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was significantly longer in RG, at 41.5 min, than in LG, though effective time was not statistically
different between the groups. Although there was no difference in the number of instrument exchanges,
the time required to exchange instruments was also significantly longer in RG than in LG. Additionally,
[47]
the operation time was reduced by about 1 h when ultrasonically activated devices were used . These
studies suggest that a smarter and simpler system is needed for the setup and for instrument change, and
development of new devices are warranted to reduce the operation time.

FUTURE PERSPECTIVES
A lack of robust evidence regarding RG use appears to be the most important future issue. Although RG
has many theoretical advantages over LG, a definite and significant benefit of RG over LG has not been
shown in a clinical setting due to the lack of randomized controlled trials (RCT). It cannot be denied that
the high cost of RG affects the difficulty in conducting RCT, with some meta-analyses and a prospective
study conducted in Korea indicating that RG is 4000-5000 USD more expensive than LG [22,29] . In Japan, RG
has been covered by health insurance since April 2018; thus, patients can undergo RG without any extra
cost. Thus, while the economic burden on medical institutions remains, the groundwork for RCT has been
completed, and a well-designed RCT is needed to investigate the superiority of RG over LG.

Currently, several companies are developing surgical robots, with such market competition expected to
decrease the price and further their use. Moreover, we anticipate the near future to bring development
of new devices or miniaturization of existing surgical robots, together with innovative development,
[49]
[48]
including concomitant use with 3D imaging , artificial intelligence, and virtual reality .

CONCLUSION
RG with DVSS facilitates meticulous surgical procedures with 3D imaging, instrument flexibility, tremor
suppression, and improved ergonomics. Problems with RG remain including an unacceptable lack in
tactile perception, longer operation times, and high medical costs. Moreover, although RG has theoretical
advantages over LG, robust evidence is lacking. Well-designed, randomized controlled trials are therefore
needed to establish stronger evidence and further develop the field of surgical robotics.

DECLARATIONS
Authors’ contributions
Designed the study, reviewed literature, and wrote the manuscript: Makuuchi R
Critical revision of the manuscript and approval of the final version: Kamiya S, Tanizawa Y, Bando E
Writing the manuscript, drafting and critical revision and editing, and approval of the final version:
Terashima M

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.