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Comparing open, keyhole and robotic

	Open surgery	Keyhole (laparoscopic)	Robotic
Incisions	One large incision	3–4 small incisions	4–5 small incisions
Time in hospital	Longest	Short	Short
Return to normal activity	Slowest	Quick	Quick
Wound complications	Highest risk	Low	Low
Precision in tight spaces	Direct hand access	Limited by rigid instruments	Best — instruments bend at the tip
Time under anaesthetic	Usually shortest	Middle	Usually longest
What it costs you	Usually funded by insurance or ACC.	Usually funded by insurance or ACC.	Same hospital cost as keyhole, but not currently funded, so paid out of pocket. Fixed price for inguinal hernia repair.
Where it’s the right choice	When keyhole isn’t safe, or in an emergency.	A well-established approach for most operations.	My preferred approach across the range, where cost allows.

Where is robotic surgery heading internationally?

One way to read a new technique is to watch what surgeons who have used both choose to do.

1.8% → 15.1%	The proportion of general surgical operations performed robotically in the United States rose from 1.8% in 2012 to 15.1% in 2018, across a study of more than 169,000 patients in 73 hospitals.
Keyhole declined	That growth came largely at the expense of conventional keyhole surgery rather than open surgery. In hospitals that introduced a robot, laparoscopic operating fell as robotic operating rose.
Over 15%	By 2023, more than 15% of general surgery in the United States was robotic-assisted, and the proportion continues to climb.
A standard approach	The American College of Surgeons now lists robotic transabdominal preperitoneal repair among the most commonly performed approaches to inguinal hernia, alongside open and laparoscopic repair.
10 million +	The da Vinci system has now been used in over 10 million operations worldwide.

Adoption is not proof. The authors of the largest study of this trend said as much themselves, warning that enthusiasm for new technology shouldn’t outpace the evidence supporting it. That is a fair caution. But it does tell you something. These are experienced surgeons deciding, operation by operation, how they want to work — and a great many of them, having used both, are choosing the robot.

A subtle advantage is hard to prove

Open surgery against keyhole surgery is an obvious comparison; one large incision versus several small ones, several days in hospital versus one. But robotic against keyhole is a finer comparison. If a man having a laparoscopic inguinal hernia repair already goes home the same day, is there much room for a robotic repair to improve on that? Having operated both ways, my impression is that robotic surgery is better tolerated: patients need less pain relief and get back to normal function sooner. However, this is just a personal observation; differences this subtle would need very large trials to demonstrate and prove.

Laparoscopic surgery was controversial at first

When laparoscopic surgery first arrived, there was real debate over whether it was any better than open surgery and a number of head-to-head trials failed to show an advantage. In hindsight, the trials were unfair as they measured an open operation that surgeons had complete mastery of against a new technique they were still learning.

Many surgeons think the same thing is happening now with robotic surgery. The most-cited trial in this area — ROLARR, comparing robotic and laparoscopic rectal surgery — found no significant difference between the two, and was criticised on exactly these grounds: the laparoscopic surgeons were experts, while several of the robotic surgeons were still relatively early in their experience with it. The evidence does not currently show robotic surgery to be clearly better for straightforward operations. But “not yet proven” is a different statement from “no advantage”, and it is the first that the evidence supports.

This is why I don’t reserve the robot only for difficult cases. The instruments and the view are better, so I’d rather operate to that standard as often as possible.

What it will cost you

At St George’s Hospital, a robotic procedure costs the hospital the same as the equivalent keyhole operation. The difficulty is funding. Private health insurers and ACC do not currently fund robotic-assisted surgery, so you’ll need to pay for robotic surgery yourself.

For inguinal hernia repair, I’ve negotiated a set fee with St George’s Hospital that matches the cost of the laparoscopic operation. So you’ll know the total price before you commit, and you won’t be paying a premium for the robotic approach — you’ll be paying what the keyhole operation would have cost, without the insurance cover. For other procedures I’ll give you a written estimate at your consultation.

Check the current position with your insurer, as policies change. And if cost is the deciding factor, say so at your consultation. For many operations a laparoscopic approach gives an equally good result. The right operation matters more than the newest one.

If you’re already paying for your own surgery

A lot of people assume robotic surgery is out of reach on price. For self-funding patients it isn’t. A growing number of people don’t hold private health cover and pay for surgery themselves. If that’s your situation, because the hospital charges the same for a robotic procedure as for the keyhole equivalent, there is no additional cost for choosing the robotic approach.

The evidence behind this page

I’ve linked the main studies underpinning what I’ve said above, so you can read them yourself or take them to your GP. Medical evidence changes, and I review these pages as it does.