潘金莲传媒映画

For a field in a constant state of development due to advancing knowledge, technique, and technology, no transition over the past 40 years has changed the surgical landscape as much as the shift toward minimally invasive surgery (MIS) from open surgery.

In disciplines ranging from general surgery to neurosurgery to urology, in procedures ranging from cholecystectomy to craniotomy to prostatectomy, surgeons using MIS often provide patients with equal or superior outcomes compared to open surgery, in addition to fewer complications, shortened hospital stays, and faster recovery, among other benefits.^1,2

MIS encompasses a range of modalities that surgeons around the world are learning, employing, and studying to determine the approach that best meets the needs of their patients and their own professional circumstances and skills鈥攁nd the field may be at an inflection point that will determine where the focus will lie in the future.

While MIS has undeniably taken a prominent role, open surgery is still being practiced and remains a core part of the profession鈥攁nd both approaches have implications for the future of surgery.

Shifting Scales Between Robotics and Laparoscopy

The history of MIS is long, but its modern conception for several specialties such as general surgery found its footing with the proliferation of laparoscopes in the 1980s and 1990s. Since then, laparoscopic surgery rapidly grew and became the 鈥済old standard鈥� of several high-volume procedures like appendectomy or cholecystectomy.³

But in 2025, many surgeons will likely have noticed that robotic surgery, or robotic-assisted surgery, is receiving significant attention in research and use across a range of procedures. The data reveal a notable trend that represents a primary conversation in modern MIS: in general, robotic surgery seems to be waxing and, concomitantly, laparoscopic surgery may be waning for several common surgical procedures.⁴

In fact, some research suggests robotic surgery will overtake, or already has overtaken, laparoscopic surgery in a variety of procedures, including prostatectomy, pancreatectomy, and hepatectomy, among others.⁵

The question is: Why is robotic surgery seeing such rapid growth today?

鈥淟aparoscopy really hasn鈥檛 changed since the 90s. It still uses the same instrumentation, so there鈥檚 no technology that has improved beyond the fidelity of the cameras,鈥� said David W. Larson, MD, MBA, F潘金莲传媒映画, a colorectal surgeon at the Mayo Clinic and professor of surgery at the Mayo Clinic Alix School of Medicine, both in Rochester, Minnesota. 鈥淵ou are looking at more than 30 years of no real technological development.鈥�

At the same time, robotic platforms are rapidly iterating, with the most popular multiport robots entering their fifth generation, while single-port platforms are gaining US Food and Drug Administration approval.

鈥淭hese platforms have all built upon each other, and each one is better than the last, supplying surgeons with new, more improved technology that鈥檚 faster, more efficient, more facile, and takes less cognitive burden,鈥� Dr. Larson said.

Overall, robotic surgery platforms have been advancing toward more complete intraoperative imaging, as well as a more comfortable operating experience for surgeons.

鈥淲ith laparoscopy, you鈥檙e using more two-dimensional cameras. You鈥檙e using straight stick instruments that have some flexibility in them. But in robotics, the difference is, you have 3D visualization and camera technology鈥攚hich does exist for laparoscopy, but it鈥檚 not as universal,鈥� said Rana Higgins, MD, F潘金莲传媒映画, a minimally invasive general and bariatric surgeon at Froedtert Hospital in Milwaukee, Wisconsin, and an associate professor of surgery at the Medical College of Wisconsin (MCW) in Milwaukee.

鈥淩obotic technology universally has 3D visualization and camera technology, and the instruments are wristed鈥攖here is also a difference, ergonomically, between the two, as laparoscopy requires standing with your arms up next to the patient while robotics allows you to sit,鈥� she said.

Those wristed instruments and the overall ergonomics of performing surgery are proving to be critical, defining benefits of robotic approaches. These benefits are more in reference to how a surgeon efficiently works through a procedure, and less regarding surgeon neck, shoulder, and back comfort, although the positive impact of these advantages is undeniable.

Adapting to Robotics

This innate familiarity with the manual ergonomics of robotic surgery has implications not just when considering performing a robotic versus laparoscopic procedure, but also for how surgeons conceptualize the transition from open surgery to MIS.

鈥淲ith robotic surgery, I can move instruments like my hand. In laparoscopy, they鈥檙e just straight sticks. So, the jump from open to robotics is a much more direct path,鈥� Dr. Larson said. 鈥淭he operation and how it鈥檚 performed, the movements鈥攖he ergonomics of it all is much more similar between robotics and open than they are from laparoscopy.鈥�

Mid-career or more experienced surgeons who have been performing laparoscopy for years had to learn an entirely different way of doing things, because the instrumentation does not move like the hand, he added.

With robotics, the transition from open surgery practice was more direct. This conversion has been particularly noticeable and transformative in some specialties in which laparoscopy did not find a foothold, such as urology, gynecology, and surgical oncology. In these, the ability of robotic platforms to provide superior visualization in compact spaces and more precise movements around sensitive or healthy tissue has resulted in superior outcomes.

General surgeons are likely to face the most challenges when deciding between laparoscopy and robotics as this specialty relies heavily on laparoscopes that can take advantage of larger operative space. But even within that field, common, high-volume procedures such as hernia repair may benefit from a robotic approach.

鈥淭here are studies to show that the learning curve for a laparoscopic inguinal hernia repair is longer than the learning curve for a robotic inguinal hernia repair,鈥� said Dr. Higgins, who also specializes in minimally invasive hernia repair. 鈥淚n addition, robotics may provide the ability to do more complex ventral hernia repairs in more ergonomically challenging positions in ways that you couldn鈥檛 do laparoscopically because you were limited by the technology.鈥�

Hernia repair is an example of how robotic platforms provide an opportunity to perform complex procedures with an ergonomic tool. An element as fundamental as suturing can be transformed into a learned skill that comes more naturally to surgeons with this technology.

鈥淎s an MIS surgeon, I do laparoscopic suturing all the time, but it is easier to teach a resident how to do robotic suturing, because it makes more sense. You鈥檙e using wrists as opposed to straight stick suturing with laparoscopy. While an incredibly important skill, it is not realistic to say that everyone is going to be a master at advanced laparoscopic suturing,鈥� Dr. Higgins said.

鈥淭he technology provides an opening for surgeons to give patients minimally invasive approaches that they may not have had if they didn鈥檛 feel comfortable or have the training or exposure to do it laparoscopically,鈥� she added.

Dr. Larson underscored that laparoscopy has a higher skill floor than robotics, meaning that while current practitioners can operate at an expert level, robotic surgery provides additional opportunities for surgeons to be involved in MIS.

鈥淭he surgeons who do laparoscopy at the highest level are incredible technicians, but robotics helps to level out skill for people who aren鈥檛 as technically gifted. They can provide the same outcomes because of the technology,鈥� he said. 鈥淲e鈥檙e upskilling surgeons from the baseline. A rising tide lifts all boats, and to me, robotics is a rising tide that not only benefits the surgeons but significantly benefits patients.鈥�

There also has been a tangible shift toward robotics in terms of the highest-quality research鈥攔andomized controlled trials.

鈥淚鈥檝e been doing robotic surgery since 2008, but we鈥檙e now just starting to see large, randomized control trials that demonstrate robotic superiority over laparoscopy,鈥� Dr. Larson said, noting that at an individual institution level, some of these results started to filter out between 2012 and 2020.

Future Promise, Present Practicalities

While the future appears to be one where the robotic approach will take the lead for many surgical procedures, that transition presently is in its early stages.

To begin with, further studies need to be completed, and research needs to be released providing a higher level of certainty regarding the superiority of robotic or laparoscopic surgery outcomes across the spectrum of disciplines and procedures.

Looking at one of the most common surgical procedures around the world鈥攃holecystectomy鈥攁s an example, current research presents a range of findings. Some indicate that the robotic approach incurs a significant increase in bile duct injury complication rate versus laparoscopic, while others show decreased complications, conversion to open procedures, and shorter hospital stays.^6,7

In this interim period, as additional outcomes research accumulates, one of the most significant questions is related to cost and how that affects availability and the financial practicality of robotic platforms. Robotic surgery is generally found to be a more expensive approach in terms of intraoperative activities and infrastructure,⁸ though there is a down trending of costs for robotics over time in certain disciplines such as bariatrics.⁹

Existing OR infrastructure, in particular, could prove to be another financial challenge.

鈥淚n terms of hospital resources, we have hundreds of operating rooms in at the Mayo Clinic, and each one of them has a laparoscopic tower. So, I can do laparoscopy in every single OR, but I can鈥檛 do robotics. That鈥檚 a huge frame shift for hospitals鈥攕o as laparoscopy diminishes, we鈥檒l need to retool the operating room so that we can do robotics,鈥� Dr. Larson said.

鈥淚鈥檓 not saying just jettison all of our laparoscopic equipment in every OR in the US, but we need to start thinking about the entire ecosystem,鈥� he said. While surgeons over time may 鈥渧ote with their feet鈥� and move toward robotics, there often are administrative and political considerations that are tied to funding the transition to the new technology.

Open Surgery and Future of Surgical Education

The current era of surgery is defined by MIS, and both patients and surgeons continue seeking operations that lead to easier recovery, fewer complications, and improved outcomes.

However, open surgery remains a necessary part of a surgeon鈥檚 toolkit. Areas such as trauma, major oncologic resection, and organ transplantation continue to be mainly performed through open surgery because of ingress and egress to the operative space, as well the need to manually manipulate large tissue or organs (although even in these, MIS is advancing¹⁰).

Another reality that any surgeon employing MIS for an operation may encounter is converting to open if a surgeon does not feel that they are able to manage an unforeseen challenge鈥攕car tissue, bleeding, or complex anatomy鈥攚ith a robotic or laparoscopic approach. Conversion to open across specialties is associated with detrimental outcomes for patients and hospitals compared with a procedure with no conversion.¹¹

So, whether through circumstance, preference, or necessity, open surgery will always need to be an option for delivering the highest-quality outcome possible for patients.

鈥淎s a minimally invasive surgeon, many of my procedures that I do are minimally invasive, but I also need to know its limitations,鈥� Dr. Higgins said. 鈥淚f a patient isn鈥檛 tolerating the insufflation from minimally invasive surgery, that鈥檚 not what鈥檚 best for the patient, and then you convert to open. You need to have all the tools in your toolbox. It鈥檚 not fair to patients for us to just know one way, and only that way.鈥�

While mastery of open surgery is essential for comprehensive surgical competence, surgical residents are, statistically, performing fewer open operations in their course of their training.¹² Experienced surgeons recognize that for as much as surgery is continuing to shift toward MIS, a lack of skill with open surgery imperils patient safety.

The core knowledge imparted by open surgery training, including a tactile understanding of a patient鈥檚 unique anatomy and disease presentation, remains a critical underpinning for MIS.

To that end, residency training must continue pushing forward with including evolving MIS technology and techniques, while also allowing adequate exposure to open surgery.

鈥淚 emphasize to the residents to get as much exposure as they can to open operative cases, which is even more important today because it is becoming less common,鈥� said Dr. Higgins, who also is the General Surgery Residency Program director at MCW.

鈥淲e stress that residents try to take advantage of being in those cases, even if you鈥檙e not the first assist surgeon or the most senior resident. Even if you鈥檙e a more junior resident, get exposure to as much as you can see,鈥� she said.

For open surgery, exposure refers to understanding how a case is set up to begin with.

鈥淚f you鈥檙e seeing less open surgery, it鈥檚 difficult to really get comfortable with that. You may understand inguinal anatomy, but if you don鈥檛 know how to set up an open inguinal hernia repair, you鈥檙e not going to do right by the patient,鈥� Dr. Higgins said.

A major part of contemporary surgical education, and an effective way to address growing gaps with open surgery experience, is surgical simulation. While wet labs and core curricula continue to grow around MIS, simulation provides a safe environment to grow skills in all surgical modalities and is becoming a critical part of residency training for surgery because of duty-hour restrictions and lessened operative experience for junior residents.

Simulation acts as an adjunct for resident training that should include robotic, laparoscopic, and open components. For both cases鈥攕etup for open surgery and using the powerful visualization and manipulation tools in the various forms of MIS鈥攕imulation has become a core part of residency training to bring trainees up to a level of proficiency that produces high-quality outcomes and provides patient safety.

鈥淲e never have our residents just jump in and start doing minimally invasive surgery. They all need to do a robotic training curriculum, they all need to complete a laparoscopic curriculum, and so on. Simulation is a must for training programs to introduce residents to the technology in a safe, protected environment before they perform these techniques on a patient,鈥� Dr. Higgins said.

The conversations happening within MIS, open surgery, and surgical training are developing, and will expand well beyond the scope of this article. Within clinical care itself, evolving technology and the balance of current practicalities and future potential will require surgeons to take the lead and emerge from this inflection point in a way that ensures patients are receiving the best possible care.

Matthew Fox is the Digital Managing Editor in the ACSDivision of Integrated Communications in Chicago, IL.

References

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