS provides better clinical outcomes for colorectal cancer patients as compared to the CLS at the expense of longer duration of operative time. However, the inconclusive trial sequential analysis and an overall low level of evidence in this review warrant future adequately powered RCTs to draw firm conclusion.