Perioperative management and challenges of robotic-assisted surgery: a narrative review

Abstract

Over the past two decades, robotic surgical technology has become increasingly widespread worldwide. RAS (robotic-assisted surgery) has attracted surgeons across various specialties with its advantages of high precision, a shorter learning curve, and reduced postoperative pain, while also imposing new requirements on the entire surgical team, including anesthesiologists. The physiological changes and unique complications associated with RAS have brought major challenges for anesthesiologists, who should respond rapidly to patient responses throughout the entire procedure.This review focuses on the potential issues encountered in the perioperative management of RAS, as well as the application of RAS across several specialties and the specific intraoperative management challenges involved.

Background

Surgical techniques have evolved at a remarkable pace. From the introduction of anesthesia and aseptic techniques in the 19th century, to the emergence of minimally invasive surgery at the end of the last century, and now to the progressive integration of medical technology and engineering science, these advancements have ultimately culminated in the development of robotic-assisted surgery (RAS). Over the past decade, with the widespread adoption of robotic systems, an increasing number of surgical specialties have begun to incorporate this technology, including urology, gynecology, cardiothoracic surgery, and general surgery. RAS offers a number of distinct advantages: it improves patient outcomes, reduces incision size, and provides enhanced precision, three-dimensional visualization, and greater dexterity during complex surgical procedures. Nevertheless, it also has certain limitations, including substantial costs, a large equipment footprint, and prolonged operative times. In addition, surgeons are required to invest considerable time in mastering the robotic platform, which poses new challenges for surgical training and education.

The first robot-assisted surgical procedure in medicine was performed in Belgium in 1997 using a platform known as “Mona,” which served as the predecessor to the da Vinci system [1]. More broadly, however, the first application of a robot in surgery dates back to 1985, when Kwoh used an industrial robot for a neurosurgical biopsy [2]. It was not until 2000 that the ‘da Vinci’ system received regulatory approval for general surgical use. In addition to the well-established da Vinci platform, Medtronic’s Hugo system has recently gained attention for its open console and modular design. The open console enhances the surgeon’s sense of freedom, improves situational awareness, facilitates communication within the surgical team, and optimizes ergonomics and comfort [3].

Currently, anesthesiologists are confronted with the challenge of making perioperative management for RAS safeness. This review introduced primarily, from the perspective of anesthesiologists, the perioperative management challenges of RAS technology, as well as its applications across different specialties and the associated unique complications. This review also summarized recent research in this field and might serve as a reference for clinicians and researchers (Table 1).

Table 1.

Comparison of selected existing robotic platforms [1, 4]

Platforms	Advantages	Disadvantages
Da Vinci (USA)	widespread adoption; image magnification, tremor filtration, and motion scaling; approved across multiple specialties	Long-standing market monopoly and extensive patents; high costs; absence of tactile feedback
Hugo (USA)	Tactile feedback; intelligent motion and collision avoidance; rapid setup and disassembly	Short duration of clinical use; small sample sizes in published studies
KangDuo (China)	Three-arm suspension configuration, facilitating triangulation during surgery	Longer docking and suturing times compared with da Vinci; currently limited scope of application
Versius (UK)	Open console allowing the surgeon to operate while seated or standing; tactile feedback available	Overall system footprint remains relatively large; relatively short period of clinical evidence accumulation
Hinotori (Japan)	Smaller footprint, suitable for smaller operating rooms; designed for patients of smaller body size	Limited clinical data in general surgery
Senhance (USA)	Tactile feedback available; infrared eye-tracking for camera control; open surgeon console; the first soft-tissue robot to receive FDA approval after da Vinci	Occupies substantial operating room space; requires polarized glasses

Introduction

The surgical robot itself does not possess the capacity to perform surgery independently. All operative maneuvers are executed by the surgeon, who is seated at a console positioned at a certain distance from the patient. The robotic arms replicate the surgeon’s movements to carry out the procedure. Meanwhile, the assistant surgeon stands beside the robotic arms, responsible for installing and exchanging the instruments required for the operation and for assisting with the adjustment of the arms. In the context of RAS, close coordination among the entire operating team is of particular importance (Fig. 1).

Fig. 1.

The perioperative care continuum for RAS

Key points of perioperative management for robotic surgery

It is well recognized that anesthesiologists face considerable challenges, arising not only from the surgical procedure itself, but also from specific measures required to facilitate the surgery (such as pneumoperitoneum and the extreme Trendelenburg position), as well as from particular patient populations and surgical types. Throughout the entire perioperative period of RAS, anesthesiologists are required to make corresponding adjustments based on the individual circumstances of each patient.

Preoperative assessment

A thorough preoperative assessment is essential to surgical safety, and this principle applies to all types of surgery. Before the operation, patients suitable for RAS should be carefully selected, and all necessary preparations—including preoperative examinations, patient optimization, and informed consent—should be completed to facilitate the smooth conduct of surgery. All patients scheduled to undergo RAS should be screened for a history of glaucoma, given the substantial impact of the extreme Trendelenburg position on intraocular pressure (IOP). Finally, patients should receive appropriate explanation and psychological reassurance to alleviate their fears regarding surgery.

In addition to routine assessment items, particular attention should be paid to the patient’s frailty status before surgery, which can be evaluated using the FRAIL scale. Furthermore, blood assessment warrants special emphasis. A study published in The Lancet identified anemia as a substantial surgical risk [5]. First, the proportion of patients with ASA grade I–II was lower among those with anemia (mild anemia 35.48%; moderate-to-severe anemia only 18.60%), indicating a greater anesthetic risk. Second, the rate of surgical site infection increased with the severity of anemia (no anemia 5.26%; mild anemia 11.44%; moderate-to-severe anemia 22.82%).

Baron and colleagues reached similar conclusions. The proportion of patients transferred to the ICU after surgery was markedly higher among those with preoperative anemia than among those with normal preoperative hemoglobin levels—only 5.4% in patients with normal hemoglobin, compared with 11.2% even in those with mild anemia and 25.6% in those with severe anemia [6]. Taken together, these findings indicate that patients with anemia face a relatively higher surgical risk and are likely to experience prolonged hospitalization. Accordingly, preoperative correction of anemia or consideration of an alternative surgical or anesthetic approach is warranted.

Before the operation begins, some articles recommend establishing two peripheral intravenous lines rather than placing a central venous catheter, although in clinical practice the choice of venous access should be tailored to the patient’s condition and the type of surgery. Routine use of elastic compression stockings is advised for thromboprophylaxis. Preoperative fasting should follow standard Enhanced Recovery After Surgery (ERAS) protocols [7].

Intraoperative management of robotic surgery

The choice of anesthetic regimen primarily involves volatile anesthesia and TIVA (total intravenous anesthesia), both of which can achieve satisfactory induction. Some studies suggest that nitrous oxide should be avoided during RAS when volatile anesthesia is used, as it may cause bowel distension [8].

Airway management shares similar considerations with other surgical procedures. An appropriate tidal volume (6–8 ml/kg) should be set, and the airway plateau pressure should be maintained at an appropriate level (≤ 30 cm H₂O). Adequate positive end-expiratory pressure (PEEP) can reduce atelectasis and improve respiratory mechanics [7]. In RAS, it is worth noting that the extreme positioning increases the likelihood of endotracheal tube (ETT) displacement. In addition to securing the tube properly, a prospective study found that three-point ETT cuff palpation (TPP) can effectively prevent ETT displacement and is simple to perform [9]. We consider this method worth trying in clinical practice, although further research is needed to establish its superiority before it can be widely adopted.

Intraoperative pain during RAS is generally mild. Remifentanil infusion can be used to minimize the responses to surgical stimuli [10]. In addition, techniques such as transversus abdominis plane (TAP) block may serve as adjunctive options for intraoperative analgesia, helping to reduce intraoperative opioid requirements.

Intraoperative monitoring for RAS is broadly similar to that for conventional surgery, including routine monitoring of blood pressure, oxygen saturation, ECG, partial pressure of carbon dioxide, bispectral index (BIS), and body temperature. Recently, monitoring of nociceptive stimuli has also become increasingly important. Notably, in RAS, patients require profound neuromuscular blockade, as even minimal movement can result in significant injury. Therefore, intraoperative monitoring of neuromuscular blockade is indispensable. Accordingly, studies have recommended the use of neuromuscular monitoring with continuous infusion of an appropriate muscle relaxant [10] (Table 2).

Table 2.

Perioperative risk factors for RAS

Factors	Mechanisms	Management recommendation
Age ≥ 65 years old	Reduced organ function; higher complication rate [11]	Comprehensive preoperative assessment and careful titration of anesthetics
Hypertension	Higher risk of surgical site infection (SSI); [12] hemodynamic instability	Preoperative blood pressure control; intraoperative invasive arterial pressure monitoring
Frailty	Higher postoperative mortality [13]; higher complication rate	Preoperative screening with FRAIL scale or Clinical Frailty Scale
Hypoalbuminemia	Higher risk of surgical site infection (SSI); delayed recovery	Preoperative albumin supplementation; treatment of underlying disease
History or family history of malignant hyperthermia	Triggered by inhaled anesthetics and succinylcholine	Use total intravenous anesthesia (TIVA), ensuring that dantrolene is readily available in advance

Intraoperative risks and challenges of robotic-assisted surgery

In RAS, anesthesiologists are confronted with challenges arising from multiple dimensions. To ensure smooth and safe emergence, anesthesiologists must recognize possible pathophysiological alterations and proactively implement preventive strategies or prompt management as needed.

Pneumoperitoneum and the extreme trendelenburg position

Both RAS and conventional laparoscopic surgery require the establishment of pneumoperitoneum with carbon dioxide. Currently, two approaches are mainly used: the traditional valved insufflation system and valve-less trocar insufflation, as exemplified by the AirSeal system. In addition to its effects on respiration, pneumoperitoneum also triggers catecholamine release, leading to an increase of systemic vascular resistance (SVR). This, in turn, raises myocardial workload and oxygen consumption, posing a particular risk for patients with impaired cardiac function [14].

In RAS, pneumoperitoneum may also induce cardiac arrhythmia. It is recommended that limiting intra-abdominal pressure to below 8–10 mmHg and insufflating carbon dioxide at a lower flow rate, which can effectively prevent pathophysiological changes during pneumoperitoneum. In clinical practice, however, these parameters should be adjusted on an individualized basis [15]. The most dangerous complication of pneumoperitoneum is air embolism. Once detected, the pneumoperitoneum should be released immediately, and gas aspiration should be attempted via the right internal jugular central vein; ECMO and hyperbaric oxygen therapy should be employed when necessary.

The effects of pneumoperitoneum on the hematologic system and the underlying mechanisms remain controversial. Some scholars hold that patients undergoing laparoscopic surgery should receive routine thromboprophylaxis [16]. On one hand, pneumoperitoneum compresses the veins and leads to venous stasis. On the other, it has been hypothesized that pneumoperitoneum may alter the structure of the subendothelial vessel wall, thereby activating the coagulation system, increasing endothelin synthesis, and consequently promoting vasospasm and deep vein thrombosis. Eva et al. [17] also found that higher pneumoperitoneum pressure (12 mmHg) elevated D-dimer levels (P = 0.004), whereas lower pneumoperitoneum pressure (8 mmHg) prolonged prothrombin time (PT) (P = 0.023). Anesthesiologists should be aware of both fronts to ensure patient safety during surgery.

The two insufflation systems differ slightly in their effects. A study conducted in Beijing, China [18] reported that the conventional insufflation system was associated with a higher incidence of subcutaneous emphysema, higher partial pressure of carbon dioxide at the end of surgery, and higher pain scores at discharge compared with the AirSeal system (p = 0.038, p < 0.001, p = 0.002). However, the hospitalization costs associated with the AirSeal system were significantly higher than those of the conventional system (p < 0.001).

The physiological changes induced by the extreme positioning and pneumoperitoneum can interact with each other. First, the Trendelenburg position can elevate central venous pressure, pulmonary artery pressure, and wedge pressure [14]. Therefore, for patients with severe pulmonary arterial hypertension (PAH) who require RAS, the decision should be made cautiously following Multidisciplinary Team (MDT) discussion. Second, the Trendelenburg position can, to some extent, increase venous return through the effects of gravity, which carries a risk of precipitating heart failure in patients with poor cardiac function. A study by Alvarez et al. found that in patients placed in the extreme Trendelenburg position, the tip of the endotracheal tube lies closer to the epiglottis [19]. Taken together, the extreme Trendelenburg position poses potential risks to patients; the duration of this positioning should therefore be minimized, and it should be avoided in high-risk patients.

Thrombotic risk

Postoperative deep vein thrombosis (DVT) is a common complication of RAS, with a reported incidence of approximately 0.5–0.8% in case reports [20]. However, some scholars have offered a different perspective on deep vein thrombosis. Satoshi Katayama and colleagues argued that the extreme Trendelenburg position has no adverse effect on postoperative complications [21]. Similarly, Junya reached comparable conclusions in a study based on robot-assisted total knee arthroplasty (RATKA); the incidence of DVT was 50.0% in the RATKA group and 39.5% in the manual total knee arthroplasty (mTKA) group, with no statistically significant difference (p = 0.23) [22]. Even so, the risk of DVT should never be underestimated in any surgical procedure. We consider DVT a potentially fatal complication; anesthesiologists should remain vigilant at all times, and the medical team should closely monitor the patient’s coagulation status before and after surgery and encourage in-bed mobilization.

Difficult patient access and intraoperative emergency management

Difficult patient access is a challenge unique to RAS relative to conventional minimally invasive surgery. Because the equipment required for RAS occupies a substantial footprint, the movement space available to medical staff is restricted, which further complicates the timely management of intraoperative emergencies. To address intraoperative crises appropriately, the core principle is closed-loop communication: the primary surgeon or anesthesiologist clearly announces the emergency, and the circulating nurse responds promptly and mobilizes resources without delay [23]. For high-risk patients, potential risks should be identified preoperatively, roles should be clearly assigned among all members of the surgical team, laparotomy instruments and vascular clamps should be prepared in advance, and adequate venous access should be secured. In cases of major intraoperative hemorrhage, direct compression should be applied first to achieve hemostasis. If initial hemostatic efforts fail, immediate resuscitation must be initiated, followed by emergent undocking of the robotic system, preparation for conversion to open surgery, activation of a massive transfusion protocol (MTP), and, when necessary, consultation with vascular surgery. Notably, the position of venous access should be planned in advance to ensure that the administration site remains relatively easy to reach [8].

Peripheral nerve injury

In both robotic and laparoscopic-assisted surgery, this is a rare complication that may nonetheless result in loss of function. It is primarily associated with the extreme Trendelenburg position and the prolonged operative times required for robotic procedures. In a case report by Devarajan and colleagues, 3 patients who underwent robotic-assisted laparoscopic prostatectomy (RALP) developed unilateral brachial plexopathy in their abducted arms [24]. A retrospective study by Mills et al. which analyzed 334 robotic urological procedures, identified a total of 22 cases of nerve palsy, 13 of which involved the upper extremities [25].

Perioperative visual loss and corneal abrasion

Perioperative visual loss (POVL) is relatively rare, with ischemic optic neuropathy (ION) being the most common cause. Studies report an incidence of ION of approximately 0.05%, with a higher rate in robotic abdominal and pelvic procedures [20].

Corneal abrasion is the most common ophthalmologic complication across all surgical procedures performed under general anesthesia, and routine protective measures such as eye patches should be applied intraoperatively. Because RAS generally involves longer operative times, perioperative visual loss (POVL) occurs more frequently in this context. Overall, POVL is most commonly reported in minimally invasive spine surgery, with the prone position and large-volume crystalloid infusion representing high-risk factors. Artificial tears or ocular protective devices may be used intraoperatively, and intraocular pressure should be monitored during prolonged procedures [26].

Rhabdomyolysis

Rhabdomyolysis is a rare but serious surgical complication, the mechanism of which can be summarized as acute renal failure resulting from the release of large amounts of creatine kinase. A study by Kazuna et al. found that rhabdomyolysis is more likely to occur during robot-assisted radical prostatectomy, primarily due to prolonged compression and ischemia of the muscles in the buttocks, lower back, and calves caused by the special positioning required for the procedure. They observed that an open-leg position helps reduce the incidence of rhabdomyolysis [27]. A study by Akifumi et al. found that rhabdomyolysis is closely associated with obesity and prolonged bed rest; therefore, the duration of bed rest should be shortened [28]. Taken together, these findings suggest that rhabdomyolysis may also occur in other RAS procedures in which well-developed muscle groups are subjected to compression and ischemia. Operative time should therefore be minimized whenever possible.

Pulmonary edema

Pulmonary complications mainly include atelectasis and pulmonary edema. Prolonged maintenance of the extreme Trendelenburg position, combined with the effects of pneumoperitoneum, leads to increased intra-abdominal pressure, decreased residual volume, and reduced lung compliance—physiological changes that increase the incidence of atelectasis [22, 29] The reported incidence of pulmonary edema varies considerably depending on the diagnostic criteria employed. Management is primarily symptomatic, with ECMO serving as a relatively important therapeutic option.

Unilateral pulmonary edema (UPE) is one of the serious complications of minimally invasive cardiac surgery. High-risk factors include preoperative pulmonary hypertension and prolonged cardiopulmonary bypass (CPB) duration exceeding 120 min.

To prevent its occurrence, Moss’s team proposed a modified approach [30]. First, vasoactive drugs should be discontinued 24–48 h before surgery. Second, once the intracardiac procedure is completed and the robot is withdrawn, bilateral lung ventilation should be initiated immediately, and pulmonary artery flow should be reestablished using the surplus venous reservoir volume, continuing until rewarming is complete and CPB is fully discontinued. Third, active cooling should be employed at a lower target temperature (28–32 °C) at the start of CPB.Their prospective study found that this approach was somewhat effective in reducing the occurrence of UPE, with none of the 435 cases managed using the modified technique developing UPE (P < 0.02) [30]. Further studies are still required to validate the effectiveness of this method and to achieve a more comprehensive understanding for the pathophysiology of UPE.

Summary of complications

RAS does not eliminate the complications associated with conventional surgical approaches, nor does it reduce their severity. Compared with open surgery, minimally invasive procedures—including RAS—can significantly lower the incidence of complications such as intraoperative bleeding, POI, postoperative pain, and incisional infection [31, 32]. However, the incidence of most complications does not differ between RAS and laparoscopic surgery. Moreover, RAS gives rise to its own unique complications and challenges, including high costs, difficult patient access, loss of tactile feedback, thermal injury caused by electrical arcing, and positioning-related peripheral nerve injury [32, 33]. The relatively long operative time associated with RAS is also an important factor influencing the occurrence of complications. In summary, while RAS can reduce surgical trauma and postoperative pain, like any surgical modality, it is associated with its own unique set of challenges and limitations. The medical team should select the most appropriate surgical approach for each individual patient in order to achieve the best possible outcome (Fig. 2).

Fig. 2.

Complications of robotic surgery

Postoperative management of robotic surgery

As with any other surgical procedure, patients may experience adverse reactions following anesthesia and surgery. The postoperative period constitutes an important component of perioperative management and is directly related to the patient’s recovery. Inadequate management can lead to prolonged hospital stays and increased hospitalization costs.

Postoperative analgesia

As a minimally invasive procedure, RAS generally does not cause substantial pain from the surgical wound itself. However, patients may experience pain from other sources, such as urinary catheters and drainage tubes. Routine use of patient-controlled analgesia (PCA), or the application of regional nerve blocks or paravertebral nerve blocks, can alleviate postoperative pain. A study by Covotta and colleagues demonstrated that ultrasound-guided TAP block reduces postoperative morphine consumption and alleviates somatic pain in patients undergoing robot-assisted partial nephrectomy [34].

Prevention and management of postoperative nausea and vomiting

PONV (postoperative nausea and vomiting) is a common complication of laparoscopic surgery. One study used ONSD (optic nerve sheath diameter) as a surrogate marker of intracranial pressure to investigate the effects of propofol versus sevoflurane in women undergoing RAS, and found that ONSD at 40 min after pneumoperitoneum establishment was significantly lower in the propofol group than in the sevoflurane group [35]. Two patients in the sevoflurane group developed PONV. Another study used the QoR-15 questionnaire to assess patients’ postoperative experience and found that patients who received automated propofol infusion via a closed-loop anesthesia system reported better outcomes than those who received desflurane anesthesia [36]. Taken together, inhalational anesthesia appears to be a modifiable contributing factor to PONV, underscoring the importance of considering total intravenous anesthesia (TIVA) in high-risk patients, although further research is needed to confirm this association.

A RCT study based on robot-assisted laparoscopic surgery for benign uterine tumors found that the incidence of PONV requiring antiemetic treatment was significantly lower in the chewing gum group (79.5%) than in the control group (95.6%). This suggests that chewing sugar-free gum for 15 min before surgery may be a simple method to improve PONV in women undergoing robot-assisted laparoscopic surgery for benign uterine tumors [37]. However, more RCTs and multicenter trials are still needed in the future to prove the effectiveness of this method and to explore its effect on PONV prevention and treatment in surgeries at other sites.

Postoperative ileus

Postoperative ileus (POI) is a relatively common complication after surgery. Major risk factors include advanced age, male sex, preoperative anemia, and intraoperative bowel injury [32]. Its occurrence is not limited to gastrointestinal surgery. A large-sample study showed that among 946 surgical procedures with postoperative complications across seven specialties, POI had the highest overall incidence (16.3%) and was also the leading cause of hospital readmission [38]. A study based on rectal tumor resection also specifically examined the occurrence of POI. The incidence was significantly higher in open surgery (31.1%) than in minimally invasive surgery, while no statistically significant difference was observed between robotic surgery and laparoscopic surgery (P = 0.092). However, regardless of the surgical approach, the severity of POI was similar, and minimally invasive surgery did not mitigate its consequences [32, 39].

Postoperative pulmonary complications

Multiple studies have found that the incidence of postoperative pulmonary complications (PPCs) appears to be higher with RAS, but the picture is not so straightforward. A study by Serafini et al. found that RAS itself was not a risk factor for PPCs; rather, the duration of intraoperative mechanical ventilation was (P < 0.001). They concluded that the observed between-group difference stemmed from the generally longer operative times associated with RAS [40].

A 2026 reader commentary on this study concurred with this view, suggesting that as surgeons become more proficient and operative times are shortened, the incidence of PPCs may be indirectly reduced [41]. In addition, an RCT found that increased intraoperative blood loss is also a risk factor for PPCs [42]. We consider that, with regard to PPCs, RAS itself may not warrant excessive criticism; as surgeons gain proficiency or as robotic platform technology advances, the incidence of PPCs may decline in parallel with shorter operative times. Nevertheless, more rigorous research is needed in the future to identify and control other key contributing factors.

Applications of RAS across different specialties

RAS has now been adopted by many clinical departments. Each specialty has its own unique surgical requirements and gives rise to distinct complications, which anesthesiologists need to understand.

Urology

Urology was among the first specialties to adopt robotic-assisted systems. In recent years, with the expiration of patents on the market-dominant da Vinci system, numerous new robotic platforms have emerged. In addition to the Hugo system from the United States, these include Versius™ from the United Kingdom and Avatera™ from Germany in Europe, as well as REVO I from South Korea and Hinotori™ from Japan in Asia. China has also developed its own domestic robotic platforms, although none have yet received FDA approval. These next-generation platforms compete with da Vinci through innovations such as modularity, portability, lower cost, and remote surgery capabilities. However, widespread clinical adoption will still require multicenter controlled trials [43].

An increasing number of urologists are now applying RAS to FRU (Functional and Reconstructive Urology). Common procedures include upper urinary tract reconstruction, ureteral reimplantation, bladder augmentation, and artificial urinary sphincter placement [44].

The primary challenges posed by RAS in urology remain the physiological changes induced by the extreme positioning and pneumoperitoneum, as well as electrolyte disturbances resulting from crystalloid absorption. Anesthesiologists should protect patients against positioning-related complications, assess fluid and electrolyte balance through blood gas analysis, and intervene promptly. For carbon dioxide accumulation caused by pneumoperitoneum, PCV (pressure-controlled ventilation) is currently recommended for prevention [45].

Thoracic surgery

RATS (robot-assisted thoracic surgery) is also widely applied, mainly for the resection of pulmonary, mediastinal, and esophageal tumors. Compared with other approaches, it is more costly and imposes stricter requirements on patient selection. Individuals who are excessively obese or excessively thin are not suitable candidates. In addition, patients with poor cardiopulmonary function who cannot tolerate surgery or OLV (one-lung ventilation) are also not eligible for RATS [8].

RATS has been increasingly used in the treatment of lung cancer in recent years. A multicenter retrospective analysis conducted in the United States found that, compared with VATS (video-assisted thoracic surgery) and open surgery, the RATS group had a shorter average length of hospital stay (P < 0.0001), although the incidence of perioperative complications did not differ substantially from that of other minimally invasive approaches (p = 0.07) [46]. The results of several large meta-analyses also indicate that, compared with the other two surgical approaches mentioned above, RATS is associated with a shorter average length of hospital stay, although its reoperation rate is not lower than that of VATS [47]. A 2021 study pointed out that RATS offers considerable advantages in lymph node dissection, performing significantly better than VATS (p = 0.001) [48].

The major complications of robot-assisted minimally invasive esophagectomy (RAMIE) include paraconduit hernia (PCH), chylothorax, and anastomotic leakage—complications common to all esophagectomies—as well as complications unique to RAMIE, such as equipment malfunction, loss of tactile feedback, and conversion to open surgery. The entire medical team must be trained in the procedure for emergency conversion to open surgery and should prepare contingency plans to respond appropriately [31].

Overall, RATS is associated with a low complication rate. The main challenges involve injuries to adjacent structures (e.g., the thoracic duct, esophagus, and diaphragm), among which pulmonary artery injury is the most common and clinically challenging. In RATS, the foremost responsibility of the anesthesiologist remains effective airway and circulatory management, maintaining hemodynamic stability, and avoiding any increase in blood loss or further harm, so as to safeguard the patient’s life.

Gynecology

In recent years, robotic technology has been widely applied in the treatment of benign gynecological diseases. A systematic review by Myriam Jerbaka and colleagues indicated that, based on current data, robotic gynecological surgery is not markedly superior to laparoscopic gynecological surgery. The data showed that robotic surgery is generally associated with higher costs and longer total operative times, while being comparable to laparoscopic surgery in terms of hospital stay and postoperative complications [49].

The main challenges of robotic gynecological surgery are intraoperative neurovascular injury or injury to solid organs (primarily the uterus) [50]. These issues are relatively manageable. Maintaining a patent airway and hemodynamic stability remains of primary importance; on this basis, the anesthesiologist cooperates with the surgeon in repairing such injuries or proceeding with laparotomy.

Otorhinolaryngology–head and neck surgery

Robot-assisted head and neck surgery is associated with faster healing and more rapid recovery of swallowing and vocal function. There is a growing trend toward robot-assisted techniques in head and neck surgery, driven by the need to meet specific aesthetic requirements while reducing visible scarring [51].

Over the past decade, research into robotic and computer-assisted ear surgery has also advanced rapidly. The related operating systems developed by various teams can be classified into three categories: co-manipulated, teleoperated, and (semi-)autonomous. Technological progress has focused on improving bone drilling accuracy, reducing tremor, and minimizing tissue damage [52]. The primary challenge that robot-assisted otorhinolaryngology–head and neck surgery poses for anesthesiologists is difficult patient access. Unlike procedures in other anatomical regions, patients undergoing robot-assisted head and neck surgery have their heads positioned far from the anesthesia machine. Anesthesiologists need to monitor ventilator-related parameters and remain attentive to airway status, and promptly interrupt the procedure and initiate emergency management when a crisis arises.

Evaluation of robotic-assisted surgery

With respect to the surgical procedure itself, RAS offers small incisions, rapid postoperative healing, and short hospital stays, thereby overcoming the limitations of conventional minimally invasive techniques and representing a major breakthrough in MIS. For patients, RAS reduces the suffering associated with surgery while increasing surgical costs. For surgeons, RAS shortens the learning curve and provides a clearer, three-dimensional field of view. For the advancement of medicine, RAS represents a technological leap that may, in the future, be integrated with technologies such as virtual reality (VR) and artificial intelligence (AI) to drive further progress. Overall, RAS is a promising and advanced technology. Although it currently remains costly, its benefits cannot be overlooked. With continued technological progress and the accumulation of clinical experience in managing its unique challenges, RAS will undoubtedly solidify its role as a revolutionary advance in minimally invasive surgery (Table 3).

Table 3.

Advantages and disadvantages of robotic surgery

Advantages	Disadvantages
For surgeons and hospitals
Shorter learning curve More three-dimensional and clearer field of view [53] Remote controllability	High costs (including those of the equipment itself, team training, and so on) [54] Greater demands on operating room space Longer operative times
For patients
Fewer instances of unintentional soft tissue injury [53] Less postoperative pain Shorter hospital stays Faster return of bowel function	More expensive hospital stays Longer operative times Higher incidence of PPCs [55]

Conclusion

The strengths of this narrative review lie in its relatively comprehensive content, its perspective grounded in the role of the anesthesiologist, and its use of relatively recent references, which may help anesthesiologists rapidly establish a fundamental understanding of this field. This review also has certain limitations: the sources are derived mainly from PubMed, representing a single data source. As a narrative review, the literature search lacks systematic rigor, and the conclusions are therefore prone to bias.

Since the birth of surgery, the field has advanced at a remarkable pace, giving rise to RAS, which has progressively matured over time.This increasingly mature technology has brought greater challenges to the entire surgical team. Compared with conventional approaches, multidisciplinary collaboration has become more important than ever in RAS, and the unique characteristics of RAS make appropriate patient selection and individualized anesthetic management particularly critical. For anesthesiologists, the new imperatives posed by RAS are to ensure careful patient selection, understand the potential complications, grasp the key considerations for procedures in different anatomical regions, and deliver effective perioperative management so that more patients can recover safely.

Abbreviations

RAS

Robotic‑assisted surgery

SSI

Surgical site infection

TIVA

Total intravenous anesthesia

ETT

Endotracheal tube

TPP

Three‑point ETT cuff palpation

PEEP

Positive end‑expiratory pressure

BIS

Bispectral index

SVR

Systemic vascular resistance

PAH

Pulmonary arterial hypertension

MDT

Multidisciplinary Team

DVT

Deep vein thrombosis

RATKA

Robot‑assisted total knee arthroplasty

mTKA

Manual total knee arthroplasty

RALP

Robot‑assisted laparoscopic prostatectomy

ION

Ischemic optic neuropathy

MV

Mitral valve

ECMO

Extracorporeal membrane oxygenation

PCA

Patient‑controlled analgesia

TAP

Transversus abdominis plane

PONV

Postoperative nausea and vomiting

ONSD

Optic nerve sheath diameter

QoR‑15

Quality of Recovery‑15

RCT

Randomized controlled trial

FRU

Functional and Reconstructive Urology

PCV

Pressure‑controlled ventilation

RATS

Robot‑assisted thoracic surgery

OLV

One‑lung ventilation

VATS

Video‑assisted thoracic surgery

TOS

Thoracic outlet syndrome

FRR

First rib resection

BABA

Bilateral axillo‑breast approach

VR

Virtual reality

AI

Artificial intelligence

PPCs

Postoperative pulmonary complications

ERAS

Enhanced Recovery After Surgery

FRC

Functional residual capacity

IOP

Intraocular pressure

POI

Postoperative ileus

POVL

Perioperative visual loss

CPB

Cardiopulmonary bypass

UPE

Unilateral pulmonary edema

Author contributions

Xu conceptualized the review framework, conducted the literature search, and drafted the initial manuscript. Wang provided critical revisions, theoretical guidance, and supervised the overall structure and clinical interpretation.

Funding

Not applicable.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

Not applicable.

Consent for publication

All we agree for the subject publication and the policies of the publisher.