Abstract
The role of robotics has grown exponentially. There is an active interest amongst practitioners in the transferability of the potential benefits into plastic and reconstructive surgery; however, many plastic surgeons report lack of widespread implementation, training, or clinical exposure. We report the current evidence base, and surgical opportunities, alongside key barriers, and limitations to overcome, to develop the use of robotics within the field. This systematic review of PubMed, Medline, and Embase has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PROSPERO (ID: CRD42024524237). Preclinical, educational, and clinical articles were included, within the scope of plastic and reconstructive surgery. 2, 181, articles were screened; 176 articles met the inclusion criteria across lymph node dissection, flap and microsurgery, vaginoplasty, craniofacial reconstruction, abdominal wall reconstruction and transoral robotic surgery (TOR). A number of benefits have been reported including technical advantages such as better visualisation, improved precision and accuracy, and tremor reduction. Patient benefits include lower rate of complications and quicker recovery; however, there is a longer operative duration in some categories. Cost presents a significant barrier to implementation. Robotic surgery presents an exciting opportunity to improve patient outcomes and surgical ease of use, with feasibility for many subspecialities demonstrated in this review. However, further higher quality comparative research with careful case selection, which is adequately powered, as well as the inclusion of cost-analysis, is necessary to fully understand the true benefit for patient care, and justification for resource utilisation.
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Introduction
The role of robotics has grown exponentially. Robotic surgery, also known as robotic-assisted surgery, allows for complex minimally invasive surgical procedures to be completely or part-performed with a mechanical system consisting of articulating arms, typically controlled at a separate console by the surgeon.
The Da Vinci Surgical Robotic System (Intuitive Surgical, Sunnyvale, CA, USA), has been widely implemented in various surgical specialities, such as general surgery, urology, and gynaecology, within 66 countries. A recent systematic review of laparoscopic and robotic surgery found comparable or improved complication rates with robotic surgery, with reduced recovery time and length of stay [1].
Robotic consoles can offer accuracy, and precision, as well as minimally invasive access to difficult areas, with improved visualisation. Surgeons have better ergonomic performance, with a reduction in mental and physical workload [2]. Additionally, wireless connection broadens opportunities within telesurgery to facilitate remote operating [3].
The application of robotic surgery in clinical plastic and reconstructive practice is yet to be well established [4]. There is an active interest amongst practitioners in the transferability of these potential benefits into a speciality that works in collaboration with many surgical disciplines; however, many plastic surgeons report lack widespread implementation or exposure [5]. Whilst Da Vinci Surgical Robotic System (Intuitive Surgical, Sunnyvale, CA, USA) is the most well-known resource, MUSA Microsure (Science Park Eindhoven, Netherlands) and Symani Surgical System (Medical Microinstruments, Italy) are competitors in the market, particularly for use within microsurgery (Fig. 1).
Robotic equipment utilised within clinical practice. All three are controlled by a separate master console
Microsurgery is an area which requires high precision, excellent magnified visualisation, and tremor reduction. Whilst robotic surgery may exceed in these domains, the impact of loss of haptic feedback requires investigation. There are other potential barriers within the widespread implementation of robotics and robotic-assisted surgery within plastic and reconstructive surgery such as the financial incurrence and sparce training opportunities [5].
The aims of this systematic review are to assess the feasibility of robotic surgery within plastic and reconstructive surgery and review the barriers and limitations to clinical implementation and training.
Methods
This systematic review has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [6]. Methodology was designed a priori, and this review is registered with PROSPERO (ID: CRD42024524237).
A literature search of PubMed, Medline and Embase for publications within the past 10 years was conducted by author L.A. Additional articles found through reference screening were included. Titles and abstracts were screened by two independent authors (B.R and E.B), with discrepancies for inclusion reviewed by a third author independently (L.A). This review includes all study types such as randomised controlled trials (RCT), prospective cohort, retrospective cohort, case series/reports, case–control, cross-sectional studies and preclinical studies.
Eligibility criteria
Articles were accepted for inclusion using the following criteria:
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Patients/populations who have undergone robotic surgery for reconstruction or oncological resection, within the scope of plastic and reconstructive surgery.
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Adults and children
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Articles which described robotic procedures within the scope of plastic and reconstructive surgery
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Preclinical and educational studies within the scope of robotic plastic and reconstructive surgery including animal, synthetic and cadaveric models.
Articles were excluded from this review using the following criteria:
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Articles pertaining to robotic surgery outside the scope of plastic and reconstructive surgery.
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Inguinal hernia repair
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Articles not available in English language
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Articles published prior to 2013.
Search strategy
Search strategy employed is described below. Key words and subject headings were combined using Boolean logic and refined with consensus from all authors:
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Robot* AND
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Micro* OR reconstruct* OR flap OR nerve OR anastomosis OR abdominal wall OR pelvic floor OR supermicrosurg* OR head and neck OR oral OR oropharyngeal OR vaginoplasty OR breast OR nasal OR plastic
Data metrics
Data were tabulated into a predetermined Excel spreadsheet by authors LA and E.B [7]. This was subsequently refined following a pilot collection with a random sample of papers. Articles upon paper review which were deemed not suitable for inclusion were discussed with an independent third party (B.L). Data items obtained included article characteristics (title, author, year, journal, impact factor, type of study, multicentre/single centre), demographics (number of participants, gender, age, control), procedure (subspeciality, specific task, robot, ports, location of ports), and outcomes (operative duration, length of Stay, blood loss, peri-operative complications, long-term outcomes, follow-up duration, learning curve, and cost).
Risk of bias
Risk of bias was assessed by authors LA and E.B. RCT’s were reviewed using Cochrane’s risk of bias tool (RoB 2) [8]. Non-randomised trials was assessed using Cochrane’s ROBINS-I tool [9]. The Joan Briggs Institute Critical Appraisal Checklist for Case Series and the Joan Briggs Institute Critical Appraisal Checklist for Case Reports was used to review case series and case reports, respectively. [10, 11] A report of bias is included in the appendices.
Data synthesis
Narrative synthesis, and quantitative analysis was performed where possible. Descriptive analysis of continuous data is represented with ranges, mean values, or overall rate. Categorical data is presented with percentage prevalence. Subcategories are defined by subspeciality and procedure.
Study characteristics were tabulated and compared against planned subgroups to determine their suitability for each synthesis. Nonparametric data were analysed using a Wilcoxon test or an unpaired T test. Forrest plots were constructed, (in subcategories with article number > 5, where possible), using odds ratios for dichotomous and continuous outcomes and heterogeneity tested for using Chi-square and I2 test. Statistical analysis was performed using RevMan Software [12].
Results
The literature search yielded a total of 2181 articles (Fig. 2). Following abstract screening, a total of 176 articles were included in this systematic review. A total of 149 clinical articles were found (Table 1). A total of 11 preclinical articles were included (Two of which also included clinical data) (Table 2) [13,14,15,16,17,18,19,20,21,22,23]. A total of 18 educational articles were included (Table 2) [24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41].
PRISMA flow diagram of the literature search for robotics in plastic and reconstructive surgery
Clinical articles were subcategorised by subspeciality (Fig. 3). A total of 11 articles described robotic lymph node dissection [13, 42,43,44,45,46,47,48,49,50,51]. A total of 21 articles described robotic pedicled or free flap harvest [52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72]. A total of eight articles described robotic flap pedicle or vessel dissection [73,74,75,76,77,78,79,80]. 16 articles detailed robotic free flap inset or anastomosis (vessel, nerve and lymphovascular) [34, 81,82,83,84,85,86,87,88,89,90,91,92,93,94,95]. Two articles described robotic craniofacial techniques (mandibular contouring) [96, 97]. One cohort study described a robotic cleft palate surgery [98]. One case report described robotic nerve decompression [99]. Three articles described vaginoplasty/gender reassignment robotic techniques [100,101,102]. A total of 28 articles described ventral abdominal wall reconstruction and hernia repair [103,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119,120,121,122,123,124,125,126,127,128,129,130]. A total of 18 articles pertained to robotic mastectomy [56, 72, 131,132,133,134,135,136,137,138,139,140,141,142,143,144,145,146]. Finally, a total of 43 articles described transoral robotic surgery (TOR) [81, 147,148,149,150,151,152,153,154,155,156,157,158,159,160,161,162,163,164,165,166,167,168,169,170,171,172,173,174,175,176,177,178,179,180,181,182,183,184,185,186,187,188].
Total number of articles in each subcategory within the scope of robotic plastic and reconstructive surgery
Peri-operative outcomes
Lymph node dissection
Reported length of stay, complications, and recurrence (of disease) are displayed in Table 3. Six articles found the average operative time to be higher for robotic surgery (Table 1). The peri-operative complication rate was found to be comparable, within the reported studies. The average length of stay was shorter for robotic surgery; however, only two articles reported length of stay for conventional lymph node dissection (P = 0.46).
Pedicled and free flap harvest
Peri-operative outcomes regarding pedicled and free flap harvest are reported in Table 4. Average harvest time is higher in the robotic group, although not this was not statistically significant. Average length of stay within comparative studies is lower in the robotic group; however, overall results show a comparable length of stay with conventional surgery. Overall, average complication rates are lower than conventional approaches; however, not statistically significant within comparative studies (P = 0.061).
Microsurgery
Peri-operative outcomes for flap pedicle dissection, flap inset, and microsurgical anastomosis are shown in Table 5. No comparative studies were found for pedicle dissection, with majority of articles pertaining to deep inferior epigastric perforator (DIEP) pedicle dissection. Anastomosis time was found to be longer for robotic surgery; however, docking time was not reported in any studies. There was a comparable rate of overall complications. Only three non-comparative studies reviewed length of stay, with the average being 7.1 days.
Mastectomy
Peri-operative outcomes regarding nipple-sparing mastectomy are shown in Table 6. Operative time was found to be comparable overall; however, this included reconstruction time. Overall length of stay was comparable between open and robotic groups. Overall rate of complication was lower in robotic nipple-sparing mastectomy (P = 0.0007) (Fig. 4).
Weighted analysis of comparative studies reviewing complication rate of robotic nipple sparing mastectomy with conventional nipple sparing mastectomy
Abdominal wall
Outcomes regarding abdominal wall reconstruction are collated in Table 7. Separate comparisons are demonstrated between robotic versus laparoscopic, and robotic versus open repair. Weighted analysis of comparative robotic versus laparoscopic studies found high heterogeneity (85%), and favours robotic surgery with reduced complications (P = 0.02) (Fig. 5). Robotic surgery had fewer complications when compared with open surgery (P = 0.0001), with lower heterogeneity (Fig. 6).
Weighted analysis of comparative studies reviewing complication rate between robotic abdominal wall reconstruction and laparoscopic abdominal wall reconstruction
Weighted analysis of comparative studies reviewing complication rates in robotic versus open abdominal wall reconstruction
Length of stay was shorter for robotic surgery in comparison to both groups, however, was only statistically significant for robotic versus open (P = 0.017). Overall operative time was higher for robotic surgery but was not statistically significant within laparoscopic and open subgroups.
Transoral robotic surgery
TOR operative outcomes are reported in Table 8. Length of stay was shorter for robotic surgery; however, this was not statistically significant. A statistically significant lower rate of complications is found for robotic surgery in comparison to open surgery (P = 0.033). Disease-free survival was higher within the robotic cohort; however, this was not found to be statistically significant.
Operative time was variable, and few conclusions can be drawn (Table 1). Lee et al. reported a longer duration compared to transoral resection; however, White et al., found a shorter duration for excision of recurrent oropharyngeal SCC [151, 154]. White et al., also found a better rate of negative margins with robotic surgery [154]. Hammoudi et al. found no difference in procedure duration for resection of primary SCC [158].
Post-operative outcomes
Patient-reported outcomes and long-term outcomes are reported in Table 1. The quality and standard of assessment varied greatly. Patient satisfaction was reported in three (27%) lymph node (neck) dissection articles, all of which found better scores compared to open with regard to cosmesis and scarring [42,43,44]. Lin et al. found comparable results for patient satisfaction and pain for mandibular contouring [96].
Flap/microsurgery
High patient satisfaction for latissimus dorsi muscle flap harvests were reported in three articles; one cohort study found significantly higher BREAST-Q scores than open [54, 66, 70]. 31% of flap inset or anastomosis articles reported post-operative outcomes other than complications [84, 85, 87, 91, 93]. Van Mulken et al. reported robotic lymphovascular anastomosis to have comparable lymph ICF scores to conventional microsurgery. Miyamoto et al. and Chen et al. reported successful patient outcomes of nerve grafts (sympathetic trunk reconstruction and nerve to deltoid) [84, 93]. Two articles detailing pedicle dissection of DIEP flaps reported favourable outcomes, and no hernias; however, there are no comparative results [73, 77].
Abdominal wall reconstruction
Patient-reported outcome measures (PROMs) were described in 8 (28.6%) articles of abdominal wall reconstruction. Three articles reviewed pain with VAS scores and found no difference (2 RCT’s) or less pain at 1 month/1 year (prospective cohort) [116, 120, 123]. Kakela et al. found comparable PROMs (SF-36) with laparoscopic surgery, with high scores for emotional status and social function for robotic surgery. Three articles found no difference between robotic and laparoscopic surgery in reported patient outcomes, including functional status [120, 122, 126]. One RCT found higher HERqLess scores for robotic versus laparoscopic ventral mesh hernia repair [118].
One RCT compared robotic extraperitoneal versus intraperitoneal onlay mesh (IPOM) for ventral hernia repair and found that IPOM had significantly higher HerQLess scores at 1 year follow-up.
Mastectomy
A total of four (22.2%) of mastectomy articles reported patient qualitative outcomes. Two articles reported high scores for cosmetic satisfaction with minimal scarring, whilst one case control study found significantly higher scores in a cosmetic outcome questionnaire than open surgery, with better scarring and a better position of the nipple–areolar complex [132,133,134, 143]. One RCT documented significantly higher satisfaction within the BREAST-Q questionnaire for robotic surgery [144].
TOR
Three TOR studies reported a lower rate of tracheostomies in the peri-operative period, as well as a lower requirement and durations of nasogastric feeding/PEG feeding [154, 155, 158].
Two studies found significantly higher 3-year disease-free survival with robotic surgery in HPV negative patients, and comparable rates of survival for HPV positive patients for oropharyngeal SCC primary resection [157, 173]. This was echoed by Lee et al., in which robotic surgery had a higher overall and disease-free survival rate at 2 years for lateral oropharyngectomy as treatment for tonsillar cancer [151]. White et al. found a higher rate of 2-year disease-free survival for open surgery to treat recurrent oropharyngeal SCC (T1-T4) [155].
Two articles evaluated patient outcomes through the Head and Neck Cancer Inventory (HCNI); Durmus et al. reported patients to have highly functional quality of life within their case series of carcinoma of unknown primary resection [156]. Sethia et al. found comparable outcomes for robotic oropharyngeal resection with and without adjuvant therapy [175]. Lee et al. also reported no difference in VHI and MDADI scores between open and robotic lateral oropharyngectomy for tonsillar cancer [151].
Cost
Gundlapalli et al. reported a higher procedural cost for their case report of a robotic-assisted DIEP breast reconstruction of $16,000 versus $14,000. There were no other articles which reported cost within robotic flap harvest or microsurgery.
Lai et al. reported a higher cost for robotic nipple-sparing mastectomy in comparison to conventional treatment of $10, 877 versus $5,702 [143].
Within the subcategory of abdominal wall reconstruction three articles (11%) reported cost. Olavarria et al. found robotic patients had an increased total cost for 90 days of care in comparison to laparoscopic ventral mesh hernia repair in their RCT ($15, 865 robotic versus $12, 955) [116]. In addition to this, a separate RCT found that whilst the cost of reusables was comparable between robotic and laparoscopic ventral hernia repair, the total cost was significantly higher for robotic patients due to the overall operative time (Cost ratio of 1.13 robotic versus laparoscopic 0.97 P = 0.03) [125]. In contrast a retrospective cohort study found whilst the procedure costs were higher for robotic surgery, the overall cost of patient care was shorter because of reduced length of hospital stay (robotic $13, 943 versus $19, 532, P = 0.07) [109].
Two TOR articles reported cost (4.7%). Chung et al. found that overall cost was significantly lower for robotic pharyngectomy ($20,706 versus $29,365) and posterior partial glossectomy ($19, 091 versus $23,414), whilst anterior partial glossectomy demonstrated no difference in the total cost of procedure between TOR and conventional approaches ($22,111 versus $21,376) [155]. Hammoudi et al. reported higher costs for robotic oropharyngeal SCC resection; however, the overall cost accounting for duration of hospital stay was significantly less ($20,885 vs $27,926) [158].
Learning curve
Learning curve was reported in clinical studies as changes in operative time (Table 1). Three abdominal wall reconstruction articles commented that skin-to-skin operating time decreased throughout their cohort [112, 116, 120]. Muysoms et al. analysed operative time for 41 transabdominal retromuscular hernia repairs, and commented that the decrease was largely contributed to by improved efficacy in the dissection aspect of the procedure [112]. Olavarria et al. reported a training exposure of 50 cases, through simulation and cadaveric models, prior to performing ventral hernia repairs was necessary to ensure optimal clinical practice [116]. A total of four mastectomy articles reported operative time to decrease with as clinical exposure increased, including a decrease in docking time [132,133,134, 139, 142]. Lai et al. achieved an average time for nipple-sparing mastectomy of 100 min, in a series of 39 patients [142].
Van Mulken et al. reported robotic microvascular anastomosis to require a longer time to complete; however, a steep learning curve resulted in a reduction in this [87]. Barbon et al. also reported a steep learning curve for anastomosis with time taken to complete being comparable to hand-sewn operative time, with the quickest robotic anastomosis taking around 10 min (Table 2) [89].
Selber et al. also reported a steep learning curve in surgical trainees over five sessions, followed by gradual improvement [29]. Two training models in microvascular anastomosis reported a plateau in learning curve of robotic anastomosis by expert surgeons on synthetic silicone vessels and rat vessels to be 5 and 8 attempts, respectively [16, 17]. Beier et al. developed a 4-week training programme with synthetic 1 and 2 mm vessels, in which 10 successful anastomosis were deemed to be the benchmark for skill acquisition before progression to clinical practice [34].
Surgical ease of use
Robotic surgery offers several mechanical advantages to aid surgical performance. Many authors commented upon improved visibility with higher 3-dimensional resolution, magnification, and lighting, allowing for depth of field perception and a 360° view of a cavity [54, 132].
The Da Vinci robotic arms have 7° of freedom which allow for higher dexterity and greater range of motion, optimising the user’s ability to dissect the surgical plane and increasing access to difficult anatomical areas [137].
Insufflation was found to be useful attribute for nipple-sparing mastectomy [131, 135, 141]. Through a single small incision approach, Toesca et al. reported easy identification of structures such as intercostal perforators which contribute to nipple–areolar complex survival and flap survival, and better view of the surgical plane [132]. The use of carbon dioxide helped to reduce bleeding and perform better haemostasis [132]. There was a higher surgical challenge with larger ptotic breasts [136]. Motion scaling, and tremor filtration provides high precision and stability; this was also found to be advantageous for flap and microsurgery [77, 132, 137].
The robotic technique of pedicle dissection of the DIEP flap minimizes incision of the anterior rectus muscles and provides improved dexterity and motion; however, due to the space occupation of the robot and the console it may be challenging for two surgical teams to work simultaneously, thus potentially increasing operative duration [73, 77, 80].
Robotic equipment also eliminates haptic feedback; however, users have reported that they were able to compensate effectively for this by relying on visual cues and felt able to complete the vessel and lymphovascular anastomosis without difficulty [83, 85, 90].
Feng et al. reviewed tremor during microsurgery, based on instrument tip movement and found that this was significantly lower in robotic surgery in an ex vivo model [14]. Furthermore, in a simulation model of 1 mm synthetic vessels, robotic anastomosis was performed with greater precision (measured in suture distance and angulation) when compared with manual approaches for 40 expert surgeons and 20 novices [17].
Discussion
This study demonstrates feasibility and safety of robotic surgery within plastic and reconstructive surgery in several subcategories. There are clear benefits to the surgeon, as described above, with improved access to difficult areas, tremor reduction and motion scaling, and improved ergonomic efficiency [2].
These attributes are particularly useful in cavity surgery and could create opportunities to complete challenging procedures which could not be accessed through an open approach due to narrow openings, such as nasopharyngeal resection and microvascular reconstruction, or where there may be a high risk of complications, or prolonged recovery time associated with conventional open approaches.
One example of this is TOR, whereby access and exposure is often obtained through techniques with higher morbidity, such as mandible splitting, leading to specific complications and expectations for recovery outside of the intended resection. Furthermore, although DIEP flap harvest can be regarded as having more superficial access, Tsai et al. found the anterior rectus sheath incision for pedicle dissection to be significantly smaller than conventional approaches, and thus less invasive [79]. It is not yet clear if this translates to reduced hernia occurrence post-operatively.
As interest within microsurgery grows, Da Vinci, and other companies such as Symani Surgical Systems and Microsure, have created an instrument portfolio that is well adapted to this field. Literature shows these tools can perform vessel, nerve and lymphovascular anastomosis with non-inferior outcomes to conventional approaches. Improved surgical ergonomics has allowed end-to-end anastomosis of 1 mm diameter vessels as reported in preclinical studies, with higher ease [16]. Whilst nerve repair can be performed robotically, there is lack of substantial evidence or comparison to conventional approaches. Whilst this approach is more minimally invasive, further research to determine the overall benefit, safety and cost would be beneficial.
Loss of haptic feedback is often considered to be disadvantage of robotic surgery. Surgeons have reported a compensation for this by relying on visual cues which has not impacted their performance. Further research could assess how easily a surgeon may adapt to the loss of true haptic feedback, as well as looking into the incorporation of haptic feedback into robotic instruments.
Single port access is highly advantageous for breast surgery including resection and reconstruction. Quicker docking can reduce operative time and the smaller incision offers a better cosmetic outcome with reduced scarring [101].
The high precision and accuracy of robotic surgery, could improve patient care, reflected in the lower rate of complications reported, reduced blood loss, reduced post-operative pain, as well as the comparable or reduced length of recovery. Whilst operative time is reported to be higher for robotics, many centres have shown a learning curve in adapting to new techniques.
Post-operative outcomes
There is a paucity of data evaluating patient reported outcomes within the literature. Outcomes within case series/case reports were often reported anecdotally, without use of validated or quantitative assessment tools. However, several articles have reported high patient satisfaction with regard to cosmetic outcome and scarring. Robotic neck dissection approach has been performed with a smaller retro-auricular incision.
Furthermore, robotic latissimus dorsi muscle flap harvest and radial forearm flap harvest can offer reduced scarring through a more minimally invasive approach, resulting in absence of long scars, on the back and forearm, respectively. Whilst this is the case, compared to open techniques, insufflation with reduced scarring, can also be achieved with an endoscopic approach. A comparison of the benefits to the surgeon and patient between endoscopic and robotic-assisted technique would be valuable to ascertain the true benefit of robotic assistance in this procedure. Some patients may require incorporation of skin within an LD flap for example in salvage procedures, or delayed reconstruction of the irradiated breast. The quality of coverage at the recipient site may be insufficient to accommodate the optimal reconstructive outcome, with particular importance of the integrity of the lower pole. In these circumstances, robotic surgery may present few advantages for LD flap harvest, and thus patient selection is important.
Patients undergoing robotic nipple-sparing mastectomy and reconstruction have also reported a higher scar satisfaction, with the use of a single incision in the axilla, in which multiple robotic arms can be used. There is a clear benefit to procedures in which access can move towards less invasive approaches, and robotic surgery within breast reconstruction and lymph node dissection are promising avenues for future research.
The rate of hernia recurrence within abdominal wall reconstruction is challenging to ascertain given the variable and often short length of follow-up reported within the literature. The mean length of follow-up within this subcategory is 9 months (0.25–33.6 months).
There is a high variance of histopathology within the transoral robotic surgery subcategory, as well as tumour location, stage of disease, and patient demographics. Few conclusions can be drawn between the comparative studies given the variability. However, the results reported, suggest that TOR results in non-inferior patient outcomes in comparison to conventional approaches.
Cost
Cost is poorly reported within the literature. Cost-analysis of robotic reconstructive procedures to review total cost of patient care would be beneficial in ascertaining the economic barriers that prevent the implementation of robotic within clinical practice in this speciality. Reasons suggested for higher cost include the initial purchase of robotic equipment, and prolonged operative duration utilising resources [118].
However, several articles within abdominal wall reconstruction and TOR, have reviewed the total cost of patient care, and found that the overall financial burden is significantly less than conventional approaches after accounting for length of hospital stay. This could be because of fewer complications, and reduced pain with a minimally invasive approach [109, 155, 158]. Chung et al. also reported reduced requirement of tracheostomies, nasogastric feeding, and percutaneous endoscopic gastrostomy (PEG) feeding, which could account for a decrease in overall consumables cost. Several articles have also described a learning curve throughout their studies, reflected in a shorter operative duration, which could have an impact for cost incurred. The cost of training surgeons, and theatre teams to use robotic equipment should also be accounted for.
Whilst the initial cost may be high for robotic surgery, the overall cost may be offset by the reduction in complication rate, and reduced length of stay. It is important to delineate when and where the cost of robotics, including resource utilisation, is balanced by proven improved patient outcomes in order to implement this effectively in future practice.
Learning curve
All studies which report a learning curve in this review, do so indirectly, as a reduction in operative time [142]. Whilst a reduction in the time taken to perform the procedure can be seen as an improvement in skill acquisition, duration of surgery can be affected by various factors in clinical practice including team efficiency and education. Standardised training for skill acquisition with appropriate measures of assessment in a controlled setting will aid in understanding the number of procedures required to achieve clinical competency in each subspeciality. global evaluative assessment of robotic skills (GEARS), and structured assessment of robotic microsurgery skills (SARMS), have been used as objective quantitative assessment tools in this field.
Training should also encompass theatre staff, as set up time including robot docking, change of arms, and equipment troubleshooting can be optimised to reduce burden and improve patient care [133]. Prolonged operative duration incurs significant resource utilisation including time, cost, equipment, and staff. Barbon et al. was able to demonstrate a steep learning curve in microvascular anastomosis to achieve an anastomotic time which was comparable with conventional approaches [89].
Vierstraete et al. describe the current training pathway of abdominal wall reconstruction and ventral hernia repair and found in their experience of posterior component separation that there was a gradual reduction in operative time until the surgical team reached their ‘comfort zone’ at around 20–25 cases. Depending on the frequency with which this procedure is performed, it may take a long period of time for the surgeon to reach that level of experience [189].
Other limitations
This report shows technical feasibility of robotic surgery; however, many articles are a relatively low level of evidence, with a high prevalence of case reports and case series. This review presents small sample sizes and as such, statistical analysis is likely to be underpowered, impeding ability to present true statistical significance. Whilst this study can suggest non-inferiority of robotic surgery, patient advantages remain to be clearly demonstrated.
There is a lack reported of long-term outcomes and formal PROMs, with variable follow-up duration. Due to large heterogeneity of the data and variance within patient selection, and outcomes reported, particularly within transoral robotic surgery, we have been unable to perform a weighted analysis for most subcategories, which would provide a more powerful comparison.
Conclusions
This literature review demonstrates technical feasibility of robotics in plastic and reconstructive surgery. High cosmetic satisfaction is reported with minimally invasive approaches. Operative time is higher than conventional approaches, although steep learning curves are reported, and this may contribute to a higher initial cost. Overall cost may be offset with improved patient outcomes within TOR and abdominal wall reconstruction; however, further reporting of cost and cost-effectiveness is necessary. Technical advantages can potentially translate to improvements in complication rate, and a faster recovery time, with non-inferior patient outcomes reported, with thoughtful case selection. However clearer evidence to support improved outcomes within the field, particularly in comparison with laparoscopic surgery, is required to justify the financial incurrence and demand on resources. Robotic surgery could play an exciting role within plastic surgery, and future research should focus on robotic training, as well as producing higher quality comparative clinical research, which is adequately powered, to fully understand the true benefit for patient care.
Data availability
No datasets were generated or analysed during the current study.
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Awad, L., Reed, B., Bollen, E. et al. The emerging role of robotics in plastic and reconstructive surgery: a systematic review and meta-analysis. J Robotic Surg 18, 254 (2024). https://doi.org/10.1007/s11701-024-01987-7
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DOI: https://doi.org/10.1007/s11701-024-01987-7