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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 This was superseded in the 2000s by two comprehensive master–slave platforms: the da Vinci system (Intuitive Surgical, CA), an eponymous nod to Leonardo da Vinci’s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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Kayani   B , Konan   S , Tahmassebi   J , Pietrzak   J , Haddad   F . Robotic-arm assisted total knee arthroplasty is associated with improved early functional recovery and reduced time to hospital discharge compared with conventional jig-based total knee arthroplasty: a prospective cohort study . Bone Joint J   2018 ; 100 : 930 – 7 .

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Bravi   CA , Larcher   A , Capitanio   U , Mari   A , Antonelli   A , Artibani   W , et al.    Perioperative outcomes of open, laparoscopic, and robotic partial nephrectomy: a prospective multicenter observational study (The RECORd 2 Project) . Eur Urol Focus   2021 ; 7 : 390 – 6 .

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A systematic review of robotic surgery: From supervised paradigms to fully autonomous robotic approaches

Affiliations.

• 1 Hamlyn Centre for Robotic Surgery and Artificial Intelligence, Imperial College London, London, UK.
• 2 National Hospital for Neurology and Neurosurgery, London, UK.
• PMID: 34953033
• DOI: 10.1002/rcs.2358

Background: From traditional open surgery to laparoscopic surgery and robot-assisted surgery, advances in robotics, machine learning, and imaging are pushing the surgical approach to-wards better clinical outcomes. Pre-clinical and clinical evidence suggests that automation may standardise techniques, increase efficiency, and reduce clinical complications.

Methods: A PRISMA-guided search was conducted across PubMed and OVID.

Results: Of the 89 screened articles, 51 met the inclusion criteria, with 10 included in the final review. Automatic data segmentation, trajectory planning, intra-operative registration, trajectory drilling, and soft tissue robotic surgery were discussed.

Conclusion: Although automated surgical systems remain conceptual, several research groups have developed supervised autonomous robotic surgical systems with increasing consideration for ethico-legal issues for automation. Automation paves the way for precision surgery and improved safety and opens new possibilities for deploying more robust artificial intelligence models, better imaging modalities and robotics to improve clinical outcomes.

Keywords: robotic assisted surgery; robotic autonomy; supervised autonomous robotic surgery.

© 2021 John Wiley & Sons Ltd.

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The evolution of robotics: research and application progress of dental implant robotic systems

• Chen Liu   ORCID: orcid.org/0009-0000-1771-5430 1 , 2 , 3 , 4   na1 ,
• Yuchen Liu 1 , 2 , 3 , 4   na1 ,
• Rui Xie 1 , 2 , 3 , 4 ,
• Zhiwen Li 1 , 2 , 3 , 4 ,
• Shizhu Bai   ORCID: orcid.org/0000-0002-2439-3211 1 , 2 , 3 , 4 &
• Yimin Zhao 1 , 2 , 3 , 4  

International Journal of Oral Science volume  16 , Article number:  28 ( 2024 ) Cite this article

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The use of robots to augment human capabilities and assist in work has long been an aspiration. Robotics has been developing since the 1960s when the first industrial robot was introduced. As technology has advanced, robotic-assisted surgery has shown numerous advantages, including more precision, efficiency, minimal invasiveness, and safety than is possible with conventional techniques, which are research hotspots and cutting-edge trends. This article reviewed the history of medical robot development and seminal research papers about current research progress. Taking the autonomous dental implant robotic system as an example, the advantages and prospects of medical robotic systems would be discussed which would provide a reference for future research.

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The development of medical robots has been a long journey of exploration. After being practically validated in industrial robots, this technology has become widespread globally and is now an essential part of modern production and lifestyles. Medical robots are increasingly in the vanguard of the field in diagnosis, treatment, visualization, and other areas of clinical practice. We are currently witnessing a transformative shift from cutting-edge research to the widespread application of medical robots. This review focused on the historical trajectory of medical robots, with a particular emphasis on the development history, current research status, and prospects of dental implant robotic systems.

Definition and history of robots

Definition and architectures of robots.

According to the International Organization for Standardization (ISO), a robot is an automatic, position-controlled, programmable multi-functional manipulator with several axes. It can process various materials, parts, tools, and special devices through programmable automation to perform intended tasks. 1 A robot’s structure typically consists of four parts: the actuation system, the drive-transmission system, the control system, and the intelligent system. The actuation system is the part of the robot that directly performs work, similar to a human hand. The drive-transmission system transmits force and motion to the actuator through a power source. The control system comprises a control computer, control software, and servo controllers, similar to a human brain. The intelligent system typically includes a perception system and an analytical decision-making intelligent system.

Evolution of robots

The history of robots can be traced back over 3 000 years. 2 Throughout history, scientists and craftsmen have designed and manufactured robot prototypes that simulate animal or human characteristics. 1 However, these inventions can only be classified as mechanical devices that primarily achieved automated functions through mechanical and physical principles with the lack of intelligence and autonomy of modern robots. These inventions demonstrate the level of engineering technology and mechanical manufacturing in ancient times, laying the foundation for later research on robots. Joseph Engelberger, recognized as the Father of Robotics, founded Unimation Corporation in 1958, the world’s first robot-manufacturing factory, which marked the official start of the industrialization of robots. In 1978, Unimation developed a Programmable Universal Machine for Assembly (PUMA) which represents a significant milestone in the development of international industrial robotics. In recent years, robotics has expanded significantly due to the continued development of sensor types, intelligent algorithms, and multidisciplinary integration. The technology has advanced from the initial industrial robotic arms to bionic robots, soft robots, nanorobots, and other forms.

Classification of robotics

The International Federation of Robotics (IFR) classifies robotics into two distinct categories: industrial robotics and service robotics, in accordance with the international standard ISO 8373:2012. 3 Industrial robotics are multipurpose manipulators with automatic control and programmability, which can operate with fixed or autonomous mobility and are primarily used in industrial production. 3 Service robotics are driving mechanisms that can perform useful tasks but do not include industrial automation applications. The IFR has classified service robotics into different segments to meet the diverse requirements of various industries (Fig. 1 ).

Categories of robots according to the International Federation of Robotics

Medical robotics

In 1985, the Puma 200 robot (Westinghouse Electric, Pittsburgh, PA) was used for needle placement in computed tomography (CT)-guided brain biopsy at the Los Angeles Hospital in the United States, marking the beginning of the era of medical robot applications. 4 , 5 After nearly 40 years of continuous development and progress, medical robotics have been widely used in multiple fields, including surgery, nursing, and rehabilitation, demonstrating numerous remarkable advantages and potential.

Yang 6 , 7 , 8 has divided the level of autonomy of medical robotics into six levels, as follows: (0) no autonomy, (1) robot assistance, (2) task autonomy, (3) conditional autonomy, (4) high autonomy, and (5) full autonomy. At level 0, the robot requires operators to perform all tasks, including monitoring, generating performance options, selecting the option to perform (decision making), and executing the decision made, such as the da Vinci robotic system (Intuitive Inc., California, USA). At level 1, operators are required to continuously control the robot while the robot provides guidance with positional constraints. The Mako Smart Robotics used in orthopedic surgery is an example. At level 2, operators are required to discretely rather than continuously control the robot, and the robot can independently complete specific tasks based on operator instructions and pre-programmed procedures. An example of this level is the ROBODOC, which performs total hip and total knee replacement surgeries. At level 3, robots have the ability to perform surgeries based on pre-programmed procedures and can also modify the pre-planned schedule in real time to accommodate changes in the intraoperative position of the target object. An example of such robotics is the CyberKnife radiation therapy robotics, which has respiratory tracking functionality. At the higher levels of autonomy (specifically level 5 and possibly level 4), the robot is not only a medical device but also capable of practicing medicine, which currently does not exist due to some regulatory, ethical, and legal considerations. 6 , 7 , 8

Medical robotics are classified by IFR as special robotics with a combination of medical diagnosis methods with new technologies, such as artificial intelligence (AI) and big data, to provide services such as surgery, rehabilitation, nursing, medical transportation, and consultation for patients. 9 Medical robotics are categorized into the following five types based on their functions: surgical robotics, rehabilitation robotics, diagnostic robotics, laboratory analysis automation, and other robotics (robotics used for medical transportation are not included in this category).

Surgical robotics

Minimally invasive surgery and accurate intervention require surgeons to exercise more discernment, expand their range of vision, and increase their flexibility which brings the surgical robotics development (the surgical robot architecture 10 was shown in Fig. 2 ). Not only can it be equipped with an advanced three-dimensional (3D) imaging system and augmented reality technology to provide high-definition images of the surgical scene, but it is also capable of displaying important anatomical structures such as blood vessel and nerve locations in real-time. This allows surgeons to perform precise operations with the assistance of robots. For higher-level automatic medical robots, precise surgical operations are performed through image guidance and navigation systems based on preoperative planning. Moreover, the robotic arm has a high level of precision and stability that surpasses the capabilities of a free hand. This allows it to perform small and delicate operations with reduced errors caused by physician experience, fatigue, and hand tremors. In addition, the surgical robot also integrates artificial intelligence technology, which can perform automatic diagnostic analysis, adjust surgical strategies, and provide personalized surgical plans through deep learning. 11 Therefore, surgical robots could utilize vision, speech recognition, telecommunication, 3D imaging, and artificial intelligence technologies to enhance surgical skills through sensing and image guidance systems. This overcomes the limitations of manual operations and improves surgical accuracy and reliability. In comparison to conventional surgery, robotic-assisted surgery could reduce trauma, shorten recovery periods, and relieve pain. 12 , 13 Additionally, it can be used for remote surgery, operates continuously without fatigue, reduces the workload of medical staff, and minimizes occupational exposure for surgeons. Medical robotics have gradually entered the commercialization stage and have been utilized in clinical settings (Table 1 ). Currently, the most well-known surgical robot is the da Vinci system, which enables surgeons to accurately and minimally perform invasive surgery for multiple complicated diseases with good hand-eye coordination and magnification.

The surgical robotic architecture

Dental treatment involves the special anatomical structure of the mouth and is characterized by limited visibility, narrow operation space, and the disturbance of saliva and tongue. As a result, the dental operation is intricate and mainly reliant on the surgeon’s experience and expertize, which takes inexperienced surgeons a long time to acquire. With the successful use of the da Vinci robotic system in laparoscopic surgery, surgeons are beginning to consider its potential application in maxillofacial surgery. Da Vinci robot has been used for cleft palate repair, 14 , 15 treating patients with obstructive sleep apnea-hypopnea syndrome (OSAHS), 16 as well as oral and oropharyngeal tumor resection. 17 , 18 However, due to the complexity of the oropharyngeal anatomy, the multiple robotic arms of the da Vinci system limit the surgeon’s vision, which is not conducive to surgical performance. In order to overcome these shortcomings, flexible robots (such as The Flex) approved by the Food and Drug Administration have made it possible to be used for oropharyngeal surgery. Additionally, oral and cranio-maxillofacial bone surgery, such as orthognathic surgery and dental implant surgery, requires accurate ostomies, which cannot be achieved by the da Vinci system. Robotic-assisted dental implant surgery research originated in 2001, and related studies have shown a gradual increase in recent years. In addition to conventional implant surgery, dental implant robotics can also perform zygomatic implant placement. 19 , 20 Among these studies, the largest number of articles were published in China, followed by the United States (Fig. 3 ). In Part 3 of this article, the relevant studies on dental implant robotics will be elaborated in detail.

Related research on robotic-assisted dental implant placement. a The number of published papers on dental implant robotics in different years and b in different countries (as of December 2023)

Rehabilitation robotics

Rehabilitation robotics are significant area and research hotspot in medical robotics, second only to surgical robotics. Rehabilitation robotics are classified into two categories, as follows: therapeutic and assistive robotics. Therapeutic robotics provide psychological or physical treatment to improve specific functions of patients and are widely used in physical training and functional recovery of patients with paralysis and in improving the interactive ability of children with autism through behavioral induction. 21 Assistive robotics aim to improve the quality of life for individuals with musculoskeletal or neuromuscular impairments by compensating for or replacing their mobility or functionality. 22 , 23 , 24 For instance, Mike Topping’s Handy1 assists the most severely disabled with several everyday functions. 25 Similarly, Israel’s ReWalk provides powered hip and knee motion to enable individuals with spinal cord injury to stand upright, walk, turn, climb, and descend stairs. 26 Moreover, Japan’s wearable powered prosthesis, HAL, can enable patients to control joint movements independently by detecting bioelectrical signals on the skin surface during movement, in combination with foot pressure sensors. 27

Diagnostic robotics

Diagnostic robotics aid doctors in conducting examinations and making diagnoses, with the aim of improving accuracy, convenience, non-invasiveness, and safety of diagnosis. For instance, wireless capsule endoscopy introduced by Given Imaging (now Medtronic) allows minimally invasive inspection of the gastrointestinal tract. Patients can swallow a pillcam that captures images deep within the intestines, which has revolutionized gastrointestinal endoscopy and is now a clinically viable alternative to standard interventional endoscopy. Furthermore, wearable robotics are increasingly being utilized to non-invasively detect various health indicators and assist in disease diagnosis.

Laboratory robotics

Laboratory robotics handle and analyze samples in medical laboratories. Innovations in robotics and information technologies have created new opportunities for laboratory automation. These robots tirelessly and accurately perform tasks, improving the precision and reliability of experiments while reducing costs. At the University of Virginia Medical Center, robots operate instruments and analyze blood gases and electrolytes in the hospital laboratory. In addition, the robotic system works continuously, not only improving laboratory efficiency but also reducing the burden on laboratory techniques. 28 Nicole Rupp, based in Germany, has utilized the Dobot Magician robot to develop an economical automated laboratory system that coordinates various instruments for experiments. The results obtained from this system were not statistically different from those obtained from manual experiments. 29

Other medical robotics

The medical field has witnessed a significant increase in the use of robotics, leading to the development of new types of robots and functions to cater to the requirements of doctors and patients. Other medical robotics include providing non-medical operational services, such as assisting nurses with guidance, transportation, cleaning, inspection, monitoring, and disinfection. Moreover, robotics could be available for daily home care, providing assistance, monitoring behavior and health, as well as offering companionship for older individuals. 30 Furthermore, there are robots specifically designed to train emergency personnel. These robots can simulate complex trauma scenarios with multiple injuries in a highly accurate manner. 31 Robotic surgery simulation practice can be combined with virtual reality (VR), 3D-printed organ tissue models, or anesthetized live animals to rapidly improve the robotic surgical skills required by novice surgeons. In addition, to pandemics such as Ebola and COVID-19, the use of sampling robotics can effectively reduce the risk of infection. There are robots also designed for emergency rescue, medical education, and training. 32 , 33 Soft robotics, bionic robotics, nanorobots, and other robotics suitable for various functional needs are also hot topics in current medical robotic research, and they exhibit the typical characteristics of specialization, personalization, remoteness, intelligence, and immersion.

Dental implant robotic system

Implantology is widely considered the preferred treatment for patients with partial or complete edentulous arches. 34 , 35 The success of the surgery in achieving good esthetic and functional outcomes is directly related to correct and prosthetically-driven implant placement. 36 Accurate implant placement is crucial to avoid potential complications such as excessive lateral forces, prosthetic misalignment, food impaction, secondary bone resorption, and peri-implantitis. 37 Any deviation during the implant placement can result in damage to the surrounding blood vessels, nerves, and adjacent tooth roots and even cause sinus perforation. 38 Therefore, preoperative planning must be implemented intraoperatively with utmost precision to ensure quality and minimize intraoperative and postoperative side effects. 39

Currently, implant treatment approaches are as follows: Free-handed implant placement, Static computer-aided implant placement, and dynamic computer-aided implant placement. The widely used free-handed implant placement provides less predictable accuracy and depends on the surgeon’s experience and expertise. 40 Deviation in implant placement is relatively large among surgeons with different levels of experience. When novice surgeons face complex cases, achieving satisfactory results can be challenging. A systematic review 41 based on six clinical studies indicated that the ranges of deviation of the platform, apex, and angle from the planned position with free-handed implant placement were (1.25 ± 0.62) mm–(2.77 ± 1.54) mm, (2.10 ± 1.00) mm–(2.91 ± 1.52) mm, and 6.90°± 4.40°–9.92°± 6.01°, respectively. Static guides could only provide accurate guidance for the initial implantation position. However, it is difficult to precisely control the depth and angle of osteotomies. 42 The lack of real-time feedback on drill positioning during surgery can limit the clinician’s ability to obtain necessary information. 42 , 43 , 44 Besides, surgical guides may also inhibit the cooling of the drills used for implant bed preparation, which may result in necrosis of the overheated bone. Moreover, the use of static guides is limited in patients with limited accessibility, especially for those with implants placed in the posterior area. Additionally, the use of guides cannot flexibly adjust the implant plan intraoperatively. With dynamic computer-aided implant placement, the positions of the patient and drills could be tracked in real-time and displayed on a computer screen along with the surgical plan, thus allowing the surgeon to adjust the drilling path if necessary. However, the surgeons may deviate from the plan or prepare beyond it without physical constraints. During surgery, the surgeon may focus more on the screen for visual information rather than the surgical site, which can lead to reduced tactile feedback. 45 The results of a meta-analysis showed that the platform deviation, apex deviation, and angular deviation were 0.91 mm (95% CI 0.79–1.03 mm), 1.26 mm (95% CI 1.14–1.38 mm), and 3.25° (95% CI 2.84°–3.66°) respectively with the static computer-aided implant placement, and 1.28 mm (95% CI 0.87–1.69 mm), 1.68 mm (95% CI 1.45–1.90 mm), and 3.79° (95% CI 1.87–5.70°), respectively, with dynamic computer-aided implant placement. The analysis results showed that both methods improved the accuracy compared to free-handed implant placement, but they still did not achieve ideal accuracy. 46 Gwangho et al. 47 believe that the key point of a surgical operation is still manually completed by surgeons, regardless of static guide or dynamic navigation, and the human factors (such as hand tremble, fatigue, and unskilled operation techniques) also affect the accuracy of implant placement.

Robotic-assisted implant surgery could provide accurate implant placement and help the surgeon control handpieces to avoid dangerous tool excursions during surgery. 48 Furthermore, compared to manual calibration, registration, and surgery execution, automatic calibration, registration, and drilling using the dental implant robotic system reduces human error factors. This, in turn, helps avoid deviations caused by surgeons’ factors, thereby enhancing surgical accuracy, safety, success rates, and efficiency while also reducing patient trauma. 7 With the continuous improvement of technology and reduction of costs, implant robotics are gradually becoming available for commercial use. Yomi (Neocis Inc., USA) has been approved by the Food and Drug Administration, while Yakebot (Yakebot Technology Co., Ltd., Beijing, China), Remebot (Baihui Weikang Technology Co., Ltd, Beijing, China), Cobot (Langyue dental surgery robot, Shecheng Co. Ltd., Shanghai, China), Theta (Hangzhou Jianjia robot Co., Ltd., Hangzhou, China), and Dcarer (Dcarer Medical Technology Co., Ltd, Suzhou, China) have been approved by the NMPA. Dencore (Lancet Robotics Co., Ltd., Hangzhou, China) is in the clinical trial stage in China.

Basic research on dental implant robotic system

Compared to other surgeries performed with general anesthesia, dental implant surgery can be completed under local anesthesia, with patients awake but unable to remain completely still throughout the entire procedure. Therefore, research related to dental implant robotic system, as one of the cutting-edge technologies, mainly focuses on acquiring intraoperative feedback information (including tactile and visual information), different surgical methods (automatic drilling and manual drilling), patient position following, and the simulation of surgeons’ tactile sensation.

Architecture of dental implant robotic system

The architecture of dental implant robotics primarily comprises the hardware utilized for surgical data acquisition and surgical execution (Fig. 4 ). Data acquisition involves perceiving, identifying, and understanding the surroundings and the information required for task execution through the encoders, tactile sensors, force sensors, and vision systems. Real-time information obtained also includes the robot’s surrounding environment, object positions, shapes, sizes, surface features, and other relevant information. The perception system assists the robot in comprehending its working environment and facilitates corresponding decision-making as well as actions.

The architecture of dental implant robotics

During the initial stage of research on implant robotics, owing to the lack of sensory systems, fiducial markers and corresponding algorithms were used to calculate the transformation relationship between the robot’s and the model’s coordinate system. The robot was able to determine the actual position through coordinate conversions. Dutreuil et al. 49 proposed a new method for creating static guides on casts using robots based on the determined implant position. Subsequently, Boesecke et al. 50 developed a surgical planning method using linear interpolation between start and end points, as well as intermediate points. The surgeon performed the osteotomies by holding the handpieces, with the robot guidance based on preoperatively determined implant position. Sun et al. 51 and McKenzie et al. 52 registered cone-beam computed tomography (CBCT) images, the robot’s coordinate system, and the patient’s position using a coordinate measuring machine, which facilitated the transformation of preoperative implant planning into intraoperative actions.

Neocis has developed a dental implant robot system called Yomi (Neocis Inc.) 53 based on haptic perception and connects a mechanical joint measurement arm to the patient’s teeth to track their position. The joint encoder provides information on the drill position, while the haptic feedback of handpieces maneuvered by the surgeon constrains the direction and depth of implant placement.

Optical positioning is a commonly used localization method that offers high precision, a wide -field -of -view, and resistance to interference. 54 This makes it capable of providing accurate surgical guidance for robotics. Yu et al. 55 combined image-guided technology with robotic systems. They used a binocular camera to capture two images of the same target, extract pixel positions, and employ triangulation to obtain three-dimensional coordinates. This enabled perception of the relative positional relationship between the end-effector and the surrounding environment. Yeotikar et al. 56 suggested mounting a camera on the end-effector of the robotic arm, positioned as close to the drill as possible. By aligning the camera’s center with the drill’s line of sight at a specific height on the lower jaw surface, the camera’s center accurately aligns with the drill’s position in a two-dimensional space at a fixed height from the lower jaw. This alignment guides the robotic arm in drilling through specific anatomical landmarks in the oral cavity. Yan et al. 57 proposed that the use of “eye-in-hand” optical navigation systems during surgery may introduce errors when changing the handpiece at the end of the robotic arm. Additionally, owing to the narrow oral environment, customized markers may fall outside the camera’s field of view when the robotic arm moves to certain positions. 42 To tackle this problem, a dental implant robot system based on optical marker spatial registration and probe positioning strategies is designed. Zhao et al constructed a modular implant robotic system based on binocular visual navigation devices operating on the principles of visible light with “eye-to-hand” mode, allowing complete observation of markers and handpieces within the camera’s field of view, thereby ensuring greater flexibility and stability. 38 , 58

The dental implant robotics execution system comprises hardware such as motors, force sensors, actuators, controllers, and software components to perform tasks and actions during implant surgery. The system receives commands, controls the robot’s movements and behaviors, and executes the necessary tasks and actions. Presently, research on dental implant robotic systems primarily focuses on the mechanical arm structure and drilling methods.

The majority of dental implant robotic systems directly adopt serial-linked industrial robotic arms based on the successful application of industrial robots with the same robotic arm connection. 59 , 60 , 61 , 62 These studies not only establish implant robot platforms to validate implant accuracy and assess the influence of implant angles, depths, and diameters on initial stability but also simulate chewing processes and prepare natural root-shaped osteotomies based on volume decomposition. Presently, most dental implant robots in research employ a single robotic arm for surgery. Lai et al. 62 indicated that the stability of the handpieces during surgery and real-time feedback of patient movement are crucial factors affecting the accuracy of robot-assisted implant surgery. The former requires physical feedback, while the latter necessitates visual feedback. Hence, they employed a dual-arm robotic system where the main robotic arm was equipped with multi-axis force and torque sensors for performing osteotomies and implant placement. The auxiliary arm consisted of an infrared monocular probe used for visual system positioning to address visual occlusion issues arising from changes in arm angles during surgery.

The robots mentioned above use handpieces to execute osteotomies and implant placement. However, owing to limitations in patient mouth opening, performing osteotomies and placing implants in the posterior region can be challenging. To overcome the spatial constraints during osteotomies in implant surgery, Yuan et al. 63 proposed a robot system based on earlier research which is laser-assisted tooth preparation. This system involves a non-contact ultra-short pulse laser for preparing osteotomies. The preliminary findings confirmed the feasibility of robotically controlling ultra-short pulse lasers for osteotomies, introducing a novel method for a non-contact dental implant robotic system.

Position following of dental implant robotic system

It can be challenging for patients under local anesthesia to remain completely still during robot-assisted dental implant surgery. 52 , 64 , 65 , 66 , 67 Any significant micromovement in the patient’s position can severely affect clinical surgical outcomes, such as surgical efficiency, implant placement accuracy compared to the planned position, and patient safety. Intraoperative movement may necessitate re-registration for certain dental implant robotic systems. In order to guarantee safety and accuracy during surgery, the robot must detect any movement in the patient’s position and promptly adjust the position of the robotic arm in real time. Yakebot uses binocular vision to monitor visual markers placed outside the patient’s mouth and at the end of the robotic arm. This captures motion information and calculates relative position errors. The robot control system utilizes preoperatively planned positions, visual and force feedback, and robot kinematic models to calculate optimal control commands for guiding the robotic arm’s micromovements and tracking the patient’s micromovements during drilling. As the osteotomies are performed to the planned depth, the robotic arm compensates for the patient’s displacement through the position following the function. The Yakebot’s visual system continuously monitors the patient’s head movement in real time and issues control commands every 0.008 s. The robotic arm is capable of following the patient’s movements with a motion servo in just 0.2 s, ensuring precise and timely positioning.

The simulation of surgeons’ tactile sensation in dental implant robotic systems

Robot-assisted dental implant surgery requires the expertise and tactile sense of a surgeon to ensure accurate implantation. Experienced surgeons can perceive bone density through the resistance they feel in their hands and adjust the force magnitude or direction accordingly. This ensures proper drilling along the planned path. However, robotic systems lack perception and control, which may result in a preference for the bone side with lower density. This can lead to inaccurate positioning compared to the planned implant position. 61 , 62 Addressing this challenge, Li et al. 68 established force-deformation compensation curves in the X, Y, and Z directions for the robot’s end-effector based on the visual and force servo systems of the autonomous dental robotic system, Yakebot. Subsequently, a corresponding force-deformation compensation strategy was formulated for this robot, thus proving the effectiveness and accuracy of force and visual servo control through in vitro experiments. The implementation of this mixed control mode, which integrates visual and force servo systems, has improved the robot’s accuracy in implantation and ability to handle complex bone structures. Based on force and visual servo control systems, Chen et al. 69 have also explored the relationship between force sensing and the primary stability of implants placed using the Yakebot autonomous dental robotic system through an in vitro study. A significant correlation was found between Yakebot’s force sensing and the insertion torque of the implants. This correlation conforms to an interpretable mathematical model, which facilitates the predictable initial stability of the implants after placement.

During osteotomies with heat production (which is considered one of the leading causes of bone tissue injury), experienced surgeons could sense possible thermal exposure via their hand feeling. However, with free-handed implant placement surgery, it is challenging to perceive temperature changes during the surgical process and establish an effective temperature prediction model that relies solely on a surgeon’s tactile sense. Zhao et al. 70 , using the Yakebot robotic system, investigated the correlation between drilling-related mechanical data and heat production and established a clinically relevant surrogate for intraosseous temperature measurement using force/torque sensor-captured signals. They also established a real-time temperature prediction model based on real-time force sensor monitoring values. This model aims to effectively prevent the adverse effects of high temperatures on osseointegration, laying the foundation for the dental implant robotic system to autonomously control heat production and prevent bone damage during autonomous robotic implant surgery.

The innovative technologies mentioned above allow dental implant robotic systems to simulate the tactile sensation of a surgeon and even surpass the limitations of human experience. This advancement promises to address issues that free-handed implant placement techniques struggle to resolve. Moreover, this development indicates substantial progress and great potential for implantation.

Clinical research on dental implant robotic systems

Clinical workflow of dental implant robotic systems.

The robotic assistant dental implant surgery consists of three steps: preoperative planning, intraoperative phase, and postoperative phase (Fig. 5 ). For preoperative planning, it is necessary to obtain digital intraoral casts and CBCT data from the patient, which are then imported into preoperative planning software for 3D reconstruction and planning implant placement. For single or multiple tooth gaps using implant robotic systems (except Yakebot), 61 , 62 , 71 , 72 a universal registration device (such as the U-shaped tube) must be worn on the patients’ missing tooth site using a silicone impression material preoperatively to acquire CBCT data for registration. The software performs virtual placement of implant positions based on prosthetic and biological principles of implant surgery, taking into account the bone quality of the edentulous implant site to determine the drilling sequence, insertion depth of each drill, speed, and feed rate. For single or multiple tooth implants performed using Yakebot, there is no need for preoperative CBCT imaging with markers. However, it is necessary to design surgical accessories with registration holes, brackets for attaching visual markers, and devices for assisting mouth opening and suction within the software (Yakebot Technology Co., Ltd., Beijing, China). These accessories are manufactured using 3D printing technology.

Clinical workflow of robotic-assisted dental implant placement

For the intraoperative phase, the first step is preoperative registration and calibration. For Yakebot, the end-effector marker is mounted to the robotic arm, and the spatial positions are recorded under the optical tracker. The calibration plate with the positioning points is then assembled into the implant handpiece for drill tip calibration. Then, the registration probe is inserted in the registration holes of the jaw positioning plate in turn for spatial registration of the jaw marker and the jaw. Robot-assisted dental implant surgery usually does not require flapped surgery, 73 , 74 , yet bone grafting due to insufficient bone volume in a single edentulous space or cases of complete edentulism requiring alveolar ridge preparation may require elevation of flaps. For full-arch robot-assisted implant surgery, a personalized template with a positioning marker is required and should be fixed with metallic pins for undergoing an intraoperative CBCT examination, thus facilitating the robot and the jaws registration in the visual space and allowing the surgical robot to track the patient’s motion. The safe deployment of a robot from the surgical site is an essential principle for robot-assisted implant surgery. In the case of most robots, such as Yomi, the surgeon needs to hold the handpieces to control and supervise the robot’s movement in real time and stop the robotic arm’s movement in case of any accidents. With Yakebot, the entire surgery is performed under the surgeon’s supervision, and immediate instructions are sent in response to possible emergencies via a foot pedal. Additionally, the recording of the entrance and exit of the patient’s mouth ensures that the instruments would not damage the patient’s surrounding tissues. The postoperative phase aims at postoperative CBCT acquisition and accuracy measurement.

In clinical surgical practice, robots with varying levels of autonomy perform implant surgeries differently. According to the autonomy levels classified by Yang et al. 6 , 8 , 33 for medical robots, commercial dental implant robotic systems (Table 2 ) currently operate at the level of robot assistance or task autonomy.

The robot-assistance dental implant robotic systems provide haptic, 75 visual or combined visual and tactile guidance during dental implant surgery. 46 , 76 , 77 Throughout the procedure, surgeons must maneuver handpieces attached to the robotic guidance arm and apply light force to prepare osteotomies. 62 The robotic arm constrains the 3D space of the drill as defined by the virtual plan, enabling surgeons to move the end of the mechanical arm horizontally or adjust its movement speed. However, during immediate implant placement or full-arch implant surgery, both surgeons and robots may struggle to accurately perceive poor bone quality, which should prompt adjustments at the time of implant placement. This can lead to incorrect final implant positions compared to the planned locations.

The task-autonomous dental implant robotic systems can autonomously perform partial surgical procedures, such as adjusting the position of the handpiece to the planned position and preparing the implant bed at a predetermined speed according to the pre-operative implant plan, and surgeons should send instructions, monitor the robot’s operation, and perform partial interventions as needed. For example, the Remebot 77 , 78 requires surgeons to drag the robotic arm into and out of the mouth during surgery, and the robot automatically performs osteotomies or places implants according to planned positions under the surgeon’s surveillance. The autonomous dental implant robot system, Yakebot, 73 , 79 , 80 can accurately reach the implant site and complete operations such as implant bed preparation and placement during surgery. It can be controlled by the surgeon using foot pedals and automatically stops drilling after reaching the termination position before returning to the initial position. Throughout the entire process, surgeons only need to send commands to the robot using foot pedals.

Clinical performance of robot-assisted implant surgery

Figure 6 shows the results of accuracy in vitro, in vivo, and clinical studies on robot-assisted implant surgery. 20 , 46 , 48 , 55 , 62 , 64 , 67 , 68 , 69 , 70 , 71 , 72 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 The results suggest that platform and apex deviation values are consistent across different studies. However, there are significant variations in angular deviations among different studies, which may be attributed to differences in the perception and responsiveness to bone quality variances among different robotic systems. Therefore, future development should focus on enhancing the autonomy of implant robots and improving their ability to recognize and respond to complex bone structures.

Accuracy reported in studies on robotic-assisted implant placement

Xu et al. 77 conducted a phantom experimental study comparing the implant placement accuracy in three levels of dental implant robotics, namely passive robot (Dcarer, level 1), semi-active robot (Remebot, level 2), and active robot (Yakebot, level 2) (Fig. 7 ). The study found that active robot had the lowest deviations at the platform and apex of the planned and actual implant positions, While the semi-active robot also had the lowest angular deviations. Chen et al. 46 and Jia et al. 79 conducted clinical trials of robotic implant surgery in partially edentulous patients using a semi-active dental implant robotic system (level 1) and an autonomous dental implant robot (level 2). The deviations of the implant platform, apex, and angle were (0.53 ± 0.23) mm/(0.43 ± 0.18) mm, (0.53 ± 0.24) mm/(0.56 ± 0.18) mm and 2.81° ± 1.13°/1.48° ± 0.59°, respectively. These results consistently confirmed that robotic systems can achieve higher implant accuracy than static guidance and that there is no significant correlation between accuracy and implant site (such as anterior or posterior site). The platform and angle deviation of autonomous dental implant robots were smaller than those of semi-active dental implant robotic systems. Li et al. 73 reported the use of the autonomous dental implant robot (level 2) to complete the placement of two adjacent implants with immediate postoperative restoration. The interim prosthesis fabricated prior to implant placement was seated without any adjustment, and no adverse reactions occurred during the operation.

Comparison of accuracy of dental implant robotics with different levels of autonomy (phantom experiments) (* P  < 0.05, ** P  < 0.01, *** P  < 0.001)

Bolding et al., 53 Li et al., 20 Jia et al., 79 and Xie et al. 90 used dental implant robots to conduct clinical trials in full-arch implant surgery with five or six implants placed in each jaw. The deviations of implant platform, apex, and angle are shown in Fig. 8 . The haptic dental implant robot (level 1) used by Bolding et al., 53 achieved more deviations compared to other studies that used semi-active (level 1) or active robots (level 2). As its handpiece must be maneuvered by the surgeon, human errors such as surgeon fatigue may not be avoided. Owing to the parallel common implant placement paths between various implant abutments, prefabricated temporary dentures could be seated smoothly, and some patients wore temporary complete dentures immediately after surgery. These results indicate that robotic systems can accurately locate and perform implant placement during surgery.

Comparison of accuracy in robotic-assisted full-arch implant placement

As there are relatively few studies of implant robots in clinical applications, Tak ́acs et al. 91 conducted a meta-analysis under in vitro conditions with free-handed, static-guided, dynamic navigated, and robotic-assisted implant placements, as shown in Fig. 9 . It was found that, compared to free-handed, static guided and dynamic navigated implant placements, robotic-assisted implant placements have more advantages in terms of accuracy. However, in vitro studies cannot fully simulate the patients’ oral condition and bone quality. Recent clinical studies 89 , 92 , 93 have shown a lower deviation in robotic-assisted implant placements compared to static-guided and dynamic-navigated implant placements. Common reasons for deviations in static-guided and dynamic-navigated implant placements include the following: deflection caused by hand tremors due to dense bone during surgery, surgeons’ experience, and other human factors. Larger clinical studies will be needed in the future to evaluate the differences between robotic and conventional surgical approaches and to provide guidance for the further development and refinement of robotic techniques.

Comparison of accuracy of free-handed, static, dynamic, and robotic-assisted implant placement. (FHIP free-hand implant placement, SCAIP static computer-aided implant placement, DCAIP dynamic computer-aided implant placement, RAIP robot-assisted implant placement)

For the long-term follow-up performance of robotic systems used in dental implant procedures, none of the comparative studies was longer than a year. One 1-year prospective clinical study by Xie et al. 90 showed that the peri-implant tissues after robot-assisted full arch surgery at 1-year visit remained stable. There is little evidence indicating clinical outcomes especially for patient-reported outcomes. A more detailed clinical assessment should be included for further research.

Current issues with dental implant robotic systems

Need for further simplification of robotic surgical procedures.

Although robotic-assisted dental implant surgery can improve accuracy and treatment quality, 94 it involves complex registration, calibration, and verification procedures that prolong the duration of surgery. These tedious processes may introduce new errors, 61 and lower work efficiency, especially in single tooth implant placement 62 that could extend visit times and affect patient satisfaction. 62 Besides, surgeons are required to undergo additional training to familiarize themselves with the robotic system. 87

Need for improved flexibility of dental implant robotic system

During implantation, the drill tips at the end of the robotic arms cannot be tilted, and this can increase the difficulty of using robots in posterior sections with limited occlusal space. 61 , 62 In addition, currently available marker systems require patients to wear additional devices to hold the marker in place. If these markers are contaminated or obstructed by blood, the visual system may not be able to detect them, limiting surgical maneuverability to some extent. During immediate implant placement or in cases of poor bone quality in the implant site, the drill tips may deviate towards the tooth sockets or areas of lower bone density, seriously affecting surgical precision.

Currently, only one study has developed a corresponding force-deformation compensation strategy for robots, 68 but clinical validation is still lacking. Additionally, the dental implant robotic system, along with other dental implant robots developed for prosthetics, endodontics, and orthodontics, is currently single-functional. Multi-functional robots are required for performing various dental treatments.

Difficulties in promoting the use of dental implant robotic system

Despite the enormous potential of robotic systems in the medical field, similar to the development of computer-aided design/computer-aided manufacturing technology, introducing and applying this technology faces multiple challenges in the initial stages. The high cost of robotic equipment may limit its promotion and application in certain regions or medical institutions. Surgeons require specialized technical training before operating robotic systems, which translates to additional training costs and time investment. 95

Prospects in the use of dental implant robotic system

Medical robots possess high-precision sensing and positioning capabilities, which enable precise operations at small scales. They are also equipped with safety mechanisms and stability controls to ensure the safety of medical procedures and reduce risks to patients. As technology evolves, hardware and algorithms are continuously updated, resulting in constant performance improvements. Today, medical robots are widely used in surgery, diagnosis, and rehabilitation. 7 They enable precise and minimally invasive operation, thus reducing patient trauma and pain, shortening hospitalization, and speeding recovery, as well as reducing the need for re-operations and blood transfusions. 96 In addition, medical robots can reduce radiation exposure for both surgeons and patients. By leveraging machine learning and artificial intelligence technologies, robots can provide personalized and intelligent treatment plans and recommendations based on large amounts of data, improving diagnostic efficiency. Robots with remote operation capabilities can enable remote surgeries or consultations across regions, facilitating access to medical services. Moreover, robots can work continuously, ensuring medical quality and consistency while reducing surgeons ’neck and back pain, 97 as well as numbness in the hands and wrists experienced by surgeons. 98 Besides, they also reduce mental and physical stress, improving surgeons’ quality of life and extending their career longevity.

From da Vinci surgical robotic system to dental implant robotic system, these innovative technologies are leading unprecedented changes in the medical field. Dental implant robotic system continuously improves software modules and optimizes operating procedures to become more intelligent, more flexible and easier to learn and use. In the future, more extensive clinical trials will be needed to continuously observe and evaluate the long-term outcomes of robot-assisted implant surgery, especially in multi-center clinical trials. Moreover, measured outcomes must include well-defined clinical outcomes (such as pathophysiology 99 ), technical outcomes (including those derived from robotic kinematic and haptic sensors 100 ), patient-reported outcomes (such as quality-of-life indicators and overall satisfaction with treatment 99 ), and wider outcomes that reflect potential robotic disruption (ergonomic benefits, impacts on accessibility to surgery 100 ) where relevant. In addition, the evaluation of dental implant robots requires the analysis of learning curves. Large prospective cohorts provide the first opportunity to capture real-world learning curves, which can be used to develop training mechanisms that shorten learning curves and minimize any negative impact on patients. 99 , 100

As a pioneering attempt, the dental implant robotic system provides an important exploration and paradigm for the application of another dental robotic system. As technology continues to advance, robotics and artificial intelligence will provide more precise diagnostic and treatment options, more intelligent medical decision support systems, as well as more flexible and precise surgical procedures. These revolutionary technologies will continue to drive advances in medicine and healthcare, opening up new possibilities for future clinical practice.

With novel technology advancements, medical robotics are bringing a new era to medicine. Innovative medical robotics can perform surgical procedures, aid rehabilitation, make diagnoses, achieve robotic laboratory automation and other robots suitable for various functional needs. In the field of dentistry, the most widely utilized robotic system presently is the dental implant robotic system. Implant robotic systems could offer a more flexible approach for the precise planning, and visual and haptic guidance of surgical procedures. Various clinical trials have confirmed the high accuracy of implant robotic-assisted surgery achieved and toward long-term implant success. However, there is still much room for improvement in terms of further simplification, the flexibility of robotic surgical procedures, and systematic education. By leveraging machine learning and artificial intelligence technologies, more precise diagnostic and treatment options, intelligent medical decision support systems, and flexible and precise surgical procedures will be provided for future clinical practice.

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This work was supported by the National Natural Science Foundation of China [grant number 81970987].

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State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Xi’an, China

Chen Liu, Yuchen Liu, Rui Xie, Zhiwen Li, Shizhu Bai & Yimin Zhao

National Clinical Research Center for Oral Diseases, Xi’an, China

Shaanxi Key Laboratory of Stomatology, Xi’an, China

Digital Center, School of Stomatology, The Fourth Military Medical University, Xi’an, China

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Liu, C., Liu, Y., Xie, R. et al. The evolution of robotics: research and application progress of dental implant robotic systems. Int J Oral Sci 16 , 28 (2024). https://doi.org/10.1038/s41368-024-00296-x

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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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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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• 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.

No funding or resources was received for the preparation of this article. The authors received a WSES institutional waiver for this publication.

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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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The emerging role of robotics in plastic and reconstructive surgery: a systematic review and meta-analysis

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The role of robotics has grown exponentially. There is an active interest amongst practitioners in the transferability of the potential benefits into plastic and reconstructive surgery; however, many plastic surgeons report lack of widespread implementation, training, or clinical exposure. We report the current evidence base, and surgical opportunities, alongside key barriers, and limitations to overcome, to develop the use of robotics within the field. This systematic review of PubMed, Medline, and Embase has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PROSPERO (ID: CRD42024524237). Preclinical, educational, and clinical articles were included, within the scope of plastic and reconstructive surgery. 2, 181, articles were screened; 176 articles met the inclusion criteria across lymph node dissection, flap and microsurgery, vaginoplasty, craniofacial reconstruction, abdominal wall reconstruction and transoral robotic surgery (TOR). A number of benefits have been reported including technical advantages such as better visualisation, improved precision and accuracy, and tremor reduction. Patient benefits include lower rate of complications and quicker recovery; however, there is a longer operative duration in some categories. Cost presents a significant barrier to implementation. Robotic surgery presents an exciting opportunity to improve patient outcomes and surgical ease of use, with feasibility for many subspecialities demonstrated in this review. However, further higher quality comparative research with careful case selection, which is adequately powered, as well as the inclusion of cost-analysis, is necessary to fully understand the true benefit for patient care, and justification for resource utilisation.

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Introduction

The role of robotics has grown exponentially. Robotic surgery, also known as robotic-assisted surgery, allows for complex minimally invasive surgical procedures to be completely or part-performed with a mechanical system consisting of articulating arms, typically controlled at a separate console by the surgeon.

The Da Vinci Surgical Robotic System (Intuitive Surgical, Sunnyvale, CA, USA), has been widely implemented in various surgical specialities, such as general surgery, urology, and gynaecology, within 66 countries. A recent systematic review of laparoscopic and robotic surgery found comparable or improved complication rates with robotic surgery, with reduced recovery time and length of stay [ 1 ].

Robotic consoles can offer accuracy, and precision, as well as minimally invasive access to difficult areas, with improved visualisation. Surgeons have better ergonomic performance, with a reduction in mental and physical workload [ 2 ]. Additionally, wireless connection broadens opportunities within telesurgery to facilitate remote operating [ 3 ].

The application of robotic surgery in clinical plastic and reconstructive practice is yet to be well established [ 4 ]. There is an active interest amongst practitioners in the transferability of these potential benefits into a speciality that works in collaboration with many surgical disciplines; however, many plastic surgeons report lack widespread implementation or exposure [ 5 ]. Whilst Da Vinci Surgical Robotic System (Intuitive Surgical, Sunnyvale, CA, USA) is the most well-known resource, MUSA Microsure (Science Park Eindhoven, Netherlands) and Symani Surgical System (Medical Microinstruments, Italy) are competitors in the market, particularly for use within microsurgery (Fig.  1 ).

Robotic equipment utilised within clinical practice. All three are controlled by a separate master console

Microsurgery is an area which requires high precision, excellent magnified visualisation, and tremor reduction. Whilst robotic surgery may exceed in these domains, the impact of loss of haptic feedback requires investigation. There are other potential barriers within the widespread implementation of robotics and robotic-assisted surgery within plastic and reconstructive surgery such as the financial incurrence and sparce training opportunities [ 5 ].

The aims of this systematic review are to assess the feasibility of robotic surgery within plastic and reconstructive surgery and review the barriers and limitations to clinical implementation and training.

This systematic review has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [ 6 ]. Methodology was designed a priori, and this review is registered with PROSPERO (ID: CRD42024524237).

A literature search of PubMed, Medline and Embase for publications within the past 10 years was conducted by author L.A. Additional articles found through reference screening were included. Titles and abstracts were screened by two independent authors (B.R and E.B), with discrepancies for inclusion reviewed by a third author independently (L.A). This review includes all study types such as randomised controlled trials (RCT), prospective cohort, retrospective cohort, case series/reports, case–control, cross-sectional studies and preclinical studies.

Eligibility criteria

Articles were accepted for inclusion using the following criteria:

Patients/populations who have undergone robotic surgery for reconstruction or oncological resection, within the scope of plastic and reconstructive surgery.

Adults and children

Articles which described robotic procedures within the scope of plastic and reconstructive surgery

Preclinical and educational studies within the scope of robotic plastic and reconstructive surgery including animal, synthetic and cadaveric models.

Articles were excluded from this review using the following criteria:

Articles pertaining to robotic surgery outside the scope of plastic and reconstructive surgery.

Inguinal hernia repair

Articles not available in English language

Articles published prior to 2013.

Search strategy

Search strategy employed is described below. Key words and subject headings were combined using Boolean logic and refined with consensus from all authors:

Micro* OR reconstruct* OR flap OR nerve OR anastomosis OR abdominal wall OR pelvic floor OR supermicrosurg* OR head and neck OR oral OR oropharyngeal OR vaginoplasty OR breast OR nasal OR plastic

Data metrics

Data were tabulated into a predetermined Excel spreadsheet by authors LA and E.B [ 7 ]. This was subsequently refined following a pilot collection with a random sample of papers. Articles upon paper review which were deemed not suitable for inclusion were discussed with an independent third party (B.L). Data items obtained included article characteristics (title, author, year, journal, impact factor, type of study, multicentre/single centre), demographics (number of participants, gender, age, control), procedure (subspeciality, specific task, robot, ports, location of ports), and outcomes (operative duration, length of Stay, blood loss, peri-operative complications, long-term outcomes, follow-up duration, learning curve, and cost).

Risk of bias

Risk of bias was assessed by authors LA and E.B. RCT’s were reviewed using Cochrane’s risk of bias tool (RoB 2) [ 8 ]. Non-randomised trials was assessed using Cochrane’s ROBINS-I tool [ 9 ]. The Joan Briggs Institute Critical Appraisal Checklist for Case Series and the Joan Briggs Institute Critical Appraisal Checklist for Case Reports was used to review case series and case reports, respectively. [ 10 , 11 ] A report of bias is included in the appendices.

Data synthesis

Narrative synthesis, and quantitative analysis was performed where possible. Descriptive analysis of continuous data is represented with ranges, mean values, or overall rate. Categorical data is presented with percentage prevalence. Subcategories are defined by subspeciality and procedure.

Study characteristics were tabulated and compared against planned subgroups to determine their suitability for each synthesis. Nonparametric data were analysed using a Wilcoxon test or an unpaired T test. Forrest plots were constructed, (in subcategories with article number > 5, where possible), using odds ratios for dichotomous and continuous outcomes and heterogeneity tested for using Chi-square and I 2 test. Statistical analysis was performed using RevMan Software [ 12 ].

The literature search yielded a total of 2181 articles (Fig.  2 ). Following abstract screening, a total of 176 articles were included in this systematic review. A total of 149 clinical articles were found (Table  1 ). A total of 11 preclinical articles were included (Two of which also included clinical data) (Table  2 ) [ 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ]. A total of 18 educational articles were included (Table  2 ) [ 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 ].

PRISMA flow diagram of the literature search for robotics in plastic and reconstructive surgery

Clinical articles were subcategorised by subspeciality (Fig.  3 ). A total of 11 articles described robotic lymph node dissection [ 13 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 ]. A total of 21 articles described robotic pedicled or free flap harvest [ 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 ]. A total of eight articles described robotic flap pedicle or vessel dissection [ 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 ]. 16 articles detailed robotic free flap inset or anastomosis (vessel, nerve and lymphovascular) [ 34 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 ]. Two articles described robotic craniofacial techniques (mandibular contouring) [ 96 , 97 ]. One cohort study described a robotic cleft palate surgery [ 98 ]. One case report described robotic nerve decompression [ 99 ]. Three articles described vaginoplasty/gender reassignment robotic techniques [ 100 , 101 , 102 ]. A total of 28 articles described ventral abdominal wall reconstruction and hernia repair [ 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 , 123 , 124 , 125 , 126 , 127 , 128 , 129 , 130 ]. A total of 18 articles pertained to robotic mastectomy [ 56 , 72 , 131 , 132 , 133 , 134 , 135 , 136 , 137 , 138 , 139 , 140 , 141 , 142 , 143 , 144 , 145 , 146 ]. Finally, a total of 43 articles described transoral robotic surgery (TOR) [ 81 , 147 , 148 , 149 , 150 , 151 , 152 , 153 , 154 , 155 , 156 , 157 , 158 , 159 , 160 , 161 , 162 , 163 , 164 , 165 , 166 , 167 , 168 , 169 , 170 , 171 , 172 , 173 , 174 , 175 , 176 , 177 , 178 , 179 , 180 , 181 , 182 , 183 , 184 , 185 , 186 , 187 , 188 ].

Total number of articles in each subcategory within the scope of robotic plastic and reconstructive surgery

Peri-operative outcomes

Lymph node dissection.

Reported length of stay, complications, and recurrence (of disease) are displayed in Table  3 . Six articles found the average operative time to be higher for robotic surgery (Table  1 ). The peri-operative complication rate was found to be comparable, within the reported studies. The average length of stay was shorter for robotic surgery; however, only two articles reported length of stay for conventional lymph node dissection ( P  = 0.46).

Pedicled and free flap harvest

Peri-operative outcomes regarding pedicled and free flap harvest are reported in Table  4 . Average harvest time is higher in the robotic group, although not this was not statistically significant. Average length of stay within comparative studies is lower in the robotic group; however, overall results show a comparable length of stay with conventional surgery. Overall, average complication rates are lower than conventional approaches; however, not statistically significant within comparative studies ( P  = 0.061).

Microsurgery

Peri-operative outcomes for flap pedicle dissection, flap inset, and microsurgical anastomosis are shown in Table  5 . No comparative studies were found for pedicle dissection, with majority of articles pertaining to deep inferior epigastric perforator (DIEP) pedicle dissection. Anastomosis time was found to be longer for robotic surgery; however, docking time was not reported in any studies. There was a comparable rate of overall complications. Only three non-comparative studies reviewed length of stay, with the average being 7.1 days.

Peri-operative outcomes regarding nipple-sparing mastectomy are shown in Table  6 . Operative time was found to be comparable overall; however, this included reconstruction time. Overall length of stay was comparable between open and robotic groups. Overall rate of complication was lower in robotic nipple-sparing mastectomy ( P  = 0.0007) (Fig.  4 ).

Weighted analysis of comparative studies reviewing complication rate of robotic nipple sparing mastectomy with conventional nipple sparing mastectomy 

Abdominal wall

Outcomes regarding abdominal wall reconstruction are collated in Table  7 . Separate comparisons are demonstrated between robotic versus laparoscopic, and robotic versus open repair. Weighted analysis of comparative robotic versus laparoscopic studies found high heterogeneity (85%), and favours robotic surgery with reduced complications ( P  = 0.02) (Fig.  5 ). Robotic surgery had fewer complications when compared with open surgery ( P  = 0.0001), with lower heterogeneity (Fig.  6 ).

Weighted analysis of comparative studies reviewing complication rate between robotic abdominal wall reconstruction and laparoscopic abdominal wall reconstruction

Weighted analysis of comparative studies reviewing complication rates in robotic versus open abdominal wall reconstruction

Length of stay was shorter for robotic surgery in comparison to both groups, however, was only statistically significant for robotic versus open ( P  = 0.017). Overall operative time was higher for robotic surgery but was not statistically significant within laparoscopic and open subgroups.

Transoral robotic surgery

TOR operative outcomes are reported in Table  8 . Length of stay was shorter for robotic surgery; however, this was not statistically significant. A statistically significant lower rate of complications is found for robotic surgery in comparison to open surgery ( P  = 0.033). Disease-free survival was higher within the robotic cohort; however, this was not found to be statistically significant.

Operative time was variable, and few conclusions can be drawn (Table  1 ). Lee et al. reported a longer duration compared to transoral resection; however, White et al., found a shorter duration for excision of recurrent oropharyngeal SCC [ 151 , 154 ]. White et al., also found a better rate of negative margins with robotic surgery [ 154 ]. Hammoudi et al. found no difference in procedure duration for resection of primary SCC [ 158 ].

Post-operative outcomes

Patient-reported outcomes and long-term outcomes are reported in Table  1 . The quality and standard of assessment varied greatly. Patient satisfaction was reported in three (27%) lymph node (neck) dissection articles, all of which found better scores compared to open with regard to cosmesis and scarring [ 42 , 43 , 44 ]. Lin et al. found comparable results for patient satisfaction and pain for mandibular contouring [ 96 ].

Flap/microsurgery

High patient satisfaction for latissimus dorsi muscle flap harvests were reported in three articles; one cohort study found significantly higher BREAST-Q scores than open [ 54 , 66 , 70 ]. 31% of flap inset or anastomosis articles reported post-operative outcomes other than complications [ 84 , 85 , 87 , 91 , 93 ]. Van Mulken et al. reported robotic lymphovascular anastomosis to have comparable lymph ICF scores to conventional microsurgery. Miyamoto et al. and Chen et al. reported successful patient outcomes of nerve grafts (sympathetic trunk reconstruction and nerve to deltoid) [ 84 , 93 ]. Two articles detailing pedicle dissection of DIEP flaps reported favourable outcomes, and no hernias; however, there are no comparative results [ 73 , 77 ].

Abdominal wall reconstruction

Patient-reported outcome measures (PROMs) were described in 8 (28.6%) articles of abdominal wall reconstruction. Three articles reviewed pain with VAS scores and found no difference (2 RCT’s) or less pain at 1 month/1 year (prospective cohort) [ 116 , 120 , 123 ]. Kakela et al. found comparable PROMs (SF-36) with laparoscopic surgery, with high scores for emotional status and social function for robotic surgery. Three articles found no difference between robotic and laparoscopic surgery in reported patient outcomes, including functional status [ 120 , 122 , 126 ]. One RCT found higher HERqLess scores for robotic versus laparoscopic ventral mesh hernia repair [ 118 ].

One RCT compared robotic extraperitoneal versus intraperitoneal onlay mesh (IPOM) for ventral hernia repair and found that IPOM had significantly higher HerQLess scores at 1 year follow-up.

A total of four (22.2%) of mastectomy articles reported patient qualitative outcomes. Two articles reported high scores for cosmetic satisfaction with minimal scarring, whilst one case control study found significantly higher scores in a cosmetic outcome questionnaire than open surgery, with better scarring and a better position of the nipple–areolar complex [ 132 , 133 , 134 , 143 ]. One RCT documented significantly higher satisfaction within the BREAST-Q questionnaire for robotic surgery [ 144 ].

Three TOR studies reported a lower rate of tracheostomies in the peri-operative period, as well as a lower requirement and durations of nasogastric feeding/PEG feeding [ 154 , 155 , 158 ].

Two studies found significantly higher 3-year disease-free survival with robotic surgery in HPV negative patients, and comparable rates of survival for HPV positive patients for oropharyngeal SCC primary resection [ 157 , 173 ]. This was echoed by Lee et al., in which robotic surgery had a higher overall and disease-free survival rate at 2 years for lateral oropharyngectomy as treatment for tonsillar cancer [ 151 ]. White et al. found a higher rate of 2-year disease-free survival for open surgery to treat recurrent oropharyngeal SCC (T1-T4) [ 155 ].

Two articles evaluated patient outcomes through the Head and Neck Cancer Inventory (HCNI); Durmus et al. reported patients to have highly functional quality of life within their case series of carcinoma of unknown primary resection [ 156 ]. Sethia et al. found comparable outcomes for robotic oropharyngeal resection with and without adjuvant therapy [ 175 ]. Lee et al. also reported no difference in VHI and MDADI scores between open and robotic lateral oropharyngectomy for tonsillar cancer [ 151 ].

Gundlapalli et al. reported a higher procedural cost for their case report of a robotic-assisted DIEP breast reconstruction of $16,000 versus $14,000. There were no other articles which reported cost within robotic flap harvest or microsurgery.

Lai et al. reported a higher cost for robotic nipple-sparing mastectomy in comparison to conventional treatment of $10, 877 versus $5,702 [ 143 ].

Within the subcategory of abdominal wall reconstruction three articles (11%) reported cost. Olavarria et al. found robotic patients had an increased total cost for 90 days of care in comparison to laparoscopic ventral mesh hernia repair in their RCT ($15, 865 robotic versus $12, 955) [ 116 ]. In addition to this, a separate RCT found that whilst the cost of reusables was comparable between robotic and laparoscopic ventral hernia repair, the total cost was significantly higher for robotic patients due to the overall operative time (Cost ratio of 1.13 robotic versus laparoscopic 0.97 P  = 0.03) [ 125 ]. In contrast a retrospective cohort study found whilst the procedure costs were higher for robotic surgery, the overall cost of patient care was shorter because of reduced length of hospital stay (robotic $13, 943 versus $19, 532, P  = 0.07) [ 109 ].

Two TOR articles reported cost (4.7%). Chung et al. found that overall cost was significantly lower for robotic pharyngectomy ($20,706 versus $29,365) and posterior partial glossectomy ($19, 091 versus $23,414), whilst anterior partial glossectomy demonstrated no difference in the total cost of procedure between TOR and conventional approaches ($22,111 versus $21,376) [ 155 ]. Hammoudi et al. reported higher costs for robotic oropharyngeal SCC resection; however, the overall cost accounting for duration of hospital stay was significantly less ($20,885 vs $27,926) [ 158 ].

Learning curve

Learning curve was reported in clinical studies as changes in operative time (Table  1 ). Three abdominal wall reconstruction articles commented that skin-to-skin operating time decreased throughout their cohort [ 112 , 116 , 120 ]. Muysoms et al. analysed operative time for 41 transabdominal retromuscular hernia repairs, and commented that the decrease was largely contributed to by improved efficacy in the dissection aspect of the procedure [ 112 ]. Olavarria et al. reported a training exposure of 50 cases, through simulation and cadaveric models, prior to performing ventral hernia repairs was necessary to ensure optimal clinical practice [ 116 ]. A total of four mastectomy articles reported operative time to decrease with as clinical exposure increased, including a decrease in docking time [ 132 , 133 , 134 , 139 , 142 ]. Lai et al. achieved an average time for nipple-sparing mastectomy of 100 min, in a series of 39 patients [ 142 ].

Van Mulken et al. reported robotic microvascular anastomosis to require a longer time to complete; however, a steep learning curve resulted in a reduction in this [ 87 ]. Barbon et al. also reported a steep learning curve for anastomosis with time taken to complete being comparable to hand-sewn operative time, with the quickest robotic anastomosis taking around 10 min (Table  2 ) [ 89 ].

Selber et al. also reported a steep learning curve in surgical trainees over five sessions, followed by gradual improvement [ 29 ]. Two training models in microvascular anastomosis reported a plateau in learning curve of robotic anastomosis by expert surgeons on synthetic silicone vessels and rat vessels to be 5 and 8 attempts, respectively [ 16 , 17 ]. Beier et al. developed a 4-week training programme with synthetic 1 and 2 mm vessels, in which 10 successful anastomosis were deemed to be the benchmark for skill acquisition before progression to clinical practice [ 34 ].

Surgical ease of use

Robotic surgery offers several mechanical advantages to aid surgical performance. Many authors commented upon improved visibility with higher 3-dimensional resolution, magnification, and lighting, allowing for depth of field perception and a 360° view of a cavity [ 54 , 132 ].

The Da Vinci robotic arms have 7° of freedom which allow for higher dexterity and greater range of motion, optimising the user’s ability to dissect the surgical plane and increasing access to difficult anatomical areas [ 137 ].

Insufflation was found to be useful attribute for nipple-sparing mastectomy [ 131 , 135 , 141 ]. Through a single small incision approach, Toesca et al. reported easy identification of structures such as intercostal perforators which contribute to nipple–areolar complex survival and flap survival, and better view of the surgical plane [ 132 ]. The use of carbon dioxide helped to reduce bleeding and perform better haemostasis [ 132 ]. There was a higher surgical challenge with larger ptotic breasts [ 136 ]. Motion scaling, and tremor filtration provides high precision and stability; this was also found to be advantageous for flap and microsurgery [ 77 , 132 , 137 ].

The robotic technique of pedicle dissection of the DIEP flap minimizes incision of the anterior rectus muscles and provides improved dexterity and motion; however, due to the space occupation of the robot and the console it may be challenging for two surgical teams to work simultaneously, thus potentially increasing operative duration [ 73 , 77 , 80 ].

Robotic equipment also eliminates haptic feedback; however, users have reported that they were able to compensate effectively for this by relying on visual cues and felt able to complete the vessel and lymphovascular anastomosis without difficulty [ 83 , 85 , 90 ].

Feng et al. reviewed tremor during microsurgery, based on instrument tip movement and found that this was significantly lower in robotic surgery in an ex vivo model [ 14 ]. Furthermore, in a simulation model of 1 mm synthetic vessels, robotic anastomosis was performed with greater precision (measured in suture distance and angulation) when compared with manual approaches for 40 expert surgeons and 20 novices [ 17 ].

This study demonstrates feasibility and safety of robotic surgery within plastic and reconstructive surgery in several subcategories. There are clear benefits to the surgeon, as described above, with improved access to difficult areas, tremor reduction and motion scaling, and improved ergonomic efficiency [ 2 ].

These attributes are particularly useful in cavity surgery and could create opportunities to complete challenging procedures which could not be accessed through an open approach due to narrow openings, such as nasopharyngeal resection and microvascular reconstruction, or where there may be a high risk of complications, or prolonged recovery time associated with conventional open approaches.

One example of this is TOR, whereby access and exposure is often obtained through techniques with higher morbidity, such as mandible splitting, leading to specific complications and expectations for recovery outside of the intended resection. Furthermore, although DIEP flap harvest can be regarded as having more superficial access, Tsai et al. found the anterior rectus sheath incision for pedicle dissection to be significantly smaller than conventional approaches, and thus less invasive [ 79 ]. It is not yet clear if this translates to reduced hernia occurrence post-operatively.

As interest within microsurgery grows, Da Vinci, and other companies such as Symani Surgical Systems and Microsure, have created an instrument portfolio that is well adapted to this field. Literature shows these tools can perform vessel, nerve and lymphovascular anastomosis with non-inferior outcomes to conventional approaches. Improved surgical ergonomics has allowed end-to-end anastomosis of 1 mm diameter vessels as reported in preclinical studies, with higher ease [ 16 ]. Whilst nerve repair can be performed robotically, there is lack of substantial evidence or comparison to conventional approaches. Whilst this approach is more minimally invasive, further research to determine the overall benefit, safety and cost would be beneficial.

Loss of haptic feedback is often considered to be disadvantage of robotic surgery. Surgeons have reported a compensation for this by relying on visual cues which has not impacted their performance. Further research could assess how easily a surgeon may adapt to the loss of true haptic feedback, as well as looking into the incorporation of haptic feedback into robotic instruments.

Single port access is highly advantageous for breast surgery including resection and reconstruction. Quicker docking can reduce operative time and the smaller incision offers a better cosmetic outcome with reduced scarring [ 101 ].

The high precision and accuracy of robotic surgery, could improve patient care, reflected in the lower rate of complications reported, reduced blood loss, reduced post-operative pain, as well as the comparable or reduced length of recovery. Whilst operative time is reported to be higher for robotics, many centres have shown a learning curve in adapting to new techniques.

There is a paucity of data evaluating patient reported outcomes within the literature. Outcomes within case series/case reports were often reported anecdotally, without use of validated or quantitative assessment tools. However, several articles have reported high patient satisfaction with regard to cosmetic outcome and scarring. Robotic neck dissection approach has been performed with a smaller retro-auricular incision.

Furthermore, robotic latissimus dorsi muscle flap harvest and radial forearm flap harvest can offer reduced scarring through a more minimally invasive approach, resulting in absence of long scars, on the back and forearm, respectively. Whilst this is the case, compared to open techniques, insufflation with reduced scarring, can also be achieved with an endoscopic approach. A comparison of the benefits to the surgeon and patient between endoscopic and robotic-assisted technique would be valuable to ascertain the true benefit of robotic assistance in this procedure. Some patients may require incorporation of skin within an LD flap for example in salvage procedures, or delayed reconstruction of the irradiated breast. The quality of coverage at the recipient site may be insufficient to accommodate the optimal reconstructive outcome, with particular importance of the integrity of the lower pole. In these circumstances, robotic surgery may present few advantages for LD flap harvest, and thus patient selection is important.

Patients undergoing robotic nipple-sparing mastectomy and reconstruction have also reported a higher scar satisfaction, with the use of a single incision in the axilla, in which multiple robotic arms can be used. There is a clear benefit to procedures in which access can move towards less invasive approaches, and robotic surgery within breast reconstruction and lymph node dissection are promising avenues for future research.

The rate of hernia recurrence within abdominal wall reconstruction is challenging to ascertain given the variable and often short length of follow-up reported within the literature. The mean length of follow-up within this subcategory is 9 months (0.25–33.6 months).

There is a high variance of histopathology within the transoral robotic surgery subcategory, as well as tumour location, stage of disease, and patient demographics. Few conclusions can be drawn between the comparative studies given the variability. However, the results reported, suggest that TOR results in non-inferior patient outcomes in comparison to conventional approaches.

Cost is poorly reported within the literature. Cost-analysis of robotic reconstructive procedures to review total cost of patient care would be beneficial in ascertaining the economic barriers that prevent the implementation of robotic within clinical practice in this speciality. Reasons suggested for higher cost include the initial purchase of robotic equipment, and prolonged operative duration utilising resources [ 118 ].

However, several articles within abdominal wall reconstruction and TOR, have reviewed the total cost of patient care, and found that the overall financial burden is significantly less than conventional approaches after accounting for length of hospital stay. This could be because of fewer complications, and reduced pain with a minimally invasive approach [ 109 , 155 , 158 ]. Chung et al. also reported reduced requirement of tracheostomies, nasogastric feeding, and percutaneous endoscopic gastrostomy (PEG) feeding, which could account for a decrease in overall consumables cost. Several articles have also described a learning curve throughout their studies, reflected in a shorter operative duration, which could have an impact for cost incurred. The cost of training surgeons, and theatre teams to use robotic equipment should also be accounted for.

Whilst the initial cost may be high for robotic surgery, the overall cost may be offset by the reduction in complication rate, and reduced length of stay. It is important to delineate when and where the cost of robotics, including resource utilisation, is balanced by proven improved patient outcomes in order to implement this effectively in future practice.

All studies which report a learning curve in this review, do so indirectly, as a reduction in operative time [ 142 ]. Whilst a reduction in the time taken to perform the procedure can be seen as an improvement in skill acquisition, duration of surgery can be affected by various factors in clinical practice including team efficiency and education. Standardised training for skill acquisition with appropriate measures of assessment in a controlled setting will aid in understanding the number of procedures required to achieve clinical competency in each subspeciality. global evaluative assessment of robotic skills (GEARS), and structured assessment of robotic microsurgery skills (SARMS), have been used as objective quantitative assessment tools in this field.

Training should also encompass theatre staff, as set up time including robot docking, change of arms, and equipment troubleshooting can be optimised to reduce burden and improve patient care [ 133 ]. Prolonged operative duration incurs significant resource utilisation including time, cost, equipment, and staff. Barbon et al. was able to demonstrate a steep learning curve in microvascular anastomosis to achieve an anastomotic time which was comparable with conventional approaches [ 89 ].

Vierstraete et al. describe the current training pathway of abdominal wall reconstruction and ventral hernia repair and found in their experience of posterior component separation that there was a gradual reduction in operative time until the surgical team reached their ‘comfort zone’ at around 20–25 cases. Depending on the frequency with which this procedure is performed, it may take a long period of time for the surgeon to reach that level of experience [ 189 ].

Other limitations

This report shows technical feasibility of robotic surgery; however, many articles are a relatively low level of evidence, with a high prevalence of case reports and case series. This review presents small sample sizes and as such, statistical analysis is likely to be underpowered, impeding ability to present true statistical significance. Whilst this study can suggest non-inferiority of robotic surgery, patient advantages remain to be clearly demonstrated.

There is a lack reported of long-term outcomes and formal PROMs, with variable follow-up duration. Due to large heterogeneity of the data and variance within patient selection, and outcomes reported, particularly within transoral robotic surgery, we have been unable to perform a weighted analysis for most subcategories, which would provide a more powerful comparison.

Conclusions

This literature review demonstrates technical feasibility of robotics in plastic and reconstructive surgery. High cosmetic satisfaction is reported with minimally invasive approaches. Operative time is higher than conventional approaches, although steep learning curves are reported, and this may contribute to a higher initial cost. Overall cost may be offset with improved patient outcomes within TOR and abdominal wall reconstruction; however, further reporting of cost and cost-effectiveness is necessary. Technical advantages can potentially translate to improvements in complication rate, and a faster recovery time, with non-inferior patient outcomes reported, with thoughtful case selection. However clearer evidence to support improved outcomes within the field, particularly in comparison with laparoscopic surgery, is required to justify the financial incurrence and demand on resources. Robotic surgery could play an exciting role within plastic surgery, and future research should focus on robotic training, as well as producing higher quality comparative clinical research, which is adequately powered, to fully understand the true benefit for patient care.

Data availability

No datasets were generated or analysed during the current study.

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Awad, L., Reed, B., Bollen, E. et al. The emerging role of robotics in plastic and reconstructive surgery: a systematic review and meta-analysis. J Robotic Surg 18 , 254 (2024). https://doi.org/10.1007/s11701-024-01987-7

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Incidence, timing, and pattern of atypical recurrence after minimally invasive surgery for urothelial carcinoma.

1. Introduction

2. materials and methods, 2.1. literature search strategy, 2.2. inclusion and exclusion criteria, 2.3. data extraction and synthesis, 3. evidence synthesis, 3.1. definition of ar, 3.2. incidence, pattern, and timing of ars, 3.3. surgery-related risk factors.

3.4. Tumor-Related Risk Factors

3.5. limitations, 4. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Bignante, G.; Manfredi, C.; Lasorsa, F.; Orsini, A.; Licari, L.C.; Bologna, E.; Roadman, D.F.; Amparore, D.; Lucarelli, G.; Schips, L.; et al. Incidence, Timing, and Pattern of Atypical Recurrence after Minimally Invasive Surgery for Urothelial Carcinoma. J. Clin. Med. 2024 , 13 , 3537. https://doi.org/10.3390/jcm13123537

Bignante G, Manfredi C, Lasorsa F, Orsini A, Licari LC, Bologna E, Roadman DF, Amparore D, Lucarelli G, Schips L, et al. Incidence, Timing, and Pattern of Atypical Recurrence after Minimally Invasive Surgery for Urothelial Carcinoma. Journal of Clinical Medicine . 2024; 13(12):3537. https://doi.org/10.3390/jcm13123537

Bignante, Gabriele, Celeste Manfredi, Francesco Lasorsa, Angelo Orsini, Leslie Claire Licari, Eugenio Bologna, Daniel F. Roadman, Daniele Amparore, Giuseppe Lucarelli, Luigi Schips, and et al. 2024. "Incidence, Timing, and Pattern of Atypical Recurrence after Minimally Invasive Surgery for Urothelial Carcinoma" Journal of Clinical Medicine 13, no. 12: 3537. https://doi.org/10.3390/jcm13123537

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• DOI: 10.1007/s11701-024-02003-8
• Corpus ID: 270198812

Comment on: "A meta‑analysis between robotic hepatectomy and conventional open hepatectomy".

• I. Chen , Li-Chen Chang , K-C Hung
• Published in Journal of Robotic Surgery 1 June 2024
• Medicine, Engineering

5 References

A meta-analysis between robotic hepatectomy and conventional open hepatectomy., impact of intravenous vitamin c as a monotherapy on mortality risk in critically ill patients: a meta-analysis of randomized controlled trials with trial sequential analysis, how to perform and write a trial sequential analysis, impact of intraoperative ketamine on postoperative analgesic requirement following bariatric surgery: a meta-analysis of randomized controlled trials, updated evaluation of endoscopic submucosal dissection versus surgery for early gastric cancer: a systematic review and meta-analysis., related papers.

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Guest Essay

What My Cancer Surgery Taught Me About Immigration

By Glenn Kramon

Mr. Kramon is a lecturer at Stanford Business School.

Wheeled into the operating room last January, staring up at the massive arms of the robot with which a surgeon would remove my cancerous gland, I was hit with an unusual realization: I owe a debt of gratitude to President Lyndon Johnson and the Immigration and Nationality Act of 1965.

Why? Without that legislation, the surgeon who operated on me probably wouldn’t be here. Nor might the doctor who pioneered the procedure. Nor the philanthropist who financed the research. Nor many workers at the company that makes these robots or those at a different company that designed the chips that enable the robot.

As my ordeal with cancer shows, immigration has become critical to our health. Immigrants account for more than a quarter of physicians, surgeons and personal care aides and about a fifth of nursing assistants.

I’m not sure we realize that immigrants help keep us alive: Just look at West Virginia , a state hostile to immigration where aging residents have died before getting off the wait list for home health aides.

While many Americans — including politicians this election year — dwell on stories like the Venezuelan migrant accused of killing a Georgia nursing student, they often forget the critical ways immigration has historically benefited us. A century ago this spring, the United States slammed the door on large sections of the world, and we could be on the verge of doing so again.

That I am so cognizant of the importance of immigrants is the result of two coincidences. The first is that I teach a class on practical writing at Stanford Business School. Frustrated by the cynicism that has pervaded my 3,000 students, many of whom were only teenagers when Donald Trump was elected and are skeptical of the government, I began showing a slide documenting the benefits they enjoy from legislation that originated in the 1960s. For one, many Stanford Business School students — I would guess roughly a quarter — come from families that would not be in this country if not for Mr. Johnson’s Immigration and Nationality Act.

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• v.239(1); 2004 Jan

Robotic Surgery

Jaydev p. desai.

From the *Department of Mechanical Engineering and Mechanics, Drexel University, Philadelphia and Drexel University College of Medicine, Philadelphia, Pennsylvania.

To review the history, development, and current applications of robotics in surgery.

Background:

Surgical robotics is a new technology that holds significant promise. Robotic surgery is often heralded as the new revolution, and it is one of the most talked about subjects in surgery today. Up to this point in time, however, the drive to develop and obtain robotic devices has been largely driven by the market. There is no doubt that they will become an important tool in the surgical armamentarium, but the extent of their use is still evolving.

A review of the literature was undertaken using Medline. Articles describing the history and development of surgical robots were identified as were articles reporting data on applications.

Several centers are currently using surgical robots and publishing data. Most of these early studies report that robotic surgery is feasible. There is, however, a paucity of data regarding costs and benefits of robotics versus conventional techniques.

Conclusions:

Robotic surgery is still in its infancy and its niche has not yet been well defined. Its current practical uses are mostly confined to smaller surgical procedures.

Robotic surgery is a proliferating new technology despite a paucity of information comparing it with conventional laparoscopy. This article reviews the early data and attempts to give the reader a broad perspective on robotic surgery.

Robotic surgery is a new and exciting emerging technology that is taking the surgical profession by storm. Up to this point, however, the race to acquire and incorporate this emerging technology has primarily been driven by the market. In addition, surgical robots have become the entry fee for centers wanting to be known for excellence in minimally invasive surgery despite the current lack of practical applications. Therefore, robotic devices seem to have more of a marketing role than a practical role. Whether or not robotic devices will grow into a more practical role remains to be seen.

Our goal in writing this review is to provide an objective evaluation of this technology and to touch on some of the subjects that manufacturers of robots do not readily disclose. In this article we discuss the development and evolution of robotic surgery, review current robotic systems, review the current data, discuss the current role of robotics in surgery, and finally we discuss the possible roles of robotic surgery in the future. It is our hope that by the end of this article the reader will be able to make a more informed decision about robotic surgery before “chasing the market.”

BACKGROUND AND HISTORY OF SURGICAL ROBOTS

Since 1921 when Czech playwright Karel Capek introduced the notion and coined the term robot in his play Rossom’s Universal Robots , robots have taken on increasingly more importance both in imagination and reality. 1,2 Robot, taken from the Czech robota , meaning forced labor, has evolved in meaning from dumb machines that perform menial, repetitive tasks to the highly intelligent anthropomorphic robots of popular culture. Although today’s robots are still unintelligent machines, great strides have been made in expanding their utility. Today robots are used to perform highly specific, highly precise, and dangerous tasks in industry and research previously not possible with a human work force. Robots are routinely used to manufacture microprocessors used in computers, explore the deep sea, and work in hazardous environment to name a few. Robotics, however, has been slow to enter the field of medicine.

The lack of crossover between industrial robotics and medicine, particularly surgery, is at an end. Surgical robots have entered the field in force. Robotic telesurgical machines have already been used to perform transcontinental cholecystectomy. 3,4 Voice-activated robotic arms routinely maneuver endoscopic cameras, and complex master slave robotic systems are currently FDA approved, marketed, and used for a variety of procedures. It remains to be seen, however, if history will look on the development of robotic surgery as a profound paradigm shift or as a bump in the road on the way to something even more important.

Paradigm shift or not, the origin of surgical robotics is rooted in the strengths and weaknesses of its predecessors. Minimally invasive surgery began in 1987 with the first laparoscopic cholecystectomy. Since then, the list of procedures performed laparoscopically has grown at a pace consistent with improvements in technology and the technical skill of surgeons. 5 The advantages of minimally invasive surgery are very popular among surgeons, patients, and insurance companies. Incisions are smaller, the risk of infection is less, hospital stays are shorter, if necessary at all, and convalescence is significantly reduced. Many studies have shown that laparoscopic procedures result in decreased hospital stays, a quicker return to the workforce, decreased pain, better cosmesis, and better postoperative immune function. 6–8 As attractive as minimally invasive surgery is, there are several limitations. Some of the more prominent limitations involve the technical and mechanical nature of the equipment. Inherent in current laparoscopic equipment is a loss of haptic feedback (force and tactile), natural hand-eye coordination, and dexterity. Moving the laparoscopic instruments while watching a 2-dimensional video monitor is somewhat counterintuitive. One must move the instrument in the opposite direction from the desired target on the monitor to interact with the site of interest. Hand-eye coordination is therefore compromised. Some refer to this as the fulcrum effect. 9 Current instruments have restricted degrees of motion; most have 4 degrees of motion, whereas the human wrist and hand have 7 degrees of motion. There is also a decreased sense of touch that makes tissue manipulation more heavily dependent on visualization. Finally, physiologic tremors in the surgeon are readily transmitted through the length of rigid instruments. These limitations make more delicate dissections and anastomoses difficult if not impossible. 10 The motivation to develop surgical robots is rooted in the desire to overcome the limitations of current laparoscopic technologies and to expand the benefits of minimally invasive surgery.

From their inception, surgical robots have been envisioned to extend the capabilities of human surgeons beyond the limits of conventional laparoscopy. The history of robotics in surgery begins with the Puma 560, a robot used in 1985 by Kwoh et al to perform neurosurgical biopsies with greater precision. 6,11 Three years later, Davies et al performed a transurethral resection of the prostate using the Puma 560. 12 This system eventually led to the development of PROBOT, a robot designed specifically for transurethral resection of the prostate. While PROBOT was being developed, Integrated Surgical Supplies Ltd. of Sacramento, CA, was developing ROBODOC, a robotic system designed to machine the femur with greater precision in hip replacement surgeries. 1 ROBODOC was the first surgical robot approved by the FDA.

Also in the mid-to-late 1980s a group of researchers at the National Air and Space Administration (NASA) Ames Research Center working on virtual reality became interested in using this information to develop telepresence surgery. 1 This concept of telesurgery became one of the main driving forces behind the development of surgical robots. In the early 1990s, several of the scientists from the NASA-Ames team joined the Stanford Research Institute (SRI). Working with SRI’s other robotocists and virtual reality experts, these scientists developed a dexterous telemanipulator for hand surgery. One of their main design goals was to give the surgeon the sense of operating directly on the patient rather than from across the room. While these robots were being developed, general surgeons and endoscopists joined the development team and realized the potential these systems had in ameliorating the limitations of conventional laparoscopic surgery.

The US Army noticed the work of SRI, and it became interested in the possibility of decreasing wartime mortality by “bringing the surgeon to the wounded soldier—through telepresence.” 1 With funding from the US Army, a system was devised whereby a wounded soldier could be loaded into a vehicle with robotic surgical equipment and be operated on remotely by a surgeon at a nearby Mobile Advanced Surgical Hospital (MASH). This system, it was hoped, would decrease wartime mortality by preventing wounded soldiers from exsanguinating before they reached the hospital. This system has been successfully demonstrated on animal models but has not yet been tested or implemented for actual battlefield casualty care.

Several of the surgeons and engineers working on surgical robotic systems for the Army eventually formed commercial ventures that lead to the introduction of robotics to the civilian surgical community. 1 Notably, Computer Motion, Inc. of Santa Barbara, CA, used seed money provided by the Army to develop the Automated Endoscopic System for Optimal Positioning (AESOP), a robotic arm controlled by the surgeon voice commands to manipulate an endoscopic camera. Shortly after AESOP was marketed, Integrated Surgical Systems (now Intuitive Surgical) of Mountain View, CA, licensed the SRI Green Telepresence Surgery system. This system underwent extensive redesign and was reintroduced as the Da Vinci surgical system. Within a year, Computer Motion put the Zeus system into production.

CURRENT ROBOTIC SURGICAL SYSTEMS

Today, many robots and robot enhancements are being researched and developed. Schurr et al at Eberhard Karls University’s section for minimally invasive surgery have developed a master-slave manipulator system that they call ARTEMIS. 13 This system consists of 2 robotic arms that are controlled by a surgeon at a control console. Dario et al at the MiTech laboratory of Scuola Superiore Sant’Anna in Italy have developed a prototype miniature robotic system for computer-enhanced colonoscopy. 14 This system provides the same functions as conventional colonoscopy systems but it does so with an inchworm-like locomotion using vacuum suction. By allowing the endoscopist to teleoperate or directly supervise this endoscope and with the functional integration of endoscopic tools, they believe this system is not only feasible but may expand the applications of endoluminal diagnosis and surgery. Several other laboratories, including the authors’, are designing and developing systems and models for reality-based haptic feedback in minimally invasive surgery and also combining visual servoing with haptic feedback for robot-assisted surgery. 15–19

In addition to Prodoc, ROBODOC and the systems mentioned above several other robotic systems have been commercially developed and approved by the FDA for general surgical use. These include the AESOP system (Computer Motion Inc., Santa Barbara, CA), a voice-activated robotic endoscope, and the comprehensive master-slave surgical robotic systems, Da Vinci (Intuitive Surgical Inc., Mountain View, CA) and Zeus (Computer Motion Inc., Santa Barbara, CA).

The da Vinci and Zeus systems are similar in their capabilities but different in their approaches to robotic surgery. Both systems are comprehensive master-slave surgical robots with multiple arms operated remotely from a console with video assisted visualization and computer enhancement. In the da Vinci system (Fig. 1) , which evolved from the telepresence machines developed for NASA and the US Army, there are essentially 3 components: a vision cart that holds a dual light source and dual 3-chip cameras, a master console where the operating surgeon sits, and a moveable cart, where 2 instrument arms and the camera arm are mounted. 1 The camera arm contains dual cameras and the image generated is 3-dimensional. The master console consists of an image processing computer that generates a true 3-dimensional image with depth of field; the view port where the surgeon views the image; foot pedals to control electrocautery, camera focus, instrument/camera arm clutches, and master control grips that drive the servant robotic arms at the patient’s side. 6 The instruments are cable driven and provide 7 degrees of freedom. This system displays its 3-dimensional image above the hands of the surgeon so that it gives the surgeon the illusion that the tips of the instruments are an extension of the control grips, thus giving the impression of being at the surgical site.

FIGURE 1. Da Vinci system set up. (Courtesy of Intuitive Surgical Inc., Mountain View, CA)

The Zeus system is composed of a surgeon control console and 3 table-mounted robotic arms (Fig. 2) . The right and left robotic arms replicate the arms of the surgeon, and the third arm is an AESOP voice-controlled robotic endoscope for visualization. In the Zeus system, the surgeon is seated comfortably upright with the video monitor and instrument handles positioned ergonomically to maximize dexterity and allow complete visualization of the OR environment. The system uses both straight shafted endoscopic instruments similar to conventional endoscopic instruments and jointed instruments with articulating end-effectors and 7 degrees of freedom.

FIGURE 2. Zeus system set up. (Courtesy of Computer Motion Inc., Santa Barbara, CA)

ADVANTAGES OF ROBOT-ASSISTED SURGERY

The advantages of these systems are many because they overcome many of the obstacles of laparoscopic surgery (Table 1) . They increase dexterity, restore proper hand-eye coordination and an ergonomic position, and improve visualization (Table 2) . In addition, these systems make surgeries that were technically difficult or unfeasible previously, now possible.

TABLE 1. Advantages and Disadvantages of Conventional Laparoscopic Surgery Versus Robot-Assisted Surgery

TABLE 2. Advantages and Disadvantages of Robot-Assisted Surgery Versus Conventional Surgery

These robotic systems enhance dexterity in several ways. Instruments with increased degrees of freedom greatly enhance the surgeon’s ability to manipulate instruments and thus the tissues. These systems are designed so that the surgeons’ tremor can be compensated on the end-effector motion through appropriate hardware and software filters. In addition, these systems can scale movements so that large movements of the control grips can be transformed into micromotions inside the patient. 6

Another important advantage is the restoration of proper hand-eye coordination and an ergonomic position. These robotic systems eliminate the fulcrum effect, making instrument manipulation more intuitive. With the surgeon sitting at a remote, ergonomically designed workstation, current systems also eliminate the need to twist and turn in awkward positions to move the instruments and visualize the monitor.

By most accounts, the enhanced vision afforded by these systems is remarkable. The 3-dimensional view with depth perception is a marked improvement over the conventional laparoscopic camera views. Also to one’s advantage is the surgeon’s ability to directly control a stable visual field with increased magnification and maneuverability. All of this creates images with increased resolution that, combined with the increased degrees of freedom and enhanced dexterity, greatly enhances the surgeon’s ability to identify and dissect anatomic structures as well as to construct microanastomoses.

DISADVANTAGES OF ROBOT-ASSISTED SURGERY

There are several disadvantages to these systems. First of all, robotic surgery is a new technology and its uses and efficacy have not yet been well established. To date, mostly studies of feasibility have been conducted, and almost no long-term follow up studies have been performed. Many procedures will also have to be redesigned to optimize the use of robotic arms and increase efficiency. However, time will most likely remedy these disadvantages.

Another disadvantage of these systems is their cost. With a price tag of a million dollars, their cost is nearly prohibitive. Whether the price of these systems will fall or rise is a matter of conjecture. Some believe that with improvements in technology and as more experience is gained with robotic systems, the price will fall. 6 Others believe that improvements in technology, such as haptics, increased processor speeds, and more complex and capable software will increase the cost of these systems. 9 Also at issue is the problem of upgrading systems; how much will hospitals and healthcare organizations have to spend on upgrades and how often? In any case, many believe that to justify the purchase of these systems they must gain widespread multidisciplinary use. 9

Another disadvantage is the size of these systems. Both systems have relatively large footprints and relatively cumbersome robotic arms. This is an important disadvantage in today’s already crowded-operating rooms. 9 It may be difficult for both the surgical team and the robot to fit into the operating room. Some suggest that miniaturizing the robotic arms and instruments will address the problems associated with their current size. Others believe that larger operating suites with multiple booms and wall mountings will be needed to accommodate the extra space requirements of robotic surgical systems. The cost of making room for these robots and the cost of the robots themselves make them an especially expensive technology.

One of the potential disadvantages identified is a lack of compatible instruments and equipment. Lack of certain instruments increases reliance on tableside assistants to perform part of the surgery. 6 This, however, is a transient disadvantage because new technologies have and will develop to address these shortcomings.

Most of the disadvantages identified will be remedied with time and improvements in technology. Only time will tell if the use of these systems justifies their cost. If the cost of these systems remains high and they do not reduce the cost of routine procedures, it is unlikely that there will be a robot in every operating room and thus unlikely that they will be used for routine surgeries

CURRENT CLINICAL APPLICATIONS AND EARLY DATA

Several robotic systems are currently approved by the FDA for specific surgical procedures. As mentioned previously, ROBODOC is used to precisely core out the femur in hip replacement surgery. Computer Motion Inc. of Goleta, CA, has 2 systems on the market. One, called AESOP, is a voice-controlled endoscope with 7 degrees of freedom. This system can be used in any laparoscopic procedure to enhance the surgeon’s ability to control a stable image. The Zeus system and the Da Vinci system have been used by a variety of disciplines for laparoscopic surgeries, including cholecystectomies, mitral valve repairs, radical prostatectomies, reversal of tubal ligations, in addition to many gastrointestinal surgeries, nephrectomies, and kidney transplants. The number and types of surgeries being performed with robots is increasing rapidly as more institutions acquire these systems. Perhaps the most notable use of these systems, however, is in totally endoscopic coronary artery grafting, a procedure formerly outside the limitations of laparoscopic technology.

The amount of data being generated on robotic surgery is growing rapidly, and the early data are promising. Many studies have evaluated the feasibility of robot-assisted surgery. One study by Cadiere et al evaluated the feasibility of robotic laparoscopic surgery on 146 patients. 20 Procedures performed with a Da Vinci robot included 39 antireflux procedures, 48 cholecystectomies, 28 tubal reanastomoses, 10 gastroplasties for obesity, 3 inguinal hernia repairs, 3 intrarectal procedures, 2 hysterectomies, 2 cardiac procedures, 2 prostatectomies, 2 artiovenous fistulas, 1 lumbar sympathectomy, 1 appendectomy, 1 laryngeal exploration, 1 varicocele ligation, 1 endometriosis cure, and 1 neosalpingostomy. This study found robotic laparoscopic surgery to be feasible. They also found the robot to be most useful in intra-abdominal microsurgery or for manipulations in very small spaces. They reported no robot related morbidity. Another study by Falcone et al tested the feasibility of robot-assisted laparoscopic microsurgical tubal anastomosis. 31 In this study, 10 patients who had previously undergone tubal sterilization underwent tubal reanastomosis. They found that the 19 tubes were reanastomosed successfully and 17 of the 19 were still patent 6 weeks postoperatively. There have been 5 pregnancies in this group so far. Margossian and Falcone also studied the feasibility of robotic surgery in complex gynecologic surgeries in pigs. 22 In this study, 10 pigs underwent adnexal surgery or hysterectomy using the Zeus robotic system. They found that robotic surgery is safe and feasible for complex gynecologic surgeries. In yet another study by Marescaux et al, the safety and feasibility of telerobotic laparoscopic cholecystectomy was tested in a prospective study of 25 patients undergoing the procedure. 33 Twenty-four of the 25 laparoscopic cholecystectomies were performed successfully, and one was converted to a traditional laparoscopic procedure. This study concluded that robotic laparoscopic cholecystectomy is safe and feasible. Another study by Abbou et al found telerobotic laparoscopic radical prostatectomy to be feasible and safe with dramatically enhanced dexterity. 34

One of the areas where robotic surgery is transforming medicine the most and one of the areas generating the most excitement is minimally invasive cardiac surgery. Several groups have been developing robotic procedures that expand laparoscopic techniques into this previously unexplored territory with encouraging results. Prasad et al successfully constructed left internal thoracic artery (LITA) to left anterior descending (LAD) artery anastomoses on 17 of 19 patients with the use of a robotic system. 21 They conclude that robotically assisted endoscopic coronary bypass surgery showed favorable short-term outcomes with no adverse events and found robotic assistance is an enabling technology that allows surgeons to perform endoscopic coronary anastomoses. Damiano et al conducted a multicenter clinical trial of robotically assisted coronary artery bypass grafting. 35 In this study 32 patients scheduled for primary coronary surgery underwent endoscopic anastomosis of the LITA to LAD. Two-month follow-up revealed a graft patency of 93%. This study concluded that robotic assisted coronary bypass grafting is feasible. In another study, Mohr et al used the Da Vinci system to perform coronary artery bypass grafting on 131 patients and mitral valve repair on 17 patients. 21 They used the robot to perform left internal thoracic artery takedown, LITA-LAD anastomosis in standard sternotomy bypass, and total endoscopic coronary artery bypass grafting LITA-LAD anastomosis on the arrested heart and the beating heart. They found that robotic systems could be used safely in selected patients to perform endoscopic cardiac surgery. Internal thoracic artery takedown is an effective modality, and total endoscopic bypass on an arrested heart is feasible but does not offer a major benefit to the minimally invasive direct approach because cardiopulmonary bypass is still required. Their study suggests that robotic systems have not yet advanced far enough to perform endoscopic closed chest beating heart bypass grafting despite some technical success in 2 of 8 patients. In addition, robotic endoscopic mitral valve repair was successful in 14 of 17 patients. In contrast, several groups in Europe have successfully performed closed-chest, off-pump coronary artery bypass grafting using an endoscopic stabilizer. Kappert and Cichon et al performed 37 off-pump totally endoscopic coronary artery bypass (TECAB) on a beating heart with the Da Vinci system and an endoscopic stabilizer. 32 In this series, they reported a 3.4% rate of conversion to median sternotomy. They concluded that their results promote optimism about further development of TECAB. Another study by Boehm and Reichenspurner et al using a similar stabilizer with the Zeus system had similar results and conclusions about TECAB. 33 Interestingly, a study by Cisowski and Drzewiecki in Poland compared percutaneous stenting with endoscopic coronary artery bypass grafting in patients with single-vessel disease. In this series of 100 patients percutaneous stenting resulted in restenosis in 6% and 12% at 1 and 6 months, respectively, compared with 2% at 6 months in the endoscopic bypass group. 34

Another use for robotic systems being investigated is pediatric laparoscopic surgery. Currently, laparoscopic pediatric surgery is limited by an inability to perform precise anastomoses of 2 to 15 millimeters. 35 Although laparoscopic techniques may be used to treat infants with intestinal atresia, choledochal cysts, biliary atresia, and esophageal atresia, it is not the standard approach because of the technical difficulties. To evaluate the feasibility of robotic systems in pediatric minimally invasive surgery, Hollands and Dixey developed a study where enteroenterostomy, hepaticojejunostomy, and portoentorostomy were performed on piglets. 30 They found all the procedure to be technically feasible with the Zeus robotic system. The study concludes that robotic-assisted laparoscopic techniques are technically feasible in pediatric surgery and may be of benefit in treating various disorders in term and preterm infants. More recently, Hollands and Dixey devised a study using 10 piglets to develop the procedure and evaluate the feasibility of performing a robot-assisted esophagoesophagostomy. In this study, robot-assisted and thoracoscopic approaches were evaluated and compared for leak, narrowing, caliber, mucosal approximation, as well as anesthesia, operative, anastomotic, and robotic set-up times. They found that the robot-assisted approach is feasible. They also discerned no statistically significant difference between the 2 approaches based on the above variables. 31

Despite many studies showing the feasibility of robotic surgery, there is still much to be desired. More high-quality clinical trials need to be performed and much more experience needs to be obtained before the full potential of these systems can be realized.

PRACTICAL USES OF SURGICAL ROBOTS TODAY

In today’s competitive healthcare market, many organizations are interested in making themselves “cutting-edge” institutions with the most advanced technological equipment and the very newest treatment and testing modalities. Doing so allows them to capture more of the healthcare market. Acquiring a surgical robot is in essence the entry fee into marketing an institution’s surgical specialties as “the most advanced.” It is not uncommon, for example, to see a photo of a surgical robot on the cover of a hospital’s marketing brochure and yet see no word mentioning robotic surgery inside.

As far as ideas and science, surgical robotics is a deep, fertile soil. It may come to pass that robotic systems are used very little but the technology they are generating and the advances in ancillary products will continue. Already, the development of robotics is spurring interest in new tissue anastomosis techniques, improving laparoscopic instruments, and digital integration of already existing technologies.

As mentioned previously, applications of robotic surgery are expanding rapidly into many different surgical disciplines. The cost of procuring one of these systems remains high, however, making it unlikely that an institution will acquire more than one or two. This low number of machines and the low number of surgeons trained to use them makes incorporation of robotics in routine surgeries rare. Whether this changes with the passing of time remains to be seen.

THE FUTURE OF ROBOTIC SURGERY

Robotic surgery is in its infancy. Many obstacles and disadvantages will be resolved in time and no doubt many other questions will arise. Many question have yet to be asked; questions such as malpractice liability, credentialing, training requirements, and interstate licensing for tele-surgeons, to name just a few.

Many of current advantages in robotic assisted surgery ensure its continued development and expansion. For example, the sophistication of the controls and the multiple degrees of freedom afforded by the Zeus and da Vinci systems allow increased mobility and no tremor without comprising the visual field to make micro anastomosis possible. Many have made the observation that robotic systems are information systems and as such they have the ability to interface and integrate many of the technologies being developed for and currently used in the operating room. 9 One exciting possibility is expanding the use of preoperative (computed tomography or magnetic resonance) and intraoperative video image fusion to better guide the surgeon in dissection and identifying pathology. These data may also be used to rehearse complex procedures before they are undertaken. The nature of robotic systems also makes the possibility of long-distance intraoperative consultation or guidance possible and it may provide new opportunities for teaching and assessment of new surgeons through mentoring and simulation. Computer Motion, the makers of the Zeus robotic surgical system, is already marketing a device called SOCRATES that allows surgeons at remote sites to connect to an operating room and share video and audio, to use a “telestrator” to highlight anatomy, and to control the AESOP endoscopic camera.

Technically, much remains to be done before robotic surgery’s full potential can be realized. Although these systems have greatly improved dexterity, they have yet to develop the full potential in instrumentation or to incorporate the full range of sensory input. More standard mechanical tools and more energy directed tools need to be developed. Some authors also believe that robotic surgery can be extended into the realm of advanced diagnostic testing with the development and use of ultrasonography, near infrared, and confocal microscopy equipment. 10

Much like the robots in popular culture, the future of robotics in surgery is limited only by imagination. Many future “advancements” are already being researched. Some laboratories, including the authors’ laboratory, are currently working on systems to relay touch sensation from robotic instruments back to the surgeon. 15–19,32 Other laboratories are working on improving current methods and developing new devices for suture-less anastomoses. 33–35 When most people think about robotics, they think about automation. The possibility of automating some tasks is both exciting and controversial. Future systems might include the ability for a surgeon to program the surgery and merely supervise as the robot performs most of the tasks. The possibilities for improvement and advancement are only limited by imagination and cost.

Although still in its infancy, robotic surgery has already proven itself to be of great value, particularly in areas inaccessible to conventional laparoscopic procedures. It remains to be seen, however, if robotic systems will replace conventional laparoscopic instruments in less technically demanding procedures. In any case, robotic technology is set to revolutionize surgery by improving and expanding laparoscopic procedures, advancing surgical technology, and bringing surgery into the digital age. Furthermore, it has the potential to expand surgical treatment modalities beyond the limits of human ability. Whether or not the benefit of its usage overcomes the cost to implement it remains to be seen and much remains to be worked out. Although feasibility has largely been shown, more prospective randomized trials evaluating efficacy and safety must be undertaken. Further research must evaluate cost effectiveness or a true benefit over conventional therapy for robotic surgery to take full root. Table 3 .

TABLE 3. Current Applications of Robotic Surgery

This material is based upon work supported by the National Science †Foundation under Grant No. 0079830 and Grant No. 0133471.

Reprints: Andres E Castellanos, MD, Assistant Professor, Department of Surgery, Drexel University College of Medicine. Mail Stop 413, 245 N. 15th Street, Philadelphia PA 19102. E-mail: [email protected] .