The mastery of the field of colorectal surgery, with its multitude of complex procedures and ever evolving modalities, begins in general surgery residency, often progresses to fellowship, and continues throughout one’s career as a lifelong endeavor. Many learning curves are encountered and overcome at each stage. During the training phase the mastery of new skills is developed in a controlled environment monitored by experienced surgeons. Post-training the surgeon learns, develops, and masters new skills in an environment that is sometimes without a roadmap, yet he or she has to begin successfully implementing this skill in a safe manner for his/her patients. Although learning curves are inevitable, they also impact the subset of patients who fall under the front end of the surgeon’s learning curve. During the initial learning curve, many factors contribute to the surgeon’s eventual acquisition of the desired skill.

“The learning curve is usually defined as the number of cases that a surgeon needs to perform before reaching competency for a given procedure based on comparisons with the outcomes of prior standard procedures.” [1]

Factors that impact the learning curve are both surgeon and patient related. Surgeon factors can include prior experience and surgical volume while patient factors may include BMI, anatomy, and/or the complexity of surgical disease process.

Laparoscopic and robotic assisted colorectal surgeries are two of the newest surgical modalities that have risen to the forefront of the field over the last 10–20 years. Laparoscopy predates robotics and as such there is much more data on its learning curves and how these curves have been analyzed and implemented, which aids in setting the stage for later uncovering the learning curves for robotic surgery.

In 1991 M. Jacobs performed the first laparoscopic colectomy and ever since surgeons have been trying to perfect the technique [2]. Initially and even currently one of large challenges of laparoscopic colorectal surgery has been the steep learning curve. Initially surgeons were learning this technique post-residency/post-fellowship. They were well trained and experienced in open surgical techniques with no exposure to laparoscopy so the steep learning curve was due to a complex combination of technology related factors such as learning to use straight, rigid instruments within small spaces, limited degrees of freedom, fulcrum effect, loss of tactile feedback, adapting to two-dimensional visualization, and suboptimal ergonomic design [3]. Many studies were published looking at the learning curve under these circumstances. During this time the patient enrollment in these types of studies began in the early 1990s and continued into the twenty-first century ([4–6). Based on studies from this time in surgical history, the learning curve for laparoscopy is varied ranging from 30–70 cases based on a series of single center or single surgeon experiences ([4, 5, 7]). A retrospective systematic review of the literature between 1995 and 2009 showed that the learning curve is even higher at 88–152 cases when multicenter information is included and multidimensional analysis is applied [8]. Currently, laparoscopy is an intimate part of general surgery residency and every colon and rectal surgery fellowship, which has created a surgeon different than the one cited in these types of studies. This places the learning curve of laparoscopic surgery within the confines of fellowship, and even beginning in residency, and may decrease the high number of laparoscopic cases needed to overcome the learning curve.

Many of these studies have used different methods to analyze the learning curve and have evaluated various end points; several key outcomes are consistently seen throughout all studies. The most common outcome measured can be divided into surgeon dependent factors that relate to the surgeon’s ability to complete the task efficiently and are frequently measured by operative time and conversion rate ([4–6]). The other outcomes are related to patient quality and outcome factors such as length of stay, readmission rates, post-op and intra-op complication rates, and patient mortality and morbidity ([4–6]). The long learning curve associated with laparoscopic colorectal surgery and with the rise of robotic surgery, literature is arising to determine if the learning curve of robotic surgery is shorter than in laparoscopy.

The first robotic assisted colectomy was performed in 2001 and interest in applying this technology continued to grow, especially with respect to the challenges of rectal surgery [9]. The potential advantages of robotic surgery over laparoscopic have been described as its multiarticulated instruments, camera stabilization, three-dimensional magnified visualization, and ergonomic operating position [10]. There is interest to know if these potential benefits translate into a shorter learning curve as compared to laparoscopy.

Currently, all published studies of the learning curves of robotic colorectal surgery focus primarily on rectal surgery and particularly with rectal cancer but some benign disease is included. These preliminary studies suggest that the learning curve can be analyzed by evaluating a combination of time related factors: total operative time, surgeon time on the console, robot docking time, total time using the robot as well as non time related factors such as conversion rates and intra and postoperative complications ([3, 9]). It was found that the learning curve had three distinct phases: