A systematic review of the true benefit of robotic surgery: Ergonomics

Sex-based differences in musculoskeletal pain among surgeons: an international survey

INTRODUCTION

Musculoskeletal (MSK) injury is a known occupational risk for surgeons. Few studies have focused on the impact of sex in MSK injuries, despite differences in physical characteristics that may influence MSK pain occurrence. The increasing number of female surgeons urges investigation on ergonomic challenges faced by this group. The aim of the survey was to evaluate incidence and impact of MSK pain among surgeons to assess sex-based differences in the occurrence of MSK pain.

METHODS

A survey comprised of demographic/practice-related questions, validated scales for work-related MSK pain assessment and effect of health impairment on quality of life (QoL) was electronically distributed. Primary outcome was MSK pain incidence across sex evaluated with comparative and logistic regression analysis.

RESULTS

1162 surgeons completed the survey (48.02% females, 51.98% males). Significant differences across demographic factors were identified whereas surgical platforms used were similar across sexes. Female surgeons reported higher frequency of MSK pain (p =  < 0.0001), and significant difference in MSK pain location. Higher burden of MSK pain in females was noted, with higher rates of "numbness", "pain" and "ache" and less often "none" with respect to the male group (p = 0.020). Higher MSK pain frequency was associated with depression-like feelings, painkiller use and work absence (p =  < 0.0001).

CONCLUSIONS

There are striking sex-based differences in work-related MSK pain across surgeons. Female surgeons experience more MSK pain than males and suffer of subsequent impacts on routine work, function, and QoL. These results highlight the need to promote appropriate surgical ergonomics in the operating room for the expanding population of female surgeons.

A New Era in Perforator Flap Surgery for Breast Reconstruction: A Comparative Study of Robotic versus Standard Harvest of Bilateral Deep Inferior Epigastric Artery Perforator Flaps

BACKGROUND

 Traditional deep inferior epigastric artery perforator (DIEP) flap harvest splits the anterior sheath, weakening the abdominal wall and predisposing patients to bulge or hernia. Abdominal wall morbidity may be decreased using minimally invasive techniques. We refined a transabdominal approach to the robotic harvest of bilateral DIEP flaps.

METHODS

 A retrospective medical record study involving all patients who underwent bilateral or bipedicled robotic DIEP (rDIEP) or standard DIEP (sDIEP) flap harvest between July 2021 and September 2022. Outcomes included abdominal wall morbidity, total operative time, length of stay (LOS), and complications.

RESULTS

 Forty-seven patients were included (48 sDIEP flaps, 46 rDIEP flaps) with no significant difference in patient characteristics. Fascial incision length in the rDIEP group was shorter (4.1 vs. 11.7 cm, p < 0.001). Mesh reinforcement of the abdominal wall was used in 13/24 sDIEP and none in rDIEP patients (p < 0.001). Operative time was longer in the rDIEP cohort (739 vs. 630 minutes, p = 0.013), although subanalysis showed no difference in the second half of the cohort. The average robotic dissection time was 135 minutes, which decreased significantly with the surgeon's experience. There were no intraoperative complications from using the robot. LOS was shorter with rDIEP but not statistically significant (3.9 vs. 4.3 days, p = 0.157).

CONCLUSION

 This study represents the most extensive cohort analysis of bilateral rDIEP flap harvest, offering a comprehensive comparison to traditional sDIEP. The initial results underscore the viability of robotic techniques for flap harvesting, highlighting potential advantages including reduced fascial incision length and decreased abdominal disruption. Furthermore, using robotics may obviate the necessity for fascial reinforcement with mesh.

Exploring Patient Experiences With and Perceptions of Robotic-Assisted Surgery in Denmark

Although the use of robotic-assisted surgery (RAS) is increasing worldwide, qualitative research on the patient experience with RAS is lacking. To understand patients' perioperative experiences, the authors conducted semi-structured interviews with five elective surgical patients from two regional hospitals. The interviews were structured to explore patient experiences that may reflect the implementation of enhanced recovery after surgery protocols. The transcribed interviews were analyzed, coded, and interpreted within a hermeneutic framework. Findings revealed three themes: perceptions of RAS as a surgical modality, preoperative preparation was soothing, and health care professionals influence the patient experience. The authors noted that although the participants reported limited knowledge of RAS, they generally felt positive about its use. The competence and demeanor of health care professionals may influence patients' experiences and perceptions of outcomes, and positive clinical outcomes may overcome negative perioperative experiences.

Influence of surgical start time on the quality of surgery for middle and low rectal cancer: a post hoc analysis of the real trial

BACKGROUND

Surgical start time is considered to influence the quality of surgery due to surgeon fatigue. High-quality studies on middle and low rectal cancer are lacking. The analysis aims to find out the influence of surgical start time on the quality of surgery for middle and low rectal cancer, and whether robotic surgery could avoid the influence.

MATERIALS AND METHODS

This study was a post hoc analysis of the REAL (robotic vs. laparoscopic surgery for middle and low rectal cancer) study, a multicenter, randomized, controlled, unblinded, parallel group, superiority trial. This analysis included the modified intention-to-treat population of the REAL study, who were divided into Group I (the surgeon's first surgery of the day), Group II (the surgeon's second surgery of the day), and Group III (the surgeon's third and subsequent surgeries of the day) based on surgical information registered in the REAL study. The primary outcome was the percentage of patients with a positive circumferential resection margin. The second outcomes were the macroscopic completeness of resection the incidence of intraoperative complications and 30-day postoperative complications.

RESULTS

A total of 1171 patients from the REAL study were included and divided into three groups: 547 (46.7%) in Group I (the surgeon's first surgery), 420 (35.9%) in Group II (the surgeon's second surgery), and 204 (17.4%) in Group III (the surgeon's third and subsequent surgeries). There was a lower percentage of circumferential resection margin (CRM)-positive patients in Group I (3.9%) than in Group II (6.6%, unadjusted P = 0.069) and Group III (8.1%, unadjusted P = 0.027, adjusted P = 0.081). Group I also had fewer intraoperative complications (5.3%) than Group II (8.3%, unadjusted P = 0.060) and Group III (9.3%, unadjusted P = 0.046, adjusted P = 0.138). Macroscopic completeness of resection was not significantly different among the three groups (complete rate: Group I vs. Group II, 94.9% vs. 92.4%, unadjusted P = 0.254; Group I vs. Group III, 94.9% vs. 92.6%, unadjusted P = 0.334; Group II vs. Group III, 92.4% vs. 92.6%, unadjusted P = 0.488). The incidence of 30-day postoperative complications showed no significant difference among the three groups (Group I vs. Group II, 18.5% vs. 20.0%, unadjusted P = 0.547; Group I vs. Group III, 18.5% vs. 22.1%, unadjusted P = 0.268; Group II vs. Group III, 20.0% vs. 22.1%, unadjusted P = 0.551). The quality of robotic surgery was not significantly influenced by surgical start time. For laparoscopic surgery, Group I had a lower CRM positivity rate (4.3%) than Group II (9.4%, unadjusted P = 0.029, adjusted P = 0.087) and Group III (10.4%, unadjusted P = 0.031, adjusted P = 0.047).

CONCLUSION

According to this post hoc analysis of the REAL study, for middle and low rectal cancer surgery, surgical start time could influence surgical quality by affecting surgeon fatigue. Surgeries start later in a day bring worse quality compared to those early in a day. Robotic surgery could reduce this influence to some extent, while laparoscopic surgery is more susceptible.

Evaluation of the Toumai robotic system in partial nephrectomy and key system features

Robotic partial nephrectomy is a standard procedure in urology, but its widespread use is limited by the high cost and technical constraints of current systems. New robotic systems are being developed to enhance affordability and accessibility, expanding the availability of advanced robotic surgery to a broader range of healthcare facilities and patients. This study evaluates the feasibility and safety of the Toumai system in partial nephrectomy, examining its advanced features and their potential impact on surgical precision and operational efficiency. In this single center study, eleven patients underwent partial nephrectomy using Toumai. Primary endpoints were feasibility and safety, while secondary outcomes included perioperative outcomes. All surgeries were completed successfully without conversion, minimal complications, and no major equipment failures. The median operative time was 107 min, docking time was 8 min, and estimated blood loss was 50 ml. One off-clamp partial nephrectomy was successfully performed and median warm ischemia time was 9 min in the remaining cases. Postoperatively, renal function remained stable, and surgical margins were negative in all cases. These preliminary results suggest that partial nephrectomy can be safely performed using the Toumai robotic system. The system's advanced features, including sensory feedback, high-frequency response, and enhanced imaging technologies, likely contributed to favorable surgical outcomes with minimal complications. However, these initial findings warrant further validation through larger studies and longer follow-up.

The Transformative Role of Artificial Intelligence in Plastic and Reconstructive Surgery: Challenges and Opportunities

Background/Objectives: This study comprehensively examines how artificial intelligence (AI) technologies are transforming clinical practice in plastic and reconstructive surgery across the entire patient care continuum, with the specific objective of identifying evidence-based applications, implementation challenges, and emerging opportunities that will shape the future of the specialty. Methods: A comprehensive narrative review was conducted analyzing the integration of AI technologies in plastic surgery, including preoperative planning, intraoperative applications, postoperative monitoring, and quality improvement. Challenges related to implementation, ethics, and regulatory frameworks were also examined, along with emerging technological trends that will shape future practice. Results: AI applications in plastic surgery demonstrate significant potential across multiple domains. In preoperative planning, AI enhances risk assessment, outcome prediction, and surgical simulation. Intraoperatively, AI-assisted robotics enables increased precision and technical capabilities beyond human limitations, particularly in microsurgery. Postoperatively, AI improves complication detection, pain management, and outcomes assessment. Despite these benefits, implementation faces challenges including data privacy concerns, algorithmic bias, liability questions, and the need for appropriate regulatory frameworks. Future directions include multimodal AI systems, federated learning approaches, and integration with extended reality and regenerative medicine technologies. Conclusions: The integration of AI into plastic surgery represents a significant opportunity to enhance surgical precision, improve outcome prediction, and expand the boundaries of what is surgically possible. However, successful implementation requires addressing ethical considerations and maintaining the human elements of surgical care. Plastic surgeons must actively engage with AI development to ensure these technologies address genuine clinical needs while aligning with the specialty's core values of restoring form and function, alleviating suffering, and enhancing quality of life.

Robotic versus laparoscopic colorectal surgery for patients with obesity: an updated systematic review and meta-analysis

BACKGROUND

Obesity poses significant challenges in colorectal surgery, affecting operative difficulty and postoperative recovery. The choice of minimally invasive approach for this patient population remains a challenge during preoperative planning. This review aims to provide an updated synthesis of studies comparing laparoscopic and robotic approaches for adult patients with obesity undergoing colorectal surgery.

METHODS

MEDLINE, Embase and CENTRAL were searched up to August 2023. Articles were included if they compared laparoscopic and robotic colorectal surgery outcomes in adults with obesity (BMI ≥30 kg/m2). Outcomes included overall postoperative morbidity, conversion to laparotomy, and operative time. Inverse variance random-effects meta-analyses were used to pool effect estimates.

RESULTS

After screening 2187 citations, 10 observational studies were included with 3281 patients with obesity undergoing robotic surgery (mean age: 58.1 years, female: 43.9%) and 11 369 patients with obesity undergoing laparoscopic surgery (mean age: 58 years, female: 53.2%). Robotic surgery resulted in longer operative times (MD 46.71 min, 95% CI 33.50-59.92, p < 0.01, I2 = 93.79%) with statistically significant reductions in conversions to laparotomy (RR 0.50, 95% CI 0.39-0.65, p < 0.01, I2 = 67.15%). No significant differences were seen in postoperative morbidity (RR 0.94, 95% CI 0.82-1.08, p = 0.40, I2 = 36.08%).

CONCLUSION

These data suggest that robotic colorectal surgery in patients with obesity may reduce the risk for conversion to laparotomy, but at the expense of increased operative times and with no overt benefits in postoperative outcomes. Further high quality randomized controlled trials assessing the utility of robotic surgery in patients with obesity undergoing colorectal surgery are warranted.

Design and evaluation of new user control devices for improved ergonomics in flexible robotic endoscopy

Background

The ergonomics of flexible endoscopes require improvement as the current design carries a high risk of musculoskeletal injury for endoscopists. Robotic systems offer a solution by separating the endoscope from the control handle, allowing a focus on ergonomics and usability. Despite the increasing interest in this field, little attention has been paid towards developing ergonomic human input devices. This study addresses two key questions: How can handheld control devices for flexible robotic endoscopy be designed to prioritize ergonomics and usability? And, how effective are these new devices in a simulated clinical environment?

Methods

Addressing this gap, the study proposes two handheld input device models for controlling a flexible endoscope in four degrees of freedom (DOFs) and an endoscopic instrument in three DOFs. A two-stage evaluation was conducted with six endoscopists evaluating the physical ergonomics and a final clinical user evaluation with seven endoscopists using a virtual colonoscopy simulator with proportional velocity and position mapping.

Results and discussion

Both models demonstrated clinical suitability, with the first model scoring 4.8 and the second model scoring 5.2 out of 6 in the final evaluation. In sum, the study presents two designs of ergonomic control devices for robotic colonoscopy, which have the potential to reduce endoscopy-related injuries. Furthermore, the proposed colonoscopy simulator is useful to evaluate the benefits of different mapping modes. This could help to optimize the design and control mechanism of future control devices.

Early postoperative outcomes in a retrospective propensity score-matched comparison of robotic extended totally extraperitoneal (r-eTEP) and extended totally extraperitoneal (eTEP) repair for ventral hernia

BACKGROUND

The extended totally extraperitoneal technique (eTEP) is a novel approach for ventral hernia repair. This technique has been recently advanced using robotics (r-eTEP). The aim of this study is to perform a comprehensive analysis of the initial results of r-eTEP and to evaluate the safety and efficacy of this technique compared to the eTEP technique.

METHODS

This is a monocentric retrospective study of patients with ventral hernias who underwent surgery via eTEP or r-eTEP in our department between 2019 and 2023. Propensity score matching was applied to compare the groups. Preoperative patient and hernia characteristics, intraoperative findings, and postoperative outcomes were subsequently analysed.

RESULTS

Patient demographics were comparable between the groups. The r-eTEP group had a significantly greater proportion of M3 hernias (p = 0.006), M4 hernias (p = 0.020), incisional hernias (p = 0.002), and hernias with rectus diastasis (p < 0.001). The r-eTEP group had a significantly larger hernia defect (p = 0.003) and larger mesh size (p = 0.015). The r-eTEP group had a shorter hospital stay (p < 0.001) and shorter operative time, though not statistically significant (p = 0.211). Intraoperative and postoperative complications, as well as postoperative pain, were comparable between the groups.

CONCLUSION

The findings of the present study show that the r-eTEP technique may offer potential benefits as the overall hospital stay was shorter while intraoperative and postoperative complications were comparable for both techniques.

The first comparative analysis of open and robotic tracheobronchoplasty for excessive central airway collapse†

OBJECTIVES

Tracheobronchoplasty is an operation to treat excessive central airway collapse by stabilizing the posterior tracheal membrane. In 2020, our institution transitioned from the traditional open approach to the robotic-assisted tracheobronchoplasty in select patients. This retrospective cohort study compares postoperative complications and short-term outcomes for patients undergoing open versus robotic tracheobronchoplasty at a high-volume complex airway centre.

METHODS

A retrospective review of all patients who underwent open tracheobronchoplasty (2018-2020) and robotic tracheobronchoplasty (2020-2023) was conducted.

RESULTS

During the study period, 43 and 69 patients underwent robotic and open tracheobronchoplasty, respectively. Robotic tracheobronchoplasty had longer median operative times than open (8.4 vs 6.2 h; P ≤ 0.01). Both median intensive care unit (ICU) length of stay (1.0 vs 3.0 days, P ≤ 0.01) and hospital length of stay (5.0 vs 7.0 days, P ≤ 0.01) were shorter after robotic tracheobronchoplasty. There were no significant differences in major or minor complications, total Clavien-Dindo Score, estimated blood loss, discharge to home, and 30-day readmission. The robotic group had two reoperations during the index hospitalization and three conversions to open. There were no mortalities in either group. Short-term (3-month) functional and quality-of-life outcomes were equivalent between groups.

CONCLUSIONS

In selected patients with severe and symptomatic excessive central airway collapse, robotic tracheobronchoplasty is a safe and feasible alternative to the traditional open approach. Patients undergoing robotic tracheobronchoplasty have shorter ICU and total hospital stays with equivalent complication rates. As the robotic approach becomes more prevalent, further comparative outcomes are necessary with longer follow-up to ensure durability of the robotic-assisted repair.

Patient Complexity and Bile Duct Injury After Robotic-Assisted vs Laparoscopic Cholecystectomy

Importance

Recent evidence suggests higher bile duct injury rates for patients undergoing robotic-assisted cholecystectomy compared with laparoscopic cholecystectomy. Proponents of the robotic-assisted approach contend that this may be due to selection of higher-risk and more complex patients being offered robotic-assisted cholecystectomy.

Objective

To evaluate the comparative safety of robotic-assisted cholecystectomy and laparoscopic cholecystectomy among patients with varying levels of risk for adverse postoperative outcomes.

Design, Setting, and Participants

This retrospective cohort study assessed fee-for-service Medicare beneficiaries aged 66 to 99 years who underwent cholecystectomy between January 1, 2010, and December 31, 2021. Data analysis was performed between June and August 2024. Medicare beneficiaries were separated into model training and experimental cohorts (60% and 40%, respectively). Random forest modeling and least absolute shrinkage and selection operator techniques were then used in a risk model training cohort to stratify beneficiaries based on their risk of a composite outcome of postoperative adverse events consisting of 90-day postoperative complications, serious complications, reoperations, and rehospitalization in an independent experimental cohort.

Exposures

Robotic-assisted vs laparoscopic cholecystectomy.

Main Outcomes and Measures

The primary outcome of interest was bile duct injury requiring operative intervention after cholecystectomy. Secondary outcomes were composite outcomes from cholecystectomy composed of any complications, serious complications, reoperations, and readmissions.

Results

A total of 737 908 individuals (mean [SD] age, 74.7 [9.9] years; 387 563 [52.5%] female) were included, with 295 807 in an experimental cohort and 442 101 in a training cohort. Bile duct injury was higher among patients undergoing robotic-assisted compared with laparoscopic cholecystectomy in each subgroup (low-risk group: relative risk [RR], 3.14; 95% CI, 2.35-3.94; medium-risk group: RR, 3.13; 95% CI, 2.35-3.92; and high-risk group: RR, 3.11; 95% CI, 2.34-3.88). Overall, composite outcomes between the 2 groups were similar for robotic-assisted cholecystectomy compared with laparoscopic cholecystectomy (RR, 1.09; 95% CI, 1.07-1.12), aside from reoperation, which was overall higher in the robotic-assisted group compared with the laparoscopic group (RR, 1.47; 95% CI, 1.35-1.59).

Conclusions and Relevance

In this cohort study of Medicare beneficiaries, bile duct injury rates were higher among low-, medium-, and high-risk surgical candidates after robotic-assisted cholecystectomy. These findings suggest that patient selection may not be the cause of differences in bile duct injury rates among patients undergoing robotic-assisted vs laparoscopic cholecystectomy.

Use of Robotic Surgery in Plastic and Reconstructive Surgery: A Narrative Review

BACKGROUND/OBJECTIVES

Robotic systems offer enhanced precision, dexterity, and visualization, which are essential in addressing the complex nature of plastic surgery procedures. Despite widespread adoption in other surgical specialties, such as urology and gynecology, their application in plastic surgery remains underexplored. This review examines the use of robotic systems in plastic and reconstructive surgery with a focus on clinical outcomes.

METHODS

A literature search was conducted using PubMed, Embase, Scopus, and Web of Science. Search terms included ("robotic surgery" OR "surgical robots") AND ("plastic surgery" OR "reconstructive surgery"). Studies on clinical outcomes and biomimetic innovations published between 1980 and 2024 were included, while non-English, cadaver-based, and animal studies were excluded. Data were systematically extracted using Covidence and analyzed.

RESULTS

Twenty-nine studies were identified that evaluated the clinical outcomes of robotics in areas including breast reconstruction, microsurgery, and craniofacial procedures. Robotic systems like the Da Vinci and Symani platforms offer motion scaling, tremor elimination, and enhanced depth perception. In nipple-sparing mastectomies, they reduced skin necrosis rates from 8% to 2%, while in DIEP flap reconstruction, they enabled smaller fascial incisions (2.67 ± 1.13 cm vs. 8.14 ± 1.69 cm) and faster recovery with fewer complications. In microsurgery, they achieved 100% patency for vessels under 0.3 mm and a 25.2% limb volume reduction in lymphedema patients in 3 months.

CONCLUSIONS

Robotic systems show significant promise, particularly in procedures such as nipple-sparing mastectomies, and have the potential to overcome challenges including surgeon fatigue. However, challenges such as longer operating times, high costs, and limited haptic feedback remain barriers to their adoption.

Towards autonomous robotic THz-based in vivo skin sensing: the PicoBot

Terahertz (THz) light has the unique properties of being very sensitive to water, non-ionizing, and having sub-millimeter depth resolution, making it suitable for medical imaging. Skin conditions including eczema, psoriasis and skin cancer affect a high percentage of the population and we have been developing a THz probe to help with their diagnosis, treatment and management. Our in vivo studies have been using a handheld THz probe, but this has been prone to positional errors through sensorimotor perturbations and tremors, giving spatially imprecise measurements and significant variations in contact pressure. As the operator tires through extended device use, these errors are further exacerbated. A robotic system is therefore needed to tune the critical parameters and achieve accurate and repeatable measurements of skin. This paper proposes an autonomous robotic THz acquisition system, the PicoBot, designed for non-invasive diagnosis of healthy and diseased skin conditions, based on hydration levels in the skin. The PicoBot can 3D scan and segment out the region of interest on the skin's surface, precisely position (± 0.5/1 mm/degrees) the probe normal to the surface, and apply a desired amount of force (± 0.1N) to maintain firm contact for the required 60 s during THz data acquisition. The robotic automation improves the stability of the acquired THz signals, reducing the standard deviation of amplitude fluctuations by over a factor of four at 1 THz compared to hand-held mode. We show THz results for skin measurements of volunteers with healthy and dry skin conditions on various parts of the body such as the volar forearm, forehead, cheeks, and hands. The tests conducted validate the preclinical feasibility of the concept along with the robustness and advantages of using the PicoBot, compared to a manual measurement setup.

Aching for Change: Musculoskeletal Pain in the Operating Theatre Amongst Surgical Trainees

OBJECTIVES

Work-related injuries are common among surgeons with up to 70 % being found to report difficulties. Given the extension expected to career longevity for current trainees, injury prevention is more important than ever. However, ergonomics education for surgical trainees in the UK is deficient. We aimed to gauge whether current trainees in Kent, Surrey and Sussex (KSS) experience pain whilst operating and what strategies, if any, they utilise.

DESIGN, SETTING AND PARTICIPANTS

A questionnaire was distributed to trainees in the KSS School of Surgery collecting data on pain related to operating and pain management strategies. Participants discussed their experiences of operating-related pain in a focus group.

RESULTS

75 trainees across the KSS region responded. Mean age was 32 years (range 26-42) and median training level was ST4. General surgery (n = 22), orthopaedics (n = 19) and urology (n = 13) were the most prevalent specialties. All trainees reported musculoskeletal pain attributed to operating, with 36 % (n = 27) experiencing pain "frequently" or "always". 69 % (n = 52) found this pain "sometimes", "frequently" or "always" distracted them whilst operating. The most common sites for pain were the lower back (73 %), neck (49.3 %), upper back (38.7 %) and shoulders (37.3 %). No participants had received formal ergonomics training and the majority (86.7 %) had not discussed pain with their supervisors. The focus group identified a culture of enduring pain without complaint and a reluctance to discuss it with mentors.

CONCLUSIONS

Musculoskeletal pain from operating was found to be a common issue in this cohort with the majority reporting distraction while operating. Ergonomics is not currently addressed by any formal training programmes and we have recommended a regional training initiative for trainees in KSS to address and prevent musculoskeletal injuries.

Surgeons' fatigue in minimally invasive and open surgery: A review of the current literature

Technological advancements have revolutionized surgical methods, with laparoscopic and robotic surgeries offering significant benefits over traditional open procedures. These benefits include reduced intraoperative blood loss, shortened hospital stays, faster recovery, and improved cosmetic outcomes. However, the learning curve for laparoscopic surgery remains a challenge. Robotic systems, like the da Vinci Surgical System, address many limitations of laparoscopic surgery, including limited range of motion and tremors, and offer superior ergonomics. Despite concerns over cost and tactile feedback, innovations like telesurgery and augmented reality are enhancing robotic surgery's potential. Moreover, robotic surgery generally results in less blood loss, fewer complications, and quicker recovery compared to open surgery. Robotic surgery tends also to be less physically demanding for surgeons, reducing fatigue and musculoskeletal strain. However, research also reveals that many surgeons still experience discomfort, particularly in the neck and shoulders, emphasizing the need for ergonomic training and improved workstation setups. The review also explores the impact of pre-procedure fatigue on surgical performance, noting that fatigue can impair performance on surgical simulators, particularly among residents. Despite this, studies showed that performing consecutive surgeries in a single day does not appear to adversely affect patient outcomes. Overall, ergonomic interventions are crucial in both laparoscopic and robotic surgeries to enhance surgeon efficiency and well-being, and further research is needed to optimize these surgical methods and understand the long-term impacts of fatigue on performance and patient outcomes.

[Ergonomic Load on the Surgical Team during Open, Laparoscopic and Robot-assisted Surgical Procedures]

The aim of this work is to investigate the ergonomic load on the surgical team during open, laparoscopic and robot-assisted surgical procedures.Employees of the Salzburg State Hospitals (SALK) were invited to take part in a standardised online survey in December 2023. The extent and differences in psychophysical stress for the individual professional groups and specialists were examined for different surgical procedures.64/111 (57.7%) of all invited employees took part in the study, of whom 30 (46.9%) were male and 34 (53.1%) female. For the majority, working in the operating theatre (OT) was physically stressful, and more than 60.9% of those surveyed had to seek medical help or take painkillers. The most commonly affected areas of the body are the back and neck, and 17.2% of respondents believe they were likely to have to retire early. Despite the physical strain, the majority enjoyed working in the OT. For 61.9%, robotic surgery was perceived as being the least physically demanding. Significant differences in psychophysical stress and preferences for the different types of operations were evident in gender, age groups, professional groups, specialist areas, years of work in the operating theatre and biometric data.The results could be used to initiate targeted measures to promote health and employee satisfaction and to carry out appropriate training.

Comparative study of robotic-assisted vs. laparoscopic surgery for colorectal cancer: a single-center experience

Background

Colorectal cancer (CRC) surgeries are commonly performed using either robotic-assisted colorectal surgery (RACS) or laparoscopic colorectal surgery (LCS). This study aimed to compare clinical and surgical outcomes between RACS and LCS for CRC patients.

Methods

We included 225 patients from Tianjin Medical University Cancer Institute & Hospital (TJMUCH) between January 2021 and June 2024, divided into RACS (n=82) and LCS (n=143) groups. Data on demographics, clinicopathological variables, surgical parameters, and perioperative outcomes were analyzed. Statistical significance was set at p < 0.05.

Results

RACS was associated with longer surgery durations (median: 218.5 vs. 165 minutes) and greater blood loss (median: 100 vs. 50 mL) compared to LCS (p < 0.001 for both). Additionally, the median hospitalization cost was notably higher for RACS at 117,822 RMB compared to 78,174 RMB for LCS (p < 0.0001). RACS was used more frequently for proctectomy (87.80% vs. 72.48%). No significant differences were found in lymph node dissection (LND), postoperative hospital stay, conversion to open surgery, or postoperative complications between the groups (p > 0.05). Anastomotic leakage was the most common complication in both groups (RACS: 3.66%, LCS: 4.20%), with no significant difference in incidence (p = 0.876). To reduce bias due to surgical site, cases of rectal and sigmoid colon cancer were singled out. Hierarchical analysis showed significant differences still remained in surgical duration, blood loss, and surgical site distribution for proctectomy and sigmoid colon resection (p < 0.001). RACS did not show a clear advantage in surgical field exposure or tissue retraction.

Conclusion

RACS, despite superior visualization, involved longer operative times and more blood loss than LCS. Both techniques had similar clinical outcomes, with LCS offering specific technical advantages.

Comparative analysis of disruptive events in robotic and laparoscopic radical prostatectomy

This study compares laparoscopic (LRP) and robotic-assisted (RARP) radical prostatectomy to identify external and internal disruptive events, focusing on tasks that require heightened attention and coordination among the surgical team. Observations conducted across three hospitals in Australia and China. Data collection was rigorously ensured through the analysis of video recordings and consultations with surgeons, followed by statistical analysis using the Wilcoxon Signed Rank test. In a sample of 54 surgeries (27 RARP, 27 LRP), 15 activities were analysed, identifying 23 internal and 38 external disruption types. The findings indicate that RARP significantly reduces both external and internal disruptions compared to LRP, with decreases of around 41% and 33%, respectively. Notably, neurovascular bundle release showed the highest internal disruptions, with 123 events in RARP and 160 in LRP, and minor vessel bleeding led to the most internal disruptions, with 200 in RARP and 251 in LRP. RARP advantages include fewer disruptions due to pre-dissection inspections for visibility, improved blood management, and a skilled assistant, reducing the need for direct eye contact and repeated instructions. This study adds new dimensions to existing research by comparing internal and external disruptions in complex surgeries-specifically radical prostatectomy-performed using two approaches: robotic-assisted and laparoscopic.

Surgical Outcomes of Multiple Robot-Assisted Hysterectomies in a Single Workday by the Same Surgeon

INTRODUCTION

Due to the growing medical need for gynecologic robotic surgery, several robotic surgeries may be performed in a single day at high-volume centers. This study evaluated the safety of performing multiple robot-assisted hysterectomies (RAHs) per day by the same surgeon.

METHODS

We reviewed the clinical data of patients who underwent robotic surgery from April 2018 to September 2024 at the Department of Gynecology, Yamanashi Central Hospital, and also examined the surgical type, order, and surgeon for each procedure.

RESULTS

A total of 352 RAHs performed by the same surgeon were included. Among them, 267 were the first and second cases performed on the same day (Group A), and 85 were the third to fifth cases (Group B). There were no statistically significant differences between the two groups regarding age, body mass index, uterine weight, surgical indication, and history of abdominal surgery. The median operative time of 68 (35-179) min in Group A and 66 (37-187) min in Group B was similar (p = 0.141). Both groups also had similar estimated blood loss (p = 0.744). Each group had two perioperative complications, and no patient underwent conversion to open or laparoscopic surgery.

CONCLUSION

Performing multiple RAHs by the same surgeon in a single day may be a safe procedure with no negative impact on operative time, blood loss, or perioperative complications. Hence, it could be a useful treatment option for high-volume centers.

On-demand robotic surgery for hysterectomies: A combination of the best of robotic and laparoscopic approach

BACKGROUND

The advantage of robot-assisted hysterectomy over standard laparoscopy remains controversial. Conventional robots offer limited flexibility to the surgeon. The novel, Dexter robotic system™, allows integration and easy switch between the laparoscopic and robotic interface.

OBJECTIVES

This study's objective is to evaluate the feasibility of using Dexter for robot-assisted laparoscopic hysterectomies by analyzing surgical data and intra- and postoperative complication rates.

DESIGN

Retrospective study.

METHODS

Women who underwent surgery using the Dexter robotic system at a University Hospital in Switzerland from March to December 2022 were included in this study. A comprehensive database containing coded demographic and clinical outcome data for these patients was analyzed for surgical data and intra- and postoperative complications.

RESULTS

We collected and evaluated data from 24 patients who underwent Dexter robot-assisted hysterectomies for indications like endometrial cancer, endometriosis, and uterine fibroids. For all patients, a hysterectomy was accompanied by other procedures such as radical lymphadenectomy or deep infiltrating endometriosis surgery that was mostly performed by conventional laparoscopy. The mean operating time was 171.9 min, with an average estimated blood loss of 130.8 ml. The patients stayed at the hospital for an average of 4 days. Clavien-Dindo grade III postoperative complications were reported in four patients with three vaginal dome infections and one umbilical (camera arm) trocar hernia. Importantly, there were no intraoperative complications or conversion to laparotomy among the operated patients.

CONCLUSION

We present the first retrospective study reporting the feasibility of Dexter in robot-assisted laparoscopic hysterectomies. All surgeries were performed successfully without technical failure or device-related adverse events. In contrast to the other robotic systems, Dexter offers an on-demand platform, allowing the surgeon to switch between laparoscopic and robotic interfaces as required. Further research is needed to validate its potential advantages and broader applicability.

A review of ergonomic positions to improve musculoskeletal distress in hepatobiliary pancreatic surgeons according to open, laparoscopic, and robotic surgeries

Advances in surgical ergonomics are essential for the performance, health, and career longevity of surgeons. Many surgeons experience work-related musculoskeletal disorders (WMSDs) resulting from various surgical modalities, including open, laparoscopic, and robotic surgeries. To prevent WMSDs, individual differences may exist depending on the surgical method; however, the key is to maintain a neutral posture, and avoid static postures. This review aims to summarize the concepts of ergonomics and WMSDs; identify the ergonomic challenges of open, laparoscopic, and robotic surgeries; and discuss ergonomic recommendations to improve them.

Safety and feasibility of single-incision robotic totally extra-peritoneal repair for inguinal hernia using the da Vinci Xi platform: a single-center prospective pilot study

PURPOSE

This study aimed to report the safety and feasibility of single-incision robotic totally extra-peritoneal repair (TEP) with the da Vinci Xi platform.

METHODS

We prospectively included patients with unilateral inguinal hernia who underwent elective single-incision robotic TEP between August 10, 2021 and December 12, 2022. The primary outcome was the determination of postoperative complications, and secondary outcomes were quality of life and recurrence rate.

RESULTS

Twenty patients were included in this study. The median age of patients was 60 (interquartile range [IQR], 44.8-62) years, and most were male (90%). Eighteen patients had an indirect hernia. The median total operative time was 70 (IQR, 60.5-82.0) min, the median docking time was 5 (IQR, 3.3-6.0) min, and the median console time was 42 (IQR, 30.3-49.8) min. No postoperative complications occurred within six months postoperatively. We observed an upward trend in quality of life, which was low preoperatively, with improvement noted one month postoperatively. During the six-month follow-up period, there were no cases of recurrence.

CONCLUSION

For uncomplicated inguinal hernias, single-incision robotic TEP using the da Vinci Xi platform can be selectively and safely attempted.

Integrating AI into Breast Reconstruction Surgery: Exploring Opportunities, Applications, and Challenges

Background: Artificial intelligence (AI) has significantly influenced various sectors, including healthcare, by enhancing machine capabilities in assisting with human tasks. In surgical fields, where precision and timely decision-making are crucial, AI's integration could revolutionize clinical quality and health resource optimization. This study explores the current and future applications of AI technologies in reconstructive breast surgery, aiming for broader implementation. Methods: We conducted systematic reviews through PubMed, Web of Science, and Google Scholar using relevant keywords and MeSH terms. The focus was on the main AI subdisciplines: machine learning, computer vision, natural language processing, and robotics. This review includes studies discussing AI applications across preoperative, intraoperative, postoperative, and academic settings in breast plastic surgery. Results: AI is currently utilized preoperatively to predict surgical risks and outcomes, enhancing patient counseling and informed consent processes. During surgery, AI supports the identification of anatomical landmarks and dissection strategies and provides 3-dimensional visualizations. Robotic applications are promising for procedures like microsurgical anastomoses, flap harvesting, and dermal matrix anchoring. Postoperatively, AI predicts discharge times and customizes follow-up schedules, which improves resource allocation and patient management at home. Academically, AI offers personalized training feedback to surgical trainees and aids research in breast reconstruction. Despite these advancements, concerns regarding privacy, costs, and operational efficacy persist and are critically examined in this review. Conclusions: The application of AI in breast plastic and reconstructive surgery presents substantial benefits and diverse potentials. However, much remains to be explored and developed. This study aims to consolidate knowledge and encourage ongoing research and development within the field, thereby empowering the plastic surgery community to leverage AI technologies effectively and responsibly for advancing breast reconstruction surgery.

A Delphi-based exploration of factors impacting blood loss and operative time in robotic prostatectomy

This study aims to investigate factors influencing the implementation of robotic-assisted radical surgery, with a specific focus on their effects on blood loss and operative time. Radical prostatectomy was chosen as the case study due to its complexity and diverse surgical activities. The study employed a three-round Delphi approach involving 25 surgeons from three countries: UK, Australia, and China. The collected data were analysed using non-parametric tests. The Delphi study showed significant correlations between the degree of difficulty and blood loss (Z = 2.698, ρ < 0.007), as well as between team coordination and blood loss (Z = 3.499, ρ < 0.0001). However, no significant relationship was found between operative time and blood loss. Surgeons reported that neurovascular bundle (NVB) release and pelvic lymph node dissection require high team coordination. NVB release is particularly challenging and poses a higher risk of blood loss. Additionally, a large prostate increases the difficulty of prostate dissection, prolongs operative time for bladder neck and NVB dissection, and leads to a considerable overall increase in operative time. The manuscript shows that effective team coordination plays a crucial role in reducing blood loss and operative time during surgical activities. When the team coordinates well, clear and efficient verbal communication suffices, reducing the need for physical proximity during robotic-assisted surgeries.

Outcomes of Adult Right Graft Living Donor Liver Transplantation Utilizing the Robotic Platform-integrated Real-time Indocyanine Green Fluorescence Cholangiography Compared to the Open Approach

OBJECTIVE

This study aimed to assess short-term biliary outcomes in adult living donor liver transplants using right grafts, comparing robotic surgery with real-time indocyanine green fluorescence cholangiography for optimal hilar plate transection, against the conventional open approach.

BACKGROUND

Determining the optimal transection plane through the hilar plate is crucial in donor hepatectomies, impacting outcomes significantly.

METHODS

From 2011 to 2023, a total of 839 right graft living donor hepatectomies were performed, with 414 (49%) performed via the open approach and 425 (51%) utilizing the robotic platform.

RESULTS

The magnetic resonant cholangiopancreatography predictions correlated moderately with the actual count of graft ducts ( r =0.57, P <0.001). Out of all 839 right donor hepatectomies, 321 (44%) were single duct grafts, of which 193/425 (49%) were retrieved with the robotic while 128/414 (38%) were with the open approach (OR: 1.58, 95% CI: 1.16-2.14), P =0.003). Overall, 50 (6%) of the donors developed a biliary complication during their hospital stay, of whom 38 (9%) were grafts retrieved with the open, while 13 (3%) with the robotic approach (OR: 0.31, 95% CI: 0.15-0.61, P <0.001). Similarly, 63 (15%) of the adult recipients developed a biliary complication of any severity when grafts were retrieved with the open approach compared to 35 (8%) with the robotic approach (OR: 0.50, 95% CI: 0.31-0.79), P =0.002).

CONCLUSIONS

The robotic platform with integrated real-time indocyanine green fluorescence cholangiography during right donor hepatectomy offers improved safety for the donor by accurately addressing the right hilar corridor, resulting in fewer graft ducts and fewer complications for the donor and recipient when compared to the standard open approach.

Opinion, uptake and current practice of robot-assisted upper gastrointestinal and oesophagogastric surgery in the UK: AUGIS national survey results

INTRODUCTION

The uptake of upper gastrointestinal (GI) robotic surgery in the United Kingdom (UK), and Europe more widely, is expanding rapidly. This study aims to present a current snapshot of the practice and opinions of the upper GI community with reference to robotic surgery, with an emphasis on tertiary cancer (oesophagogastric) resection centres.

METHODS

An electronic survey was circulated to the UK upper GI surgical community via national mailing lists, social media and at an open-invitation conference on robotic upper GI surgery in January 2023. The survey included questions on surgeons' current practice or planned adoption (if any) of robotics at individual and unit level, and their opinions on robotic upper GI surgery in general. Priority ranking and Likert-scale response options were used.

RESULTS

In total, 81 respondents from 43 hospitals were included. Thirty-four resectional centres responded, including 30 of 31 (97%) recognised upper GI cancer centres in England. Respondents reported performing robotic surgery in 21 of 34 (61.8%) resectional centres, with a median of 65 procedures per centre performed at the time of the survey (range 0-500, interquartile range 93.75). Every centre without a robotic programme expressed a desire or had active plans to implement one. Respondents ranked surgeon ergonomics as the most important reason for pursuing robotics, followed by improvements in patient outcomes and oncological efficacy.

CONCLUSIONS

Robotic upper GI practice is nascent but rapidly growing in the UK with plans for uptake in almost all tertiary centres. There is growing opinion that this is likely to become the predominant surgical approach in future with benefits to both patients and surgeons. This snapshot offers a point of reference to all stakeholders in upper GI surgery.

Caseload per Year in Robotic-Assisted Minimally Invasive Esophagectomy: A Narrative Review

Esophageal surgery is deemed one of the most complex visceral operations. There is a well-documented correlation between higher caseload and better outcomes, with hospitals that perform more surgeries experiencing significantly lower mortality rates. The approach to caseload per year varies across different countries within Europe. Germany increased the minimum annual required caseload of complex esophageal surgeries from 10 to 26 starting in 2023. Furthermore, the new regulations present challenges for surgical training and staff recruitment, risking the further fragmentation of training programs. Enhanced regional cooperation is proposed as a solution to ensure comprehensive training. This review explores the benefits of robotic-assisted minimally invasive esophagectomy (RAMIE) in improving surgical precision and patient outcomes and aims to evaluate how the caseload per year influences the quality of patient care and the efficacy of surgical training, especially with the integration of advanced robotic techniques.

Feasibility and safety of robotic-assisted surgical approach in median arcuate ligament syndrome-a systematic review

Median arcuate ligament syndrome (MALS) is rare syndrome and is diagnosis of exclusion. Though first robotic median arcuate ligament release (MALR) was described in 2007, there are only a few case reports (CR), case series (CS), and retrospective cohort studies (RCS) in the published literature. The purpose of this study was to assess the feasibility and safety of robotic-assisted MALR (r-MALR). PubMed, Embase, and Cochrane databases were searched (last search December 2023) for articles reporting r-MALR. All studies including CR, CS, RCS reporting technical feasibility (operating time and rate of conversions), safety (intra-operative complications, blood loss, post-operative complications), and outcome (length of stay [LoS]) were included (PROSPERO: CRD42024502792). A total of 23 studies (8-CR, 5-CS, 10-RCS) with total 290 patients were available in the literature. Except 1-RCS, all studies reported age and mean age for CR was 40.38 ± 17.7, 36.08 ± 15.12 for CS, 39.72 ± 7.35 years for RS; except 2-RCS, all studies reported gender distribution and there were 57 males and 214 females. Operating time: 3-CR, 4-CS, 9-RCS reported operating time, and mean time was 111 ± 54, 131.69 ± 7.51, 117.34 ± 35.03 min, respectively. Conversion rate: All studies reported data on conversion and only four (1.37%) cases were converted-one to laparoscopic approach, three to open approach (1-inadvertent celiac arteriotomy, 2-reasons not mentioned). Intraoperative complications: only 5-CR, 4-CS, and 9-RCS reported data on intra-operative complications, and there were only 6 complications (1.5%): 1-inadvertent celiac arteriotomy converted to open; 3-unnamed vascular injuries (2 managed robotically, 1 converted to open); 1-bleeding managed robotically; there were no other reported injuries. Estimated blood loss ranged from 5 to 30 ml. Post-operative complications: 5-CR, 4-CS, 8-RCS described post-operative complications in 21 (7%) patients. Twenty cases were grade I, one was grade IIIa, and all managed successfully. LoS stay: 2-CR, 4-CS, 10-RCS reported LoS and overall, it was 2 days. r-MALR is reasonable, technically feasible, safe, and has acceptable outcomes. In addition, robotic approach provided superior vision, improved dexterity, precise, and easy circumferential dissection.PROSPERO registration: The protocol was registered in the PROSPERO database (CRD42024502792).

Ergonomic considerations for unique surgeon populations

PURPOSE OF REVIEW

Surgeons are rapidly diversifying as a population, introducing new ergonomic challenges. This review describes the challenges that are experienced by special populations of surgeons including small-handed surgeons, pregnant surgeons, and trainees, and evidence-based solutions to overcome them.

RECENT FINDINGS

Small-handed and female surgeons report more musculoskeletal complaints compared with their male counterparts. Pregnant surgeons frequently report development or worsening of musculoskeletal disorders such as carpal tunnel syndrome and low back pain. Trainees also report high rates of musculoskeletal complaints with minimal autonomy to alter their environment. Limited objective data exists regarding the ideal instruments currently available for special populations. Several small, randomized studies have proposed exercise regimens targeting the upper extremities and pregnancy-related pain syndromes with improvements in symptoms. Various methods of ergonomic education have been studied in trainees with improvements in operating room posture and performance.

SUMMARY

Limited objective data is available to recommend specific surgical instruments for high-risk surgeon populations. Beneficial exercise regimens have been described for musculoskeletal disorders commonly plaguing surgeons but have yet to be studied explicitly in small-handed or pregnant surgeons and trainees.

Robotic versus laparoscopic general surgery in the emergency setting: a systematic review

Robot-assisted general surgery, an advanced technology in minimally invasive procedures, is increasingly employed in elective general surgery, showing benefits over laparoscopy in specific cases. Although laparoscopy remains a standard approach for common acute abdominal conditions, the role of robotic surgery in emergency general surgery remains uncertain. This systematic review aims to compare outcomes in acute general surgery settings for robotic versus laparoscopic surgeries. A PRISMA-compliant systematic search across MEDLINE, EMBASE, Science Citation Index Expanded, and the Cochrane Library was conducted. The literature review focused on articles comparing perioperative outcomes of emergency general surgery managed laparoscopically versus robot-assisted. A descriptive analysis was performed, and outcome measures were recorded. Six articles, involving 1,063 patients, compared outcomes of robotic and laparoscopic procedures. Two articles covered cholecystectomies, while the others addressed ileocaecal resection, subtotal colectomy, hiatal hernia and repair of perforated gastrojejunal ulcers. The level of evidence was low. Laparoscopic bowel resection in patients with inflammatory bowel disease (IBD) had higher complications; no significant differences were found in complications for other operations. Operative time showed no differences for cholecystectomies, but robotic approaches took longer for other procedures. Robotic cases had shorter hospital length of stay, although the associated costs were significantly higher. Perioperative outcomes for emergency robotic surgery in selected general surgery conditions are comparable to laparoscopic surgery. However, recommending robotic surgery in the acute setting necessitates a well-powered large population study for stronger evidence.

Surgical Techniques and Related Perioperative Outcomes After Robot-assisted Minimally Invasive Gastrectomy (RAMIG): Results From the Prospective Multicenter International Ugira Gastric Registry

OBJECTIVE

To gain insight into the global practice of robot-assisted minimally invasive gastrectomy (RAMIG) and evaluate perioperative outcomes using an international registry.

BACKGROUND

The techniques and perioperative outcomes of RAMIG for gastric cancer vary substantially in the literature.

METHODS

Prospectively registered RAMIG cases for gastric cancer (≥10 per center) were extracted from 25 centers in Europe, Asia, and South-America. Techniques for resection, reconstruction, anastomosis, and lymphadenectomy were analyzed and related to perioperative surgical and oncological outcomes. Complications were uniformly defined by the Gastrectomy Complications Consensus Group.

RESULTS

Between 2020 and 2023, 759 patients underwent total (n=272), distal (n=465), or proximal (n=22) gastrectomy (RAMIG). After total gastrectomy with Roux-en-Y-reconstruction, anastomotic leakage rates were 8% with hand-sewn (n=9/111) and 6% with linear stapled anastomoses (n=6/100). After distal gastrectomy with Roux-en-Y (67%) or Billroth-II-reconstruction (31%), anastomotic leakage rates were 3% with linear stapled (n=11/433) and 0% with hand-sewn anastomoses (n=0/26). Extent of lymphadenectomy consisted of D1+ (28%), D2 (59%), or D2+ (12%). Median nodal harvest yielded 31 nodes (interquartile range: 21-47) after total and 34 nodes (interquartile range: 24-47) after distal gastrectomy. R0 resection rates were 93% after total and 96% distal gastrectomy. The hospital stay was 9 days after total and distal gastrectomy, and was median 3 days shorter without perianastomotic drains versus routine drain placement. Postoperative 30-day mortality was 1%.

CONCLUSIONS

This large multicenter study provided a worldwide overview of current RAMIG techniques and their respective perioperative outcomes. These outcomes demonstrated high surgical quality, set a quality standard for RAMIG, and can be considered an international reference for surgical standardization.

Gastrointestinal Stromal Tumors of the Stomach: Is There Any Advantage of Robotic Resections? A Systematic Review and Meta-Analysis

Background: The role of robotic surgery for gastrointestinal stromal tumor (GIST) resection remains unclear. This systematic review and meta-analysis aimed to investigate the outcomes of robotic versus laparoscopic surgery in patients requiring surgery for gastric GISTs. Methods: MEDLINE, EMBASE, and the Cochrane databases were searched from inception to September 4, 2023. Two independent reviewers conducted a systematic review of the literature to select all types of analytic studies comparing robotic versus laparoscopic surgery for GISTs and reporting intraoperative, postoperative, and/or pathological outcomes. Results: Overall, 4 retrospective studies were selected, including a total of 264 patients, specifically 111 (42%) in the robotic and 153 (58%) in the laparoscopic group. Robotic surgery was associated with longer operating time (+42.46 min; 95% confidence interval [CI]: 9.34, 75.58; P=0.01; I2: 85%) and reduced use of mechanical staplers (odds ratio [OR]: 0.05; 95%CI: 0.02, 0.11; P<0.00001; I2: 92%;) compared with laparoscopy. Although nonsignificant, conversion to open surgery was less frequently reported for robotic surgery (2.7%) than laparoscopy (5.2%) (OR: 0.59; 95%CI: 0.17, 2.03; P=0.4; I2: 0%). No difference was found for postoperative and oncological outcomes. Conclusions: Robotic surgery for gastric GISTs provides similar intraoperative, postoperative, and pathological outcomes to laparoscopy, despite longer operative time.

Comparative Study of Ergonomics in Conventional and Robotic-Assisted Laparoscopic Surgery

BACKGROUND

This study aims to implement a set of wearable technologies to record and analyze the surgeon's physiological and ergonomic parameters during the performance of conventional and robotic-assisted laparoscopic surgery, comparing the ergonomics and stress levels of surgeons during surgical procedures.

METHODS

This study was organized in two different settings: simulator tasks and experimental model surgical procedures. The participating surgeons performed the tasks and surgical procedures in both laparoscopic and robotic-assisted surgery in a randomized fashion. Different wearable technologies were used to record the surgeons' posture, muscle activity, electrodermal activity and electrocardiography signal during the surgical practice.

RESULTS

The simulator study involved six surgeons: three experienced (>100 laparoscopic procedures performed; 36.33 ± 13.65 years old) and three novices (<100 laparoscopic procedures; 29.33 ± 8.39 years old). Three surgeons of different surgical specialties with experience in laparoscopic surgery (>100 laparoscopic procedures performed; 37.00 ± 5.29 years old), but without experience in surgical robotics, participated in the experimental model study. The participating surgeons showed an increased level of stress during the robotic-assisted surgical procedures. Overall, improved surgeon posture was obtained during robotic-assisted surgery, with a reduction in localized muscle fatigue.

CONCLUSIONS

A set of wearable technologies was implemented to measure and analyze surgeon physiological and ergonomic parameters. Robotic-assisted procedures showed better ergonomic outcomes for the surgeon compared to conventional laparoscopic surgery. Ergonomic analysis allows us to optimize surgeon performance and improve surgical training.

The Role of Robotics in Meeting Institutional Goals: A Unified Strategy to Facilitate Program Excellence

PURPOSE

The rapid expansion of robotic surgical equipment necessitates a review of the needs and challenges faced by hospitals introducing robots for the first time to compete with experienced institutions. The aim of this study was to analyze the impact of robotic surgery on our hospital compared to open and laparoscopic surgery, examine internal transformations, and assess regional, domestic, and international implications.

METHODS

A retrospective review was conducted of electronic medical records (EMRs) from 2019 to 2022 at Inha University Hospital, including patients who underwent common robotic procedures and equivalent open and laparoscopic operations. The study investigated clinical and operational performance changes in the hospital after the introduction of robotic technology. It also evaluated the operational effectiveness of robot implementation in local, national, and international contexts. To facilitate comparison with other hospitals, the data were transmitted to Intuitive Surgical, Inc. for analysis. The study was conducted in compliance with domestic personal information regulations and received approval from our Institutional Review Board.

RESULTS

We analyzed EMR data from 3,147 patients who underwent surgical treatment. Over a period of 3.5 years, the adoption of robotic technology in a hospital setting significantly enhanced the technical skills of all professors involved. The introduction of robotic systems led to increased patient utilization of conventional surgical techniques, as well as a rise in the number of patients choosing robotic surgery. This collective trend contributed to an overall increase in patient numbers. This favorable evaluation of the operational effectiveness of our hospital's robot implementation in the context of local, national, and global factors is expected to positively influence policy changes.

CONCLUSION

Stakeholders should embrace data science and evidence-based techniques to generate valuable insights from objective data, assess the health of robot-assisted surgery programs, and identify opportunities for improvement and excellence.

Emerging Role of Robotic Surgery in the Breast

In recent years, there has been increased adoption of robotic technology in oncologic breast surgery, particularly with the use of robotic nipple sparing mastectomy (r-NSM). Here we review the emergence of robotic-assisted surgery in breast procedures, and discuss the safety, limited oncologic outcomes, apparent advantages, and potential limitations of r-NSM compared to conventional open-NSM (c-NSM). Limited data suggests that robotic-assisted surgery offers smaller incisions and potential for improved cosmesis and ergonomic advantage when compared to c-NSM. Similar periprocedural complication rates are seen with r-NSM compared with c-NSM. Short-term oncologic follow-up is reassuring however, but remains early and continues to be investigated. The increased cost of r-NSM compared to open surgery and feasibility of widespread adoption of the procedure are important considerations that need to be evaluated. Randomized trials are currently ongoing to address the apparent advantages, oncologic outcomes, and cost/feasibility of robotic breast surgery.

Robotic assisted surgery reduces ergonomic risk during minimally invasive colorectal resection: the VOLCANO randomised controlled trial

PURPOSE

Minimally invasive surgery benefits patients but poor operating ergonomics causes musculoskeletal injuries in surgeons. This randomised controlled trial aims to assess whether robotic-assisted surgery with the open-console Versius® system can reduce surgeons' ergonomic risks during major colorectal resections.

METHODS

Prospectively registered at ClinicalTrials.gov (NCT05262296) in March 2022. Adult patients requiring a minimally invasive colorectal resection were potentially eligible. Photographs taken at 2-min intervals were analysed using the objective Rapid Entire Body Assessment (REBA) posture analysis scale to calculate intraoperative surgeon ergonomic risk. Secondary outcomes included team communication (Oxford NOTECHS II), surgeon cognitive strain (modified NASA-TLX scale), and clinical outcomes.

RESULTS

Sixty patients were randomised in a 2:1 ratio (40 robot, 20 laparoscopic). Mean age was 65yrs and 34 (57%) were male. Body Mass Index did not differ between the 2 groups (overall mean 29.0 ± 5) and there were equal proportions of left and right-colonic resections. REBA was significantly lower in the robotic arm (median robot REBA score 3 vs lap REBA 5 [p < 0.001]), equating to an injury risk category drop from "medium" to "low risk". There were no significant differences in team communication, operative duration, or patient outcomes. Surgeon cognitive strain was lower in robotic cases (mean robot 32.4 ± 10.3 vs lap 45.6 ± 14.3 [p < 0.001]).

CONCLUSIONS

This trial demonstrates that robotic surgery with an open-console system reduces ergonomic risk scores and cognitive strain during colorectal resections, with no apparent detriment to team communication. This may therefore be a safe & feasible solution to the increasing problem of work-related musculoskeletal injuries in surgeons.

Preclinical Performance of the Combined Application of Two Robotic Systems in Microsurgery: A Two-center Study

Background

Recent advancements in the development of robotic devices increasingly draw the attention toward the concept of robotic microsurgery, as several systems tailored to open microsurgery are being introduced. This study describes the combined application of a novel microsurgical robot, the Symani, with a novel robotic microscope, the RoboticScope, for the performance of microvascular anastomoses in a two-center preclinical trial.

Methods

Six novices, residents, and experienced microsurgeons (n = 18) performed five anastomoses on 1.0-mm-diameter silicone vessels with a conventional versus combined robotic approach, resulting in 180 anastomoses. Microsurgical performance was evaluated, analyzing surgical time, subjective satisfaction with the anastomosis and robotic setup, anastomosis quality using the anastomosis lapse index score, microsurgical skills using the Structured Assessment of Microsurgery Skills score, and surgical ergonomics using the Rapid Entire Body Assessment score.

Results

All participants significantly improved their performance during the trial and quickly adapted to the novel systems. Surgical time significantly decreased, whereas satisfaction with the anastomosis and setup improved over time. The use of robotic systems was associated with fewer microsurgical errors and enhanced anastomosis quality. Especially novices demonstrated accelerated skill acquisition upon robotic assistance compared with conventional microsurgery. Moreover, upper extremity positioning was significantly improved. Overall, the robotic approach was subjectively preferred by participants.

Conclusions

The concept of robotic microsurgery holds great potential to improve precision and ergonomics in microsurgery. This two-center trial provides promising evidence for a steep learning curve upon introduction of robotic microsurgery systems, suggesting further pursuit of their clinical integration.

Robot-assisted surgery and artificial intelligence-based tumour diagnostics: social preferences with a representative cross-sectional survey

BACKGROUND

The aim of this study was to assess social preferences for two different advanced digital health technologies and investigate the contextual dependency of the preferences.

METHODS

A cross-sectional online survey was performed among the general population of Hungary aged 40 years and over. Participants were asked to imagine that they needed a total hip replacement surgery and to indicate whether they would prefer a traditional or a robot-assisted (RA) hip surgery. To better understand preferences for the chosen method, the willingness to pay (WTP) method was used. The same assessment was conducted for preferences between a radiologist's and AI-based image analysis in establishing the radiological diagnosis of a suspected tumour. Respondents' electronic health literacy was assessed with the eHEALS questionnaire. Descriptive methods were used to assess sample characteristics and differences between subgroups. Associations were investigated with correlation analysis and multiple linear regressions.

RESULTS

Altogether, 1400 individuals (53.7% female) with a mean age of 58.3 (SD = 11.1) years filled in the survey. RA hip surgery was chosen by 762 (54.4%) respondents, but only 470 (33.6%) chose AI-based medical image evaluation. Those who opted for the digital technology had significantly higher educational levels and electronic health literacy (eHEALS). The majority of respondents were willing to pay to secure their preferred surgical (surgeon 67.2%, robot-assisted: 68.8%) and image assessment (radiologist: 70.9%; AI: 77.4%) methods, reporting similar average amounts in the first (p = 0.677), and a significantly higher average amount for radiologist vs. AI in the second task (p = 0.001). The regression showed a significant association between WTP and income, and in the hip surgery task, it also revealed an association with the type of intervention chosen.

CONCLUSIONS

Individuals with higher education levels seem to accept the advanced digital medical technologies more. However, the greater openness for RA surgery than for AI image assessment highlights that social preferences may depend considerably on the medical situation and the type of advanced digital technology. WTP results suggest rather firm preferences in the great majority of the cases. Determinants of preferences and real-world choices of affected patients should be further investigated in future studies.

Feasibility and safety of minimally invasive multivisceral resection for T4b rectal cancer: A 9-year review

BACKGROUND

Colorectal cancer is the third most common cancer and the second highest cause of cancer-related mortality worldwide. About 5%-10% of patients are diagnosed with locally advanced rectal cancer (LARC) on presentation. For LARC invading into other structures (i.e. T4b), multivisceral resection (MVR) and/or pelvic exenteration (PE) remains the only potential curative surgical treatment. MVR and/or PE is a major and complex surgery with high post-operative morbidity. Minimally invasive surgery (MIS) has been shown to improve short-term post-operative outcomes in other gastrointestinal malignancies, but there is little evidence on its use in MVR, especially so for robotic MVR.

AIM

To assess the feasibility and safety of minimally invasive MVR (miMVR), and compare post-operative outcomes between robotic and laparoscopic MVR.

METHODS

This is a single-center retrospective cohort study from 1st January 2015 to 31st March 2023. Inclusion criteria were patients diagnosed with cT4b rectal cancer and underwent MVR, or stage 4 disease with resectable systemic metastases. Patients who underwent curative MVR for locally recurrent rectal cancer, or metachronous rectal cancer were also included. Exclusion criteria were patients with systemic metastases with non-resectable disease. All patients planned for elective surgery were enrolled into the standard enhanced recovery after surgery pathway with standard peri-operative management for colorectal surgery. Complex surgery was defined based on technical difficulty of surgery (i.e. total PE, bladder-sparing prostatectomy, pelvic lymph node dissection or need for flap creation). Our primary outcomes were the margin status, and complication rates. Categorical values were described as percentages and analysed by the chi-square test. Continuous variables were expressed as median (range) and analysed by Mann-Whitney U test. Cumulative overall survival (OS) and recurrence-free survival (RFS) were analysed using Kaplan-Meier estimates with life table analysis. Log-rank test was performed to determine statistical significance between cumulative estimates. Statistical significance was defined as P < 0.05.

RESULTS

A total of 46 patients were included in this study [open MVR (oMVR): 12 (26.1%), miMVR: 36 (73.9%)]. Patients' American Society of Anesthesiologists score, body mass index and co-morbidities were comparable between oMVR and miMVR. There is an increasing trend towards robotic MVR from 2015 to 2023. MiMVR was associated with lower estimated blood loss (EBL) (median 450 vs 1200 mL, P = 0.008), major morbidity (14.7% vs 50.0%, P = 0.014), post-operative intra-abdominal collections (11.8% vs 50.0%, P = 0.006), post-operative ileus (32.4% vs 66.7%, P = 0.04) and surgical site infection (11.8% vs 50.0%, P = 0.006) compared with oMVR. Length of stay was also shorter for miMVR compared with oMVR (median 10 vs 30 d, P = 0.001). Oncological outcomes-R0 resection, recurrence, OS and RFS were comparable between miMVR and oMVR. There was no 30-d mortality. More patients underwent robotic compared with laparoscopic MVR for complex cases (robotic 57.1% vs laparoscopic 7.7%, P = 0.004). The operating time was longer for robotic compared with laparoscopic MVR [robotic: 602 (400-900) min, laparoscopic: Median 455 (275-675) min, P < 0.001]. Incidence of R0 resection was similar (laparoscopic: 84.6% vs robotic: 76.2%, P = 0.555). Overall complication rates, major morbidity rates and 30-d readmission rates were similar between laparoscopic and robotic MVR. Interestingly, 3-year OS (robotic 83.1% vs 58.6%, P = 0.008) and RFS (robotic 72.9% vs 34.3%, P = 0.002) was superior for robotic compared with laparoscopic MVR.

CONCLUSION

MiMVR had lower post-operative complications compared to oMVR. Robotic MVR was also safe, with acceptable post-operative complication rates. Prospective studies should be conducted to compare short-term and long-term outcomes between robotic vs laparoscopic MVR.

Robot-assisted surgery in thoracic and visceral indications: an updated systematic review

BACKGROUND

In surgical advancements, robot-assisted surgery (RAS) holds several promises like shorter hospital stays, reduced complications, and improved technical capabilities over standard care. Despite extensive evidence, the actual patient benefits of RAS remain unclear. Thus, our systematic review aimed to assess the effectiveness and safety of RAS in visceral and thoracic surgery compared to laparoscopic or open surgery.

METHODS

We performed a systematic literature search in two databases (Medline via Ovid and The Cochrane Library) in April 2023. The search was restricted to 14 predefined thoracic and visceral procedures and randomized controlled trials (RCTs). Synthesis of data on critical outcomes followed the Grading of Recommendations, Assessment, Development, and Evaluation methodology, and the risk of bias was evaluated using the Cochrane Collaboration's Tool Version 1.

RESULTS

For five out of 14 procedures, no evidence could be identified. A total of 20 RCTs and five follow-up publications met the inclusion criteria. Overall, most studies had either not reported or measured patient-relevant endpoints. The majority of outcomes showed comparable results between study groups. However, RAS demonstrated potential advantages in specific endpoints (e.g., blood loss), yet these findings relied on a limited number of low-quality studies. Statistically significant RAS benefits were also noted in some outcomes for certain indications-recurrence, quality of life, transfusions, and hospitalisation. Safety outcomes were improved for patients undergoing robot-assisted gastrectomy, as well as rectal and liver resection. Regarding operation time, results were contradicting.

CONCLUSION

In summary, conclusive assertions on RAS superiority are impeded by inconsistent and insufficient low-quality evidence across various outcomes and procedures. While RAS may offer potential advantages in some surgical areas, healthcare decisions should also take into account the limited quality of evidence, financial implications, and environmental factors. Furthermore, considerations should extend to the ergonomic aspects for maintaining a healthy surgical environment.

Robot-assisted pelvic and renal surgery compared with laparoscopic or open surgery: Literature review of cost-effectiveness and clinical outcomes

BACKGROUND AND AIM

The purpose of this study was to evaluate clinical experiences and cost-effectiveness by comparing robot-assisted surgery with laparoscopic- or open surgery for pelvic and renal operations.

METHODS

A narrative review was carried out.

RESULTS

When using robotic-assisted surgery, oncological and functional results are similar to after laparoscopic or open surgery. One exception may be a shorter survival in cancer of the cervix uteri. In addition, postoperative complications after robotic-assisted surgery are similar, bleeding and transfusion needs are less, and the hospital stay is shorter but the preparation of the operating theater before and after surgery and the operation times are longer. Finally, robot-assisted surgery has, in several studies, been reported to be not cost-effective primarily due to high investment costs. However, more recent studies provide improved cost-effectiveness estimates due to more effective preparation of the operating theater before surgery, improved surgeon experience, and decreased investment costs.

CONCLUSIONS

Complications and functional and oncological outcomes after robot-assisted surgery are similar to open surgery and laparoscopic surgery. The cost-effectiveness of robot-assisted surgery is likely to equal or surpass the alternatives.

The stress for surgeons: exploring stress entities with the robotic senhance surgical system

Robotic surgery is on its way to revolutionizing traditional surgical procedures, offering precise and minimally invasive techniques hypothesized to shorten recovery times and improve patient outcomes. While there have been multiple publications on robotic systems' medical and procedural achievements, more emphasis should be put on the surgeon's experience, especially in comparison with laparoscopic surgery. The present report aims to systematically examine the stress impact on surgeons by comparing the robotic Senhance Surgical System (Asensus Surgical, Durham, North Carolina, U.S.A) to laparoscopic surgery. The well-established "SURG-TLX" survey is used to measure distinct stress entities. The "SURG-TLX" survey is a modified version of the NASA-TLX, validated for surgery by M. Willson. Based on a comprehensive database from six centers encompassing various disciplines and surgical procedures, our analysis indicates significantly reduced "overall stress" levels for robotic (cockpit) compared to laparoscopic surgeons. Exploring the "SURG-TLX" stress dimensions further between methods (robotic vs. laparoscopic) and surgeon position (laparoscopic, (robotic) bedside, or (robotic) cockpit) resulted in significantly more Mental (p.value < 0.015), less Physical Demands (p.value < 0.001) and less Distraction (p.value < 0.009) for robotic surgery, especially regarding the robotic cockpit surgeons. This finding suggests that robotic surgery with the Senhance Surgical System contributes to a favorable stress profile for surgeons, potentially enhancing their overall well-being and performance.

Feasibility of robotic cholecystectomy at an academic center with a young robotic surgery program: a retrospective cohort study with umbrella review

Laparoscopic cholecystectomy (LC) has been standard of care for surgical treatment of benign gallbladder pathology for decades. With the advent of robotic surgical technology, robotic cholecystectomy (RC) has gained attention as an alternative to conventional laparoscopy. This study introduces a single-surgeon experience with laparoscopic versus robotic cholecystectomy and an umbrella systematic review of the outcomes of both approaches. A retrospective chart review was performed at a single institution on a prospectively maintained database of patients undergoing laparoscopic or robotic cholecystectomy for benign gallbladder pathology. An umbrella systematic review was conducted using PRISMA methodology. A total of 103 patients were identified; 61 patients underwent LC and 42 underwent RC. In the RC cohort, 17 cases were completed using a four-port technique while 25 were completed using a three-port technique. Patients undergoing RC were older compared to the LC group (44.78 vs 57.02 years old; p < 0.001) and exhibited lower body mass index (29.37 vs 32.37 kg/m2, p = 0.040). No statistically significant difference in operative time or need for postoperative ERCP was noted. Neither this series nor the umbrella systematic review revealed significant differences in conversion to open surgery or readmissions between the LC and RC cohorts. Three-port RC was associated with reduced operative time compared to four-port RC (101.28 vs 150.76 min; p < 0.001). Robotic cholecystectomy is feasible and safe at a young robotic surgery program in an academic center setting and comparable to laparoscopic cholecystectomy clinical outcomes.

Examining surgeon stress in robotic and laparoscopic surgery

Robotic surgery may decrease surgeon stress compared to laparoscopic. To evaluate intraoperative surgeon stress, we measured salivary alpha-amylase and cortisol. We hypothesized robotic elicited lower increases in surgeon salivary amylase and cortisol than laparoscopic. Surgical faculty (n = 7) performing laparoscopic and robotic operations participated. Demographics: age, years in practice, time using laparoscopic vs robotic, comfort level and enthusiasm for each. Operative data included operative time, WRVU (surgical "effort"), resident year. Saliva was collected using passive drool collection system at beginning, middle and end of each case; amylase and cortisol measured using ELISA. Standard values were created using 7-minute exercise (HIIT), collecting saliva pre- and post-workout. Linear regression and Student's t test used for statistical analysis; p values < 0.05 were significant. Ninety-four cases (56 robotic, 38 laparoscopic) were collected (April-October 2022). Standardized change in amylase was 8.4 ± 4.5 (p < 0.001). Among operations, raw maximum amylase change in laparoscopic and robotic was 23.4 ± 11.5 and 22.2 ± 13.4; raw maximum cortisol change was 44.21 ± 46.57 and 53.21 ± 50.36, respectively. Values normalized to individual surgeon HIIT response, WRVU, and operative time, showing 40% decrease in amylase in robotic: 0.095 ± 0.12, vs laparoscopic: 0.164 ± 0.16 (p < 0.02). Normalized change in cortisol was: laparoscopic 0.30 ± 0.44, robotic 0.22 ± 0.4 (p = NS). On linear regression (p < 0.001), surgeons comfortable with complex laparoscopic cases had lower change in normalized amylase (p < 0.01); comfort with complex robotic was not significant. Robotic may be less physiologically stressful, eliciting less increase in salivary amylase than laparoscopic. Comfort with complex laparoscopic decreased stress in robotic, suggesting laparoscopic experience is valuable prior to robotic.

The rise of robotic colorectal surgery: better for patients and better for surgeons

Robotic colorectal surgery represents a major technological advancement in the treatment of patients with colorectal disease. Several recent randomized controlled trials comparing robotic colorectal surgery with laparoscopic surgery have demonstrated improved short-term patient outcomes in the robotic group. Whilst the primary focus of research in robotic surgery has been on patient outcomes, the robotic platform also provides unparalleled benefits for the surgeon, including improved ergonomics and surgeon comfort, with the potential to reduce occupational injuries and prolong career longevity. It is becoming clear that robotic surgical systems improve patient outcomes and may provide significant benefits to the surgical workforce.

Robots for surgeons? Surgeons for robots? Exploring the acceptance of robotic surgery in the light of attitudes and trust in robots

BACKGROUND

Over the last century, technological progress has been tremendous, and technological advancement is reflected in the development of medicine. This research assessed attitudes towards surgical robots and identified correlations with willingness to participate in robotic surgery based on factors influencing trust in automated systems.

METHOD

Using data from a survey, which included the Multi-dimensional Robot Attitude Scale (MdRAS) and a questionnaire consisting of attitude statements regarding the factors affecting trust in automated systems, the experiment assessed the attitudes of healthcare workers and potential patients towards surgery robots, and attempted to find a correlation between these attitudes, age, and gender.

RESULTS AND CONCLUSION

Statistical evaluation of the responses (N = 197) showed that positive attitude towards surgical robots showed a high correlation with the willingness to participate in robotic surgery and gave the strongest correlations with the MdRAS utility and negative attitude towards robots subscales. For the assessment of willingness, the MdRAS subscales alone did not provide a strong enough correlation. All factors examined showed a significant correlation with participation. Having faith in the surgery robot, the propensity to trust technology, the designer's reputation, the ease of work that a surgical robot provides, positive experience with robots, and believing the surgeon is competent at operating the machine seemed to have been the most important positive correlations, while fear of errors gave the highest negative correlation. The healthcare workers and potential patients showed significant differences in the subscales of the questionnaire perceived risk and knowledge but no significant difference in the characteristics of the surgical robot. There was no difference in willingness to participate between the samples. Age did not show a significant correlation with the score achieved and willingness in any of the samples. Significant differences were found between male and female respondents, with men having more positive attitudes and being more likely to participate in surgeries using surgery robots than women. As a result, the research potentially sheds light on the factors that need to be considered when building trust in robotic surgery.

Racial disparities in complications following elective colon cancer resection: Impact of laparoscopic versus robotic approaches

BACKGROUND

We sought to examine differences in outcomes for Black and White patients undergoing robotic or laparoscopic colectomy to assess the potential impact of technological advancement.

METHODS

We queried the ACS-NSQIP database for elective robotic (RC) and laparoscopic (LC) colectomy for cancer from 2012 to 2020. Outcomes included 30-day mortality and complications. We analyzed the association between outcomes, operative approach, and race using multivariable logistic regression.

RESULTS

We identified 64,460 patients, 80.9% laparoscopic and 19.1% robotic. RC patients were most frequently younger, male, and White, with fewer comorbidities (P ​< ​0.001). After adjustment, there was no difference in mortality by approach or race. Black patients who underwent LC had higher complications (OR 1.10, 95% CI 1.03-1.08, P ​= ​0.005) than their White LC counterparts and RC patients.

CONCLUSIONS

Robotic colectomy was associated with lower rates of complications in minority patients. Further investigation is required to identify the causal pathway that leads to our finding.

The IDEAL framework for surgical robotics: development, comparative evaluation and long-term monitoring

The next generation of surgical robotics is poised to disrupt healthcare systems worldwide, requiring new frameworks for evaluation. However, evaluation during a surgical robot's development is challenging due to their complex evolving nature, potential for wider system disruption and integration with complementary technologies like artificial intelligence. Comparative clinical studies require attention to intervention context, learning curves and standardized outcomes. Long-term monitoring needs to transition toward collaborative, transparent and inclusive consortiums for real-world data collection. Here, the Idea, Development, Exploration, Assessment and Long-term monitoring (IDEAL) Robotics Colloquium proposes recommendations for evaluation during development, comparative study and clinical monitoring of surgical robots-providing practical recommendations for developers, clinicians, patients and healthcare systems. Multiple perspectives are considered, including economics, surgical training, human factors, ethics, patient perspectives and sustainability. Further work is needed on standardized metrics, health economic assessment models and global applicability of recommendations.

A systematic review of full economic evaluations of robotic-assisted surgery in thoracic and abdominopelvic procedures

This study aims to conduct a systematic review of full economic analyses of robotic-assisted surgery (RAS) in adults' thoracic and abdominopelvic indications. Authors used Medline, EMBASE, and PubMed to conduct a systematic review following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 guidelines. Fully published economic articles in English were included. Methodology and reporting quality were assessed using standardized tools. Majority of studies (28/33) were on oncology procedures. Radical prostatectomy was the most reported procedure (16/33). Twenty-eight studies used quality-adjusted life years, and five used complication rates as outcomes. Nine used primary and 24 studies used secondary data. All studies used modeling. In 81% of studies (27/33), RAS was cost-effective or potentially cost-effective compared to comparator procedures, including radical prostatectomy, nephrectomy, and cystectomy. Societal perspective, longer-term time-horizon, and larger volumes favored RAS. Cost-drivers were length of stay and equipment cost. From societal and payer perspectives, robotic-assisted surgery is a cost-effective strategy for thoracic and abdominopelvic procedures.Clinical trial registration This study is a systematic review with no intervention, not a clinical trial.