One step forward, two steps back: preserving surgical skill in the age of robotics

The past two decades have seen a meteoric rise in robotic surgery offered to patients as an alternative to surgical laparoscopy. The benefits have often been described as better operative visualization and precision afforded by the robotic platform itself, as well as improved ergonomics and less workload for the surgeon (1). On the other hand, criticism of the increased use of robotics has been directed towards prolonged operative time and a significant increase in healthcare costs with no tangible demonstrable benefits to the patient (2). However, over the past decade, comparative studies have neglected to address the impact of the robotic platform on the skill and comfort of surgical trainees in performing core general surgical and subspecialty-specific minimally invasive procedures following the completion of training.

Between 2012 and 2018, the use of the robotic platform increased in the United States from 1.8% of surgeries to 15.1%, with even greater increases for certain procedures, such as inguinal hernia, which increased from 0.7% to 28.8% robotic usage; this increase was associated with a decrease in the use of laparoscopy (3). This escalation in robotic utilization, however, has not yet been shown to yield superior patient outcomes, economic or environmental value, or training advantages, with studies evaluating robotics essentially concluding that robotic surgery is clinically non-inferior to laparoscopy. This point is particularly highlighted by one recent systematic review that found patient outcomes of robotic surgery to be non-inferior to laparoscopic outcomes, but also underscored that robotic surgery resulted in increasing operative times and greater hospital or health system costs, even when performed by very expert surgeons (2). The findings of increased robotic operative time and added healthcare costs have been borne out in studies of abdominal wall surgery (4-8), bariatric surgery (9-12), and foregut surgery (13)—which together comprise minimally invasive general surgery and in which use of robotics has become more ubiquitous than in other general surgical subspecialties—as well as colorectal surgery (14-17), with no proven clinical or economic benefit over traditional laparoscopy. Even within the range of what can be considered “bread and butter” general surgery procedures such as cholecystectomy, the safety of using the robotic platform, which has been increasing in this procedure, has been called into question, with one recent study demonstrating increased risk of common bile duct injury during robotic cholecystectomy (18). Regardless of the lack of demonstrated benefit, estimates project that 87% of the market for robotic surgery in the United States will be within general surgery and its subspecialties by 2030, after seeing a projected 10.5% compound annual growth rate in the United States throughout the preceding decade (19). With the field of robotic surgery growing so rapidly, it is perhaps unsurprising that over three-fourths of surgical trainees feel that robotics will be important for their futures and should be formally incorporated into training (20). However, despite the increasing prevalence of robotics in surgical training environments, there has been little if any attention focused on the role that robotics should play during the short, time-limited years during which general surgical trainees must achieve adequate competence and mastery across a large spectrum of surgical disciplines including open and laparoscopic surgery.

Even prior to the growth of robotic surgery, concern has risen among surgical educators both nationally and internationally that surgical training may not produce surgeons who are clinically ready to enter independent practice upon the completion of training. This is evidenced by both a recent study demonstrating that trainees perform cases independently less than 4% of the time during training (21), which may compromise trainee readiness to enter independent practice after training, and also by the recently created American College of Surgeons’ Mastery in General Surgery fellowship, which indicates a need for additional training in general surgery following completion of residency prior to entering independent practice. However, when considering the addition of robotic surgery into surgical training, one is confronted with a primordial question: is it possible to incorporate a third operative modality into the current paradigm of surgical training without eroding surgical skill and competence in laparoscopy and open surgery? How do we prepare the next generation of surgeons for an evolving practice environment while still safeguarding both surgical proficiency and patient safety?

General surgical trainees in the United States must complete at least 850 cases during their training, including a minimum of 175 laparoscopic cases, while most other countries require fewer cases (22). With estimates placing the number of cases required to be considered competent on the robotic platform for already well-established laparoscopic surgeons at around 50 cases, the number of cases required for trainees to reach a similar level of proficiency on the robot is likely substantially higher (23-29). Considering the learning threshold for this third operative modality, the addition of robotic surgery to time-bound surgical training will necessarily reduce the number of laparoscopic and/or open cases completed by trainees to a significant degree and may have a deleterious effect on open and laparoscopic surgical skill of recent graduates, given the time dedicated towards achieving competence on the robotic platform in lieu of true mastery of open and laparoscopic techniques.

Two robotic surgery-specific elements that are not seen in either open or laparoscopic surgery further complicate this picture. The first issue is that robotic surgery is designed to be performed by one surgeon controlling all operative instruments without an active surgical assistant; because of this, research has shown that most residents are often relegated to the role of bedside assistant or passive observer during cases (30). The second issue is that, when trainees do perform significant portions of cases, the cases tend to be less complex than what an equivalently experienced trainee would perform in a laparoscopic case (30).

To help elucidate the educational barrier presented by robotic surgery, residents from this study expressed sentiment that “when [the case is on] the robot, the attending is sitting down and doing the case. While it’s easy to switch, there has to be somebody bedside assisting, so the attending has to make a conscious decision to let the resident on the console. It’s not like you’re already there and doing the case together. It’s more like ‘I’ll step aside now and let you do it.’ So, it has to be a much more conscious decision to let you do it.” (30). Attending surgeons have likewise acknowledged similar but different educational issues with the robotic platform, by adding that “The... barrier is having someone at the bedside. Because now, instead of requiring just one resident in the case as in laparoscopy, now in order to be on the console, I have to find another resident to be at the bedside assisting.” (30). And while dedicated robotic-bedside physician assistants, who have been associated with increased trainee operative console time (31), do exist and are likely increasing in number, they are still far from the norm, with one attending physician in the preceding study also noting that “We’re a relatively well-staffed service, so we’ve always had a resident [at bedside]. But it’s not the best use of that resident.” (30).

This study brings to the forefront the glaring issue that most surgical training programs and their educators have yet to find a way to successfully integrate robotics into their teaching styles and curricula without sacrificing the quality and complexity of operative time and experience. While there is no question that some skilled robotic surgical educators do permit trainees to perform significant, postgraduate year (PGY)-level appropriate portions of cases, this is much more the exception than the norm, with one survey of over 240 training programs showing that only 18% of trainees reported having operated at the console while 45% reported having served as a bedside assistant without ever operating on the console, and approximately half expressing that robotic surgery performed in their programs interfered with their overall acquisition of surgical skills (32). Another study performed across multiple academic centers with robotic training curricula found that approximately one third of residents had functioned only in the capacity of a bedside assistant, with another third having split time between the bedside and the console (33). This study also found that nearly half of respondents reported that they were either somewhat or extremely dissatisfied with their robotic training experience, with nearly three-fourths reporting that they received less operative autonomy during robotic cases than during laparoscopic cases (33). To this same end, a more recent study evaluated actual trainee participation in cases through a measure of robotic operative “active control time”, defined as the amount of time a given trainee spent in active robotic console manipulations over the total active console manipulation time between both the trainee and attending surgeon consoles. Investigators found that fifth-year residents performed 60% of a typical standard case and only 35% of a case considered complex, while fellows performed approximately 74% of standard cases and 47% of complex cases (34). If examined through the lens of the Robotic Surgery Education Working Group’s 2024 consensus recommendations for a 5-level Robotic Surgery Curriculum Pathway intended to provide a standardized curriculum in robotic surgery in order to ensure competence on the robotic platform, fellows and fifth-year residents performing less than half of complex cases are not considered “procedurally proficient” (35), a troubling conclusion for those in what is to be their final year of surgical training. Given this discussion, it seems reasonable to conclude that the educational value provided to trainees from robotic cases is not equivalent to that which would be derived from laparoscopic cases.

An additional robotic surgery-specific element complicating its integration into surgical training is that operative experience on the robotic platform may actually hinder the acquisition of laparoscopic skill, with skill-acquisition and transference research demonstrating positive skill transference when transitioning from laparoscopy to robotics, but negative skill transference from the robotic platform to laparoscopy—primary exposure to the robotic platform, absent the haptic feedback which is a vital element of laparoscopy and generally considered critical to the development of safe tissue handling (36), actually had a negative impact on subjects’ abilities to perform tasks laparoscopically (37). This surprising element of skill-acquisition may indicate trainees are best served by the focus on laparoscopic skill acquisition and the omission of significant robotic exposure until laparoscopic competence is fully achieved.

Despite the foregoing, there are several educational advantages that are specific to the robotic platform and are not available with traditional laparoscopy (38). The first stems from several mechanisms built into dual console robotic systems which are designed to prevent trainee harm to patients, such as the ability to grant the trainee single to multiple instrument control as appropriate based on skill and experience level, as well as a full system instrument safety freeze or swap simply at the press of a button by the lead surgeon (39,40). Additionally, these systems include a 3-dimensional pointer which can be used in real time and provide the lead surgeon with an opportunity for telestration to teach techniques and guide procedures without actively manipulating the instruments him or herself for demonstration purposes (39,41). Though far from universal in their use, these educational features of the robotic platforms do offer unique educational advantages that are not afforded via laparoscopy.

In addition to the potential educational advantages provided by the robotic systems, there may be a competitive advantage for hospitals that offer robotic surgery, as literature has found that there is growing patient interest in robotic-assisted surgery (42), particularly in the United States, and that patients worldwide believe that both hospitals and surgeons offering robotic surgery are better than those that do not offer robotic surgery (43). Furthermore, some studies have found that current surgical trainees have greater interest in robotic surgery than in either open or laparoscopic surgery (44). These interests and perceptions combine to create an atmosphere in which hospitals reasonably might choose to invest in robotic surgery programs in order to remain attractive to both patients and younger surgeons, subsequently putting pressure on established surgeons who did not master or have access to robotic training during residency or earlier in their careers either to learn and/or perform robotic surgery. Given that trainees have attributed attendings’ limited experience and comfort with robotics as a primary barrier to educational value (in the form of resident autonomy) during robotic surgery (33,44), pressure on established surgeons to adopt robotics could result in a significant loss of educational opportunities for trainees to learn laparoscopic technique from seasoned educators. While studies from both developing nations (45) and parts of Europe (46) demonstrate relatively limited public understanding of and trust in robotic assisted surgery (47), and therefore lower patient-driven demand, data indicate that attitudes toward robotic surgery are more favorable in developed countries (48) which might indicate that increased public understanding of robotic surgery will result in increased interest and later pressure for hospitals and surgeons to adopt the technology.

As it currently stands, general surgical trainees face a world in which the robotic surgical platform plays an increasingly central role. Due to significant uncertainty regarding the effectiveness of the robotic platform as a training tool in surgical education, coupled with still unanswered questions regarding the benefits of the technology either from a clinical or economic perspective, one must approach the rising ubiquity of the platform in surgical training with an appropriate degree of caution. Particularly in light of evidence indicating the educational value derived by trainees from robotic cases is diminished for reasons discussed previously, plus the afore-mentioned negative skill transference when transitioning from robotics to laparoscopy, and that robot platforms are not necessarily ubiquitous in hospitals throughout the developing or even the developed world, a world in which today’s surgical trainees rely on advanced technologies to develop safety and skill but fail to develop surgical technique with haptic feedback may inadvertently endanger tomorrow’s patients and the integrity of our profession.

It seems likely that trainees are correct in their view that the robotic platform will be important in their future specialties and practices. However, while it is necessary to welcome new surgical technology, such tools in the surgical armamentarium must not be embraced at the expense of learning the fundamentals of surgical skills (whether for robotic, laparoscopic, or open surgery) during the period of time devoted to the acquisition of these skills. While it remains to be determined whether the acquisition of robotic mastery is best done during initial surgical training or at a later time, there is no question that the incorporation of robotics in surgical training requires deliberate, intentional, and thoughtful action in order to embrace these technological advances and prepare the next generation of surgeons for an evolving practice environment while still safeguarding both surgical proficiency and patient safety in all approaches.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article has undergone external peer review.

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-24-20/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-24-20/coif). A.F. serves as the co-Editor-in-Chief of Annals of Laparoscopic and Endoscopic Surgery from April 2016 to April 2026. G.S.F. serves as an unpaid editorial board member of Annals of Laparoscopic and Endoscopic Surgery from April 2023 to March 2025. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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