Although minimally invasive surgery (MIS) is accepted as the modern standard of care for many surgical diseases^[1,2], there are disparities in MIS access across the globe^[3-5]. This inequity creates an ethical dilemma since it deviates from the World Health Organization constitution that considers the “highest attainable standard of health as a fundamental right of every human being without distinction of race, geography, religion, economic, or social condition”^[6,7]. Achieving equity is one of the basic tenets of fairness and human rights in modern society^[6,7].

In an attempt to bring attention to these inequities, Mitzman et al. coined the term “MIS deserts” to describe areas where MIS access/utilization remained subpar^[8]. We discuss the factors contributing to the existence of MIS deserts and discuss strategies to achieve equitable global access to robotic surgery.

The advantages of MIS are multifaceted. Surgeons who utilize MIS techniques experience better ergonomics and greater operator comfort, that translate into fatigue mitigation, reduced musculoskeletal strain, and increased longevity in their careers^[9]. Robotic platforms offer the added advantage of superior visualization through high-definition cameras, tremor reduction, and better maneuverability with surgical instruments^[10].

These impact outcomes by exposing patients to fewer postoperative complications and improved surgical quality outcomes^[1,2]. The resultant rapid recovery, improved mobility, reduced demand for hospital-based resources, and morbidity containment results in faster return to work and drives long-term cost reduction, ultimately benefiting the society and the entire healthcare system^[1,2,9].

Although 28%-32% of global disease burden is attributable to surgically treatable conditions, over half the global population cannot access surgical treatment^[11]. In other words, an estimated 5-billion people worldwide lack access to safe and affordable surgical care^[11]. This would result in a predicted negative effect on overall health status, healthcare expenditure, life expectancy, and functionality for those populations affected^[12]. Some estimate that, without urgent investment in surgical scale-up, low- and middle-income countries (LMICs) would sustain cumulative losses in economic productivity of US$12.3 trillion between 2015 and 2030^[11].

Many authors defined factors contributing to MIS deserts, including: inadequately trained workforces, paucity of MIS equipped hospitals, inadequate insurance coverage, limited healthcare funding, geography, economic circumstance, and individualized limitations within specific healthcare delivery systems^[10,13,14]. Despite better understanding of these factors, there has been little measurable progress toward global MIS equity over the past three decades.

This dismal view of global health metrics dims further when four factors are brought into focus: (1) the data documenting the superiority of MIS is robust^[1-5]; (2) the statistics quoted describe general access to surgical care^[11,12]; (3) inequities worsen when we focus on MIS deserts alone instead of surgery in general^[3-5]; and (4) the disparities expand further when robotic surgery is substituted for MIS deserts. The reality is that the gaps are even greater in robotic surgery, where higher capital costs and increased infrastructure needs exacerbate existing barriers to equitable care.

The key components of robotic surgical platforms are mechanical arms that replicate the movement of surgeons’ hands with remarkable precision^[13]. The surgeon manipulates the robotic instruments from a console that features high-definition 3D visualization systems to provide depth perception and clarity^[15]. The robotic system’s software includes advanced algorithms that assist with real-time tracking and motion scaling, ensuring smooth and controlled movements^[15]. Some platforms also feature simulation capabilities for training, allowing surgeons to practice techniques in a virtual environment^[15]. Robotic systems may also be integrated with various imaging technologies such as fluoroscopy or magnetic resonance imaging (MRI), providing real-time feedback and enhanced intraoperative guidance^[16]. These systems are equipped with safety and override features that prevent accidental movements or errors and ensure that they operate reliably^[15]. The smaller incisions and wristed intracorporeal movement of the instruments decrease movement, torque and abdominal wall trauma^[15]. These components make robotic surgical platforms superior to conventional laparoscopy.

Currently, several surgical platforms are in use [Table 1]. The Intuitive Surgical da Vinci system is the most widely adopted, operating in over 70 countries^[15]. It received U.S. Food and Drug Administration (FDA) approval in 2000 and has more than 8,600 platforms deployed worldwide, with more than 14 million procedures performed worldwide by 2022 in virtually all surgical subspecialties^[15]. Newer systems such as Versius, Hugo, and Senhance are also gaining traction and expanding utilization across Europe, Asia, and Latin America^[17-19].

While the da Vinci system has the highest upfront and recurring costs, other platforms may offer lower cost for specialized applications, as listed in Table 1^[17-19]. The da Vinci and Hugo systems utilize proprietary consoles, whereas the Versius and Senhance platforms feature modular, open-architecture designs^[15,17-19]. Additionally, the da Vinci instruments have limited reusability, while Senhance and Versius emphasize reusability, and the Avatera platform utilizes disposable tools^[15,17-19].

With 25 years of FDA approval, the da Vinci system boasts the longest safety record and a substantial body of studies on safety and efficacy^[15]. It has also established simulation tools to facilitate adoption and training^[15]. Other platforms show promising safety profiles but require longer-term data to confirm their effectiveness.

The rapid adoption of robotic surgery has widened the disparity because LMIC health systems have limited funding to afford the technology^[25,26]. It is useful to distinguish between three levels of cost burden: capital costs borne primarily by hospitals and health systems (acquisition and installation), per-case costs driven by disposable instruments and consumables, and system-level costs borne by governments and payers through reimbursement structures. The initial investment to obtain the most commonly utilized robotic platform ranges from approximately USD $1.5-2.5 million, with additional costs for maintenance, training, and consumables^[25]. Newer systems have lower capital costs, which may impact global adoption^[25].

Many studies have examined the cost-effectiveness of robotic surgery, yielding mixed results. Ng et al. observed an increase in robotic surgery between 2012 and 2019, accompanied by increased hospitalization costs for all robotic surgeries reviewed^[27]. Conversely, other studies suggest that the initial capital costs of robotic-assisted surgery are offset by the long-term benefits, including reduced hospital stays, quicker recovery times, lower complication rates, and improved surgical outcomes^[28].

Healthcare systems considering acquisition should consider a per-case model. When capital costs are amortized over expected annual procedure volumes, the per-case cost of robotic surgery decreases substantially with increasing utilization; systems performing < 100 robotic cases annually may find per-case costs prohibitive, while those achieving ≥ 300 cases annually may approach cost-parity with laparoscopic approaches^[28].

Robotic surgery offers many advantages over laparoscopic, including three-dimensional visualization, tremor reduction, increased instrument dexterity, and greater degrees of freedom of wristed instruments^[10,13]. These benefits directly lead to better exposure in the operative field, accurate dissection planes, and technically proficient procedures. The resulting data demonstrate that robotic procedures result in lower complication rates, decreased blood loss, shorter hospitalization, improved overall patient satisfaction scores, quicker return to daily activities, reduced hospital costs and long-term healthcare costs^[28]. Procedure-specific advantages have also been documented, such as decreased anastomotic leak rates in robotic Roux-en-Y gastric bypasses^[2], decreased blood loss in robotic hysterectomies^[29], and decreased mortality in robotic cardiac surgery^[30].

While robotic surgery is propelled by technology-driven advantages, conventional laparoscopic approaches are effective, equally viable, and often yield comparable results without the high capital investment for robotic systems^[31]. Indeed, for simple procedures, such as cholecystectomy, appendectomy, and straightforward herniorrhaphy, well-performed laparoscopic surgery achieves equivalent outcomes at substantially lower cost, and should remain the standard of care in resource-limited settings where robotic investment is not feasible^[31,32]. This should be balanced by the fact that laparoscopy has a steep learning curve, which can prove challenging for surgeons who have not yet mastered the approach^[9].

When discussing the distribution of robotic platforms, it is important to distinguish between low-income (LIC) and middle-income countries (MICs), as their challenges and viable solutions differ substantially. In LICs, such as those in sub-Saharan Africa, there are critical shortages of basic surgical infrastructure, trained workforce, and safe perioperative capacity, making direct robotic adoption impractical without foundational investment^[11,33]. On the other hand, MICs such as Brazil, India, and Thailand may have the institutional infrastructure to support phased robotic adoption, but face barriers of affordability, uneven geographic distribution of technology, and inequitable access across urban and rural populations^[33-36]. These challenges are magnified when considering access to robotic surgery, which requires substantial healthcare resources, including reliable power, strong information technology services, and a robust hospital infrastructure^[25].

It is clear that there cannot be a single overarching strategy to achieve equitable access to robotic surgery for all nations across the globe since each nation faces differing individual challenges. However, we attempt to discuss strategies to overcome the obstacles in general.

Several powerful robotic and AI-assisted surgical innovations have emerged, such as digital twin simulations, image-based segmentation, and advanced vision models, which possess the ability to provide autonomous suturing. While these cutting-edge innovations and future developments have the potential to enhance surgical care, they may also widen the gap in equitable access to these technologies^[53]. However, it also presents an underexplored opportunity to lower training barriers by enabling surgeons with limited robotic experience to perform procedures safely under AI-assisted, real-time, remote expert supervision, reducing the dependency on in-person fellowship training. Low-cost AI integrated with entry-level robotic platforms could create a viable pathway for LMICs to introduce robotic-assisted surgery at a fraction of current costs. Realizing this potential will require deliberate investment in open-access AI training datasets, affordable computational infrastructure, and international regulatory harmonization that does not inadvertently restrict LMIC adoption^[47].

While robotic surgery brings proven benefits for patients, surgeons, communities, and health systems, there are challenges in expanding its use in global, rural, and low-resource settings. Collaboration with government, industry, and health system leadership is now required to create multi-partner implementation models, accounting for country-specific variables such as health policies, financing models, availability of surgically trained workforce, and training models. The introduction of lower-cost platforms, expanded access to current platforms, and healthcare policies and financial models prioritizing access to safe, affordable surgical care are necessary.

Three action-oriented priorities should guide the field: (1) establish globally harmonized, competency-based training standards for robotic surgery that are accessible to surgeons in LMICs through simulation, twinning programs, and virtual mentorship; (2) develop sustainable, context-appropriate financing and equipment-sharing models - including leasing, regional hubs, and public–private partnerships with robust governance - to broaden platform access beyond high-income hospital systems; and (3) build comprehensive, whole-team capacity that includes surgeons, anesthesiologists, nurses, and biomedical engineers, ensuring that technology introduction does not outpace local ability to operate, maintain, and benefit from it safely and equitably.