Challenges and Learning Curves in Adopting TaTME and Robotic Surgery for Rectal Cancer: A Cusum Analysis

SIMPLE SUMMARY: Rectal cancer surgery remains a challenge and information about the learning curve in adopting new techniques is lacking. This paper analyzes our experience in taTME (since 2015) and robotic surgery (since 2018) at a fully accredited referral center for the treatment of rectal cancer in Spain. In this retrospective study, we aim to analyze the learning curves for taTME and robot-assisted rectal procedures in the incorporation of these platforms into our practice. We sought to describe our team’s experience in incorporating these techniques and to analyze the difficulties that we have had. Hoping that sharing our experience can help other groups improve their results during the difficult initial phase of incorporating new techniques. ABSTRACT: New techniques are being developed to improve the results of laparoscopic surgery for rectal cancer. This paper analyzes the learning curves for transanal total mesorectal excision (taTME) and robot-assisted surgery in our colorectal surgery department. We analyzed retrospectively data from patients undergoing curative and elective surgery for rectal cancer ≤12 cm from the anal verge. We excluded extended surgeries. We used cumulative sum (CUSUM) curve analysis to identify inflection points. Between 2015 and 2021, 588 patients underwent surgery for rectal cancer at our center: 67 taTME and 79 robot-assisted surgeries. To overcome the operative time learning curve, 14 cases were needed for taTME and 53 for robot-assisted surgery. The morbidity rate started to decrease after the 17th case in taTME and after the 49th case in robot-assisted surgery, but it is much less abrupt in robot-assisted group. During the initial learning phase, the rate of anastomotic leakage was higher in taTME (35.7% vs. 5.7%). Two Urological lesions occurred in taTME but not in robot-assisted surgery. The conversion rate was higher in robot-assisted surgery (1.5% vs. 10.1%). Incorporating new techniques is complex and entails a transition period. In our experience, taTME involved a higher rate of serious complications than robot-assisted surgery during initial learning period but required a shorter learning curve.