Published via DMIHER Datta

Open Access Review Article Meghe Medical College

Role of Robotic-Assisted Surgery in Public

Health: Its Advantages and Challenges
Received 04/16/2024
Alisha Handa 1 , Abhay Gaidhane 2 , Sonali G. Choudhari 3
Review began 05/31/2024
Review ended 06/10/2024 1. Community Medicine, Datta Meghe Institute of Higher Education and Research, Wardha, IND 2. School of
Published 06/23/2024
Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences,
© Copyright 2024 Wardha, IND 3. School of Epidemiology and Public Health, Community Medicine, Jawaharlal Nehru Medical College,
Handa et al. This is an open access article Datta Meghe Institute of Medical Sciences, Wardha, IND
distributed under the terms of the Creative
Commons Attribution License CC-BY 4.0.,
which permits unrestricted use, distribution,
Corresponding author: Alisha Handa, [email protected]
and reproduction in any medium, provided
the original author and source are credited.

DOI: 10.7759/cureus.62958
Abstract
The modern hospital setting is closely related to engineering and technology. In a hospital, modern
equipment is abundant in every department, including the operating room, intensive care unit, and
laboratories. Thus, the quality of treatment provided in hospitals and technology advancements are closely
tied. Robotic systems are used to support and improve the accuracy and agility of human surgeons during
medical procedures. This surgical approach is commonly referred to as robotic surgery or robotic-assisted
surgery (RAS). These systems are not entirely autonomous; they are managed by skilled surgeons who carry
out procedures with improved accuracy and minimized invasiveness using a console and specialized
instruments. Because RAS offers increased surgical precision, less discomfort after surgery, shorter hospital
stays, and faster recovery time, all of which improve patient outcomes and lessen the strain on healthcare
resources, it plays a critical role in public health. Its minimally invasive technique benefits patients and the
healthcare system by lowering problems, reducing the requirement for blood transfusions, and reducing the
danger of infections related to medical care. Furthermore, the possibility of remote surgery via robotic
systems can increase access to specialized care, reducing regional differences and advancing fairness in
public health. In this review article, we will be covering how RAS has its role in public health.

Categories: Preventive Medicine, Epidemiology/Public Health, Healthcare Technology

Keywords: robotic-assisted surgery, robotic-assisted surgery advantages, challenges of robotic-assisted surgery,
evolution of ras, role of public health in ras

Introduction And Background

Although robots have been around for a while, they are still relatively new in the medical field. The field
gained popularity as a means of minimally invasive surgery in the 1980s. Even though laparoscopy was
already widely used, its capabilities were somewhat restricted compared to the then-believed promise of
robotic surgery. The NASA Ames Research Centre also began developing the idea of telepresence in surgery
simultaneously. In the 1990s, Stanford joined them, creating a highly developed telemanipulator as the
foundation for ensuing systems. The FDA authorized AESOP (Computer Motion, Inc., Goleta, CA) in 1994 [1].
The first direct interventional support by a robotically assisted surgical system (RASS) on a human patient
occurred in 1985: A PUMA-200 industrial robot positioned and locked a biopsy channel during a computer
tomography (CT)-guided brain biopsy in neurosurgery [2]. For nearly three decades, the robotic surgery
market has seen enormous expansion, mainly in terms of innovation and advancement in medical
equipment. Improved surgical results, precise procedure execution, and quick patient recovery following
surgery are some of these technologies' main benefits.

A minimally invasive surgical system called the da Vinci Surgical System debuted in 1999 [3]. By the end of
2017, there were a total of 8,77,000 surgical procedures (approximately) performed by the da Vinci robotic
surgical system with the help of 4,409 surgical systems installed worldwide, compared with 7,53,000 in 2016
and 6,52,000 procedures done in 2015, respectively [4]; until today, more than seven million procedures have
been performed utilizing RASSs [2]. The American Computer Motion's AESOP® and ZEUS robotic surgical
systems were the first to be used in general surgery [5]. Following protracted legal proceedings, American
Computer Motion merged with its primary rival, Intuitive Surgical, which had been established eight years
earlier in 2003 [5]. The corporation registered over 7000 patents, which was the primary impediment to
competitors' development and allowed them to create multiple generations of master-slave multi-arm
robots to safeguard their products [6]. The earliest registered patents gradually expire after 20 years,
allowing rival products to be developed. Due to the products' purported technical advantages over
laparoscopy, the Intuitive Surgical firm was able to enjoy a 20-year monopoly, which gave them a significant
competitive advantage of 3D imaging, magnification, dexterity, tremor filtration, motion scaling, and a
short learning curve over laparoscopy [7]. By the start of 2023, over 11 million robotic procedures had been
carried out globally using Intuitive Surgical Da Vinci robots, with over 7,500 systems in use [8].

India received its first urologic robotic installation in 2006 at the All India Institute of Medical Sciences, New
Delhi, following the US FDA's 2000 approval of the da Vinci system [9]. India witnessed an unparalleled boom

How to cite this article

Handa A, Gaidhane A, Choudhari S G (June 23, 2024) Role of Robotic-Assisted Surgery in Public Health: Its Advantages and Challenges. Cureus
16(6): e62958. DOI 10.7759/cureus.62958
 in robotic surgery throughout the subsequent ten years. As of July 2019, our nation had 66 centers and 71
robotic installations, housing over 500 skilled surgeons. Over 12,800 surgeries have been carried out in the
past 12 years with robotic help. The numbers should rise as more robotic surgeons receive training and
other surgical specialties use this platform more often. The pattern indicates that robotic surgery has been
and will continue to grow rapidly and significantly in India [10]. In India, private hospitals are the central
locations for robotic-assisted surgery (RAS); however, many government institutions have also set up robotic
surgical platforms. The cost-effectiveness of robotic surgery has been vigorously debated in developing India
[10,11]. Since surgery is a relatively new area, surgeon training is crucial. Nonetheless, most resident
training programs in India need a standardized curriculum for teaching robotic surgery [12]. Like other
surgical methods, mastery of robotic surgery can be attained by surpassing the learning curve, typically
necessitating the surgeon to execute a certain quantity of single procedures [13].

Review
Methodology
The eligibility criteria for this review included all articles, studies, and documents that discussed
implementing the role of RAS in public health, its operationalization, and challenges in India. For the
literature search, we used electronic PubMed, Google Scholar, and Web of Science databases for relevant
results. These were combined with "AND" to obtain desired results. The search was limited to publications
for 10 years, from 2003 to 2023. We obtained 621 articles from the search engines using search terms like
"robotic-assisted surgery” in “public health" and "challenges of robotic-assisted surgery” and their
synonyms. After filtering the results by full free-text article availability and articles from 2003 to 2023, we
obtained 62 articles. After screening the title and abstract, 60 articles were selected. Finally, after reading
the full-text articles available, 58 articles were used for this article. Only English-language literature was
included in the search parameters. The PRISMA flowchart for the methodology has been demonstrated, as
shown in Figure 1.

FIGURE 1: Eligibility criteria of the literature search process

A brief overview of the evolution of RAS is depicted in Table 1.

2024 Handa et al. Cureus 16(6): e62958. DOI 10.7759/cureus.62958 2 of 14

 Year Milestone

First robotic-assisted surgical system PUMA 560 was used in a neurosurgical biopsy - an initial exploration of robotic capabilities
1985
in surgery.

1990s Early research and development in robotic-assisted surgery. Focus on enhancing precision and control.

Da Vinci Surgical System receives F.D.A. approval. Introduced for urological procedures. Marked the beginning of a new era in
2000
robotic surgery.

2003 Expansion of Da Vinci applications to gynecology. Widening the range of procedures amenable to robotic assistance.

Introduction of single-site surgery with Da Vinci. Enabled surgery through a single incision. Reduced scarring and improved
2008
cosmetic outcomes.

2010s Growing adoption in various surgical specialties. Increased use in urology, gynecology, and general surgery.

FDA approval for Senhance surgical system. Designed for minimally invasive surgery. Added to options available to surgeons and
2014
hospitals.

Continued advancements in robotic technology Improved visualization, better ergonomics, and enhanced agility. Surgeons gain
2018
greater control and precision.

Increased adoption of robotic systems worldwide. Expanding applications in colorectal surgery, thoracic surgery, and more
2020
enhanced training programs for surgeons using robotic platforms.

Ongoing research and development for enhanced robotic-assisted technologies Integration of AI for smarter surgical assistance.
2023
Emphasis on improving accessibility in remote and underserved areas.

TABLE 1: Brief overview of the evolution of robotic-assisted surgery

PUMA: Programmable Universal Machine for Assembly, FDA: Food and Drug Administration, AI: artificial intelligence

Table credits: Alisha Handa

Table 2 is a comprehensive table summarizing the important articles' key findings.

Author Title Key findings

Shah et al., The History of Robotics in Tele-surgery, in which the physician performs the procedure while not being present in the
2014 [1] Surgical Specialties same room as the patient, is another potential development area for robotic surgery.

An Introduction to
Klodmann Robotically Assisted At present, proven robotic platforms are being used more and more in research on robotically
et al., 2021 Surgical Systems: Current assisted surgical systems (RASSs). Miniaturized tools and semi-autonomous aid functions are
[2] Developments and Focus designed to reduce patient trauma while maximizing the surgeon's skill.
Areas of Research

Impacts of Robotic The study's primary findings indicate that, while robotic surgery may not always be cost-
Platis et al.,
Assisted Surgery on effective, overall, and when considering all hospital-related factors, it is a worthwhile procedure
2014 [3]
Hospital’s Strategic Plan to use.

Robotic Surgery-Safety
and Effectiveness, in
Evidence from a phase III multicenter randomized trial assessing the disease-free survival
Comparison with
Boyina et state in patients following a radical hysterectomy procedure 4.5 years ago revealed that the
Traditional Surgery,
al., 2020 [4] use of robotic or minimally invasive techniques during a radical hysterectomy is linked to a
Present Context and
higher recurrence rate compared to open approaches.
Recent FDA Safety
Warning

History of Robotic
Surgery: From It has become feasible to show the true value of robotics in minimally invasive surgery,
Pugin et al.,
especially in the area of bariatric surgery, as expertise with the da Vinci® robotic system in
2014 [5] AESOP® and ZEUS® to
visceral surgery has grown (more than 250 significant surgeries completed).
da Vinci ®

Accessibility: The majority of them (84%), were urological operations; yet, the study does show

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 The Availability, Cost, that patient accessibility to robotic surgery facilities varies, even in a relatively small nation like
Limitations, Learning England. Cost: The initial cost of procurement, as well as ongoing maintenance and
Hughes et Curve and Future of consumable costs, constitute a significant barrier. Learning curves and training- The majority of
al., 2023 [6] Robotic Systems in the early adopters of robotic surgery in urology switched from another surgical technique (open
Urology and Prostate and/or laparoscopic). As a result, trainees had less opportunities to start honing these abilities
Cancer Surgery in the field because older urologists who had already finished their training had to learn how to
use RAS later in their careers.

The only surgical robotic systems that are currently offered for sale that offer haptic feedback
are the Senhance and MAKO RIO systems. Clinical studies contrasting the advantages of
Brodie et The Future of Robotic
haptic feedback with no haptic feedback in these systems have not been conducted. Haptic
al., 2018 [7] Surgery
feedback is present in most robotic systems under development, and it appears that this will set
the standard for systems to come.

New Robotic Platforms in In the fields of hepatobiliary, colorectal, abdominal wall, upper gastrointestinal, endocrine, and
Marchegiani
General Surgery: What’s breast surgery, more and more robotic surgeries using novel robotic equipment have been
et al., 2023
the Current Clinical reported. This review indicates that most surgical therapies are technically possible despite the
[8]
Scenario? low quality of the available evidence.

Retropubic, Laparoscopic,
and Robot-Assisted For individuals with localized prostate cancer, RRP, LRP, and RARP treatments carried out in
Coelho et
Radical Prostatectomy: A high-volume centers are safe choices with comparable overall complication rates. However,
al., 2010 [9]
Critical Review of when compared to RRP, LRP and RARP are linked to lower surgical blood loss and lower
Outcomes Reported by transfusion risk.
High-Volume Centers

Strengths: increased insurance, rising patient base, improving economy, skilled laparoscopic
Bora et al., Robot-Assisted Surgery in
surgeons, training and mentorship, and a rise in the number of experienced surgeons (National
2020 [10] India: A SWOT Analysis
Health Profile, 2018).

The remarkable and satisfying spread of laparoscopic surgery throughout India is a notable
achievement in the advancement of surgery in small towns. This can be attributed to the fervor,
Udwadia et Robotic Surgery Is Ready
resourcefulness, and unwavering determination of small-town and rural Indian surgeons who
al., 2015 for Prime Time in India:
have persevered through numerous challenges related to safety, innovation, and cost-
[11] Against the Motion
effectiveness. For new technology to be useful in developing nations, it must follow the five
advantages: Reasonably priced, agreeable, reachable, accessible, and suitable.

The use of robotic surgery technology has grown rapidly in many regions of the world and in
many different specialties, but sadly, robotic surgeon certification and training are still in their
Carpenter Training the Next
infancy. A standardized robotics training program is long overdue and desperately required.
et al., 2017 Generation of Surgeons in
Depending on the location and specialization of the trainee, there might be significant
[12] Robotic Surgery
differences in the quality of robotic training due to the absence of a standardized training
program.

The majority of residents view the introduction of robotic surgery into surgical residency
Darlington A Cross-Sectional Study
programs as a danger to their training in conventional surgical techniques. This demands that
et al., 2022 of Resident Training in
resident training cases be distributed equally throughout programs across the nation and that
[13] Robotic Surgery in India
robotic training be successfully included in residency training.

Surgical Aspects and This article examines a number of limited access techniques that are still under development,
Jones et al.,
Future Developments of are becoming more widely acknowledged, or have been put into practice. It has been stressed
2001 [14]
Laparoscopy that there are complete contraindications to laparoscopy.

Early Experience with

From the first industrial robot used for stereotactic biopsies to the development of robotic
Telemanipulative Robot-
B et al., guidance systems that allowed solo endoscopic surgery to the use of robotic devices for
Assisted Laparoscopic
2002 [15] telemanipulative surgery with master-servant computer-enhanced robotic devices, the history
Cholecystectomy Using da
of robotic devices is remarkable.
Vinci

Over the past ten years, all surgical specialties have seen a change in method due to minimally
invasive surgery. This trend has prompted surgeons to reconsider standard practices with
relation to perioperative factors like pain management, in addition to replacing conventional
Fuchs et al., Minimally Invasive Surgery
procedures with less invasive ones. Nevertheless, since the advent of this new technique, two
2002 [16]
significant disadvantages have surfaced: first, most surgeons have a longer learning curve
than during open surgery; and second, costs have increased because of the equipment
needed, the use of disposable instruments, and longer operating times.

Postoperative Immune
Allendorf et Function Varies Inversely The level of surgical trauma has an inverse relationship with postoperative cell-mediated
al., 1997 With the Degree of immune function. Findings from the groups that underwent laparoscopy and mini-laparotomy

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 [17] Surgical Trauma in a indicate that techniques involving tiny incisions may preserve postoperative immune function.
Murine Model

Lanfranco
Since robotic surgery is still in its early stages, its market niche is yet unclear. Nowadays, its
et al., 2004 Robotic Surgery
practical applications are mainly limited to minor surgical procedures.
[18]

The focus is on the advancements in the usage of these devices during surgical procedures
Bramhe et and the positive outcomes they have produced for various therapies. In this instance, the
Robotic Surgery: A
al., 2022 bioethical debate around robotic surgery—which is still in its infancy in academic circles and
Narrative Review
[19] medical research—becomes extremely beneficial in assisting with decision-making when
robots are involved in providing care for people.

Vermandois Evaluation of Surgical Site One of the most frequent surgical consequences is surgical site infection (SSI), which is linked
et al., 2019 Infection in Mini-invasive to death, longer hospital stays, higher rates of re-admission, and a worsening of health-related
[20] Urological Surgery quality of life.

One-Year Healthcare
Costs After Robotic-
Okhawere
Assisted and The cost-benefit analysis of laparoscopic surgery (Lap) against partial and radical nephrectomy
et al., 2023
Laparoscopic Partial and (PN) is not well established, despite the widespread use of robotic-assisted surgery (RAS).
[21]
Radical Nephrectomy: A
Cohort Study

The robotic approach to prostatectomy and hysterectomy enables the advantages of

laparoscopic surgery—such as reduced blood loss, reduced pain after surgery, improved
Giri et al., Current Status of Robotic
cosmetic results, and a quicker return to physical activity—to the open procedures. Therefore,
2012 [22] Surgery
improved outcomes in clinical trials can be attributed to the well-established advantages of
laparoscopy over open surgery.

One of the better choices available to women undergoing myomectomy, hysterectomy, and
pelvic organ prolapse surgery is robot-assisted surgery. In addition to gynecology, other
Bankar et
Robot-Assisted Surgery in specialties like neurosurgery, orthopedic surgery, colon endoscopy, benign prostate surgery,
al., 2022
Gynecology urology, general surgery, respiratory surgery, and cardiac surgery also include robotic surgery.
[23]
Robotic surgery can lower the danger of infection while improving and correcting a number of
developing issues.

Robot-Assisted
Reconstructive Surgery of It is safe and practical to repair the lower urinary system in youngsters using robotics. Better
Upasani et Lower Urinary Tract in access is provided with a robotic method, particularly in the small area inside the pelvis. It
al., 2023 Children: A Narrative enables an earlier recovery and discharge by lowering blood loss and post-operative
[24] Review on Technical discomfort. Extended monitoring along with growing experience may confirm these preliminary
Aspects and Current findings.
Literature

Virtual Reality Training in

The field of neurosurgery is beginning to use fully immersive technology. Detailed virtual reality
Alaraj et al., Neurosurgery: Review of
neurosurgery modules will soon become a crucial component of the neurosurgeon training
2011 [25] Current Status and Future
program.
Applications

In-person mentoring and hands-on training sessions are great teaching methods for
Telementoring for
Sereno et laparoscopic surgery; nevertheless, financial, scheduling and geographical limitations make it
Minimally Invasive
al., 2007 impractical for specialized teachers to be present all the time. A wireless videoconferencing
Surgical Training by
[26] mobile robot used for remote robotic telementoring may be a substitute for in-person
Wireless Robot
instruction.

Case volumes and nationwide accessibility to robotic treatments are inconsistent and do not
Uptake and Accessibility
Lam et al., provide excellent value for the National Health Service (NHS). A national registry for robotic
of Surgical Robotics in
2021 [27] surgery is necessary to evaluate the availability of this technology on a dynamic basis and has
England
the potential to enhance the quality of robotic surgery.

Physician Pain and

An increasing number of gynecologic oncologists describe physical issues associated with
McDonald Discomfort During
MIS. There seems to be a correlation between female sex and robotic surgery and physical
et al., 2014 Minimally Invasive
discomfort. We must endeavor to enhance the ergonomics of MIS for surgeons in addition to
[28] Gynecologic Cancer
our goal of using it to improve patient outcomes and lower patient morbidity.
Surgery

Robot-Assisted
Laparoscopic

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 Coughlin et Prostatectomy Versus The lack of standardization in postoperative management across the two trial groups and the
al., 2018 Open Radical Retropubic utilization of additional cancer treatments warrant caution when interpreting the oncological
[29] Prostatectomy: 24-Month results of our study. It is important for patients and doctors to understand that a robotic
Outcomes From a technique has many advantages, chief among them being less invasiveness.
Randomised Controlled
Study

A Randomized Trial of
Bochner et
Robot-Assisted When compared to open surgery, retrospective studies show that robot-assisted laparoscopic
al., 2014
Laparoscopic Radical surgery has a lower risk of complications and a shorter hospital stay.
[30]
Cystectomy

Effect of Robotic-Assisted
vs Conventional
Laparoscopic Surgery on In contrast to traditional laparoscopic surgery, robotic-assisted laparoscopic surgery did not
Risk of Conversion to significantly lower the likelihood of conversion to open laparotomy among patients with rectal
Jayne et al.,
Open Laparotomy Among adenocarcinoma eligible for curative resection. These results imply that there is no benefit to
2017 [31]
Patients Undergoing robotic-assisted laparoscopic surgery in rectal cancer resection when the surgery is carried out
Resection for Rectal by surgeons with different levels of robotic surgery experience.
Cancer: The ROLARR
Randomized Clinical Trial

Novel therapeutic uses may emerge as a result of new technical developments. Even if there
are obstacles and problems with the 5G infrastructure, compatibility, cost, and security, more
Pandav et Leveraging 5G
research is needed to understand the advantages of incorporating the technology into practice
al., 2022 Technology for Robotic
and get over the barriers before it is widely used in clinical settings. 5G-enabled remote and
[32] Surgery and Cancer Care
tele-mentored surgeries may provide a new tool for treating patients who need robotic surgical
treatment, such as those with prostate cancer.

Robotic Prostatectomy Is
Maurice et Access to care may be hampered by RARP's correlation with increased patient travel and
Associated With Increased
al., 2016 treatment delays. It is yet unknown how significant these discoveries are from a therapeutic
Patient Travel and
[33] standpoint.
Treatment Delay

Embracing Robotic Socioeconomic limitations are one of the main things preventing access. Licensing universal
Surgery in Low- and robotic technology has the potential to reduce installation costs by increasing product
Mehta et al., Middle-Income Countries: availability and competitiveness. Encouragement of HICS to pool resources and equipment, the
2022 [34] Potential Benefits, establishment of a national cloud system supported by many countries, and the creation of
Challenges, and Scope in subsidies to enable financial support for implementation for hospitals in more remote areas are
the Future further possible strategies to lessen the burden.

Although it has numerous obstacles, telesurgery, often known as remote surgery, is a

promising development in surgery. For precise and well-executed procedures, zero-latency
time and advancements in haptic feedback technologies are necessary. Telesurgery should
Mohan et Telesurgery and Robotics: incorporate technologies such as 5G networks, IoT, and haptic robotics in order to get over
al., 2021 An Improved and Efficient these obstacles. There are still costs and legalization to consider when addressing moral and
[35] Era legal dilemmas. By reducing the number of surgical staff members in the operating rooms,
robotic surgery can play a crucial part in the surgical procedures being conducted during the
present pandemic and so reduce the risk of COVID-19 infection, which can cause severe
morbidity and mortality.

By evaluating the enormous volumes of diverse data that patients and healthcare facilities
continuously capture, artificial intelligence will help meet the demands of the medical field in
The Impact of Artificial
the future. AI is probably going to help and enhance doctors by eliminating the repetitive
Ahuja et al., Intelligence in Medicine on
aspects of their job, which should allow them to spend more valuable time with their patients
2019 [36] the Future Role of the
and provide a better human touch. Medical personnel must understand the foundations of AI
Physician
technology and how AI-based solutions might support them in their job to improve patient
outcomes, even though AI is unlikely to replace doctors in the near future.

It is well known that there are numerous medical specializations and procedures where
minimally invasive surgery is superior to open surgery. These variations include shorter
Gould et al., hospital stays, reduced discomfort, fewer hernias and wound infections, a speedier return of
Da Vinci Surgical System
2019 [37] bowel function, and a shorter recovery period before returning to regular activities. Robotic
surgical systems have allowed surgeons to use less invasive procedures more often and to
abandon open surgery in some specialties, most notably gynecology and urology.

Remily et Impact of Robotic Assisted When comparing robotic-assisted THA to traditional techniques, there were only slight
al., 2021 Surgery on Outcomes in reductions in LOS and expenses. However, there was little correlation between automation and
[38] Total Hip Arthroplasty increased blood transfusions and readmissions.

2024 Handa et al. Cureus 16(6): e62958. DOI 10.7759/cureus.62958 6 of 14

 The best surgical procedure for treating localized prostate cancer (PCa) is robotic-assisted
Rethinking the Need for laparoscopic prostatectomy or RAP. Less than 5% of patients have problems and
Kotamarti et Overnight Admission After readmissions, according to multi-institutional series, and the majority of patients are now
al., 2020 Robotic-Assisted released from the hospital 24 hours after surgery. A number of busy surgeons have recently
[39] Laparoscopic shown that same-day discharge (SDD) following RALP is safe. The primary advantages
Prostatectomy encompass decreased expenses and a decreased risk of nosocomial infections and hospital
blunders.

Radical Hysterectomy: A
Comparison of Surgical
Soliman et Patients undergoing radical hysterectomy have benefited greatly from minimally invasive
Approaches After
al., 2011 surgery, including a reduction in blood loss and transfusion rates; nonetheless, operating times
Adoption of Robotic
[40] were noticeably longer than with open radical hysterectomy.
Surgery in Gynecologic
Oncology

A Comparative Study of 3
Surgical Methods for
Boggess et Hysterectomy With Women undergoing endometrial cancer staging may experience less patient morbidity when
al., 2008 Staging for Endometrial using minimally invasive endoscopic surgical methods. Surgical staging with laparoscopic
[41] Cancer: Robotic assistance leads to less blood loss and quicker recovery.
Assistance, Laparoscopy,
Laparotomy

The available data supports the viability and safety of the robotic technique in gynecologic
Advincula et
The Role of Robotic surgery. However, experience is still in its infancy, and further studies are required to assess
al., 2007
Surgery in Gynecology the effectiveness in comparison to traditional laparoscopy and to help identify which patients
[42]
and applications should benefit most from robotically assisted surgery.

Improvement in Quality of Minimally invasive surgery has several well-documented advantages, such as reduced blood
Arms et al., Life After Robotic Surgery loss, a shorter hospital stay, and a quicker recovery. Although there is growing recognition for
2015 [43] Results in Patient robotic surgery in gynecologic oncology, little information about the quality of life (QOL)
Satisfaction following robotic surgery is currently accessible.

Quality of Life After Total

Laparoscopic
Hysterectomy Versus
When treating stage I endometrial cancer, TLH is more favorable than TAH in terms of adverse
Janda et al., Total Abdominal
event profile and quality of life improvements from baseline during early and later periods of
2010 [44] Hysterectomy for Stage I
recovery.
Endometrial Cancer
(LACE): A Randomised
Trial

Quality of Life of Patients

With Endometrial Cancer
Undergoing Laparoscopic
The QoL advantage of using laparoscopy to stage patients with early endometrial cancer is
International Federation of
Kornblith et somewhat supported by statistically significantly better QoL across many parameters in the
Gynecology and
al., 2009 laparoscopy arm at 6 weeks, even though the FACT-G did not show a MID between the two
Obstetrics Staging
[45] surgical groups and only modest differences were found in return to work and BI between the
Compared With
two groups.
Laparotomy: A
Gynecologic Oncology
Group Study

Effectiveness of an
Intermediate Care
Hospital on Readmissions,
Mortality, Activities of
Dahl et al., Daily Living and Use of Shorter hospital stays were made possible by the municipality's ICH, which also maintained
2015 [46] Health Care Services mortality, readmission, and post-hospitalization care demands at the same level as before.
Among Hospitalized
Adults Aged 60 Years and
Older–a Controlled
Observational Study

Patient’s Safety and

Satisfaction on Same Day
Discharge After Robotic
and Laparoscopic Radical In a subset of patients with prostate cancer, same-day release was safe, and practical, and did
Faria et al.,

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 2023 [47] Prostatectomy Versus not seem to have an impact on patient satisfaction. The Gleason score should be taken into
Discharge After 24 or 48 account by surgeons when deciding whether same-day release is appropriate.
H: A Longitudinal
Randomized Prospective
Study
Intuitive R.A.S. has been utilized increasingly frequently; according to Intuitive Surgical of Sunnyvale,
Surgical Annual Report California, 1.25 million procedures were performed worldwide in 2020 using the da Vinci
[48] surgical system alone.

The nexus of robotics-derived "big data" and machine learning (ML) is a fast-moving field of
research with the potential to improve surgical quality and safety. The ultimate purpose of
these investigations has been to provide fast and meaningful surgical input intraoperatively to
Machine Learning in the
Ma et al., prevent adverse outcomes. To this end, ML models have been used to provide objective and
Optimization of Robotics
2020 [49] efficient surgical assessment. The selection of surgical patients has been guided by predictive
in the Operative Field
machine-learning algorithms. In conclusion, machine learning (ML) enables surgical robots to
acquire autonomous procedural knowledge via expert demonstrations, trial-and-error, or a
combination of these two methods.

Advancements and
Challenges in the With its potential to improve patient outcomes and revolutionize conventional surgical
Mithany et
Application of Artificial techniques, artificial intelligence has become a major player in the surgical field. The review
al., 2023
Intelligence in Surgical has brought to light the noteworthy influence of artificial intelligence in a number of surgical
[50]
Arena: A Literature domains, from preoperative planning to postoperative analysis.
Review

Sandip et Artificial Intelligence and By the end of the twenty-first century, surgical robots that are therapeutically feasible should
al., 2019 the Future of Surgical become a reality. Artificial intelligence (AI) and surgical robotics may be used to enhance
[51] Robotics surgical capability in order to improve results and expand access to care.

Higher CM per case is driven by high acuity procedures like thoracic surgery, provided that
Financial Impact of variable costs, particularly LOS, are maintained to a minimum. Lower CMI procedures might
Abbas et
Adapting Robotics to a not yield a high enough CM to balance the fixed and variable costs. Outpatient robotic surgical
al., 2020
Thoracic Practice in an cases may result in large losses because the reimbursement does not equal the out-of-pocket
[52]
Academic Institution expenses. Hospitals should endeavor to reduce overall LOS and give priority to inpatient
treatments with greater CMI when allocating robotic resources.

A Systematic Review The studies that assessed the expenses of robotic surgery had poor methodological quality.
About Costing The longest follow-up period was four months, and most investigations lacked the use of
Korsholm et
Methodology in Robotic comprehensive cost data overall. Seldom were important factors like purchase, robotic platform
al., 2018
Surgery: Evidence for Low maintenance expenses, and surgical equipment utilization disclosed. Healthcare cost studies
[53]
Quality in Most of the might not offer a solid basis for decision-making if they are opaque about the cost drivers they
Studies take into account.

Estimates of the learning curve were quite uncertain. There was a dearth of solid evidence
Soomro et Systematic Review of because of study design flaws, reporting gaps, and significant variation in the approaches
al., 2020 Learning Curves in Robot- taken to evaluate learning curves. There is still time to develop the best quantitative techniques
[54] Assisted Surgery for evaluating learning curves in order to guide surgical education initiatives and enhance
patient outcomes.

The initial adoption, integration, and maintenance of RAS in clinical practice were hampered by
Barriers and Enablers to
Lawrie et a number of factors, both behavioral and organizational in nature. The impact of specific
the Effective
al., 2022 obstacles and facilitators varied according to the implementation stage. These findings will help
Implementation of Robotic
[55] managers and physicians make the most of the expensive technology by actively anticipating
Assisted Surgery
and comprehending these influences.

Jenison et Robotic Surgical Skills: It is imperative to give robotic surgeons with active curricula that aim to sustain performance
al., 2012 Acquisition, Maintenance, during periods of inactivity, as newly trained surgeons' robotic surgical abilities deteriorate
[56] and Degradation quickly. This will help to assure patient safety.

El-Hakim et The current state of robotic surgery is costly and provides only marginally better outcomes than
Challenges of Robotic
al., 2007 traditional methods. The robotic system in use now is cumbersome and inadequately
Surgery
[57] adaptable.

The enforcement of robotic technology in operations of widespread surgical operations

Gkegkes et Robotics in General constitutes a novelty that can have an effect on each surgical remedy of several pathologies
al., 2017 Surgery: A Systematic and the postoperative outcomes. The robot-assisted surgical operation has severe
[58] Cost Assessment opportunities to conform to a cost-powerful technique, particularly in centers with a wide variety
of cases, no matter the simple improved fees of acquisition and maintenance.

2024 Handa et al. Cureus 16(6): e62958. DOI 10.7759/cureus.62958 8 of 14

 TABLE 2: Summary of some important articles selected on the role of robotic-assisted surgeries
in public health, its advantages, and challenges.

RAS plays a significant role in public health in various ways.

Minimally Invasive Procedure

The first laparoscopic cholecystectomy occurred in 1987, marking the beginning of minimally invasive
surgery. Since then, the number of laparoscopic surgeries has increased at a rate consistent with
technological advancements and surgical expertise [14]. The benefits of minimally invasive surgery are well-
liked by patients, physicians, and insurance providers. There are fewer incisions, a lower chance of infection,
shorter hospital stays, if any, and markedly quicker convalescence. Numerous studies have demonstrated the
benefits of laparoscopic surgeries, including shorter hospital stays, a faster return to work, less pain,
improved cosmesis, and improved immune function after surgery [15],16,17,18].

Precision and Accuracy

Because of their extreme precision, robots can perform intricate and delicate movements that could be
challenging for a human surgeon. The precision and accuracy may result in better surgical outcomes, fewer
errors, and fewer problems. Better outcomes lower the risk of the issues following surgery and the need for
followup care, which benefits public health overall. Without question, robotic surgery has altered surgical
practice and intervention. Nowadays, many platforms are employed with varying performance and
applicability to perform various processes. Due to several technological advancements, including vibration
filtration, continued improvement of wrist motion freedom, motion scalability, and improved ergonomics
due to a more pleasant user interface, surgeons and the medical community reported better outcomes with
this procedure than conventional laparoscopy [19].

Reduced Blood Loss and Transfusions

It has been shown that minimally invasive surgery (MIS) results in less blood loss than open surgery. It helps
sustain greater serum levels of albumin and globulin, essential for immune system-based infection
prevention. In addition, MIS has been linked to a decreased transfusion rate [20]. Robotic surgery techniques
reduce the need for blood transfusions by often decreasing blood loss during surgeries. Because it reduces
the likelihood of problems from transfusions and preserves the limited supply of donated blood, it is vital for
public health.

Shorter Hospital Stays

Long-term healthcare utilization costs tend to be reduced due to more excellent proficiency with robotic
surgery and a decline in Emergency room and office visits [21]. The main advantages of minimally invasive
surgery for the patient are less pain medication use, quicker healing, better cosmesis, and fewer wound
problems. These advantages account for the widespread use of laparoscopy globally and the standard of care
that minimally invasive methods are thought to provide for several procedures, including fundoplication,
adrenalectomies, cholecystectomy, and bariatric surgery [22]. The benefits of RAS include shorter clinic
stays, decreased blood loss, increased periodic blood exchange, and reduced pain medication [23]. Adults
and children benefit from robotic surgery due to its focused approach to the target organ or location. It
minimizes operating stress, reduces postoperative pain, lessens the need for postoperative opiate use, and
shortens hospital stays [24]. In addition to helping specific patients, this also lessens overpopulation in
medical institutions.

Enhanced Training

Currently, simulator training aims to assist students in gaining the abilities required to carry out intricate
surgical procedures before practicing on actual patients. In certain domains, such as laparoscopic and
endovascular surgery training, it has been shown that surgical residents perform better in the OR while
using virtual reality (VR) simulators in their current configuration [25]. Sereno et al. reported a successful
experiment utilizing the RP-6 (predecessor to the RP-7) remote presence robot. They have employed two
different types of mentoring: (1) the typical assistance known as "active onsite mentoring," in which the
skilled surgeon offers help verbally and practically by adjusting the instruments and camera's positions as
needed, and (2) "passive onsite mentoring," in which the skilled surgeon restricts their support to verbal
assistance without using hands to adjust the instruments' or camera's positions (a method that is more
similar to the one provided by the robot). They concluded that although remote "robotic" mentoring is
considered inferior to "human" mentoring, the two groups differed in more minor ways than anticipated. A
remote presence robot can't take the position of an in-person mentor, but it can be a valuable tool for
telementoring minimally invasive operations [26].

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 Accessibility

The advantages of the robotic technique are frequently noted as its increased maneuverability and enhanced
vision. This enhanced vision is particularly evident in technically challenging anatomical locations like the
pelvis [27]. One possible explanation for the rising use of robotic surgery is the surgeon's preference.
Compared to the laparoscopic technique, the ergonomic benefits of the robotic approach have been
demonstrated to reduce both physical workload and mental stress [28]. However, this expansion has
happened due to the lack of solid proof from numerous RCTs, which have yet to demonstrate a clear benefit
of robotics over open or laparoscopic procedures [29,30,31]. Robotic surgery is easily accessible in big cities,
which are usually the locations of teaching hospitals [27]. Systems for robotic surgery have become more
widely available over time, and more medical facilities are implementing this technology. Making cutting-
edge medical operations more accessible to a larger community improves public health by granting access to
modern surgical procedures.

Telemedicine and Remote Surgery

Master-slave technology is the other name for telesurgery or remote surgery. Robotic surgery has
significantly advanced in many big countries and has substantially impacted its field in various procedures.
However, a lack of surgical expertise in rural areas could increase the travel time and treatment delays for
patients who need robotic surgical management, which also includes cancer patients [32]. Robot-assisted
surgical management may result in treatment delays and increased travel burdens due to the concentration
of robotic surgeons in urban regions [33]. By removing geographical restrictions and cutting travel time,
telesurgery enables doctors to perform surgeries from a distance, increasing surgical productivity. In
addition, telesurgery improves surgical results by allowing more experienced surgeons to mentor less
experienced surgeons through the operative process and possibly even by giving operating surgeons real-
time guidance [34]. Telesurgery can provide surgical care to a global population, particularly in inaccessible
or remote regions like spaceships and rural areas or battlefields [35].

Reduced Complications and Readmissions

Cognitive-assisted robotics, considered minimally invasive, uses miniature surgical instruments to replace
extensive incisions with a series of quarter-inch incisions [36]. Compared to open surgery, laparoscopic
surgery reduced pain, scarring, and length of stay, enabling doctors to execute complex surgeries with more
ease in the 1980s. In several surgical subspecialties today, laparoscopy-based minimally invasive surgery has
emerged as the gold standard for several routine surgical operations. It is just as successful as open surgery.
It is linked to shorter lengths of time in the operating room, fewer incisions, less discomfort after surgery,
and higher levels of patient satisfaction [37]. Compared to traditional approaches, RAS is related to a modest
decrease in length of stay (LOS) and expenses; however, no differences in surgical complications were seen.
The possibility of robotics may be seen as an increasingly relevant and economical process [38]. Most robotic
surgeries generally showed reduced length of stay, blood loss, and complications [39].

Patient Satisfaction

The rapid adoption of robotic surgery in gynecology can be attributed to multiple factors. Like laparoscopy,
robotic surgery has benefits over open surgery, such as reduced pain, less blood loss, shorter hospital stays,
and quicker recovery times [40,41]. RAS has several advantages over traditional laparoscopy, including
enhanced ergonomics, articulated instruments, three-dimensional vision, and the removal of hand tremors
[42]. Because of these characteristics, robotic surgery is believed to be more widely available. Compared to
traditional laparoscopy, it has a shorter learning curve, so surgeons who would otherwise rely on an open
approach can now provide their patients with minimally invasive surgery [43]. Research comparing the
quality of life following gynecologic laparotomy versus traditional laparoscopy for similar causes reveals
that patients have superior results from less invasive surgery [44,45]. Robot-assisted laparoscopy is a
minimally invasive surgery that should provide benefits comparable to traditional laparoscopy in terms of
quality of life. The idea is that a patient's motivation and choice of care significantly impact whether or not
they are discharged from the hospital the same day after surgery. Similarly, having a solid support system
after being released from the hospital is crucial to recovery during the first few days following surgery. The
use of an intermediate care hospital built in a municipality was demonstrated by reducing the LOS without
increasing readmissions, admissions, mortality, activities of daily living, primary healthcare utilization, or
total care days [46]. Improving acceptability and the success of early discharge may be achieved by providing
initial assistance in a support home under the supervision of a technical nursing assistant. Nonetheless, it is
well-known that not all nursing and support homes exist globally. Thus, early outpatient followup and easy
access to the medical team through electronic communication may reduce postoperative anxiety [47].

Artificial Intelligence (AI) and RAS

One of the medical specializations that produce extremely massive datasets that AI can evaluate in-depth
and thoroughly is surgery. Preoperative staging (clinical, laboratory, and imaging test results of patients),
intraoperative data (based on video recordings and kinematic data), and intraoperative datasets (such as

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 operative times, morbidity and mortality, patient outcomes, and patient-reported outcome measures; the
latter were introduced during the previous 40 years to offer an evaluation of the treatment received from the
patient's point of view) are among the surgical datasets on these topics. AI advancements are expected to aid
digital surgical techniques, such as the master-slave manipulators used in RAS. RAS has been used more
frequently; in 2020, 1.25 million procedures globally were conducted with the da Vinci surgical system alone
(Intuitive Surgical, Sunnyvale, CA, United States) [48]. At this point, RASs are helping surgeons by
magnifying their vision, improving their agility, and reducing tool vibrations [49]. AI has many benefits,
including increased diagnostic precision through genetic data analysis, which permits early detection and
individualized treatment plans. Evaluating each person's risk profile makes non-invasive screening easier
and lessens the need for intrusive procedures [50]. AI and machine learning (ML) are transforming the area
of robotic surgery. Robotic surgeons can support human surgeons during complex surgeries by utilizing
sophisticated algorithms, which lower the possibility of problems and improve results. Surgical robots use
AI, ML, and deep learning (DL) to help surgeons perform complex procedures more precisely and accurately
[51].

A comparison table is shown to compare the traditional surgeries versus RASs (Table 3).

Robotic-assisted surgeries Traditional surgeries

Invasion Minimally invasive Highly invasive

Precision and accuracy Higher Decreased

Blood loss and transfusion Reduced Increased

Hospital stay duration Shorter Longer

Recovery time Short Extended

Complications Less risk Higher risk

TABLE 3: Difference between robotic-assisted surgeries and traditional surgeries

Table credits: Alisha Handa

Challenges of RAS in public health

Like any new technology, the choice to use robotic surgery must consider financial feasibility. All healthcare
professionals are under increasing pressure to offer high-quality care to more patients at a lower cost in the
present healthcare climate. Using new, expensive technology that might (or not) improve patient care
directly competes with this mandate [52]. There needs to be more availability for robotic surgery despite its
potential. High-income countries have been at the forefront of creative advancements in robotic procedures
that will help improve surgical precision. However, these ideas have yet to reach low-income nations due to
a lack of financial infrastructure. Because robotic surgery requires less recovery time, it is practical in the
long run, but the upfront expenditures are still very high [34]. Because robotic surgery requires less recovery
time, it is functional in the long run, but the upfront prices are still very high [53]. The uptake of robotic
technology has been slow despite the reported benefits of RAS over traditional minimally invasive
approaches and the improved hospital experience. This is mainly due to high capital and maintenance costs
and uncertainty about the potential advantages of robot-assisted methods over conventional laparoscopic
procedures [54].

The disruptive process of integrating RAS services into the more extensive clinical system necessitates a
significant investment in personnel training, equipment expenditures, and service alignment. The
successful implementation of RAS is especially difficult since it necessitates a considerable financial
investment, physical adaptation to the new technology, and a significant shift in organizational and human
processes and behaviors to operate with the latest systems [55]. Specific complex and highly specialized
surgeries can still be better performed using the traditional method, limiting the scope of RAS use. Regular
maintenance is usually necessary for robotic systems to function at their best. The robotic system might
momentarily stop working during planned maintenance intervals, which would cause delays in the surgery
schedule. To reduce the impact of this downtime on patient care, it must be carefully controlled [56]. The
current state of robotic surgery is costly and provides only marginally better outcomes than traditional
methods. The existing robotic technology must be more versatile and more convenient [57]. Apart from the
initial investment, other expenses include replacement parts, continuous upkeep, and anticipated
depreciation. Salaries, overhead for administration, and the cost of non-robotic instruments are additional,
less obvious, but equally significant expenses [52].

The hospital's payment for using the robot directly correlates with the kind of health insurance and the

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 health system itself, which benefits the nations without universal health care and is harmful for those with
universal health care [58]. Public health facilities already have infrastructure issues that make it challenging
to integrate robotic technologies smoothly. Enhancing infrastructure to support robotic surgery could
necessitate extra funds and time.

Conclusions
RAS in public health offers a complicated and transformational landscape with many benefits and
drawbacks. Several possible advantages include better patient outcomes due to increased precision,
decreased invasiveness, and faster recovery times. These benefits are consistent with the main objectives of
public health, which are to effectively provide diverse populations with high-quality healthcare. Navigating
the difficulties of integrating RAS into public health settings is crucial. To guarantee fair and widespread
adoption, it is necessary to overcome financial limitations, training needs, and discrepancies in access.
Additional challenges include standardization, regulatory compliance, and infrastructure changes, which
need a planned and cooperative approach. Given the potential for RAS to transform healthcare provision,
efforts to overcome these obstacles are imperative. Public health institutions must actively participate in
comprehensive planning, education, and resource allocation as technology advances and becomes more
affordable. Careful evaluation of patient awareness, legal frameworks, and ethical issues is also necessary to
build trust and guarantee the proper application of this novel strategy. In summary, despite ongoing
difficulties, the benefits of RAS in public health highlight its potential to change the surgical intervention
environment completely. Incorporating robotics into public health practices can improve surgical outcomes,
improve patient care, and further the worldwide advancement of healthcare with careful thought,
investment, and teamwork.

Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.

Concept and design: Alisha Handa, Sonali G. Choudhari, Abhay Gaidhane

Acquisition, analysis, or interpretation of data: Alisha Handa, Sonali G. Choudhari, Abhay Gaidhane

Drafting of the manuscript: Alisha Handa, Sonali G. Choudhari, Abhay Gaidhane

Critical review of the manuscript for important intellectual content: Alisha Handa, Sonali G.
Choudhari, Abhay Gaidhane

Supervision: Alisha Handa, Sonali G. Choudhari, Abhay Gaidhane

Disclosures
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the
following: Payment/services info: All authors have declared that no financial support was received from
any organization for the submitted work. Financial relationships: All authors have declared that they have
no financial relationships at present or within the previous three years with any organizations that might
have an interest in the submitted work. Other relationships: All authors have declared that there are no
other relationships or activities that could appear to have influenced the submitted work.

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