Quality Without Compromise: A Propensity Score-Matched Analysis of Robotic Versus Laparoscopic Surgery for Locally Advanced Colorectal Cancer

Background: Minimally invasive surgery is the standard approach in colorectal cancer (CRC), yet the clinical value of robotic-assisted surgery (RAS) compared with laparoscopy remains under debate. This study aimed to compare surgical quality using textbook outcome (TO) and textbook oncological outcome (TOO) in patients undergoing minimally invasive resection for locally advanced CRC. Methods: A retrospective analysis of patients with locally advanced CRC (cT2-4N0-2M0) treated in a high-volume centre was performed. Patients undergoing laparoscopic or robotic surgery were included. Propensity score matching (PSM) was applied to balance baseline characteristics. TO was defined as an optimal perioperative course without complications, conversion, reintervention, prolonged length of stay, or mortality. TOO extended TO by including oncological parameters such as R0 resection and adequate lymph node yield. Results: A total of 123 patients were included (80 laparoscopic, 43 robotic), with 80 patients analyzed after PSM (40 per group). RAS was associated with significantly higher rates of intracorporeal (97% vs. 18.9%) and mechanical anastomoses (96.9% vs. 48.6%). No differences were observed in postoperative complications, reintervention rates, length of stay, or mortality. Although the comprehensive complication index was lower in the robotic group, this did not translate into improved TO or TOO rates. After matching, TO was achieved in 72.5% of RAS and 85.0% of laparoscopic cases (p = 0.1745), while TOO rates were also comparable between groups. No independent predictors of TO or TOO were identified in multivariable analysis. Conclusions: Robotic surgery for locally advanced CRC provides comparable perioperative safety and oncological quality to laparoscopy. The implementation of RAS in a high-volume centre does not compromise short-term outcomes, supporting its safe integration into clinical practice.