The age of robotic surgery

The more widespread introduction of robotic surgery is a welcome development, but it requires careful management

I’m about to operate on a patient, but I’m not physically touching them. My head is inside an oculus mask and all I can see is the picture in front of me.

I’m using a robot to control instruments inside the patient’s body and I’m communicating with the surgical team from the corner of the operating room.

When the patient goes under the anaesthetic, we carefully and painstakingly turn them to the optimum position for the operation. Supports, cushions, and tape keep the patient in the exact position we need.

We spend time connecting the robot ports that allow us access into the body. Surgery begins.

At the patient’s side, my assistant helps by passing instruments like needles and stitches, or sucking blood away to help me see.

Sometimes, I stop and think about how bizarre this shift is. At the turn of the century, few surgeons could have imagined operating this way, yet change has come fast.

In the mid-2000s, urologists were the first to embrace robotic surgery, starting with prostate operations. The reason? The prostate sits deep within the confined space of the pelvis, making it notoriously difficult to access. Traditional laparoscopic instruments were not quite up to the task and surgeons often struggled with poor ergonomics, leading to chronic neck and back strain from working in awkward positions.

Robotic systems changed the game, offering enhanced dexterity, superior visualisation, and improved ergonomics. This made complex procedures in tight spaces more accessible and allowed surgeons to operate with greater control and stability.

Transformation

We are in the midst of a major transformation in surgery. Robotic technology is no longer confined to a few specialties – it is rapidly expanding across many disciplines, with more and more procedures now being performed robotically. Even within individual specialties, we are seeing indications for robotic surgery that would have seemed unlikely just a few years ago. It’s not a panacea; it’s not suitable for all operations; and some hospitals don’t yet have the capacity to carry out all operations using a robotic platform. However, the pace of change in robotics is accelerating, driven by advancements in artificial intelligence (AI), automation, and surgical innovation.

For the first time, data from the US shows a fundamental shift: Procedures that were traditionally laparoscopic are now being done robotically – not necessarily because they are better, but because surgeons have access to the robot and prefer using it. As a result, trainees today are gaining far more robotic experience, but less laparoscopic exposure, making them more confident at the console than with conventional laparoscopy. This shift is actively shaping the next generation of surgeons and redefining how procedures are performed.

Capital costs and service contracts in robotic surgery are significant investments. However, once a hospital has a robotic system in place, these costs are fixed. In contrast, laparoscopic surgery incurs ongoing expenses, as disposable ports, clips, and instruments quickly add up.

Many robotic systems use reusable, sterilised metal ports, reducing consumable costs over time. Given this, hospitals should aim to maximise robotic usage – not only to make the most of their investment, but also to offset day-to-day surgical expenses where possible.

Additionally, appendectomy and cholecystectomy provide ideal training opportunities. As low-risk, technically straightforward procedures, they allow trainees to develop robotic skills and refine console control in a safe setting. For consultant surgeons in specialties with fewer robotic cases, these procedures offer a valuable way to maintain proficiency and stay familiar with the platform.

Expansion

Beyond urology, robotic surgery is rapidly expanding across multiple specialties, including:

Thoracic surgery for lung cancer resections;

Gynaecology for hysterectomies;

Colorectal surgery for bowel cancer operations;

Upper GI surgery for oesophagectomy and gastrectomy;

Bariatric surgery for obesity-related procedures;

Hepatobiliary surgery for liver and pancreatic cancer;

Breast surgery for nipple-sparing mastectomies, a new and evolving robotic procedure.

One of the most notable applications of robotic surgery has been in ear, nose, and throat (ENT) surgery. In select cases, removing a tumour at the back of the throat previously required an extensive and highly morbid approach – cutting through the skin of the chin, splitting the lower jaw, and moving the tongue aside, often leading to days in intensive care. While this remains an uncommon indication and other approaches exist, robotic surgery offers a minimally invasive alternative for carefully selected patients, reducing surgical trauma and, in some cases, allowing for a shorter recovery.

Robotic surgery has transformed many procedures that were once out of reach for traditional laparoscopic techniques and could only be performed through open surgery. Where larger incisions and prolonged hospital stays were once the norm, robotics has allowed many complex operations to be performed with smaller incisions, shorter admissions, and a faster return to normal life for patients.

Robotic systems changed the game, offering enhanced dexterity, superior visualisation, and improved ergonomics

That said, not every operation is best suited to robotic surgery and some hospitals have limited robotic capacity. Open surgery remains essential in many cases and laparoscopy continues to play a crucial role. The reason robotic surgery has gained such traction is not just because it’s technologically advanced or enjoyable for the surgeon – it’s because, in the right cases, it offers advantages that are difficult to fully quantify in studies. Precision, access, and a more controlled operating environment are just some of the reasons why surgeons have embraced it so widely.

Although the robotic console is always in the same room as the patient during surgery, the technology exists to operate from thousands of miles away. At a recent conference, I watched as surgeons in the US performed operations on patients in China over a 5G network, demonstrating the feasibility of remote surgery. Naturally, the surgeon carried out the procedure in a suit rather than traditional scrubs – an unusual, but fitting detail in the world of telemedicine.

Robotic technology is not new to Irish hospitals – neurosurgeons were among the earliest adopters. However, the term ‘robotic surgery’ is now used broadly, often to describe technologies that assist surgeons rather than true robotic systems.

There are two distinct types of surgical robotics:

1. Navigation-based systems – Used in procedures like knee replacements, spinal surgery, and neurosurgery, these robots integrate imaging, sensors, and AI to enhance accuracy and guide precision placement. They act like a GPS, ensuring the surgeon reaches the right location, but do not physically perform the procedure.

2. Soft tissue robotic systems – Used in abdominal, thoracic, and other soft tissue surgeries, these robots are fully controlled by the surgeon’s hands at a console. The robotic arms replicate the surgeon’s movements with precision, but do not function autonomously. Unlike navigation-based robots, they provide greater dexterity and freedom of movement, mimicking the natural range of human hands.

For clarity, when discussing robotic surgery in soft tissue procedures, we should refer to these as soft tissue robotic systems, distinguishing them from image-guided navigation robots used in orthopedics and neurosurgery.

Management

The introduction of robotic surgery is a positive advancement, but it requires careful management. One key challenge is that a surgeon’s situational awareness can be different compared to open or laparoscopic surgery – when operating at the console, the ability to look around the room is limited. This makes clear communication and teamwork even more critical, particularly in emergencies.

While an experienced surgeon may be highly skilled in open or laparoscopic procedures, those skills do not automatically transfer to robotic surgery. The learning curve is distinct and even after initial training, ongoing support and structured learning are essential to ensure safe and effective practice.

Patients sometimes assume that robotic surgery is inherently safer; however, in reality, safety always depends on training and oversight. If these elements are lacking, the potential for risk increases. In the early adoption of robotics, a study from the US found that over a quarter of complications were linked to training deficiencies. Significant improvements have been made since then and we are now in a much stronger position. However, this serves as an important reminder that proper training and oversight are extremely important in ensuring the safe expansion of robotic surgery.

Robotic soft tissue surgery has gradually made its way into Ireland, one robot at a time. Today, every major hospital has at least one, and it will not be long before multiple systems are the norm.

I regularly switch between two completely distinct robotic platforms on different days of the week, and I’m always struck by how seamlessly I can transition between different platforms within the same week. It’s a bit like driving different types of cars – once you understand the fundamentals, adapting is second nature.

Although training and regulation in robotic surgery has always been of a high standard, we’ve now reached a tipping point where standardised safety and governance practices must take priority.

Until now, robotic surgery has been managed based on local policies, procedures, and practices. However, a recent national survey – sampling input from surgeons, clinical directors, CEOs, nurse managers, and industry representatives – showed overwhelming support for dedicated governance specific to robotics, rather than relying solely on existing hospital frameworks. This shift reflects the need for a structured approach to ensure safety, consistency, and the best possible outcomes for patients.

Committee

In December 2023, following the results of a national survey, the RCSI established the National Leads on Robotic Surgery Committee (NLRSC). Our goal is to take the lead in robotic surgical safety, standards, governance, education, and any national issues that may arise related to robotics in surgery.

One of our first major contributions was the publication of Robotic Surgery Governance in Ireland: A Guide to Good Practice. This document provides practical guidance on setting up and managing a hospital robotics programme, including how to establish a hospital robotics governance committee to oversee training, governance, and safety.

It also introduces key recommendations, such as regular emergency scenario rehearsals and specific protocols like ‘well leg’, which ensures that a patient’s non-operated leg is repositioned every four hours to prevent swelling and associated complications.

The NLRSC is a team of experts solely focused on ensuring the safe and effective delivery of robotic surgery. One of our key initiatives has been enhancing the support system for surgeons in the early stages of their robotic training. While mentorship has always been a fundamental part of surgical education, we have introduced additional layers of oversight and structured safety measures to strengthen this process.

These improvements ensure that newly trained robotic surgeons have the necessary guidance and safeguards as they transition into independent practice, ultimately maintaining the highest standards of patient care.

The days of transitioning established surgeons to robotic surgery are nearly behind us. Now, almost all surgeons entering the field receive robotic surgery training during their time as trainees or through dedicated fellowships. As robotic surgery becomes an integral part of modern practice, structured training from the outset is essential.

Fellowships in robotic surgery play a crucial role and we need to expand access to these opportunities for trainees in Ireland. Our next ambition is to develop a standardised robotic surgery curriculum within RCSI, ensuring that surgeons are trained in a consistent and comprehensive manner.

At RCSI, we are committed to fostering a culture of excellence in robotic surgery training. Our approach includes hands-on experience across multiple robotic platforms and extensive simulation-based learning. This is vital because in the 15 to 20 years it takes to become a consultant surgeon, surgical technology and practice will evolve significantly. By equipping our trainees with adaptable skills and a deep understanding of robotic surgery, we are preparing them not just for today’s operating theatres, but for the future of surgery.

Every advancement in AI sparks ethical debates about autonomous machines that can think and operate independently. It’s important to clarify that robotic surgery is not AI, and these robots are not autonomous in any way. They do not make decisions or perform surgery on their own; rather, they serve as an extension of the surgeon’s hands, eyes, and brain – enhancing precision, control, and vision, but never replacing human judgment.

In fact, autonomous surgery is not what we want. A surgeon needs to use their hands daily, even for simple tasks, as part of developing and maintaining essential surgical skills. Surgery is more than just technical execution; it requires adaptability, experience, and critical decision-making that only a trained human can provide.

Robotic surgery is not about eliminating all risk – complications can occur in any procedure – but it does help to reduce their likelihood.

More importantly, a strong culture of training and supervision ensures that we minimise unpredictable events, improve patient safety, and achieve better surgical outcomes. It’s not about avoiding investigations or sanctions. Instead, it’s about delivering the best possible care through rigorous training, oversight, and continuous improvement.