Robot-assisted surgery in thoracic and visceral indications

In robot-assisted surgery, the surgeons control the instruments with a telemanipulator. This technology allows for a higher mobility than the human hand, thus ensuring a high degree of precision. Robot-assisted surgery should result in benefits in terms of complications, disease-free survival, quality of life, and resource consumption compared to open surgery or laparoscopy. Our systematic review examined thoracic and abdominal surgery and concluded that there is insufficient evidence to confirm these claims. There is insufficient evidence for nine of the 13 investigated procedures to demonstrate the benefits of robot-assisted surgery versus laparoscopy and open surgery. No randomised controlled trials (RCTs) could be identified for thoracic indications. Four non-randomised controlled trials (nRCTs) with a total of 114 patients treated with robots were included. The indications in the abdominal area were divided into four major areas: oesophagus, stomach, bowel and gall bladder/liver/hernia. For indications in the area of the oesophagus, a total of five RCTs and two nRCTs were found, for stomach three RCTs, for bowel seven RCTs and for gallbladder/liver/hernia four RCTs and three nRCTs were included. In addition, in most studies, the relevant endpoints were either not reported, not measured, or showed no statistically significant differences. About forty studies are ongoing or are in the planning phase. The majority of them investigate robot-assisted surgery in rectal resection, gastrectomy, hernia repair, oesophagectomy, lobectomy. However, only five of them include more than a thousand patients. The first results are expected from 2021. These studies should provide more evidence of higher quality to allow making more concrete statements regarding the clinical benefit of robot-assisted surgery versus laparoscopy or open surgery. There was some low to moderate quality evidence only for four of the assessed procedures (oesophagectomy, gastrectomy, rectal resection, cholecystectomy) and only for some of the outcomes of these procedures. Most of the findings were in favour of robot-assisted surgery over the comparators. These findings are subject to uncertainty due to the quality of evidence. Robot-assisted surgery is currently much more costly than conventional surgical techniques. To justify its price, the robot-assisted surgery would have to deliver more evidence to demonstrate its benefits.