Trend of robot-assisted surgery system in gastrointestinal and liver surgery: A bibliometric analysis

Abstract

BACKGROUND

Robot-assisted gastrointestinal and liver surgery has been an important development direction in the field of surgery in recent years and it is also one of the fastest developing and most concerning fields in surgical operations.

AIM

To illustrate the major areas of research and forward-looking directions over the past twenty-six years.

METHODS

Using the Web of Science Core Collection database, a comprehensive review of scholarly articles pertaining to robot-assisted gastrointestinal and liver surgery was researched out between 2000 and 2023. We used Citespace (Version 6.2.4) and Bibliometrix package (Version 4.3.0) to visualize the analysis of all publications including country, institutional affiliations, authors, and keywords.

RESULTS

In total, 346 articles were retrieved. Surgical Endoscopy had with the largest number of publications and was cited in this field. The United States was a core research country in this field. Yonsei University was the most productive institution. The current focus of this field is on rectal surgery, long-term prognosis, perioperative management, previous surgical experience, and the learning curve.

CONCLUSION

The scientific interest in robot-assisted gastrointestinal and liver surgery has experienced a significant rise since 1997. This study provides new perspectives and ideas for future research in this field.

Key Words: Bibliometric analysis; Robot-assisted surgery system; Gastrointestinal surgery; Liver surgery; Citespace

Core Tip: A total of 346 articles were enrolled. This study presents the first bibliometric analysis in the field of robot-assisted surgery system in gastrointestinal and liver surgery. The prominent words shown low anterior resection has proceeded presently, reflecting that related research is still a key trend in gastrointestinal and liver robotic surgery in the future. The United States is the leading country in the number of publications, Yonsei University is the most productive institution. The current focus of this field is on rectal surgery, long-term prognosis, perioperative management.

INTRODUCTION

Robot-assisted surgery is a recent medical method that uses robotic technology to assist surgeons in performing surgical operations and has the advantages of being more precise, less invasive, and more convenient[1]. It can improve surgical outcomes and safety, shorten the recovery time of patients, and reduce the fatigue and radiation damage to surgeons[2].

The history of robot-assisted surgery could be traced back to 1985, when a doctor in Los Angeles, utilized the mechanical robot PUMA560 to perform the first robot-assisted neurosurgery[3]. In the 1990s, Intuitive Surgical, a United States company, developed the Da Vinci laparoscopic surgical robot, which was the foremost fruitful and widely utilized surgical robot in the world. Since 2010, various surgical fields have entered the era of robotics, including percutaneous puncture, natural orifice transluminal endoscopic surgery, vascular surgery, and other operations[4].

Robot-assisted surgery has unique advantages in gastrointestinal and liver surgery. As rectal cancer surgery requires fine lymph node dissection and intestinal anastomosis in a narrow pelvic space, conventional laparoscopic surgery has certain limitations and challenges. Robot-assisted surgery can provide a stable high-definition three-dimensional image system and a flexible operation system, achieve smooth and accurate movements, and completely remove the lesion[5]. Robot-assisted surgery can diminish anastomotic fistulas, protect autonomic nerves, and increase the anal preservation rate[5]. Liver surgery requires precisely separation and resection of the hepatic portal area with rich blood vessels and complex anatomy, which poses certain risks and difficulties for traditional open or laparoscopic surgery. Robot-assisted surgery can provide a better view and operation angle, accomplish more exact margin control, and reduce bleeding and other complications[6].

Although robot-assisted surgery has obvious technical advantages in gastrointestinal and liver surgery, it also faces a few shortcomings and challenges such as high cost, long operation time, steep learning curve, and insufficient clinical evidence, etc.[7]. The existing research contents are scattered, but it is also one of the fastest developing and most concerning fields in surgical operations. It is fundamental to combine various scientific measurement methods to conduct the in-depth mining and analysis of literature data. In this manner, this study uses bibliometric software to sort and analyze the research hotspots, evolution process, and development context of robot-assisted surgery systems in gastrointestinal and liver surgery from a general perspective, hoping to supply new investigation points of view and contemplations for the improvement of this field.

MATERIALS AND METHODS

Purpose

To investigate the dynamics and evolution trajectory of robot-assisted surgery in gastrointestinal and liver surgery, we conducted a study on journal literature based on the aspects of publication journals, countries, authors, institutions, prominent words, and keywords. The information mining is carried out to summarize the development characteristics of the research and to provide a critical reference for researchers to conduct relevant theoretical research.

Literature retrieval

All literature data used in this study are from the core database of Web of Science, an important global academic database. The journal time span is set from 1997 to 2023, and the search criteria is: TI = (robot surgery OR robot assisted surgery OR robotic surgical OR robotic surgery) AND [TS = (Liver OR Hepatocellular OR Hepatic) OR TS = (stomach OR gastric OR colorectal OR colon OR rectal OR intestinal OR gastrointestinal OR gastroenterology)], document type = "ARTICLE”.

Research methods and software

We used Citespace (Version 6.2.4) and Bibliometrix package (Version 4.3.0) in R software (Version 4.1.2) to visualize the analysis of all publications, using text information extraction strategy, qualitative and quantitative combination method, mining out the current hotspots of robot-assisted surgery in gastrointestinal and liver surgery worldwide, and revealing its network visualization maps, cluster analysis, and burst words.

RESULTS

After searching the literature on robot-assisted surgery in gastrointestinal and liver surgery in the WOS database, we conducted a descriptive analysis of 346 journal articles on this field. From Figure 1, it can be seen that the volume of literature on robot-assisted surgery in gastrointestinal and liver surgery from 1997 to 2023 appeared to be expanding annually, and from 2015 to 2023, the volume of literature in related fields showed a rapid upward trend. In 2001, the Food and Drug Administration approved the Da Vinci robotic surgical system to enter the operating room, and international research on robotic surgery has risen. However, the research results were rare[8], which was primarily affected by two aspects: On the one hand, the essential research about surgical technology in worldwide needed to be progressed, and on the other hand, the limitations of instruments, software, and price had not been widely popularized. It wasn't until 2010 that the number of articles began to increase.

Figure 1  The trend number of articles from 1997 to 2023 in robot-assisted surgery in gastrointestinal and liver surgery.

Figures 2 and 3 showed the journals with the most published papers and the most cited journals, respectively. Surgical Endoscopy was positioned to begin with in both the number of published papers and the number of citations and was widely favored by relevant researchers. Two journals related to robotic surgery, Journal of Robotic Surgery and International Journal of Medical Robotics and Computer Assisted Surgery, were ranked second and third in terms of the number of published articles. Even though Annals of Surgery, Annals of Surgical Oncology and British Journal of Surgery did not have a high number of published articles, their published articles were widely recognized by researchers for their quality, so their citations were also among the top five.

Figure 2  The journals with the most published and more than 6 articles.

Figure 3  The top 10 most cited journals.

Research on the distribution of high-output countries

In Figure 4, each node represents a country and the connection between the two nodes represents the connection between the two countries. The size of each node equals to the number of publications.

Figure 4 National cooperation network. Each node represents a country, the ring represents the year in which the article was published, and the lighter the color, the closer it is to 2023. The purple ring represents a centrality greater than 0.1.

To better obtain the node hierarchy in this field, assist data mining was performed, as shown in Figure 5. From the viewpoint of articles output, the United States and Japan had published the most research on robot-assisted surgery in gastrointestinal and liver surgery, followed by China, South Korea, and Italy, with little difference in paper numbers. Among them, the United States and Italy started their research earlier in this field, and some of their papers were key turning points in the research, which may be a critical reason for their rapid improvement in robot-assisted gastrointestinal and liver surgery. On the other hand, from the perspective of centrality, nodes with a centrality value greater than 0.1 were considered as key nodes, which were usually regarded as important factors that cause changes in the research field. The Figure 4 shows that three countries, the United States, Germany, and England, were more prominent than 0.1. These three countries had a high innovation ability and played a tremendous role in robot-assisted gastrointestinal and liver surgery.

Figure 5  Total number and centrality of publications per country.

Research on the distribution of high-output institutions

A distribution map of high-output institutions could be obtained by running the software and selecting the "Institution" option. The collaboration map of high-output institutions had 277 nodes and 385 links. Each node represents the number of papers in the institution, and the connect speaks to the collaboration between institutions. Supplementary Figure 1 shows that there was a lack of cooperation among various institutions, and institutions generally cooperate with their own affiliated hospitals or other subordinate institutions, mainly using internal resources for independent research, and lack multi-center and multi-regional research cooperation. The high-output research institutions were Yonsei University, Korea University, University of Illinois System and the others were listed in Table 1.

Table 1 Articles published by institutions (only those with more than 3 articles are listed).

Institution	Year of first publication	Number of articles
Yonsei University Health System	2017	7
Yonsei University	2017	7
Korea University Medicine (KU Medicine)	2011	6
Korea University	2011	6
University of Illinois System	2001	5
George Washington University	2016	5
Central South University	2017	5
University of California System	2003	5
University of Illinois Chicago	2001	5
Fujita Health University	2011	5
University of Illinois Chicago Hospital	2001	5
Advent Health	2013	4
Amrita Vishwa Vidyapeetham	2020	4
National Taiwan University	2014	4
University of Texas System	2020	4
Azienda Ospedaliero Universitaria Careggi	2015	4
Cleveland Clinic Foundation	2012	4
Adventist Health Services	2013	4
Fujian Medical University	2018	4
Amrita Vishwa Vidyapeetham Kochi	2020	4
Institutul Clinic Fundeni	2016	3
Charité University Berlin Medical School	2008	3
University of California Irvine	2003	3
IRCCS European Institute of Oncology (IEO)	2011	3
National Taiwan University Hospital	2014	3
National University of Singapore	2010	3
Hopital Universitaire Hotel-Dieu-APHP	2016	3
Herlev and Gentofte Hospital	2013	3
Istanbul Medeniyet University	2013	3
Technical University of Munich	2015	3
Hopital Universitaire Paul-Brousse - APHP	2016	3
Chinese People's Liberation Army General Hospital	2016	3
Tianjin University	2017	3
University of North Carolina	2001	3
Imperial College London	2003	3
Assistance Publique Hopitaux Paris (APHP)	2016	3
Ajou University	2010	3
Autonomous University of Barcelona	2022	3
University of Copenhagen	2013	3
Shizuoka Cancer Center	2014	3
Carol Davila University of Medicine & Pharmacy	2016	3
Chinese University of Hong Kong	2016	3
Intuitive Surgical	2020	3
Army Medical University	2014	3

Distribution of high-output authors

To better reflect the core authors and relevance of robot-assisted surgery in gastrointestinal and liver surgery, a visual analysis of author collaboration maps was performed on 346 papers. In total, 230 authors had published articles. The authors with the highest number of publications were Uyama Ichiro, Mario Annecchiarico, and Enrico Andolfi, who published four, three, and three papers, respectively. 53 authors published two papers each (Table 2), and most authors published one paper. The size of the nodes in Figure 6 represents the number of papers published by the author and the link represents the mutual collaboration relationship. The cooperative relationship of authors was relatively close, and the research force in this field was in a moderately concentrated state. The close contact between researchers within the same research institution encompasses a certain note for the in-depth exploration of this field.

Figure 6 Author collaboration network. Each node represents an author, and the connection represents a co-occurrence relationship between two authors.

Table 2 Articles published by institutions (only those with more than 2 articles are listed).

Author	Year of first publication	Number of articles
Ichiro Uyama	2011	4
Mario Annecchiarico	2015	3
Enrico Andolfi	2017	3
Valentina Valle	2020	2
Anuradha R Bhama	2016	2
Luciano Casciola	2011	2
Ismail Gogenur	2018	2
Pier C Giulianotti	2020	2
Makoto Hashizume	2003	2
Omar Kadri	2017	2
Alberto Mangano	2020	2
Ismail Pinar	2018	2
Paolo Dario	2010	2
Kang-young Lee	2021	2
Nam-kyu Kim	2021	2
Sharona Ross	2023	2
Hyoung-Il Kim	2021	2
Wanda Petz	2016	2
Tina Fransgaard	2018	2
Alexander Rosemurgy	2023	2
Sam Atallah	2013	2
Robert K Cleary	2016	2
Ajay Varun Reddy	2017	2
Alberto Bartoli	2011	2
Dong-won Park	2017	2
W. Scott Melvin	2003	2
Hyuk Hur	2021	2
Bilgi Baca	2018	2
Yoshinori Ishida	2011	2
Jin-Hong Lim	2017	2
Eduardo Fernandes	2020	2
Gianandrea Baldazzi	2013	2
Se-Hoon Kim	2017	2
Heiko Aselmann	2016	2
Dariush Kamali	2017	2
Samir Agarwal	2017	2
Mario Masrur	2020	2
Orhan Alimoglu	2015	2
Seung-Yoon Yang	2021	2
Woo-Jung Lee	2017	2
Ninh T Nguyen	2015	2
Erman Aytac	2018	2
Natasha Alvarado	2016	2
Amalanshu Jha	2017	2
Gabriela Aguiluz	2020	2
Yusuke Kinugasa	2023	2
Byung-soh Min	2021	2
Madan Jha	2017	2
Graziano Ceccarelli	2011	2
Roberto Bustos	2020	2
Alberto Patriti	2011	2
Chang-moo Kang	2017	2
Iswanto Sucandy	2023	2
Santiago Horgan	2001	2
Jian-Min Li	2020	2
James F Vandewarker	2016	2

Based on prominent word visualization analysis and keyword prediction

The prominent words shown in Figure 7 from 2007 to 2017 incorporated robotic surgery experience, robotic surgery system, robotic surgery, and inter-sphincteric resection; from 2017 to 2019, meta-analysis and robotic surgery feasibility appeared; from 2020 onwards, low anterior resection was performed. These prominent words reflected the developmental context and trends of robot-assisted surgery in gastrointestinal and liver surgery. Among these, low anterior resection has proceeded presently, reflecting that related research is still a key trend in gastrointestinal and liver surgery in the future.

Figure 7 The prominent words from 2007 to 2023. The red line on the right indicates the main occurrence time.

Research hotspot analysis based on keyword co-occurrence and clustering

Keywords reflect the interrelationships among various topics expressed in the literature and are the core summary of the article's center. Analyzing keywords is conducive to considering hotspots in this field. According to the keywords with a recurrence more prominent than 10 generated by Citespace software (Table 3), the keyword with the highest frequency was “robotic surgery”, with a frequency of 95 times; followed by “rectal surgery”, with a frequency of 76 times. Keywords with high centrality included “learning curve”, “cancer”, “rectal cancer”, which were also core nodes in the network structure. From the clustering time view (Figure 8), 10 clusters with the most clusters were obtained, with a Q value of 0.891, indicating that the clustering structure is significant and the clustering is good[9]; and an S value of 0.9606 indicates that the clustering results are convincing[10]. From the figure, cluster 2, 8, 9 belonged to the comparison between robotic surgery and laparoscopic surgery appeared the most punctual, and it was still a key research field. Cluster 5 was the only cluster that was associated with robotic surgery. Cluster 0, 3, 6, 7 were associated with the specific surgical sites. Research on colorectal surgery appeared prior, and in 2010-2015, rectal surgery became a research focus, indicating that robotic surgery had unique advantages in rectal surgery and has received wide attention from researchers. Research in the early stage mainly focused on learning curves and short-term outcomes, later progressed to comparative research on multiple dimensions and surgical methods. Robotic surgery of the stomach appeared later than that of the colorectum, and research trends have declined in recent years. Robotic liver surgery was a current research focus. Although compared with gastrointestinal robotic surgery, liver robotic surgery keywords appeared slightly later, the evolution of keywords was clearer, from examining surgical experience in 2005-2010, to gradually developing to study perioperative complications and long-term prognosis.

Figure 8  The clustering time view.

Table 3 Keywords with the occurrence more than 10.

Keywords	Year of first occurrences	Frequency	Centrality
Robotic surgery	2007	95	0.14
Rectal cancer	2013	76	0.34
Resection	2011	68	0.06
Surgery	2010	57	0.06
Outcome	2010	46	0.21
Laparoscopic surgery	1997	43	0.11
Learning curve	2012	42	0.51
Total mesorectal excision	2011	42	0.29
Minimally invasive surgery	2007	33	0.2
Colorectal surgery	2009	32	0.04
Meta analysis	2014	27	0.11
Gastric cancer	2012	27	0.06
Cancer	2007	26	0.38
Short term outcome	2013	23	0.1
Experience	2007	22	0.23
Complications	2014	22	0.17
Colorectal cancer	2016	21	0
Robot-assisted surgery	2005	19	0.08
Low anterior resection	2012	18	0.02
Trial	2011	17	0.06
Impact	2016	15	0.03
Survival	2019	15	0.02
Lymph node dissection	2010	14	0.08
Multicenter	2005	13	0.23
Colon cancer	2018	10	0.04
Classification	2015	10	0

DISCUSSION

Robot-assisted surgery in gastrointestinal and liver surgery is an imperative development direction in the field of surgery in later a long time. It uses advanced robotic technology to assist doctors in performing precise, minimally invasive, and safe surgical operations; improving surgical outcomes and patient satisfaction; and providing a new platform and opportunity for surgical education and training[11]. This study used bibliometric methods to systematically analyze and examine 346 articles in the field over the past 26 years.

The number of articles published each year showed an increasing trend, especially in the last 10 years. This showed that robotic surgery has been widely performed, and the technology was becoming increasingly mature. From the perspective of journals, Surgical Endoscopy ranked first in both the number of published papers and the number of citations, demonstrating that this journal had a high impact and authority in robot-assisted surgery in gastrointestinal and liver surgery and reflected the close intersection between this field and endoscopic surgery. Other journals with more papers or citations were mainly concentrated in the fields of surgery, medical engineering, and computer science, reflecting the multidisciplinary and comprehensive nature of this field. An article published in the Annals of Surgery in 2018 that prospectively compared robotic surgery and laparoscopy for rectal cancer again aroused researchers’ enthusiasm, and related articles appeared in the following years[12].

From the perspective of paper output, the United States and Japan have published the most papers on robot-assisted surgery in gastrointestinal and liver surgery, indicating that these two countries have solid research quality and innovation capacity in this field[13,14], and were related to the advanced level of these two countries in robotic technology and medical level. Other countries with more papers are mainly China, South Korea, and Italy, indicating that these countries were also effectively carrying out research and application in this field, reflecting the popularity and development of this field in the global scope[4].

From the perspective of high-output institutions and authors, Yonsei University was the most productive institution, and Uyama Ichiro, Mario Annecchiarico, and Enrico Andolfi were the most productive authors, indicating that these institutions and authors had a high academic status and contribution in this field[15]. However, from the perspective of cooperation between institutions and authors, it was not connected closely, mainly based on cooperation within the same institution or between affiliated hospitals, missing cross-institutional, cross-national, and cross-disciplinary cooperation models, which may constrain the knowledge sharing and innovation ability of this field.

From the perspective of research hotspots, the current focus of robot-assisted surgery in gastrointestinal and liver surgery was on rectal surgery, long-term prognosis, perioperative management, previous surgical experience, the learning curve to focus on each disease, and comparison with laparoscopic surgery. It appeared that this field had entered a profound stage from an exploratory stage, paying more attention to the assessment and enhancement of surgical effects and quality, and paying more consideration to the advantages and adaptability of different surgical methods[5,16]. Rectal surgery is a critical branch of this field. Because robotic surgery has self-evident preferences in rectal surgery, such as better vision, more precise operation, and a higher anal preservation rate, it has received wide attention and application. Robotic surgery of the stomach[17] and liver[18] appeared relatively late, and research trends have declined in recent years. This may be related to the anatomical structure and surgical difficulty of these parts. It may also be related to the cost-effectiveness and insufficient clinical evidence of robotic surgery.

Be that as it may, this paper also has some limitations such as single source of literature data, insufficient depth of analysis methods, incomplete conclusions etc., which need to be improved and culminated in future research.

CONCLUSION

In summary, robot-assisted surgery in gastrointestinal and liver surgeries is a vibrant and promising field. It involves multiple disciplines and fields and has high academic value and social importance. This study used bibliometric methods to systematically analyze and discuss the research status, development trends, and hot issues in this field. This provides modern perspectives and ideas for further research in this field.