The current status of robotic metabolic and bariatric surgery in the UK

According to Professor Ahmed Ahmed, President of the British Obesity and Metabolic Specialist Society, robotic metabolic and bariatric surgery (rMBS) in the UK is still in the early stage of adoption. He said that there are several reasons why the speciality has been slower to adopt this technology compared with other surgical specialities such as urology, thoracic or colorectal.

Ahmed Ahmed

“I believe one of the reasons is so far there is no clear benefit of rMBS over the more conventional laparoscopic approach for primary MBS procedures. Laparoscopic MBS, as evidenced by data from National Bariatric Surgical Registry (NBSR) and published scientific reports, have demonstrated it is highly safe and effective in the UK, boasting low complication and mortality rates comparable to common operations like laparoscopic cholecystectomy or knee replacement,” he argued. “The perceived advantages of robotic surgery - such as a magnified view and precise movements in tight spaces and angles - are less impactful in the broader abdominal field of primary MBS because you're not working in a tight space, you're working in the whole abdomen, unlike in prostate surgery.”

He added there is a lack of strong scientific evidence for rMBS vs laparoscopic MBS. He explained that there is currently no robust scientific data, such as randomised controlled trials (RCTs) that demonstrate superior patient outcomes (e.g., fewer complications, lower mortality) for rMBS compared to standard laparoscopic primary procedures. Indeed, he noted that the existing literature, often single-centre and potentially industry-funded, primarily highlights increased cost and longer procedure times for robotics, with no real difference in complications or weight loss outcomes, so there are no clear patient benefits identifiable yet.

“We've made MBS so safe using laparoscopic approaches, the benefit of using a robotic platform is less clear because what are you going to gain from it? Of course, another important factor is cost, robotic systems are very expensive with the initial hardware costing about £1.5-£2.5 million, plus ongoing costs for consumables, in additional to other resources, such as surgeon training.”

Revision surgery

That is not to say Mr Ahmed does not believe rMBS does not have a future in the UK. In fact, data from the NBSR shows that rMBS procedures have increased in the UK. In 2016, rMBS accounted for only 0.45% of all primary MBS procedures however, this increased to more than one in five (20.98%) of all primary rMBS procedures in 2025 (Figure 1). He also believes that the costs of robotic surgery will be reduced as competition in the market increases and robotic surgery will play an important role in revisional MBS.

“I think the cost is probably going to go down as different manufacturers enter the market. Large companies like Medtronic with Hugo and Ethicon with its upcoming Ottava robot offer alternatives to the Intuitive Da Vinci system, which has been the main robotic platform till now.  Moreover, there are some really good robots coming in from China, which are cheaper, so that might also help increase the adoption of the robotic surgery. I also believe that if the NHS can change its approach to purchasing - contracts not with individual trusts but with the NHS as a whole - then we could benefit from economies of scale.

“More importantly, we know one of the key benefits of robotic surgery is the ability to give the surgeon greater agility, particularly in complex anatomy, because it offers more precision than laparoscopic approaches. Therefore, I think the robotic platform is going to be quite helpful to surgeons performing revisional MBS, because it offers better optics with the 3D view, the magnified view, increased freedom of movement from the degrees of movement of the effectors, allowing the surgeon to suture with really complicated, awkward angles, which one struggles to do with laparoscopic surgery. We are doing more revision operations in the NHS year on year, so I think over the next ten years, we will definitely see more rMBS procedures, especially in the field of revision bariatric surgery.”

One advantage that laparoscopic MBS has over rMBS is procedural time. At a time when resources within the NHS are limited, Mr Ahmed noted that it is very important that surgeons can perform as many cases as possible on each operative list.

“I know there are some really fast robotic surgeons in the US and they have quick docking times. But I would argue that if you take the fastest robotic surgeon and the fastest laparoscopic surgeon - same operation, same patient - my money would be on the laparoscopic surgeon being faster. And, we certainly know that when people start robotic surgery, it takes longer because they're on their learning curves and procedure times are an issue.”

Improvements

So, from a surgical standpoint, what enhancements are needed to current robotic platforms to improve outcomes and the overall surgical experience? According to Mr Ahmed, enhancement should focus on real time haptic feedback, improved visual guidance and the development of smaller instruments.

“When I'm suturing during laparoscopic or open surgery, you can actually feel tissues and when I am tying a knot, I can feel the tension. As far as I am aware, when performing robotic surgery, you rely on visual cues, which is pretty primitive. This means there's always a chance that you over tighten or under tighten a knot, which could potentially lead to problems in the future. That's a big problem. Integrating real-time haptic feedback is a critical area for development.

“A second issue is improved visual guidance. Current methods like Indocyanine Green (ICG) imaging for tissue highlighting are imprecise. There's a need for more precise, detailed augmented reality or smart visual guidance. One final improvement would be for the manufacturers to make even thinner instruments. In conventional laparoscopic surgery, we use 5 millimetres and in mini laparoscopy we use 3 millimetres. It would be great if robotic instruments could be designed so that they can match what we're currently using in laparoscopic surgery. This would potentially reduce the incidence of port-site hernias and improve cosmetic outcomes.”