Advances in Robotic Surgery: A Review of New Surgical Platforms

Abstract

In recent decades, the development of surgical systems which minimize patient impact has been a major focus for surgeons and researchers, leading to the advent of robotic systems for minimally invasive surgery. These technologies offer significant patient benefits, including enhanced outcome quality and accuracy, reduced invasiveness, lower blood loss, decreased postoperative pain, diminished infection risk, and shorter hospitalization and recovery times. Surgeons benefit from the elimination of human tremor, ergonomic advantages, improved vision systems, better access to challenging anatomical areas, and magnified 3DHD visualization of the operating field. Since 2000, Intuitive Surgical has developed multiple generations of master-slave multi-arm robots, securing over 7000 patents, which created significant barriers for competitors. This monopoly resulted in the widespread adoption of their technology, now used in over 11 million surgeries globally. With the expiration of key patents, new robotic platforms featuring innovative designs, such as modular systems, are emerging. This review examines advancements in robotic surgery within the fields of general, urological, and gynecological surgery. The objective is to analyze the current robotic surgical platforms, their technological progress, and their impact on surgical practices. By examining these platforms, this review provides insights into their development, potential benefits, and future directions in robotic-assisted surgery.

1. Introduction

In recent decades, robotics has expanded beyond traditional industrial applications to address a variety of human needs, particularly in healthcare [1,2]. Among its most transformative advancements is the integration of robots in the medical field, especially in surgery. Robot-assisted surgical systems (RASSs) have revolutionized minimally invasive surgery (MIS), enabling surgeons to perform intricate procedures with heightened precision, dexterity, and control [3,4]. Initially met with scepticism, robotic surgery has gained widespread acceptance as technological improvements have enhanced system reliability. Today, robotic procedures are increasingly common, accounting for approximately 3% of all surgeries globally and offering patients benefits such as fewer complications, faster recovery, shorter hospital stays, and quicker returns to normal activities [5,6,7]. Analysis of 108 studies involving 14,448 patients [5] showed that robotic surgery, compared with open surgery, reduces blood loss by 50.5%, transfusion rates by 27.2%, hospital stays by 69.5%, and 30 day complications by 63.7%. Also, compared with minimally invasive surgery (MIS), robotic surgery reduces blood loss (85.3%) and transfusion rates (62.1%).

In surgical applications, robotic systems excel due to their ability to perform complex tasks in confined spaces with unmatched precision. These systems, characterized by their small size, optimized force control, and accuracy, are particularly impactful in specialties such as urology, gynecology, and general surgery, where they help minimize tissue trauma [3,4,5,6]. Consequently, robotic surgery has seen significant growth in these fields compared with others, as they represent the most widely adopted areas of robotic surgery [8,9,10].

Despite these advancements, widespread adoption of robotic surgery faces several hurdles. High system costs, complex technology, a challenging patent landscape, and strict regulatory barriers hinder their integration into routine practice [11]. Furthermore, the time-intensive and resource-heavy training required to familiarize surgeons with robotic techniques limits accessibility, particularly in resource-constrained healthcare systems [12,13,14].

The da Vinci system by Intuitive Surgical^® has dominated the robotic surgery market for over two decades, with more than 7500 installations and 11 million procedures performed as of early 2023 [15,16]. However, the expiration of key patents is reshaping the competitive landscape, enabling new players to introduce alternative robotic systems [7] which aim to challenge da Vinci’s market dominance [2,17,18].

This narrative review presents a comprehensive examination of the latest robotic systems—representing alternatives with respect to Intuitive Surgical^®’s device—developed for urology, gynecology, and general surgery, many of which were not covered in prior reviews because they were not yet developed. These specialties were chosen because they represent the most widely performed robotic surgeries [10], reflecting the areas where robotic systems have had the greatest impact. Additionally, this review uniquely emphasizes the technical characteristics of these systems. By analyzing these emerging platforms, this review provides a detailed understanding of their innovations, operational efficiencies, and clinical outcomes, highlighting their potential advantages and limitations.

2. Materials and Methods

A narrative literature review was conducted to provide a comprehensive overview of the surgical systems available for use in urology, gynecology, and general surgery. The focus of this review on these three surgical specialties was due to their prevalence as the most commonly performed procedures in robotic surgery [8,9,10].

An initial search was performed in the gray literature and online sources to identify robotic platforms which have recently become available on the market, specifically focusing on systems developed by manufacturers other than Intuitive Surgical^®.

An electronic search was conducted across the PubMed, Scopus, and Web of Science databases up to June 2024. The following keywords were used to perform the search: “avatera surgical robot”, “senhance surgical robot”, “canady surgical robot”, “revo-i surgical robot”, “autolap surgical robot”, “enos surgical robot”, “micro hand s surgical robot”, “hugo surgical robot”, “mira surgical robot”, “vicarios surgical robot”, “anovo surgical robot”, “dexter surgical robot”, “emaro surgical robot”, “vista surgical robot”, “panorama surgical robot”, “Endomaster EASE system surgical robot”, “hinotori surgical robot”, “EPIONE surgical robot”, “LBR Med surgical robot”, “XACT surgical robot”, “Galen surgical robot”, “Versius surgical robot”, “Bitrack surgical robot”, “Verb surgical robot”, “SurgiBot surgical robot”, “PROCEPT surgical robot”, “Roboflex surgical robot”, “Flex surgical robot”, “Monarch surgical robot”, “Maestro surgical robot”, “Mantra surgical robot”, “Kangduo surgical robot”, “Sensei X surgical robot”, and “Toumai surgical robot”.

The following criteria for inclusion were employed in the article selection process:

• Written in the English language.
• Full articles excluding reviews, perspectives, and communications.
• Full text available.
• Published from 2014 to June 2024.
• Any general surgery intervention performed in gynecology, urology, or general surgery.
• Any robotic system which has a console.

Otherwise, the following exclusion criteria were considered:

• Articles which contained simulations and tests.
• Papers centered on telesurgery, telementoring, or telepresence.
• Studies which report only the procedure.
• Papers related to studies on animals or cadavers.
• Articles concerned with surgeon training.

The references from the review were examined to identify relevant papers for inclusion in the research. The titles and abstracts of the articles were screened to evaluate their relevance based on the inclusion and exclusion criteria.

3. Results

During the keyword searches in the relevant databases, several of the previously mentioned robotic platforms were excluded for two primary reasons; either they were not relevant to the specific surgical specialties under investigation, or there were no related articles available in the scientific literature.

Consequently, the following robots were retained for further consideration: Avatera, Senhance^®, Revo-i^®, Micro Hand S, Hugo^TM, Dexter, Hinotori^TM, Versius^®, Mantra, KangDuo, and Toumai^®.

In searching for these robots across databases, a total of 1298 articles were retrieved from the previously mentioned electronic research sources, along with 13 records identified through snowball sampling. After eliminating duplicates, 856 papers were left. Screening the titles and abstracts led to the exclusion of 649 items. Of the 197 articles which remained, 73 did not fulfil the inclusion criteria. The selection process is illustrated in the PRISMA flowchart (Figure 1).

Appendix A provides a comprehensive list of the 124 papers which were included in this review. Alongside each entry, the key characteristics are detailed, including the surgical platform used, the surgical specialty, the publication year, and the country of origin.

This section is dedicated to presenting the findings of the review. The first paragraph (Section 3.1) offers an in-depth analysis of the characteristics of the studies under consideration, highlighting important aspects of their methodologies. In the second paragraph (Section 3.2), a summary of the technical features of each platform is provided, allowing for a comparative analysis which underscores the distinctions and similarities among them.

3.1. Studies’ Characteristics

Among the studies included in this review, there were 22 case reports [19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40], 73 non-comparative studies [41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113], and 27 comparative studies [114,115,116,117,118,119,120,121,122,123,124,125,126,127,128,129,130,131,132,133,134,135,136,137,138,139,140,141,142]. In the majority of the comparative studies, the da Vinci robot served as the primary comparator (n = 23), though in some cases, traditional laparoscopy (n = 6) and open surgery (n = 1) were also used. Of the comparative studies, only four were randomized controlled trials (RCTs).

Considering the studies included in this review, the total number of patients treated with the new platforms was 4993. The reported cases belong to different surgical specialties: general surgery, urology, and gynecology [19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119,120,121,122,123,124,125,126,127,128,129,130,131,132,133,134,135,136,137,138,139,140,141,142].

Table 1. The number of patients treated with a new surgical platform by specialty and surgical robot.

	Robotic Platform
Surgical Specialty	HugoTM	Versius®	Senhance®	Revo-i®	Micro Hand S	Avatera	Dexter	HinotoriTM	Mantra	KangDuo	Toumai®
General Surgery	126	607	764	27	277	-	12	33	10	101	-
Gynecology	253	204	114	-	-	-	1	12	-	-	-
Urology	962	86	1036	48	-	9	11	105	-	175	20

reports the number of patients treated with the new surgical platform divided by specialty.

The majority of the papers included in the review were studies conducted in Italy (n = 24), Japan (n = 20), China (n = 18), Belgium (n = 7), and Germany (n = 7). Figure 2 reports the number of papers for each country.

3.2. Surgical Robotic Platforms

In this section, the new surgical robotic platforms are described, and a technical comparison is reported.

Table 2. Main information about the new surgical platforms.

Surgical Platform	Company	Year	Country	CE Mark	FDA Approval	Approved in the Origin Nation
Senhance®	TransEnterix Surgical, which became Asensus Surgical in 2021, Durham, NC, USA	2017	USA	yes	yes	yes
Revo-i®	Meerecompany, Yongin, Gyeonggi-do, Republic of Korea	2017	Republic of Korea	no	no	yes
Micro Hand S	Shandon Wego Surgical Robot Co., Weihai, Shandong, China	2017	China	no	no	yes
Toumai®	Shanghai MicroPort MedBot (Group), Shanghai, China	2018	China	no	no	yes
Avatera	Avatera Medical, Jena Germany	2019	Germany	yes	NAI	yes
Versius®	CMR Surgical, Cambridge, UK	2019	UK	yes	no	yes
HinotoriTM	Medicaroid Inc., Kobe, Japan	2020	Japan	no	yes	yes
KangDuo	Suzhou KangDuo Robot Co., Suzhou, Jiangsu, China	2020	China	NAI	no	yes
HugoTM	Medtronic, Minneapolis, Minnesota, USA	2021	USA	yes	yes	yes
Dexter	Distalmotion, Epalinges, Switzerland	2022	Switzerland	yes	no	yes
Mantra	SS Innovation, Gurugram, Haryana, India	2023	India	ongoing	ongoing	yes

NAI = no available information; CE = European conformity; FDA = Food and Drug Administration.

reports the main information about the surgical robotic platforms included in this review.

3.2.1. Senhance^®

The Senhance^® surgical system [143], developed by TransEnterix Surgical, Inc., is a robotic platform designed to improve precision and control in minimally invasive surgeries. Launched in 2017 after receiving Food and Drug Administration (FDA) clearance and European conformity (CE) mark approval in 2016, Senhance^® (Figure 3) was introduced as a cost-effective alternative to systems like the da Vinci surgical system [127,141]. It incorporates unique features such as haptic feedback, which provides tactile sensations to the surgeon, and eye-tracking camera control, allowing hands-free camera manipulation based on the surgeon’s gaze.

The system uses standard laparoscopic ports, which reduces the learning curve for surgeons accustomed to traditional laparoscopy and makes conversion to standard surgery easier if needed. Senhance^® also features an open cockpit design, where the surgeon sits in a comfortable, ergonomic position at the console, reducing physical strain during long procedures.

Senhance^®’s multi-arm robotic design offers versatility in a wide range of surgeries, including general surgery, gynecology, and urology. Clinical studies and case reports have demonstrated its safety and feasibility [24,25,44,56,91], including its use in procedures such as laparoscopic gastrectomy for gastrointestinal tumors and robotic sigmoidoscopy for colon cancer. In gynecology, a study [57] involving 100 patients showed minimal complications, with average operative times of 145 min. The learning curve was short, improving after 20–30 cases. In general surgery [57], 30 patients undergoing procedures like cholecystectomy and colectomy saw operative times between 75 and 180 min, with no major complications. The learning curve improved after 10–15 cases. In colorectal surgery [47], 45 operations had operative times between 180 and 220 min, with minor complications and a learning curve which plateaued after 20–25 cases.

The system is used in the United States, Europe, and Asia, with notable uptake in Japan following regulatory approval in 2019.

3.2.2. Revo-i^®

The Revo-i^® (Figure 4) robotic surgical system, developed by the South Korean company Meerecompany, was launched in 2017 [144]. It provides an affordable alternative to other robotic systems like the da Vinci system [114,128] to offer lower costs. The system includes a master console which the surgeon operates, translating their movements into the robotic arms for precise, minimally invasive surgeries. The Revo-i^® provides high-definition 3D visualization for enhanced depth perception and magnified views during surgery [20,48].

The system’s robotic arms offer seven degrees of freedom, allowing for flexibility in instrument movements and mimicking the natural movements of a human wrist. Additionally, the system features haptic feedback, enabling surgeons to feel tactile sensations and enhancing precision during tissue manipulation. The Revo-i^® is equipped with advanced optical control and camera-hopping technology, enabling the surgeon to adjust views dynamically during the procedure.

Cost efficiency is a key benefit as the system incorporates reusable instruments [48], significantly reducing the cost per procedure compared with other robotic platforms. The clutching mechanism allows the surgeon to reposition instruments without moving the robotic arms, and this process is operated via finger or foot pedals.

Revo-i^® is used in various surgical fields, including urology, gynecology, general surgery, and thoracic surgery.

3.2.3. Micro Hand S

The Micro Hand S surgical system represents a significant advancement in minimally invasive surgical technology, developed domestically in China. Launched in clinical trials between 2017 and 2019, it was designed to meet the growing demand for precision and efficacy in surgeries, particularly in the realm of robot-assisted procedures [19,120].

One of the standout features of the Micro Hand S is its articulated robotic arms, which offer seven degrees of freedom. This flexibility allows surgeons to perform intricate maneuvers which would be challenging with traditional laparoscopic tools. Coupled with 3D visualization capabilities, the system enhances depth perception and spatial awareness, which are crucial for delicate operations.

The design also prioritizes ergonomics. The surgeon’s console is crafted for comfort, enabling prolonged use without the physical strain which can accompany lengthy procedures. This focus on user experience is complemented by features such as tremor reduction and motion scaling, which help mitigate hand tremors and allow for greater control over instrument movements. Such advancements are particularly beneficial in surgeries where precision is paramount.

The key findings are shown in [119], including significantly lower blood loss in both robotic groups (65.50 mL for da Vinci and 66.54 mL for Micro Hand S) compared with laparoscopic surgery (95.04 mL). Both robotic groups also had lower conversion rates (2.2% for da Vinci and 2.3% for Micro Hand S) compared with laparoscopic surgery (6.8%). However, the operation times were longer for robotic surgeries (230.05 min for da Vinci and 235.03 min for Micro Hand S) compared with laparoscopic surgery (205.53 min).

Clinical evaluations comparing the Micro Hand S to established robotic systems, such as da Vinci, have shown promising results [116,117]. Although the operative time was slightly longer than those for laparoscopic techniques [119], the quality of surgical outcomes remained high, with a notable increase in sphincter-preserving procedures.

3.2.4. Hugo^TM

The Hugo™ robotic-assisted surgery system (Figure 5) [145], developed by Medtronic, represents a significant advancement in minimally invasive surgical technology. Launched in Europe in March 2022, the system has received CE approval for various applications, including gynecological and urological surgeries.

One of the defining features of the Hugo™ RAS system is its modular design, which allows for flexible configurations depending on the surgical procedure. It can accommodate set-ups with three or four robotic arms, enhancing the versatility of the surgical approach. The open console design is another notable aspect; it provides a 3D high-definition visualization system which allows both the surgeon and observers to view the surgical field simultaneously. This is particularly beneficial for training and collaborative surgical environments.

The system is equipped to support a variety of instruments, such as bipolar graspers, monopolar scissors, and needle drivers, all designed to enhance surgical precision. Its docking configurations, including the “compact” and “bridge” set-ups, allow for optimal access to different anatomical areas, reducing the likelihood of instrument collisions, a common challenge in robotic surgery.

While early experiences with the Hugo™ system have shown promising results, including significant symptom relief in procedures such as robotically assisted endometriosis surgery [29,128], further research is needed to compare its effectiveness against established robotic platforms like the da Vinci system [122,129,131,132]. Overall, the Hugo™ RAS system represents a valuable tool for surgeons seeking to enhance their capabilities in complex surgical scenarios.

3.2.5. Hinotori^TM

The Hinotori™ surgical robot system (Figure 6), developed by Medicaroid Inc., marks a significant advancement in robotic surgical technology, particularly within Japan. Launched in 2020 and receiving clinical approval in November 2022, the Hinotori^TM system is designed to enhance surgical precision and patient outcomes in minimally invasive procedures, such as robotic gastrectomy and colorectal surgeries.

One of the distinguishing features of the Hinotori^TM system is its closed console design, which creates a stable and immersive environment for surgeons. This set-up allows for a high-definition 3D visualization of the surgical field, utilizing a 16:9 monitor which expands the surgeon’s view compared with traditional systems. The robotic arms feature eight axes of movement, enabling greater flexibility and reducing the risk of interference between instruments. This enhanced maneuverability is crucial during complex procedures, where precision is paramount.

Hinotori^TM also integrates advanced imaging capabilities, including fluorescence imaging, which helps in identifying critical structures and assessing tissue viability during surgery. While the system currently lacks haptic feedback and eye-tracking features, its ergonomic design and intuitive controls contribute to a more comfortable surgical experience.

Despite being a newer entrant in the market, Hinotori^TM has demonstrated its potential through successful clinical applications [34,89,125,126]. It has gained acceptance in Japan, where it was specifically developed to address the growing demand for robotic surgeries. The system’s pricing is notably lower than that of its primary competitor, the da Vinci system [126,140], which may facilitate wider adoption and accessibility in surgical settings.

3.2.6. KangDuo

The KangDuo surgical system, developed by Kangduo Medical Robotics Co., Ltd. (Suzhou, China), was launched in 2019, and it is based in China. This innovative robotic surgical platform is designed to enhance the precision and effectiveness of minimally invasive surgeries across various medical fields, including general, urological, and gynecological procedures [33,49,123,136].

One of the standout features of the KangDuo system is its high-definition imaging capabilities. While it does not include 3DHD vision, the system provides clear, detailed visuals, which are crucial for surgeons during complex operations. The ergonomic design of the surgical console allows for optimal comfort and control, enabling surgeons to perform intricate tasks with improved dexterity.

The system’s robotic arms are engineered for superior maneuverability, allowing surgeons to navigate through surgical sites with precision. This enhances the ability to perform delicate procedures while minimizing trauma to surrounding tissues. Additionally, the KangDuo system includes advanced fluorescence imaging technology, which aids in the visualization of critical structures and tissues during surgery, improving surgical outcomes.

With a focus on user experience, the KangDuo also features haptic feedback, providing surgeons with tactile sensations which simulate the feel of traditional surgery. This feedback is essential for maintaining control and accuracy. The inclusion of eye-tracking technology further enhances the system’s usability, allowing surgeons to maintain focus and precision throughout a procedure.

The KangDuo Surgical System is CE marked, indicating its compliance with European health and safety standards, and it is commercially available, making it a competitive option in the field of robotic surgery. Its affordability and versatility make it an attractive choice for hospitals and surgical centers looking to adopt robotic-assisted techniques.

3.2.7. Versius^®

The Versius^® surgical robotic system (Figure 7), developed by CMR Surgical, is a innovative platform designed to enhance the precision and accessibility of minimally invasive surgeries. Launched in 2019, Versius^® has gained recognition for its innovative approach to robotic surgery, offering several advantages over traditional systems.

One of the defining features of Versius^® is its modular and flexible design. Unlike conventional robotic systems, which are often bulky and confined to specific set-ups, Versius^® consists of independent robotic arms which can be arranged around the patient as needed. This flexibility allows it to adapt to various surgical environments, making it suitable for a wide range of procedures, including colorectal, urological, gynecological, thoracic, and general surgeries.

The system is controlled by a surgeon console, which provides a high-definition 3D view of the surgical site and hand-held controllers which mimic the natural movements of the human hand. This precise control allows for intricate procedures with improved dexterity and range of motion compared with standard laparoscopic methods. Versius^® was designed with surgeon ergonomics in mind, offering a seated position at the console to reduce fatigue during lengthy operations, a significant improvement over older systems.

3.2.8. Avatera

The Avatera robotic system [149], launched in 2021 by the German company Avatera Medical GmbH (Bavaria, Germany), represents a major advancement in robotic-assisted surgery. Designed with both precision and ease of use in mind, this system offers surgeons enhanced control over minimally invasive procedures, aiming to improve patient outcomes while reducing surgical complexity.

At its core, the Avatera system features a modular design comprising a surgeon’s console and a surgical unit with robotic arms. The console’s slender eyepiece is ergonomically designed to allow the surgeon to maintain visual contact with the operating room team, fostering improved communication throughout procedures. This open design differentiates Avatera from other robotic systems which require the surgeon to be more isolated while operating.

One of the key innovations of the Avatera system is its use of single-use instruments. These disposable instruments not only ensure sterility for every procedure but also significantly reduce the risks associated with cross-contamination and infection. The robotic arms, equipped with seven degrees of freedom, provide surgeons with precise control for intricate tasks such as suturing and dissection, offering a high level of dexterity. The system supports 5 mm trocars, enabling less invasive access points for surgeries and thus promoting quicker recovery times for patients.

Additionally, the system operates on bipolar energy, which ensures safer tissue manipulation by minimizing the depth of energy penetration and reducing potential damage to surrounding tissues. This safety feature makes the Avatera system particularly appealing for complex surgeries.

In one study [68], nine patients underwent transperitoneal robot-assisted dismembered pyeloplasty. All procedures were successfully completed with no reported complications. The draping time for the robotic unit was a median of 10 min (ranging from 7 to 15 min), while the docking time took a median of 17 min (ranging from 10 to 24 min). The console time, or the time spent performing the surgery by the surgeon at the console, had a median of 88 min (ranging from 78 to 116 min).

With its compact, flexible set-up and focus on ergonomics, safety, and accessibility, Avatera is positioned as a cost-effective alternative to existing robotic systems [68], offering a more streamlined and efficient solution for hospitals and surgical teams aiming to adopt robotic technology.

3.2.9. Dexter

The Dexter Robotic System [150], developed by Distalmotion SA in Switzerland and launched in 2020, is a groundbreaking robotic platform designed to enhance minimally invasive surgery. Unlike fully robotic systems which often replace traditional laparoscopic methods, Dexter offers a hybrid approach, combining the precision of robotics with the flexibility of standard laparoscopy. This on-demand set-up allows surgeons to seamlessly switch between robotic and manual control, optimizing workflow and reducing procedure times.

In one study [69], 12 colorectal surgeries were performed using the Dexter Robotic System™. There were no robot-related complications intraoperatively, though two patients required a switch to laparoscopy due to visceral obesity. Overall, there were no major complications within 60 days post-surgery.

Another study [92] reported on 10 robot-assisted radical prostatectomy (RARP) procedures, all of which were successfully completed without complications, conversions to open surgery, or technical failures. The median operative time was 230 min, and the median hospital stay was 3 days.

Dexter’s system consists of a sterile surgeon console, two patient carts, and a robotic endoscope arm. The robotic arms feature seven degrees of freedom and a 75 degree angulation, providing a wide range of motion and high dexterity, which are critical for intricate procedures like suturing or central vascular dissection. The endoscope arm is fully compatible with any 3D endoscopic system, allowing surgeons complete control of camera navigation from the console while ensuring stability and image clarity.

One of Dexter’s significant advantages is its open platform design, allowing integration with existing operating room equipment, including insufflation devices, and 3D optics. This flexibility eliminates the need for specialized or proprietary tools, reducing costs and making it easier to implement in various surgical environments. Additionally, the system uses single-use instruments, such as needle holders and graspers, ensuring sterility and reliability during each procedure.

A key feature of Dexter is its ability to switch between robotic and laparoscopic modes in seconds [69]. The robotic arms can be folded back at the press of a button, providing space for traditional laparoscopic tools and techniques without undocking the robot. This seamless transition is particularly useful in colorectal and gynecological surgeries, where certain tasks may be performed more efficiently through laparoscopy, while others benefit from robotic precision.

3.2.10. Mantra

The SSI Mantra surgical system [151] is a groundbreaking robotic surgical platform launched in 2023 by SS Innovations. Designed to enhance the efficiency and effectiveness of minimally invasive surgeries, the Mantra system (Figure 8) represents a significant advancement in surgical technology, aiming to make robotic surgery more accessible and cost-effective.

In one study [93], 10 patients underwent elective robotic transabdominal pre-peritoneal (rTAPP) hernia repairs, where the average operative time was 113 min. All patients were discharged within 24–36 h. There were no deaths or postoperative complications, including hematoma, seroma, infection, or recurrence, within 30 days.

One of the standout features of the Mantra system is its wristed instruments, which offer unparalleled dexterity. This allows surgeons to perform intricate movements with greater precision, particularly in confined spaces. Coupled with a high-definition three-dimensional camera system, the platform provides enhanced visualization, ensuring that surgeons have a clear and comprehensive view of the surgical field. This combination of advanced instruments and superior optics facilitates complex procedures which may be challenging with traditional laparoscopic techniques.

The port placement flexibility of the Mantra system is another significant advantage. By allowing meticulous placement of ports, the system maximizes the working space and minimizes the risk of complications. This feature is particularly beneficial during procedures like rTAPP hernia repairs [93], where precise maneuvering is crucial.

A key aspect of the SSI Mantra surgical system is its focus on cost-effectiveness. Robotic surgeries have traditionally been associated with high costs, which can limit their availability in many healthcare settings. The Mantra system addresses this concern by providing similar benefits to other robotic platforms at a significantly lower price point. This affordability has the potential to democratize access to robotic surgery, making it a viable option for a broader range of patients.

As the medical community begins to evaluate the long-term implications of the SSI Mantra system, early experiences suggest it is a promising tool for enhancing surgical outcomes while reducing costs. Continued research will be essential to fully understand its advantages and establish its role in the evolving landscape of robotic surgery.

3.2.11. Toumai^®

The Toumai^® surgical robotic platform is a cutting-edge system developed by Shanghai MicroPort MedBot (Group) Co., Ltd. (Shanghai, China), a prominent Chinese company specializing in medical robotics. Introduced in the early 2020s, the platform represents a significant advancement in robotic-assisted surgery, particularly in the field of urology, and it is poised to offer an affordable alternative to the dominant da Vinci robotic system.

The Toumai^® system operates on a master-slave model, where the surgeon controls the robotic arms from a closed console. This set-up allows for precision and dexterity during complex procedures, such as nephrectomies (both partial and radical) and radical prostatectomies. The system includes four robotic arms mounted on a cart which can manipulate instruments with high accuracy.

The platform is equipped with high-definition 3D optics, providing the surgeon with a magnified, immersive view of the surgical field. However, details such as haptic feedback and camera-hopping technology are not disclosed, though these are common in modern surgical robotics for enhancing the precision of procedures. The docking times for surgeries were reported to be efficient, with a median of 20–22 min depending on the type of procedure, and no major robotic malfunctions were observed [94].

3.2.12. Technical Comparison

Table 3. Technical comparison of the surgical platforms.

Surgical Platform	Single Port or Multiport	Chart	Number of Arms	Console	Vision	Fluorescence	Haptic Feedback	Eye Tracking	Instruments
Senhance®	Multiport	multiple	4	Semi-open	3DHD	NAI	yes	NAI	wristed, 5 mm, disposable
Revo-i®	Multiport	single	4	Open	3DHD	yes	yes	yes	rigid with a kit, wristed, unlimited uses, 5 mm
Micro Hand S	Multiport	single	4	Close	3D HD	no	yes	no	wristed, multi-use (20)
Toumai®	Multiport	single	4	Open	3DHD	yes	no	no	wristed, reusable
Avatera	Multiport	single	4	Open	3D HD	no	no	yes	wristed, reusable
Versius®	Multiport	multiple	4	Open	3D HD	yes	no	yes	wristed, disposable
HinotoriTM	Multiport	single	4	Semi-open	3D HD	NAI	no	no	wristed, reusable used up to 10 times
Kangduo	Multiport	single	3	Open	3D HD	yes	yes	NAI	wristed, reusable up to 10 uses
HugoTM	Multiport	multiple	4	Open	3D 4k	NAI	NAI	Yes	NAI
Dexter	Multiport	multiple	3	Open	3DHD	yes	No	NAI	reusable up to 10 times
Mantra	Multiport	multiple	5	Open	3DHD	NA	NAI	NAI	NAI

NAI = no available information.

reports a comparison between the different robotic platforms from a technical point of view.

All of the robots included in the review have a multiport architecture.

Six robotic platforms (Revo-i^®, Micro Hand S, Toumai^®, Avatera, Hinotori^TM, and KangDuo) feature a single patient cart equipped with 3–4 robotic arms. In contrast, other systems utilize a modular multi-arm design where each cart supports a single robotic arm, providing greater flexibility during surgery.

Most robotic surgical systems (Revo-i^®, Toumai^®, Avatera, Versius^®, KangDuo, Hugo^TM, Dexter, and Mantra) use an open console for surgeon vision, allowing the surgeon to remain engaged with the operating room environment. Micro Hand S, however, features a closed console similar to the da Vinci systems, where the surgeon’s face is fully immersed in the vision system for a more immersive experience. Meanwhile, the Hinotori^TM and Senhance^® platforms offer a semi-open console design which includes a visor, enabling the surgeon to maintain communication with the operating room staff while still benefiting from focused visual guidance.

4. Discussion

The evolution of surgical robotics has dramatically transformed the realm of minimally invasive surgery over the past two decades, particularly with the significant impact of the da Vinci system by Intuitive Surgical [1,2,3,4,13,14]. Initially dominating the market due to its advanced capabilities and comprehensive regulatory approvals, the da Vinci system has established a high standard which upcoming robotic platforms now seek to challenge [2,13,14,15,16]. Since the expiration of critical patents in 2019, a wave of new surgical robots has emerged, driven by technological advancements and the need for more cost-effective solutions. Many companies have developed innovative systems, some of which have already secured CE marking in Europe and obtained FDA approval. In some cases, the new robotic platforms include technological innovation. For instance, Senhance^® [43,56] incorporates eye-tracking and haptic feedback, features which could enhance surgeon control and precision compared with the da Vinci system, which notably lacks such advancements. This indicates a shift toward more ergonomic designs which prioritize user experience alongside clinical efficacy.

Furthermore, the design philosophies of newer platforms highlight a significant departure from the centralized multi-arm configuration characteristic of da Vinci. Systems like CMR’s Versius^® [85,109] exemplify a modular approach which enhances flexibility in surgical settings, allowing surgeons to adapt robotic assistance to the specific needs of each operation. This modularity could be particularly beneficial in specialties such as colorectal and hepatobiliary surgery, where the complexity of the procedure demands precise movements. Miniaturization of the system has also become a focal point, introducing compact robots designed for portability and ease of use. Such innovations could democratize access to robotic surgery, especially in smaller medical facilities which may not have the resources to accommodate larger, more expensive systems.

Despite these advancements, several challenges remain in evaluating the clinical efficacy and economic impact of these new robotic platforms. While recent reviews indicate that many surgical procedures performed with these systems have minimal adverse events, the existing studies often feature small sample sizes and lack long-term follow-up data, making it difficult to ascertain definitive conclusions regarding their efficacy. The number of randomized controlled trials in this area must be increased to provide a more robust evidence base for clinical practices.

One of the most significant hurdles to widespread adoption of robotic surgery is the high cost associated with these platforms. The expense of the initial purchase, installation, and ongoing maintenance of robotic systems is substantial, and many healthcare institutions—especially smaller hospitals or those in resource-limited regions—find these costs prohibitive. This financial burden exacerbates disparities in access to robotic surgery, as only well-funded or specialized institutions can afford to integrate these advanced technologies. In turn, this can limit the reach of robotic-assisted surgeries, preventing many patients from benefiting from these cutting-edge procedures.

The cost of robotic instruments, which typically have a limited lifespan of 5–10 uses or a specified number of working hours, further compounds this challenge. Although not all studies provide detailed information on these aspects, reusable robotic instruments offer a significant advantage by reducing both operational costs and environmental impact. Future analyses should explore these cost-related variations in depth to understand their implications for different healthcare settings.

Beyond the financial challenges, the lack of standardized educational curricula for robotic surgery presents another major barrier to adoption. While the da Vinci system has established some training pathways, the increasing diversity of robotic platforms on the market—each with unique features and interfaces—demands a universal training framework. The absence of such a framework complicates the safe and effective transfer of skills across different systems, creating inconsistencies in surgeon proficiency. This issue is further compounded by the limited availability of qualified instructors and the lack of advanced simulation programs. The absence of structured, accredited training programs poses a risk to the proficiency of surgeons, potentially affecting clinical outcomes. A standardized credentialing process, which ensures competence across multiple platforms, could greatly benefit the field, but achieving this will require significant collaboration between industry leaders, regulatory bodies, and medical institutions.

While the da Vinci system has established pathways for training, many of the newer systems lack a universal framework for assessing and certifying surgeon proficiency. This inconsistency raises concerns about skill transferability across platforms, which may complicate the integration of multiple robotic systems within hospitals. Efforts to develop simulation-based training and proctoring for new robots are encouraging but require further validation to ensure comprehensive adoption.

The COVID-19 pandemic further emphasized the critical role of robotics in healthcare, particularly in telemedicine. Hospitals, as high-risk environments for infectious disease transmission, experienced heightened demand for remote medical interventions. Robotic systems enabled healthcare providers to maintain social distancing while delivering quality care, thereby enhancing safety for both patients and medical staff [152]. This experience underscores the broader potential of robotics not only in surgery but also in enhancing safety and accessibility in healthcare delivery.

Looking ahead, the future of robotic surgery promises continued innovation, particularly with the integration of artificial intelligence and machine learning capabilities.

One of the areas poised for the most significant development in this field is the application of AI. Artificial intelligence in robotic surgery holds transformative potential, enhancing precision, efficiency, and safety in surgical procedures [153]. Current advancements, such as real-time visual enhancement [154], tissue recognition [155], and instrument delineation [156], are providing valuable support to surgeons, particularly in minimally invasive operations. Partial automation of tasks like suturing [157] and camera positioning [158] reduces the workload on surgeons, paving the way toward higher levels of robotic autonomy. In the coming years, these technologies are expected to develop significantly, potentially enabling autonomous execution of complex surgeries in remote or extreme environments.

As these technologies evolve, they may significantly enhance the capabilities of robotic surgery, ultimately leading to better patient outcomes and more efficient surgical practices. In summary, while the da Vinci system remains a cornerstone of robotic surgery, the emergence of new platforms introduces possibilities and challenges which could reshape the future of surgical interventions. However, to fully harness the transformative potential of these new robotic systems, further rigorous research is imperative. This includes not only an increase in randomized controlled trials (RCTs) to establish robust clinical evidence on their efficacy and safety but also comprehensive analyses which address their economic and organizational implications. Understanding the long-term cost-effectiveness of these platforms, their impact on hospital workflows, and their adaptability to diverse healthcare settings is critical. Such research will provide valuable insights into how these systems can be optimized for widespread use, ensuring they deliver meaningful benefits to both patients and healthcare providers while addressing challenges related to accessibility and sustainability.

In conclusion, the emergence of new robotic surgery platforms presents significant advantages for market competition, potentially leading to reduced costs and continuous technological advancements.

5. Conclusions

The emergence of new robotic surgery platforms marks a significant evolution in the field, introducing innovations such as modular designs, haptic feedback, and enhanced portability. These advancements have the potential to increase accessibility and improve surgical outcomes, particularly in smaller healthcare settings.

However, widespread adoption remains hindered by high costs, limited access in resource-constrained regions, and the lack of standardized training frameworks. Addressing these challenges through collaboration among the industry, regulators, and healthcare providers is essential.

As artificial intelligence and machine learning further enhance robotic systems, the future promises safer, more precise, and efficient surgical procedures. By fostering innovation and reducing barriers, these advancements can lead to more equitable and impactful global adoption of robotic surgery.