Sex-Based Disparities in Surgical Opportunities During Early Adoption of Robot-Assisted Surgery

Highlight

• Early adoption of robot-assisted surgery shows substantial sex disparities in operative opportunities among gastroenterological surgeons in Japan.

• Female surgeons perform a markedly lower proportion of robot-assisted distal gastrectomies and low anterior resections compared to male surgeons.

• Operative volume for robot-assisted procedures increases with experience for male surgeons but not for females, with disparities emerging approximately 10 years after medical registration.

• These inequities may contribute to persistent sex-based career differences in surgery.

Study Background

The surgical field has witnessed rapid technological advancement, among which robot-assisted surgery represents a cutting-edge modality promising enhanced precision, reduced invasiveness, and improved patient outcomes. Early experience and operative volume notably influence surgeon proficiency and career trajectory. However, surgical careers differ by sex, with evidence of underrepresentation and slower advancement for female surgeons. Understanding how early access to innovative surgical technologies like robot-assisted surgery is distributed across sexes is crucial to addressing disparities that may perpetuate long-term inequities in surgical practice and leadership.

Study Design

This retrospective observational study utilized data from Japan’s National Clinical Database (NCD), a comprehensive multicenter registry capturing over 95% of all surgeries nationwide. The study population included male and female gastroenterological surgeons performing two complex procedures: distal gastrectomy and low anterior resection, between January 1, 2023, and December 31, 2024.

The interventions assessed were three surgical approaches: robot-assisted, laparoscopic, and open surgery. The primary outcome measured was the number of surgeries performed per surgeon, stratified by the surgeon’s sex and years since medical registration, serving as a proxy for clinical experience.

Key Findings

A total of 47,934 distal gastrectomies and 38,230 low anterior resections formed the analysis base. The sex distribution showed significantly different engagement patterns across surgical approaches.

For distal gastrectomy, female surgeons performed 4.32% of robot-assisted cases, 9.47% of laparoscopic cases, and 11.86% of open surgeries. Similarly, for low anterior resection, these proportions were 5.41% for robot-assisted, 8.41% for laparoscopic, and 8.57% for open procedures.

Thus, female surgeons were least represented in robot-assisted surgeries compared to laparoscopic or open methods, indicating a distinct gap at the forefront of surgical technology adoption.

Analyzing operative volume in relation to years since medical registration uncovered that for robot-assisted surgery, male surgeons’ procedural volume increased with clinical experience. In contrast, female surgeons did not demonstrate a similar increase, with disparities becoming pronounced about 10 years post-registration. This pattern was less evident or absent in laparoscopic and open surgeries.

Expert Commentary

The findings highlight systemic barriers that female surgeons face in accessing early robotic surgery opportunities, potentially related to institutional biases, mentorship disparities, exclusion from early training, or sociocultural factors influencing operative assignments.

Early exposure to robot-assisted surgery is critical for skill development and positioning within competitive subspecialties. Disparate access may thus undermine career advancement, reinforcing persistent gender gaps in surgical leadership and academic ranks.

While the study’s nationwide database strengthens generalizability within Japan, the retrospective design limits causal inferences. Cultural and healthcare system differences may affect applicability to other countries. Additionally, factors such as individual surgeon preference, case complexity, and institutional policies require further exploration to contextualize the observed disparities fully.

Conclusion

This study presents robust evidence of sex-based inequities in operative opportunities during the critical early phase of robot-assisted surgery adoption. Female gastroenterological surgeons perform significantly fewer robot-assisted operations and do not exhibit increasing operative volume with experience seen in male counterparts. These findings suggest structural factors limiting female surgeons’ access to innovative surgical technologies, which may perpetuate broader career disparities.

Addressing these gaps requires targeted initiatives including mentorship programs, institutional transparency in case allocation, equitable training opportunities, and policies fostering inclusive adoption of new surgical techniques.

Funding and ClinicalTrials.gov

No funding sources were reported. The study was observational using registry data and was not registered as an interventional clinical trial.

References

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