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. 2024 Jun 15;18(1):254. doi: 10.1007/s11701-024-01987-7

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

Laura Awad 1,2,3,, Benedict Reed 1,2, Edward Bollen 1, Benjamin J Langridge 1,2,3, Sara Jasionowska 1,2, Peter E M Butler 1,2,3, Allan Ponniah 1,2
PMCID: PMC11180031  PMID: 38878229

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.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11701-024-01987-7.

Keywords: Robotic, Robotic assisted, Plastic and reconstructive surgery

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).

Fig. 1.

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:

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

  • Adults and children

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

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

Articles were excluded from this review using the following criteria:

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

  • Inguinal hernia repair

  • Articles not available in English language

  • Articles published prior to 2013.

Search strategy

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

  • Robot* AND

  • 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) [1323]. A total of 18 educational articles were included (Table 2) [2441].

Fig. 2.

Fig. 2

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

Table 1.

Clinical publications within the scope of robotic plastic and reconstructive surgery (BL blood loss, LOS length of stay)

Reference Year N =  Robot Specific skill/task Control procedure Outcomes Duration of surgery compared to control LOS compared to control Peri-operative complications difference compared to control Length of f/u (months) Additional outcomes
Lymph Node Dissection = 11 Articles
Kim et al 2013 20 Da Vinci Neck dissection Conventional

Operative time, BL

Complications, LOS

Number of nodes

Significantly higher No difference No difference 8 Higher scar satisfaction with robotic patients
Tae et al 2013 11 Da Vinci Neck dissection Conventional

Operative time

Post-operative drainage

Cosmetic satisfaction

Significantly higher No difference Higher cosmetic satisfaction with robotic patients
Kim et al 2015 2 Da Vinci S Neck dissection Endoscopic neck dissection

Operative time

Complications

Scarring

Lymphoedema

Higher No lymphoedema Excellent cosmetic satisfaction, hidden scar
Du et al 2017 1 Da Vinci Axillary dissection

Operative time, LOS

Complications

Number of nodes

10
Lira et al 2017 6 da Vinci Si Neck dissection Endoscopic and conventional

Operative time

Complications, LOS

Number of nodes

Disease-free survival

Higher Statistically lower 18.6 No difference in resection outcomes or disease-free survival
Melly et al 2017 1 Da Vinci Axillary dissection

LOS,

Complications

He et al 2018 13 Da Vinci Axillary dissection

Operative time, BL

Number of nodes

Complications

16.5
Singh et al 2018 51 Da Vinci si Inguinal dissection Conventional inguinal dissection

Operative time, LOS, BL

Number of Nodes

Complications

Significantly higher (excluding docking time) Significantly shorter Significantly lower incidence of major complications, edge necrosis, limb oedema 40
Paek et al 2019 28 Da Vinci Neck dissection Conventional neck dissection

Complications

Number of Nodes

Significantly higher No difference No statistical difference
Lee et al 2020 1 Da Vinci Xi Axillary dissection

Operative time, LOS

Complications

Number of Nodes

none
Song et al 2020 4 Da Vinci Neck dissection

Operative time

Blood Loss

Complications

Craniofacial = 2 Articles
Lin et al 2022 15 KUKA robotic arm Mandibular contouring

Osteotomy surface position error/plane angle error

Operation time

BL, LOS,

Complications

Safety outcomes

Patient satisfaction/pain scale/score at 1&6 months

No statistical difference No difference No difference
Lin et al 2023 15 KUKA robotic arm Mandibular contouring Conventional

Osteotomy surface position error/plane angle error

Operation time

BL, LOS,

Complications

Safety outcomes

Patient satisfaction/pain scale/score at 1&6 months

No difference No difference No difference 6
Cleft Palate = 1 Article
Teblick et al 2023 29 Da Vinci Modified Furlow double-opposing Z-palatoplasty Eustachian Tube Function Lower hearing thresholds and faster resolution of OME were found
Pedicled and Free Flap Harvest = 21 Articles
Pederson et al 2014 10 Da Vinci RAM

Operative time

Complications

12 No recurrence
Clemens et al 2014 12 Da Vinci Pedicled LD Conventional

Operative time, LOS

Complications

7.1
Chung et al 2015 12 Da Vinci Pedicled LD

Operative time, LOS Complications

Patient satisfaction

15.7 High patient satisfaction with 1–10 Likert scale
Lai et al 2018 1 Da Vinci Pedicled LD Complications 5
Lai et al 2018 2 Da Vinci Si Pedicled LD

Operative time

Complications

Blood Loss

Technical report

8
Houvenaeghal et al 2019 80 Da Vinci Si /Xi Pedicled LD

Operative time, LOS

Complications, BL

Lack of long dorsal scar
Ozkan et al 2019 1 da Vinci Xi Omental

Operative time

Complications

Flap Survival

12
Houvenaegel et al 2020 46 da Vinci Xi/Si Pedicled LD Conventional

Operative time, LOS

Complications

Significantly higher (improved with experience) No difference Significantly lower
Fouarge et al 2020 6 da Vinci si /Xi Pedicled LD

Operative time, LOS

Complications

Technical report

Frey et al 2020 5 da Vinci xi Free omental flap (lymph node transfer) LOS, Complications
Haverland et al 2020 6 Da Vinci RAM (pelvic recon) Complications 9.2
Moon et al 2020 21 da Vinci xi Pedicled LD

Operative time

Complications

19.2
Winocour et al 2020 25 Da Vinci Pedicled LD Conventional

Operative time, LOS

Complications

Flap Survival

Significantly higher Significantly shorter Higher rate of seroma 60 Reduction of opioid requirements but not significant
Asaad et al 2021 7 Da Vinci RAM (pelvic reconstruction)

LOS, BL

Complications

Day et al 2021 1 Da Vinci Pedicled omental Complications
Joo et al 2021 1 Da Vinci SP Pedicled LD

Histology

Operative time

Complications

PROMS—BREAST Q

Cheon et al 2022 41 da Vinci Si/Xi/SP Pedicled LD

Operative time, LOS

Complications

15.6 Higher patient satisfaction with robotic group
Davila et al 2022 16 Da Vinci RAM (pelvic reconstruction) Conventional

Operative time, LOS

Complications

No difference No difference No difference statistically but lower rate in robotic group 36
Hwang et al 2022 3 da Vinci SP Pedicled LD

Operative time

Complications

Seon Eo et al 2023 20 Da Vinci Pedicled LD Endoscopic conventional

Operative time, LOS

Opioid requirement

Complications

Significantly higher No difference No difference 18.4 statistically higher overall patient satisfaction
Shin et al 2023 11 da Vinci si RFFF harvest

Operative time

Method of anastomosis

Flap Survival

Complications

Significantly longer Notably less scarring with no longitudinal volar incision
Hans et al 2013 2 (1 flap inset) Da Vinci RFF inset, TOR resection

Operative time, LOS

Resection margins

8
Flap Inset and Anastomosis (Vessel, Nerve. Lymph) = 16 Articles
Song et al 2013 5 Da Vinci Flap inset, anastomosis, TOR resection

Operative time

Complications

12.8
Lai et al 2014 5 da Vinci Si RFF inset, venous anastomosis

Operative time

Complications

Flap Loss

7
Miyamato et al 2014 6 da Vinci S Nerve graft

Complications

Deltoid function recovery

10 5/6 regained deltoid function
Tsai et al 2017 14 Da Vinci RFF inset, secondary venous anastomosis Conventional

Complications

Flap Revision

Long Term Outcome (FIGS)

No difference 3
Lai et al 2019 15 Da Vinci RFF anastomosis (vein/artery) Microscope (conventional)

Operative duration

Complications

Vessel Diameter

Significantly higher 100% flap survival 11.5
Van Mulken et al 2020 20 MUSA LVA Microscope (conventional)

Operative time

Anastomosis patency

Complications

Patient satisfaction

Postoperative: daily wearing of compressive garment, manual lymph drainage, lymph ICF score, EUL index score

Significantly higher anastomosis time but showed steep improvement with learning curve No difference 3 No difference in Lymph ICF score
Chang et al 2021 1 da Vinci Xi Bilateral sympathetic trunk recon with sural nerve graft (neurosynthesis)

LOS

PROM (questionnaire)

42 70% improvement in symptoms
Barbon et al 2022 22 Symani surgical system Arterial/venous/nerve/lymph Microscope (conventional)

Operative duration

Learning curve

Suture size

Number of sutures

Patency

significantly higher BUT improved in second cohort more than hand-sewn Steep robotic learning curve to a comparable time with hand sewn anastomosis
Lindenblatt et al 2022 5 Symani surgical system LVA/arterial

Operative Time

Surgical Experience

Van mulken et al 2022 20 MUSA LVA Microscope (conventional) 1-year outcomes—QOL (Arm circumference, compression garment, manual drainage, arm dermal backflow and patency of anastomosis tested with ICG 12 Patient outcomes were comparable with conventional procedure. 42.9% reduction in use of compression garments
Beier et al 2023 23 Symani surgical System Arterial End-to-end/End-to -side anastomosis

Operative Time

Revisions

Besmens et al 2023 6 Symani Surgical System (and exoscope) Arterial anastomosis/neurosynthesis

Operative time

Anastomosis patency

Chen et al 2023 23 da Vinci xi Nerve anastomosis

Operative time, LOS

Level of nerve injury

Length of defect

Complications

24 Effective in reducing sweating across all sites assessed
Innocenti et al 2023 1 Symani surgical system Arterial/venous anastomosis ALT

Surgical Experience

Number of sutures

Operative Time

Complications

Weinzierl et al 2023 8 Symani surgical system LVA

Operative Time

Number of sutures

Anastomotic Patency

Flap Pedicle Dissection = 8 Articles
Gundlapalli et al 2018 1 Da Vinci DIEP

Operative Time

Complications

Cost

9
Choi et al 2021 17 da Vinci sp DIEP

Operative time

Complication

Bishop et al 2022 21 Da Vinci DIEP

Operative time, LOS

Complications

5
Daar et al 2022 4 da Vinci xi DIEP

Operative time, LOS

Complications

6.31
Dayaratna et al 2022 1 da Vinci Xi DIEP submuscular pedicle dissection

Operative time

Complications

PROM—BREAST Q

None, minimal pain, low analgesic requirements 3
Wittesaele et al 2022 10 Da Vinci DIEP

Operative time, LOS

Complications

1
Tsai et al 2023 13 Da Vinci DIEP Conventional pedicle dissection

Operative time

Complications

14
Zanaty et al 2023 1 Da Vinci Internal thoracic artery harvest

Surgical Experience

Complications

Vaginoplasty = 3 Articles
Boztosun et al 2016 1 Da Vinci Xi Sigmoid vaginoplasty

Operative time, LOS

Complications

Long term outcomes

6 More minimally invasive approach
Dy et al 2021 47 2 groups—Da Vinci SP/Xi Vaginoplasty—gender affirmation SP vs Xi da Vinci

Operative time

Complications, BL

Neovaginal dimensions

SP shorter duration No statistical difference

Not statistically different

lower rate of BO in xi, higher rate of transfusion and vaginal stenosis in SP

12

Few incisions result in better cosmetic benefit

single port shorter and doesn’t impede second surgeon

Blasdel et al 2023 43 Da Vinci SP Vaginoplasty with peritoneal flap recon, in patients with genital hypoplasia Traditional vaginal canal dissection, peritoneal flap

Complications

PROMs

12
Nerve Decompression = 1 Article
Bruyere et al 2016 1 Da Vinci Si Neurolysis of lateral cutaneous nerve of the thigh LOS, Complications - 6 100% reduction in pain (0/10 from 5/10)
Abdominal Wall Reconstruction = 28 Articles
Chen et al 2016 39 Da Vinci Small ventral hernia mesh repair Laparoscopic

Operative time, LOS

Complications

Defect size

Significantly longer (65) No difference No difference in readmissions, no difference in complication rate 1.5
Bittner et al 2017 26 da Vinci si/xi Transversus Abdominis release and mesh Open

Hermia Characteristics

Operative time, LOS

Complications

Significantly higher (287) Significantly shorter (6) No difference 2
Gonzalez et al 2017 368 Da Vinci Xi Ventral wall hernia repair mesh/direct closure

Operative time, LOS

Complications

Jamshidian et al 2017 3 da Vinci Xi Spigelian hernia repair with mesh

Operative time, BL, LOS

Complications

Opioid Use

Prabhu et al 2017 177 Intraperitoneal mesh repair Laparoscopic

Operative time, LOS

Complications

Significantly higher Significantly shorter Statistically lower Higher rate of bowel injury, and systemic problems in laparoscopic group
Wang et al 2017 1 Da Vinci Stratafix/mesh intercostal hernia repair LOS, Complications
Warren et al 2017 53 Da Vinci Retromuscular/ PP mesh ventral hernia repair Laparoscopic

Rate of fascial closure

Operative time, LOS

Opioid use

Complications

Cost

Significantly longer Significantly shorter Significantly higher rate of seroma 2

LVHR and RRVHR ($13,943 vs. $19,532; p = 0.07) Robotic cost of procedure higher, however overall cost comparable as shorter length of hospital stay

fascial closure achieved more in robotic surgery,

extraperitoneal mesh was performed majority of robotic cases

Carbonell et al 2018 111 Da Vinci Retromuscular mesh hernia repair Open

Complications, LOS

Readmission/Reoperations

Significantly longer Significantly shorter Higher rate of seroma/sso 1 Higher surgical site occurrences were noted with r-RVHR, consisting mostly of seromas not requiring intervention
Martin-Del-Campo et al 2018 38 not specified Transversus Abdominis release & retromuscular synthetic mesh Open

Hernia dimensions

Operative time, LOS, BL, Complications

Significantly higher (211) Significantly shorter (6) Systemic complications significantly lower (0 vs 13)
Muysoms et al 2018 41 da Vinci xi Retromuscular TAR mesh umbilical hernia repair

Learning curve

Operative time

Complications

PROM—EuraHS-QoL

1

Total skin-to-skin operative time decreased through the series

Significant improvement in PROMS compared to preop scores

Walker et al 2018 142 Da Vinci Preperitoneal mesh ventral hernia repair Laparoscopic

Operative time, LOS

Complications

Significantly longer No difference Significantly lower 4
Kudsi et al 2019 1 da Vinci Xi Sugarbaker parastomal hernia repair with mesh and TAR Operative time, LOS, BL, Complications 3
Kudsi et al 2020 164 da Vinci xi Transabdominal vs totally extraperitoneal hernia repair all robotic Transabdominal vs totally extraperitoneal hernia repair all robotic (all retromuscular)

Operative time, BL, LOS

Complications

Pain

Readmission

TEP shorter duration of surgery No difference Minor complications statistically higher for TA group, seroma frequency and rate of SSE also higher Minor complications statistically higher for TA group, seroma frequency and rate of SSE also higher
Olavarria et al 2020 65 da Vinci xi Intraperitoneal mesh ventral hernia repair Laparoscopic

Operative time, LOS

Complications

Long term outcomes—Recurrence, QOL,

Cost

Significantly longer No difference No differences 6.4

Clinicians had 50 cases as a learning curve prior trial

Increased cost for robotics of 90 days of care including surgery ($15 865 (£12 746; €14 125) v $12 955; cost ratio 1.21, 1.07 to 1.38; adjusted absolute cost difference $2767, $910 to $4626; P = 0.004)

Mudyanadzo et al 2020 16 not specified Ventral incisional hernia repair Laparoscopic LOS, Opioid use No difference Use of opioids reduced for robotic group 2
Petro et al 2020 39 da Vinci si/xi Intraperitoneal ventral hernia mesh repair Laparoscopic

Operative time, LOS

Long term outcomes—recurrence, NRS 11 score, PROM ISPI, hernia specific QOL

Cost

significantly longer (94) No difference No difference 3

Cost of reusables was comparable but higher cost for robotics because of higher operative time

Comparable NRS 11 score/PROMS

Bergholz et al 2021 1 Mesh intercostal hernia repair LOS, Complications
Dhanani et al 2021 65 da Vinci xi Intraperitoneal mesh and direct closure repair Laparoscopic

Complications

Long term outcomes—PROM, functional status, VAS, cosmetic satisfaction

Not reported 12 No difference in PROM outcomes at 1 year
Rayman et al 2021 3 da Vinci Si Transabdominal preperitoneal spigelian hernia repair Laparoscopic

Operative time, LOS

Complications

Post op pain

Defect/mesh size

17
costa et al 2022 18 Not specified Intraperitoneal ventral hernia mesh repair Laparoscopic

Operative time, LOS

Complications

Long term outcomes—recurrence, EORTC QLQ-C30

Significantly longer No difference No difference 24 No difference in long-term outcomes
Kakela et al 2022 19 da Vinci xi Retromuscular TEP mesh laparoscopic

Operative time, LOS

Long term outcomes.- pain, VAS (M1, 12), SF-36 PROM, hernia recurrence

Significantly longer No difference 12 Robotic less pain at 1 month and 1 year using VAS all 9 scores for SF-36 favour robotics but not statistically significant for most emotional status and social function improved significantly
Kudsi et al 2022 138 Da Vinci Mixed methods ventral hernia repair Obesity class II vs class III LOS, Complications No difference No difference 33.6 Comparison of patient BMI and outcomes in robotics no difference in peri-operative outcomes and intra-operative variables, except higher rate of mesh use in more obese patients
Petro et al 2022 38 da Vinci si/xi Intraperitoneal ventral hernia mesh repair Laparoscopic LOS, Long term outcomes—pain intensity, PROMIS pain score, HERQless, recurrence, reoperations 12 Higher rate of recurrence but better PROM outcomes
Pereira et al 2022 665 Lateral abdominal mesh hernia repair Open

Operative time, LOS

Complications

Long-term outcomes—PROM (HerQless, PROMIS pain,)

Significantly longer Significantly shorter

Bowel injury higher in open but not significant

SSI/use of epidural significantly lower

overall significantly lower rate of complications

12 No difference in long-term outcomes
Shimada 2022 1 da Vinci xi Retromuscular extraperitoneal mesh ventral hernia repair Operative time, LOS, BL, Complications 7
Dhanani et al 2023 65 da Vinci xi Intraperitoneal mesh and direct closure repair Laparoscopic

Complications

Long term outcomes—functional status, VAS, cosmetic satisfaction

No difference 24 Significantly lower rate of revision surgery in robotic group no difference in SSO at 2 years (seroma/haematoma) no difference in PROMS
Lima et al 2023 1 Spigelian hernia mesh repair Complications 0.25
Petro et al 2023 100 Da Vinci Robotic enhanced view totally extraperitoneal (eTEP) or robotic intraperitoneal onlay mesh midline ventral hernia < 7 cm TEP vs intraperitoneal mesh

LOS, Complications

Opioid Use

Long term—PROM

Significantly longer for TEMP No difference between robotic groups 12

Significant difference in HERQLes favouring IPOM (but only 12 months post op) no difference in recurrence at 1 year

(51 totally extraperitoneal, 49 intraperitoneal mesh)

Mastectomy = 18 Articles
Sarfati et al 2017 1 Da Vinci Nipple-sparing mastectomy Operative time, LOS 3
Toesca et al 2017 3 Da Vinci S Nipple-sparing mastectomy

Operative time, LOS

Complications

Patient satisfaction

8

No complications at 8 months, high cosmetic satisfaction small incision

Reduction in operative time from 7–2.5 h over 3 cases

Toesca et al 2017 29 Da Vinci Xi/Si Nipple-sparing mastectomy

Learning Curve

Operative time

Complications, LOS

8
Lai et al 2018 15 Da Vinci Si Nipple-sparing mastectomy

Learning Curve

Operative time

Complications, LOS

6.3 100% high satisfaction reported, shorter duration of surgery with more surgical experience
Park et al 2018 1 Da Vinci Xi Nipple-sparing mastectomy

Operative time

Pathology, LOS

Complications

0 12
Rajappa et al 2018 1 Da Vinci Si Nipple-sparing mastectomy

Operative time, LOS

Complications

Not specified
Sarfati et al 2018 1 Da Vinci Xi Nipple-sparing mastectomy Complications
Sarfati et al 2018 33 da Vinci Xi Nipple-sparing mastectomy (immediate implant recon)

Operative time

Complications

PROMS—BREAST Q

12
Lai et al 2018 2 da Vinci Si Nipple-sparing mastectomy & lat dorsi flap harvest

Operative time, LOS

Complications

0 8
Houvenaeghal et al 2019 27 (17 lat dorsi flap) da vinci Si /Xi Nipple-sparing mastectomy

Operative time

Learning curve

Complications, LOS

Time of surgery and anaesthesia decreased with learning curve
Houvenaeghal et al 2019 80 Da Vinci Si /Xi Latissimus dorsi flap robotic ± mastectomy

Operative time, LOS

Complications

Single incision, lack of long of long dorsal scar
Kuo et al 2019 3 da vinci xi Nipple-sparing/skin-sparing mastectomy

Operative time, LOS

Complications

5
Lai et al 2019 22 Da Vinci Nipple-sparing mastectomy

Operative time

docking time

BL, complications

recurrence

Docking time dropped with more experience 6.9 ± 3.5

All patients reported to be satisfied with outcome

US $6000/ use

Lai et al 2019 39 Da Vinci Nipple-sparing mastectomy

Operative time

Learning curve

complications

pathology/resection margins

8.6 Significantly reduced surgical duration with procedures performed over 1 year
Lai et al 2020 54 Da Vinci Si Nipple-sparing mastectomy Conventional

Operative time, BL

Resection margins

Complications

Cost

Long term outcomes -photography, PROMS (cosmesis)

Significantly longer Significantly longer no difference 14

$10,877 robotic vs $5702 conventional—significantly higher

Significantly higher patient satisfaction (better scar, better nipple position)

Toesca et al 2021 40 Da Vinci S Nipple-sparing mastectomy Conventional

Operative time, LOS

Complications, BL

Long term recurrence, survival, PROMs (breast-Q, NAC questionnaire)

Significantly higher Significantly shorter significantly lower (notably nipple ischaemia, skin necrosis, haematoma, seroma, and open group more likely to have > 1 complication 28.6

Significantly higher satisfaction in robotic, and in psychological wellbeing

No difference in rate of implant loss

Park et al 2022 167 Da Vinci Si Nipple-sparing mastectomy Conventional

Complications

Recurrence

significantly lower rate of complications in 30 days including nipple necrosis

lower rate of Clive dindo classification 3

18 No difference in recurrence
Moon et al 2022 40 da Vinci S Nipple-sparing mastectomy Conventional

Complications

Pain

Significantly longer No difference Perioperative only Lower pain reported for robotic group
Transoral Robotic Surgery = 43 Articles
Chan et al 2013 4 Da Vinci Resection parapharyngeal space neoplasm

Histopathology

Complications, LOS

Long term outcomes—function/oral diet

None 1–15 months
Chia et al 2013 2015 Oropharyngeal carcinoma (majority t1/t2 staging) Complications Low rate of long-term PEG dependency
Durmus et ala 2013 22 da Vinci S/Si Resection of cancer of unknown primary oral

Operative time

Complications

All achieved oral diet D1 RT 100% of patients 0 trachy, 0 gastrostomy
Durmus et alb 2013 3

Retromolar trigone tumour resection

HPV neg

Operative time, BL

Complications

1–16 months
Hans et al 2013 2 Da Vinci T3 hypopharyngeal SCC resection and RFF inset

Operative time, LOS

Complications

8 (1 flap inset)
Lee et al 2013 27 Da Vinci Lateral oropharyngectomy (T1/T3 tonsillar cancer) Conventional

Operative time, LOS

BL, Complications

Long term outcomes—survival, VHI, MDADI

Significantly shorter than mandibulotomy

significantly longer than transoral

Significantly shorter than mandibulotomy, no difference from transoral No difference 20.3

Higher disease-free and overall survival compared with control

No difference in VHI/MDADI scores

Patel et al 2013 47 Oropharyngeal tumour identification

Resection margins

Complications

Tsang et al 2013 1 Da Vinci S Nasopharyngectomy via lateral palatal flap approach

Resection margins

Operative duration

Complications

6
White et al 2013 64 Da Vinci Recurrent oropharyngeal SCC resection T1-4 Open

Operative time, LOS

Complications, BL

Long term—OS, DFS, death

Significantly shorter Significantly shorter Significantly fewer (fistula and oedema and overall) 24

Lower rate of tracheostomy/NG tube with robotic surgery

Decreased incidence of positive margins with robotic surgery (significant)

2-year recurrence free significantly higher for robotic

Chung et al 2014 641 Partial pharyngectomy Conventional LOS, Complications Significantly shorter Significantly lower

Lower cost for robotic surgery overall. $29,365 vs $20,706

lower rate of tracheostomy and peg

Chung et al

(same as above × 3 diff data sets)

2014 147 Partial glossectomy base of tongue Conventional LOS, Complications Significantly shorter No difference

Lower overall cost for robotics $19,091 vs $23,414 open

Significantly lower rate of tracheostomy and PEG

Chung et al

(same as above × 3 diff data sets)

2014 68 Partial glossectomy (anterior) Conventional LOS, Complications Significantly longer No difference (except higher rates of transient dysphagia)

No difference in total cost ( robotic $22,111 vs open $21,376)

Signifiantly lower rate of tracheostomy and PEG

Durmus et al 2014 22 Oral cancer of unknown primary resection

Operative time

Complications

Long term outcomes—HCNI PROM

12 Patients maintain long-term and highly functional QOL status
Ford et al 2014 65 Da Vinci OPSCC resection (majority t1/t2) Conventional

Operative time

Resection Margins

long-term—OS, DFS

36

Significantly higher 3-year survival for robotic group

recurrence free survival

Hammoudi et al 2014 26 Da Vinci Primary scc resection (any neck dissections were conventional) Conventional

Operative time

Resection margins

Length of Stay

Complications

Tracheostomy prevalence

Cost

No difference Significantly shorter No difference 19

Significantly fewer tracheostomies (n = 4)

SIGNIFICANTLY shorter duration of NG feed

No difference in 3-year disease-free survival

Significantly lower cost for robotics (higher operative cost ($7781 vs $4375) lower overall cost due to length of stay ($20,885 vs $27,926)

Van Loon et al 2014 18 Da Vinci T1/T2 OP cancer resection

Operative time

Resection Margins

Blood loss

Long term outcomes -PROMS (EORTC-C30, H&N35)

33.7 2-year disease-free survival of 86%
Almeida et al 2015 410 Larynx/pharyngeal cancer

Resection margins

Long term outcomes -OS, DFS

20
Dabas et al 2015 60 Da Vinci Resection oropharyngeal ca and conventional neck dissection (ipsilateral)

Operative time

Blood Loss

Complications

Long term—functional outcomes

8
Mercante et al 2015 13 T1/T2 OP ca without adjuvant Tx

procedure time, set up time, operative time

complications

hospital stay

blood loss

recovery to normal breathing

swallowing/removal of NGT

12 Long term—QoL, dysphagia score, FESS, penetration aspiration scale, MDADI, VHI-10 @ 6&12 months
Mockelmann et al 2015 41 Oropharyngeal resection T1-4 Staged vs concomitant neck dissection (21 control with concurrent, and 20 in intervention arm)

Length of Stay

Complications

Timing of neck dissection

Timing of neck dissection didn’t make a difference in outcomes. (immediate vs average of 10 days)
Razafindranaly et al 2015 84 Da Vinci Supraglottic scc resection

Resection margins

Complications

Oral diet/tracheostomy prevalence

20—tracheostomy temp

64—NG for median of 8 days (0–10)

8—permanent PEG

14
Smith et al 2015 42 Da Vinci oropharyngeal SCC resection and neck dissection (majority t3/4) CRT ( non-operative)

Resection margins

Complications

Long term—OS, DFS

36
Aubry et al 2016 178 Da Vinci Tumour resection

Length of stay

Complications

Fujiwara et al 2016 10 Da Vinci OPSCC T1-T2

Operative time

Length of Stay

Complications

Resection margins

Surgical feasibility

Blood Loss

Function (swallow)

Granell et al 2016 1 Da Vinci S HD Access and resection of parapharyngeal tumour (cavernous haemangioma)

Resection margins

length of Stay

Complications

None described 12
Duek et al 2017 1 Da Vinci Resection parapharyngeal space tumour

Operative time

Complications

None 4
Frenkel et al 2017 425

H&N resection

(333 concurrent neck dissection, 92 staged neck dissection)

Complications

Length of Stay

Risk adjusted LOS was less for concurrent neck dissection timing not associated with changes in complications, readmissions, tracheostomy, or gastrostomy
Gorphe et al 2017 27 Da Vinci Xi TOR resection

Operative time

resection margins

complications

unplanned tracheostomy/death

15 temp tracheostomies
Lallemant et al 2017 23 Da Vinci SCC posterior pharyngeal wall resection

Resection margins

Length of Stay

Complications

Long term—OS, DFS

NG feed needed for average of 22 days

 × 4 PEG (note post -op dysphagia—most likely due to site)

27
Mahmoud et al 2017 559 TOR OPSCC vs primary CRT Primary CRT Long term outcomes—DFS, OS 29
Rubek et al 2017 30 Da Vinci Si HD Oropharyngeal SCC

Length of Stay

Resection margins

Complications

Tube dependency 4.6 days 19
Sethia et al 2017 111 OP cancer resection—TOR vs TOR and adjuvant therapy

Complications

Long term—PROM (HCNI), OS, recurrence

Reduced rate of PEG at immediately post op 3,6,12 months 12 There were no statistically significant differences (P > .05) in aesthetics, social disruption (attitudinal), or speech (attitudinal) at any time point. Also, there were no statistically significant differences (P > .05) for all QOL domains at 12 months
Alessandrini et al 2018

8—Xi

8—S

da vinci Xi vs S

BOT SCC resection (T1/T2)

Da vinci si vs xi

 × 2 robotic groups

operative time

Resection margins

complications

blood loss

post-operative functional outcomes (VAS, LOS, NG)

Si had statistically longer console time and overall operating time Significantly shorter for Xi

Xi significantly shorter NG use and pain scores

no complications reported

Not specified
Doazan et al 2018 122 Supraglottic SCC Long term—OS, DFS, recurrence 42.8
Li et al 2018 2224 T1/T2 OPSCC resection Conventional and TLM

Resection margins

OS

Significantly shorter 60

TOR not associated with increased survival however there is a

lower likelihood of need for CRT "

Scott-Wittenborn et al 2018 6 Da Vinci Base of tongue/palate unknown primary ICG intraoperative tumour identification intraoperatively using ICG—unsuccessful ICG was not beneficial for tumour identification or resection using the da vinci
Hardy et al 2019 1 T3 pharyngeal SCC

resection margins

complications

recurrence

24
Nichols et al 2019 34 OPSCC T1-T2 Radiotherapy

Complications

Long term outcomes -PROMS, recurrence

25 Higher rate of neutropenia, hearing loss, and tinnitus in radiotherapy group, with a higher rate of trismus reported within the TOR group
Petruzzi et al 2019 1 Da Vinci Si Retropharyngeal lymph node dissection Operative time
Holcomb et al 2020 2 Da Vinci Si Salvage oropharyngectomy and submental artery island flap inset

Operative time, LOS

Complications

4
Kubik et al 2020 23 Da Vinci HPV unknown primary—BOT mucosectomy

Surgical experience

Complications

Long term—survival, recurrence

23
Sano et al 2021 68 Resection Conventional and TLM Resection margins
D'Andrea et al 2022 53 Da vinci Xi Salvage surgery oropharyngeal (Mostly T2)

Complications

Long term outcomes—PROM (MDADI, EORTC QLQC30/ H&N35

24 The preoperative, 1-year, and 2-year MDADI total scores were 71.4, 64.3, and 57.5, respectively. The preoperative, 1-year, and 2-year QLQ-C30 global scores were 61.2, 59.4, and 80.6, respectively. Decannulation was possible in 97.1% of the tracheotomized patients. The two-year enteral tube dependence was 23.1%. The two-year overall survival, disease-free survival, and local control rates were 59%, 46.1%, and 80.9%, respectively
Nichols et al 2022 34 TOR OPSCC T1-T2 Radiotherapy

Long term outcomes recurrence

MDADI

QLQ-C30

H&N35

VHI-10

FOIS

45 MDADI 2 years—84.8, 3 years 83.3. no difference in functional outcome
Virgilio et al 2023 139 OPSCC resection and neck dissection (mostly t1/t2)

Resection margins

tracheostomy/PEG prevalence

Long term—recurrence, OS, DFS

26 TOR can de-intensify the need for CRT

Table 2.

Preclinical and educational articles within the scope of robotic plastic and reconstructive surgery

Topic First author Year Robot Model/number Operation performed Participant Outcomes reported
Preclinical – 11 articles
Lymph node dissection Lee et al 2020 Da Vinci Xi

Cadaveric

N = 2

Axillary dissection Expert surgeon Safety and feasibility prior to clinical implementation
Microsurgery Feng et al 2017 Robotic ENT Microsurgical System

Chicken

N = 7 (each arm)

conventional vs Robotic

End-to-end anastomosis

6 novices

1 Expert surgeon

Microvascular tremor scale (based on instrument tip movement) was significantly lower for robotic

Comparable duration between conventional and robotic groups

Subjective feedback found robotic performance to be more accurate with improved handling and stability

Microsurgery Van Mulken 2018 Microsure

Silicone vessel/Rat

N = 8 (Each arm)

conventional vs robotic

Preparation, transection, and anastomosis Expert surgeon

Longer time to complete procedure for robotic (27 vs 12 min)

3 events of system reset required

Microsurgery Ballestin et al 2020 Symani Surgical System

Synthetic 1 mm vessel

(6 manual & 6 robotic performed by each trainee)

Microneedle driving, stitch placement, anastomosis 40 expert surgeon 20 novices

Improved precision with robot in both groups (suture distances, angulation)

Longer time to perform anastomosis (11 vs 6.5 min)- decreased with practice, however experts did not show improvement after 5th attempt

Microsurgery Malzone et al 2023 Symani Surgical System

Rat femoral vessels

conventional vs robotic

End-to-end arterial and venous anastomosis Not specified

Rat vessel diameter 1.09 mm average

Procedure performance time higher in robotic group

Plateau in learning curve at 60 sutures

Mean number of sutures/anastomoses = 8 in both manual and robotic groups

Equivalent vessel patency with histologically assessed lower tissue damage for robotic

Flap Zhu et al 2016 Omega 6, Force Dimension, Nyon

Sheep mandible

N = 6

Conventional vs Robot assisted

Free fibula flap—osteotomy

robot assisted guidance for osteotomy line and bony fixation. Manual harvest and inset

Expert surgeon Higher accuracy and improved implant orientation compared to freehand measurement/technique
Flap Manrique et al 2020 Da Vinci Xi

Cadaveric

N = 8

Bilateral DIEP pedicle dissection (TAPP and TEP approach) Expert surgeon

Duration: TEP 56 min, TAPP 65 min

Mean pedicle dissection TEP 39 min, TAPP 36 min

Demonstrated feasibility, with TEP representing a less invasive technique

Abdominal wall Sanchez et al 2018 Da Vinci

Synthetic training model

Laparoscopic vs Robotic

N = 14 (1 performed by each surgeon)

Incisional hernia repair 14 expert surgeons Less upper limb disturbance and lower mental effort for robotic group
TOR Chen et al 2017 Da Vinci Sp/Si

Cadaveric

N = 4

Transoral base of tongue resection Expert surgeon Single port system allows for more streamlined workflow
TOR Tay et al 2018 Endomaster

Cadaveric

N = 4

Radical tonsillectomies Expert surgeon Good visualisation, quick docking
Miscellaneous Friedrich et al 2018 Da Vinci

Silicone bench model

Manual vs Laparoscopic vs Robotic

N = 15 (for each)

Assessment of Haptic Feedback

correctly order silicone with defined rigidity and 5 steel tension springs

Expert surgeon Manual model demonstrated higher rate of correctly performed task
Education – 18 articles
Suturing Leijte et al 2020 RobotiX Mentor VR simulator VR simulator Suturing

15 Robotic surgeons

26 Laparoscopic surgeons

29 Novices

Time, economy of movement/error, accuracy, precision assessed through RobotiX Qualitative feedback reported good didactic value for proficiency-based training
Suturing De Groote et al 2022 Not specified

Chicken

Proficiency based progression training vs traditional training

N = 18 (each arm)

Suturing/knot tying 36 novices Higher rate of competency achieved with PBP group (eLearning until proficiency prior to task completion)
Microsurgery Liverneaux et al 2013 Da Vinci VR simulator, earthworm, rat model Anastomosis Surgical trainees Description of training course involving 3 tier model approach with validated Structured Assessment of Robotic Microsurgery Skills (SARMS)
Microsurgery Perez et al 2013 Da Vinci Trainer

VR exercise

N = 49

VR exercise

11 trainees with microsurgery experience

38 trainees without microsurgery experience

Quantitative assessment: microsurgery trainees achieved better results regarding economy of movement, precision, and force

Qualitative feedback: microsurgical trainees reported similar ergonomics between microsurgery and robotics

Microsurgery Alrasheed et al 2014 Da Vinci

3 mm synthetic vessel

N = 5 performed by each participant

End-to-end anastomosis 10 trainees

Structured Assessment of Robotic Microsurgical Skills (SARMS) assessed by 4 expert surgeons

Operative Time (9-44 min)

Decrease in operative time over 5 performed procedures

Microsurgery Selber et al 2014 Da Vinci

Synthetic vessel

N = 5 (performed by each participant in each arm)

Robotic only

End-to-end anastomosis 10 surgical trainees

All skill and overall performance improved over 5 sessions, and operative time decreased for all

Initially steep skill learning curve followed by gradual improvement

Microsurgery Willems et al 2016 Da Vinci

Synthetic vessel

N = 80 performed by each participant ( at depths of 0, 10, 20 cm with sidewall angles of 20 and 30 degrees

conventional vs robotic

End-to-end anastomosis 2 surgical trainees

OSAT—no difference between manual and robotic

longer duration in manual group

higher subjective comfort in robotic group

robotic group performed better as depth increased

Microsurgery Clarke et al 2018

Rat vessel aorta

N = 6 (by each surgeon in each arm)

Conventional vs robotic

End-to-end anastomosis

14 microsurgeon with no robotic experience

14 robotic surgeons with no microsurgical experience

Manual Group: 17 min (microsurgeon) 44 min (robotic)

Robotic Group: 37.5 min (microsurgeon) 48.5 min (robotic surgeon)

Steeper learning curve with microsurgeon

Feasible skill acquisition exercise

Microsurgery Van Mulken et al 2018 Microsure

2 mm silicone vessels

N = 10 (each arm, and by each of the participants)

conventional vs robotic

End-to-end anastomosis 3 various level trainees

Anastomosis time manual vs robotic (12.5 vs 35.1 min)

Comparable rate of improvement between manual and robotic when assessed with Structured Assessment of Microsurgical Skills

Demonstrated steeper learning curve with the robotic group

Microsurgery Yang et al 2022 Da Vinci Trainer

VR exercise

N = 60

VR exercise

30 trainees with da Vinci training

30 trainees with Da Vinci training and microsurgery training

Microsurgery aided memory retention, with steeper learning curves and better skill level
Microsurgery Beier et al 2023 Symani Surgical System

Synthetic 1/2 mm vessels / Chicken

N = 10

End-to-end anastomosis Expert surgeons 4-week training programme in which 10 successful anastomosis was deemed to be sufficient for progression into clinical practice
Flap Louis et al 2017 Da Vinci Si

Porcine

N = 3

RAM harvest Expert surgeon

4 trocars used

80 min average operative time

16 cm average muscle length

Demonstrated learning curve reflected in reduced operating time

Abdominal wall Thomaier et al 2016 Da Vinci Trainer

Bench model

N = 20 laparoscopic box trainer

N = 20 robotic simulation

Peg transfer tasks Novices

Assessment through OSATS, Global Operative Assessment of Laparoscopic Skills (GOALS) and Global Evaluative Assessment of Robotic Skills (GEARS

Skill acquisition and retention following time

No differences between groups after first training session. Robotic training group demonstrated higher economy of motion, and fewer errors in comparison to laparoscopic, with no significant deterioration over time

Abdominal wall Orlando et al 2017 Da Vinci Trainer

Bench model

N = 20 laparoscopic

N = 20 robotic simulation

Peg transfer tasks Novices

Assessment through OSATS, GOALS, GEARS

Skill acquisition and retention following time

No differences between groups after first training session. Robotic training group demonstrated higher economy of motion, and fewer errors in comparison to laparoscopic, with no significant deterioration over time

Abdominal wall Jacob et al 2017 Da Vinci Xi

Porcine

N = 1

Extended total extraperitoneal dissection Expert surgeons Successful completion of abdominal wall dissection
Mastectomy Lee et al 2021 Da Vinci Si/Xi

Cadaveric/animal

N = 24

Nipple-sparing mastectomy

2 Plastic surgeons

13 breast surgeons

Subjective participant feedback indicated positive learning experience
TOR Bur et al 2017 Da Vinci

Synthetic

Porcine

N = 29

Posterior hemi glossectomy

20 surgical trainees

5 expert Surgeons

GEARS

Faster performance and better technical skill in more senior surgeons

Increase in scores and speed of operating over time

Good qualitative feedback from trainees as a teaching model

TOR Zhang et al 2017 Da Vinci Trainer

VR Simulator

N = 16

12 simulated exercises Novices

Article validates simulation training in robotic skills, with all novices achieving competency (benchmark 91%)

A longer gap between training resulted in a longer time to achieve competency

Clinical articles were subcategorised by subspeciality (Fig. 3). A total of 11 articles described robotic lymph node dissection [13, 4251]. A total of 21 articles described robotic pedicled or free flap harvest [5272]. A total of eight articles described robotic flap pedicle or vessel dissection [7380]. 16 articles detailed robotic free flap inset or anastomosis (vessel, nerve and lymphovascular) [34, 8195]. 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 [100102]. A total of 28 articles described ventral abdominal wall reconstruction and hernia repair [103130]. A total of 18 articles pertained to robotic mastectomy [56, 72, 131146]. Finally, a total of 43 articles described transoral robotic surgery (TOR) [81, 147188].

Fig. 3.

Fig. 3

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).

Table 3.

Lymph node dissection length of stay, complications, and rate of recurrence within the literature

Robotic vs conventional Control procedure Number Length of stay (days) Complications Complication rate Recurrence Recurrence rate
Robot Control Robot Control Robot Control Robot Control Robot Control Robot Control
Kim et al., [42] Endoscopic neck dissection 2 3
Tae et al., [43] Conventional 11 19 3 7 27.27% 36.9% 0 2 0.00% 10.53%
Kim et al., [42] Conventional 20 33 17 15.5 6 9 30.00% 27.27% 0 2 0.00% 6.06%
Singh et al., [49] Conventional inguinal dissection 51 100 0 0 0.00%
Paek et al., [50] Conventional neck dissection 28 117 4.5 4.1
Total Total Average Total Average complication rate Total Overall rate Overall rate
112 272 10.75 10.75 9 16 28.64% 32.10% 0 4 0.00% 7.69%
Un- paired single tail T test (5%) P = 0.46 P = 0.096 P = 0.281 P = 0.00* P = 0.008*
Robotic only Number Length of stay (Days) Complications Complication rate Recurrence Recurrence rate
Lira et al., [46] 6 5 4 66.67%
Lee et al., [13] 3 8 0
Du et al., [45] 1 6 0 0 0.00%
He et al., [48] 13 0 0 0.00%
Melly et al., [47] 1 3
Song et al., [51] 4 1 25.00% 0 0.00%
Total Average Total Average complication rate Total Overall rate
28 5.50 1 25.00% 4 16.67%
Overall
Number of patients Average length of stay (Days) Complications Average complication rate Recurrence (total N) Recurrence rate %
Robot Control Robot Control Robot Control Robot Control Robot Control Robot Control
140 272 7.25 9.80 10 16 27.42% 31.10% 4 4 3.77% 7.69%

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).

Table 4.

Peri-operative outcomes of robotic and robotic-assisted pedicled and free flap harvest (RFFF radial forearm free flap, RAM rectus abdominis muscle, LD latissimus dorsi)

Robotic vs conventional Control procedure Number of patients Length of stay (days) Complications Complication rate Harvest time (min)
Robot Control Robot Control Robot Control Robot Control Robot Control
Shin et al., [71]. (RFFF) Conventional 11 11 0 1 0.00% 9.09% 107.2 67
Davila et al., [68] (RAM) Conventional 16 20 10.2 11.2 5 11 31.25% 55.00%
Winocour et al., [63] (LD) Conventional 25 27 2 3 4 1 16.00% 3.00%
Houvenaegel et al., [58] (LD) Conventional 46 59 4.3 3.86 14 34 30.43% 57.60%
Clemens et al., [53] (LD) Conventional 12 64 2.7 3.4 2 24 16.67% 37.50% 92 58
Eo et al., [70] (LD) Endoscopic/Conventional 20 37 10.2 10.8 5 9 25.00% 24.32% 75.9 35.5
Total Average Total Average Complication Rate Average Harvest Time
130 218 5.88 6.45 30 80 19.89% 36.70% 91.7 53.50
Un- paired single tail T test P = 0.415 P = 0.088 P = 0.061 P = 0.057
Robotic Only Number of patients Length of stay Complications Complication rate Harvest time
Robot Robot Robot Robot Robot
Ozkan et al., [57] (Omental) 1 12 0 0.00% 60
Pederson et al., 2014 (RAM) 10 1 10.00% 60
Day et al., [65] (Omental) 1 0 0.00%
Lai et al., [72] (LD) 1 0 0.00%
Moon et al., [62] (LD) 21 7 4 19.05% 58
Cheon et al., [67] (LD) 41 9 17 41.46% 70
Chung et al., [155] (LD) 12 0 0.00% 85.8
Hwang et al., [69] (LD) 3 0 0.00% 59
Fouarge et al., [59] (LD) 6 5 0 0.00% 110
Joo et al., [66] (LD) 1 6 0 0.00% 100
Haverland et al., [61] (RAM) 6 1 16.67%
Asaad et al., [64] (RAM) 7 7 1 14.29%
Frey et al., [60] (Omental) 5 5.2 2 40.00%
Total Average Total Average complication rate Average harvest time
115 7.31 26 10.88% 75.35
Overall
Number of patients Average length of stay Total complications Average complication rate Average harvest time
Robot Control Robot Control Robot Control Robot Control Robot Control
245 218 6.72 6.45 56 80 13.73% 36.70% 79.81 53.50

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.

Table 5.

Peri-operative outcomes of robotic pedicle dissection and microsurgery. (DIEP deep inferior epigastric perforator)

Flap Pedicle Dissection
Robotic Only Number of patients Length of stay (days) Complications Complication rate Procedure time (mins) Docking time (mins) Harvest time (mins) Console time (mins)
Zanaty et al., [80] (Thoracic artery) 1
Gundlapalli et al., [73] (DIEP) 1 0 0.0% 480 20 40
Dayaratna et al., [77] (DIEP) 1 0 0.0% 680 16 92 92
Bishop et al., [75] (DIEP) 21 3.8 5 23.8% 425.3 44.8 44.8
Daar et al., [75] (DIEP) 4 3.7 2 50.0% 717.6
Wittesaele et al., [78] (DIEP) 10 4.5 1 10.0% 479 27.5 86 86
Tsai et al., [79] (DIEP) 13 1 7.7% 15 53 53
Choi et al., [74] (DIEP) 17 487 65 65
Total Average Total Average complication rate Average Average Average Average
68 4 9 15.3% 545 20 63 68
Flap inset/microsurgical anastomosis
Robotic Only Number of patients Length of stay Complications Complication rate Procedure time (mins) Inset time (mins) Anastomosis time (mins) Console time (mins)
Hans et al., [81] (RFFF inset) 1 14 0 0% 310 35 75
Song et al., [82] (RFF inset/anastomosis) 5 0 0% 591 150
Lai et al., [83] (RFF inset, venous anastomosis) 5 0 0.0% 142 31 40
Miyamato et al., [84] (Nerve) 6 0 0.0%
Chang et al., [88] (Nerve graft) 1 4 0 0.0%
Lindenblatt et al., [90] (LVA/arterial anastomosis) 5
Beier et al., [34] (arterial anastomosis) 23 6 18.75% 69 69
Besmens et al., [92] (arterial anastomosis) 6 33 33
Chen et al., [93] (nerve anastomosis) 23 3.2 2 13.0% 510
Innocenti et al., [94] (arterial/venous anastomosis) 1 0 0.0% 22 22
Weinzierl et al., [95] (LVA) 8 0 0% 22.6 22.6
Total Average Total Average complication rate Average Average Average Average
76 7.07 8 3.5% 388 33 63 50
Flap inset/microsurgical anastomosis
Robotic Vs Conventional Control Number of patients Length of stay Complications Complication rate Procedure time (mins) Inset time (mins) Anastomosis time (mins) Console time (mins)
Robot Control Robot Control Robot Control Robot Control Robot Control Robot Control Robot Control
Tsai et al., [85] (RFF inset, secondary venous anastomosis) Conventional 14 33 2 1 15.4% 3.03%
Lai et al., [86] (arterial/venous anastomosis) Conventional 15 26 1 0 6.67% 38 28 38 28
Van Mulken et al., [87] (LVA) Conventional 20 12 0 0 0% 115 81 25 9
Barbon et al., [89] (arterial/venous/nerve/lymph anastomosis) Conventional 22 11 25.3 14.1
Van mulken et al., [91] (LVA) Conventional 20 12
Total Total Total Average Complication Rate Average Average Average
91 94 0 3 1 3.3% 3.03% 115 81.0 32 18.5 32 21.1
Overall (anastomosis/inset)
Total number of patients Average length of stay (days) Total complications Average complication rate Average procedure time Average inset time Average anastomosis time Average console time
Robot Control Robot Control Robot Control Robot Control Robot Control Robot Control Robot Control Robot Control
167 94 7.07 11 1 3.40% 3.03% 409.01 81.00 33.00 49.95 18.50 37.56 28.00

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).

Table 6.

Peri-operative outcomes in robotic nipple-sparing mastectomy

Robotic vs Conventional Control procedure Number Length of stay (days) Complications Complication rate Procedure time (resection alone) Procedure time + implant Recurrence Recurrence rate
Robot Control Robot Control Robot Control Robot Control Robot Control Robot Control Robot Control Robot Control
Toesca et al., [144] Conventional 40 40 2.3 2.4 12 20 30.0% 50% 108 60 138 216
Moon et al., [146] Conventional 40 41 9.2 7.1 6 11 15.0% 26.83% 279 207
Lai et al., [143] Conventional 54 62 7 5 29 38 53.7% 61.29% 224 197 0 5 0.00% 8.06%
Park et al., [145] Conventional 167 334 47 132 28.1% 39.5 0 2 0.00% 0.60%
Total Average Total Average complication rate Average Average Total Overall rate
301 477 6.17 4.83 94 208 31.7% 44.41% 108 60.0 214 206.7 0 7.0 0.0% 1.8%
Un-paired single tale T test P = 0.307 P = 0.198 P = 0.144 P = 0.437 P = 0.072 P = 0.183
Robotics only Number Length of stay (days) Complications Complication rate Procedure time Procedure time + implant Recurrence Recurrence rate
Robot Robot Robot Robot Robot Robot Robot Robot
Kuo et al., [140] - 3 10 94 0 0.00%
Sarfati et al., [131] 1 5 0 0.0% 150 0 0.00%
Lai et al., [134] - 2 1 50.0% 0 0.00%
Toesca et al., [132] 3 2 0 0.0% 285
Rajappa et al., [136] - 1 2 0 0.0% 330
Houvenaeghal et al., [56] 44 3 26 59.1% 154
Houvenaeghal et al., [139] - 80 4 46 57.5% 305
Park et al., [135] 1 0 0.0% 409 0 0.00%
Lai et al., [142] - 39 6.7 12 30.8% 257
Sarfati et al., [137] 33 0 0.0% 85
Toesca et al., [132] - 29 2 0 0.0% 180
Lai et al., [141] 22 0 0.0% 192
Lai et al., [72] - 15 6.7 3 20.0% 282
Sarfati et al., [137] 1
Total Total Total Average Complication Rate Average Average Total Overall Rate
274 41.4 88 18.1% 241 220 0 0.0%
Overall
Number Average length of stay Total complications Average complication rate Average procedure time Average procedure time + implant Total recurrence Recurrence rate
Robot Control Robot Control Robot Control Robot Control Robot Control Robot Control Robot Control Robot Control
575 477 4.99 4.83 182 208 21.5% 44.41% 214 60 214 206.7 7 0.0% 1.8%

Fig. 4.

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).

Table 7.

Peri-operative outcomes reported in abdominal wall reconstruction. (TAR transversus abdominis release)

Robotic vs Laparoscopic Hernia Repair Control Procedure Number of Patients Length of Stay (Days) Complications Complication Rate Operative Time (mins)
Robot Control Robot Control Robot Control Robot Control Robot Control
Costa et al., [122] Laparoscopic 18 19 3.67 3.95 3 2 16.67% 10.53% 355.6 293.5
Chen et al., [103] Laparoscopic 39 33 0.49 0.21 3 3 7.69% 9.09% 156 65
Petro et al., [118] Laparoscopic 39 36 0.5 1 4 4 10.26% 11.11% 146 94
Olavarria et al., [116] Laparoscopic 65 59 0 0 14 11 21.54% 18.64% 141 77
Walker et al., [113] Laparoscopic 142 75 1.4 0.7 37 43 26.06% 57.33% 116.9 98.7
Warren et al., [109] Laparoscopic 53 103 1 2 36 37 67.92% 35.92% 245 122
Kakela et a, [123] Laparoscopic 19 19 0.9 0.6 0.00% 0.00% 135 43.6
Prabhu et al., [107] Laparoscopic 177 450 0 1 14 84 7.91% 18.67% N = 47 < 2 h) N = 31 > 2 h
Total Average Total Average Complication Rate Average
552 794 0.995 1.18 111 184 19.76% 20.16% 185 113
Un-paired single tail T test P = 0.382 P = 0.216 P = 0.484 P = 0.069
Robotic vs Open Control procedure Number Length of stay (days) Complications Complication rate Operative time (mins)
Robot Control Robot Control Robot Control Robot Control Robot Control
Martin-Del-Campo et al., [111] (TAR) Open 38 76 1.3 6 0 13 0.00% 17.11% 299 211
Pereira et al., [126] Open 665 665 1 3 79 123 11.88% 18.50%
Bittner et al., [104] (TAR) Open 26 76 3 6 5 34 19.23% 44.74% 365 287
Carbonell et al., [110] Open 111 222 2 3 47 61 42.34% 27.48% 45% > 240
Total Average Total Average complication rate Average
840 1039 1.83 4.50 131 231 18.36% 26.95% 332 249
Un-paired single tail T test P = 0.017* P = 0.220 P = 0.231 P = 0.120
Robotics only Number of patients Length of stay (days) Complications Complication rate Operative time (min)
Robot Robot Robot Robot Robot
Wang et al., [108] 1 4 0 0.00%
Jamshidian et al., [106] 3 1 0 0.00% 88
Kudsi et al., [114] (TAR) 1 1 0 0.00% 302
Muysoms et al., [112] 41 114
Shimada et al., [127] 1 5 0 0.00% 253
Lima et al., [129] 1 0 0.00%
Bergholz et al., [119] 1 1 0 0.00%
Gonzalez et al., [105] 368 1 44 11.96% 102.1
Total Average Total Average Complication Rate Average
417 2.17 44 1.71% 172
Overall
Total number of patients Average length of stay (days) Total complications Average complication rate Average operative time (mins)
Robot Control Robot Control Robot Control Robot Control Robot Control
1809 1833 1.57 2.29 286 415 12.81% 22.43% 201 144

Fig. 5.

Fig. 5

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

Fig. 6.

Fig. 6

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.

Table 8.

Peri-operative outcomes reported for transoral robotic surgery (TOR) (DFS; disease-free survival)

Robotic Vs Conventional Control procedure Number of patients Length of stay (Days) Complications Complication rate DFS
Robot Control Robot Control Robot Control Robot Control Robot Control
Li et al., [178] Open 2224 6697 4.3 5.1
Chung et al., [54] (anterior partial glossectomy) Open 68 3915 4.8 4 0 131 0.0% 3.3%
Chung et al., [54] (posterior pharyngectomy) Open 641 1426 3.7 5.2 21 71 3.3% 5.0%
Chung et al., [54] (posterior partial glossectomy) Open 147 747 3.54 5.06 14 37 9.5% 5.0%
Sano et al., [185] Open 68 236
Ford et al., [157] Open 65 65 89% 73%
White et al., [154] Open 64 64 3.8 8 26 55 40.6% 85.9% 74% 43%
Lee et al., [151] Open 27 30 14.6 24.6 95.70% 91.60%
Hammoudi et al., [158] Open 26 26 11 19 1 2
Total Average Total Average complication rate Average rate of DFS
3330 13,206 6.53 10.14 62 296 13.36% 24.80% 86.2% 69.2%
Un-paired, single tail T test (5%) 0.164 0.033* 0.314 0.126
Robotic Vs Radiotherapy Control procedure Number of patients Length of stay (days) Complications Complication rate DFS
Robot Control Robot Control Robot Control Robot Control Robot Control
Mahmoud et al., [173] Radiotherapy 559 1314
Nichols et al., [181] Radiotherapy 34 34 94 74 276.5% 217.6%
Smith et al., [165] CRT 42 38 94% 85%
Nichols et al., [187] Radiotherapy 34 34 88.20%
Total Total Average Complication Rate Average DFS Rate
669 1420 94 74 276.47% 217.65% 91.1% 85%
Robotic Only Number Length of stay (days) Complications Complication rate DFS Recurrence Recurrence rate
Van Loon et al., [159] 18 4.2 2 11.1% 86% 2 11.1%
Mercante et al., [162] 13 7 4 30.8%
Sethia et al., [175] 111 9 8.1%
Chan et al., [147] 4 4.25 0 0.0%
Chia et al., [148] 2015 205 10.2%
Durmus et al., [149] 22 0 0.0%
Durmus et al., [150] 3
Hans et al., [81] 3 14 0 0.0% 0 0.0%
Patel et al., [152] 47 5 10.6%
Tsang et al., 2013 1 0 0.0%
Almeida et al., [160] 410 94.50% 43 10.5%
Dabas et al., [161] 60 4.15 3 5.0% 64%
Razafindranaly et al., [164] 84 37 44.0% 2 2.4%
Aubry et al., [166] 178 12.6 87 48.9%
Fujiwara et al., [167] 10 8 0 0.0% 1 10.0%
Graneli et al., [168] 1 3 0 0.0% 0 0.0%
Duek et al., [169] 1 3 0 0.0% 0 0.0%
Lallemant et al., [172] 23 12.7
Rubek et al., [174] 30 5.3 6 20.0%
Doazan et al., [177] 122 90.20% 14 11.5%
Scott-Wittenbom et al., [179] 6
Hardy et al., [180] 1 0 0.0% 0 0.0%
Petruzzi et al., [182] 1 0 0.0%
Holcomb et al., [183] 2 0 0.0% 1 50.0%
Kubik et al., [184] 23 1 4.3%
D’Andrea et al., [186] 53 21 39.6% 46.10%
Virgilio et al., [188] 139 71.30%
Durmus et al. [156] 22 0 0.0%
Frenkel et al., [170] 425 273 64.2%
Gorphe et al., [171] 27 8 29.6%
Mockelmann et al., [163] 41 8 9 22.0%
Allessandrini et al., [176] 16 6.13 0.0%
Total Average Total Average complication rate Average DFS Average recurrence Overall recurrence rate
3912 7.10 661 13.6% 75.35% 6.5 9.44%
Overall
Number of patients Length of stay Complications Average complication rate Average DFS rate Average recurrence Overall recurrence rate
Robot Control Robot Control Robot Control Robot Control Robot Control Robot Control Robot Control
7911 14,626 6.90 10.14 817 370 22.3% 63.37% 81.18% 73.15% 6.5 9.44%

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 [4244]. 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 [132134, 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 [132134, 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.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

Authors Contributions are detailed below Design: L.A, B.R, E.B, B.L, S.J, P.B, A.P Literature Search/Screening: L.A, B.R, E.B, B.L Data Collection : L.A, E.B, B.R Data Analysis: L.A, B.R Manuscript Writing : L.A, B.R, S.J, B.L, PB, AP Tables and Figures: S.J, B.L, B.R, LA Risk of Bias: E.B, L.A Editing : L.A, B.R, E.B, B.L, S.J, P.B, A.P All authors have reviewed the final submission.

Funding

There was no funding allocated for this research.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Conflict of interest

There are no conflicts of interest to declare.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

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Supplementary Materials

Data Availability Statement

No datasets were generated or analysed during the current study.


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