Yesterday, José María Balibrea from Germans Trias i Pujol University Hospital visited Rey Juan Carlos University Hospital to present their pioneering robotic emergency surgery program. It was an exceptionally enriching session—strategically valuable not only from a clinical standpoint, but from the perspective of program governance, implementation, and long-term vision.
One word from his presentation stayed with me: “democratize.”
He referred to the democratizing role of robotics in surgery—not only because robotic systems allow us to measure what we do with increasing precision and so helps standardizing, but because they reduce dependence on individual technical virtuosity. Robotics lowers the threshold of access to minimally invasive surgery. It makes complex approaches less dependent on exceptional manual skill and long learning curves.
Robotics lowers the threshold of access to minimally invasive surgery
It seemed like the perfect moment to revisit an idea we discussed years ago.
Let me quote myself.
In our first book on robotic surgery, published in 2016 (J Granell, R Gutierrez. ISBN: 978-84-608-6749-4), ten years ago, we wrote:
“With the evolution of robotic surgery in gynecology, something analogous to urology occurred. Twenty-four years after the introduction of laparoscopy in gynecology, only 16% of hysterectomies in the United States were performed laparoscopically. This persisted despite scientific evidence and position statements such as that of the American Association of Gynecologic Laparoscopists (AAGL), which in 2010 acknowledged that vaginal and laparoscopic hysterectomy had demonstrated safety, efficacy, and favorable cost-effectiveness, making them the preferred techniques. The same document urged surgeons without sufficient training or skill to seek assistance from colleagues or refer patients. Seven years after the introduction of the da Vinci, 31% of hysterectomies in the United States were robotic. In other words, there was no evidence that robotic surgery was superior—but it clearly contributed to generalizing approaches that were evidently better.”
At the time, that observation felt almost provocative. Today, it feels self-evident.
The situation is somewhat different now, because a new generation of surgeons is often trained from the outset in minimally invasive surgery using robotic instrumentation. But the underlying dynamic remains worth analyzing.
Why did the da Vinci consolidate its success in urology? Why was radical prostatectomy the historical driving force behind its development?
Because minimally invasive surgery in the deep pelvis is technically demanding. Laparoscopic prostatectomy required advanced skills, long learning curves, and a degree of ambidexterity and spatial adaptation that only a subset of surgeons mastered comfortably. The robot did not make the operation conceptually different. It made it technically accessible.
That is the key.
When the da Vinci entered the market, endoscopic surgery was already established. Laparoscopy had years of accumulated evidence and technical maturity. And yet, what percentage of urologists were performing laparoscopic prostatectomy twenty years ago? A minority. Today, what percentage perform it robotically? The overwhelming majority.
What changed?
The anatomy did not change. The oncologic principles did not change. The indication did not change.
The ergonomics changed. The instrumentation changed. The learning curve changed.
The robot democratized access to minimally invasive prostatectomy, not for patients, but for surgeons.
The same pattern was visible in gynecology. The AAGL position statement did not trigger massive referral flows to highly skilled laparoscopists. Evidence alone did not reshape practice. But once robotic systems became widely available, surgeons transitioned to minimally invasive hysterectomy at scale.
Why not before? Because technical barriers matter more than declarations. Because professional inertia is real. Because the average surgeon behaves differently when the technical challenge becomes manageable within a reasonable training framework.
As José María Balibrea said at the end of his lecture: resistance is futile. This transition will happen. Endoscopic surgery will progressively become robotic surgery (and in parallel we will advance toward increasing robotic autonomy).
But understanding how and why this happened is essential if we want to guide the future rather than be dragged by technological momentum.
And here is where the discussion becomes uncomfortable.
The story of robotic democratization does not always leave surgeons in a flattering light. It reveals that widespread adoption of better approaches often required technology to compensate for human limitations—limitations in dexterity, yes, but also in willingness to retrain, to endure long learning curves, or to refer complex cases.
Yet this is not an indictment of individuals. From a technical point of view there will always be exceptional surgeons and standard surgeons. What robotics does—quietly but decisively—is narrow the gap between them.
And now we are entering the most important phase.
The latest generations of robotic systems are no longer just mechanical extensions of our hands. They are data platforms. Every movement can be recorded. Every metric can be analyzed. Instrument trajectories, energy activation times, camera stability, economy of motion, complication patterns, conversion rates—all of it becomes measurable. Transparency is no longer theoretical.
For the first time in surgical history, we are approaching true procedural accountability. Not reputation-based. Not volume-based. Not anecdotal. Measurable.
This may well be one of the most immediate and transformative indirect benefits of robotization: the establishment of a visible standard of surgical quality below which it will no longer be acceptable to operate. Performance will be auditable. Variation will be detectable. Outcomes will be attributable.
Accountability—long awaited, often demanded, rarely operationalized—will become structurally embedded in the technology itself.
- Democratization was the first wave.
- Standardization is the second.
- Accountability is the third—and it is arriving faster than many realize.
The future of robotic surgery will not be defined only by better instruments or increasing autonomy. It will be defined by the fact that what we do in the operating room will finally be transparent, measurable, and comparable.
And that will change surgery even more than the robot has done.
J Granell. Feb 14, 2026
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Why you should not perform a conventional tonsillectomy with the da Vinci robot. Feb 6, 2026