The minimally invasive treatment of rectal cancer with Total Mesorectal Excision is a complex and challenging procedure due to technical and anatomical issues which could impair postoperative, oncological and functional outcomes, especially in a defined subgroup of patients. The results from recent randomized controlled trials comparing laparoscopic versus open surgery are still conflicting and trans-anal bottom-up approaches have recently been developed. Robotic surgery represents the latest consistent innovation in the field of minimally invasive surgery that may potentially overcome the technical limitations of conventional laparoscopy thanks to an enhanced dexterity, especially in deep narrow operative fields such as the pelvis. Results from population-based multicenter studies have shown the potential advantages of robotic surgery when compared to its laparoscopic counterpart in terms of reduced conversions, complication rates and length of stay. Costs, often advocated as one of the main drawbacks of robotic surgery, should be thoroughly evaluated including both the direct and indirect costs, with the latter having the potential of counterbalancing the excess of expenditure directly related to the purchase and maintenance of robotic equipment. Further prospectively maintained or randomized data are still required to better delineate the advantages of the robotic platform, especially in the subset of most complex and technically challenging patients from both an anatomical and oncological standpoint.

Robotic surgery may offer significant advantages for treating extraperitoneal rectal cancer. Although laparoscopy has been shown to be safe and effective, laparoscopic total mesorectal excision (TME) remains technically challenging and is still performed in selected centers. Robotic anterior resection (RAR) may overcome the drawback of conventional laparoscopy, providing high-quality surgery with favorable oncological outcomes. Moreover, recent data show how RAR offers clinical and oncological benefits when affording difficult TMEs, such as low and advanced rectal tumors, in terms of complication rate, specimen quality, recurrence rate, and survival. This series aims to review the most recent and relevant literature, reporting mid- and long-term oncological outcomes and focusing on minimally invasive RAR for low rectal cancer.

Complex abdominal wall hernias remain a major surgical challenge. Traditional open approaches, while still needed in selected cases, often necessitate extensive dissection and are associated with substantial wound morbidity and longer length of stay. Robotic-assisted surgery has emerged as a powerful alternative to open surgery, combining the benefits of minimally invasive access with midline functional reconstruction and retromuscular/extraperitoneal mesh placement. This chapter reviews robotic strategies for the repair of large midline and lateral incisional hernias with posterior component separation/transversus abdominis release (TAR). In midline defects, bilateral TAR allows for myofascial release and midline reconstruction with giant prosthetic reinforcement of the visceral sac, eventually with the Madrid modification of the technique for pure preperitoneal/pretransversalis dissection in the subdiaphragmatic/epigastric area. For large lateral incisional hernias, unilateral TAR offers asymmetric component separation while preserving neurovascular bundles, thereby optimizing fascial closure and lateral mesh overlap. A single docking unilateral approach can be also performed for treating associated midline (according to rectus-to-defect width ratio) and lateral defects. Technical considerations, operative strategies, and available clinical evidence are discussed, underscoring the safety, efficacy, and expanding role of robotic platforms in complex abdominal wall reconstruction.