Outcomes of restorative proctectomy and ileal pouch-anal anastomosis: a matched-cohort analysis of robot-assisted, laparoscopic, and open surgery.

BACKGROUND: Ileal pouch-anal anastomosis (IPAA) remains the gold standard for restorative proctocolectomy, yet its technical complexity has limited widespread minimally invasive adoption. Robotic surgery was introduced to overcome the ergonomic and visualization challenges of laparoscopy, but comparative evidence among open, laparoscopic, and robot-assisted IPAA in tertiary care remains scarce. METHODS: A matched-cohort analysis was performed on adult patients undergoing proctectomy with IPAA for ulcerative and indeterminate colitis (January 2005-September 2025) at a tertiary referral center. Patients were stratified by surgical approach: open, laparoscopic, and robot-assisted. The robot-assisted cohort included only cases performed with the modular Hugo™ RAS platform. Primary endpoints were total operative time and 30-day postoperative surgical complications. Multivariable regression, propensity score matching, and G-computation were applied to adjust for confounders such as age, BMI, ASA class, disease duration, and biologic exposure. RESULTS: Among 764 patients, 573 underwent open, 145 laparoscopic, and 46 robot-assisted IPAA. Adjusted analyses demonstrated no significant differences in 30-day surgical complications between robot-assisted and laparoscopic (OR 1.56, 95% CI 0.63-3.90) or open (OR 1.40, 95% CI 0.57-3.44) approaches. Both minimally invasive techniques yielded faster bowel function recovery (- 1.2 days vs open, p < 0.001) and reduced hospital stay (- 4.1 days for robot-assisted, - 4.7 days for laparoscopic; p < 0.05). Operative time was longer in minimally invasive groups but similar between robot-assisted and laparoscopic cases. CONCLUSION: In expert centers, open, laparoscopic, and robot-assisted completion IPAA demonstrate preliminary safety, feasibility, and short-term equivalence. Minimally invasive approaches enhance postoperative recovery, and modern robotic platforms achieve procedural efficiency comparable to laparoscopy, although larger multicenter cohorts are needed to confirm equivalence for rare postoperative outcomes.