# Learning Curve of Da Vinci Xi Robotic Low Anterior Resection: A Cumulative Sum Analysis of a Single High-Volume Surgeon

## TL;DR

This study shows that a high-volume surgeon quickly becomes proficient in robotic low anterior resection using the da Vinci Xi system after about 16 cases, with no increase in complications.

## Contribution

The study defines a rapid learning curve for robotic LAR using the da Vinci Xi system in a high-volume, standardized setting.

## Key findings

- Technical proficiency was achieved after 16 cases, marked by reduced docking time and no open surgery conversions.
- Comparable complication rates and satisfactory oncological outcomes were observed between learning and proficiency phases.
- Low robotic stapler firings were consistently maintained, indicating technical precision from the start.

## Abstract

Background: The learning curve for robotic low anterior resection (LAR) utilizing the modern da Vinci Xi system within a high-volume, standardized environment remains poorly defined. This study aimed to delineate the technical proficiency of a single high-volume surgeon using the Xi platform. Methods: A retrospective analysis of 95 consecutive patients undergoing robotic LAR for primary rectal malignancy between 2020 and 2023 was conducted. All procedures were performed by a single surgeon using the da Vinci Xi system under a standardized ERAS protocol. Cumulative sum (CUSUM) analysis of operative time was used to define learning phases. Results: CUSUM analysis identified a proficiency inflection point after 16 cases. Median docking time significantly decreased in the proficiency phase (14.5 vs. 10.0 min, p < 0.01). Notably, zero conversions to open surgery occurred throughout the series. Comparative analysis revealed comparable overall complication rates (0.0% vs. 13.9%, p = 0.201) and postoperative length of stay between phases. Short-term oncological quality, including lymph node yield and circumferential resection margins, remained satisfactory in both groups. Technical precision, reflected by consistently low robotic stapler firings (median 2.0), was maintained from the outset. Conclusions: Technical proficiency in robotic LAR using the da Vinci Xi system was rapidly achieved after approximately 16 cases in this high-volume standardized setting. This accelerated learning curve was not associated with compromised perioperative safety or oncological outcomes.