Robotics Integration Is Transforming Global Surgical Care

Robotic-assisted surgery represents one of the latest advances in surgical practice, offering advantages across specialties including urology, neurosurgery, gynecology, ophthalmology, traumatology, and orthopaedics, as well as cardiothoracic and general surgery.¹

For certain procedures, when compared to laparoscopic and open surgery, robotic-assisted surgery is associated with reductions in recovery time, postoperative pain, complication rates, blood loss, and length of stay. This technology also allows for greater precision, dexterity, and visualization during procedures, which are particularly useful in complex cases such as those with dense adhesions and significant prior surgical history.

In addition, robotic-assisted surgery provides significant advantages for specific patient populations, such as those with obesity or complex anatomy, allowing for safer and more tailored interventions. From a surgeon’s perspective, robotics systems improve ergonomics and reduce physical fatigue during lengthy operations, positively impacting performance and surgical outcomes.

The Lancet Commission on Global Surgery (LCoGS) highlights the importance of surgery as a component of universal health coverage (UHC)² and advocates for strategies to strengthen surgical systems, including implementation of the National Surgical, Obstetric, and Anesthesia Plans. These comprehensive frameworks address gaps in surgical access, workforce training, infrastructure, and financing.

Evidence from LCoGS suggests that deficiencies in surgical, anesthetic, and obstetric (SAO) care contribute to 18 million preventable deaths annually.² As robotic surgical systems evolve, their integration into healthcare infrastructure may align with global efforts to strengthen surgical systems and capacity while reducing disparity in access to quality care.

Application Across Surgical Subspecialties

Robotic assistance has been applied across various surgical subspecialties. In 1985, the first surgical robot, the Programmable Universal Machine for Assembly 560 (PUMA 560), was used in neurosurgery for a biopsy procedure.

In urology, robotics platforms are primarily used for laparoscopic radical and partial prostatectomy in the treatment of prostate cancer, as well as for nephrectomy and lymphadenectomy procedures. In orthopaedic surgery, total hip arthroplasty was the first robotic procedure performed, followed by knee arthroplasty. Studies have shown that robotic assistance in orthopaedics improves alignment, facilitates limb lengthening, and enhances patient satisfaction. Fracture fixation in trauma surgery represents a substantial potential for future robotics innovation.

In gynecology, robotics systems are widely used for procedures such as hysterectomies and myomectomies. While in the area of otolaryngology, applications are generally categorized into retro-auricular hairline incisions and transoral robotic surgery, depending on the pathology.

The field of cardiac surgery also has seen growing use of robotics platforms, particularly for minimally invasive procedures such as endoscopic coronary artery bypass grafting and mitral valve repair. One of the earliest robotic cardiac procedures included the closure of an atrial septal defect.

While vascular surgeons are beginning to explore robotic assistance, its use remains off label in the US, and broader application in this specialty is still in the early stages of development. Specialized robotics platforms also have been developed for spinal, ophthalmic, and other nonabdominal surgeries. These platforms continue to evolve, offering various capabilities designed to improve microsurgical precision while maintaining safety and reproducibility.

Global Trends in Robotic Surgery

Initially approved solely for the purpose of visualization and retraction, the da Vinci system became the first to receive US Food and Drug Administration (FDA) approval for general surgery in 2000.³ To demonstrate its safety, 300 robotic-assisted surgeries were performed in Europe, beginning with a robotic-assisted cholecystectomy in Belgium in 1997.⁴

Today, robotic-assisted surgery accounts for 5% of surgeries in the US, 2% in Europe, and less than 1% in the rest of the world, correlating with the proportion of each region’s gross domestic product spent on healthcare.⁵ In 2005, a robotic-assisted cystectomy was performed in Egypt, and robotic surgery for achalasia cardia was performed in Argentina, which was the first procedure of its kind performed in the region. India and China were among the first Asian countries to adopt robotic surgery in 2006, with other countries, including Japan, Pakistan, and Indonesia following suit in 2009, 2011, and 2012, respectively. Robotic surgery has gradually spread across the former Soviet states since the 2000s, with Russia adopting the technology in 2007, Poland in 2010, and Kazakhstan in 2018.

In comparison, robotic surgery has seen less adoption in Latin America and Africa. Brazil, Chile, Colombia, Mexico, and Venezuela have had incremental adoption of this technology, while in Africa, robotic surgery has only been reported in Egypt, South Africa, and Tunisia.

Recently, newer robotics platforms have been developed in China, Germany, India, Italy, South Korea, Switzerland, and the UK.³ Although most of these platforms are approved only by local regulatory bodies, their availability is expected to reduce costs and promote further integration of robotics into surgical practice. The development and adoption of robotics systems have been limited in low- and middle-income countries (LMICs), where public health priorities often focus on infectious diseases, maternal health, and trauma. Robotic surgery is typically concentrated in private or urban healthcare facilities, exacerbating existing disparities.

From a global health perspective, robotic-assisted surgery aligns with key health priorities, such as the third aim outlined in the United Nations Sustainable Development Goals, which emphasizes good health and well-being and supports efforts to improve access to safe, high-quality surgical care.² Robotic surgery can contribute to achieving UHC by increasing access to advanced surgical interventions and reducing perioperative morbidity and mortality.

While the initial investment and operational costs of robotic surgery are substantial, often due to longer OR times and higher equipment-related expenses, some studies suggest that the long-term benefits, such as reduced postoperative complications, shorter hospital stays, and quicker return to work may offset these costs and support overall health system sustainability.⁶ However, evidence remains mixed and further research is needed to determine whether these benefits translate to low hospitalization costs for patients. For more information on the cost of robotic surgery, see the cover story in this issue, “Cost of Robotic Surgery Remains Complex Equation.”

Training and Capacity Building

Robotic surgery necessitates specialized training and continued practice for surgeons, anesthesiologists, nurses, OR staff, and technical teams. Notably, many LMICs face a shortage of a skilled surgical workforce, not limited to robotic surgery. LCoGS has set a target of achieving a minimum SAO density of 20 per 100,000 population by 2030 for adequate access to surgical care. More than 808,000 SAO healthcare providers need to be trained by 2030 to reach this density.² It is critical to first develop an adequate surgical workforce that provides essential, safe, comprehensive care to support training in minimally invasive surgery.

Following the development of an adequate surgical workforce, future hurdles include a lack of structured fellowships, mentorship, and exposure to minimally invasive surgical techniques. This diminished exposure contributes to the continuing gap in implementing robotic surgery programs. Fortunately, middle-income countries in Latin America and India are developing solutions to the unique hurdles healthcare systems face in resource-limited settings. Brazil has 2,500 da Vinci-trained surgeons and a national accreditation program due to industry partnerships, while surgeons practicing in India may seek out robotic surgery fellowships through a philanthropic platform, the Vattikuti Foundation.

Virtual reality (VR) surgical training and remote-controlled robotics systems are technological solutions that may address some of these training-related hurdles. The Eyesi surgical simulator is a VR training platform that is intended to accelerate surgeon proficiency and reduce operative times. Remote-control systems show promise in expanding access to surgical care and supervised robotic surgery training in underserved regions, potentially reducing travel-related logistical and financial burdens.

Barriers to Widespread Implementation

Additional challenges impeding enhanced adoption of this technology include infrastructure gaps, high costs, and a lack of institutional support. An estimated $1 million–$1.5 million is necessary to implement a robotic platform in the US, with expenditures averaging $4,000 per procedure.⁶ These costs encompass the initial purchase, maintenance, and the supply of specialized instruments. Individual institutions routinely bear the financial burden owing to a lack of government funding.

Insurance coverage can also hinder widespread adoption. For instance, while robotic-assisted surgery was introduced in Japan in 2009, many procedures were not covered until 2018.⁷

A prevalent barrier for many healthcare facilities in LMICs and rural settings within high- income countries (HICs) is the inconsistency in basic infrastructural elements, such as reliable power supply, advanced imaging facilities, and high-speed internet connectivity for potential telemedicine applications, posing significant constraints for adopting a unified robotic surgical system and training. Health policy initiatives and industry collaboration may ease some of these challenges.

In many LMICs and rural HICs, access to the technical support necessary to implement and maintain robotics systems is limited. For example, the first robotic surgery platform in Pakistan was rendered dysfunctional soon after installation until an improved platform was installed 2 years later.⁸

Data regarding quality control, cost-effectiveness, and overall outcomes in LMICs are lacking, and extrapolation from the HIC data may not be appropriate for this setting. Addressing these technological gaps is crucial for successfully adopting robotic surgery in these settings.

Legal and Regulatory Framework

The European Union, the FDA, and Japan classify robotics systems as medical devices. At the same time, in other countries, such as Indonesia, this technology is unregulated with healthcare institutions making decisions without legal directives from the government. Regulatory bodies may approve robotic surgery systems, but their application and prerequisite training are left to surgeons, healthcare institutions, and manufacturers.

While the companies that manufacture these devices provide some quality assurance and benefits for approved uses, robotics systems are also used for unapproved indications. Policymakers in several industrialized nations seek to implement more stringent oversight of emerging technology, especially given its increasing autonomous capabilities. Autonomous surgical robots have demonstrated proficiency in phlebotomy, bowel anastomosis, and knee replacement surgery, among other procedures.⁹ These applications remain in the experimental phase for now but risks to patient safety and other concerns must be considered to preempt misuse.

One proposal is to define six levels of autonomy to distinguish various categories of medical devices and establish unique risks and, thereby, regulations required for each. Another consideration is requiring specialized robotics training for surgeons before performing robotic surgery on patients. As surgical robots continue to reside within a legal and regulatory gray area, the benefits and drawbacks of additional regulations that may hinder scientific advancement are unclear.

Financial Support and Funding Initiatives

Historically, surgery has been significantly underfunded within the broader context of global health, receiving limited attention compared to other health concerns such as maternal and child health and infectious diseases.

A significant step was taken in 2020, when policymakers directed the US Agency for International Development (USAID) funding toward global surgery programs, signaling a financial commitment to addressing surgical disparities and responding to a growing public health need. This move reflects a pivotal shift in funding priorities and firmly establishes surgery as a key component of global health agendas.

However, comprehensive estimates of these financial investments are challenging to quantify, as funding allocations often flow through multiple channels. A systematic analysis indicated that multilateral organizations like the World Health Organization and USAID collectively disbursed approximately 31% of total health development assistance worldwide, including nonsurgical disciplines.¹⁰ Shifting funding priorities may lead to significant impact on the accessibility of surgical services, and could hinder innovative advancements, including broader access to robotic surgery platforms.

Emerging Innovations and Advancement

Emerging technologies hold significant promise in making robotic surgery more accessible, particularly in LMICs and rural areas.

Efforts are underway to develop more affordable and modular robotics systems, such as India’s locally developed SSi Mantra platform, explicitly designed to reduce acquisition and operational costs compared with existing platforms.³ Integrating artificial intelligence (AI) into robotic surgical systems, such as the SSi Mantra platform, offers opportunities to support intraoperative decision-making, precision, and overall surgical performance, ultimately aiming to reduce complications and improve patient outcomes. AI-driven algorithms can support surgeons by providing real-time analytics and guidance, which is valuable in resource-constrained settings.

Telesurgery and remote tele-proctoring technologies offer promising solutions to bridge geographical and logistical barriers by enabling experienced surgeons to operate remotely and mentor and train surgeons with limited robotics experience, thereby extending robotic surgical expertise to underserved regions. However, successfully implementing this technology requires robust telecommunication networks, stable sources of electricity, and technical support to realize their full potential. These innovations represent advancements toward achieving equitable, scalable, high-quality surgical care worldwide.

Ethical Considerations

Equitable access remains a significant concern worldwide as robotics systems are predominantly concentrated in high-income, urban settings, widening the global healthcare gap. Bridging this divide requires intentional efforts in equitable distribution of this technology and expanded infrastructure development. Health systems also must critically assess the cost-effectiveness of robotics platforms, as their high acquisition and maintenance costs may not be justifiable in all contexts.

In deciding between robotic-assisted surgery and conventional surgical options, patient autonomy and informed consent are important considerations. Patients should be informed about the nature of robotic assistance, including potential risks, benefits, alternatives, and the surgeon’s experience, to ensure ethical, transparent, and patient-centered care. Misconceptions regarding robotic surgery should be clarified, as many patients may mistakenly assume this approach to be superior to traditional surgical approaches in all indications.

Financial incentives may encourage inappropriate use of robotic surgery in instances where it is not indicated and offers minimal advantages. Prioritizing the acquisition of robotics systems in regions without access to laparoscopic surgery and other vital resources may represent an inappropriate use of financial resources, leading to suboptimal patient outcomes. Ethical and sustainable adoption of robotics systems requires evaluation of local needs and capabilities to ensure this technology serves patients and does not come at the cost of broader surgical access.

Robotic-assisted surgery is an advancement in modern medicine and minimally invasive surgery, offering improved surgical precision, patient outcomes, and ergonomics. However, global implementation and adoption remain variable, with significant infrastructure, training, and funding barriers, especially in low-resource settings. Efforts to close these gaps through capacity building, regulatory frameworks, and emerging technologies such as AI and telesurgery may address some of these barriers. Investment in robotic surgery in the global surgery context must be considered in light of existing unmet needs to ensure optimal population-level outcomes.

Dr. Kaiser Sadiq is a preliminary general surgery resident at The George Washington University in Washington, DC, and is Vice-Chair of the ACS Resident and Associate Society Membership Workgroup.

Dr. Surmai Shukla is an Institutional National Research Service Award (T32)-funded postdoctoral fellow at the University of Pittsburgh Medical Center in Pennsylvania.

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