title: Robotic surgery: disruptive innovation or unfulfilled promise? A systematic review and meta-analysis of the first 30 years.
abstract: Robotic surgery has been in existence for 30 years. This study aimed to evaluate the overall perioperative outcomes of robotic surgery compared with open surgery (OS) and conventional minimally invasive surgery (MIS) across various surgical procedures.
  
  
  
  MEDLINE, EMBASE, PsycINFO, and ClinicalTrials.gov were searched from 1990 up to October 2013 with no language restriction. Relevant review articles were hand-searched for remaining studies. Randomised controlled trials (RCTs) and prospective comparative studies (PROs) on perioperative outcomes, regardless of patient age and sex, were included. Primary outcomes were blood loss, blood transfusion rate, operative time, length of hospital stay, and 30-day overall complication rate.
  
  
  
  We identified 99 relevant articles (108 studies, 14,448 patients). For robotic versus OS, 50 studies (11 RCTs, 39 PROs) demonstrated reduction in blood loss [ratio of means (RoM) 0.505, 95 % confidence interval (CI) 0.408-0.602], transfusion rate [risk ratio (RR) 0.272, 95 % CI 0.165-0.449], length of hospital stay (RoM 0.695, 0.615-0.774), and 30-day overall complication rate (RR 0.637, 0.483-0.838) in favour of robotic surgery. For robotic versus MIS, 58 studies (21 RCTs, 37 PROs) demonstrated reduced blood loss (RoM 0.853, 0.736-0.969) and transfusion rate (RR 0.621, 0.390-0.988) in favour of robotic surgery but similar length of hospital stay (RoM 0.982, 0.936-1.027) and 30-day overall complication rate (RR 0.988, 0.822-1.188). In both comparisons, robotic surgery prolonged operative time (OS: RoM 1.073, 1.022-1.124; MIS: RoM 1.135, 1.096-1.173). The benefits of robotic surgery lacked robustness on RCT-sensitivity analyses. However, many studies, including the relatively few available RCTs, suffered from high risk of bias and inadequate statistical power.
  
  
  
  Our results showed that robotic surgery contributed positively to some perioperative outcomes but longer operative times remained a shortcoming. Better quality evidence is needed to guide surgical decision making regarding the precise clinical targets of this innovation in the next generation of its use.
authors.affiliation: Department of Surgery and Cancer, Imperial College London, 10th Floor QEQM Building, St. Mary's Hospital, London, W2 1NY, UK.
authors.forename: Alan
authors.initials: A
authors.lastname: Tan
authors.affiliation: Department of Surgery and Cancer, Imperial College London, 10th Floor QEQM Building, St. Mary's Hospital, London, W2 1NY, UK. h.ashrafian@imperial.ac.uk.
authors.forename: Hutan
authors.initials: H
authors.lastname: Ashrafian
authors.affiliation: Department of Surgery and Cancer, Imperial College London, 10th Floor QEQM Building, St. Mary's Hospital, London, W2 1NY, UK.
authors.forename: Alasdair J
authors.initials: AJ
authors.lastname: Scott
authors.affiliation: Department of Surgery and Cancer, Imperial College London, 10th Floor QEQM Building, St. Mary's Hospital, London, W2 1NY, UK.
authors.forename: Sam E
authors.initials: SE
authors.lastname: Mason
authors.affiliation: Department of Surgery and Cancer, Imperial College London, 10th Floor QEQM Building, St. Mary's Hospital, London, W2 1NY, UK.
authors.forename: Leanne
authors.initials: L
authors.lastname: Harling
authors.affiliation: Department of Surgery and Cancer, Imperial College London, 10th Floor QEQM Building, St. Mary's Hospital, London, W2 1NY, UK.
authors.forename: Thanos
authors.initials: T
authors.lastname: Athanasiou
authors.affiliation: Department of Surgery and Cancer, Imperial College London, 10th Floor QEQM Building, St. Mary's Hospital, London, W2 1NY, UK.|Institute of Global Health Innovation, Imperial College London, London, SW7 2NA, UK.
authors.forename: Ara
authors.initials: A
authors.lastname: Darzi
mesh_terms: D016063:Blood Loss, Surgical / Q000706:statistics & numerical data*; D001803:Blood Transfusion / Q000706:statistics & numerical data*; D006801:Humans; D010535:Laparoscopy; D007813:Laparotomy; D007902:Length of Stay / Q000706:statistics & numerical data*; D019060:Minimally Invasive Surgical Procedures; D061646:Operative Time; D011183:Postoperative Complications / Q000453:epidemiology*; D011446:Prospective Studies; D065287:Robotic Surgical Procedures; D013514:Surgical Procedures, Operative
keywords: Conventional surgery; Perioperative outcomes; Robotic surgery