Adoption and expansion of robotic surgery across General Surgery in the United Kingdom: a 10-year procedure-specific analysis (2015–2024)

Abstract

Robotic surgery (RS) has become an increasingly integral component of minimally invasive surgery (MIS) within General Surgery (GS) over the past 20 years. However, national-level data describing its adoption remain limited. This study provides the first procedure-specific analysis of RS utilization and growth trends of GS procedures within the United Kingdom (UK). Freedom of Information requests were submitted to 153 UK hospitals, requesting annual procedure specific data on six common robotically performed surgeries (colectomy, anterior resection/abdominoperineal resection [AR/APR], cholecystectomy, hernia repair, fundoplication, and gastrectomy) from 2015 to 2024. Stratified data by open, laparoscopic and robotic approaches were provided and analysed for trends using linear regression across centres that provided complete 10-year datasets. 70 trusts provided data totalling 1,054,576 procedures. Robotic utilisation increased markedly from 0.4% in 2015 to 7.0% in 2024 (12.8% of MIS). The largest proportional increases were observed in colectomies (+ 5,240%) and AR/APRs (+ 1,517%). Significant positive trends were detected for robotic approaches in 5 of 6 procedures. Open surgery demonstrated a significant trend (r =-0.77, P < 0.05), while laparoscopic approaches remained stable. Median institutional RS volume in 2024 was 84 cases (IQR 48–155), with wide inter-centre variability. RS within UK GS has expanded substantially, particularly in colorectal procedures, accelerating growth suggesting RS may soon become the dominant minimally invasive modality. Nonetheless, utilisation remains low in high-volume procedures such as cholecystectomy and hernia repair. Standardised data collection, formal training frameworks, and cost-effectiveness evaluation will be essential to support safe and equitable expansion of RS across the UK.

Background

During the turn of the 21st century laparoscopic surgery (LS) became the standard of care for the majority of General Surgery procedures [1]. In a similar manner to how LS progressively replaced open surgery, the past decade has witnessed a marked rise in the adoption of robotic surgery (RS), which now represents an increasing proportion of all minimally invasive surgeries (MIS). This trend has been well demonstrated by Sheetz et al., using large-scale data from the United States [2].

Robotic surgery has been suggested to have reduced wound infection rates, reduced length of stay, lower conversion rates and reduced mortality rates [3]. Within colorectal surgery, RS has demonstrated outcomes equivalent to or superior to those achieved with conventional laparoscopy [4]. Reported advantages also include improved oncological results and enhanced autonomic nerve preservation [5]. However, despite these potential benefits, widespread implementation within the United Kingdom (UK) has been limited, largely due to the substantial setup and maintenance costs associated with robotic platforms [6].

At present, no centralised database for RS exists within the United Kingdom (UK). Previous studies have identified a general increase in RS utilisation nationally. However, there are no contemporary analyses assessing current trends [7, 8]. Moreover, existing research has typically focused on either specific subspecialties or limited procedure types which restrict broader interpretation. To the authors’ knowledge there has been no procedure specific analysis for General Surgery (GS) within the UK. Similarly no prior studies have attempted to quantify the temporal trends of different approaches on a national level with the inclusion of RS.

Our primary aim was to provide the first up-to-date evaluation of RS utilisation across common general surgical procedures in the UK and to identify temporal trends in adoption. Secondary aims were to assess the impact of RS uptake on volumes of open and laparoscopic surgery, and to examine variations in centre-level activity.

Methods

We submitted online Freedom of Information (FOI) requests to all 153 secondary care NHS trusts providing surgical services in England, Scotland, Wales and Northern Ireland [9–12]. Under the Freedom of Information Act (2000), the public may request information from public bodies, which should respond within 20 working days [13]. Requests were distributed during the last week of January, with regular interval follow ups and data collection concluded on 03/09/2025, allowing a minimum response period of 150 working days.

Procedures were selected by consensus among the three authors (ND, JS, GP) based on their likelihood of being performed robotically, while ensuring compliance with Sect. 12 of the Freedom of Information (FOI) Act, which limits requests where the cost of compliance exceeds the statutory threshold (18 hours of work) [14]. Six procedures were included: colectomy, anterior resection/abdominoperineal resection (AR/APR), cholecystectomy, hernia repair, fundoplication, and gastrectomy. These were chosen to maximise capture of robotic activity within general surgery.

For each procedure, trusts were asked to provide the number performed using open, laparoscopic, and robotic approaches.

Where exact figures could not be disclosed due to confidentiality exemptions (typically when numbers were very low), average values were recorded to one significant figure; for example, entries of “<5” were recorded as “3.” Trusts which were unable to provide data under Sect. 12 are not obliged to provide an exact reason why cost of compliance was exceeded, therefore the number of unique procedures were limited to six in order to minimise Sect. 12 breaches.

Ethical statement

Ethical approval was not required for this study, as all data were obtained from publicly accessible sources under the Freedom of Information Act (2000). This Act grants the public the right to access information held by UK public authorities, including NHS trusts. All responding trusts provided anonymised aggregate data in accordance with the UK Data Protection Act (2018) and UK General Data Protection Regulation (GDPR), which prohibit the disclosure of identifiable third-party information. The responsibility for releasing surgical data under Freedom of Information requests rests with the individual trust. Identifiable data are exempt from disclosure under Sect. 40 of the Freedom of Information Act [15].

Statistical analysis

We compiled our data on Microsoft Excel^® and statistical analysis was conducted using the R version 3.6.3 and the package ggplot 2 [16, 17]. Trend analysis was conducted using the Spearman’s rank correlation coefficient and Pearson correlation coefficient and significance was determined to be a P value of < 0.05.

Results

149/153 trusts were able to reply to the FOI request. 100 stated they performed RS and procedural data was provided by 70 of these, encompassing 1,054,576 operations over the 10-year study period. Across all six included procedures, the number of robotic cases increased substantially. Overall, robotic procedures accounted for 7.0% of all operations in 2024, compared with 0.4% in 2015. As a proportion of minimally invasive surgery (MIS), robotic approaches rose from 0.8% to 12.8%, while MIS overall increased from 48.7% to 55.4%.

The greatest relative increases for RS were observed for colectomies (+ 5,240%), followed by cholecystectomies (+ 4,857%), hernia repairs (+ 3,070%), anterior resection/abdominoperineal resection (AR/APR; +1,517%), fundoplications (+ 812%), and gastrectomies (+ 453%). AR/APRs were the most frequently performed robotic procedure throughout the study period, accounting for 33% of all RS operations overall over the 10-year period and 27% in 2024 alone.

We also found in 2024, AR/APRs demonstrated the highest utilisation of a robotic approach, comprising 30% of the total number of AR/APRs and 47% of all minimally invasive AR/APRs. Colectomies and gastrectomies followed, with robotic approaches representing 16% of each procedure’s total volume. When limited to minimally invasive cases, robotic approaches accounted for 27% of colectomies and 22% of gastrectomies.

Although robotic cholecystectomies and hernia repairs showed substantial absolute growth over the study period, their proportional uptake remained low relative to total case volumes − 5% and 2% of total operations respectively, and 6% and 10% when restricted to minimally invasive procedures. Full data is shown in Table 1.

Table 1.

Number of each procedure by approach

Procedure		2015	2016	2017	2018	2019	2020	2021	2022	2023	2024
Colectomy	Open	6701	6693	6798	6959	6717	6318	6823	6572	6657	6187
	Lap	4001	4350	4794	5508	5862	5205	6563	6541	6295	5918
	Robot	42	43	64	99	130	206	420	873	1529	2243
AP/AR	Open	3246	3352	3264	3188	3230	3128	3175	3069	3083	2839
	Lap	1983	2264	2641	2842	2946	2603	3642	3467	3245	2637
	Robot	148	148	186	315	389	396	739	1189	1825	2325
Cholecystectomy	Open	4505	4693	4963	5088	4855	4518	4624	5251	5671	5690
	Lap	29,853	30,706	31,515	31,003	31,385	23,056	27,449	30,525	33,374	35,097
	Robot	42	40	83	73	50	83	150	691	1064	2082
Hernia repair	Open	35,376	35,047	36,083	35,226	34,670	20,907	24,428	30,844	35,070	36,415
	Lap	10,006	10,244	11,356	10,735	10,533	6357	7009	8162	9249	10,340
	Robot	37	39	73	69	104	80	116	318	538	1173
Fundoplication	Open	1749	1661	1618	1491	1574	890	979	1132	1621	1462
	Lap	2843	2806	2791	2680	2609	1374	1536	1708	2110	2236
	Robot	24	21	15	12	30	22	43	140	201	219
Gastrectomy	Open	984	1023	992	921	856	700	699	886	935	944
	Lap	825	1101	1314	1237	1306	727	955	1286	1684	1770
	Robot	91	102	84	98	136	216	276	333	401	504
Total	Open	52,561	52,469	53,718	52,873	51,902	36,461	40,728	47,754	53,037	53,537
	Lap	49,511	51,471	54,411	54,005	54,641	39,322	47,154	51,689	55,957	57,998
	Robot	384	393	505	666	839	1003	1744	3544	5558	8546

Trend analysis was conducted in 55 trusts that provided complete data over the 10-year study period, encompassing 953,950 procedures (90% of the total dataset). Detailed information on included cases and corresponding trend outcomes is presented in Table 2.

Table 2.

Overall numbers included in trend analysis, trends with corresponding P values

Procedure		2015	2016	2017	2018	2019	2020	2021	2022	2023	2024	Spearman’s	P Value
Colectomy	Open	6701	6635	6478	6447	6265	5608	5765	5476	5516	5034	−0.98	P < 0.001
	Lap	3855	4234	4316	4656	4907	4048	5177	5077	4852	4553	+0.58	P = 0.93
	Robot	42	43	64	94	112	161	313	689	1234	1931	+1	P <0.001
AP/AR	Open	3246	3323	3114	2896	2900	2720	2692	2594	2508	2104	−0.98	P <0.001
	Lap	1974	2228	2365	2455	2534	1973	2673	2565	2260	1846	+0.04	P = 0.45
	Robot	148	148	186	285	339	350	620	937	1530	1960	+1	P <0.001
Cholecystectomy	Open	4505	4678	4431	4439	4016	3015	3049	3144	3324	3354	−0.73	P <0.05
	Lap	29,206	29,921	29,843	29,265	29,376	20,542	23,928	26,085	28,939	30,126	−0.2	P = 0.63
	Robot	42	40	83	69	49	53	118	607	813	1719	+0.88	P < 0.01
Hernia repair	Open	35,376	34,692	34,882	33,736	32,933	18,733	21,980	27,457	30,989	31,636	−0.75	P <0.05
	Lap	9859	10,037	10,358	9604	9325	5463	6287	7345	8295	9215	−0.71	P <0.05
	Robot	37	39	67	56	83	71	102	291	469	984	+0.98	P < 0.01
Fundoplication	Open	1749	1661	1587	1440	1524	824	894	1009	1473	1316	−0.70	P <0.05
	Lap	2810	2767	2701	2589	2480	1298	1388	1536	1901	2003	−0.76	P <0.05
	Robot	24	21	15	12	30	22	34	112	168	191	+0.81	P < 0.01
Gastrectomy	Open	984	1023	951	872	771	615	561	739	752	782	−0.70	P <0.05
	Lap	813	1066	1248	1196	1261	642	759	1049	1217	1266	+0.22	P = 0.56
	Robot	253	261	242	262	238	243	287	300	241	346	+0.32	P = 0.37

Across all procedures in the included centres, an overall negative trend was observed (–0.65 P = 0.05), which approached but did not reach statistical significance based on the study’s predefined threshold of P < 0.05. Robotic case volumes, however, increased substantially, with an average annual growth of 32%. This growth accelerated markedly over the final four years of observation, reaching an average annual increase of 69%.

When analysed by procedure, significant positive trends were observed for colectomies (+ 0.72, P < 0.05) and AR/APRs (+ 0.70, P < 0.05). In contrast, hernia repairs (–0.72, P < 0.05) and fundoplications (–0.77, P < 0.05) demonstrated significant negative trends. No significant trends were identified for cholecystectomies (–0.26, P = 0.48) or gastrectomies (–0.10, P = 0.98). These results are illustrated in Figs. 1a and b and 2a-c.

Fig. 1.

(a, b) Percentages of open, laparoscopic and robotic approaches for AR/APRs and colectomies

Fig. 2.

(a-c)Percentages of open, laparoscopic and robotic approaches for cholecystectomy, fundoplication and gastrectomy

Overall, we found open approaches demonstrated a significant negative trend (–0.77, P < 0.05), laparoscopic approaches showed a non-significant negative trend (–0.50, P = 0.15), while robotic approaches demonstrated a strong positive trend (+ 1.0, P < 0.001). Overall MIS trends were not significant (+ 0.18 P = 0.71).

When we excluded hernia repairs, which are frequently performed via open surgery, this strengthened the negative trend for open procedures (–0.87, P < 0.01). Laparoscopic approaches showed a smaller, non-significant negative trend (–0.35, P = 0.34), while the positive trend for robotic procedures remained unchanged. MIS remained positive but not significant (+ 0.26 P = 0.48).

In 2015 open procedures accounted for 52% of all procedures (30% when hernia repairs were excluded). By 2024, this proportion had decreased to 44% overall (21% excluding hernias). Laparoscopic surgery remained stable across the study period. In contrast RS increased from 0.5% to 7% of all procedures, and from 0.9% to 11% when hernias were excluded. These trends are illustrated in Fig. 3.

Fig. 3.

Percentage of surgical approach over time both with and excluding hernia repairs

Subgroup analysis

Colorectal surgery

We found the greatest relative rise in robotic utilisation was observed in AR/APRs and colectomies. In 2015 robotic approaches were employed in 2.8% and 0.4% of these procedures respectively, by 2024 this had risen to 29.8% and 15.6%. In 2024, the distribution of approaches for AR/APRs was 36.4% open, 33.8% laparoscopic, and 29.8% robotic while for colectomies the respective proportions were 43.1%, 41.2%, and 15.6%.

RS growth in colorectal pelvic surgery (APR/AR) averaged 31% per year, accelerating to 55% annually in the last four years. Based on current trajectories, we estimate robotic approaches to surpass open and laparoscopic techniques to become the predominant modality for AR/APRs within the next few years.

Similarly, for colectomies, robotic approaches demonstrated an average annual growth rate of 52%, which accelerated to 88% per year in the last four years. If current trends persist, we project robotic colectomies to surpass both laparoscopic and open approaches within the next 3–5 years to become the predominant technique.

Upper Gastrointestinal (UGI)

Robotic gastrectomies have demonstrated modest growth, averaging 3.5% per year, whereas laparoscopic gastrectomies increased by 5.1% annually over the same period. Robotic gastrectomies accounted for 15.7% of all gastrectomies in 2024. Fundoplications experienced more substantial growth, with robotic cases increasing 26% per year, accelerating to 87% annually over the last four years. However, by 2024, robotic approaches still account for only 5.6% of all fundoplications and 8.9% of minimally invasive approaches.

Cholecystectomies exhibited the highest proportional growth in RS of all six procedures, with robotic cases increasing 53% per year, accelerating to 171% over the past four years. Despite this rapid growth robotic cholecystectomy remains the least-utilised approach, behind both open and laparoscopic, representing 4.9% of all operations and 5.6% of minimally invasive procedures, well below the laparoscopic approach, which accounts for 81.9% of cases and open at 13.3%.

Centre volumes

We were able to calculate centre level RS volumes for 70 trusts. Median GS procedure volumes in 2024 was 1629 (IQR 1122–2358). We found annual RS case volumes ranged from 3 to 721, with a median of 84 (IQR 48–155). We stratified centres into low (< 100 cases), medium (100–200), high (200–300), and very high (> 300) robotic volume groups. We found the majority of centres were low volume (53%), followed by medium volume (36%), while high and very high volume centres each comprised 6%. The largest proportion of robotic operations were performed in medium volume centres (42%), followed by very high volume (25%), then low volume (22%) and lastly high volume (11%).

On linear regression, a weak but statistically significant relationship was observed between total centre volume and robotic case volume (R² = 0.07, P < 0.05). A similar weak association was seen between laparoscopic and robotic volumes (R² = 0.08, P < 0.05).

When we analysed only colorectal procedures (colectomies and AP/APRs) we found a slightly stronger trend between overall and robotic procedure volumes (R² = 0.10, P < 0.01), but no trend between laparoscopic and robotic (R² = 0, P = 0.93).

Discussion

Our project provides the most up to date evaluation of RS within General Surgery in the UK. It is the first to break down and provide procedure specific analysis and to identify trends over the past decade. Similarly, it is the first to attempt to examine the impact of RS upon both conventional laparoscopic and open approaches on a national level within the UK. We found RS increased dramatically over the past decade, and whilst there were increases in all six procedures, with significant trends in five, the greatest growth concentrated within the colorectal subspeciality.

Growth rates have particularly accelerated within the past four years. In colorectal surgery, centres performing robotic procedures are projected to conduct the majority of cases robotically within the coming years. However, whilst there has been robotic growth in the UGI subspeciality and hernia repairs, RS still accounts for only a small proportion of total operations.

We observed a significant negative trend in open approaches, however no significant trend in laparoscopic or overall MIS, though we did note a higher proportion of operations being performed with MIS. Importantly, the procedures showing the greatest RS growth, colectomy and AR/APRs, also demonstrated increases in total case numbers, suggesting RS expansion may be associated with procedural volume growth.

Our institutional analysis demonstrated wide variation in robotic utilisation, with most centres performing fewer than 100 cases annually and only a small minority exceeding 300. Weak but significant correlations between total and robotic volumes indicate uneven adoption across trusts. Further investigation into the factors driving this variability is warranted to inform strategies for optimising RS deployment and access across the UK.

Although determining the underlying causes of these trends was beyond the scope of this study, it is plausible that some procedures previously considered too complex for LS are now being performed robotically. Likewise, certain operations traditionally undertaken laparoscopically may have shifted toward robotic approaches.

Interestingly, in centres that provided complete data across all study years, we observed an overall negative trend in total GS procedure volumes. This likely reflects the impact of the COVID-19 pandemic and subsequent industrial action within the UK, both of which disrupted elective surgical activity. Procedural volumes have since shown recovery, with 2024 reaching 98% of the 2017 peak, following a decline to 64% in 2020. A less likely, though noteworthy, possibility is that oncological procedures have been prioritised and increasingly performed robotically, contributing to a relative reduction in lower-priority operations such as hernia repairs (92% of their 2017 peak) and fundoplications (77% of their 2015 peak).

Internationally, RS utilisation remains considerably higher. In the USA, the global leader in RS adoption, GS was the fastest-growing specialty for RS uptake between 2008 and 2018 [18]. Sheetz et al. reported that 15.1% of all GS procedures across 73 hospitals were robotic in 2018, compared with 7.0% in our UK dataset [2]. Similarly, an analysis of 119,191 cases, within the USA, from 2015 to 2019 found that by 2019, 8.07% of all cholecystectomies were performed robotically (versus 0.1% in the UK at that time, and 4.9% currently) [19]. Inguinal hernia repairs showed a similar pattern, with 10.6% performed robotically in the USA compared to 0.2% in the UK during the same period and 2.4% at present, though our study grouped all hernia types collectively.

The NHS has targeted 90% of all MIS to be performed robotically within the next decade [20]. This is an ambitious target within GS with RS currently at 12.8% of all MIS. This ambitious target would require large sustained periods of RS growth across high-volume GS operations, such as hernia repairs and cholecystectomies, and not just within operations for which typically RS is already well established such as AR/APRs.

However, widespread implementation of RS in procedures with limited evidence of benefit, such as cholecystectomy, poses practical and ethical challenges [21]. Furthermore, with the NHS under considerable pressure to reduce elective surgery waiting lists, the longer operative times often associated with RS may continue to hinder its broader adoption for routine operations [22].

Furthermore, the transition from open to laparoscopic surgery (LS) was initially associated with a short-term rise in complication and mortality rates, reflecting the recognised learning curve [23]. This challenge prompted the development of a national laparoscopic training programme [7]. However, no equivalent formal training framework currently exists for RS within GS higher specialty training [24]. This gap may have significant implications for future GS consultants, who may require additional RS training after completion of their formal programmes, potentially affecting service delivery within the UK. We therefore suggest that the introduction of a standardised national RS curriculum would be highly beneficial for GS trainees.

The NHS, which is publicly funded, accounts for 92% of all inpatient activity, with the remaining minority being in the private sector either self-funded or by healthcare insurance [25]. However as these private institutions are not covered under the same FOI act regulations we were unable to obtain data from these centres. Therefore our data was only from publicly funded institutions, and as these account for the vast majority of inpatient admissions we suggest their impact upon data would be limited. Similarly, we feel whilst further investigation into the private sector RS trends is required, trends within the NHS are of much more relevance to UK healthcare policy formulation and the wider patient cohort as the NHS is the route through which the vast majority access healthcare.

Currently, no standardised robotic surgery (RS) database exists within the UK, and procedural coding is managed independently by each NHS trust. To support national benchmarking and the establishment of performance standards, we recommend the development of a centralised RS register would facilitate consistent data collection and analysis in both the public and private sectors.

Further research should explore the underlying causes of the negative trends observed in open surgery and assess whether the expansion of RS is contributing to this shift. Additionally, procedure-specific analyses, such as comparing uptake between right and left colectomies, and evaluation of RS utilisation within emergency general surgery warrant further investigation.

Limitations

One limitation of this study concerns the reliability of coding and the accuracy of data supplied by individual trusts. Differences in how surgical approaches are coded across institutions mean there is no uniform system, introducing potential inconsistencies in documentation and data capture. In some instances, historical data were lost or incomplete due to system changes or trust mergers. As these events largely occurred during the early adoption phase of robotic surgery, when case numbers were low, their effect on overall findings is expected to be minimal. 10% of data was removed for trend analysis to increase robustness, however we anticipate the ratio of open/LS/RS to be similar and therefore limiting the effects of any trends. We were also limited in the number of procedures to be requested and therefore may miss capturing some GS procedure volumes. A further limitation of our study was that there were some centres that were unable to provide procedure specific data despite conducting robotic surgeries. This was due to cost compliances exceeding the threshold or trusts not storing data in a suitable way to allow requested information to be captured or retrieved. Similarly, we were unable to obtain data from the private sector as these do not fall within the regulatory framework of FOI requests. Whilst this would lead to an underreporting of total volumes we anticipate the trends and ratios of specific approaches to be similar across most centres and therefore their impact upon trend analysis to be minimised.

Conclusion

Over the past decade RS use has expanded markedly across common general surgery procedures, rising from 0.4% of all operations in 2015 to 7.0% in 2024. As a proportion of minimally invasive surgery (MIS), robotics increased from 0.8% to 12.8%, driving most of the overall MIS growth. The greatest uptake occurred in colorectal surgery, particularly anterior resection/abdominoperineal resection (AR/APR) and colectomy, where robotic approaches accounted for 30% and 16% of all cases, respectively.

Trend analysis showed a strong positive trajectory for robotic approaches (P < 0.001), contrasting with a significant decline in open surgery and stability in laparoscopy. Robotic case volumes increased by 32% annually on average, accelerating to 69% per year during the final four years. Based on current trends, robotic AR/APR and colectomy are projected to surpass laparoscopic and open approaches within the next three to five years in trusts performing robotic surgeries.

Our results have demonstrated robotic surgery has transitioned from a niche modality to a core component of minimally invasive practice, particularly in colorectal surgery. Continued monitoring of outcomes, cost-effectiveness, and access will be essential as adoption expands.

Author contributions

ND contributed to project conception and design. ND and GP contributed to methodology. ND conducted data collection, curation and formal analysis. ND, JS and GP contributed to original draft and review and editing. JS and GP contributed to project supervision.

Data availability

All data is available online via individual trusts Freedom of Information publically viewable web pages. Full data can be provided upon request.

Declarations

Competing interests

The authors declare no competing interests.