research paper on robotic surgery

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• v.15(12); 2023 Dec
• PMC10784205

Advancements in Robotic Surgery: A Comprehensive Overview of Current Utilizations and Upcoming Frontiers

Kavyanjali reddy.

1 Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND

Pankaj Gharde

Harshal tayade, mihir patil, lucky srivani reddy.

2 Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND

Dheeraj Surya

Robotic surgery, a groundbreaking advancement in medical technology, has redefined the landscape of surgical procedures. This comprehensive overview explores the multifaceted world of robotic surgery, encompassing its definition, historical development, current applications, clinical outcomes, benefits, emerging frontiers, challenges, and future implications. We delve into the fundamentals of robotic surgical systems, examining their components and advantages. From general and gynecological surgery to urology, cardiac surgery, orthopedics, and beyond, we highlight the diverse specialties where robotic surgery is making a significant impact. The many benefits discussed include improved patient outcomes, reduced complications, faster recovery times, cost-effectiveness, and enhanced surgeon experiences. The outlook reveals a healthcare landscape where robotic surgery is increasingly vital, enabling personalized medicine, bridging healthcare disparities, and advancing surgical precision. However, challenges such as cost, surgeon training, technical issues, ethical considerations, and patient acceptance remain relevant. In conclusion, robotic surgery is poised to continue shaping the future of health care, offering transformative possibilities while emphasizing the importance of collaboration, innovation, and ethical governance.

Introduction and background

Robotic surgery, a cutting-edge field within the broader realm of medical technology, has transformed the landscape of surgical procedures. Combining robotics's precision with human surgeons' expertise has opened up new horizons in medical practice. This review article delves into the multifaceted domain of robotic surgery, offering a comprehensive overview of its current utilizations and upcoming frontiers [ 1 , 2 ].

Robotic surgery, also known as robot-assisted surgery, refers to a minimally invasive surgical technique where specialized robotic systems are employed to assist surgeons in performing procedures with unparalleled precision and control. These systems consist of robotic arms equipped with surgical instruments, a surgical console operated by the surgeon, and a high-definition vision system that provides a magnified 3D view of the surgical site. Robotic surgery is distinct from traditional open surgery and conventional laparoscopy, as it combines the surgeon's skills with robotic technology to enhance the quality and safety of procedures [ 3 ].

The roots of robotic surgery trace back to the mid-20th century when the idea of using machines to aid in surgery first emerged. However, it was in the late 20th century that significant progress was made. In 1985, the PUMA 560, a pioneering robotic system, performed neurosurgical biopsies. This marked the beginning of robotic surgery as we know it today [ 4 ].

The watershed moment in the history of robotic surgery occurred with the introduction of the da Vinci Surgical System in the early 2000s. Developed by Intuitive Surgical, this system revolutionized minimally invasive surgery by providing surgeons with enhanced dexterity, precision, and improved visualization. The da Vinci Surgical System quickly gained acceptance in various surgical specialties, paving the way for the rapid expansion of robotic-assisted procedures [ 5 ].

The primary purpose of this overview is to provide a comprehensive and up-to-date exploration of the world of robotic surgery. It seeks to inform healthcare professionals, researchers, policymakers, and the general public about the current state of robotic surgery, its applications, and the emerging frontiers that hold promise for the future. By examining the advancements and challenges in this field, this article aims to contribute to a broader understanding of the role of robotic surgery in modern medicine.

The significance of advancements in robotic surgery cannot be overstated. These developments have improved patient outcomes, reduced complications, shorter hospital stays, and enhanced surgical precision. Moreover, they have opened doors to new possibilities, such as telesurgery, personalized medicine, and the integration of artificial intelligence (AI). The potential to democratize surgical expertise, improve access to health care, and redefine the boundaries of what is achievable in surgery underscores the importance of staying abreast of the latest robotic surgical innovations. This overview serves as a critical resource for comprehending the evolving landscape of robotic surgery and its profound impact on health care [ 6 ].

Fundamentals of robotic surgery

Robotic Surgical Systems

Da Vinci surgical system:   The Da Vinci system features multiple robotic arms with surgical instruments. These arms precisely mimic the surgeon's hand movements and provide a more excellent range of motion than traditional laparoscopic instruments [ 7 ]. The surgeons control the robotic arms from a surgical console in the operating room. The console offers a 3D view of the surgical field and hand controls that allow the surgeon to manipulate the instruments precisely [ 8 ]. High-definition cameras on the robotic arms provide a detailed view of the surgical site. The vision system offers 3D visualization and magnification, enhancing the surgeon's ability to navigate complex anatomical structures [ 9 ]. The Da Vinci system has been employed across various surgical specialties, including urology, gynecology, general surgery, and cardiac surgery. Its success is attributed to its ability to enhance surgical precision, reduce invasiveness, and expedite patient recovery.

Competing Systems

While the Da Vinci system remains dominant, several emerging competitors and alternative robotic surgical systems have entered the field. Medtronic, Stryker, and Titan Medical have developed robotic platforms to provide alternative solutions for minimally invasive surgery [ 10 ]. These competing systems offer healthcare providers and patients additional choices for robotic-assisted procedures, fostering innovation and competition within robotic surgery. These alternatives contribute to robotic surgical technology's ongoing development and advancement [ 1 ].

Key Components and Features

Robotic arms: They are the mechanical extensions of robotic surgical systems that replicate the movements of the surgeon's hands with remarkable precision. These arms are equipped with surgical instruments and can access tight spaces within the body, making them essential for intricate procedures. The articulation and dexterity of robotic arms enable surgeons to manipulate tissues and perform tasks accurately [ 11 ].

Surgical console: It is the command center where the surgeon sits to control the robotic arms during the procedure. It includes hand controls and foot pedals that allow the surgeon to manipulate the instruments with finesse and accuracy. The robotic arms within the patient's body translate the surgeon's movements into precise actions. The console also provides a 3D view of the surgical site through high-definition screens, enhancing visualization and enabling the surgeon to make informed decisions during the procedure [ 3 ].

Vision system: It is a critical component of robotic surgical systems, offering high-definition 3D visualization of the surgical field. This system gives surgeons a magnified, detailed view of the operative site, which is essential for performing delicate maneuvers and precise incisions. The clarity of visual feedback enables surgeons to navigate complex anatomical structures, confidently enhancing surgical precision [ 12 ].

Instruments and Tools

Robotic surgical instruments are specially designed to replicate the human hand's range of motion while filtering out any tremors or unintended movements. These instruments are vital for performing various surgical tasks, including suturing, dissecting, cauterizing, and cutting. They are interchangeable during procedures, allowing for versatility and adaptability to the specific requirements of each surgery. The advanced instrumentation contributes to robotic surgery's overall precision and effectiveness [ 13 ].

Advantages of Robotic Surgery

Precision: Robotic systems excel in precision, enabling surgeons to perform intricate and delicate maneuvers with accuracy that surpasses what the human hand alone can achieve. The robotic arms' stability and precision reduce the risk of errors during surgery, leading to improved patient outcomes and reduced postoperative complications [ 14 ].

Enhanced dexterity: Robotic surgical systems are equipped with robotic arms that can rotate 360 degrees and mimic the natural movements of a surgeon's hand but with significantly reduced tremors. This enhanced dexterity is particularly valuable for working in confined spaces within the body and efficiently performing complex tasks. Surgeons can manipulate tissues and instruments with high control, enhancing their surgical capabilities [ 15 ].

Three-dimensional visualization: Robotic systems provide high-quality 3D visualization of the surgical field, offering depth perception and spatial awareness that surpasses traditional 2D laparoscopy. This enhanced visual feedback greatly benefits surgeons by improving their ability to navigate anatomical structures safely and accurately. It allows for better identification of critical structures and precise instrument placement [ 16 ].

Reduced surgeon fatigue: Robotic surgery minimizes the physical strain on surgeons. Unlike traditional open surgery, which often requires prolonged standing and holding heavy instruments, robotic surgery allows surgeons to operate comfortably from a seated position at the surgical console. This reduction in physical fatigue enables surgeons to maintain peak performance throughout lengthy procedures, ultimately enhancing patient safety and surgical outcomes [ 17 ].

Current utilization of robotic surgery

General Surgery

Cholecystectomy: Robotic-assisted cholecystectomy, the gallbladder removal, is one of the most common general surgical procedures performed robotically. Robotic systems provide surgeons with enhanced precision, which is particularly important when working in the confined space of the abdomen. The robotic instruments reduce the risk of injury to surrounding structures, such as the bile ducts and blood vessels. Patients undergoing robotic cholecystectomy benefit from smaller incisions, reduced postoperative pain, and faster recovery [ 18 ].

Hernia repair: Robotic-assisted hernia repair has become increasingly popular due to its precision and minimally invasive techniques. Robotic systems allow surgeons to perform precise mesh placement for hernia repair, reducing the risk of recurrence. Smaller incisions, less postoperative pain, and faster recovery times make robotic hernia repair an attractive option for patients seeking a quicker return to their daily activities [ 19 ].

Appendectomy: The removal of the appendix, known as an appendectomy, can be accomplished robotically. Robotic appendectomy involves smaller incisions and precise instrumentation, reducing tissue trauma and postoperative pain. Patients benefit from quicker recovery times and a shorter hospital stay than traditional open appendectomy [ 20 ].

Gynecological Surgery

Hysterectomy: Robotic-assisted hysterectomy has gained popularity for treating various gynecological conditions, including fibroids and endometriosis. During a robotic hysterectomy, the uterus is removed with robotic instruments, resulting in smaller incisions and reduced scarring. This minimally invasive approach offers several advantages, including shorter hospital stays, quicker recovery times, and improved cosmetic outcomes. Patients undergoing robotic hysterectomy often experience less postoperative pain and a faster return to normal activities [ 21 ].

Ovarian cystectomy: Removing ovarian cysts can be performed robotically with enhanced precision. Robotic systems allow surgeons to navigate delicate ovarian tissues with dexterity, minimizing the risk of damage and reducing blood loss during the procedure. Patients benefit from smaller incisions, less postoperative discomfort, and faster recovery times. Robotic ovarian cystectomy is particularly valuable for preserving ovarian function in cases where cyst removal is required [ 22 ].

Myomectomy: Surgical removal of uterine fibroids, known as myomectomy, can be performed robotically. This approach allows surgeons to target and remove fibroids while preserving the uterus, making it an option for women who wish to retain their fertility. Robotic myomectomy offers improved precision and control, reducing tissue damage and a faster patient return to normal activities. The minimally invasive procedure also leads to less scarring and postoperative pain [ 23 ].

Urological Surgery

Prostatectomy: Robotic prostatectomy is a widely adopted treatment for prostate cancer. This procedure involves the removal of the prostate gland. Robotic systems give surgeons enhanced precision and dexterity, allowing them to spare nerves critical for urinary continence and sexual function. Smaller incisions and improved visualization contribute to reduced postoperative pain and shorter hospital stays. Patients undergoing robotic prostatectomy experience faster recovery times and improved quality of life compared to traditional open surgery [ 24 ].

Nephrectomy: Partial or complete kidney removal due to tumors, kidney disease, or donation can be performed robotically. Robotic nephrectomy offers the advantage of smaller incisions, which result in less pain, reduced scarring, and a quicker return to normal activities. Patients also benefit from shorter hospital stays and a lower risk of postoperative complications, making robotic nephrectomy a preferred option for many [ 25 ].

Pyeloplasty: Robotic pyeloplasty is a highly effective treatment for ureteropelvic junction (UPJ) obstruction, which causes blockage in the urinary system. Robotic systems assist surgeons in precisely reconstructing the UPJ, ensuring proper urine flow. This minimally invasive approach results in shorter recovery times and high success rates for resolving the obstruction. Patients can expect improved renal function and symptom relief following the procedure [ 26 ].

Cardiac Surgery

Coronary artery bypass grafting (CABG): Robotic-assisted CABG has transformed the landscape of cardiac surgery. This technique allows for the precise revascularization of blocked coronary arteries with smaller incisions than traditional open-heart surgery. Surgeons use robotic systems to access the heart through small ports, reducing trauma to the chest wall. The robotic arms provide a high degree of dexterity and accuracy for suturing and grafting, resulting in improved outcomes, reduced postoperative pain, and faster patient recovery [ 27 ].

Mitral valve repair/replacement: Robotic systems have greatly improved the precision and effectiveness of mitral valve repair or replacement surgeries. Surgeons can perform these intricate procedures with the assistance of robotic arms, which provide enhanced dexterity and control. Robotic-assisted mitral valve surgery is associated with smaller incisions, reduced blood loss, and shorter hospital stays. Patients benefit from improved valve function and minimized chest trauma, resulting in a faster return to normal activities [ 28 ].

Atrial fibrillation ablation: Robotic systems are increasingly used in minimally invasive procedures for treating atrial fibrillation, a common heart rhythm disorder. Surgeons use robotic instruments to access the heart's atria, performing ablation procedures to restore normal rhythm. Robotic-assisted atrial fibrillation ablation offers precise lesion creation and mapping, reducing the risk of complications and the need for repeat procedures. Patients experience shorter recovery times and a lower risk of postoperative complications [ 29 ].

Orthopedic Surgery

Total knee arthroplasty (TKA): Robotic-assisted TKA has revolutionized knee replacement surgery. It enhances the alignment and positioning of knee implants with high precision. Surgeons use robotic systems to create a personalized surgical plan based on the patient's anatomy. During the procedure, the robot assists the surgeon in executing the plan, ensuring accurate implant placement. This precision improves long-term outcomes, reduces implant wear and tear, and enhances patient satisfaction [ 30 ].

Total hip arthroplasty (THA): Robotic systems have also improved the precision and accuracy of hip replacement surgery. THA procedures benefit from robotic technology, which allows for meticulous preoperative planning and intraoperative guidance. The robot assists the surgeon in optimizing implant placement, reducing the risk of complications such as dislocation and leg length discrepancy. Patients undergoing robotic-assisted THA experience improved joint function and a lower likelihood of revision surgeries [ 31 ].

Spinal surgery: Robotic technology is increasingly used in spinal surgery to enhance precision and minimize the invasiveness of procedures. Some spinal surgeries, such as spinal fusion, are performed robotically. Robotic systems assist surgeons in creating detailed maps of the spine and guide the placement of implants and instrumentation. The result is smaller incisions, reduced tissue damage, and greater accuracy in achieving spinal stability. Patients benefit from improved postoperative pain management and faster recovery [ 32 ].

Head and Neck Surgery

Transoral robotic surgery (TORS): Transoral robotic surgery treats head and neck cancers, allowing for the precise removal of tumors while minimizing trauma to surrounding tissues. TORS offers several advantages, including improved access to difficult-to-reach areas, reduced postoperative pain, and quicker recovery times. It is particularly beneficial for patients with oropharyngeal cancers and offers the potential for improved speech and swallowing outcomes [ 33 ].

Thyroidectomy: Robotic-assisted thyroid surgery is performed through small incisions, offering a minimally invasive approach for thyroid gland removal. This approach minimizes scarring and improves cosmetic outcomes for patients. Robotic thyroidectomy is often employed in thyroid nodules, thyroid cancer, and hyperthyroidism, providing surgeons with enhanced visualization and precision during the procedure [ 34 ].

Parathyroidectomy: The removal of overactive parathyroid glands can be performed robotically with high precision. Robotic parathyroidectomy offers advantages such as smaller incisions, reduced postoperative discomfort, and shorter recovery times. The precision of robotic instruments allows surgeons to target the affected glands accurately, improving patient outcomes and reducing the risk of complications associated with hyperparathyroidism [ 34 ].

Clinical outcomes and benefits

Improved Patient Outcomes

Enhanced precision: Robotic systems provide unparalleled precision in surgical procedures. Surgeons can perform intricate tasks with submillimeter accuracy, minimizing tissue damage and optimizing the surgical outcome. The ability to precisely control robotic instruments benefits patients by reducing the risk of complications and postoperative issues [ 3 ].

Reduced blood loss: The precise control offered by robotic instruments can lead to significantly reduced blood loss during surgery. This reduction in blood loss is critical in minimizing the need for blood transfusions and the associated risks, contributing to safer and more successful surgical outcomes [ 35 ].

Smaller incisions: Minimally invasive robotic procedures typically require smaller incisions than open surgery. These smaller incisions result in several patient benefits, including less pain, reduced scarring, and a lower risk of infection. Patients appreciate the cosmetic advantages of smaller incisions and experience less postoperative discomfort [ 33 ].

Shorter hospital stays: Robotic surgery often leads to faster recovery and reduced postoperative complications. Many patients can be discharged from the hospital sooner, enhancing their overall quality of life and reducing healthcare costs associated with prolonged hospitalization [ 36 ].

Lower risk of infection: Minimally invasive robotic procedures carry a lower risk of surgical site infections due to smaller incisions and reduced exposure to external contaminants. Lower infection rates contribute to improved patient safety and satisfaction [ 37 ].

Reduced Complications

Lower infection rates: Robotic surgery's minimally invasive approach involves smaller incisions and reduced handling of tissues, which minimizes the risk of postoperative infections. Smaller incisions result in less exposure of internal tissues to the external environment, reducing the likelihood of contamination. Lower infection rates are particularly significant in complex surgeries where infection can lead to severe complications [ 36 ].

Fewer complications: The precision of robotic instruments and enhanced visualization provided by high-definition 3D imaging contribute to fewer intraoperative and postoperative complications. Surgeons can manipulate tissues with high accuracy and control, reducing the risk of unintended damage or bleeding. Improved visualization allows for meticulous surgical techniques, minimizing the risk of complications during the procedure and improving patient safety [ 38 ].

Reduced postoperative pain: Robotic surgery's smaller incisions and minimized tissue trauma often lead to less postoperative pain than open surgery. Patients experience less discomfort, which reduces the need for pain medication and promotes faster recovery. This enhanced postoperative comfort improves patient experience and satisfaction [ 39 ].

Shorter hospital readmissions: Patients who undergo robotic surgery are less likely to require readmission to the hospital for postoperative complications. The reduced risk of complications and infections, coupled with faster recovery times, means that patients can often return home sooner and with greater confidence in their recovery [ 40 ].

Faster Recovery Times

Quicker return to normal activities: Robotic surgery's minimally invasive approach offers the advantages of reduced pain, smaller incisions, and fewer complications than traditional surgery. As a result, patients can typically resume their daily routines and activities more rapidly. Whether returning to work, caring for their families, or engaging in physical activities, patients experience less disruption. This accelerated return to normalcy improves the quality of life and patient satisfaction [ 28 ].

Shorter hospital stays: Many robotic surgical procedures are performed outpatient or short-stay. Patients can often go home on the same day or within a short period after surgery. This minimizes the disruption to a patient's life and reduces healthcare costs associated with more extended hospitalizations. Shorter hospital stays translate to more efficient use of healthcare resources, freeing up beds and medical staff for other needy patients [ 28 ].

Less postoperative fatigue: Robotic surgery reduces postoperative fatigue and discomfort. Patients report less pain and physical strain after minimally invasive procedures, which enables a faster return to their usual level of energy and mobility. This reduction in postoperative fatigue is particularly significant for elderly or frail patients, as it allows them to recover with less physical and emotional stress [ 28 ].

Cost-Effectiveness

Reduced hospitalization costs: Robotic surgery often leads to shorter hospital stays than traditional open surgery, reducing overall hospitalization costs. Patients who undergo minimally invasive robotic procedures typically experience less pain, reduced risk of infection, and faster recovery times. These factors contribute to shorter postoperative hospitalization, freeing healthcare resources and reducing associated costs. Decreased stay also enhances patient comfort and satisfaction [ 41 ].

Faster recovery means an earlier return to work: The faster recovery associated with robotic surgery benefits patients by allowing them to return to work and normal activities sooner. This reduces financial strain for individuals due to fewer days off work and a quicker return to their productive roles. Additionally, shorter recovery times can decrease the need for temporary disability benefits, reducing indirect costs related to lost productivity [ 41 ].

Lower complication rates: Robotic surgery has been shown to have lower complication rates compared to traditional surgical approaches. Fewer complications mean reduced healthcare costs associated with follow-up surgeries, treatments, and hospital readmissions. Avoiding complications also contributes to improved patient outcomes and quality of life, which can lead to further cost savings over the long term [ 42 ].

Long-term benefits: The long-term benefits of robotic surgery go beyond immediate cost reductions. Improved patient outcomes and lower postoperative complications can result in ongoing cost savings by avoiding expensive healthcare interventions, such as prolonged hospitalizations, additional surgeries, and extensive rehabilitation. These long-term benefits contribute to the overall cost-effectiveness of robotic surgery programs [ 6 ].

Surgeon Experience and Training

Enhanced surgical skills: Robotic systems allow surgeons to enhance their surgical skills and perform complex procedures with greater precision. Robotic instruments' intuitive interfaces and dexterity allow surgeons to refine their techniques and tackle challenging cases more effectively. The high-definition 3D visualization and fine instrument control improve surgical outcomes, ultimately benefiting patients by reducing the risk of complications and postoperative issues. Continuous practice and experience with robotic surgery empower surgeons to provide high-quality, minimally invasive care across various specialties [ 3 ].

Reduced physical strain: Robotic surgery minimizes the physical strain experienced by surgeons during procedures. Unlike traditional surgery, where surgeons often maintain physically demanding positions for extended periods, robotic surgeons operate from a seated position at the console. This ergonomic advantage reduces the risk of musculoskeletal injuries and fatigue, contributing to the long-term well-being of surgical teams. Surgeons can perform intricate procedures more comfortably and precisely, enhancing their overall job satisfaction and longevity [ 43 ].

Structured training programs: To ensure safety and proficiency, comprehensive training programs are readily available for surgeons interested in adopting robotic surgical techniques. These structured programs offer hands-on training, simulation-based exercises, and mentorship opportunities. Surgeons in training can gain the necessary skills and knowledge to operate robotic systems effectively and safely. Training programs also emphasize patient safety and ethical considerations, ensuring that surgeons are well prepared to provide their patients with the highest quality of care. As robotic surgery becomes more widespread, the availability of structured training programs helps build a skilled and competent workforce of robotic surgeons [ 44 ].

Emerging frontiers in robotic surgery

Miniaturization of Robotic Systems

Micro-robotics: Advancements in miniaturization have given rise to micro-robotics, tiny robotic devices designed to perform targeted tasks within the human body. These miniature robots hold significant promise for various applications, including precise drug delivery, tissue repair, and even exploratory surgery in hard-to-reach areas. Micro-robots can navigate through intricate anatomical structures with high precision, enabling minimally invasive interventions that reduce trauma to surrounding tissues. Surgeons can remotely control them to carry out delicate procedures or deliver therapeutic agents directly to specific sites, offering new possibilities for personalized medicine and minimally invasive surgery [ 45 ].

Single-port robotic surgery: Miniaturized robotic systems have paved the way for single-port robotic surgery, a minimally invasive approach in which multiple robotic instruments are inserted through a single incision. This technique reduces the invasiveness of surgery, resulting in smaller scars, reduced postoperative pain, and faster recovery times for patients. Single-port robotic surgery leverages miniaturized robots' compact design and dexterity to perform various procedures, from gynecological and urological surgeries to gastrointestinal interventions. By consolidating multiple instruments into a single entry point, surgeons can provide patients with the benefits of minimally invasive surgery while optimizing cosmetic outcomes and minimizing the risk of complications [ 46 ].

AI and Machine Learning (ML) Integration

Autonomous robotic surgery: AI and ML algorithms are at the forefront of enabling autonomous robotic surgery. These systems can analyze vast amounts of patient data, assist with surgical planning, and sometimes perform certain aspects of surgery with minimal human intervention. Autonomous robotic surgery is a groundbreaking development that holds the potential to enhance the precision and efficiency of procedures. By relying on AI-driven automation, surgeons can benefit from real-time data analysis, assistance in decision-making, and the ability to perform tasks with submillimeter precision. While full autonomy is a long-term goal, current implementations involve a collaborative approach, where robots and surgeons work together to optimize surgical outcomes [ 47 ].

Predictive analytics: AI algorithms are increasingly utilized to predict surgical outcomes and identify potential complications. These algorithms can provide surgeons valuable insights during procedures by analyzing patient data, including medical history, imaging, and real-time surgical data. Predictive analytics enable surgeons to anticipate challenges and make real-time adjustments, ultimately improving patient safety and surgical outcomes. Surgeons can receive alerts or recommendations from AI systems that highlight critical factors to consider during surgery, such as the risk of bleeding, tissue damage, or postoperative complications. This proactive approach enhances the surgeon's decision-making process and contributes to more successful procedures [ 48 ].

Telesurgery and Remote Surgery

Telesurgery: Telesurgery, also known as remote surgery, leverages robotic systems and high-speed internet connections to enable surgeons to perform procedures on patients in different locations. This transformative technology brings specialized surgical expertise to underserved or remote areas, addressing healthcare disparities and expanding access to advanced surgical care. Telesurgery is particularly valuable in responding to emergencies, as it allows remote surgeons to provide critical surgical interventions quickly and efficiently. Robotic systems' real-time control and precision ensure that patients receive high-quality care, even when distance separates them from the surgical team [ 49 ].

Training and education: Telesurgery is crucial in surgical training and education. It allows experienced surgeons to mentor and guide less-experienced colleagues in real time, fostering skill development and knowledge transfer. Surgeons in training can benefit from remote guidance during procedures, receiving valuable feedback and guidance from mentors elsewhere. This approach enhances the proficiency of surgical teams, particularly in regions where access to comprehensive training programs may be limited. Additionally, telesurgical platforms facilitate collaborative learning and peer-to-peer knowledge sharing among surgeons, promoting continuous improvement in surgical techniques and patient care [ 50 ].

Nanorobots in Surgery

Nanomedicine: Nanorobots, operating at the nanoscale, are at the forefront of research in nanomedicine. These minuscule machines have the potential to revolutionize health care by enabling targeted drug delivery, early cancer detection, and cellular-level tissue repair. Nanorobots can be engineered to carry payloads of therapeutic agents directly to diseased or damaged cells, sparing healthy tissue. This precision in drug delivery reduces side effects and enhances the effectiveness of treatments. Additionally, nanorobots with sensors can detect disease-associated biomarkers, enabling early diagnosis and intervention. The intersection of nanorobots and surgery promises a future where diseases can be treated at their earliest stages, with minimal invasiveness and maximal efficacy [ 51 ].

Intravascular nanorobots: Intravascular nanorobots represent a groundbreaking application of nanotechnology in surgery. These microscopic robots have the potential to navigate the bloodstream with remarkable precision. They could be employed to remove blockages in blood vessels, repair damaged vascular tissues, or deliver medications directly to target sites. Intravascular nanorobots can access locations challenging for traditional surgical tools to reach, offering a minimally invasive approach to treating cardiovascular and cerebrovascular diseases. Their ability to perform intricate tasks within the circulatory system can improve patient outcomes by reducing the risks associated with conventional surgical interventions [ 52 ].

Haptic Feedback and Sensory Augmentation

Haptic feedback: Advances in haptic technology have introduced the capability of providing surgeons with tactile feedback during robotic procedures. This haptic feedback enables surgeons to "feel" the resistance and texture of tissues as they manipulate robotic instruments. By simulating the sensation of touch, surgeons gain a more intuitive understanding of the surgical environment, enhancing their control and precision. This sensory input is invaluable in tasks that require delicate manipulation, such as suturing, tissue dissection, and organ resection. Haptic feedback contributes to safer and more accurate surgeries and reduces the learning curve for surgeons transitioning to robotic techniques [ 53 ].

Sensory augmentation: Emerging technologies are pushing the boundaries of sensory augmentation in surgery. These innovations aim to provide surgeons with enhanced visual, auditory, or tactile information during surgery. For instance, augmented reality (AR) and virtual reality (VR) systems can overlay 3D visualizations, real-time data, or navigation guides onto a surgeon's field of view. This augmented sensory input can help surgeons more clearly visualize complex anatomical structures, critical landmarks, and instrument positioning. Additionally, sensory augmentation may include auditory cues or feedback that provide real-time information about tissue characteristics or instrument status. These advancements empower surgeons with a comprehensive understanding of the surgical site, leading to more informed decision-making and precise execution of procedures [ 54 ].

Personalized Surgery and Genomic Medicine

Genomic surgery: Integrating a patient's genomic data into surgical planning represents a groundbreaking advancement in personalized surgery. Genomic information can provide valuable insights into an individual's genetic makeup and susceptibility to specific diseases. Surgeons can leverage this data to tailor surgical procedures to the patient's unique genetic profile. For example, genetic markers may indicate a predisposition to certain complications or suggest the most effective treatment strategies. This personalized approach enables surgeons to optimize surgical interventions, improve outcomes, and minimize risks. By aligning surgical techniques with a patient's genetic characteristics, healthcare providers can offer more effective treatments and less likely to result in adverse events [ 55 ].

Three-dimensional printing: 3D printing technology has become an invaluable tool in personalized surgery. It allows for the creation of patient-specific surgical models and instruments, enabling surgeons to practice and plan procedures with unprecedented accuracy. These 3D-printed models replicate a patient's unique anatomy, giving surgeons a tangible and precise representation of the surgical site. Surgeons can rehearse complex procedures, assess potential challenges, and strategize their approach before surgery. This preoperative planning enhances surgical precision and reduces the risk of complications. Moreover, 3D printing enables the fabrication of customized surgical instruments tailored to the patient's anatomy, further enhancing the safety and efficacy of surgical interventions [ 56 ].

Regulatory and Ethical Considerations

Regulatory frameworks: As robotic surgery advances, regulatory bodies are actively developing guidelines and standards to ensure patient safety and the effectiveness of these technologies. Regulatory frameworks aim to establish precise requirements for robotic surgical systems' design, manufacturing, and operation. They may encompass equipment certification, surgeon training, maintenance protocols, and patient consent processes. These regulations are essential to mitigate risks and provide a framework for accountability, helping to ensure that robotic surgery adheres to the highest standards of safety and quality [ 57 ].

Ethical challenges: Integrating AI and automation in surgery raises many ethical challenges that warrant careful consideration. These challenges include liability in autonomous surgical procedures, privacy concerns regarding patient data and informed consent, and the role of human oversight in robotic surgery. Ethical guidelines must address issues such as ensuring transparency in AI-driven decision-making, safeguarding patient privacy, and defining the boundaries of autonomous surgical actions. Striking the right balance between the advantages of automation and the ethical principles that underpin medical practice is crucial to fostering public trust and ensuring the responsible use of robotic surgery [ 58 ].

Challenges and limitations

Cost and Accessibility

High initial costs: Robotic surgical systems' acquisition and maintenance costs can be substantial. Purchasing equipment and ongoing maintenance, training, and software updates require a significant financial investment. This financial barrier can be incredibly challenging for smaller hospitals and healthcare facilities with limited budgets. To address this, healthcare institutions may explore options such as group purchasing agreements, financing arrangements, or partnerships with more extensive facilities to make robotic surgery more accessible [ 59 ].

Economic disparities: The high cost of robotic surgery can exacerbate healthcare disparities, limiting access to advanced surgical options for patients in underserved or economically disadvantaged regions. Patients in such areas may need help receiving care from facilities that offer robotic surgery, leading to unequal access to the benefits of this technology. Healthcare providers and policymakers must work together to address these disparities by implementing strategies that ensure equitable access to robotic surgery, such as telemedicine programs or mobile surgical units [ 60 ].

Financial sustainability: Healthcare institutions must carefully evaluate the financial sustainability of robotic surgery programs. While robotic systems offer numerous benefits, including shorter hospital stays and reduced complications, the financial considerations are complex. Hospitals must balance the upfront costs with the potential long-term benefits and patient demand for robotic procedures. A thorough cost-benefit analysis should inform decisions about adopting and expanding robotic surgery programs, considering patient volume, reimbursement rates, and overall financial viability [ 61 ].

Learning Curve for Surgeons

Training requirements: Becoming proficient in robotic surgery demands specialized training and a significant commitment of time and effort. Surgeons must acquire the skills to operate robotic systems effectively, navigate the surgical console, and precisely manipulate robotic instruments. Training programs typically include hands-on simulations, supervised training on live patients, and proficiency assessments. These programs ensure surgeons are well prepared to safely handle robotic surgery's unique features and challenges. Continuous education and ongoing training are crucial to keep surgeons up-to-date with evolving technology and techniques [ 62 ].

Transition from conventional techniques: Experienced surgeons transitioning to robotic surgery may encounter distinct challenges as they adapt their skills and techniques to this technology. The transition from traditional open or laparoscopic surgery to robotic surgery involves a shift in surgical approach and the need to master a new set of tools. During this learning phase, patient outcomes may be affected as surgeons familiarize themselves with the nuances of robotic procedures. Healthcare institutions must provide support and resources to facilitate this transition, including mentorship, proctoring, and opportunities for skill refinement. Patient safety must be prioritized during this learning curve, and patients should be informed about the surgeon's experience with robotic surgery [ 63 ].

Technical Issues and Safety Concerns

Technical failures: Like any technology, robotic surgical systems can experience technical failures, from hardware malfunctions to software glitches. These failures may lead to interruptions or complications during surgery. Healthcare facilities must implement rigorous maintenance protocols and redundancy measures to mitigate these risks. Regular equipment inspections, software updates, and backup systems are essential to minimize the impact of technical failures on patient safety [ 64 ].

Intraoperative challenges: Surgeons operating with robotic systems must be prepared to handle unexpected intraoperative challenges. These may include robotic arm malfunctions, communication issues between the surgeon and the console, or unforeseen obstacles during the procedure. Surgeons and their surgical teams must receive training in troubleshooting and have contingency plans to ensure patient safety and the successful completion of the surgery [ 65 ].

Infection risk: Robotic systems introduce new infection risks if not adequately sterilized between procedures. Proper cleaning and sterilization protocols must be established and strictly adhered to, following the manufacturer's guidelines and best practices. Maintaining a sterile surgical environment is essential to prevent surgical site infections and other complications associated with microbial contamination [ 66 ].

Lack of haptic feedback: While haptic feedback improves in robotic surgical systems, they still lack the full range of tactile sensations available in traditional surgery. This limitation can affect a surgeon's ability to assess tissue properties, such as texture, tension, and elasticity. Surgeons must rely on visual and auditory cues and their experience and training to compensate for the absence of complete haptic feedback. Research and development efforts continue to work toward enhancing haptic feedback further to improve the safety and effectiveness of robotic surgery [ 67 ].

Ethical and Legal Challenges

Informed consent: Informed consent is a fundamental ethical principle in health care. Patients must comprehensively understand the risks and benefits of robotic surgery, including potential complications from using this technology. Additionally, patients should be informed about the surgeon's level of experience and training with robotic systems. It is incumbent upon healthcare providers to ensure that patients are fully informed, allowing them to make autonomous decisions about their treatment options. Adequate patient education materials and a straightforward, transparent consent process are essential to meeting this ethical obligation [ 68 ].

Liability issues: Introducing AI and autonomous features in robotic surgery raises complex questions regarding liability in case of errors or malfunctions. Determining responsibility when human surgeons collaborate with AI-driven robotic systems presents legal challenges. Healthcare institutions and regulatory bodies must work together to establish clear guidelines and frameworks for defining liability, particularly in cases where autonomous AI plays a significant role in surgical decision-making and execution. Addressing these legal complexities is essential to safeguarding both patient rights and the interests of healthcare professionals [ 69 ].

Privacy and data security: The collection and transmission of patient data during telesurgery or remote surgery raise significant concerns about privacy and data security. Particularly in cases involving sensitive medical information, maintaining the confidentiality and security of patient data is paramount. Ethical standards and legal regulations must be established and rigorously followed to safeguard patient data throughout the surgical process. This includes secure data transmission, storage, access controls, and comprehensive policies for data breach prevention and reporting [ 70 ].

Patient Acceptance

Limited awareness: A significant barrier to patient acceptance of robotic surgery is the limited awareness of this advanced technology. Many patients may need to be fully informed about robotic surgery or its advantages, leading to a lack of confidence in choosing this option when appropriate. To address this, healthcare providers must prioritize patient education and awareness campaigns. Patients can make more informed decisions about their healthcare by providing comprehensive information about robotic surgery, its benefits, and its suitability for specific conditions [ 71 ].

Perceived risk: Patients may have concerns about the safety and effectiveness of robotic surgery, which can deter them from considering this approach. Healthcare providers must communicate openly and transparently with patients to address their concerns and misconceptions. Sharing success stories and clinical outcomes data and emphasizing surgical teams' rigorous training and expertise using robotic systems can help alleviate perceived risks and build patient confidence [ 72 ].

Access to information: Access to accurate and unbiased information about robotic surgery can vary among patients, leading to disparities in knowledge and decision-making. Healthcare institutions should prioritize providing accessible and patient-friendly resources that explain robotic surgery clearly and understandably. Additionally, ensuring that patients can access reputable online and offline sources can empower them to make well-informed choices about their healthcare options [ 17 ].

Future outlook and implications

The Role of Robotic Surgery in Health Care

Mainstream integration: Robotic surgery is on the cusp of widespread integration into mainstream healthcare. It will offer an expanded array of minimally invasive options across various medical specialties. Robotic systems will cater to increasing surgical procedures as they become more versatile and adaptable. Patients can benefit from reduced trauma, quicker recoveries, and smaller incisions. Surgeons can access precise tools that enhance their capabilities, improving surgical outcomes [ 73 ].

Patient-centered care: The patient experience is poised for a transformation with the incorporation of robotic surgery into healthcare. Personalized treatment plans will take center stage, with genomic data and patient-specific information guiding surgical approaches. Surgeons can tailor procedures to individual patient profiles, optimizing outcomes and minimizing risks. This patient-centric model ensures that health care is not just about treating diseases but also about delivering care uniquely attuned to each patient's needs and genetic makeup [ 74 ].

Global healthcare access: Robotic surgery can potentially bridge healthcare gaps globally. Telesurgery and remote surgery are becoming increasingly feasible, enabling patients in remote and underserved areas to access specialized surgical expertise. This technology can facilitate real-time consultations and surgeries conducted by experts far from the patient. By reducing geographical barriers and enhancing access to surgical care, robotic surgery can reduce healthcare disparities and ensure that patients worldwide receive the best possible treatment, regardless of location [ 49 ].

Potential Impact on Healthcare Delivery

Efficiency and cost-efficiency: Further elaboration is required on the impact of robotic surgery on the overall surgery cost. While the current text highlights the potential efficiency gains through advancements in robotic technology and AI integration, it is important to delve deeper into how these improvements translate into specific cost reductions. Specifically, more detailed insights into how the precision and automation of robotic systems contribute to shorter surgery times, reduced blood loss, and faster recovery periods must be provided. The connection between these factors and the subsequent impact on hospital stays, postoperative care expenses, and the need for additional interventions must be clearly articulated. Additionally, it must be considered to discuss how hospitals and healthcare systems can optimize resources, ultimately leading to a potential reduction in the financial burden on both institutions and patients [ 75 ].

Outpatient and same-day surgery: As robotic systems become more sophisticated and minimally invasive, surgical procedures may transition to outpatient or same-day surgery settings. Patients can undergo surgeries and return home on the same day, eliminating the need for prolonged hospital stays. This shift can alleviate the demand for hospital resources, freeing up beds for more critical cases and enhancing overall healthcare system capacity. Additionally, outpatient and same-day surgery options offer patients greater convenience and comfort during their recovery, leading to a more patient-centered approach to healthcare delivery [ 41 ].

Preventive and early intervention: The precision and capabilities of robotic surgery extend beyond traditional treatment modalities. Robotic systems can facilitate preventive and early intervention strategies. For instance, the high-resolution imaging and enhanced dexterity of robotic instruments can enable the earlier detection and removal of precancerous or abnormal tissue. This proactive approach to health care can prevent disease progression, reduce the need for aggressive treatments, and improve long-term patient outcomes. By shifting the focus from late-stage interventions to early, less-invasive procedures, robotic surgery can contribute to a more holistic and preventive approach to health care [ 76 ].

Collaboration Between Robots and Surgeons

Integrating robotic technology in surgery has undoubtedly advanced the field, offering precision and efficiency that can enhance surgical outcomes. However, it is unlikely that surgeons will solely rely on robots in the foreseeable future. Surgeons possess a unique combination of adaptability, creativity, and intricate manual skills that current robotic systems may not fully replicate. Surgical procedures often demand on-the-spot decision-making and adjustments based on the patient's specific condition, aspects where human expertise excels. While robots provide stability and precision, their lack of sensory feedback, haptic perception, and the complexity of certain procedures present limitations. Moreover, the high initial costs, ongoing maintenance expenses, and the need for specialized training contribute to the challenges associated with widespread adoption. There is also a concern about overreliance on robotic assistance, potentially leading to an erosion of surgical skills. Striking a balance and ensuring that surgeons continue to develop and maintain their manual skills is crucial. Moreover, addressing patient and public perceptions about robotic surgery is essential for widespread acceptance. In essence, the collaboration between surgeons and robotic systems should be viewed as a synergistic relationship, with surgeons at the forefront, leveraging technology to augment their capabilities rather than replacing them entirely.

Human-robot synergy: The future of surgical collaboration will be marked by a dynamic synergy between human surgeons and robotic systems. Robots will assume routine and repetitive tasks, freeing surgeons to concentrate on the complex decision-making and critical elements of surgery that demand their expertise. This collaboration enhances the precision and efficiency of procedures while reducing the physical strain on surgeons. Robots will act as reliable extensions of the surgical team, amplifying human capabilities and ensuring consistent, high-quality outcomes [ 17 ].

Robot-assisted training: Robotic systems are set to play an increasingly pivotal role in surgeon training and education. These systems will provide aspiring surgeons with immersive and realistic simulations, replicating various surgical scenarios. Surgeon trainees will gain valuable hands-on experience and receive guidance from robotic systems, helping them refine their skills and build confidence. Additionally, experienced surgeons can use robotic platforms to hone their abilities, explore new techniques, and stay updated with the latest advancements in surgical practice. Ultimately, this training will contribute to a more skilled and proficient surgical workforce [ 77 ].

Remote assistance: The advent of remote surgical assistance will revolutionize healthcare delivery. Surgeons can access real-time support and guidance from robotic systems, experts, and AI algorithms, regardless of geographic location. This remote assistance will enable rapid consultations and collaborations between surgeons, fostering knowledge exchange and enhancing decision-making during complex procedures. Surgeons in remote or underserved areas can seek expert guidance, reducing disparities in access to specialized surgical expertise. Moreover, remote assistance can facilitate telesurgery, allowing skilled surgeons to perform procedures on patients far from their physical location and bringing expertise to regions with limited access to surgical care [ 78 ].

Research and Development Directions

AI and ML: As robotic surgery advances, so does the integration of AI and ML. Further development in AI and ML algorithms will usher in an era of autonomous surgical procedures. These algorithms will be designed to analyze patient data in real time, offering precise recommendations to surgeons during surgery. For instance, AI-driven robotic systems may assist in identifying critical structures, optimizing incision locations, and adapting to unforeseen complications seamlessly. Predictive analytics will play a pivotal role, allowing for the anticipation of patient-specific responses and complications, leading to a higher level of personalized care and optimized surgical outcomes [ 47 ].

Nanorobotics: Nanorobotics, operating at the cellular and molecular levels, is an exciting frontier in surgical research and development. Continued exploration of nanorobots holds the potential to revolutionize disease diagnosis and management. These miniature robotic agents could be designed to navigate the human body, targeting and treating diseases at their source with unparalleled precision. For example, nanorobots might deliver medications directly to cancer cells, perform delicate repairs at the cellular level, or remove plaque from arteries, all while minimizing collateral damage to healthy tissues. Research in nanorobotics promises to open new frontiers in the early detection and treatment of diseases [ 79 ].

Biocompatible materials: The development of biocompatible materials is indispensable for the next generation of robotic surgical systems. Advancements in materials science are essential to ensure that robotic systems can interact with the human body safely and efficiently. Biocompatible materials will be crucial for constructing robotic components, such as surgical instruments and implants, seamlessly integrating with human tissues. These materials should not trigger immune responses, be resistant to degradation within the body, and maintain their structural integrity over time. Research in biocompatible materials will contribute to creating surgical robots capable of achieving optimal surgical outcomes while minimizing the risk of adverse reactions and complications [ 80 ].

Ethical and legal frameworks: Investigating the ownership of databases within the realm of big data raises crucial ethical and legal inquiries. Determining who possesses the ownership rights to the databases and the ethical and legal aspects related to the sharing and utilization of such data are vital considerations. From an ethical standpoint, issues such as informed consent, transparency in decision-making, and the allocation of liability for errors or malfunctions must be thoroughly examined. Additionally, establishing clear, comprehensive, and adaptable ethical and legal frameworks is imperative. These frameworks should not only address the current challenges associated with robotic surgery, AI, and data privacy but also anticipate and accommodate future developments. In doing so, we can ensure patient safety, safeguard patient rights, and delineate the roles and responsibilities of both human surgeons and autonomous robotic systems. This ongoing research and development effort is essential to responsibly and ethically navigate the evolving landscape of robotic surgery [ 81 ].

Conclusions

In conclusion, robotic surgery is a testament to human innovation and the relentless pursuit of excellence in health care. This comprehensive overview has illuminated the field's evolution from its historical roots to its current prominence, underscoring its vital role in modern medicine. Robotic surgery has already profoundly impacted patient care with its precision, reduced complications, and faster recovery times. As we peer into the future, it becomes evident that this transformative field will continue to shape the healthcare landscape, offering the promise of more accessible, efficient, and personalized surgical interventions. While challenges persist, such as cost considerations and ethical complexities, they are eclipsed by the boundless potential for improving patients' lives worldwide. Robotic surgery's journey is far from over. As it advances, it reaffirms our commitment to advancing the frontiers of medical science and providing the highest standards of care to those in need.

The authors have declared that no competing interests exist.

Author Contributions

Concept and design:   Kavyanjali Reddy, Mihir Patil, Lucky Srivani Reddy, Dheeraj Surya, Pankaj Gharde

Acquisition, analysis, or interpretation of data:   Kavyanjali Reddy, Mihir Patil, Lucky Srivani Reddy, Dheeraj Surya, Pankaj Gharde, Harshal Tayade

Drafting of the manuscript:   Kavyanjali Reddy, Lucky Srivani Reddy, Dheeraj Surya

Critical review of the manuscript for important intellectual content:   Kavyanjali Reddy, Mihir Patil, Lucky Srivani Reddy, Dheeraj Surya, Pankaj Gharde, Harshal Tayade

Supervision:   Harshal Tayade

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Article Contents

Cardiothoracic surgery, general surgery, head and neck surgery, orthopaedic surgery, urology and gynaecology, conflict of interest statement.

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Robotic surgery: an evolution in practice

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Elizabeth Z Goh, Tariq Ali, Robotic surgery: an evolution in practice, Journal of Surgical Protocols and Research Methodologies , Volume 2022, Issue 1, January 2022, snac003, https://doi.org/10.1093/jsprm/snac003

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Robotic surgery is a progression on the minimally invasive spectrum and represents an evolution in practice across numerous disciplines.

From its origins in the late 1980s, pioneering technologies like the ROBODOC for hip replacements and the PROBOT for urological procedures were early iterations of the idea that mechanical augmentations could at the very least be useful adjuncts in the complex task that is surgery [ 1 ]. In the 1990s, researchers from the United States (US) National Aeronautics and Space Administration and Stanford Research Institute investigated the potential of robotics for telepresence surgery [ 1 ]. Subsequent US Army funding attempted to devise a system to remotely operate on wounded soldiers via robotic equipment, in hopes of decreasing battlefield mortality [ 1 ]. Commercial development introduced Automated Endoscopic System for Optimal Positioning (AESOP) (Computer Motion, CA), a voice-controlled robotic arm with an endoscopic camera, to the civilian surgical community [ 1 ]. This was superseded in the 2000s by two comprehensive master–slave platforms: the da Vinci system (Intuitive Surgical, CA), an eponymous nod to Leonardo da Vinci’s fifteenth-century ‘mechanical knight’ automaton [ 2 ], and the Zeus system (Computer Motion, CA), which was designed for cardiac surgery [ 1 ]. A company merger established the former as today’s main platform [ 1 ].

The da Vinci system consists of a console from which the surgeon remotely controls arms connected to a robotic cart beside the patient [ 3 ]. A dual-camera endoscope mounted on one arm transmits images of the surgical field to the console, providing the surgeon with a magnified three-dimensional (3D) view [ 3 ]. In response, the surgeon manipulates instruments attached to the other arms via the console [ 3 ]. The assistant is positioned beside the patient to suction and retract at the surgical field [ 3 ].

Robotic surgery offers advantages over conventional endoscopic surgery in visualization, dexterity and ergonomics, while maintaining the peri-operative benefits of minimally invasive surgery [ 1 ]. The dual-camera system offers 3D views with depth perception, unlike conventional endoscopic views [ 1 ]. Precision features include articulated ‘EndoWrist’ instruments with increased degrees of freedom, removal of the fulcrum effect and motion scaling with tremor filtration [ 1 , 3 ]. Accordingly, objective advantages over laparoscopic techniques in terms of dexterity and muscle fatigue have been demonstrated [ 4 ]. The remote console also allows an ergonomic operating position while optimizing visualization and manoeuvrability [ 1 ]. Recent da Vinci iterations have included a reconfigured robotic arm design to improve access; faster docking to reduce operative time; fluorescence-detection to identify structures and lesions of interest; robotic staplers to overcome difficulties in endoscopic stapler positioning by the assistant and a dual console for training [ 5 , 6 ].

Feasibility, efficacy and cost considerations exist. Access concerns may be ameliorated with a pre-operative screening endoscopy, whereas operative time reduces with experience [ 3 ]. Ongoing technological advances and global uptake of robotic surgery are expected to improve efficacy through optimization of case selection and equipment guided by growing longitudinal data [ 3 ]. Purchase and maintenance costs are significant, but will be offset by high volume use as well as savings from reduced length of stay and improved clinical outcomes [ 3 ].

The benefits of 3D vision and enhanced manoeuvrability provided by robotic surgery are crucial in the mediastinum, which contains many vital structures. Myriad applications exist for cardiac surgery, including cardiac revascularization and mitral valve repair, which were some of the earliest robotic surgeries performed [ 7 ]. Robotic thymectomy for thymomas is aided by fluorescence-guided detection of the tumour and adjacent structures [ 5 ]. Robotic lobectomy for lung cancer is also gaining traction, with Yang et al. ’s 10-year cohort study reporting comparable oncologic and peri-operative outcomes to video-assisted and open approaches [ 8 ].

Robotic surgery is feasible for numerous general surgical procedures, pending cost and operative time considerations, which will improve with technological advances. It has been used for rectal cancer resection, with the 2017 ROLARR trial finding comparable open conversion rates with laparoscopic techniques [ 9 ], and Lee et al. ’s large cohort study finding comparable resection quality with transanal techniques [ 10 ]. Robotic surgery is also a safe and effective clinical alternative for common operations such as gastrectomy [ 11 ], Roux-en-Y gastric bypass [ 12 ] and thyroidectomy [ 13 ]; as well as rare procedures such as median arcuate ligament (MAL) release in MAL syndrome [ 14 ]. Recent da Vinci iterations incorporate a more flexible robotic arm configuration to simplify set-up and facilitate four-quadrant access for complex procedures, and specific single-site surgery instruments with similar peri-operative benefits to single-port laparoscopic surgery [ 6 ].

The head and neck area is difficult to access due to its complex anatomy and confined space. Transoral robotic surgery (TORS) is an emerging option for oropharyngeal carcinoma, as it enables minimally invasive access to the oropharynx without large and mutilating open procedures such as a mandibulotomy and/or pharyngotomy, which cause significant functional and aesthetic deficits [ 15 ]. It also offers similar oncologic and functional outcomes to radiotherapy, pending further comparisons [ 16 , 17 ]. In addition, TORS is being increasingly used for cancers of unknown origin. Systematic reviews by Farooq et al. [ 18 ] and Fu et al. [ 19 ] found that tongue base mucosectomies and lingual tonsillectomies performed with TORS and transoral laser microsurgery (TLM) identified the primary tumour in over 70% of cases with negative conventional diagnostic findings. Other indications for TORS include laryngeal tumours [ 20 ] and parapharyngeal space tumours [ 21 ]; salvage surgery [ 22 ]; free flap reconstruction [ 23 ] and sleep apnoea surgery [ 24 ].

Various robotic systems for orthopaedic procedures exist. Haptic systems, which provide intra-operative feedback based on pre-operative data for accurate resection and reconstruction, are commonly used [ 25 ]. A common application is robotic-arm-assisted total knee arthroplasty, which has been found to result in decreased iatrogenic trauma to periarticular soft tissue and bone, increased accuracy of component positioning and improved peri-operative outcomes compared to conventional jig-based techniques [ 26 , 27 ]. Cost-effectiveness analysis of robotic arthroplasty is also in progress via the Robotic Arthroplasty: a Clinical and cost Effectiveness Randomised controlled (RACER) trial [ 28 ]. Still under investigation for clinical use are passive systems, such as the da Vinci platform for hip and shoulder arthroscopy, and active systems, which can independently perform procedures without surgeon input [ 29 ].

Robotic surgery is particularly suited for surgical access within the anatomically restrained pelvic space. Robotic-assisted radical prostatectomy is one of the most common robotic procedures. It is a widely-accepted management option for prostate cancer, with Tewari et al. ’s landmark meta-analysis reporting comparable oncologic and peri-operative outcomes to laparoscopic and open techniques [ 30 ]. Robotic partial nephrectomy is an emerging indication, with Bravi et al. ’s prospective multicentre cohort study reporting better peri-operative outcomes than laparoscopic and open approaches for anatomically low-risk renal tumours [ 31 ]. Robotic surgery provides improved outcomes for complex benign hysterectomy, where superior post-operative quality-of-life may offset the increased operating time, and endometrial cancer staging, where obesity and other comorbidities are common in the population [ 32 ]. There is emerging evidence for its use in cervical and ovarian cancer [ 33 ], myomectomy and sacrocolpopexy [ 32 ].

Robotic surgery is an emerging modality across numerous surgical specialties. It offers advantages over conventional endoscopic surgery in visualization, dexterity and ergonomics, while maintaining the benefits of minimally invasive surgery. Feasibility, efficacy and cost concerns may be ameliorated with technological advances and increased uptake. Robust longitudinal comparisons with established treatment modalities are imperative to support this evolution in practice.

None declared.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

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• Introduction
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Data are from the Michigan Surgical Quality Collaborative from January 1, 2012, through June 30, 2018. These data reflect practices at all hospitals included in the study.

Proportional use of robotic, laparoscopic, and open approaches for general surgical procedures are shown in the 4 years before and after hospitals began performing robotic general surgery. From 2012 to 2018, 23 of 73 hospitals (31.5%) in the Michigan Surgical Quality Collaborative started performing robotic general surgery. These data are restricted to those hospitals.

eTable 1. Trends in the Use of Open Surgery for Specific Procedures, 2012-2018

eTable 2. Trends in the Use of Laparoscopic Surgery for Specific Procedures, 2012-2018

eFigure. Proportion of Hospitals and Surgeons Performing Any Robotic General Surgery in Michigan, 2012-2018

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Sheetz KH , Claflin J , Dimick JB. Trends in the Adoption of Robotic Surgery for Common Surgical Procedures. JAMA Netw Open. 2020;3(1):e1918911. doi:10.1001/jamanetworkopen.2019.18911

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Trends in the Adoption of Robotic Surgery for Common Surgical Procedures

• 1 Department of Surgery, University of Michigan, Ann Arbor
• 2 Center for Healthcare Outcomes and Policy, University of Michigan School of Medicine, Ann Arbor
• 3 currently a medical student at University of Michigan School of Medicine, Ann Arbor

Question   Given concerns that robotic surgery is increasing for common surgical procedures with limited evidence and unclear clinical benefit, how is the use of robotic surgery changing over time?

Findings   In this cohort study of 169 404 patients in 73 hospitals, the use of robotic surgery for all general surgery procedures increased from 1.8% to 15.1% from 2012 to 2018. Hospitals that launched robotic surgery programs had a broad and immediate increase in the use of robotic surgery, which was associated with a decrease in traditional laparoscopic minimally invasive surgery.

Meaning   These findings highlight a need to continually monitor the adoption of robotic surgery to ensure that enthusiasm for new technology does not outpace the evidence needed to use it in the most effective clinical contexts.

Importance   Increasing use of robotic surgery for common surgical procedures with limited evidence and unclear clinical benefit is raising concern. Analyses of population-based trends in practice and how hospitals’ acquisition of robotic surgical technologies is associated with their use are limited.

Objective   To characterize trends in the use of robotic surgery for common surgical procedures.

Design, Setting, and Participants   This cohort study used clinical registry data from Michigan from January 1, 2012, through June 30, 2018. Trends were characterized in the use of robotic surgery for common procedures for which traditional laparoscopic minimally invasive surgery was already considered a safe and effective approach for most surgeons when clinically feasible. A multigroup interrupted time series analysis was performed to determine how procedural approaches (open, laparoscopic, and robotic) change after hospitals launch a robotic surgery program. Data were analyzed from March 1 through April 19, 2019.

Exposures   Initiation of robotic surgery.

Main Outcomes and Measures   Procedure approach (ie, robotic, open, or laparoscopic).

Results   The study cohort included 169 404 patients (mean [SD] age, 55.4 [16.9] years; 90 595 women [53.5%]) at 73 hospitals. The use of robotic surgery increased from 1.8% in 2012 to 15.1% in 2018 (8.4-fold increase; slope, 2.1% per year; 95% CI, 1.9%-2.3%). For certain procedures, the magnitude of the increase was greater; for example, for inguinal hernia repair, the use of robotic surgery increased from 0.7% to 28.8% (41.1-fold change; slope, 5.4% per year; 95% CI, 5.1%-5.7%). The use of robotic surgery increased 8.8% in the first 4 years after hospitals began performing robotic surgery (2.8% per year; 95% CI, 2.7%-2.9%). This trend was associated with a decrease in laparoscopic surgery from 53.2% to 51.3% (difference, −1.9%; 95% CI, −2.2% to −1.6%). Before adopting robotic surgery, hospitals’ use of laparoscopic surgery increased 1.3% per year. After adopting robotic surgery, the use of laparoscopic surgery declined 0.3% (difference in trends, −1.6%; 95% CI, −1.7% to −1.5%).

Conclusions and Relevance   These results suggest that robotic surgery has continued to diffuse across a broad range of common surgical procedures. Hospitals that launched robotic surgery programs had a broad and immediate increase in the use of robotic surgery, which was associated with a decrease in traditional laparoscopic minimally invasive surgery.

Robotic surgery continues to diffuse across an increasingly broad range of surgical procedures. However, concerns have been raised that robotic surgery is more costly 1 , 2 and may be no more effective 3 , 4 than other established operative approaches, such as traditional laparoscopic minimally invasive and open surgery. With respect to costs, for example, robotic surgery has been associated with episode costs as much as 25% higher compared with laparoscopic surgery. There are also concerns about the rapid growth of robotic surgery in areas with limited evidence to support its use and little theoretical benefit or clinical rationale (eg, inguinal hernia repair). The US Food and Drug Administration (FDA) recently issued a warning against the use of robotic surgery for the treatment of breast and cervical cancers. 5 In their communication, they expressed concerns about the lack of epidemiologic data characterizing the use of robotic surgery in real-world practice settings. Current estimates are limited to single-center studies, 6 - 8 device manufacturers’ financial statements, 9 and claims data, which may be inaccurate owing to unreliable coding. 10 , 11 We used population-based data from a manually abstracted statewide clinical registry to characterize contemporary trends in the adoption of robotic surgery across a range of general surgical procedures, which now represent the largest market for the technology in the United States.

This cohort study used data from the Michigan Surgical Quality Collaborative (MSQC), an Agency for Healthcare Research and Quality–recognized patient safety organization. The MSQC represents a voluntary partnership between 73 Michigan hospitals and Blue Cross/Blue Shield of Michigan that focuses on clinical quality improvement for surgical care. Hospitals participating in the MSQC perform more than 90% of all surgical procedures in Michigan. The MSQC maintains a clinical registry using a standardized data collection platform, validated case-sampling methods, and trained nurse data abstractors at each participating site. Data accuracy is maintained through rigorous training, internal data audits, and annual site visits by MSQC program staff. This data source allowed us to identify robotic procedures with greater precision and accuracy than is possible using claims data. This study was approved by the University of Michigan institutional review board, which deemed the study exempt from informed consent owing to use of secondary data. This study was designed and reported in adherence to the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We used data from the complete MSQC clinical registry file to identify all inpatient and outpatient general surgical episodes from January 1, 2012, through June 30, 2018. Procedures were identified and categorized by Current Procedural Terminology codes. We focused on general surgical procedures, which represent the clinical domain with the largest growth in robotic surgery. These files include additional information on patient age, demographic characteristics, and comorbid conditions in addition to detailed procedural information (eg, operative approach and anesthesia type), postoperative complications, death, and resource use (readmissions and emergency department visits).

Our primary outcome of interest was the surgical approach—robotic, laparoscopic, or open. The MSQC data were manually abstracted, and data on surgical approach were derived directly from the operative reports rather than procedural codes. Procedures were considered robotic if surgeons reported using the surgical robot in their operative report. Cases in which a robotic procedure was unexpectedly converted to another approach (eg, conversion to open procedure for bleeding) were characterized as robotic because this was the original approach chosen by the surgeon.

Data were analyzed from March 1 through April 19, 2019. The purpose of this analysis was to characterize trends in the use of surgical approaches over time for common general surgical procedures. We first reported raw proportions that were not adjusted for patient or hospital characteristics. We evaluated trends by calculating the fold change in each approach over time by dividing the proportional use of robotic surgery in 2018 by the proportional use in 2012. We also calculated the annual increase or decrease in the proportional use of each approach using linear regression. The coefficient for study years, modeled as a continuous variable, is reported as the annual trend. We then replicated the overall analysis stratified by specific procedures to determine whether overall trends were influenced by changes in practice for certain procedures.

To determine how hospitals change their practices after they begin performing robotic surgery, we performed a multigroup interrupted time series analysis. During the study period, 23 of the 73 MSQC participating hospitals (31.5%) began performing robotic surgery (32 hospitals were already performing robotic surgery at the time that MSQC began collecting data on this approach in 2012). We determined the date of the first robotic general surgery procedure within each of the hospitals that adopted robotic surgery during the study period. We then centered all hospitals on this date and evaluated the trends in the proportional use of each approach in the years before and after the hospital performed its first robotic operation. We used linear splines to model absolute levels and trends in the periods before and after introduction of robotic surgery. This analysis was designed to test the incremental association of adopting robotic surgery with trends in surgical practice but not to make assumptions about what would have happened had the hospital not begun performing robotic surgery. Our primary analysis was not adjusted for specific procedures, but we generated estimates for each procedure group in a sensitivity analysis. We estimated cluster-robust standard errors to account for repeated observations within hospitals. We performed all statistical analyses using Stata, version 14.2 statistical software (StataCorp LLC).

Characteristics for the 169 404 patients and 73 hospitals are included in Table 1 . The mean (SD) age for all patients was 55.4 (16.9) years; 90 595 (53.5%) were women and 78 809 (46.5%) were men. Cholecystectomy was the most common operation (62 854 [37.1%]). Of the 73 hospitals included in the study, 31 (42.5%) had fewer than 200 beds and 11 (15.1%) had at least 500 beds. Sixty-two hospitals (84.9%) were teaching hospitals, and the mean (SD) total surgical volume was 12 068 (10 933) cases.

From January 2012 through June 2018, the use of robotic surgery for all general surgery procedures increased from 1.8% to 15.1% (8.4-fold change; slope, 2.1% per year; 95% CI, 1.9%-2.3%) ( Figure 1 and Table 2 ). During the same period, the use of both laparoscopic and open surgery declined. For example, the proportional use of open surgery was 42.4% in 2012 compared with 32.4% in 2018 (0.8-fold change; slope, −1.5% per year; 95% CI, −1.8% to −1.2%) (eTable 1 and eTable 2 in the Supplement ). Trends in robotic surgery use were similar for specific procedures, although for some, the magnitude of the increase was greater. For example, the use of robotic surgery for inguinal hernia repair increased from 0.7% to 28.8% from January 2012 through June 2018 (41.1-fold change; slope, 5.4% per year; 95% CI, 5.1%-5.7%).

The proportion of hospitals and surgeons performing robotic surgery increased from January 2012 through June 2018. For example, 8.7% of surgeons performed robotic general surgery in 2012 compared with 35.1% in 2018 (eFigure in the Supplement ). During the study period, 23 hospitals (31.5%) began performing robotic surgery. In those hospitals, the use of robotic surgery increased from 3.1% in the first year to 13.1% in the fourth year after hospitals began performing robotic general surgery operations (overall mean in first 4 years, 8.8%; slope, 2.8% per year; difference, 2.8% [95% CI, 2.7%-2.9%]) ( Figure 2 and Table 3 ). The use of laparoscopic surgery decreased from 53.2% to 51.3% after hospitals began performing robotic surgery (difference, −1.9%; 95% CI, −2.2% to −1.6%) ( Table 3 ). Before hospitals performed robotic surgery, a trend toward greater use of laparoscopic surgery occurred (slope, 1.3% per year). A trend toward less laparoscopic surgery after hospitals began performing robotic surgery occurred (slope, −0.3% per year; difference, −1.6%; 95% CI, −1.7% to −1.5%). Results remained the same when stratified across specific procedures.

This study used a unique, clinically oriented, and manually abstracted data source to characterize the use of robotic surgery across a wide range of common general surgical procedures. These data identify the correct procedure approach with greater precision and accuracy than claims. We found that the use of robotic surgery increased dramatically from 2012 to 2018. Although the use of robotic surgery increased across all procedures, for certain operations, such as inguinal hernia repair, practice patterns shifted by an order of magnitude toward greater use of robotics. We also found that the use of robotic surgery increased rapidly and diffused widely across numerous different procedures in the years after hospitals begin performing robotic surgery. This trend was associated with a decrease in the use of open and laparoscopic minimally invasive procedures, which for most surgeons was already considered a safe and effective approach when clinically feasible.

Recent work suggests that the United States now performs more robotic surgery than any other country in the world, although overall trends in other specialties (eg, urology) toward greater use of robotic surgery have been present for many years. 9 Based on robotic device manufacturers’ financial statements, procedure volumes exceeded 600 000 in 2017, with the largest and fastest growing contributor being the field of general surgery. 9 This finding suggests that the clinical footprint for robotic surgery will continue to increase as it has for more than a decade already. However, accurate data on how robotic surgery is being applied in contemporary practice is lacking. Prior studies are limited to single-center reports and claims-based analyses that may be inaccurate owing to unreliable coding. 6 - 8 , 10 , 11 This inaccuracy is problematic because it may limit our ability to understand the clinical implications of this rapid change in practice. It also limits the ability of policy makers and regulators to scope oversight or, more broadly, the public health implications of rapid changes in surgical practice.

Within this context, regulators from the FDA recently expressed safety concerns about the rapidly growing use of robotic approaches for certain cancer operations. 5 These concerns stem from the limited evidence of benefit (eg, fewer complications or better oncologic resection quality) for robotic surgery. For example, randomized clinical trials have failed to demonstrate the benefits of robotic surgery over other approaches in the treatment of rectal cancer 12 and have shown even potentially worse outcomes in procedures for cervical cancer. 4 Observational studies that compared robotic surgery with more established laparoscopic or open approaches have also failed to demonstrate superior outcomes after inguinal hernia repair, 8 kidney resections, 1 colectomy, 13 - 16 or cholecystectomy. 7 The discrepancy between the ongoing rapid adoption of robotic surgery and unclear clinical benefit highlights why accurate information on how it is being applied in contemporary surgical practice is necessary.

This study expands on prior work in several ways. We used manually abstracted data from a statewide surgical registry to ensure that our estimates reflect the true incidence of robotic surgery across a wide range of procedures, hospitals, and surgeons. Making further use of these unique data, we estimated how the initiation of robotic surgery within hospitals had broad associations with surgical practice for numerous procedures that differed in complexity, anatomical location, and surgical indications (eg, repair of a hernia vs removal of an organ). This investigation builds on existing literature, which has shown similar associations of an increase in robotic prostatectomy with hospital acquisitions of robotic systems. 17 We also demonstrate that increasing use of robotic surgery changed existing trends toward greater use of laparoscopic surgery. For many common and low-risk procedures, such as cholecystectomy, conventional laparoscopic surgery is already the accepted standard of care. Laparoscopic approaches are also less expensive and can be performed by most general surgeons without robotics. 18 This situation highlights a questionable trend: robotic surgery is replacing conventional laparoscopic approaches for procedures that may not be complex enough to warrant the consideration of an advanced, expensive, and unproven minimally invasive platform.

This study suggests that regulators and the surgical community can take additional steps to monitor the ongoing diffusion of robotic surgery and ensure that this trend does not lead to diminished patient safety. Because accurate data are necessary to inform the creation of appropriate safeguards, the FDA and the Centers for Medicare & Medicaid Services should consider providing coverage for robotic surgery with provisions for evidence development. 19 This process has been previously used by the Centers for Medicare & Medicaid Services to create registries of patients treated with new and unproven surgical technologies (eg, carotid artery stenting). Use of these provisions would facilitate greater understanding of how robotic procedures are being used in real-world practice. Akin to postmarket surveillance of pharmaceuticals, such provisions would also create a common data resource from which the comparative safety and effectiveness of robotic operations can be evaluated by numerous investigators.

This action would also allow hospitals, which provide credentials to perform robotic surgery, to better understand where sufficient evidence suggests plausible benefit. At present, surgeons are largely able to use robotic surgery for any procedure at their professional discretion. As has been shown in the FDA warning and through prior studies, this discretionary use may place patients at risk for poor outcomes. 3 Facilitating transparency around the allocation of robotic surgery would allow patients to make better collaborative decisions with their surgeons. After all, for many of the procedures we report in this study, little to no evidence suggests that robotic surgery increases patient safety or treatment effectiveness compared with other approaches.

Our results should be interpreted within the context of several limitations. Our clinical registry only captures data from Michigan and therefore may not be generalizable to the country as a whole. However, the MSQC represents a heterogeneous group of hospitals, surgeons, and practice settings. Furthermore, we report on the most common general surgery procedures performed in the United States. Changes in patient factors, such as obesity, may influence trends in procedure choice. Our estimates may therefore be limited by a lack of adjustment for patient characteristics. That said, adjusting for patient factors may introduce its own biases because no clinical consensus exists around how robotic procedures should be allocated. Much of this decision-making is based on case-by-case surgeon assessments and clinical nuance not captured in any registry. Our results are consistent across multiple different procedures, which also suggests that these trends are independent of unique clinical domains or disease processes. Our study is unable to account for how other nonclinical factors, such as marketing, may influence the adoption of robotic surgery. However, others have found that the chances of receiving robotic surgery were 2- to 5-fold greater in highly competitive vs noncompetitive health care markets. 20 Moreover, evidence suggests that hospitals immediately begin advertising their acquisition of robotic surgical services through web-based and conventional health system marketing campaigns. 21 These data are complementary to ours and suggest that the greatest forces driving robotic surgery adoption may be the technological imperative and economic pressures experienced by hospitals in certain health care markets.

This study found that robotic surgery is rapidly diffusing across a broad range of common general surgical procedures. Trends toward greater use of the robotic platform appeared to occur rapidly after hospitals begin performing robotic surgery and were associated with a decrease in the use of established minimally invasive techniques, such as laparoscopic surgery. This trend was consistent across numerous specific procedures, even those for which conventional laparoscopic surgery is already considered standard of care and for which robotic surgery offers little theoretical clinical benefit to the patient. These findings highlight a need to continually monitor the diffusion of robotic surgery to ensure that enthusiasm for a new technology does not outpace the evidence needed to use it in the most effective clinical contexts.

Accepted for Publication: November 14, 2019.

Published: January 10, 2020. doi:10.1001/jamanetworkopen.2019.18911

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2020 Sheetz KH et al. JAMA Network Open .

Corresponding Author: Kyle H. Sheetz, MD, MSc, Center for Healthcare Outcomes & Policy, University of Michigan School of Medicine, 2800 Plymouth Rd, NCRC Bldg 16, Room 100N-11, Ann Arbor, MI 48109 ( [email protected] ).

Author Contributions: Drs Sheetz and Dimick had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: Sheetz, Dimick.

Statistical analysis: All authors.

Obtained funding: Dimick.

Administrative, technical, or material support: Dimick.

Supervision: Dimick.

Conflict of Interest Disclosures: Dr Dimick reported receiving personal fees from ArborMetrix, Inc, outside the submitted work and being an equity owner of ArborMetrix, Inc. No other disclosures were reported.

Funding/Support: This study was supported grants 2T32HS000053-27 (Dr Sheetz) and R01HS023597 (Dr Dimick) from the Agency for Healthcare Research and Quality and grant R01AG039434 from the National Institute on Aging, National Institutes of Health.

Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.

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Computer Science > Robotics

Title: accelerating surgical robotics research: a review of 10 years with the da vinci research kit.

Abstract: Robotic-assisted surgery is now well-established in clinical practice and has become the gold standard clinical treatment option for several clinical indications. The field of robotic-assisted surgery is expected to grow substantially in the next decade with a range of new robotic devices emerging to address unmet clinical needs across different specialities. A vibrant surgical robotics research community is pivotal for conceptualizing such new systems as well as for developing and training the engineers and scientists to translate them into practice. The da Vinci Research Kit (dVRK), an academic and industry collaborative effort to re-purpose decommissioned da Vinci surgical systems (Intuitive Surgical Inc, CA, USA) as a research platform for surgical robotics research, has been a key initiative for addressing a barrier to entry for new research groups in surgical robotics. In this paper, we present an extensive review of the publications that have been facilitated by the dVRK over the past decade. We classify research efforts into different categories and outline some of the major challenges and needs for the robotics community to maintain this initiative and build upon it.

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The future of robotic surgery in safe hands

• Guohui Wang 1 ,
• Zheng Li 2 ,
• Liyong Zhu 3 ,
• Pengzhou Li 4 ,
• Weizheng Li 5 ,
• Song Zhi 6 ,
• Shaihong Zhu 7 &
• Jianmin Li 8

Third Xiangya Hospital, Central South University

Tianjin University

Produced by

Researchers at the Third Xiangya Hospital of Central South University are making preparations to test the surgical robotic system, Micro Hand S. Credit: Third Xiangya Hospital of Central South University

Robots have been working in the manufacturing industry since the 1950s, but their entry into the realm of medicine was not until the 1990s, along with a demand for minimally invasive surgery. Since then, the growth of the robotics industry, and the emergence of artificial intelligence (AI) technology, have driven advances in robotic surgery.

In China, the demand for minimally invasive surgery has promoted research and development (R&D) into building the country’s own medical robots.

A collaborative project that started in 2008 has led to a novel robotic system for multi-incision laparoscopic surgery, expected to be available for clinical use soon.

A growing need

Robotic systems in medicine are relatively new, but advances are developing quickly. The first surgical robot can be traced back to the Automated Endoscopic System for Optimal Positioning (AESOP), which was approved for clinical use by the US Food and Drug Administration (FDA) in 1994. Essentially a robotic arm for holding an endoscope, AESOP is voice controlled, with adjustable positioning to ensure a steady view of the operating field during endoscopic surgery. Further progress with AESOP led to a master-slave robotic system, ZEUS, in 1996, developed by Computer Motion, the same US company that produced AESOP. This upgraded system has three robotic arms to perform surgical tasks, and allows for remote manipulation by surgeons.

The most popular surgical robot today is the da Vinci Surgical System, developed by the US company, Intuitive Surgical. Its three-dimensional (3D) vision system accurately captures images. With an advanced motion control system, its robotic arms can replicate what the human arm can do, with the capacity to perform more complicated surgeries. In 2000, the FDA approved the use of the da Vinci system, and it has since become the most widely used surgical robot.

The da Vinci system entered the Chinese medical market in 2008. By 2019, 112 had been installed, and used in more than 110,000 surgical operations, ranging from gastrointestinal and cardiothoracic, to hepatobiliary, urologic, and gynaecological surgeries. These robots offer clearer imaging, greater accuracy, stability, and range of motion. The ergonomic design means greater comfort for the operating surgeon, eliminating the problem of fatigue. The improved precision means smaller incisions and less pain for patients, enabling faster recovery.

However, the high cost of these imported machines limits their broad use in China, so the prevalence of robotic surgery is much lower in China than in some Western countries, as well as Japan and Korea.

The need to advance minimally invasive technologies, while lowering medical costs, has driven a major research project supported by the National Natural Science Foundation of China (Project No: 51875580), and National Key Research and Development Plan Fund (Grant No: 2017YFC0110402), to develop China’s own surgical robots. Led by Central South University, in collaboration with Tianjin University and Beihang University, the project will fill the gap in China’s development of high-end medical instruments. It is also in line with the national strategic plan to upgrade Chinese industry.

Making of a novel surgical robot

Interdisciplinary collaboration is essential to the development of surgical robots, which requires application of theories and technologies in medicine, mechanical engineering, robotics, optics, computer science and automatic control. The project has brought together interdisciplinary teams with broad experience in related key technologies and minimally invasive medicine, setting a good model for medical-engineering collaboration.

Innovations are made in improving clinical safety and effectiveness. The design of surgical robot, Micro Hand S, was informed by studies of rich clinical data from the Third Xiangya Hospital of Central South University, from which researchers can prioritise necessary and desirable features of the robot. By studying the mechanisms underlying bio-machine interface, integrating bionic techniques, mechanical and new materials technologies, the joint research team has optimized the design to address safety issues, leading to more dexterous robotic arms, and precise, real-time control.

In robotic surgeries, the lack of force feedback presents a challenge for a surgeon to maintain precise control, without damaging tissues. Researchers at the Third Xiangya Hospital of Central South University, based on their vast experience in minimally invasive surgeries, have built classified databases on physical characteristics of patients, the interaction between human soft tissues and surgical instruments, as well as operator-instrument interface. Design standards for the surgical robot were set based on careful studies of these data, which have also informed product safety and reliability evaluation systems. These guidelines have brought a design that ensures clinical safety and effectiveness, while improving usability.

Specifically, simulation evaluation studies are based on mapping instrument movement when it is in safe range, and the rapid upper limb assessment (RULA) is used to check how well mapping is performed, leading to a design that enables adjustable operation. The assessment also informs an ergonomic design where the surgeon’s palm, rather than fingers is force-bearing, improving comfort, as well as operation efficiency.

For a master-slave robotic system, where one device (the master) has a unidirectional control over the other, precision is key. Based on an intuitive motion control strategy, researchers have built a model of bilateral control, enabling simulation of control signals at the master end to ensure their accuracy before they are sent to the slave devices. Given the complexity of motion planning for such a master-slave system, special techniques were applied to decouple the control of master and slave manipulators. This enables efficient joint matching to the human arm, and precise control of surgical instruments.

Based on a model for origami of thick panels, Micro Hand S features a foldable, compact design that allows for extensive movement. Credit: Third Xiangya Hospital of Central South University

The Micro Hand S features a compact, foldable, design that allows for a wide range of possible movements by the instruments in a limited space. While origami principals are typically applied to the folding of very thin materials, such as paper, researchers from Tianjin University have developed a model for rigid origami of thick panels, capable of reproducing a folding motion identical to that of zero-thickness origami 1 . Using this model, instruments delivered by the robotic arm have large degrees of freedom in a small working space, and the driver and control structures of the robotic system can be made more compact. Being smaller and lighter, the robot saves space, and the time needed for installation is also reduced. The flexible single-shaft configuration can adjust positioning of instruments, so that multi-quadrant operation is possible without moving the robot, and coordination between the operator and the robotic system is made easier.

Another feature of Micro Hand S is the integration of bionics in the instrument interface design. Inspired by the carnivorous tropical pitcher plant, Nepenthes alata , whose rim has a surface with multiscale structure to allow for quick, unidirectional water transport, researchers at Beihang University proposed a novel, anti-stick solution for surgical instruments 2 . The self-lubricating design prevents adhesion to tissue without additional energy. The biomimetic design also drew on studies of tree frogs, known for their ability to cling to surfaces. By exploring the properties underlying enhanced friction for frogs’ foot pads, researchers have designed non-slip devices for the robotic system, achieving high friction without adding outside pressure. This ensures that the force applied by the instrument end effector is in a safe range, which is usually hard to control when force feedback is lacking.

With a 3D camera system, Micro Hand S offers on-site demonstration of minimally invasive surgery to help train less experienced surgeons. Credit: Third Xiangya Hospital of Central South University

A 3D camera system is also essential. It allows the operating surgeon to clearly identify the diseased organ or tissue, differentiating them from the linked blood vessels and nerves, to prevent excessive bleeding or nerve damage when performing resection. The robotic system also allows for on-site, real-time demonstration of minimally invasive surgery, allowing less experienced surgeons to communicate with an operating surgeon in front of a monitor screen. The visualized learning helps shorten the learning curve for mastering the technology.

Using 5G communication technology, Micro Hand S can be connected to other digital devices, which help accelerate data transmission and reduce control delay, leading to optimized telemanipulation with improved accuracy.

Based on safety and effectiveness studies at the minimally invasive surgery centre at the Third Xiangya Hospital, the surgical robotic system was updated several times. Now a prototype machine is undergoing a phase II clinical trial.

Moving from lab to theatre

The development of Micro Hand S took a patient-centred approach. It closely follows protocols for evidence-based medicine to complete in vitro studies, animal experiments, and clinical trials.

First, in vitro studies were conducted based on real-time movement tracking data for safety evaluation. Mapping of the robot motion was analysed to see how well it coordinates movement of the multiple instruments by the robotic arm. The study results suggest that the movement of the instruments at the slave end of Micro Hand S closely follows that of the surgeon’s operation at the master end, with minimal superfluous movement. Both ends operate smoothly and efficiently, showing great coordination. Compared with traditional laparoscopic surgery, the surgical robot uses less operating space, and the surgical knot it ties is firmer and tighter, showing higher efficiency and precision. Its greater flexibility and stability confer advantages over laparoscopic surgery 3 .

In studies, Micro Hand S was used to perform 200 surgeries on pigs, including gallbladder removal, liver lobectomy, gastroenterostomy, which makes a new connection between the stomach and the duodenum, as well as intestinal anastomosis. Using 5G technology, the project team also experimented with telemanipulation. In these animal experiments, the Chinese-designed surgical robot proved capable of performing clamping, separation, cutting, electrocautery, stitching, and knot tying, completing all the complicated procedures required for minimally invasive surgeries.

In 2014, with accreditation from the Association for the Accreditation of Human Research Protection Program, a phase-I clinical trial was conducted to test the safety and efficacy of Micro Hand S. By January 2019, 103 robotic procedures were performed in gastrointestinal, hepato-pancreato-biliary, thoracic, urologic, and gynaecological surgery. From simple surgeries, or those aimed for single disease treatment, the robot was gradually used in more complicated procedures requiring greater dexterity, such as gastrectomy plus D2 lymphadenectomy, which combines lymph node removal and gastric resection for treating advanced gastric cancer.

In a few cases when complications occurred, the surgical robot was able to perform repair procedures. These robotic surgeries take reduced installation time (a median of 20 minutes) and shorter operative time (a median of 245 minutes) 4 , 5 .

Based on animal studies and phase-I clinical trials, phase II trials were launched in late 2019, with approval from China’s National Medical Products Administration. These are prospective, randomized, single-blind trials with paralleled intervention and control groups for comparing safety and effectiveness. A total of 84 gallbladder surgeries were performed, half by Micro Hand S, and half by the da Vinci system. The main indicator for success was the rate of change into non-robotic surgeries during the operation. Operative time, bleeding levels during operation, post-operative pain, bowel function recovery time, length of hospitalization, an index for complications, and rating for robot performance by the operating surgeon, were also considered in the study. The two groups appeared to show similar results in the comparison study.

Next, the project team is planning for multi-centre, prospective, randomised trials to collect more evidence for safety and effectiveness of the domestically developed surgical robot. It looks to push forward manufacturing of the surgical robot, boosting China’s industry.

The project team plans to build a national training base to educate surgeons about the use of the surgical robot, promoting its broad use. Plans are also made to establish a clinical data centre, by collecting big data on the use of surgical robots, and using AI algorithms for analysis, to guide further upgrade of China’s surgical robot, optimizing its performance, and making it globally competitive.

The development of medical robots will also extend to systems for prosthesis, rehabilitation, psychological rehabilitation, personal care, and health monitoring, which, along with surgical robots will be the emphasis of future research focuses.

Contact details:

[email protected]

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• Published: 20 January 2022

Robotic surgery in emergency setting: 2021 WSES position paper

• Nicola de’Angelis   ORCID: orcid.org/0000-0002-1211-4916 1 , 2 ,
• Jim Khan 3 ,
• Francesco Marchegiani 4 ,
• Giorgio Bianchi 1 ,
• Filippo Aisoni 1 ,
• Daniele Alberti 5 ,
• Luca Ansaloni 6 ,
• Walter Biffl 7 ,
• Osvaldo Chiara 8 ,
• Graziano Ceccarelli 9 ,
• Federico Coccolini 10 ,
• Enrico Cicuttin 10 ,
• Mathieu D’Hondt 11 ,
• Salomone Di Saverio 12 ,
• Michele Diana 13 , 14 ,
• Belinda De Simone 15 ,
• Eloy Espin-Basany 16 ,
• Stefan Fichtner-Feigl 17 ,
• Jeffry Kashuk 18 ,
• Ewout Kouwenhoven 19 ,
• Ari Leppaniemi 20 ,
• Nassiba Beghdadi 1 , 2 ,
• Riccardo Memeo 21 ,
• Marco Milone 22 ,
• Ernest Moore 23 ,
• Andrew Peitzmann 24 ,
• Patrick Pessaux 25 , 26 , 27 ,
• Manos Pikoulis 28 ,
• Michele Pisano 29 ,
• Frederic Ris 30 ,
• Massimo Sartelli 31 ,
• Giuseppe Spinoglio 32 ,
• Michael Sugrue 33 ,
• Edward Tan 34 ,
• Paschalis Gavriilidis 35 ,
• Dieter Weber 36 ,
• Yoram Kluger 37 &
• Fausto Catena 38  

World Journal of Emergency Surgery volume  17 , Article number:  4 ( 2022 ) Cite this article

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Robotics represents the most technologically advanced approach in minimally invasive surgery (MIS). Its application in general surgery has increased progressively, with some early experience reported in emergency settings. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a systematic review of the literature to develop consensus statements about the potential use of robotics in emergency general surgery.

This position paper was conducted according to the WSES methodology. A steering committee was constituted to draft the position paper according to the literature review. An international expert panel then critically revised the manuscript. Each statement was voted through a web survey to reach a consensus.

Ten studies (3 case reports, 3 case series, and 4 retrospective comparative cohort studies) have been published regarding the applications of robotics for emergency general surgery procedures. Due to the paucity and overall low quality of evidence, 6 statements are proposed as expert opinions. In general, the experts claim for a strict patient selection while approaching emergent general surgery procedures with robotics, eventually considering it for hemodynamically stable patients only. An emergency setting should not be seen as an absolute contraindication for robotic surgery if an adequate training of the operating surgical team is available. In such conditions, robotic surgery can be considered safe, feasible, and associated with surgical outcomes related to an MIS approach. However, there are some concerns regarding the adoption of robotic surgery for emergency surgeries associated with the following: (i) the availability and accessibility of the robotic platform for emergency units and during night shifts, (ii) expected longer operative times, and (iii) increased costs. Further research is necessary to investigate the role of robotic surgery in emergency settings and to explore the possibility of performing telementoring and telesurgery, which are particularly valuable in emergency situations.

Conclusions

Many hospitals are currently equipped with a robotic surgical platform which needs to be implemented efficiently. The role of robotic surgery for emergency procedures remains under investigation. However, its use is expanding with a careful assessment of costs and timeliness of operations. The proposed statements should be seen as a preliminary guide for the surgical community stressing the need for reevaluation and update processes as evidence expands in the relevant literature.

Robotics represents the most technologically advanced approach in minimally invasive surgery (MIS). Its application has progressively gained acceptance in several surgical fields, being routinely used for elective urology, gynecology, digestive, and hepato-bilio-pancreatic surgery [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 ]. Conversely, robotic surgery in the emergency setting has not been explored, although some early experience has been reported in the literature [ 9 , 10 , 11 , 12 ]. Consequently, the issue regarding the role and potential applications of robotics for emergency procedures remains open. However, it deserves to be continuously monitored and updated in the future as evidence would emerge.

Project rationale and design

The present position paper is supported by the World Society of Emergency Surgery (WSES) and aims to provide a systematic review of the literature investigating the use of robotics in emergency general surgery to develop consensus statements based on the currently available evidence and practice. The present document should be seen as a preliminary guide for the surgical community stressing the need for reevaluation and update processes as evidence expands in the relevant literature.

For the purpose of this WSES position paper, the organizing committee (composed of Fausto Catena, Nicola de’Angelis, and Jim Khan) constituted a steering committee (made up of 16 experts), who had the task of drafting the present position paper, and an international expert panel composed of 21 experts who were asked to critically revise the manuscript and position statements. The position paper was conducted according to the WSES methodology [ 13 ]. We shall present the systematic review of the literature and provide the derived statements upon which a consensus was reached, specifying the quality of the supporting evidence and suggesting future research directions.

Systematic review

Review question, selection criteria, and search strategy.

The systematic review of the literature was performed following the Cochrane Collaboration specific protocol [ 14 ] and was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [ 15 ].

The focus question was the following: what are the applications and outcomes of robotics for general surgery in emergency settings?

Studies reporting the use of a robotic surgical platform to manage general surgery emergencies and urgencies were searched in the following databases on June 30, 2021: MEDLINE (through PubMed), Embase, and the Cochrane Library. A specific research query was formulated for each database, using the following keywords and MeSH terms: emergency, emergency surgery, emergency setting, urgent, robotic surgery, robotic, robotics, robot-assisted, minimally invasive surgery, and minimally invasive surgery procedures.

According to the PICOS format, the following items were used as selection criteria for articles emerging from the literature search:

P, population: adult patients requiring surgery in emergent/urgent settings.

I, intervention: robotic or robot-assisted general surgery intervention.

C, comparisons: laparoscopy or open surgery or no comparison.

O, outcome(s): operative and postoperative surgical outcomes.

S, study design: due to the expected paucity of studies on the topic, all types of comparative study, but also case series and case reports were considered aiming to provide the most exhaustive picture of the current evidence and practice in robotic emergency general surgery.

The research was limited to studies published in English.

The literature search and selection were performed by two independent reviewers (GB and FM), who also screened the reference list of the selected articles to potentially include additional studies. First, all records from merged searches were reviewed for relevance concerning title and abstract. Records were removed when both reviewers excluded them. Otherwise, the disagreement was resolved via discussion or with the intervention of a tiebreaker (NdeA). Both reviewers then performed an independent full-text analysis, which allowed to finally include or exclude the preselected article.

Data extraction and synthesis

Data extraction was performed by filling in an electronic spreadsheet, which included the following items: first author’s name, year of publication, scientific journal, type of study, number of patients, pathological state requiring surgical intervention, type of surgical intervention, surgical approach, operative surgical outcomes, and postoperative surgical outcomes. The risk of bias in the selected studies was assessed by using validated systems according to the type of study design [ 16 , 17 , 18 ].

Literature search and selection

The initial search yielded 3767 results; after removing duplicates, 3662 articles were screened for eligibility based on title and abstract, and 31 articles were retrieved for a full-text evaluation. A total of 10 studies fulfilled the selection criteria and were finally included in the review (Fig.  1 ).

Flowchart of the literature search and selection

Study characteristics

The selected 10 studies were published between 2012 and 2021. They consisted of 5 cohort studies and 5 case reports conducted in Europe ( n  = 3) and North America ( n  = 7). The characteristics of the examined studies are summarized in Table 1 . Overall, they considered 279 patients.

Three studies reported interventions of colorectal surgery [ 9 , 10 , 19 ], two studies reported on hiatal hernia surgery [ 20 , 21 ], two studies reported on gallbladder surgery [ 22 , 23 ], two studies reported on bariatric surgery [ 12 , 24 ], and one study reported on abdominal wall surgery [ 25 ]. Only one case was a cancer-related emergency [ 10 ].

Qualitative synthesis of the literature

Robotics in emergency colorectal surgery

An early preliminary report of an emergent robotic repair of a colonic iatrogenic perforation was published by Pedraza et al. in 2012 [ 19 ]. The authors showed that such a procedure was feasible and successful. In 2014, Felli et al. [ 10 ] described the case of an 86-year old woman who underwent a robotic right colectomy for a bleeding ascending colon neoplasia. The surgery was uneventful and the reported postoperative outcomes were excellent. More recently, Anderson et al. [ 9 ] published a matched case–control study focusing on the use of robotics for urgent subtotal colectomies in patients presenting with ulcerative colitis. The results showed similar short-term outcomes for robotic and laparoscopic approaches.

Robotics in emergency hiatal hernia surgery

Over the last years, two groups published their early experience with robotic surgery for emergency hiatal hernia repair. In a case series of 3 patients undergoing robotic surgery for complicated giant hiatal hernia, Ceccarelli et al. [ 21 ] showed that postoperative outcomes were good. The authors suggested that the potential advantages of robotics over a conventional laparoscopic approach were mainly related to the surgeon’s comfort and precision during the intervention. Hosein et al. [ 20 ] performed a cohort-based analysis using data from the 2015–2017 Vizient clinical database, which included inpatient data from over 300 hospitals in the USA. Trend analysis demonstrated that laparoscopy was the most common approach in emergency hiatal hernia repair, representing 64.09% of cases, followed by the open (30.38%) and the robotic approach (5.53%). Concerning operative and postoperative outcomes, a trend was also observed for better outcomes in case of MIS (laparoscopy or robotic) hiatal hernia repair as compared to open surgery.

Robotics in emergency gallbladder surgery

In 2016, Kubat et al. [ 22 ] published a retrospective case series of 76 elective and 74 urgent robotic single-site cholecystectomies. The authors reported good perioperative outcomes, concluding that this approach was safe and efficient. In 2019, Milone et al. [ 23 ] described a case series of 3 patients who underwent robotic cholecystectomy for acute cholecystitis. The reported perioperative outcomes were excellent and the authors recommended the introduction of robotics in emergency settings in order to validate their preliminary results.

Robotics in emergency bariatric surgery

The first report of robotic emergency surgery after complicated robotic biliopancreatic diversion with duodenal switch was published by Sudan et al. in 2012 [ 24 ]. The robotic approach was preferred over open surgery in the management of postoperative complications in order to preserve the benefits of the previous MIS approach. The authors highlighted how the adoption of the robotic platform was useful in a patient in order to identify the damage and to repair it. More recently, Robinson et al. [ 12 ] published a retrospective cohort study comparing emergent laparoscopic and robotic gastrojejunal ulcer repair. The authors showed that in-room-to-surgery-start time was significantly reduced in the robotic group. Additionally, perioperative outcomes were in favor of the robotic approach, although not significantly different. However, robotic surgery was significantly more expensive than laparoscopy.

Robotics in emergency abdominal wall surgery

In 2020, Kudsi et al. [ 25 ] published an article on the perioperative and mid-term outcomes of 34 patients who underwent emergency robotic ventral hernia repair with different techniques between 2013 and 2019. With a 20.5% rate of minor postoperative complications (Clavien-Dindo grades I-II), a 11.7% rate of major postoperative complications (Clavien-Dindo grades III-IV), and only one (2.9%) patient experiencing hernia recurrence, the authors concluded that robotic ventral hernia repair was associated with promising results and overall feasibility in emergency settings, to be tested in further long-term follow-up studies.

Evaluation of the quality of evidence

Five out of 10 selected studies were retrospective cohort studies and were evaluated according to the NOS [ 18 ]. Two studies received a score of 8/9 [ 9 , 12 ], one study was graded 7/9 [ 20 ], and two studies had a score of 6/9 [ 22 , 25 ] (Table 2 ). The remaining studies were evaluated according to the tool described by Murad et al. [ 16 ]. All studies received a score of 6/8 [ 10 , 19 , 21 , 23 , 24 ] (Table 3 ).

Position statements

Following a comprehensive literature review and the summary of current scientific evidence on the applications of robotics for emergency general surgery procedures, the following position statements (PS) were put forward. For each statement, the supporting literature, the level of evidence, and the strength of the consensus are indicated. The level of evidence is classified according to the GRADE system ( https://training.cochrane.org/introduction-grade ). For each statement, the consensus was assessed through a web survey (by means of a Google Form) open to all members of the steering committee and panel of experts and to the members of the Board of Governors of the WSES. If a statement reached < 70% of agreement, it was rediscussed via email or videoconference, modified, and resubmitted to the experts’ vote until a consensus was reached.

The experts involved were also asked to describe their current practice. The great majority (82.6%) worked in a hospital equipped with a robotic surgical platform. However, the access to the robotic surgical system for emergency procedures appeared to be limited, with difficult availability (39.1%) only during the day (13%), or not available at all (43.5%).

PS-1. Robotic surgery in emergency settings is highly dependent on the surgeon’s experience and should only be performed in an appropriately equipped operating room with trained nursing staff.

Supporting literature

Robotic surgery requires a high level of technical expertise when compared to open or even laparoscopic surgery. A complete specialized training is required to be proficient in performing standardized surgical interventions associated with acceptable operative and postoperative outcomes [ 26 ]. In a recent article, Thomas et al. [ 27 ] analyzed the robotic colorectal surgery activity of a tertiary colorectal unit and concluded that success relies on a structured training curriculum, a dedicated surgical team, the institution’s support, and many other variables in addition to the training at the robotic console itself. The adoption of the robot in the emergency setting does not change the rules of the game. Rather, it enhances the need for a safe and efficient strategy starting from the standardization of the robotic platform setting and docking, up to the execution of the surgical procedure. In order to successfully perform emergency cases with a robotic system, the on-call surgical team must be adequately trained with robotic technology. As reported by Robinson et al. [ 12 ] in a case series of 24 robotic emergency bariatric surgeries, which were compared to 20 laparoscopic procedures, the surgeon who adopted the robotic approach was the same in all cases. It is the proof that a specific attitude of the operator is fundamental. However, it also highlights the need for a “can do” attitude from the entire surgical team [ 28 ]. The importance of the shared viewpoint is reinforced by Sudan et al. [ 24 ] who described the adoption of the robotic platform during the night and during the weekend in order for the staff to be comfortable with this technology. In addition, proper team work and communication in such a challenging workspace are required [ 29 ] as much as the completion of the learning curve for the entire surgical team [ 30 ]. The ideal operating room team in an emergency setting should be made up of the first operating surgeon with an extensive expertise in robotic surgery, an assisting surgeon familiar with the robotic technology, and a scrub nurse dedicated to the robotic program. All team members should work in a simulation environment before starting a robotic emergency surgery program.

Limitations linked to the adoption of robotic surgery in emergency settings are related to the time required for robotic setting and docking and the accessibility of the robotic platform for emergency surgical units. Concerning the time issue, Robinson et al. [ 12 ] reported that, when the entire team is appropriately trained and prepared, the in-room-to-surgery-start time is reduced and has no significant impact on the overall duration of the scheduled emergency procedure. However, in this study, the authors highlighted how the majority of the staff were familiar with the robotic technology, and there were no limitations to its accessibility. This may not be the case for all emergency care units, and trained nursing staff may not be always available during night shifts. A good coordination between the hospital administration, the surgeons, and the staff is the key point to have an efficient and extensive organization for the use of robotic technology, also in emergency surgery scenarios.

Level of evidence: case reports and case series → expert opinion

Strength of consensus (based on the survey evaluation): 100%

PS-2. Robotic surgery in emergency settings may be considered in highly selected clinically stable patients only.

Due to the very limited evidence in the literature and the consensus that robotic surgery required a high level of expertise for the operating surgeon and the entire surgical team, particularly if performed in emergency settings, it should be considered for clinically stable patients only.

A recent review [ 31 ] on the anesthetic aspects of robotic surgery suggested that when the surgical team gains confidence, even more complex operations or patients with comorbidities can be considered candidates for the robotic approach. A precise preoperative assessment based on a case-by-case evaluation, and multidisciplinary decision-making are crucial to guarantee the choice of the most indicated surgical strategy. Even if a comprehensive preoperative assessment is not always possible in emergency situations, a careful patient selection is advised in order not to expose frail or unstable patients to longer emergency procedures or unnecessary complications related to the surgical technique.

Indeed, in unstable patients or patients with cardiopulmonary comorbidities, the adoption of MIS with the need for carbon dioxide insufflation may result in a higher intra-abdominal pressure and hypercarbia with metabolic and respiratory changes which may be deleterious [ 32 ]. Osagiede et al. [ 11 ] showed that the presence of a metastatic disease and the higher number of comorbidities negatively influenced the adoption of MIS in emergency colorectal cancer surgery. Likewise, Arnold et al. [ 33 ] demonstrated that the adoption of MIS is confined to physiologically clinically stable patients while those with abdominal gross contamination or severe infectious processes are more prone to undergo open surgery. Despite this selection bias, when the results are corrected for preoperative risk factors, the adoption of laparoscopy is associated with a reduced wound infection rate, risk of death, and length of hospital stay.

Recently, emergency laparoscopy was evaluated as a valid approach to the treatment of perforated diverticulitis with generalized peritonitis [ 34 ], iatrogenic colonoscopy perforations [ 35 ], and perforated peptic ulcers [ 36 ]. In addition, in simple cases of adhesive small bowel obstruction, a laparoscopic approach may be beneficial despite the considerable risk of conversion to open surgery and the higher probability of bowel injuries [ 37 ]. In all of the abovementioned pathological states, the prerequisite for a safe minimally invasive treatment is the selection of a stable patient.

In terms of anesthetic management in emergency settings, the robotic approach can be considered as an alternative to laparoscopy because it does not change the risk exposure but it may be associated with longer operative times if the surgical team is not properly trained. Additional costs must also be considered. Further studies are necessary in order to clarify the future role of a low pressure pneumoperitoneum in emergency robotic surgery [ 38 ].

Strength of consensus: 94.6%

PS-3. Robotic surgery may be considered in challenging situations, which are foreseen as a reason for conversion to open surgery if operating in laparoscopy.

The available literature suggests that the main potential advantages of robotic surgery over laparoscopy are related to suturing and dissection. In case of emergency robotic surgery, the published studies described the following procedural steps: hiatoplasties [ 20 , 21 ], ventral suturing or mesh fixations [ 25 ], colonic suturing [ 19 ], duodenal stump suturing [ 24 ], strictureplasty [ 24 ], and dissection of inflamed gallbladder [ 22 , 23 ] or colon [ 9 ]. All of these tasks are particularly challenging in laparoscopic surgery and they often lead to conversion to open surgery, which can also be a source of postoperative complications [ 39 , 40 ]. The technological advances of the robotic surgical platform, such as deep magnification, 3D stereoscopic vision, a stable field with elimination of physiological tremors, motion scaling, and improved ergonomics as compared to laparoscopy, may contribute to facilitate the performance of some difficult procedural steps and reduce the risk of conversion. However, this remains to be proven, especially for surgical interventions performed in emergency settings.

Level of evidence: case reports and case series → expert opinion.

Strength of consensus: 83.8% (based on the survey evaluation)

PS-4. In a near future, robotic surgery may offer the advantage of telementoring and telesurgery, which could be useful to promote a safe and standardized application of robotics, also in low-volume centers or specific environments.

One of the limitations of laparoscopic surgery is the absence of telementoring during a difficult procedure. Even if communicating systems dedicated to telementoring are available, no opportunity for the direct control of movements is present in laparoscopy. In robotic surgery, an in-person mentoring can be performed if a second robotic console is present in the hospital (such as telestration or tele-assisted surgery). In a near future, it can be expected to perform telementoring during elective and emergency robotic procedures. After the first transatlantic robot-assisted surgery performed by Jacques Marescaux in 2001 [ 41 ], the surgical community was waiting for a routine use of telesurgery which, however, was not feasible due to technical limitations. Today, thanks to the evolution of telecommunications, namely fifth generation (5G) networks, there is a growing opportunity for a surgeon with a proven expertise in the field to remotely operate on a distant patient [ 42 , 43 ]. A digital connection with a reference center which can evaluate the case, suggest a solution, and eventually manage the surgical situation if need be, represents a powerful tool, especially in emergency settings. Indeed, in emergency surgery where a maximal experience improves outcomes, it would be beneficial to have a mentor observing and remotely participating in the intervention. Additionally, this technology could be applied to provide surgical care to rural areas, to establish surgical collaborations, and to eliminate the shortage of surgeons. This is also applicable for specific environments, such as in the space station, where an emergency medical condition has to be managed by a trained component of the crew, or close to a battlefield, where the surgeon may operate at a safe distance, or again at the bottom of the ocean [ 44 ]. Telesurgery could well be an option in such situations.

However, these applications conceal some limitations in terms of global network development, legal and ethical issues, costs, and cyber security. These issues are under examination. However, despite the current skepticism, it is unquestionable that robotic surgery can have a pivotal role in developing telemedicine and telesurgery [ 45 , 46 ].

Strength of consensus: 89.2% (based on the survey evaluation)

PS-5. The use of robotic surgery for unscheduled and urgent operations needs to be implanted without creating scheduling conflicts in the occupation of the operating room. Moreover, the increased costs need to be justified in the context of an efficient implementation of robotic surgery. Currently, the availability and accessibility of the robotic platforms for emergency care surgical units are very limited.

A consistently growing number of hospitals, mainly tertiary care and university-based hospitals, are acquiring a robotic surgical platform in order to satisfy daily requests and advertise the most advanced technology. The robotic platform is often shared between different specialties, subsequently limited in terms of availability for a single surgical field and not adaptable to changing schedules. In this perspective, several reports suggested that the use of the robotic surgical platform by experienced teams could be prolonged to night hours and even to the weekend. This approach was called “after hours” by Sudan et al. [ 24 ], whose report aimed to highlight the potential of a robotic system which is available 24 h/7 days per week. The availability of the platform during the night shift could potentially favor a more cost-effective use of the robotic system. However, this remains very limited and, as previously highlighted, a proper attitude and excellent training of the entire team are key to guarantee surgical proficiency and efficiently implement robotic surgery for emergency procedures.

Concerns for the adoption of robotics for emergency surgeries also persist in relation to the increased costs that a robotic surgical procedure implies also need to be justified in the context of an efficient implementation of robotic surgery.

PS-6. The development of new modular robotic platforms may contribute to increase the applications of robotic surgery in emergency settings.

The surgical marketplace was recently enhanced with several different robotic platforms either approved for human use, such as the CMR Versius (Cambridge Medical Robotics, Cambridge, UK) and the Distalmotion Dexter (Distalmotion, Epalinges, Switzerland) or under approval, such as the Medtronic Hugo (Medtronic Inc., Minneapolis, USA). Most of them share the opportunity of switching from a conventional laparoscopic setting to a robot-assisted one. This key point, which could be less relevant in elective surgery, should be carefully considered when approaching emergency surgery. In fact, when no specific port placement is required, the surgeon can simply use a different approach depending on the procedural step and on his/her own ability. In addition, these robotic platforms offer an improved vision with advanced near-infrared imaging, not routinely available in laparoscopic surgery. The objective evaluation of tissue anatomy or perfusion could limit the surgical bias in emergency settings by mitigating the personal opinion [ 47 , 48 ].

In the future, advances in surgical technologies will offer multiple new opportunities, which are currently under development, like hyperspectral imaging [ 49 ] and robotic single-port surgery [ 50 ]. Their potential applications and outcomes in emergency surgery need to be evaluated and updated once evidence is available.

Strength of consensus: 94.6% (based on the survey evaluation)

Research agenda

The experts recognized that there is a substantial lack of evidence to support the use of robotic surgery for emerging general surgery procedures. For this reason, a research agenda has been proposed.

Observational (cohort study, case–control) and interventional studies are anticipated to investigate the applications and outcomes of robotic surgery in emergency settings and to compare them with those obtained with laparoscopy and open surgery.

Future studies should evaluate patient preferences considering patient-related outcome measures (PROMs), including pain evaluation and mid-/long-term quality of life.

Future studies should evaluate the cost-effectiveness of robotic surgery implementation in emergency settings at hospital level (e.g., scheduling conflict alleviation) and at the level of the healthcare system (e.g., length of hospital stay, productivity losses, reimbursement systems).

Future studies should evaluate the applicability of the robotic surgical platforms to perform telementoring and telesurgery, which are theoretically promising technologies to expand the applications of robotic surgery.

With the aim to enrich the available evidence and fill knowledge gaps, the WSES plans to launch an open registry on emergency robotic general surgery. The WSES calls for an international participation, which is essential to gather sufficient data and obtain generalizable results.

The establishment of a dedicated registry is also mandatory to perform a deep analysis on this technique, in order to define the following: characteristics of the patient candidate for emergency robotic procedures, operative and postoperative outcomes, PROMs, minimum requisites in terms of personnel and equipment, cost-effectiveness, and ethical issues.

Hospitals that are currently equipped with a robotic surgical platform need to implement it efficiently. The role of robotic surgery for emergency procedures remains under investigation. However, its use is expanding despite the lack of evidence-based guidelines. In this scenario, the WSES wished to provide this position paper to the surgical community. This position paper summarizes the current evidence and practice and proposes consensus statements to be reevaluated and updated as the evidence in the supporting literature emerges. For now, the experts recommend a strict patient selection while approaching emergent general surgery procedures with robotics. However, an emergency setting should not be seen as a contraindication for robotic surgery if adequate training of the operating surgical team is available. When such prerequisites are met, robotic surgery can be considered safe and feasible, and surgical outcomes related to an MIS approach are expected. Finally, the application of the robotic surgical platform may grow with improvements in telementoring and telesurgery, which are particularly valuable in emergency settings.

Availability of data and materials

There are no data from individual authors that reach the criteria for availability.

Abbreviations

• Minimally invasive surgery

Newcastle–Ottawa Scale

Patient-related outcome measures

World Society of Emergency Surgery

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Acknowledgements

The authors are grateful to Guy Temporal and Christopher Burel, professionals in medical English proofreading, for their valuable help.

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GB, FM, and NdeA conducted the systematic review of the literature and wrote the first draft of the manuscript. All authors were involved in the statement evaluation and consensus process. All authors critically reviewed the manuscript and approved the final version. All authors read and approved the final manuscript.

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P Pessaux declared that he received consulting fees from 3M and Integra and has stock-options of Virtualisurg. E Kouwenhoven is proctor for Intuitive Surgical. M Sugrue received consulting fee with 3M, Smith and Nephew and Novus Scientific. G Spinoglio received honoraria as proctor for Intuitive Surgical. F. Ris reports research funding from Quantgene, personal fees from Arthrex, Stryker, Hollister, Fresenius Kabi and Distal Motion, outside the submitted work. E Espin Bsany received honoraria as proctor for Intuitive Surgical. JS Khan is a proctor for Intuitive Surgical. All other authors have no conflicts of interest to declare in relation to the matter of this publication.

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de’Angelis, N., Khan, J., Marchegiani, F. et al. Robotic surgery in emergency setting: 2021 WSES position paper. World J Emerg Surg 17 , 4 (2022). https://doi.org/10.1186/s13017-022-00410-6

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Body mass index influence on short-term perioperative results in robotic-assisted laparoscopic partial nephrectomy: a comprehensive systematic review and meta-analysis

• Published: 10 April 2024
• Volume 18 , article number  169 , ( 2024 )

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• Xiao-Bing Chen 1   na1 ,
• Qiu-Lin Du 1   na1 &
• Ping-Yu Zhu 1  

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The objective of this meta-analysis was to evaluate the perioperative outcomes of robotic-assisted partial nephrectomy (RAPN) in obese and non-obese patients. Through March 2024, we executed an exhaustive search in internationally acclaimed databases such as PubMed, Cochrane Library, and Web of Science, limiting our scope to publications in English. We discarded review articles, protocols lacking empirical data, conference abstracts, and materials not pertinent to our research. Our analytical framework utilized the Cochran–Mantel–Haenszel method alongside a random-effects model for evaluating dichotomous variables’ mean differences, expressed through odds ratios (OR) with 95% confidence intervals (CI). We established statistical significance at a P value below 0.05. The comprehensive meta-analysis incorporated data from eight cohort studies, collectively assessing 3657 patients. Findings indicated that, relative to individuals of normal weight, those in the obese category had prolonged operative durations (WMD − 25.68 95% CI − 42.07 to − 9.29; P  = 0.002), increased estimated blood loss (WMD − 48.55ml, 95% CI − 78.27 to − 18.83; P  = 0.001), and longer warm ischemia times (WMD − 1.11, 95% CI − 2.03 to − 0.19; P  = 0.02). However, no significant disparities were observed in hospital stay duration, intraoperative and total postoperative complications, severe postoperative complications, or alterations in postoperative estimated glomerular filtration rate (eGFR). Our findings conclude that robotic-assisted partial nephrectomy (RAPN) represents a viable and safe surgical approach for obese patients. This assertion is backed by the observation that crucial metrics, including postoperative renal function alterations, surgical complication rates, and hospitalization duration, exhibit no substantial variances when juxtaposed with counterparts of normal weight.

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Xiao-Bing Chen and Qiu-Lin Du equally contributed to this work.

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Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China

Xiao-Bing Chen, Qiu-Lin Du & Ping-Yu Zhu

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All authors participated in the conception and design of the study. Data collection and analysis were conducted by CXB and DQL. The initial draft of the manuscript was prepared by CXB. Subsequent revisions and critical intellectual content were provided by ZPY and DQL. All authors contributed to reviewing and providing feedback on earlier versions of the manuscript. Finally, all authors read and approved the final version of the manuscript for submission.

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Chen, XB., Du, QL. & Zhu, PY. Body mass index influence on short-term perioperative results in robotic-assisted laparoscopic partial nephrectomy: a comprehensive systematic review and meta-analysis. J Robotic Surg 18 , 169 (2024). https://doi.org/10.1007/s11701-024-01926-6

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DOI : https://doi.org/10.1007/s11701-024-01926-6

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A small robot car can reduce children's stress before surgery

by Open University of Catalonia

Undergoing medical treatment, having surgery or simply being admitted to hospital are situations that make children fearful and anxious, especially during early childhood. And in addition to having a short-term impact, their subsequent psychological, social and educational development may also be affected.

To overcome this problem, an international team of researchers working with Sant Joan de Déu Barcelona Children's Hospital have developed and tested a small robot vehicle that aims to reduce stress among children aged between 3 and 10 years old before they undergo minor surgical procedures.

According to the results of this first pilot test, this type of robot could be a successful strategy for reducing anxiety and fear before surgery, and could be an effective alternative to the medication strategies commonly used to relax children. The paper is published in the journal Companion of the 2024 ACM/IEEE International Conference on Human-Robot Interaction .

This first prototype also provides information about the potential and challenges involved in integrating affective technologies in pediatric hospital environments.

"Children are admitted to hospital, which is already an unwelcoming environment for them, and they have to go with people they don't know, like medical staff, and undergo unpleasant procedures, such as an injection. This all creates situations of stress which can end up causing chronic pain in the long term," explained Jordi Albo, the scientific director of Lighthouse DIG and co-principal investigator of the project.

"We try to minimize the stress that children experience during this process by using a robot car that changes color, makes music and creates smells, and talks to them and interacts with them," added this expert in social robots.

Children's stress before surgery

According to a study conducted by Sant Joan de Déu Barcelona Children's Hospital, 6 out of every 10 young patients who have to undergo surgery suffer from stress before they receive anesthesia. The hospital has explored various alternatives in order to improve the children's emotional state, ranging from doing activities and playing games with the children before surgery to therapies involving dogs and clowns, and even letting parents into the operating theater.

However, the most widely used strategy is usually pharmacological, which can paradoxically make the children's experience even more stressful due to the bitter taste of the drugs used and their side effects.

Previous studies had already shown that using small motorized electric vehicles is effective in reducing children's unease. The researchers used those results as the basis for developing their prototype, as well as the research on assisted driving for adults that was being carried out at the Massachusetts Institute of Technology (MIT) Media Lab.

"We installed AI and sensors in our robotic car, as well as a surface for interaction. This enables the car to capture the child's facial expressions, heart rate and breathing patterns, which are indicators of their emotions, and adapt to how the child is feeling by changing the music, or colors, or producing smells to help them relax," said Àgata Lapedriza, researcher at the Universitat Oberta de Catalunya (UOC), member of its Faculty of Computer Science, Multimedia and Telecommunications, and leader of the Artificial Intelligence for Human Wellbeing (AIWELL) research group at the UOC's eHealth Center.

The project is an example of affective computing, "which focuses on developing AI systems that perceive emotions, understand emotions and can respond to emotions in an emotionally intelligent way," emphasized Lapedriza, who led the project with Albo.

The participants involved in designing the vehicle included doctors, nurses and experts in affective computing, social robotics, data science , sensor design, machine learning and computer vision. The prototype was manufactured by the Hyundai car company in South Korea, and sent to Sant Joan de Déu Barcelona Children's Hospital, where it was tested with 86 children between 3 and 9 years old (mean age of 5.23 years) who had to undergo a procedure between December 2020 and May 2023.

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