Real Robotic Surgery: A New Paradigm of Surgical Approach

Dear Editors,

Robotic surgery has introduced a fundamental conceptual shift that we refer to as Real Robotic Surgery. In daily practice, the true revolution of the robotic platform lies in the possibility of performing surgery entirely robotically, without any laparoscopic assistance. This approach highlights a profound difference in how robotic surgery is conceived, compared with laparoscopy or laparotomy.

In open and laparoscopic surgery, the operating team functions through several hands controlled by a single brain: the lead surgeon’s. In this traditional configuration, the execution of the technical gesture is unavoidably influenced by the skill level and interpretation of the assistant(s). Even when the assistant is highly experienced, the positioning and movement of retracting hands or instruments inevitably reflect the assistant’s perception of what should be done, not the precise intention of the lead surgeon at that exact moment.

In laparoscopy, this paradox of coordination is amplified, since even the camera is held by another operator. Consequently, the surgeon’s field of view is dependent on what the assistant thinks the surgeon wants to see. A significant portion of the surgeon’s intraoperative communication is therefore devoted to instructing the assistant on what to do and how to do it. This is true for junior assistants, but also for senior assistants and long-standing surgical duos who, despite their experience together, remain limited by the intrinsic constraints of shared manual control.

We might compare this to driving a car where one person holds the steering wheel, another controls the brake, and a third manages the accelerator and all are expected to follow the intentions of the “lead driver.” An absurdity, yet this is essentially the coordination model we still rely on in laparoscopy. As with the fulcrum effect, the fact that surgeons have learned to adapt to these constraints does not make them natural or optimal, especially when such constraints shape the surgery we perform for our patients.

Robotic surgery disrupts this paradigm completely. The surgical gesture is executed solely by the lead surgeon, who controls all instruments with the highest level of coordination in nonautomated surgery. However, this does not reduce the role of the assistant surgeons. On the contrary, the assistants, whether at a secondary console or bedside, can fully focus on observation, anticipation, decision-making, and meaningful guidance in an atmosphere of respect, listening and collaboration. Their contribution is no longer constrained by the need to manually maintain retraction or handle the camera according to the surgeon’s preferences.

The result is a surgical environment where multiple brains collaborate, while only one pair of hands controls the operative instruments. This eliminates the variability of skill levels or psychomotor coordination between two operators, and creates a uniquely coherent and stable execution of the surgical gesture. This, in our view, is the essence of Real Robotic Surgery and represents the true revolution brought by robotics.

A useful parallel can also be drawn from aviation. In modern flight operations, responsibilities are clearly divided between the Pilot Flying (PF) and the Pilot Monitoring (PM). At any given moment, only one pilot actively controls the aircraft, while the other focuses on monitoring, cross-checking, anticipating, and supporting decision-making. These roles are independent of seniority or rank and are routinely alternated during the flight. This model ensures clarity of control, minimizes ambiguity, and enhances safety through structured collaboration.¹

In our practice, we apply the Real Robotic Surgery concept to all digestive procedures, with the sole exception of the Whipple procedure, for which two laparoscopic ports are still required. This means that we perform fully robotic, no laparoscopic assisting port, surgery for esophageal, gastric, liver, colorectal, adrenal, and pancreatic body/tail procedures, for both oncologic and benign indications, as well as for bariatric and metabolic surgery.

To these profound conceptual advantages are naturally added the well-established benefits of robotic surgery: articulated instruments, exceptional visual stability, high-quality three-dimensional (3D) imaging and better ergonomy for the surgeon.^2–8

We believe that recognizing and formalizing the concept of Real Robotic Surgery is essential to understanding the transformative nature of robotic platforms and the evolution they bring to surgical practice.