The paradigm shift in robot surgery: current strategies and upcoming challenges

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INTRODUCTION: EVOLUTION OF ROBOT SURGERY

When robotic surgical systems were first introduced, initial evaluations focused on whether they could match the efficacy of conventional laparoscopy. Concerns were raised regarding their excessive bulk, potential safety issues—specifically the difficulty of responding rapidly to intraoperative emergencies after setup—and the steep learning curve that resulted in longer operative times compared to established methods. Above all, the high cost remained a significant barrier [1].

However, the advancement of robotic systems has exceeded expectations, securing enhanced efficiency, safety, and speed. Consequently, increasing patient satisfaction has led more individuals to opt for robotic procedures despite the higher costs. In Korea, there has been a sharp rise in preference for laparoendoscopic single-site surgery (LESS), particularly among young women undergoing gynecological procedures. While LESS was difficult to universalize due to its limited range of motion and the high physical strain on surgeons relative to low medical fees [2], the da Vinci Si system enabled a transition to robotic single-site surgery. Ultimately, Korea has come to lead the global introduction and application of the da Vinci SP (Single Port) system [3].

CLINICAL DEMAND AND TECHNOLOGICAL ADVANCEMENT

As social trends shift toward increased female professional activity and delayed childbirth, the incidence of gynecological surgery among young women has risen. These patients demand minimal postoperative pain, rapid recovery for an immediate return to work, and superior cosmetic outcomes with hidden scars. Simultaneously, since sophisticated surgery is required to preserve fertility for future pregnancies, the popularity of robot surgery—especially robotic single-site surgery—is steadily increasing in the field of gynecology.

Conventional laparoscopy is based on 2D imaging and utilizes rigid, rod-like instruments with limited degrees of freedom, requiring extensive training to master fertilitysparing techniques. To overcome these limitations, robot surgery emerged as a groundbreaking platform. Since the da Vinci S system, the platform has been continuously upgraded through the Si, Xi, X, and SP models, reaching the latest dV5.

ACADEMIC MILESTONES AND RESEARCH PROGRESS

Uterine myoma is a common gynecological condition in women of reproductive age. Due to the limitations of laparoscopy and the associated risk of uterine rupture during pregnancy, the transition to robot surgery has accelerated. Furthermore, following the ban on power morcellation for removing resected myomas, manual “chopping” via the umbilicus has become common practice, highlighting the advantages of the single-site approach.

Since reporting on robotic single-site myomectomy using the da Vinci Si system in 2017 [4], we have accumulated clinical data on robot surgery for endometriosis and adenomyosis [5,6]. To optimize these new systems, we have concurrently conducted research on preoperative imaging and intraoperative anesthesia to ensure efficiency and safety [7-9]. Following a 2020 publication of 626 cases of robotic single-site surgery for benign gynecological diseases [10], we have expanded the application of the newly introduced da Vinci SP system [11,12]. Our research has further extended to fertility preservation, including the preservation of ovarian reserve in endometriosis patients [13].

THE FUTURE: AUTOMATION AND ARTIFICIAL INTELLIGENCE (AI)

What lies ahead for the future of gynecological robotic surgery? Much like autonomous driving in the automotive industry, the automation of robotic surgery is no longer an impossible dream. Given the current medical environment and training challenges—both in Korea and abroad—developing autonomous robotic systems may eventually prove more feasible than producing a steady supply of highly skilled surgeons. Programs like “My Institute” already analyze and accumulate individual surgeon data, while the da Vinci SP and dV5 systems feature integrated “Hub” systems that facilitate remote surgical education and data sharing.

The current limitations of artificial intelligence (AI) in clinical practice are not a matter of technical capability, but rather a question of whether the scale of the target population justifies the social cost-effectiveness and whether manufacturers can assume liability for complications. While current consensus suggests we are “choosing not to” rather than “unable to” implement full autonomy, the unpredictable pace of robotic evolution suggests a future surgical landscape that may defy current expectations.

CONCLUSION

We have evolved from open surgery to laparoscopy, reduced the number of trocars to develop single-site techniques, and upgraded to robotic systems that add humanlike degrees of freedom to surgical instruments. The next task is to determine how and where to apply AI to propel robot surgery to the next level. In doing so, we must remain mindful of the social and ethical issues that accompany such cutting-edge medical innovations.

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