
==== Front
J Minim Invasive Surg
J Minim Invasive Surg
Journal of Minimally Invasive Surgery
2234-778X
2234-5248
The Korean Society of Endo-Laparoscopic & Robotic Surgery

39300723
10.7602/jmis.2024.27.3.142
jmis-27-3-142
Original Article
Analyzing the emergence of surgical robotics in Africa: a scoping review of pioneering procedures, platforms utilized, and outcome meta-analysis
https://orcid.org/0000-0001-9509-4844
Falola Adebayo Feranmi 12
https://orcid.org/0000-0002-1056-3742
Dada Oluwasina Samuel 13
https://orcid.org/0000-0003-1739-5013
Adeyeye Ademola 456
https://orcid.org/0009-0004-9792-0838
Ezebialu Chioma Ogechukwu 12
https://orcid.org/0009-0002-0514-7864
Fadairo Rhoda Tolulope 12
https://orcid.org/0000-0001-5120-7851
Okere Madeleine Oluomachi 17
https://orcid.org/0000-0001-8103-1375
Ndong Abdourahmane 18
1 General Surgery Community, Surgery Interest Group of Africa, Lagos, Nigeria
2 Department of Medicine and Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria
3 Department of General Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
4 Significant Polyp and Early Colorectal Cancer (SPECC) Service, King&rsquo;s College Hospital, London, United Kingdom
5 Department of Surgery, Afe Babalola University, Ado-Ekiti, Nigeria
6 Department of Surgery, University of Ilorin Teaching Hospital, Nigeria
7 Department of Medicine and Surgery, College of Medicine, University of Port Harcourt, Choba, Nigeria
8 Department of Surgery, Gaston Berger University, Saint-Louis, Senegal
Corresponding author Adebayo Feranmi Falola, Department of Medicine and Surgery, College of Medicine, University of Ibadan, Ibadan 200212, Nigeria, E-mail: falolabayo@gmail.com, https://orcid.org/0000-0001-9509-4844
This paper was presented at the ASiT x RaDiST Robotics for Trainees Conference, Royal College of Surgeons, Edinburgh, May 23–24, 2024.

15 9 2024
15 9 2024
15 9 2024
27 3 142155
29 4 2024
27 6 2024
25 8 2024
© 2024 The Korean Society of Endo-Laparoscopic & Robotic Surgery
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Purpose

Surgical practice globally has undergone significant advancements with the advent of robotic systems. In Africa, a similar trend is emerging with the introduction of robots into various surgical specialties in certain countries. The need to review the robotic procedures performed, platforms utilized, and analyze outcomes such as conversion, morbidity, and mortality associated with robotic surgery in Africa, necessitated this study. This is the first study examining the status and outcomes of robotic surgery in Africa.

Methods

A thorough scoping search was performed in PubMed, Google Scholar, Web of Science, and African Journals Online. Of the 1,266 studies identified, 16 studies across 3 countries met the inclusion criteria. A meta-analysis conducted using R statistical software estimated the pooled prevalences with the 95% confidence interval (CI) of conversion, morbidity, and mortality.

Results

Surgical robots are reportedly in use in South Africa, Egypt, and Tunisia. Across four specialties, 1,328 procedures were performed using da Vinci (Intuitive Surgical), Versius (CMR Surgical), and Senhance (Asensus Surgical) surgical robotic platforms. Urological procedures (90.1%) were the major procedures performed, with robotic prostatectomy (49.3%) being the most common procedure. The pooled rate of conversion and prevalence of morbidity from the meta-analysis was 0.21% (95% CI, 0%–0.54%) and 21.15% (95% CI, 7.45%–34.85%), respectively. There was no reported case of mortality.

Conclusion

The outcomes highlight successful implementation and the potential for wider adoption. Based on our findings, we advocate for multidisciplinary and multinational collaboration, investment in surgical training programs, and policy initiatives aimed at addressing barriers to the widespread adoption of robotic surgery in Africa.

Robotic surgical procedures
Minimally invasive surgical procedures
Africa
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pmcINTRODUCTION

From conventional open surgery to the advent of cutting-edge robotic systems, the trajectory of surgical innovation is quite intriguing and complex [1]. In recent decades, minimal access surgical practice has undergone a transformative evolution, with technological advancements leading to the development and adoption of robotic systems [2]. Robotic surgery has emerged as a paradigm-shifting approach, offering surgeons enhanced precision, reduced fatigue, improved visualization, and improved patient care and outcomes [3,4].

The application of robots in surgery began in the late 1980s, with the use of the PUMA 560 (Unimation) for a neurological procedure [5]. Several surgical robots including da Vinci (Intuitive Surgical), Senhance (Asensus Surgical), and Versius (CMR Surgical) have since then gained wide application in various surgical specialties globally [6,7], especially in the United States where about 70% of all Intuitive Surgical robotic procedures are presently performed [8]. The same trend is emerging in Africa with certain countries reporting the adoption of these surgical robots for use in different surgical specialties [9,10].

The da Vinci system, developed in the United States in 1995 [11], is renowned for its precision in urological, gynecological, general surgical, and otolaryngological procedures [6,7,12], while the Senhance system, first used for a hysterectomy procedure in Rome [13], offers unique haptic feedback capabilities [6], and the Versius is a more recent ergonomic and collaborative platform indicated for use in adult general surgery, gynecology, urology, and cardiac surgery [6,7,12]. Other robotic systems, including Kangduo (Suzhou Kangduo Robot), Hinotori (Medicaroid), MicroHand (Tianjin University and WEGO), Revo-I (MeereCompany), Toumai (Shanghai MicroPort MedBot), MP1000 and SP1000 (Shenzhen Edge Medical Records), SSi Mantra (SS Innovations), Shurui (Shurui Robotics), and Carina (Ronovo Surgical), were developed and are in use in Asia [6,7,14]. Hugo (Medtronic), Avatera (AvateraMedical GmbH), and Dexter (Distalmotion) are other robotic systems in use in European and American settings [6,15]. Emerging surgical robots include Enos (Titan Medical), MIRA (Virtual Incision), MiroSurge (DLR), Vicarious (Vicarious Surgical), Bitrack (Rob Surgical), and Ottava (Medtronic) [6,7]. Micro-robots, single-port robotic surgery, and nanorobots are emerging frontiers in surgical robotics [3]. While the da Vinci platform by Intuitive Surgical has long been the dominant robotic system globally [11], new and cheaper platforms bring the potential of improved utilization in resource-constrained environments such as Africa [16].

Robotic surgery has no doubt proven to be a game-changer globally, promising benefits such as increased surgical precision, reduced invasiveness, and faster patient recovery [17,18]. However, in a World Health Organization report of 2023, approximately 60% of hospitals in Sub-Saharan Africa face regular power outages, while 15% of facilities lack any access to electricity, significantly impacting the feasibility of adopting advanced surgical technologies like robotic systems [19]. The adoption of robotic surgery in Africa thus presents a nuanced picture, one interwoven with the continent’s unique healthcare challenges and socioeconomic realities [18–20].

This study was prompted by the necessity to evaluate the current status of robotic surgery in Africa, including outlining the robotic procedures performed across the continent and analyzing outcomes such as the conversion rate to open surgery, as well as the associated morbidity and mortality.

METHODS

A single-blind scoping literature review was conducted in December 2023 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) [21]. This study was registered in the Open Science Framework registries (doi.org/10.17605/OSF.IO/UDYZW).

Search strategy

The literature search was performed in four databases. PubMed, Google Scholar, and Web of Science, due to their extensive coverage of biomedical literature. In addition, African Journals Online was searched because of its peculiar representation of African healthcare research. The search was conducted by three independent reviewers between December 6, 2023 and January 13, 2024 using these keywords in combination with Boolean operators: (‘Robotic’ OR ‘Robot-assisted’ OR ‘Robot’) AND (‘Surgery’ OR ‘Procedure’) AND (‘Africa’ OR ‘Country names’). Truncation and synonyms were employed to account for variations in terminology and ensure comprehensive coverage of relevant literature. The full strategy can be seen in Appendix.

Search results were uploaded to Rayyan [22] for deduplication and screening, using the set-out inclusion and exclusion criteria. Discrepancies or disagreements among reviewers during the screening and data extraction phases were resolved through consensus meetings. In cases where consensus could not be reached, a third reviewer was consulted to arbitrate and make the final decision regarding study inclusion.

We recognize the potential for language bias in our review. To mitigate language bias, we attempted to identify relevant non-English articles through translation of the search keywords to French, Arabic, and Portuguese, the three major non-English official languages in Africa. Non-English articles were translated to English using Google Translate, for screening and data extraction.

Eligibility for inclusion

Studies deemed eligible for inclusion had to meet the following PICOS criteria [23].

• P (Population): Patients who had robotic procedures in Africa

• I (Intervention): Robotic procedures

• C (Comparators): Different robotic procedures performed, countries where they were performed, and robotic systems used

• O (Outcomes): Full recovery, morbidity or mortality

• S (Study design): Editorial, case report, prospective, retrospective, and cross-sectional studies

Inclusion criteria

Studies that report the use of robotic systems for surgical procedures performed in Africa.

Exclusion criteria

Studies not carried out in Africa and those that do not include procedures done and the outcomes. Editorials, case reports. Studies with less than 10 participants (n ≤ 10) were excluded from the meta-analysis.

Data extraction

Data extracted from selected studies include the title of the paper, lead author, author’s affiliation, year of publication, period of study, study design, country of study, total sample size, age range, mean age, presenting symptoms, robotic procedures performed, robotic surgery system used, surgical techniques, operative data, mean robotic time, mean total operative time, estimated blood loss, mean hospital stay, technical difficulties, conversion to open surgery, morbidity, and mortality.

Meta-analysis

A meta-analysis was carried out in R statistical software version 4.4.1 (R Foundation for Statistical Computing) and R Studio version 2024.04.2+764, using “meta” and “metafor” packages. The pooled prevalences with the 95% confidence interval (CI) of conversion of robotic procedures to open surgery, morbidity, and mortality were obtained. Only cohort reports with a sample size (n ≥ 10) were included in the meta-analysis. Heterogeneity between studies was tested by the I2 test. A random-effects model was used when I2 > 50% (high risk of heterogeneity) and a fixed-effects model was used when I2 ≤ 50% (low risk of heterogeneity).

Assessment of methodologic quality and risk of bias

Risk of bias was assessed using The Cochrane tool, Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) [24,25]. Risk-of-bias plots were then visually generated using the ROBVIS (Risk-of-Bias Visualization) tool [26]. Each included publication was assigned a risk-of-bias category as follows: low risk, which is similar to a well-executed randomized controlled trial in terms of this specific bias domain; moderate risk, which represents a well-conducted nonrandomized study within this domain but does not fully meet the standards of a high-quality randomized trial; serious risk, indicating important limitations within this domain; critical risk, highlighting severe issues that render the study unable to provide reliable evidence on the intervention’s effects; and no information, indicating insufficient information to make a judgment about the risk of bias within this domain [25]. Three included studies which were not studies of interventions (editorial and cross-sectional studies) were not assessed.

RESULTS

Flow of studies

The scoping search performed across four databases returned 1,266 articles, 402 of which were excluded as duplicates. One report was identified from the official website of the Middle East and Mediterranean Association of Gynaecologic Oncologists. Of the remaining 864 studies, we excluded 588 at the title and abstract screening level because they did not meet the inclusion criteria, and subjected the remaining 276 articles to full text screening. In total, 16 studies were ultimately included in this study, after exclusion of 260 articles due to various reasons as shown in the PRISMA flow diagram (Fig. 1).

Study characteristics

The included studies were published between 2003 and 2023. The majority were published between 2020 and 2024 (Fig. 2). Out of these studies, two (12.5%) were editorials, three (18.8%) were case reports, one (6.3%) was a cross-sectional study, 5 (31.25) were retrospective cohorts, four (25.0%) were prospective cohorts, and one (6.3%) was a prospective randomized controlled trial. The included studies were published across three African countries: Egypt, South Africa, and Tunisia while 51 African countries (94.4%) have not reported the use of surgical robots.

Most of the studies, specifically 12 (75%), were published in Egypt. South Africa contributed three studies (18.8%), while one (6.3%) was from Tunisia. The majority of procedures, 1,101 (82.9%) were performed in South Africa, followed by 216 (16.3%) performed in Egypt, and 11 (0.8%) in Tunisia. Fig. 3 illustrates the distribution of procedures and reports across different countries.

A total of three robotic platforms were used across the 16 studies. The robotic platforms used were reported in 13 studies. Among these, the da Vinci surgical system was utilized in the majority, comprising 11 studies (68.8%), while the Versius and Senhance surgical robotic systems were each used in one study (6.3%). The robotic platforms used in three studies (18.8%) were not reported. The total sample size across the 16 studies is 1,328. The study characteristics are presented in Table 1 [9,10,27–40].

Robotic procedures performed

Our study shows that robotic surgery has been adopted across four surgical specialties in Africa: cardiothoracic, general, gynecological, and urological surgery. A total of 1,328 procedures were performed. Urological procedures performed in 1,196 cases (90.1%) across six studies were the predominant robotic procedures performed in Africa. This is followed by general surgical procedures, performed in 98 patients (7.4%). Prostatectomy, performed in 655 patients (49.3%) is the most common procedure performed. Table 2 displays the number of reports, percentage of reports, sample sizes, percentage of sample sizes, and procedures performed in each specialty. The percentage of reports per specialty is depicted in Fig. 4.

Conversion to open surgery

Six cases of conversion of robotic to open surgery were identified. There were no procedures converted to laparoscopy. The first was a case of robot-assisted rectal surgery converted to open surgery as a result of a bulky mid-rectal tumor in a very narrow male pelvis. Another was a case of robotic radical prostatectomy which was converted due to difficulty with the urethrovesical anastomosis. Also, a case of robotic colorectal surgery was converted due to a locally advanced tumor. Reasons for conversion in three cases were not reported.

Meta-analysis

Eight cohort studies with sample size (n ≥ 10) which reported the rate of conversion among their study population were included in the meta-analysis of conversion of robotic to open surgery. Zero events were observed in three studies [9,32,36]. To improve feasibility and validity of the analysis [41], continuity correction of one was added to zero events. Common effects model was used since I2 was less than 50% (low risk of heterogeneity). The meta-analysis revealed a pooled conversion rate of 0.2% (95% CI, 0%–0.5%; eight studies and 775 participants) (Fig. 5).

Morbidity and mortality

A total of 56 complications were recorded in 49 patients following various robotic procedures (Table 3). Prolonged postoperative ileus which occurred following robotic resection of rectal carcinoma, urine leak, and Intraoperative hemorrhage requiring blood transfusion were the major complications. Urine leakage occurred in eight cases of radical prostatectomy and was managed with exploration and percutaneous nephrostomy in two cases. There was no recorded case of mortality.

Meta-analysis

Eight cohort studies with sample size (n ≥ 10) reported the complications among their study population and were included in the meta-analysis of prevalence of morbidity. The meta-analysis revealed a 21.2% pooled prevalence of morbidity (95% CI, 7.0%–35.0%; eight studies and 772 participants) (Fig. 6).

Methodologic quality and risk of bias

The ROBINS-I [24,25] was used to evaluate seven bias domains within each included study (Fig. 7, 8).

• Bias due to confounding (D1): low risk (four studies), moderate risk (four studies), serious risk (four studies), and no information (one study)

• Bias due to selection of participants (D2): low risk (eight studies), moderate risk (one study), serious risk (four studies)

• Bias in classification of interventions (D3): low risk (11 studies), moderate risk (two studies)

• Bias due to deviations from intended intervention (D4): low risk (six studies), moderate risk (four studies), no information (two studies)

• Bias due to missing data (D5): low risk (10 studies), moderate risk (one study), no information (two studies)

• Bias in measurement of outcomes (D6): low risk (nine studies), moderate risk (three studies), no information (one study)

• Bias in selection of reported results (D7): low risk (11 studies), moderate risk (two studies)

• Overall risk: low (three studies), moderate (four studies), and serious (six studies)

DISCUSSION

Our study has provided an important overview of the early phase of robotic surgical practice in Africa, highlighting three countries that have reported its use: Egypt, South Africa, and Tunisia. Further investigation is needed to understand the specific factors facilitating the adoption of surgical robots in these countries, particularly in Egypt and South Africa, unlike in other countries where robotic surgery is yet to be reportedly available. Possible factors may include early investment in robotic surgery training programs, favorable regulatory environments, and partnerships with industry stakeholders. In other countries, however, its adoption remains an uncertain possibility as a result of inadequate healthcare budget allocation, unreliable power supply, and most importantly, ineffective leadership [16,20].

The da Vinci, Senhance, and Versius are the three surgical robotic systems currently in use in Africa. Understandably, da Vinci, used in 11 of the included studies (68.8%), is the most used platform. It is a master-slave laparoscopic robotic platform with wide application in several surgical specialties that have been in use globally since 1998 [4]. The Senhance and Versius, however, are newer master-slave robotic platforms that only came into light in 2017 and 2020, respectively [4,7,42]. The case report from Egypt, by Maurice et al. [39], is the first report on the use of the ergonomic Versius platform in Africa. The majority of surgical robots cost over one million US dollars [6]. The arrival of newer and cheaper robotic platforms may thus be necessary for more widespread adoption of robotic surgery in low- and middle-income settings like Africa [16].

The number of robot-assisted surgeries reported increased over the years, between 2003 and 2023. In Africa, robotic surgery is presently in use across four surgical specialties: urological, general, gynecological, and cardiothoracic surgery. In other settings, however, surgical robots have been applied in other specialties, including otolaryngology, orthopedic surgery, and neurosurgery [3,43,44]. Our study shows that prostatectomy is the most commonly performed robotic procedure in Africa. This is consistent with global reports that urology has been at the forefront of adoption of the robotic approach, and that robotic prostatectomy is the most commonly performed procedure [44–46]. The differential uptake of robotic surgery across surgical specialties however underscores the need for tailored approaches to surgical training, infrastructure development, and patient access initiatives. Future research should explore how healthcare policies and resource allocation strategies can optimize the integration of robotic surgery across diverse surgical specialties.

A pooled conversion rate of 0.2% was obtained. Conversion of robotic procedures to open surgery is known to be associated with adverse outcomes and thus should be anticipated and planned for [47]. The conversion rate is however similarly low, compared to reports from other settings [48–50].

The pooled prevalence of morbidity is high compared to the 6% to 15% reported in studies done in Europe and the United States [48,49,51]. The morbidity rates observed vary significantly across reports. The retrospective study of 600 patients who had robotic prostatectomy in South Africa recorded only two cases of morbidity [9], while studies from other countries like Egypt recorded a significantly higher number of cases of complications [10,34]. Extensive perioperative evaluation, investigations, and an experienced robotic team are vital for reduction, early identification, and proper management of complications from robotic surgery [52].

The 0% prevalence of mortality obtained in our study is similar to the low prevalence (0%–0.4%) observed in other settings [48,51,53]. Africa has similarly recorded a low mortality rate with laparoscopy, another minimally invasive approach [54]. This suggests an even level of expert know-how with minimally invasive surgeries in Africa and other parts of the world, and the potential for wider use [54,55]. The low mortality rate associated with minimal access surgery is one of its major advantages over conventional open surgery [56]. Although our findings suggest similarities in robotic surgery outcomes between Africa and other regions, such as low mortality rates [48,51,53], it is important to recognize the unique challenges and opportunities facing African healthcare systems. Future research should explore how cultural attitudes toward technology, economic disparities, and healthcare policy frameworks influence the adoption and utilization of robotic surgery in Africa.

While our study reports no mortality associated with robotic surgery in Africa, it’s important to acknowledge the variability in reported morbidity rates across studies. Factors such as differences in perioperative care protocols, surgeon experience, and patient comorbidities may contribute to variations in outcomes. Future research should focus on standardizing outcome measures and implementing quality improvement initiatives to optimize patient safety and surgical outcomes in robotic surgical practice in Africa.

Considering the fact that the gold standard of care, unlike in developed settings, is providing the best possible care within the constraints of available resources, rather than pursuing cutting-edge treatment [57], several African settings may need to solve impeding issues such as low health care system budgets, lack of a suitable training environment, inadequate power supplies, inadequate management, amongst others, before robotics can fully replace the conventional open or laparoscopic approach as gold standard [16,19]. In Africa, there is still much needed to be done before robot-assisted surgery can be adopted fully into our health system [16,58].

Based on our findings, we advocate for multidisciplinary collaboration, investment in surgical training programs, and policy initiatives aimed at addressing barriers to robotic surgery adoption in Africa. There is also a need for multicenter and national databases to keep records of the robotic surgical procedures performed in Africa. Future research should prioritize longitudinal studies to assess the long-term outcomes of robotic surgery, explore patient-centered outcomes, and evaluate the cost-effectiveness of robot-assisted procedures in diverse healthcare settings.

This study has provided the first and an important analysis of the robotic procedures performed, the robotic platforms utilized, and the outcomes of the first set of surgical patients managed with the robotic approach in Africa. The study has also provided recommendations for wider use and a foundation for future research on robotic surgery in Africa. However, the limitations include a language barrier, which might have limited the discoverability of non-English publications in the databases searched. Additionally, some data, such as cost, estimated blood loss, and operation time, were not available or inconsistently reported in the reviewed publications, thus limiting the possibility of analysis and inclusion in this study. We recommend that future research should focus on this data to provide stronger evidence on the topic.

In conclusion, our study not only sheds light on the present state of robotic surgery in Africa but also provides a roadmap for future research, policy development, and strategic planning. By addressing the outlined challenges and implementing the suggested recommendations, Africa has the potential to bridge the gap and become an integral participant in the global landscape of robot-assisted surgery, thereby advancing surgical healthcare outcomes across the continent. Also, with the arrival of newer and cheaper robotic platforms, the promising outcomes so far signal a high likelihood of robot-assisted surgery being widely used in African healthcare management in the future.

Notes

Fig. 1 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 flow diagram for new systematic reviews which included searches of databases and registers only.

Fig. 2 Number of studies per year of publication.

Fig. 3 Distribution of robotic procedures and number of reports per country.

Fig. 4 Percentage report and sample size per specialty.

Fig. 5 Forest plot for conversion. The midpoint of each line illustrates the prevalence; the horizontal line indicates the confidence interval; and the diamond shows the pooled prevalence. CI, confidence interval.

Fig. 6 Forest plot for morbidity. The midpoint of each line illustrates the prevalence; the horizontal line indicates the confidence interval; and the diamond shows the pooled prevalence. CI, confidence interval.

Fig. 7 Traffic light plot of risk of bias according to ROBINS-I (Risk of Bias in Non-randomized Studies of Interventions).

Fig. 8 Summary light plot according to ROBINS-I (Risk of Bias in Non-randomized Studies of Interventions).

Table 1 Study characteristics

Study	Country	Study design	Publication year	Sample size	Robotic surgery system used	Procedure(s) performed	
De Jager et al. [9]	South Africa	Retrospective cohort	2021	600	Not reported	Robot-assisted laparoscopic radical prostatectomy	
Zaghloul et al. [10]	Egypt	Retrospective cohort	2021	55	da Vinci	Robotic radical prostatectomy	
Debakey et al. [27]	Egypt	Prospective randomized control trial	2018	21	da Vinci	Robot-assisted rectal surgery	
Abbas et al. [28]	Egypt	Retrospective cohort	2012	25	da Vinci	Robot-assisted cystoprostatectomy with urinary diversion	
Abd-erRazik et al. [29]	Egypt	Case study	2022	2	Not reported	Robotic-assisted transgastric cystogastrostomy and pancreatic debridement	
Forgan and Lazarus [30]	South Africa	Editorial	2023	500	da Vinci	Robot-assisted laparoscopic partial nephrectomy and pyeloplasty	
Shokralla and Fathalla [31]	Egypt	Prospective cohort	2021	2	Not reported	Robotic hysterectomy	
Zaghloul et al. [32]	Egypt	Prospective cohort	2018	20	da Vinci	Robotic radical hysterectomy	
Van der Merwe et al. [33]	South Africa	Editorial	2022	1	da Vinci	Robotic-assisted Mc Keown esophagectomy and thoracic outlet decompression surgery	
Zaghloul and Mahmoud [34]	Egypt	Prospective cohort	2016	10	da Vinci	Robotic colorectal surgery	
El-Tabey and Shoma [35]	Egypt	Case study	2005	1	da Vinci	Robot-assisted laparoscopic radical cystectomy	
Menon et al. [36]	Egypt	Retrospective cohort	2003	15	da Vinci	Robot-assisted radical cystoprostatectomy	
Korany et al. [37]	Egypt	Cross-sectional	2023	24	da Vinci	Robotic bariatric sleeve surgery	
Farag et al. [38]	Egypt	Prospective cohort	2023	40	da Vinci	Robot-assisted laparoscopic resection of mid- and low-rectal carcinoma	
Maurice et al. [39]	Egypt	Case study	2023	1	Versius	Robotic-assisted Mc Keown esophagectomy	
Hassouna et al. [40]	Tunisia	Retrospective cohort	2019	11	Senhance	Robotic oophorectomy, adnexectomy and hysterectomy	
da Vinci, Intuitive Surgical; Versius, CMR Surgical; Senhance, Asensus Surgical.

Table 2 Robotic procedures performed per specialty

Specialty	No. of reports	Proportion of reports per specialty (%)	Sample size	Proportion of sample size per specialty (%)	Robotic procedure(s)	
Urological surgery	6	37.5	1,196	90.1	Prostatectomy, cystoprostatectomy, nephrectomy, and pyeloplasty	
General surgery	6	37.5	98	7.4	Colorectal surgery, cystogastrostomy, pancreatic debridement, and bariatric sleeve surgery	
Gynecological surgery	3	18.8	33	2.5	Hysterectomy, oophorectomy and adnexectomy	
Cardiothoracic surgery	1	6.3	1	0.1	McKeown esophagectomy and thoracic outlet decompression surgery	
Total	16	100	1,328	100		

Table 3 Complications of robotic surgery

Morbidity	No. of reports	Robotic procedure(s)	
Ileus	8	Colorectal surgery	
Urine leak	8	Radical prostatectomy	
Intraoperative hemorrhage requiring blood transfusion	8	Radical prostatectomy (3) and radical hysterectomy (5)	
Anastomotic leakage	3	Colorectal surgery	
Wound infection	3	Colorectal surgery (2) and radical prostatectomy (1)	
Bladder injuries	3	Radical hysterectomy	
Bladder neck stenosis	3	Radical prostatectomy	
Lymphocele	3	Radical prostatectomy	
Chest infection	3	Radical hysterectomy	
Ureteric injury	2	Radical prostatectomy	
Port site hernia	2	Radical prostatectomy	
Deep vein thrombosis	1	Colorectal surgery	
Epigastric pain	1	Transgastric cystogastrostomy and pancreatic debridement	
Vomiting	1	Transgastric cystogastrostomy and pancreatic debridement	
Local recurrence of cervical cancer	1	Radical hysterectomy	
Trocar site infection	1	Radical hysterectomy	
Reoperation	1	Colorectal surgery	
Port site metastasis	1	Radical cystectomy	
Urinary tract infection	1	Radical prostatectomy	
Venous thromboembolism	1	Radical prostatectomy	
Small bowel obstruction	1	Radical prostatectomy	

Authors’ contributions

Conceptualization, Formal analysis: AFF

Data curation: AFF, OSD, RTF, COE, MOO

Methodology: OSD, AFF, AA

Supervision, Validation: AA, AN, ODD, OSD

Writing–original draft: AFF, AA, RTF, COE, OSD

Writing–review & editing: OSD, AA, AFF, AN

All authors read and approved the final manuscript.

Conflict of interest

All authors have no conflicts of interest to declare.

Funding/support

None.

Data availability

The data presented in this study are available upon reasonable request to the corresponding author.
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References

1 Camarillo DB Krummel TM Salisbury JK 2004 Robotic technology in surgery: past, present, and future Am J Surg 188 2S 15S 10.1016/j.amjsurg.2004.08.025 15476646
2 Fairag M Almahdi RH Siddiqi AA 2024 Robotic revolution in surgery: diverse applications across specialties and future prospects review article Cureus 16 e52148 10.7759/cureus.52148 38344598
3 Reddy K Gharde P Tayade H Patil M Reddy LS Surya D 2023 Advancements in robotic surgery: a comprehensive overview of current utilizations and upcoming frontiers Cureus 15 e50415 10.7759/cureus.50415 38222213
4 Peters BS Armijo PR Krause C Choudhury SA Oleynikov D 2018 Review of emerging surgical robotic technology Surg Endosc 32 1636 1655 10.1007/s00464-018-6079-2 29442240
5 Kwoh YS Hou J Jonckheere EA Hayati S 1988 A robot with improved absolute positioning accuracy for CT guided stereotactic brain surgery IEEE Trans Biomed Eng 35 153 160 10.1109/10.1354 3280462
6 Boal M Di Girasole CG Tesfai F 2024 Evaluation status of current and emerging minimally invasive robotic surgical platforms Surg Endosc 38 554 585 10.1007/s00464-023-10554-4 38123746
7 Millan B Nagpal S Ding M Lee JY Kapoor A 2021 A scoping review of emerging and established surgical robotic platforms with applications in urologic surgery Soc Int Urol J 2 300 310 10.48083/EWWQ2677
8 Childers CP Maggard-Gibbons M 2018 Estimation of the acquisition and operating costs for robotic surgery JAMA 320 835 836 10.1001/jama.2018.9219 30167686
9 De Jager S Howlett J Bruwer G Moolman C 2021 Analysis of the learning curve in robotic-assisted laparoscopic radical prostatectomy in a South African setting Afr Urol 1 19 24 10.36303/AUJ.2021.1.1.0002
10 Zaghloul A Abdelbary A Fergany A Aboulkassem H Fadlalla WM 2021 Robotic radical prostatectomy at the Egyptian National Cancer Institute: overcoming the challenges in the initial case series Open Access Maced J Med Sci 9 367 372 10.3889/oamjms.2021.6107
11 DiMaio S Hanuschik M Kreaden U Rosen J Hannaford B Satava R The da Vinci surgical system Surgical robotics Springer 2011 199 217 10.1007/978-1-4419-1126-1_9
12 Gamal A Moschovas MC Jaber AR 2024 Clinical applications of robotic surgery platforms: a comprehensive review J Robot Surg 18 29 10.1007/s11701-023-01815-4 38231279
13 Fanfani F Monterossi G Fagotti A 2016 The new robotic TELELAP ALF-X in gynecological surgery: single-center experience Surg Endosc 30 215 221 10.1007/s00464-015-4187-9 25840895
14 Gu L Yin C Jia T He K Ma X Zhang X 2023 Robotic surgery in China Innovation (Camb) 4 100499 10.1016/j.xinn.2023.100499 37705606
15 Pavone M Marescaux J Seeliger B 2023 Current status of robotic abdominopelvic surgery Show-Chwan Med J 22 468 474
16 Oyebamiji TA 2020 Robotic surgery in Nigeria: an uncertain possibility Int Surg J 7 3876 3879 10.18203/2349-2902.isj20204713
17 Kamarajah SK Bundred JR Marc OS 2020 A systematic review and network meta-analysis of different surgical approaches for pancreaticoduodenectomy HPB (Oxford) 22 329 339 10.1016/j.hpb.2019.09.016 31676255
18 Alverdy JC 2021 The benefits of robotic surgery: are they technical or molecular? J Gastrointest Surg 25 578 580 10.1007/s11605-020-04901-2 33409821
19 World Health Organization (WHO) 2024 WHO fact sheets [Internet] WHO Available from: https://www.who.int/news-room/fact-sheets/ cited 2024 Mar 10
20 Mehta A Cheng Ng J Andrew Awuah W 2022 Embracing robotic surgery in low- and middle-income countries: potential benefits, challenges, and scope in the future Ann Med Surg (Lond) 84 104803 10.1016/j.amsu.2022.104803 36582867
21 Tricco AC Lillie E Zarin W 2018 PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation Ann Intern Med 169 467 473 10.7326/M18-0850 30178033
22 Ouzzani M Hammady H Fedorowicz Z Elmagarmid A 2016 Rayyan: a web and mobile app for systematic reviews Syst Rev 5 210 10.1186/s13643-016-0384-4 27919275
23 Eriksen MB Frandsen TF 2018 The impact of patient, intervention, comparison, outcome (PICO) as a search strategy tool on literature search quality: a systematic review J Med Libr Assoc 106 420 431 10.5195/jmla.2018.345 30271283
24 Sterne JA Hernán MA Reeves BC 2016 ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions BMJ 355 i4919 10.1136/bmj.i4919 27733354
25 Sterne JA Higgins JP Elbers RG Reeves BC the development group for ROBINSI 2016 Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I): detailed guidance [Internet] The authors Available from http://www.riskofbias.info cited 2024 Mar 10
26 McGuinness LA Higgins JP 2021 Risk-of-bias VISualization (robvis): an R package and Shiny web app for visualizing risk-of-bias assessments Res Synth Methods 12 55 61 10.1002/jrsm.1411 32336025
27 Debakey Y Zaghloul A Farag A Mahmoud A Elattar I 2018 Robotic-assisted versus conventional laparoscopic approach for rectal cancer surgery, first Egyptian academic center experience, RCT Minim Invasive Surg 2018 5836562 10.1155/2018/5836562 30245874
28 Abbas DN Kamal JM El Sheikh SM Mahmod AM 2013 Early experience in anesthesia of robot assisted cystoprostatectomy Egypt J Anaesth 29 77 81 10.1016/j.egja.2012.09.003
29 Abd-erRazik MA Abdel Hamid MA Rashed AM 2022 Egypt's initial experience with robotic-assisted cystogastrostomy and pancreatic debridement for large walled-off pancreatic necrosis: a report of two cases Cureus 14 e32005 10.7759/cureus.32005 36589168
30 Forgan T Lazarus J 2023 Embracing the future: the necessity of implementing robotic surgery in South African training institutions S Afr J Surg 61 144 149 10.36303/SAJS.4111 37381802
31 Shokralla HA Fathalla AE 2021 Adenocarcinoma of the cervix uteri; does it really carry a worse prognosis? A single institutional review from Egypt Med Sci 25 26 35
32 Zaghloul AS El-Minawi AM ElKordy MA 2018 First experience of the Egyptian National Cancer Institute using the robot-assisted laparoscopic approach in radical hysterectomies for cervical cancer J Egypt Natl Canc Inst 30 61 67 10.1016/j.jnci.2018.03.003 29691094
33 van der Merwe B 2021 Establishing ionising radiation safety culture during interventional cardiovascular procedures Cardiovasc J Afr 32 271 275 10.5830/CVJA-2021-030 34405852
34 Zaghloul AS Mahmoud AM 2016 Preliminary results of robotic colorectal surgery at the National Cancer Institute, Cairo University J Egypt Natl Canc Inst 28 169 174 10.1016/j.jnci.2016.05.003 27312241
35 El-Tabey NA Shoma AM 2005 Port site metastases after robot-assisted laparoscopic radical cystectomy Urology 66 1110 10.1016/j.urology.2005.05.048 16286145
36 Menon M Hemal AK Tewari A 2003 Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion BJU Int 92 232 236 10.1046/j.1464-410X.2003.04329.x 12887473
37 Korany BM 2023 Lived experience of patients following robotic sleeve surgery Assiut Sci Nurs J 11 240 249 10.21608/asnj.2023.218845.1616
38 Farag AF Mahmoud AM Azmy HM 2023 Robotic-assisted laparoscopic low anterior resection versus trans-anal total mesorectal excision for malignant rectal lesion: a prospective cohort trial Egypt J Surg 42 859 867 10.4103/ejs.ejs_167_23
39 Maurice K Moussa H Hawary R 2023 484. Robotic assisted prone esophagectomy using versius platform: a promising approach Dis Esophagus 36 Suppl 2 doad052.265 10.1093/dote/doad052.265
40 Hassouna BJ Chemlali M Slimane M Rahal K 2019 Introduction of robotic surgery in gynecologic oncology: a Tunisian experience [Internet]. Presented at: 4th MEMAGO Annual Congress in Association with the 1st Emirates Gynecological Oncology Conference; October 11-12, 2019; Abu Dhabi, UAE MEMAGO Available at: https://memago.org/memagoData/userfiles/file/Jamel-Ben-Hassouna--Introduction.pdf cited 2024 Jan 5
41 Zabriskie BN Cole N Baldauf J Decker C 2024 The impact of correction methods on rare-event meta-analysis Res Synth Methods 15 130 151 10.1002/jrsm.1677 37946591
42 Brodie A Vasdev N 2018 The future of robotic surgery Ann R Coll Surg Engl 100 Suppl 7 4 13 10.1308/rcsann.supp2.4 30179048
43 Stumpo V Staartjes VE Klukowska AM 2021 Global adoption of robotic technology into neurosurgical practice and research Neurosurg Rev 44 2675 2687 10.1007/s10143-020-01445-6 33252717
44 Sundram M 2010 Asian robotic experience Urol Oncol 28 677 681 10.1016/j.urolonc.2010.03.003 21062651
45 Shah AA Bandari J Pelzman D Davies BJ Jacobs BL 2021 Diffusion and adoption of the surgical robot in urology Transl Androl Urol 10 2151 2157 10.21037/tau.2019.11.33 34159097
46 Fantus RJ Cohen A Riedinger CB 2019 Facility-level analysis of robot utilization across disciplines in the National Cancer Database J Robot Surg 13 293 299 10.1007/s11701-018-0855-9 30062641
47 Halpern AL Friedman C Torphy RJ 2020 Conversion to open surgery during minimally invasive esophagectomy portends worse short-term outcomes: an analysis of the National Cancer Database Surg Endosc 34 3470 3478 10.1007/s00464-019-07124-y 31591657
48 Samalavicius NE Janusonis V Siaulys R 2020 Robotic surgery using Senhance® robotic platform: single center experience with first 100 cases J Robot Surg 14 371 376 10.1007/s11701-019-01000-6 31301021
49 Moretti TB Magna LA Reis LO 2022 Surgical results and complications for open, laparoscopic, and robot-assisted radical prostatectomy: a reverse systematic review Eur Urol Open Sci 44 150 161 10.1016/j.euros.2022.08.015 36110904
50 Melling N Barr J Schmitz R 2019 Robotic cholecystectomy: first experience with the new Senhance robotic system J Robot Surg 13 495 500 10.1007/s11701-018-0877-3 30264180
51 Aguayo E Dobaria V Nakhla M 2020 National trends and outcomes of inpatient robotic-assisted versus laparoscopic cholecystectomy Surgery 168 625 630 10.1016/j.surg.2020.06.018 32762874
52 Ou YC Yang CK Chang KS 2016 Prevention and management of complications during robotic-assisted laparoscopic radical prostatectomy following comprehensive planning: a large series involving a single surgeon Anticancer Res 36 1991 1998 27069192
53 Liss MA Skarecky D Morales B Osann K Eichel L Ahlering TE 2013 Preventing perioperative complications of robotic-assisted radical prostatectomy Urology 81 319 323 10.1016/j.urology.2012.09.033 23374792
54 Falola AF Fadairo RT Dada OS 2024 Current state of minimally invasive general surgical practice in Africa: a systematic review and meta-analysis of the laparoscopic procedures performed and outcomes World J Surg 48 1634 1650 10.1002/wjs.12195 38809177
55 Onibokun O Boatin A Diouf K 2016 The role of minimally invasive gynecologic surgery in Sub Saharan Africa Curr Obstet Gynecol Rep 5 333 340 10.1007/s13669-016-0184-9
56 Sheng S Zhao T Wang X 2018 Comparison of robot-assisted surgery, laparoscopic-assisted surgery, and open surgery for the treatment of colorectal cancer: a network meta-analysis Medicine (Baltimore) 97 e11817 10.1097/MD.0000000000011817 30142771
57 Fagan JJ 2023 Implementing robotic surgery in South African training institutions: fiddling while Rome burns S Afr J Surg 61 5 6 10.36303/SAJS.4142
58 Morris B 2005 Robotic surgery: applications, limitations, and impact on surgical education MedGenMed 7 72 16369298
