literature review introduction length

How to write a literature review introduction (+ examples)

The introduction to a literature review serves as your reader’s guide through your academic work and thought process. Explore the significance of literature review introductions in review papers, academic papers, essays, theses, and dissertations. We delve into the purpose and necessity of these introductions, explore the essential components of literature review introductions, and provide step-by-step guidance on how to craft your own, along with examples.

Why you need an introduction for a literature review

In academic writing , the introduction for a literature review is an indispensable component. Effective academic writing requires proper paragraph structuring to guide your reader through your argumentation. This includes providing an introduction to your literature review.

It is imperative to remember that you should never start sharing your findings abruptly. Even if there isn’t a dedicated introduction section .

Instead, you should always offer some form of introduction to orient the reader and clarify what they can expect.

When you need an introduction for a literature review

There are three main scenarios in which you need an introduction for a literature review:

What to include in a literature review introduction

It is crucial to customize the content and depth of your literature review introduction according to the specific format of your academic work.

Academic literature review paper

The introduction of an academic literature review paper, which does not rely on empirical data, often necessitates a more extensive introduction than the brief literature review introductions typically found in empirical papers. It should encompass:

Regular literature review section in an academic article or essay

In a standard 8000-word journal article, the literature review section typically spans between 750 and 1250 words. The first few sentences or the first paragraph within this section often serve as an introduction. It should encompass:

Introduction to a literature review chapter in thesis or dissertation

Some students choose to incorporate a brief introductory section at the beginning of each chapter, including the literature review chapter. Alternatively, others opt to seamlessly integrate the introduction into the initial sentences of the literature review itself. Both approaches are acceptable, provided that you incorporate the following elements:

Examples of literature review introductions

Example 1: an effective introduction for an academic literature review paper.

To begin, let’s delve into the introduction of an academic literature review paper. We will examine the paper “How does culture influence innovation? A systematic literature review”, which was published in 2018 in the journal Management Decision.

Example 2: An effective introduction to a literature review section in an academic paper

The second example represents a typical academic paper, encompassing not only a literature review section but also empirical data, a case study, and other elements. We will closely examine the introduction to the literature review section in the paper “The environmentalism of the subalterns: a case study of environmental activism in Eastern Kurdistan/Rojhelat”, which was published in 2021 in the journal Local Environment.

Thus, the author successfully introduces the literature review, from which point onward it dives into the main concept (‘subalternity’) of the research, and reviews the literature on socio-economic justice and environmental degradation.

Examples 3-5: Effective introductions to literature review chapters

Numerous universities offer online repositories where you can access theses and dissertations from previous years, serving as valuable sources of reference. Many of these repositories, however, may require you to log in through your university account. Nevertheless, a few open-access repositories are accessible to anyone, such as the one by the University of Manchester . It’s important to note though that copyright restrictions apply to these resources, just as they would with published papers.

Master’s thesis literature review introduction

Phd thesis literature review chapter introduction.

The second example is Deep Learning on Semi-Structured Data and its Applications to Video-Game AI, Woof, W. (Author). 31 Dec 2020, a PhD thesis completed at the University of Manchester . In Chapter 2, the author offers a comprehensive introduction to the topic in four paragraphs, with the final paragraph serving as an overview of the chapter’s structure:

PhD thesis literature review introduction

The last example is the doctoral thesis Metacognitive strategies and beliefs: Child correlates and early experiences Chan, K. Y. M. (Author). 31 Dec 2020 . The author clearly conducted a systematic literature review, commencing the review section with a discussion of the methodology and approach employed in locating and analyzing the selected records.

Steps to write your own literature review introduction

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The Guide to Literature Reviews

• What is a Literature Review?
• The Purpose of Literature Reviews
• Guidelines for Writing a Literature Review
• How to Organize a Literature Review?
• Software for Literature Reviews
• Using Artificial Intelligence for Literature Reviews
• How to Conduct a Literature Review?
• Common Mistakes and Pitfalls in a Literature Review
• Methods for Literature Reviews
• What is a Systematic Literature Review?
• What is a Narrative Literature Review?
• What is a Descriptive Literature Review?
• What is a Scoping Literature Review?
• What is a Realist Literature Review?
• What is a Critical Literature Review?
• Meta Analysis vs. Literature Review
• What is an Umbrella Literature Review?
• Differences Between Annotated Bibliographies and Literature Reviews
• Literature Review vs. Theoretical Framework
• How to Write a Literature Review?
• How to Structure a Literature Review?
• How to Make a Cover Page for a Literature Review?
• How to Write an Abstract for a Literature Review?
• How to Write a Literature Review Introduction?
• How to Write the Body of a Literature Review?
• How to Write a Literature Review Conclusion?
• How to Make a Literature Review Bibliography?
• How to Format a Literature Review?

Introduction

What determines the length of a literature review, structure and organization, lengths in different kinds of literature reviews.

• Examples of Literature Reviews
• How to Present a Literature Review?
• How to Publish a Literature Review?

How Long Should a Literature Review Be?

A literature review is an essential part of many academic papers and research projects. It provides a comprehensive overview of existing research on a particular topic, allowing the researcher to identify gaps, build on previous work, and position their study within the broader academic context. The length of a literature review can vary significantly depending on the context, purpose, and research scope . In this article, we will explore the factors that influence the length of a literature review and provide guidelines to help you determine the appropriate length for your work.

The length of a literature review is influenced by multiple factors, including the type of review, the research aims, the scope of the topic, and institutional guidelines. Writing a literature review involves synthesizing existing research and providing a critical analysis, which varies depending on the depth and breadth of the subject. Additionally, a literature review involves evaluating and summarizing scholarly sources to support the research objectives. Understanding these factors is crucial for researchers to effectively plan and structure their reviews, ensuring they meet academic standards and adequately cover the relevant literature.

Context and purpose

In most literature reviews, the length largely depends on the context and purpose of your research. Here are some common scenarios to consider:

Undergraduate research papers : Typically concise, these reviews range from 1,000 to 3,000 words (4-12 pages) and provide a basic overview of the existing literature. They are usually integrated into the introduction or background section of the paper.

Master's theses : More detailed and comprehensive, literature reviews for master's theses usually span 3,000 to 10,000 words (10-40 pages). They demonstrate the student's understanding of the field and justify the research question.

Doctoral dissertations : The literature review can be extensive for postgraduate dissertations, often ranging from 8,000 to 20,000 words (30-80 pages). These reviews need to cover a wide range of studies and theories, providing a thorough background for the research and highlighting gaps the dissertation aims to address.

Journal articles : Concise and focused, literature reviews in journal articles typically range from 2,000 to 5,000 words (8-20 pages), depending on the journal's guidelines. They concentrate on recent and relevant studies that directly inform the research question.

Grant proposals : Brief and focused, literature reviews in grant proposals are usually around 1,000 to 2,000 words (4-8 pages). Their purpose is to provide a quick overview of the current state of research and justify the need for the proposed study.

Research scope

The breadth and depth of the literature you need to cover will also affect the length of your review. If your research focuses on a specific niche or well-defined topic, your literature review might be shorter, around 1,000 to 3,000 words. This is because there may be fewer studies to review, allowing you to focus on the most relevant ones. For topics that span multiple disciplines or have a vast body of literature, the review will be longer, potentially exceeding 10,000 words. A broader scope requires a more extensive review to ensure all relevant research is covered.

Guidelines and requirements

Always check the guidelines provided by your institution, advisor, or the journal to which you are submitting. These guidelines often specify the expected length and format for the literature review. Adhering to these requirements is crucial for ensuring your review meets academic standards and is accepted for publication or evaluation.

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A well-structured literature review typically includes the following sections, which can influence its length:

Provides an overview of the topic and the review's purpose. This section usually accounts for 5-10% of the total word count. In a 3,000-word review, the introduction might be around 150-300 words.

Discusses key themes, theories, and findings in the literature. This section is the core of the review and can be divided into sub-sections based on themes, methodologies, or chronological order. It usually makes up 70-80% of the total word count. For example, in a 3,000-word review, the main body might be around 2,100-2,400 words.

Summarizes the key findings and highlights gaps or areas for future research. This section usually accounts for 10-15% of the total word count. In a 3,000-word review, the conclusion might be around 300-450 words.

Different methods of conducting literature reviews affect the length. The length of a literature review depends on several factors, including the chosen approach, institutional guidelines, and the specific requirements of the research project. Systematic reviews are usually the most extensive due to their rigorous and comprehensive nature, while narrative reviews are more flexible and shorter. Scoping reviews provide a broad overview without the detailed synthesis required by systematic reviews, placing them in the middle range of length. Umbrella reviews and realist reviews vary in length but generally provide a comprehensive synthesis of existing reviews or focus on the mechanisms of interventions.

Understanding these differences helps researchers select the appropriate approach and determine the optimal length for their literature review, ensuring it meets academic standards and contributes meaningfully to the field of study.

The length of a literature review is influenced by several factors, including the type of review, the scope of the research topic, and institutional guidelines. Most literature reviews vary in length depending on the specific requirements of the research project. The process of literature review writing is crucial for determining length, as it involves synthesizing research articles, current research, and existing scholarship to adequately cover the topic. For instance, a thesis literature review tends to be more extensive compared to a literature review for a research paper or journal article.

When determining how long a literature review should be, it's essential to consider the need to address current theories and provide a critical analysis of scholarly sources. Systematic reviews are typically more detailed and extensive, often requiring a substantial number of pages, while narrative reviews may only span a few pages. The length is also shaped by the research aims and the depth of coverage needed for the original research. Creating an annotated bibliography also affects the length of the review. Adhering to institutional guidelines is crucial, as they often provide specific directions on the expected length and structure of the review.

Ultimately, the length of a literature review is dictated by the comprehensive coverage required to support the research aims and the specific nature of the research project. Whether it's a thesis literature review, a journal article, or part of a larger research paper, the goal is to ensure the review is thorough, insightful, and aligned with the objectives of the current project. By understanding these factors, researchers can determine the optimal length for their literature review, ensuring it meets academic standards and effectively contributes to the field of study.

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Writing a Literature Review

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A literature review is a document or section of a document that collects key sources on a topic and discusses those sources in conversation with each other (also called synthesis ). The lit review is an important genre in many disciplines, not just literature (i.e., the study of works of literature such as novels and plays). When we say “literature review” or refer to “the literature,” we are talking about the research ( scholarship ) in a given field. You will often see the terms “the research,” “the scholarship,” and “the literature” used mostly interchangeably.

Where, when, and why would I write a lit review?

There are a number of different situations where you might write a literature review, each with slightly different expectations; different disciplines, too, have field-specific expectations for what a literature review is and does. For instance, in the humanities, authors might include more overt argumentation and interpretation of source material in their literature reviews, whereas in the sciences, authors are more likely to report study designs and results in their literature reviews; these differences reflect these disciplines’ purposes and conventions in scholarship. You should always look at examples from your own discipline and talk to professors or mentors in your field to be sure you understand your discipline’s conventions, for literature reviews as well as for any other genre.

A literature review can be a part of a research paper or scholarly article, usually falling after the introduction and before the research methods sections. In these cases, the lit review just needs to cover scholarship that is important to the issue you are writing about; sometimes it will also cover key sources that informed your research methodology.

Lit reviews can also be standalone pieces, either as assignments in a class or as publications. In a class, a lit review may be assigned to help students familiarize themselves with a topic and with scholarship in their field, get an idea of the other researchers working on the topic they’re interested in, find gaps in existing research in order to propose new projects, and/or develop a theoretical framework and methodology for later research. As a publication, a lit review usually is meant to help make other scholars’ lives easier by collecting and summarizing, synthesizing, and analyzing existing research on a topic. This can be especially helpful for students or scholars getting into a new research area, or for directing an entire community of scholars toward questions that have not yet been answered.

What are the parts of a lit review?

Most lit reviews use a basic introduction-body-conclusion structure; if your lit review is part of a larger paper, the introduction and conclusion pieces may be just a few sentences while you focus most of your attention on the body. If your lit review is a standalone piece, the introduction and conclusion take up more space and give you a place to discuss your goals, research methods, and conclusions separately from where you discuss the literature itself.

Introduction:

• An introductory paragraph that explains what your working topic and thesis is
• A forecast of key topics or texts that will appear in the review
• Potentially, a description of how you found sources and how you analyzed them for inclusion and discussion in the review (more often found in published, standalone literature reviews than in lit review sections in an article or research paper)
• Summarize and synthesize: Give an overview of the main points of each source and combine them into a coherent whole
• Analyze and interpret: Don’t just paraphrase other researchers – add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
• Critically Evaluate: Mention the strengths and weaknesses of your sources
• Write in well-structured paragraphs: Use transition words and topic sentence to draw connections, comparisons, and contrasts.

Conclusion:

• Summarize the key findings you have taken from the literature and emphasize their significance
• Connect it back to your primary research question

How should I organize my lit review?

Lit reviews can take many different organizational patterns depending on what you are trying to accomplish with the review. Here are some examples:

• Chronological : The simplest approach is to trace the development of the topic over time, which helps familiarize the audience with the topic (for instance if you are introducing something that is not commonly known in your field). If you choose this strategy, be careful to avoid simply listing and summarizing sources in order. Try to analyze the patterns, turning points, and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred (as mentioned previously, this may not be appropriate in your discipline — check with a teacher or mentor if you’re unsure).
• Thematic : If you have found some recurring central themes that you will continue working with throughout your piece, you can organize your literature review into subsections that address different aspects of the topic. For example, if you are reviewing literature about women and religion, key themes can include the role of women in churches and the religious attitude towards women.
• Qualitative versus quantitative research
• Empirical versus theoretical scholarship
• Divide the research by sociological, historical, or cultural sources
• Theoretical : In many humanities articles, the literature review is the foundation for the theoretical framework. You can use it to discuss various theories, models, and definitions of key concepts. You can argue for the relevance of a specific theoretical approach or combine various theorical concepts to create a framework for your research.

What are some strategies or tips I can use while writing my lit review?

Any lit review is only as good as the research it discusses; make sure your sources are well-chosen and your research is thorough. Don’t be afraid to do more research if you discover a new thread as you’re writing. More info on the research process is available in our "Conducting Research" resources .

As you’re doing your research, create an annotated bibliography ( see our page on the this type of document ). Much of the information used in an annotated bibliography can be used also in a literature review, so you’ll be not only partially drafting your lit review as you research, but also developing your sense of the larger conversation going on among scholars, professionals, and any other stakeholders in your topic.

Usually you will need to synthesize research rather than just summarizing it. This means drawing connections between sources to create a picture of the scholarly conversation on a topic over time. Many student writers struggle to synthesize because they feel they don’t have anything to add to the scholars they are citing; here are some strategies to help you:

• It often helps to remember that the point of these kinds of syntheses is to show your readers how you understand your research, to help them read the rest of your paper.
• Writing teachers often say synthesis is like hosting a dinner party: imagine all your sources are together in a room, discussing your topic. What are they saying to each other?
• Look at the in-text citations in each paragraph. Are you citing just one source for each paragraph? This usually indicates summary only. When you have multiple sources cited in a paragraph, you are more likely to be synthesizing them (not always, but often
• Read more about synthesis here.

The most interesting literature reviews are often written as arguments (again, as mentioned at the beginning of the page, this is discipline-specific and doesn’t work for all situations). Often, the literature review is where you can establish your research as filling a particular gap or as relevant in a particular way. You have some chance to do this in your introduction in an article, but the literature review section gives a more extended opportunity to establish the conversation in the way you would like your readers to see it. You can choose the intellectual lineage you would like to be part of and whose definitions matter most to your thinking (mostly humanities-specific, but this goes for sciences as well). In addressing these points, you argue for your place in the conversation, which tends to make the lit review more compelling than a simple reporting of other sources.

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Methodology

• How to Write a Literature Review | Guide, Examples, & Templates

How to Write a Literature Review | Guide, Examples, & Templates

Published on January 2, 2023 by Shona McCombes . Revised on September 11, 2023.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research that you can later apply to your paper, thesis, or dissertation topic .

There are five key steps to writing a literature review:

• Search for relevant literature
• Evaluate sources
• Identify themes, debates, and gaps
• Outline the structure
• Write your literature review

A good literature review doesn’t just summarize sources—it analyzes, synthesizes , and critically evaluates to give a clear picture of the state of knowledge on the subject.

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Table of contents

What is the purpose of a literature review, examples of literature reviews, step 1 – search for relevant literature, step 2 – evaluate and select sources, step 3 – identify themes, debates, and gaps, step 4 – outline your literature review’s structure, step 5 – write your literature review, free lecture slides, other interesting articles, frequently asked questions, introduction.

• Quick Run-through
• Step 1 & 2

When you write a thesis , dissertation , or research paper , you will likely have to conduct a literature review to situate your research within existing knowledge. The literature review gives you a chance to:

• Demonstrate your familiarity with the topic and its scholarly context
• Develop a theoretical framework and methodology for your research
• Position your work in relation to other researchers and theorists
• Show how your research addresses a gap or contributes to a debate
• Evaluate the current state of research and demonstrate your knowledge of the scholarly debates around your topic.

Writing literature reviews is a particularly important skill if you want to apply for graduate school or pursue a career in research. We’ve written a step-by-step guide that you can follow below.

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Writing literature reviews can be quite challenging! A good starting point could be to look at some examples, depending on what kind of literature review you’d like to write.

• Example literature review #1: “Why Do People Migrate? A Review of the Theoretical Literature” ( Theoretical literature review about the development of economic migration theory from the 1950s to today.)
• Example literature review #2: “Literature review as a research methodology: An overview and guidelines” ( Methodological literature review about interdisciplinary knowledge acquisition and production.)
• Example literature review #3: “The Use of Technology in English Language Learning: A Literature Review” ( Thematic literature review about the effects of technology on language acquisition.)
• Example literature review #4: “Learners’ Listening Comprehension Difficulties in English Language Learning: A Literature Review” ( Chronological literature review about how the concept of listening skills has changed over time.)

You can also check out our templates with literature review examples and sample outlines at the links below.

Download Word doc Download Google doc

Before you begin searching for literature, you need a clearly defined topic .

If you are writing the literature review section of a dissertation or research paper, you will search for literature related to your research problem and questions .

Make a list of keywords

Start by creating a list of keywords related to your research question. Include each of the key concepts or variables you’re interested in, and list any synonyms and related terms. You can add to this list as you discover new keywords in the process of your literature search.

• Social media, Facebook, Instagram, Twitter, Snapchat, TikTok
• Body image, self-perception, self-esteem, mental health
• Generation Z, teenagers, adolescents, youth

Search for relevant sources

Use your keywords to begin searching for sources. Some useful databases to search for journals and articles include:

• Your university’s library catalogue
• Google Scholar
• Project Muse (humanities and social sciences)
• Medline (life sciences and biomedicine)
• EconLit (economics)
• Inspec (physics, engineering and computer science)

You can also use boolean operators to help narrow down your search.

Make sure to read the abstract to find out whether an article is relevant to your question. When you find a useful book or article, you can check the bibliography to find other relevant sources.

You likely won’t be able to read absolutely everything that has been written on your topic, so it will be necessary to evaluate which sources are most relevant to your research question.

For each publication, ask yourself:

• What question or problem is the author addressing?
• What are the key concepts and how are they defined?
• What are the key theories, models, and methods?
• Does the research use established frameworks or take an innovative approach?
• What are the results and conclusions of the study?
• How does the publication relate to other literature in the field? Does it confirm, add to, or challenge established knowledge?
• What are the strengths and weaknesses of the research?

Make sure the sources you use are credible , and make sure you read any landmark studies and major theories in your field of research.

You can use our template to summarize and evaluate sources you’re thinking about using. Click on either button below to download.

Take notes and cite your sources

As you read, you should also begin the writing process. Take notes that you can later incorporate into the text of your literature review.

It is important to keep track of your sources with citations to avoid plagiarism . It can be helpful to make an annotated bibliography , where you compile full citation information and write a paragraph of summary and analysis for each source. This helps you remember what you read and saves time later in the process.

To begin organizing your literature review’s argument and structure, be sure you understand the connections and relationships between the sources you’ve read. Based on your reading and notes, you can look for:

• Trends and patterns (in theory, method or results): do certain approaches become more or less popular over time?
• Themes: what questions or concepts recur across the literature?
• Debates, conflicts and contradictions: where do sources disagree?
• Pivotal publications: are there any influential theories or studies that changed the direction of the field?
• Gaps: what is missing from the literature? Are there weaknesses that need to be addressed?

This step will help you work out the structure of your literature review and (if applicable) show how your own research will contribute to existing knowledge.

• Most research has focused on young women.
• There is an increasing interest in the visual aspects of social media.
• But there is still a lack of robust research on highly visual platforms like Instagram and Snapchat—this is a gap that you could address in your own research.

There are various approaches to organizing the body of a literature review. Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

The simplest approach is to trace the development of the topic over time. However, if you choose this strategy, be careful to avoid simply listing and summarizing sources in order.

Try to analyze patterns, turning points and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred.

If you have found some recurring central themes, you can organize your literature review into subsections that address different aspects of the topic.

For example, if you are reviewing literature about inequalities in migrant health outcomes, key themes might include healthcare policy, language barriers, cultural attitudes, legal status, and economic access.

Methodological

If you draw your sources from different disciplines or fields that use a variety of research methods , you might want to compare the results and conclusions that emerge from different approaches. For example:

• Look at what results have emerged in qualitative versus quantitative research
• Discuss how the topic has been approached by empirical versus theoretical scholarship
• Divide the literature into sociological, historical, and cultural sources

Theoretical

A literature review is often the foundation for a theoretical framework . You can use it to discuss various theories, models, and definitions of key concepts.

You might argue for the relevance of a specific theoretical approach, or combine various theoretical concepts to create a framework for your research.

Like any other academic text , your literature review should have an introduction , a main body, and a conclusion . What you include in each depends on the objective of your literature review.

The introduction should clearly establish the focus and purpose of the literature review.

Depending on the length of your literature review, you might want to divide the body into subsections. You can use a subheading for each theme, time period, or methodological approach.

As you write, you can follow these tips:

• Summarize and synthesize: give an overview of the main points of each source and combine them into a coherent whole
• Analyze and interpret: don’t just paraphrase other researchers — add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
• Critically evaluate: mention the strengths and weaknesses of your sources
• Write in well-structured paragraphs: use transition words and topic sentences to draw connections, comparisons and contrasts

In the conclusion, you should summarize the key findings you have taken from the literature and emphasize their significance.

When you’ve finished writing and revising your literature review, don’t forget to proofread thoroughly before submitting. Not a language expert? Check out Scribbr’s professional proofreading services !

This article has been adapted into lecture slides that you can use to teach your students about writing a literature review.

Scribbr slides are free to use, customize, and distribute for educational purposes.

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If you want to know more about the research process , methodology , research bias , or statistics , make sure to check out some of our other articles with explanations and examples.

• Sampling methods
• Simple random sampling
• Stratified sampling
• Cluster sampling
• Likert scales
• Reproducibility

 Statistics

• Null hypothesis
• Statistical power
• Probability distribution
• Effect size
• Poisson distribution

Research bias

• Optimism bias
• Cognitive bias
• Implicit bias
• Hawthorne effect
• Anchoring bias
• Explicit bias

A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a thesis, dissertation , or research paper , in order to situate your work in relation to existing knowledge.

There are several reasons to conduct a literature review at the beginning of a research project:

• To familiarize yourself with the current state of knowledge on your topic
• To ensure that you’re not just repeating what others have already done
• To identify gaps in knowledge and unresolved problems that your research can address
• To develop your theoretical framework and methodology
• To provide an overview of the key findings and debates on the topic

Writing the literature review shows your reader how your work relates to existing research and what new insights it will contribute.

The literature review usually comes near the beginning of your thesis or dissertation . After the introduction , it grounds your research in a scholarly field and leads directly to your theoretical framework or methodology .

A literature review is a survey of credible sources on a topic, often used in dissertations , theses, and research papers . Literature reviews give an overview of knowledge on a subject, helping you identify relevant theories and methods, as well as gaps in existing research. Literature reviews are set up similarly to other  academic texts , with an introduction , a main body, and a conclusion .

An  annotated bibliography is a list of  source references that has a short description (called an annotation ) for each of the sources. It is often assigned as part of the research process for a  paper .  

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How To Write A Literature Review - A Complete Guide

Table of Contents

A literature review is much more than just another section in your research paper. It forms the very foundation of your research. It is a formal piece of writing where you analyze the existing theoretical framework, principles, and assumptions and use that as a base to shape your approach to the research question.

Curating and drafting a solid literature review section not only lends more credibility to your research paper but also makes your research tighter and better focused. But, writing literature reviews is a difficult task. It requires extensive reading, plus you have to consider market trends and technological and political changes, which tend to change in the blink of an eye.

Now streamline your literature review process with the help of SciSpace Copilot. With this AI research assistant, you can efficiently synthesize and analyze a vast amount of information, identify key themes and trends, and uncover gaps in the existing research. Get real-time explanations, summaries, and answers to your questions for the paper you're reviewing, making navigating and understanding the complex literature landscape easier.

In this comprehensive guide, we will explore everything from the definition of a literature review, its appropriate length, various types of literature reviews, and how to write one.

What is a literature review?

A literature review is a collation of survey, research, critical evaluation, and assessment of the existing literature in a preferred domain.

Eminent researcher and academic Arlene Fink, in her book Conducting Research Literature Reviews , defines it as the following:

“A literature review surveys books, scholarly articles, and any other sources relevant to a particular issue, area of research, or theory, and by so doing, provides a description, summary, and critical evaluation of these works in relation to the research problem being investigated.

Literature reviews are designed to provide an overview of sources you have explored while researching a particular topic, and to demonstrate to your readers how your research fits within a larger field of study.”

Simply put, a literature review can be defined as a critical discussion of relevant pre-existing research around your research question and carving out a definitive place for your study in the existing body of knowledge. Literature reviews can be presented in multiple ways: a section of an article, the whole research paper itself, or a chapter of your thesis.

A literature review does function as a summary of sources, but it also allows you to analyze further, interpret, and examine the stated theories, methods, viewpoints, and, of course, the gaps in the existing content.

As an author, you can discuss and interpret the research question and its various aspects and debate your adopted methods to support the claim.

What is the purpose of a literature review?

A literature review is meant to help your readers understand the relevance of your research question and where it fits within the existing body of knowledge. As a researcher, you should use it to set the context, build your argument, and establish the need for your study.

What is the importance of a literature review?

The literature review is a critical part of research papers because it helps you:

• Gain an in-depth understanding of your research question and the surrounding area
• Convey that you have a thorough understanding of your research area and are up-to-date with the latest changes and advancements
• Establish how your research is connected or builds on the existing body of knowledge and how it could contribute to further research
• Elaborate on the validity and suitability of your theoretical framework and research methodology
• Identify and highlight gaps and shortcomings in the existing body of knowledge and how things need to change
• Convey to readers how your study is different or how it contributes to the research area

How long should a literature review be?

Ideally, the literature review should take up 15%-40% of the total length of your manuscript. So, if you have a 10,000-word research paper, the minimum word count could be 1500.

Your literature review format depends heavily on the kind of manuscript you are writing — an entire chapter in case of doctoral theses, a part of the introductory section in a research article, to a full-fledged review article that examines the previously published research on a topic.

Another determining factor is the type of research you are doing. The literature review section tends to be longer for secondary research projects than primary research projects.

What are the different types of literature reviews?

All literature reviews are not the same. There are a variety of possible approaches that you can take. It all depends on the type of research you are pursuing.

Here are the different types of literature reviews:

Argumentative review

It is called an argumentative review when you carefully present literature that only supports or counters a specific argument or premise to establish a viewpoint.

Integrative review

It is a type of literature review focused on building a comprehensive understanding of a topic by combining available theoretical frameworks and empirical evidence.

Methodological review

This approach delves into the ''how'' and the ''what" of the research question —  you cannot look at the outcome in isolation; you should also review the methodology used.

Systematic review

This form consists of an overview of existing evidence pertinent to a clearly formulated research question, which uses pre-specified and standardized methods to identify and critically appraise relevant research and collect, report, and analyze data from the studies included in the review.

Meta-analysis review

Meta-analysis uses statistical methods to summarize the results of independent studies. By combining information from all relevant studies, meta-analysis can provide more precise estimates of the effects than those derived from the individual studies included within a review.

Historical review

Historical literature reviews focus on examining research throughout a period, often starting with the first time an issue, concept, theory, or phenomenon emerged in the literature, then tracing its evolution within the scholarship of a discipline. The purpose is to place research in a historical context to show familiarity with state-of-the-art developments and identify future research's likely directions.

Theoretical Review

This form aims to examine the corpus of theory accumulated regarding an issue, concept, theory, and phenomenon. The theoretical literature review helps to establish what theories exist, the relationships between them, the degree the existing approaches have been investigated, and to develop new hypotheses to be tested.

Scoping Review

The Scoping Review is often used at the beginning of an article, dissertation, or research proposal. It is conducted before the research to highlight gaps in the existing body of knowledge and explains why the project should be greenlit.

State-of-the-Art Review

The State-of-the-Art review is conducted periodically, focusing on the most recent research. It describes what is currently known, understood, or agreed upon regarding the research topic and highlights where there are still disagreements.

Can you use the first person in a literature review?

When writing literature reviews, you should avoid the usage of first-person pronouns. It means that instead of "I argue that" or "we argue that," the appropriate expression would be "this research paper argues that."

Do you need an abstract for a literature review?

Ideally, yes. It is always good to have a condensed summary that is self-contained and independent of the rest of your review. As for how to draft one, you can follow the same fundamental idea when preparing an abstract for a literature review. It should also include:

• The research topic and your motivation behind selecting it
• A one-sentence thesis statement
• An explanation of the kinds of literature featured in the review
• Summary of what you've learned
• Conclusions you drew from the literature you reviewed
• Potential implications and future scope for research

Here's an example of the abstract of a literature review

Is a literature review written in the past tense?

Yes, the literature review should ideally be written in the past tense. You should not use the present or future tense when writing one. The exceptions are when you have statements describing events that happened earlier than the literature you are reviewing or events that are currently occurring; then, you can use the past perfect or present perfect tenses.

How many sources for a literature review?

There are multiple approaches to deciding how many sources to include in a literature review section. The first approach would be to look level you are at as a researcher. For instance, a doctoral thesis might need 60+ sources. In contrast, you might only need to refer to 5-15 sources at the undergraduate level.

The second approach is based on the kind of literature review you are doing — whether it is merely a chapter of your paper or if it is a self-contained paper in itself. When it is just a chapter, sources should equal the total number of pages in your article's body. In the second scenario, you need at least three times as many sources as there are pages in your work.

Quick tips on how to write a literature review

To know how to write a literature review, you must clearly understand its impact and role in establishing your work as substantive research material.

You need to follow the below-mentioned steps, to write a literature review:

• Outline the purpose behind the literature review
• Search relevant literature
• Examine and assess the relevant resources
• Discover connections by drawing deep insights from the resources
• Structure planning to write a good literature review

1. Outline and identify the purpose of  a literature review

As a first step on how to write a literature review, you must know what the research question or topic is and what shape you want your literature review to take. Ensure you understand the research topic inside out, or else seek clarifications. You must be able to the answer below questions before you start:

• How many sources do I need to include?
• What kind of sources should I analyze?
• How much should I critically evaluate each source?
• Should I summarize, synthesize or offer a critique of the sources?
• Do I need to include any background information or definitions?

Additionally, you should know that the narrower your research topic is, the swifter it will be for you to restrict the number of sources to be analyzed.

2. Search relevant literature

Dig deeper into search engines to discover what has already been published around your chosen topic. Make sure you thoroughly go through appropriate reference sources like books, reports, journal articles, government docs, and web-based resources.

You must prepare a list of keywords and their different variations. You can start your search from any library’s catalog, provided you are an active member of that institution. The exact keywords can be extended to widen your research over other databases and academic search engines like:

• Google Scholar
• Microsoft Academic
• Science.gov

Besides, it is not advisable to go through every resource word by word. Alternatively, what you can do is you can start by reading the abstract and then decide whether that source is relevant to your research or not.

Additionally, you must spend surplus time assessing the quality and relevance of resources. It would help if you tried preparing a list of citations to ensure that there lies no repetition of authors, publications, or articles in the literature review.

3. Examine and assess the sources

It is nearly impossible for you to go through every detail in the research article. So rather than trying to fetch every detail, you have to analyze and decide which research sources resemble closest and appear relevant to your chosen domain.

While analyzing the sources, you should look to find out answers to questions like:

• What question or problem has the author been describing and debating?
• What is the definition of critical aspects?
• How well the theories, approach, and methodology have been explained?
• Whether the research theory used some conventional or new innovative approach?
• How relevant are the key findings of the work?
• In what ways does it relate to other sources on the same topic?
• What challenges does this research paper pose to the existing theory
• What are the possible contributions or benefits it adds to the subject domain?

Be always mindful that you refer only to credible and authentic resources. It would be best if you always take references from different publications to validate your theory.

Always keep track of important information or data you can present in your literature review right from the beginning. It will help steer your path from any threats of plagiarism and also make it easier to curate an annotated bibliography or reference section.

4. Discover connections

At this stage, you must start deciding on the argument and structure of your literature review. To accomplish this, you must discover and identify the relations and connections between various resources while drafting your abstract.

A few aspects that you should be aware of while writing a literature review include:

• Rise to prominence: Theories and methods that have gained reputation and supporters over time.
• Constant scrutiny: Concepts or theories that repeatedly went under examination.
• Contradictions and conflicts: Theories, both the supporting and the contradictory ones, for the research topic.
• Knowledge gaps: What exactly does it fail to address, and how to bridge them with further research?
• Influential resources: Significant research projects available that have been upheld as milestones or perhaps, something that can modify the current trends

Once you join the dots between various past research works, it will be easier for you to draw a conclusion and identify your contribution to the existing knowledge base.

5. Structure planning to write a good literature review

There exist different ways towards planning and executing the structure of a literature review. The format of a literature review varies and depends upon the length of the research.

Like any other research paper, the literature review format must contain three sections: introduction, body, and conclusion. The goals and objectives of the research question determine what goes inside these three sections.

Nevertheless, a good literature review can be structured according to the chronological, thematic, methodological, or theoretical framework approach.

Literature review samples

1. Standalone

2. As a section of a research paper

How SciSpace Discover makes literature review a breeze?

SciSpace Discover is a one-stop solution to do an effective literature search and get barrier-free access to scientific knowledge. It is an excellent repository where you can find millions of only peer-reviewed articles and full-text PDF files. Here’s more on how you can use it:

Find the right information

Find what you want quickly and easily with comprehensive search filters that let you narrow down papers according to PDF availability, year of publishing, document type, and affiliated institution. Moreover, you can sort the results based on the publishing date, citation count, and relevance.

Assess credibility of papers quickly

When doing the literature review, it is critical to establish the quality of your sources. They form the foundation of your research. SciSpace Discover helps you assess the quality of a source by providing an overview of its references, citations, and performance metrics.

Get the complete picture in no time

SciSpace Discover’s personalized suggestion engine helps you stay on course and get the complete picture of the topic from one place. Every time you visit an article page, it provides you links to related papers. Besides that, it helps you understand what’s trending, who are the top authors, and who are the leading publishers on a topic.

Make referring sources super easy

To ensure you don't lose track of your sources, you must start noting down your references when doing the literature review. SciSpace Discover makes this step effortless. Click the 'cite' button on an article page, and you will receive preloaded citation text in multiple styles — all you've to do is copy-paste it into your manuscript.

Final tips on how to write a literature review

A massive chunk of time and effort is required to write a good literature review. But, if you go about it systematically, you'll be able to save a ton of time and build a solid foundation for your research.

We hope this guide has helped you answer several key questions you have about writing literature reviews.

Would you like to explore SciSpace Discover and kick off your literature search right away? You can get started here .

Frequently Asked Questions (FAQs)

1. how to start a literature review.

• What questions do you want to answer?

• What sources do you need to answer these questions?

• What information do these sources contain?

• How can you use this information to answer your questions?

2. What to include in a literature review?

• A brief background of the problem or issue

• What has previously been done to address the problem or issue

• A description of what you will do in your project

• How this study will contribute to research on the subject

3. Why literature review is important?

The literature review is an important part of any research project because it allows the writer to look at previous studies on a topic and determine existing gaps in the literature, as well as what has already been done. It will also help them to choose the most appropriate method for their own study.

4. How to cite a literature review in APA format?

To cite a literature review in APA style, you need to provide the author's name, the title of the article, and the year of publication. For example: Patel, A. B., & Stokes, G. S. (2012). The relationship between personality and intelligence: A meta-analysis of longitudinal research. Personality and Individual Differences, 53(1), 16-21

5. What are the components of a literature review?

• A brief introduction to the topic, including its background and context. The introduction should also include a rationale for why the study is being conducted and what it will accomplish.

• A description of the methodologies used in the study. This can include information about data collection methods, sample size, and statistical analyses.

• A presentation of the findings in an organized format that helps readers follow along with the author's conclusions.

6. What are common errors in writing literature review?

• Not spending enough time to critically evaluate the relevance of resources, observations and conclusions.

• Totally relying on secondary data while ignoring primary data.

• Letting your personal bias seep into your interpretation of existing literature.

• No detailed explanation of the procedure to discover and identify an appropriate literature review.

7. What are the 5 C's of writing literature review?

• Cite - the sources you utilized and referenced in your research.

• Compare - existing arguments, hypotheses, methodologies, and conclusions found in the knowledge base.

• Contrast - the arguments, topics, methodologies, approaches, and disputes that may be found in the literature.

• Critique - the literature and describe the ideas and opinions you find more convincing and why.

• Connect - the various studies you reviewed in your research.

8. How many sources should a literature review have?

When it is just a chapter, sources should equal the total number of pages in your article's body. if it is a self-contained paper in itself, you need at least three times as many sources as there are pages in your work.

9. Can literature review have diagrams?

• To represent an abstract idea or concept

• To explain the steps of a process or procedure

• To help readers understand the relationships between different concepts

10. How old should sources be in a literature review?

Sources for a literature review should be as current as possible or not older than ten years. The only exception to this rule is if you are reviewing a historical topic and need to use older sources.

11. What are the types of literature review?

• Argumentative review

• Integrative review

• Methodological review

• Systematic review

• Meta-analysis review

• Historical review

• Theoretical review

• Scoping review

• State-of-the-Art review

12. Is a literature review mandatory?

Yes. Literature review is a mandatory part of any research project. It is a critical step in the process that allows you to establish the scope of your research, and provide a background for the rest of your work.

But before you go,

• Six Online Tools for Easy Literature Review
• Evaluating literature review: systematic vs. scoping reviews
• Systematic Approaches to a Successful Literature Review
• Writing Integrative Literature Reviews: Guidelines and Examples

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Consensus GPT vs. SciSpace GPT: Choose the Best GPT for Research

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• Dissertation
• What is a Literature Review? | Guide, Template, & Examples

What is a Literature Review? | Guide, Template, & Examples

Published on 22 February 2022 by Shona McCombes . Revised on 7 June 2022.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research.

There are five key steps to writing a literature review:

• Search for relevant literature
• Evaluate sources
• Identify themes, debates and gaps
• Outline the structure
• Write your literature review

A good literature review doesn’t just summarise sources – it analyses, synthesises, and critically evaluates to give a clear picture of the state of knowledge on the subject.

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Table of contents

Why write a literature review, examples of literature reviews, step 1: search for relevant literature, step 2: evaluate and select sources, step 3: identify themes, debates and gaps, step 4: outline your literature review’s structure, step 5: write your literature review, frequently asked questions about literature reviews, introduction.

• Quick Run-through
• Step 1 & 2

When you write a dissertation or thesis, you will have to conduct a literature review to situate your research within existing knowledge. The literature review gives you a chance to:

• Demonstrate your familiarity with the topic and scholarly context
• Develop a theoretical framework and methodology for your research
• Position yourself in relation to other researchers and theorists
• Show how your dissertation addresses a gap or contributes to a debate

You might also have to write a literature review as a stand-alone assignment. In this case, the purpose is to evaluate the current state of research and demonstrate your knowledge of scholarly debates around a topic.

The content will look slightly different in each case, but the process of conducting a literature review follows the same steps. We’ve written a step-by-step guide that you can follow below.

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Writing literature reviews can be quite challenging! A good starting point could be to look at some examples, depending on what kind of literature review you’d like to write.

• Example literature review #1: “Why Do People Migrate? A Review of the Theoretical Literature” ( Theoretical literature review about the development of economic migration theory from the 1950s to today.)
• Example literature review #2: “Literature review as a research methodology: An overview and guidelines” ( Methodological literature review about interdisciplinary knowledge acquisition and production.)
• Example literature review #3: “The Use of Technology in English Language Learning: A Literature Review” ( Thematic literature review about the effects of technology on language acquisition.)
• Example literature review #4: “Learners’ Listening Comprehension Difficulties in English Language Learning: A Literature Review” ( Chronological literature review about how the concept of listening skills has changed over time.)

You can also check out our templates with literature review examples and sample outlines at the links below.

Download Word doc Download Google doc

Before you begin searching for literature, you need a clearly defined topic .

If you are writing the literature review section of a dissertation or research paper, you will search for literature related to your research objectives and questions .

If you are writing a literature review as a stand-alone assignment, you will have to choose a focus and develop a central question to direct your search. Unlike a dissertation research question, this question has to be answerable without collecting original data. You should be able to answer it based only on a review of existing publications.

Make a list of keywords

Start by creating a list of keywords related to your research topic. Include each of the key concepts or variables you’re interested in, and list any synonyms and related terms. You can add to this list if you discover new keywords in the process of your literature search.

• Social media, Facebook, Instagram, Twitter, Snapchat, TikTok
• Body image, self-perception, self-esteem, mental health
• Generation Z, teenagers, adolescents, youth

Search for relevant sources

Use your keywords to begin searching for sources. Some databases to search for journals and articles include:

• Your university’s library catalogue
• Google Scholar
• Project Muse (humanities and social sciences)
• Medline (life sciences and biomedicine)
• EconLit (economics)
• Inspec (physics, engineering and computer science)

You can use boolean operators to help narrow down your search:

Read the abstract to find out whether an article is relevant to your question. When you find a useful book or article, you can check the bibliography to find other relevant sources.

To identify the most important publications on your topic, take note of recurring citations. If the same authors, books or articles keep appearing in your reading, make sure to seek them out.

You probably won’t be able to read absolutely everything that has been written on the topic – you’ll have to evaluate which sources are most relevant to your questions.

For each publication, ask yourself:

• What question or problem is the author addressing?
• What are the key concepts and how are they defined?
• What are the key theories, models and methods? Does the research use established frameworks or take an innovative approach?
• What are the results and conclusions of the study?
• How does the publication relate to other literature in the field? Does it confirm, add to, or challenge established knowledge?
• How does the publication contribute to your understanding of the topic? What are its key insights and arguments?
• What are the strengths and weaknesses of the research?

Make sure the sources you use are credible, and make sure you read any landmark studies and major theories in your field of research.

You can find out how many times an article has been cited on Google Scholar – a high citation count means the article has been influential in the field, and should certainly be included in your literature review.

The scope of your review will depend on your topic and discipline: in the sciences you usually only review recent literature, but in the humanities you might take a long historical perspective (for example, to trace how a concept has changed in meaning over time).

Remember that you can use our template to summarise and evaluate sources you’re thinking about using!

Take notes and cite your sources

As you read, you should also begin the writing process. Take notes that you can later incorporate into the text of your literature review.

It’s important to keep track of your sources with references to avoid plagiarism . It can be helpful to make an annotated bibliography, where you compile full reference information and write a paragraph of summary and analysis for each source. This helps you remember what you read and saves time later in the process.

You can use our free APA Reference Generator for quick, correct, consistent citations.

Prevent plagiarism, run a free check.

To begin organising your literature review’s argument and structure, you need to understand the connections and relationships between the sources you’ve read. Based on your reading and notes, you can look for:

• Trends and patterns (in theory, method or results): do certain approaches become more or less popular over time?
• Themes: what questions or concepts recur across the literature?
• Debates, conflicts and contradictions: where do sources disagree?
• Pivotal publications: are there any influential theories or studies that changed the direction of the field?
• Gaps: what is missing from the literature? Are there weaknesses that need to be addressed?

This step will help you work out the structure of your literature review and (if applicable) show how your own research will contribute to existing knowledge.

• Most research has focused on young women.
• There is an increasing interest in the visual aspects of social media.
• But there is still a lack of robust research on highly-visual platforms like Instagram and Snapchat – this is a gap that you could address in your own research.

There are various approaches to organising the body of a literature review. You should have a rough idea of your strategy before you start writing.

Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

The simplest approach is to trace the development of the topic over time. However, if you choose this strategy, be careful to avoid simply listing and summarising sources in order.

Try to analyse patterns, turning points and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred.

If you have found some recurring central themes, you can organise your literature review into subsections that address different aspects of the topic.

For example, if you are reviewing literature about inequalities in migrant health outcomes, key themes might include healthcare policy, language barriers, cultural attitudes, legal status, and economic access.

Methodological

If you draw your sources from different disciplines or fields that use a variety of research methods , you might want to compare the results and conclusions that emerge from different approaches. For example:

• Look at what results have emerged in qualitative versus quantitative research
• Discuss how the topic has been approached by empirical versus theoretical scholarship
• Divide the literature into sociological, historical, and cultural sources

Theoretical

A literature review is often the foundation for a theoretical framework . You can use it to discuss various theories, models, and definitions of key concepts.

You might argue for the relevance of a specific theoretical approach, or combine various theoretical concepts to create a framework for your research.

Like any other academic text, your literature review should have an introduction , a main body, and a conclusion . What you include in each depends on the objective of your literature review.

The introduction should clearly establish the focus and purpose of the literature review.

If you are writing the literature review as part of your dissertation or thesis, reiterate your central problem or research question and give a brief summary of the scholarly context. You can emphasise the timeliness of the topic (“many recent studies have focused on the problem of x”) or highlight a gap in the literature (“while there has been much research on x, few researchers have taken y into consideration”).

Depending on the length of your literature review, you might want to divide the body into subsections. You can use a subheading for each theme, time period, or methodological approach.

As you write, make sure to follow these tips:

• Summarise and synthesise: give an overview of the main points of each source and combine them into a coherent whole.
• Analyse and interpret: don’t just paraphrase other researchers – add your own interpretations, discussing the significance of findings in relation to the literature as a whole.
• Critically evaluate: mention the strengths and weaknesses of your sources.
• Write in well-structured paragraphs: use transitions and topic sentences to draw connections, comparisons and contrasts.

In the conclusion, you should summarise the key findings you have taken from the literature and emphasise their significance.

If the literature review is part of your dissertation or thesis, reiterate how your research addresses gaps and contributes new knowledge, or discuss how you have drawn on existing theories and methods to build a framework for your research. This can lead directly into your methodology section.

A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a dissertation , thesis, research paper , or proposal .

There are several reasons to conduct a literature review at the beginning of a research project:

• To familiarise yourself with the current state of knowledge on your topic
• To ensure that you’re not just repeating what others have already done
• To identify gaps in knowledge and unresolved problems that your research can address
• To develop your theoretical framework and methodology
• To provide an overview of the key findings and debates on the topic

Writing the literature review shows your reader how your work relates to existing research and what new insights it will contribute.

The literature review usually comes near the beginning of your  dissertation . After the introduction , it grounds your research in a scholarly field and leads directly to your theoretical framework or methodology .

Cite this Scribbr article

If you want to cite this source, you can copy and paste the citation or click the ‘Cite this Scribbr article’ button to automatically add the citation to our free Reference Generator.

McCombes, S. (2022, June 07). What is a Literature Review? | Guide, Template, & Examples. Scribbr. Retrieved 21 August 2024, from https://www.scribbr.co.uk/thesis-dissertation/literature-review/

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• UConn Library
• Literature Review: The What, Why and How-to Guide
• Introduction

Literature Review: The What, Why and How-to Guide — Introduction

• Getting Started
• How to Pick a Topic
• Strategies to Find Sources
• Evaluating Sources & Lit. Reviews
• Tips for Writing Literature Reviews
• Writing Literature Review: Useful Sites
• Citation Resources
• Other Academic Writings

What are Literature Reviews?

So, what is a literature review? "A literature review is an account of what has been published on a topic by accredited scholars and researchers. In writing the literature review, your purpose is to convey to your reader what knowledge and ideas have been established on a topic, and what their strengths and weaknesses are. As a piece of writing, the literature review must be defined by a guiding concept (e.g., your research objective, the problem or issue you are discussing, or your argumentative thesis). It is not just a descriptive list of the material available, or a set of summaries." Taylor, D.  The literature review: A few tips on conducting it . University of Toronto Health Sciences Writing Centre.

Goals of Literature Reviews

What are the goals of creating a Literature Review?  A literature could be written to accomplish different aims:

• To develop a theory or evaluate an existing theory
• To summarize the historical or existing state of a research topic
• Identify a problem in a field of research 

Baumeister, R. F., & Leary, M. R. (1997). Writing narrative literature reviews .  Review of General Psychology , 1 (3), 311-320.

What kinds of sources require a Literature Review?

• A research paper assigned in a course
• A thesis or dissertation
• A grant proposal
• An article intended for publication in a journal

All these instances require you to collect what has been written about your research topic so that you can demonstrate how your own research sheds new light on the topic.

Types of Literature Reviews

What kinds of literature reviews are written?

Narrative review: The purpose of this type of review is to describe the current state of the research on a specific topic/research and to offer a critical analysis of the literature reviewed. Studies are grouped by research/theoretical categories, and themes and trends, strengths and weakness, and gaps are identified. The review ends with a conclusion section which summarizes the findings regarding the state of the research of the specific study, the gaps identify and if applicable, explains how the author's research will address gaps identify in the review and expand the knowledge on the topic reviewed.

• Example : Predictors and Outcomes of U.S. Quality Maternity Leave: A Review and Conceptual Framework:  10.1177/08948453211037398  

Systematic review : "The authors of a systematic review use a specific procedure to search the research literature, select the studies to include in their review, and critically evaluate the studies they find." (p. 139). Nelson, L. K. (2013). Research in Communication Sciences and Disorders . Plural Publishing.

• Example : The effect of leave policies on increasing fertility: a systematic review:  10.1057/s41599-022-01270-w

Meta-analysis : "Meta-analysis is a method of reviewing research findings in a quantitative fashion by transforming the data from individual studies into what is called an effect size and then pooling and analyzing this information. The basic goal in meta-analysis is to explain why different outcomes have occurred in different studies." (p. 197). Roberts, M. C., & Ilardi, S. S. (2003). Handbook of Research Methods in Clinical Psychology . Blackwell Publishing.

• Example : Employment Instability and Fertility in Europe: A Meta-Analysis:  10.1215/00703370-9164737

Meta-synthesis : "Qualitative meta-synthesis is a type of qualitative study that uses as data the findings from other qualitative studies linked by the same or related topic." (p.312). Zimmer, L. (2006). Qualitative meta-synthesis: A question of dialoguing with texts .  Journal of Advanced Nursing , 53 (3), 311-318.

• Example : Women’s perspectives on career successes and barriers: A qualitative meta-synthesis:  10.1177/05390184221113735

Literature Reviews in the Health Sciences

• UConn Health subject guide on systematic reviews Explanation of the different review types used in health sciences literature as well as tools to help you find the right review type
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Introduction

Literature reviews take time. here is some general information to know before you start.  .

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• CAREER FEATURE
• 04 December 2020
• Correction 09 December 2020

How to write a superb literature review

Andy Tay is a freelance writer based in Singapore.

You can also search for this author in PubMed   Google Scholar

Credit: Getty

Literature reviews are important resources for scientists. They provide historical context for a field while offering opinions on its future trajectory. Creating them can provide inspiration for one’s own research, as well as some practice in writing. But few scientists are trained in how to write a review — or in what constitutes an excellent one. Even picking the appropriate software to use can be an involved decision (see ‘Tools and techniques’). So Nature asked editors and working scientists with well-cited reviews for their tips.

WENTING ZHAO: Be focused and avoid jargon

Assistant professor of chemical and biomedical engineering, Nanyang Technological University, Singapore.

When I was a research student, review writing improved my understanding of the history of my field. I also learnt about unmet challenges in the field that triggered ideas.

For example, while writing my first review 1 as a PhD student, I was frustrated by how poorly we understood how cells actively sense, interact with and adapt to nanoparticles used in drug delivery. This experience motivated me to study how the surface properties of nanoparticles can be modified to enhance biological sensing. When I transitioned to my postdoctoral research, this question led me to discover the role of cell-membrane curvature, which led to publications and my current research focus. I wouldn’t have started in this area without writing that review.

Collection: Careers toolkit

A common problem for students writing their first reviews is being overly ambitious. When I wrote mine, I imagined producing a comprehensive summary of every single type of nanomaterial used in biological applications. It ended up becoming a colossal piece of work, with too many papers discussed and without a clear way to categorize them. We published the work in the end, but decided to limit the discussion strictly to nanoparticles for biological sensing, rather than covering how different nanomaterials are used in biology.

My advice to students is to accept that a review is unlike a textbook: it should offer a more focused discussion, and it’s OK to skip some topics so that you do not distract your readers. Students should also consider editorial deadlines, especially for invited reviews: make sure that the review’s scope is not so extensive that it delays the writing.

A good review should also avoid jargon and explain the basic concepts for someone who is new to the field. Although I trained as an engineer, I’m interested in biology, and my research is about developing nanomaterials to manipulate proteins at the cell membrane and how this can affect ageing and cancer. As an ‘outsider’, the reviews that I find most useful for these biological topics are those that speak to me in accessible scientific language.

Bozhi Tian likes to get a variety of perspectives into a review. Credit: Aleksander Prominski

BOZHI TIAN: Have a process and develop your style

Associate professor of chemistry, University of Chicago, Illinois.

In my lab, we start by asking: what is the purpose of this review? My reasons for writing one can include the chance to contribute insights to the scientific community and identify opportunities for my research. I also see review writing as a way to train early-career researchers in soft skills such as project management and leadership. This is especially true for lead authors, because they will learn to work with their co-authors to integrate the various sections into a piece with smooth transitions and no overlaps.

After we have identified the need and purpose of a review article, I will form a team from the researchers in my lab. I try to include students with different areas of expertise, because it is useful to get a variety of perspectives. For example, in the review ‘An atlas of nano-enabled neural interfaces’ 2 , we had authors with backgrounds in biophysics, neuroengineering, neurobiology and materials sciences focusing on different sections of the review.

After this, I will discuss an outline with my team. We go through multiple iterations to make sure that we have scanned the literature sufficiently and do not repeat discussions that have appeared in other reviews. It is also important that the outline is not decided by me alone: students often have fresh ideas that they can bring to the table. Once this is done, we proceed with the writing.

I often remind my students to imagine themselves as ‘artists of science’ and encourage them to develop how they write and present information. Adding more words isn’t always the best way: for example, I enjoy using tables to summarize research progress and suggest future research trajectories. I’ve also considered including short videos in our review papers to highlight key aspects of the work. I think this can increase readership and accessibility because these videos can be easily shared on social-media platforms.

ANKITA ANIRBAN: Timeliness and figures make a huge difference

Editor, Nature Reviews Physics .

One of my roles as a journal editor is to evaluate proposals for reviews. The best proposals are timely and clearly explain why readers should pay attention to the proposed topic.

It is not enough for a review to be a summary of the latest growth in the literature: the most interesting reviews instead provide a discussion about disagreements in the field.

Careers Collection: Publishing

Scientists often centre the story of their primary research papers around their figures — but when it comes to reviews, figures often take a secondary role. In my opinion, review figures are more important than most people think. One of my favourite review-style articles 3 presents a plot bringing together data from multiple research papers (many of which directly contradict each other). This is then used to identify broad trends and suggest underlying mechanisms that could explain all of the different conclusions.

An important role of a review article is to introduce researchers to a field. For this, schematic figures can be useful to illustrate the science being discussed, in much the same way as the first slide of a talk should. That is why, at Nature Reviews, we have in-house illustrators to assist authors. However, simplicity is key, and even without support from professional illustrators, researchers can still make use of many free drawing tools to enhance the value of their review figures.

Yoojin Choi recommends that researchers be open to critiques when writing reviews. Credit: Yoojin Choi

YOOJIN CHOI: Stay updated and be open to suggestions

Research assistant professor, Korea Advanced Institute of Science and Technology, Daejeon.

I started writing the review ‘Biosynthesis of inorganic nanomaterials using microbial cells and bacteriophages’ 4 as a PhD student in 2018. It took me one year to write the first draft because I was working on the review alongside my PhD research and mostly on my own, with support from my adviser. It took a further year to complete the processes of peer review, revision and publication. During this time, many new papers and even competing reviews were published. To provide the most up-to-date and original review, I had to stay abreast of the literature. In my case, I made use of Google Scholar, which I set to send me daily updates of relevant literature based on key words.

Through my review-writing process, I also learnt to be more open to critiques to enhance the value and increase the readership of my work. Initially, my review was focused only on using microbial cells such as bacteria to produce nanomaterials, which was the subject of my PhD research. Bacteria such as these are known as biofactories: that is, organisms that produce biological material which can be modified to produce useful materials, such as magnetic nanoparticles for drug-delivery purposes.

Synchronized editing: the future of collaborative writing

However, when the first peer-review report came back, all three reviewers suggested expanding the review to cover another type of biofactory: bacteriophages. These are essentially viruses that infect bacteria, and they can also produce nanomaterials.

The feedback eventually led me to include a discussion of the differences between the various biofactories (bacteriophages, bacteria, fungi and microalgae) and their advantages and disadvantages. This turned out to be a great addition because it made the review more comprehensive.

Writing the review also led me to an idea about using nanomaterial-modified microorganisms to produce chemicals, which I’m still researching now.

PAULA MARTIN-GONZALEZ: Make good use of technology

PhD student, University of Cambridge, UK.

Just before the coronavirus lockdown, my PhD adviser and I decided to write a literature review discussing the integration of medical imaging with genomics to improve ovarian cancer management.

As I was researching the review, I noticed a trend in which some papers were consistently being cited by many other papers in the field. It was clear to me that those papers must be important, but as a new member of the field of integrated cancer biology, it was difficult to immediately find and read all of these ‘seminal papers’.

That was when I decided to code a small application to make my literature research more efficient. Using my code, users can enter a query, such as ‘ovarian cancer, computer tomography, radiomics’, and the application searches for all relevant literature archived in databases such as PubMed that feature these key words.

The code then identifies the relevant papers and creates a citation graph of all the references cited in the results of the search. The software highlights papers that have many citation relationships with other papers in the search, and could therefore be called seminal papers.

My code has substantially improved how I organize papers and has informed me of key publications and discoveries in my research field: something that would have taken more time and experience in the field otherwise. After I shared my code on GitHub, I received feedback that it can be daunting for researchers who are not used to coding. Consequently, I am hoping to build a more user-friendly interface in a form of a web page, akin to PubMed or Google Scholar, where users can simply input their queries to generate citation graphs.

Tools and techniques

Most reference managers on the market offer similar capabilities when it comes to providing a Microsoft Word plug-in and producing different citation styles. But depending on your working preferences, some might be more suitable than others.

Reference managers

Here is a comparison of the more popular collaborative writing tools, but there are other options, including Fidus Writer, Manuscript.io, Authorea and Stencila.

Collaborative writing tools

*Markdown and LaTex are code-based formatting languages favoured by physicists, mathematicians and computer scientists who code on a regular basis, and less popular in other disciplines such as biology and chemistry.

doi: https://doi.org/10.1038/d41586-020-03422-x

Interviews have been edited for length and clarity.

Updates & Corrections

Correction 09 December 2020 : An earlier version of the tables in this article included some incorrect details about the programs Zotero, Endnote and Manubot. These have now been corrected.

Hsing, I.-M., Xu, Y. & Zhao, W. Electroanalysis 19 , 755–768 (2007).

Article   Google Scholar  

Ledesma, H. A. et al. Nature Nanotechnol. 14 , 645–657 (2019).

Article   PubMed   Google Scholar  

Brahlek, M., Koirala, N., Bansal, N. & Oh, S. Solid State Commun. 215–216 , 54–62 (2015).

Choi, Y. & Lee, S. Y. Nature Rev. Chem . https://doi.org/10.1038/s41570-020-00221-w (2020).

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How Long Should a Literature Review Be?

4-minute read

• 7th October 2023

If you’re writing a research paper or dissertation , then you know how important it is to include a thorough, comprehensive literature review. But exactly how long should your literature review be in relation to the rest of your work? While there’s no one-size-fits-all answer to that question, there are some factors that will help determine the length of your review. In this post, we’ll discuss what information to include in your literature review and how long it should be.

Keep reading to learn more.

What Is a Literature Review?

A literature review is a critical summary and evaluation of the current resources (e.g., books and journal articles) on a specific topic or research question. It is a crucial part of academic writing, such as dissertations, in all categories and fields. Essentially, literature reviews help contextualize your investigations and show how your work is building on existing research.

No matter how long your literature review is, it should generally:

●  Establish context for your research (i.e., provide relevant background information so your reader understands the historical significance of your study ).

●  Identify gaps in the existing literature (such as unaddressed questions or aspects of your topic).

●  Highlight significant concepts related to your topic.

●  Cite relevant studies.

●  Support your argument.

It’s also essential that a literature review critically analyze the sources cited in your study, considering factors such as sample size, research design, and potential biases. Be sure to structure your literature review using the same referencing style as the rest of your research paper (e.g., APA , Chicago , MLA ).

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The length of your literature review depends on several factors, including the scope and purpose of your research. In general, the length of the review should be proportionate to your overall paper. For example, if you’re writing a fifty-thousand-word dissertation, then your literature review will likely be an entire chapter comprising about 20 pages. If it’s for a 15-page research paper, your literature review may only be a few pages.

Here are several factors that could affect the length of your literature review:

●  Institutional guidelines : Always check the guidelines provided by your institution or journal (such as an APA journal ). There may be a specific length or word count required for publication.

●  Scope : If your research topic is narrow and focused, your literature review may be shorter. Conversely, if your topic is broad and encompasses a large body of literature, your review may need to be longer.

●  Field of study : Different academic fields may have different expectations regarding the length of literature reviews. For example, literature reviews in the humanities might be longer than those in the natural sciences.

Also, consider your audience. If your literature review is for a general audience or a class assignment, it can probably be shorter and less specialized. However, if it’s for an academic audience in your field of study, you may need to be more thorough and provide an extensive review of the existing literature.

Most literature reviews follow the same basic structure of an introduction, body, and conclusion. Most of the time, they are part of a larger work, so the introduction and conclusion paragraphs will be relatively brief.

However, if the review is a standalone piece, then your introduction and conclusion will be longer since you will need to discuss your research objectives, methods, and findings as well as analyze the literature used in your study.

To ensure your literature review makes an impression, have it professionally proofread by our expert literature review editing services . Submit your free sample of 500 words or less to get started today!

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Writing Research Papers

• Writing a Literature Review

When writing a research paper on a specific topic, you will often need to include an overview of any prior research that has been conducted on that topic.  For example, if your research paper is describing an experiment on fear conditioning, then you will probably need to provide an overview of prior research on fear conditioning.  That overview is typically known as a literature review.  

Please note that a full-length literature review article may be suitable for fulfilling the requirements for the Psychology B.S. Degree Research Paper .  For further details, please check with your faculty advisor.

Different Types of Literature Reviews

Literature reviews come in many forms.  They can be part of a research paper, for example as part of the Introduction section.  They can be one chapter of a doctoral dissertation.  Literature reviews can also “stand alone” as separate articles by themselves.  For instance, some journals such as Annual Review of Psychology , Psychological Bulletin , and others typically publish full-length review articles.  Similarly, in courses at UCSD, you may be asked to write a research paper that is itself a literature review (such as, with an instructor’s permission, in fulfillment of the B.S. Degree Research Paper requirement). Alternatively, you may be expected to include a literature review as part of a larger research paper (such as part of an Honors Thesis). 

Literature reviews can be written using a variety of different styles.  These may differ in the way prior research is reviewed as well as the way in which the literature review is organized.  Examples of stylistic variations in literature reviews include: 

• Summarization of prior work vs. critical evaluation. In some cases, prior research is simply described and summarized; in other cases, the writer compares, contrasts, and may even critique prior research (for example, discusses their strengths and weaknesses).
• Chronological vs. categorical and other types of organization. In some cases, the literature review begins with the oldest research and advances until it concludes with the latest research.  In other cases, research is discussed by category (such as in groupings of closely related studies) without regard for chronological order.  In yet other cases, research is discussed in terms of opposing views (such as when different research studies or researchers disagree with one another).

Overall, all literature reviews, whether they are written as a part of a larger work or as separate articles unto themselves, have a common feature: they do not present new research; rather, they provide an overview of prior research on a specific topic . 

How to Write a Literature Review

When writing a literature review, it can be helpful to rely on the following steps.  Please note that these procedures are not necessarily only for writing a literature review that becomes part of a larger article; they can also be used for writing a full-length article that is itself a literature review (although such reviews are typically more detailed and exhaustive; for more information please refer to the Further Resources section of this page).

Steps for Writing a Literature Review

1. Identify and define the topic that you will be reviewing.

The topic, which is commonly a research question (or problem) of some kind, needs to be identified and defined as clearly as possible.  You need to have an idea of what you will be reviewing in order to effectively search for references and to write a coherent summary of the research on it.  At this stage it can be helpful to write down a description of the research question, area, or topic that you will be reviewing, as well as to identify any keywords that you will be using to search for relevant research.

2. Conduct a literature search.

Use a range of keywords to search databases such as PsycINFO and any others that may contain relevant articles.  You should focus on peer-reviewed, scholarly articles.  Published books may also be helpful, but keep in mind that peer-reviewed articles are widely considered to be the “gold standard” of scientific research.  Read through titles and abstracts, select and obtain articles (that is, download, copy, or print them out), and save your searches as needed.  For more information about this step, please see the Using Databases and Finding Scholarly References section of this website.

3. Read through the research that you have found and take notes.

Absorb as much information as you can.  Read through the articles and books that you have found, and as you do, take notes.  The notes should include anything that will be helpful in advancing your own thinking about the topic and in helping you write the literature review (such as key points, ideas, or even page numbers that index key information).  Some references may turn out to be more helpful than others; you may notice patterns or striking contrasts between different sources ; and some sources may refer to yet other sources of potential interest.  This is often the most time-consuming part of the review process.  However, it is also where you get to learn about the topic in great detail.  For more details about taking notes, please see the “Reading Sources and Taking Notes” section of the Finding Scholarly References page of this website.

4. Organize your notes and thoughts; create an outline.

At this stage, you are close to writing the review itself.  However, it is often helpful to first reflect on all the reading that you have done.  What patterns stand out?  Do the different sources converge on a consensus?  Or not?  What unresolved questions still remain?  You should look over your notes (it may also be helpful to reorganize them), and as you do, to think about how you will present this research in your literature review.  Are you going to summarize or critically evaluate?  Are you going to use a chronological or other type of organizational structure?  It can also be helpful to create an outline of how your literature review will be structured.

5. Write the literature review itself and edit and revise as needed.

The final stage involves writing.  When writing, keep in mind that literature reviews are generally characterized by a summary style in which prior research is described sufficiently to explain critical findings but does not include a high level of detail (if readers want to learn about all the specific details of a study, then they can look up the references that you cite and read the original articles themselves).  However, the degree of emphasis that is given to individual studies may vary (more or less detail may be warranted depending on how critical or unique a given study was).   After you have written a first draft, you should read it carefully and then edit and revise as needed.  You may need to repeat this process more than once.  It may be helpful to have another person read through your draft(s) and provide feedback.

6. Incorporate the literature review into your research paper draft.

After the literature review is complete, you should incorporate it into your research paper (if you are writing the review as one component of a larger paper).  Depending on the stage at which your paper is at, this may involve merging your literature review into a partially complete Introduction section, writing the rest of the paper around the literature review, or other processes.

Further Tips for Writing a Literature Review

Full-length literature reviews

• Many full-length literature review articles use a three-part structure: Introduction (where the topic is identified and any trends or major problems in the literature are introduced), Body (where the studies that comprise the literature on that topic are discussed), and Discussion or Conclusion (where major patterns and points are discussed and the general state of what is known about the topic is summarized)

Literature reviews as part of a larger paper

• An “express method” of writing a literature review for a research paper is as follows: first, write a one paragraph description of each article that you read. Second, choose how you will order all the paragraphs and combine them in one document.  Third, add transitions between the paragraphs, as well as an introductory and concluding paragraph. 1
• A literature review that is part of a larger research paper typically does not have to be exhaustive. Rather, it should contain most or all of the significant studies about a research topic but not tangential or loosely related ones. 2   Generally, literature reviews should be sufficient for the reader to understand the major issues and key findings about a research topic.  You may however need to confer with your instructor or editor to determine how comprehensive you need to be.

Benefits of Literature Reviews

By summarizing prior research on a topic, literature reviews have multiple benefits.  These include:

• Literature reviews help readers understand what is known about a topic without having to find and read through multiple sources.
• Literature reviews help “set the stage” for later reading about new research on a given topic (such as if they are placed in the Introduction of a larger research paper). In other words, they provide helpful background and context.
• Literature reviews can also help the writer learn about a given topic while in the process of preparing the review itself. In the act of research and writing the literature review, the writer gains expertise on the topic .

Downloadable Resources

• How to Write APA Style Research Papers (a comprehensive guide) [ PDF ]
• Tips for Writing APA Style Research Papers (a brief summary) [ PDF ]
• Example APA Style Research Paper (for B.S. Degree – literature review) [ PDF ]

Further Resources

How-To Videos     

• Writing Research Paper Videos
• UCSD Library Psychology Research Guide: Literature Reviews

External Resources

• Developing and Writing a Literature Review from N Carolina A&T State University
• Example of a Short Literature Review from York College CUNY
• How to Write a Review of Literature from UW-Madison
• Writing a Literature Review from UC Santa Cruz  
• Pautasso, M. (2013). Ten Simple Rules for Writing a Literature Review. PLoS Computational Biology, 9 (7), e1003149. doi : 1371/journal.pcbi.1003149

1 Ashton, W. Writing a short literature review . [PDF]     

2 carver, l. (2014).  writing the research paper [workshop]. , prepared by s. c. pan for ucsd psychology.

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Reference management. Clean and simple.

What is a literature review? [with examples]

What is a literature review?

The purpose of a literature review, how to write a literature review, the format of a literature review, general formatting rules, the length of a literature review, literature review examples, frequently asked questions about literature reviews, related articles.

A literature review is an assessment of the sources in a chosen topic of research.

In a literature review, you’re expected to report on the existing scholarly conversation, without adding new contributions.

If you are currently writing one, you've come to the right place. In the following paragraphs, we will explain:

• the objective of a literature review
• how to write a literature review
• the basic format of a literature review

Tip: It’s not always mandatory to add a literature review in a paper. Theses and dissertations often include them, whereas research papers may not. Make sure to consult with your instructor for exact requirements.

The four main objectives of a literature review are:

• Studying the references of your research area
• Summarizing the main arguments
• Identifying current gaps, stances, and issues
• Presenting all of the above in a text

Ultimately, the main goal of a literature review is to provide the researcher with sufficient knowledge about the topic in question so that they can eventually make an intervention.

The format of a literature review is fairly standard. It includes an:

• introduction that briefly introduces the main topic
• body that includes the main discussion of the key arguments
• conclusion that highlights the gaps and issues of the literature

➡️ Take a look at our guide on how to write a literature review to learn more about how to structure a literature review.

First of all, a literature review should have its own labeled section. You should indicate clearly in the table of contents where the literature can be found, and you should label this section as “Literature Review.”

➡️ For more information on writing a thesis, visit our guide on how to structure a thesis .

There is no set amount of words for a literature review, so the length depends on the research. If you are working with a large amount of sources, it will be long. If your paper does not depend entirely on references, it will be short.

Take a look at these three theses featuring great literature reviews:

• School-Based Speech-Language Pathologist's Perceptions of Sensory Food Aversions in Children [ PDF , see page 20]
• Who's Writing What We Read: Authorship in Criminological Research [ PDF , see page 4]
• A Phenomenological Study of the Lived Experience of Online Instructors of Theological Reflection at Christian Institutions Accredited by the Association of Theological Schools [ PDF , see page 56]

Literature reviews are most commonly found in theses and dissertations. However, you find them in research papers as well.

There is no set amount of words for a literature review, so the length depends on the research. If you are working with a large amount of sources, then it will be long. If your paper does not depend entirely on references, then it will be short.

No. A literature review should have its own independent section. You should indicate clearly in the table of contents where the literature review can be found, and label this section as “Literature Review.”

The main goal of a literature review is to provide the researcher with sufficient knowledge about the topic in question so that they can eventually make an intervention.

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Ten Simple Rules for Writing a Literature Review

Marco pautasso.

1 Centre for Functional and Evolutionary Ecology (CEFE), CNRS, Montpellier, France

2 Centre for Biodiversity Synthesis and Analysis (CESAB), FRB, Aix-en-Provence, France

Literature reviews are in great demand in most scientific fields. Their need stems from the ever-increasing output of scientific publications [1] . For example, compared to 1991, in 2008 three, eight, and forty times more papers were indexed in Web of Science on malaria, obesity, and biodiversity, respectively [2] . Given such mountains of papers, scientists cannot be expected to examine in detail every single new paper relevant to their interests [3] . Thus, it is both advantageous and necessary to rely on regular summaries of the recent literature. Although recognition for scientists mainly comes from primary research, timely literature reviews can lead to new synthetic insights and are often widely read [4] . For such summaries to be useful, however, they need to be compiled in a professional way [5] .

When starting from scratch, reviewing the literature can require a titanic amount of work. That is why researchers who have spent their career working on a certain research issue are in a perfect position to review that literature. Some graduate schools are now offering courses in reviewing the literature, given that most research students start their project by producing an overview of what has already been done on their research issue [6] . However, it is likely that most scientists have not thought in detail about how to approach and carry out a literature review.

Reviewing the literature requires the ability to juggle multiple tasks, from finding and evaluating relevant material to synthesising information from various sources, from critical thinking to paraphrasing, evaluating, and citation skills [7] . In this contribution, I share ten simple rules I learned working on about 25 literature reviews as a PhD and postdoctoral student. Ideas and insights also come from discussions with coauthors and colleagues, as well as feedback from reviewers and editors.

Rule 1: Define a Topic and Audience

How to choose which topic to review? There are so many issues in contemporary science that you could spend a lifetime of attending conferences and reading the literature just pondering what to review. On the one hand, if you take several years to choose, several other people may have had the same idea in the meantime. On the other hand, only a well-considered topic is likely to lead to a brilliant literature review [8] . The topic must at least be:

• interesting to you (ideally, you should have come across a series of recent papers related to your line of work that call for a critical summary),
• an important aspect of the field (so that many readers will be interested in the review and there will be enough material to write it), and
• a well-defined issue (otherwise you could potentially include thousands of publications, which would make the review unhelpful).

Ideas for potential reviews may come from papers providing lists of key research questions to be answered [9] , but also from serendipitous moments during desultory reading and discussions. In addition to choosing your topic, you should also select a target audience. In many cases, the topic (e.g., web services in computational biology) will automatically define an audience (e.g., computational biologists), but that same topic may also be of interest to neighbouring fields (e.g., computer science, biology, etc.).

Rule 2: Search and Re-search the Literature

After having chosen your topic and audience, start by checking the literature and downloading relevant papers. Five pieces of advice here:

• keep track of the search items you use (so that your search can be replicated [10] ),
• keep a list of papers whose pdfs you cannot access immediately (so as to retrieve them later with alternative strategies),
• use a paper management system (e.g., Mendeley, Papers, Qiqqa, Sente),
• define early in the process some criteria for exclusion of irrelevant papers (these criteria can then be described in the review to help define its scope), and
• do not just look for research papers in the area you wish to review, but also seek previous reviews.

The chances are high that someone will already have published a literature review ( Figure 1 ), if not exactly on the issue you are planning to tackle, at least on a related topic. If there are already a few or several reviews of the literature on your issue, my advice is not to give up, but to carry on with your own literature review,

The bottom-right situation (many literature reviews but few research papers) is not just a theoretical situation; it applies, for example, to the study of the impacts of climate change on plant diseases, where there appear to be more literature reviews than research studies [33] .

• discussing in your review the approaches, limitations, and conclusions of past reviews,
• trying to find a new angle that has not been covered adequately in the previous reviews, and
• incorporating new material that has inevitably accumulated since their appearance.

When searching the literature for pertinent papers and reviews, the usual rules apply:

• be thorough,
• use different keywords and database sources (e.g., DBLP, Google Scholar, ISI Proceedings, JSTOR Search, Medline, Scopus, Web of Science), and
• look at who has cited past relevant papers and book chapters.

Rule 3: Take Notes While Reading

If you read the papers first, and only afterwards start writing the review, you will need a very good memory to remember who wrote what, and what your impressions and associations were while reading each single paper. My advice is, while reading, to start writing down interesting pieces of information, insights about how to organize the review, and thoughts on what to write. This way, by the time you have read the literature you selected, you will already have a rough draft of the review.

Of course, this draft will still need much rewriting, restructuring, and rethinking to obtain a text with a coherent argument [11] , but you will have avoided the danger posed by staring at a blank document. Be careful when taking notes to use quotation marks if you are provisionally copying verbatim from the literature. It is advisable then to reformulate such quotes with your own words in the final draft. It is important to be careful in noting the references already at this stage, so as to avoid misattributions. Using referencing software from the very beginning of your endeavour will save you time.

Rule 4: Choose the Type of Review You Wish to Write

After having taken notes while reading the literature, you will have a rough idea of the amount of material available for the review. This is probably a good time to decide whether to go for a mini- or a full review. Some journals are now favouring the publication of rather short reviews focusing on the last few years, with a limit on the number of words and citations. A mini-review is not necessarily a minor review: it may well attract more attention from busy readers, although it will inevitably simplify some issues and leave out some relevant material due to space limitations. A full review will have the advantage of more freedom to cover in detail the complexities of a particular scientific development, but may then be left in the pile of the very important papers “to be read” by readers with little time to spare for major monographs.

There is probably a continuum between mini- and full reviews. The same point applies to the dichotomy of descriptive vs. integrative reviews. While descriptive reviews focus on the methodology, findings, and interpretation of each reviewed study, integrative reviews attempt to find common ideas and concepts from the reviewed material [12] . A similar distinction exists between narrative and systematic reviews: while narrative reviews are qualitative, systematic reviews attempt to test a hypothesis based on the published evidence, which is gathered using a predefined protocol to reduce bias [13] , [14] . When systematic reviews analyse quantitative results in a quantitative way, they become meta-analyses. The choice between different review types will have to be made on a case-by-case basis, depending not just on the nature of the material found and the preferences of the target journal(s), but also on the time available to write the review and the number of coauthors [15] .

Rule 5: Keep the Review Focused, but Make It of Broad Interest

Whether your plan is to write a mini- or a full review, it is good advice to keep it focused 16 , 17 . Including material just for the sake of it can easily lead to reviews that are trying to do too many things at once. The need to keep a review focused can be problematic for interdisciplinary reviews, where the aim is to bridge the gap between fields [18] . If you are writing a review on, for example, how epidemiological approaches are used in modelling the spread of ideas, you may be inclined to include material from both parent fields, epidemiology and the study of cultural diffusion. This may be necessary to some extent, but in this case a focused review would only deal in detail with those studies at the interface between epidemiology and the spread of ideas.

While focus is an important feature of a successful review, this requirement has to be balanced with the need to make the review relevant to a broad audience. This square may be circled by discussing the wider implications of the reviewed topic for other disciplines.

Rule 6: Be Critical and Consistent

Reviewing the literature is not stamp collecting. A good review does not just summarize the literature, but discusses it critically, identifies methodological problems, and points out research gaps [19] . After having read a review of the literature, a reader should have a rough idea of:

• the major achievements in the reviewed field,
• the main areas of debate, and
• the outstanding research questions.

It is challenging to achieve a successful review on all these fronts. A solution can be to involve a set of complementary coauthors: some people are excellent at mapping what has been achieved, some others are very good at identifying dark clouds on the horizon, and some have instead a knack at predicting where solutions are going to come from. If your journal club has exactly this sort of team, then you should definitely write a review of the literature! In addition to critical thinking, a literature review needs consistency, for example in the choice of passive vs. active voice and present vs. past tense.

Rule 7: Find a Logical Structure

Like a well-baked cake, a good review has a number of telling features: it is worth the reader's time, timely, systematic, well written, focused, and critical. It also needs a good structure. With reviews, the usual subdivision of research papers into introduction, methods, results, and discussion does not work or is rarely used. However, a general introduction of the context and, toward the end, a recapitulation of the main points covered and take-home messages make sense also in the case of reviews. For systematic reviews, there is a trend towards including information about how the literature was searched (database, keywords, time limits) [20] .

How can you organize the flow of the main body of the review so that the reader will be drawn into and guided through it? It is generally helpful to draw a conceptual scheme of the review, e.g., with mind-mapping techniques. Such diagrams can help recognize a logical way to order and link the various sections of a review [21] . This is the case not just at the writing stage, but also for readers if the diagram is included in the review as a figure. A careful selection of diagrams and figures relevant to the reviewed topic can be very helpful to structure the text too [22] .

Rule 8: Make Use of Feedback

Reviews of the literature are normally peer-reviewed in the same way as research papers, and rightly so [23] . As a rule, incorporating feedback from reviewers greatly helps improve a review draft. Having read the review with a fresh mind, reviewers may spot inaccuracies, inconsistencies, and ambiguities that had not been noticed by the writers due to rereading the typescript too many times. It is however advisable to reread the draft one more time before submission, as a last-minute correction of typos, leaps, and muddled sentences may enable the reviewers to focus on providing advice on the content rather than the form.

Feedback is vital to writing a good review, and should be sought from a variety of colleagues, so as to obtain a diversity of views on the draft. This may lead in some cases to conflicting views on the merits of the paper, and on how to improve it, but such a situation is better than the absence of feedback. A diversity of feedback perspectives on a literature review can help identify where the consensus view stands in the landscape of the current scientific understanding of an issue [24] .

Rule 9: Include Your Own Relevant Research, but Be Objective

In many cases, reviewers of the literature will have published studies relevant to the review they are writing. This could create a conflict of interest: how can reviewers report objectively on their own work [25] ? Some scientists may be overly enthusiastic about what they have published, and thus risk giving too much importance to their own findings in the review. However, bias could also occur in the other direction: some scientists may be unduly dismissive of their own achievements, so that they will tend to downplay their contribution (if any) to a field when reviewing it.

In general, a review of the literature should neither be a public relations brochure nor an exercise in competitive self-denial. If a reviewer is up to the job of producing a well-organized and methodical review, which flows well and provides a service to the readership, then it should be possible to be objective in reviewing one's own relevant findings. In reviews written by multiple authors, this may be achieved by assigning the review of the results of a coauthor to different coauthors.

Rule 10: Be Up-to-Date, but Do Not Forget Older Studies

Given the progressive acceleration in the publication of scientific papers, today's reviews of the literature need awareness not just of the overall direction and achievements of a field of inquiry, but also of the latest studies, so as not to become out-of-date before they have been published. Ideally, a literature review should not identify as a major research gap an issue that has just been addressed in a series of papers in press (the same applies, of course, to older, overlooked studies (“sleeping beauties” [26] )). This implies that literature reviewers would do well to keep an eye on electronic lists of papers in press, given that it can take months before these appear in scientific databases. Some reviews declare that they have scanned the literature up to a certain point in time, but given that peer review can be a rather lengthy process, a full search for newly appeared literature at the revision stage may be worthwhile. Assessing the contribution of papers that have just appeared is particularly challenging, because there is little perspective with which to gauge their significance and impact on further research and society.

Inevitably, new papers on the reviewed topic (including independently written literature reviews) will appear from all quarters after the review has been published, so that there may soon be the need for an updated review. But this is the nature of science [27] – [32] . I wish everybody good luck with writing a review of the literature.

Acknowledgments

Many thanks to M. Barbosa, K. Dehnen-Schmutz, T. Döring, D. Fontaneto, M. Garbelotto, O. Holdenrieder, M. Jeger, D. Lonsdale, A. MacLeod, P. Mills, M. Moslonka-Lefebvre, G. Stancanelli, P. Weisberg, and X. Xu for insights and discussions, and to P. Bourne, T. Matoni, and D. Smith for helpful comments on a previous draft.

Funding Statement

This work was funded by the French Foundation for Research on Biodiversity (FRB) through its Centre for Synthesis and Analysis of Biodiversity data (CESAB), as part of the NETSEED research project. The funders had no role in the preparation of the manuscript.

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A literature review should be structured like any other essay: it should have an introduction, a middle or main body, and a conclusion.

The introduction should:

• define your topic and provide an appropriate context for reviewing the literature;
• establish your reasons – i.e. point of view – for
• reviewing the literature;
• explain the organisation – i.e. sequence – of the review;
• state the scope of the review – i.e. what is included and what isn’t included. For example, if you were reviewing the literature on obesity in children you might say something like: There are a large number of studies of obesity trends in the general population. However, since the focus of this research is on obesity in children, these will not be reviewed in detail and will only be referred to as appropriate.

The middle or main body should:

• organise the literature according to common themes;
• provide insight into the relation between your chosen topic and the wider subject area e.g. between obesity in children and obesity in general;
• move from a general, wider view of the literature being reviewed to the specific focus of your research.

The conclusion should:

• summarise the important aspects of the existing body of literature;
• evaluate the current state of the literature reviewed;
• identify significant flaws or gaps in existing knowledge;
• outline areas for future study;
• link your research to existing knowledge.

• Open access
• Published: 17 August 2024

Emergency robotic surgery: the experience of a single center and review of the literature

• Graziano Ceccarelli 1 ,
• Fausto Catena 2 ,
• Pasquale Avella 3 , 4 ,
• Brian WCA Tian 5 ,
• Fabio Rondelli 1 ,
• Germano Guerra 4 ,
• Michele De Rosa 1 &
• Aldo Rocca 3 , 4  

World Journal of Emergency Surgery volume  19 , Article number:  28 ( 2024 ) Cite this article

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Backgrounds

Laparoscopic surgery is widely used in abdominal emergency surgery (AES), and the possibility of extending this approach to the more recent robotic surgery (RS) arouses great interest. The slow diffusion of robotic technology mainly due to high costs and the longer RS operative time when compared to laparoscopy may represent disincentives, especially in AES. This study aims to report our experience in the use of RS in AES assessing its safety and feasibility, with particular focus on intra- and post-operative complications, conversion rate, and surgical learning curve. Our data were also compared to other experiences though an extensive literature review.

We retrospectively analysed a single surgeon series of the last 10 years. From January 2014 to December 2023, 36 patients underwent urgent or emergency RS. The robotic devices used were Da Vinci Si (15 cases) and Xi (21 cases).

36 (4.3%) out of 834 robotic procedures were included in our analysis: 20 (56.56%) females. The mean age was 63 years and 30% of patients were ≥ 70 years. 2 (5.55%) procedures were performed at night. No conversions to open were reported in this series. According to the Clavien-Dindo classification, 2 (5.5%) major complications were collected. Intraoperative and 30-day mortality were 0%.

Conclusions

Our study demonstrates that RS may be a useful and reliable approach also to AES and intraoperative laparoscopic complications when performed in selected hemodynamically stable patients in very well-trained robotic centers. The technology may increase the minimally invasive use and conversion rate in emergent settings in a completely robotic or hybrid approach.

Introduction

Abdominal Emergency Surgery (AES) can be defined as a procedure requiring to deal with an acute threat to life, organ, trauma, acute disease process, acute exacerbation of a chronic disease process, or complication of a surgical or other interventional procedure, normally within hours of decision to operate [ 1 , 2 ].

Further, “expedited surgery” refers to the clinical situation exemplified by a patient in need of prompt treatment but not in imminent danger to life or organ survival; this procedure often takes place a few days after the decision to operate [ 3 ].

Nowadays, minimally invasive laparoscopic approach to urgent abdominal surgery (cholecystitis, acute appendicectomies, bowel perforation or obstruction, etc.) represents the standard of care in many cases and recent guidelines recommend it [ 4 , 5 , 6 , 7 ].

Nevertheless, after more than 20 years from clinical introduction, Robotic Surgery (RS) represents the most important technological evolution and a revolutionary concept of computer-assisted technology in minimally invasive surgery [ 8 ]. It allows to overcome many limits of conventional laparoscopy and to expand the use of minimally invasive approaches.

Its peculiar features include a three-dimensional high-definition view, articulated instruments, tremor eradication, and improved ergonomics for surgeons, enable the performance of extremely accurate procedures (micro-sutures, fine dissections, etc.) with consequently lowering conversion rates and postoperative complications, particularly in case of challenging surgical procedures [ 9 , 10 , 11 ]. In addition, compared to traditional laparoscopic surgery, RS demonstrated shorter learning curves for several complex procedures [ 12 , 13 ]. On the other hand, the main drawbacks of robotic technology are linked to its limited diffusion also due to expensive costs [ 14 , 15 , 16 , 17 , 18 , 19 , 20 ].

Nevertheless, robotic surgical technologies have expanded and evolved over the past 20 years, bringing new devices, and improving the most established ones [ 21 , 22 ].

The spreading of robotic platforms and their easier management led to increased RS applications in all abdominal surgical specialities including upper gastrointestinal surgery [ 15 , 23 , 24 , 25 ], colorectal surgery [ 26 , 27 , 28 ], HBP surgery [ 14 , 18 , 29 , 30 , 31 ], abdominal wall surgery and many others [ 7 ].

Despite the huge diffusion of RS in all surgical fields, its application in urgent scenarios has never been investigated representing a new field of interest, with limited literature experiences [ 32 ].

So considering that our experience in RS has been implemented since 2002 and it raised from general to major complex surgery [ 33 , 34 , 35 , 36 , 37 , 38 ], we aim to set the state of art of Robotic Emergency Surgery sharing our experience through the analysis of our peri-operative outcomes and indications in RS. Furthermore, due to the limited evidence available, we have as a secondary endpoint an extensive analysis of previous literature experiences.

Study design and patient selection

We retrospectively reviewed a prospectively collected database of patients undergoing RS at General and Robotic Surgery Unit of San Giovanni Battista Hospital (Foligno, Italy) and General Surgery Unit of San Donato Hospital (Arezzo, Italy) from January 2014 to December 2023.

The patients’ data were analyzed according to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) [ 39 ]. All patients signed an informed consent allowing the anonymous scientific use of clinical data and images. The study was carried out according to the Declaration of Helsinki guidelines and was approved by the Institutional Review Board of the University of Molise (protocol number 10/21, approved date: May 12, 2021).

In all participating centres, data were prospectively collected from electronic patient records.

We selected 834 consecutive robotic procedures for abdominal surgery performed by both centres. Patients were divided into two cohorts: elective surgery and urgent or emergency surgery groups.

Urgent surgery was defined as a condition requiring surgery within 72 h in stable patients, but not suitable for discharge. Moreover, emergency surgery was defined as a clinical scenario requiring within 24 h in stable patients, with a low risk of deterioration. All patients < 18 years old and affected by hemodynamical instability were excluded.

Criteria adopted to assess baseline characteristics of patients, surgical issues and technologies that allow to benefit of RS in urgent and emergency settings are summarized in Table  1 .

Furthermore, to analyze the diagnosis and intraoperative data we carried out a specialities classification as reported in Table  2 .

Implementation of the robotic surgery program and learning curve completion

Our experience with RS started in September 2002 with the da Vinci S ® platform (Intuitive Surgical, Sunnyvale, California, USA), and over time, its application in abdominal surgery grew as well as platform technologies. During the study period, the da Vinci Si ® platform (Intuitive Surgical, Sunnyvale, California, USA) and, since 2017, da Vinci Xi ® (Intuitive Surgical, Sunnyvale, California, USA) were available at our institutions.

Beginning from colorectal surgery, hiatal hernia repairs and cholecystectomies, our surgical team have gradually selected more challenging procedures by carrying out liver and pancreatic resections, oesophageal benign and malignant disorders, bariatric surgery, abdominal wall hernia repairs and nephrectomies [ 14 , 15 , 25 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 ].

All procedures were performed by a well-trained surgeon in minimally invasive surgery (G.C.) with 10 years of previous experience in RS.

36 (4.3%) out of 834 robotic procedures were included in our analysis and treated as urgent or emergent procedures.

All patients signed an informed consent allowing the anonymous scientific use of clinical data and images. The study was carried out according to the Declaration of Helsinki guidelines and was approved by the Institutional Review Board of the University of Molise (protocol number 10/21, approved date: 12 May 2021).

The collected data included demographic characteristics such as age, sex, and preoperative comorbidities classified according to the Charlson comorbidity Index (CCI) [ 48 ]. The anesthetic risk assessment was performed thanks to the American Society of Anesthesiologists (ASA) score [ 49 ].

We reviewed pre-operative diagnosis, main and associated surgical procedures, operative time and intraoperative complications, and conversion to open rate. Postoperative complications were stratified according to the Clavien-Dindo classification [ 50 ] and were considered severe when ≥ 3. Patients were monitored until their 30th postoperative day.

Categorical variables were expressed as frequencies and percentages, while quantitative data were collected as means or medians and interquartile ranges.

Literature review

We performed literature research on the PubMed Dataset (US National Library of Medicine, http://www.ncbi.nlm.nih.gov/PubMed ), using the subsequent keywords: “robotic surgery”, “urgent surgery”, and “emergency surgery”. We selected only English studies. Original articles, case reports and case series were included, while editorials, letters, and reviews were excluded. Number of treated patients does not represent an exclusion criterion. Articles were first evaluated by title and abstract examination, then a full-text read was performed. More than 50 studies described RS in AES. An extensive analysis was performed to summarize similarities and differences among RS approaches according to abdominal surgery specialities.

Pre-, intra- e post-operative outcomes

36 (4.3%) out of 834 robotic procedures were included in our analysis. Baseline characteristics of patients are listed in Table  3 .

According to surgical procedures, Fig.  1 shows AES performed thanks to RS compared to elective surgery.

Over the cohort of 36 patients treated, 16 (44.44%) were males while 20 (56.56%) were females. The mean age was 63.20 years (range: 43–88 years): 30.55% [ 11 ] of patients were ≥ 70 years. The mean Body Mass Index was 26.68 kg/m 2 (range: 23–42). According to the ASA score, 8 (22.22%) patients were classified as ASA 3. No ASA 4 was treated. Patients’ CCI are listed in Table  3 . The da Vinci Si platform was used for the first 15 (41.67%) cases, while Xi for the last 21 (58.33%). 2 (5.55%) procedures were performed at night. No conversions to open were reported in this series. According to Clavien-Dindo grade, 2 (5.55%) major complication was collected: 1 after urgent surgery and 1 after emergency setting. Two minor complications requiring conservative treatments were observed: both complications were related to primary disorders and not to RS. Intraoperative and 30-day mortality were 0%. The mean length of stay was 4.92 days (range: 1–21). The mean follow-up was 26.53 months (range: 7–68).

Number of elective and urgent/emergency procedures ( A ) and percentage of overall surgical procedures performed in emergency settings ( B ) according to abdominal surgery specialities. Abbreviations: HPB, Hepatopancreatic and Biliary Surgery;

Our experience demonstrates the safety and feasibility of RS also in urgent and emergency abdominal settings in patients not affected by hemodynamic instability. To date, the minimally invasive approaches in emergency scenarios are mainly validated for laparoscopy, as reported by several literature experiences included in the last WSES review [ 51 ]. Despite the diagnostic role of MIS, authors demonstrated several benefits of laparoscopic approaches in hemodynamically stable patients undergone AES, including trauma. However, patient selection, surgeons’ expertise as well as specific surgical training represent crucial key points [ 51 ].

In literature, RS in AES studies is related to high-volume centres, and well-trained surgeons’ experiences and their optimal outcomes should encourage further applications and Randomized Clinical Trials [ 32 , 52 ]. We further analyzed short- and long-term outcomes of RS in AES according to specialties (Table  4 ).

Robotic surgery in emergency setting

In the literature, RS in the emergency setting is reported by a limited number of experiences, especially case reports and case series.

The urologist experience described by Capibaribe et al. [ 53 ] demonstrated the safety and efficacy of robotic treatment in the case of vesicourethral anastomotic stenosis after open radical prostatectomy, providing better continence results, without pubectomy.

Globally, the major barrier to RS adoption is due to limited device access resulting from a shared use policy by several surgical teams (gynaecologists, general surgeons, thoracic surgeons, and urologists). Furthermore, the lack of dedicated teams (surgeons, nurses, and anaesthesiologists) during the night shift might further limit RS.

On the other hand, in emergency settings, the “time-sparing” concept is largely known. Commonly, to avoid useless costs due to waste disposable instruments, a hybrid approach should be discussed by the whole surgical team: before robotic docking, a laparoscopic exploration could be the first surgical step to verify clinical environments for doing RS.

A crucial issue is represented by frequent operating table position changes, especially during explorative steps (tilting, Trendelenburg, or reverse-Trendelenburg positions) and rapid conversion to open surgery when necessary [ 54 ]. It could be underlined that quick and safe docking and undocking are performed by skilled teams and well-trained surgeons in elective procedures [ 54 , 55 ].

In the last years, the RS technologies have also impacted operative time [ 56 ]: The Xi robot represents a radical evolution from the Si robot. Literature experiences demonstrated better docking ability during Da Vinci Xi surgery when compared to previous robotic systems (Da Vinci S, Si, X) [ 57 , 58 ]. These features were due to laser targeting and improved cannula mounts that resulted in a simplified “linear” port configuration and an abbreviated docking time.

Besides, the ability to exchange the robotic camera from port-to-port increased versatility for multi-quadrant surgeries thanks to the smaller 8 mm camera [ 59 , 60 ]. The multi-quadrant operations represent challenges due to the axis of visualization shift up to 360°. This procedure requires undocking the robot and rotating it on the axis. It is crucial for many colorectal surgeries that require access to the entire abdomen such as subtotal colectomy and total proctocolectomy.

Furthermore, it was reported that the Xi system’s better fluency is also due to thinner robotic arms that reduce their collisions during surgery and synchronous movements with the operating Table [ 56 ]. In addition, Da Vinci Xi integrates the Indocyanine-Green technology that could be easily used to better identify bile duct during cholecystectomy in patients affected by acute cholecystitis, to assess organ vascularization during their resections and anastomosis, as reported in our experience.

Bianchi et al. [ 61 ] performed an extensive comparison of Da Vinci Si and Xi systems to define their advantages and disadvantages. 89 patients (64 in the Si system vs. 25 in the Xi system group) who underwent liver surgery were included. The Si system group experienced a greater total incisional length (+ 8.99 mm; p  < 0.0001) due to a higher number of robotic/laparoscopic ports. Nevertheless, no differences were described regarding operative time, conversion rate, estimated blood loss, postoperative complications, mortality, use of analgesics, and costs. The authors concluded that da Vinci Xi represents an effective technological advancement.

Hill et al. [ 62 ] hypothesized that Da Vinci Xi will allow for greater efficiency and result in shorter operative times if compared to Da Vinci Si. To validate their hypothesis, the authors performed a retrospective review of patients undergoing sigmoid colon resection or Low Anterior Rectal resection. A total of 93 patients underwent sigmoid resection thanks to RS (Si, n  = 52 vs. Xi, n  = 41). The Xi group had significantly shorter surgical times for Low Anterior Rectal and sigmoid resection (162 vs. 238 min, p  = 0.0001). Nowadays, no data are available on the Da Vinci Si and Xi comparison in AES.

However, according to the type of procedures, the mean operative times of Da Vinci Xi were superimposable to the Si group in our experience.

The robotic technology in hemodynamically stable patients could potentially reduce the conversion to open rate (0% in our short series), thanks to high-definition view and accuracy of dissection and fine micro-sutures.

In 2022, the World Society of Emergency Surgery (WSES) published a position paper on RS in AES after the literature evaluation by a steering committee and an international expert panel [ 32 ]. Ten studies (3 case reports, 3 case series, and 4 retrospective comparative cohort articles) were found and 6 statements were proposed. Experts concluded that RS can be considered safe, and feasible in selected cases represented by hemodynamically stable patients. It should be emphasized that the WSES team reported some RS drawbacks: it is mandatory to perform dedicated surgical training, RS showed longer operative times, higher costs and difficult availability and accessibility represent the main issues during night shifts [ 32 ].

These aspects probably may change in the future with RS diffusion and new robotic devices in the health market.

In our experience, the mean age of patients was 63 years. Therefore, more than 30% of patients were older than 70 years (range: 43–88 years) and it is in line with RS literature experiences that showed good outcomes also in the elderly population [ 28 , 41 ]. Nevertheless, operative time represents a crucial point in this frail cohort. Despite RS showing longer operative time when compared to open and laparoscopic surgery, this disadvantage may be offset by lower postoperative complication rates, shorter hospital stays, and lower conversion rates [ 28 , 41 , 63 , 64 , 65 ].

Another key aspect is represented by enhanced vision through near-infrared imaging. It may be useful in AES in case of tissue perfusion evaluations or biliary tree identification in challenging procedures. This feature is not routinely available in laparoscopic surgery [ 66 , 67 ].

Figure  2 shows an emergency scenario due to splenic artery aneurysm repair thanks to RS.

The robotic approach during Emergency Setting for patients affected by splenic artery aneurysms using a vessel resection and end-to-end vascular anastomosis

Robotics in emergency upper-GI and bariatric surgery

One of the earliest studies on RS in AES was published in 2012 [ [ 68 ]]: Sudan et al. experience in complex bariatric surgery involved 2 patients affected by a stomach stricture and an acute abdomen due to perforation with biliary peritonitis after biliopancreatic diversion, respectively. The perforation was treated through an initial laparoscopic investigation followed by a handsewn robotic stitch reparation of duodenal stump dehiscence.

In 2020, Cubas et al. [ 69 ] presented an RS procedure for incarcerated Morgagni Hernia in a 29-year-old male. The hernia defect (reported as 10 × 7 cm) was corrected via mesh placement. Patient discharge was possible on POD 5. No recurrence was detected at 1-year follow-up.

During the same year, Ceccarelli et al. [ 45 ] published a series of 5 patients affected by strangulated Giant Hiatal Hernia: 3 (60%) patients experienced RS while 2 (40%) laparoscopic approach. The authors described an easier incarcerated stomach management thanks to RS, maybe due to better surgeon ergonomic position and more accurate dissection preserving pleural integrity and vagus nerve.

Kim et al. [ 70 ] reported a case of robotic transthoracic repair of a right-sided traumatic diaphragmatic rupture in a 45-year-old male with a history of chronic obstructive pulmonary disease presented as a restrained driver in a low-speed motor vehicle collision. The patient was effectively operated after a 48-hour observation.

In 2021, 300 USA hospitals were involved in retrospective data collection of adult patients affected by Hiatal Hernia and treated in elective and urgent/emergency scenarios from 2015 to 2017 [ 71 ]. Data analysis revealed that laparoscopy (64%) was the most frequent approach used during AES, followed by open surgery (30%). A limited number of patients (6%) experienced RS. After cost evaluations and outcomes analysis, authors declared the technical feasibility of minimally invasive approaches when compared to open surgery due to lower cost, lower length of hospital stay, complications, and mortality.

Robinson et al. [ 72 ], in 2021, performed a statistical analysis of “in-room-to-surgery-start time” in a retrospective cohort study of 44 patients affected by emergent perforated gastrojejunal ulcers. The comparison between RS and laparoscopic (24 and 20 cases respectively) showed encouraging results for RS (25 versus 31 min, p  = 0.01). Furthermore, no statistical differences were observed in terms of intra- and post-operative outcomes (operative time, complication rate, complication severity, hospital length of stay, discharge to home, and 30-day readmission). Despite RS showing higher surgical costs, authors concluded that emergency gastric perforation could be safely approached thanks to RS.

No complications were reported in all studies reported in our review [ 69 , 70 , 71 , 72 ].

Robotics in emergency colorectal surgery and appendectomies

Nowadays, emergency laparoscopy represents a safe and valid approach to colorectal disorders such as perforated diverticulitis with generalized peritonitis [ 73 ], iatrogenic colonoscopy perforations [ 74 ], bowel obstructions and anastomotic leaks management [ 75 , 76 , 77 ].

In 2012, Pedraza et al. [ 78 ] showed successful robotic colectomy due to iatrogenic colon perforation following colonoscopy.

Two years later, Felli et al. [ 79 ] described a case of an 86-year-old woman admitted to the emergency unit for massive intestinal bleeding due to ascending colon cancer. After patient resuscitation thanks to blood transfusions, surgeons carried out a robotic right colectomy. The postoperative period was uneventful.

Several series compared laparoscopic and robotic outcomes in patients who underwent elective colorectal surgery [ 80 , 81 , 82 ], suggesting the potential role of RS in this surgical field. Nevertheless, an interesting analysis was performed by Beltzer et al. [ 83 ] in 2019. 106 patients were treated for uncomplicated, complicated, or recurrent diverticulitis. The authors concluded that RS achieves better outcomes when compared to laparoscopic surgery in challenging cases (abscess or relapsing diverticulitis).

Three monocentric experiences reported by Kudsi et al. [ 84 , 85 , 86 ] showed the effectiveness of urgent RS for the treatment of obstructive transverse colon cancer, bleeding sigmoid diverticulosis and caecal volvulus.

However, RS could represent a crucial approach also in colorectal autoimmune diseases. Concerning this field, Anderson et al. [ 87 ] in 2020 reported a matched case-control study of 6 patients treated by urgent subtotal colectomy for ulcerative colitis using the robotic platform. In addition, authors compared patients who underwent RS to laparoscopic urgent procedures (6 versus 13 cases) concluding that no differences in perioperative outcomes were observed.

According to Yang et al. [ 88 ] estimation, more than 17 millions of patients were affected by appendicitis in 2019, making it the most common surgical emergency worldwide. Nevertheless, regarding urgent robotic appendectomies, only 5 literature experiences reported robotic approaches [ 89 , 90 , 91 , 92 , 93 ]. A total of 11 patients were collected and 3 (27.27%) required an appendix stump suture. No complications or conversions were reported. Moreover, Hüttenbrink et al. [ 94 ] described incidental appendicectomy during robotic prostatectomy.

Figure  3 shows our experience during RS for complicated sigmoid diverticulitis with sigmoid-bladder fistula.

Lunardi et al. [ 95 ] presented an interesting analysis of temporal trends in the use of minimally invasive surgery in Abdominal Emergency and Urgent Settings. The authors compared 89,098 emergency colectomies performed between 2013 and 2021. The increase per year for robotic colectomy was 0.9% (from 1.4% of total procedures in 2013 to 8.8% in 2021). As a result of this increase, a 0.7% decrease was registered for the open approach. Furthermore, patients who underwent RS were older, had more comorbidities and had higher BMI when compared to laparoscopic and open groups. Intraoperative outcomes were encouraging for RS: after Propensity Score Matching, a conversion rate of 25.5% (860/3,375 patients) was registered during laparoscopic surgery, while in 11.2% (379/3,375 patients) of RS cases, a conversion to open was required ( p  < 0.001). After Propensity Score Marching of patients underwent Emergency surgery only, RS demonstrated advantages in terms of conversion to open (27.5% vs. 12% in laparoscopic and robotic groups respectively, p  < 0.001) and post-operative LOS (7.12 vs. 6.85 days respectively, p  = 0.001).

In conclusion, conventional open surgery should be recommended for unstable and frail patients who require time-critical surgery. Nevertheless, it could be underlined that stable and frail patients may benefit from an enhanced recovery after surgery associated with RS in the acute setting when compared to open surgery.

Robotic approach during emergency setting for patients affected by complicated sigmoid diverticulitis with sigmoid-bladder fistula. We performed a fistula resection and bladder suture in double-layer barbed suture

Robotics in acute cholecystitis and biliary tree diseases

Another interesting field of application in AES may be the biliary tree and gallbladder diseases including cholecystitis, Mirizzi syndromes, biliary fistulas, iatrogenic diseases and common bile duct stones.

In 2016, Kubat et al. [ 96 ] published a retrospective series of 150 consecutive robotic single-site cholecystectomies (74 versus 76 cases treated in emergency scenarios and elective settings respectively). The mean operative time for ES cohort was significantly longer (95.0 ± 4.4 versus 71.9 ± 2.6 min; p  < 0.001). Both cohorts required 1 conversion to open (1.35% for the emergency group and 1.31% for the elective group). One bile duct injury (0.7%) was reported in patients treated in emergency conditions. The authors concluded that robotic single-site cholecystectomy can be performed safely and effectively in both elective and urgent scenarios with a learning curve of about 48 cases to reach acceptable perioperative outcomes.

Mirizzi syndrome represents one of the most challenging complications of cholelithiasis [ 97 , 98 , 99 ].

In 2014, Lee et al. [ 97 ] evaluated the outcomes of five patients treated by endoscopic biliary stent placement and subsequent robotic partial cholecystectomy due to Mirizzi syndrome. No conversion to open was reported and all patients experienced an uneventful postoperative course.

In 2017 Magge et al. [ 98 ] reported a 6-patient series. All cases were treated performing a combined endoscopic and robotic approaches. In 3 cases (50%) a Roux-en-Y hepatico-jejunostomy was carried out. In these challenging scenarios, RS showed relevant benefits when compared to laparoscopy, facilitating complex dissections, and reducing conversion to open rate.

The most representative cohort of patients was described by Gangemi et al. [ 100 ] in 2017. Authors compared a large series of 676 patients receiving a robotic cholecystectomy with 284 treated by conventional laparoscopy: data analysis showed a significantly lower conversion to open in RS group, especially in patients affected by acute or gangrenous cholecystitis.

A 3-patient experience was described by Milone et al. [ 101 ] in 2019, achieving good perioperative outcomes in acute cholecystitis treatment.

Major bile duct injuries after cholecystectomy require complex surgical repairs that are usually performed with a conventional open approach [ 102 ]. This field may represent an interesting application of RS to safety perform biliary anastomosis. Cubisino et al. presented a systematic review of 13 literature experiences on minimally invasive biliary anastomosis after iatrogenic bile duct injury [ 103 ]. 198 patients were included. 135 patients (63.1%) underwent laparoscopic biliary anastomosis, while 73 (36.1%) received an analogue robotic procedure. According to Strasberg’s classification [ 104 ], all Bile Duct Injuries were types D and E (E1–E5). No conversions occurred in the RS series, while 4 patients required conversion to open surgery among the laparoscopic ones. Postoperative complications were superimposable (18.7% and 19.7% in laparoscopic and robotic approaches, respectively). Nevertheless, the overall reoperation rate was 4.4%, 5.5% in laparoscopic and 2.6% in robotic repairs.

During the follow-up period (median 24.6 months), 9 patients developed an anastomotic stricture: 5 (3.70%) in laparoscopic and 4 (5.48%) in robotic series that required a redo-anastomosis in 60% and 25% respectively.

When compared to open and laparoscopic cholecystectomy in AES, RS showed an increase of 0.7% per year in Lunardi et al. cohort of 793’800 cholecystectomies [ 95 ], ranging from 2.5 to 8.8% between 2013 and 2021. It could be underlined that conversion rate and LOS were statistically lower in RS group ( p  < 0.001). Despite these findings, laparoscopic cholecystectomy yet represents the preferred approach in AES.

Robotics emergencies in hernia and abdominal wall surgery

Only a few studies analyzed urgent hernia operations treated using robotic surgery.

In 2020, Bou-Ayash et al. [ 105 ] published a retrospective series of 19 patients (including 23 surgical procedures) affected by inguinal hernia, treated from 2013 to 2020. The authors concluded that the robotic approach represents a safe procedure in selected patients, with a short length of stay and a low complication rate compared to open and laparoscopic surgery.

In 2021, Kudsi et al. [ 106 ] described perioperative outcomes of RS in a 34-patient cohort treated between 2013 and 2019. All patients experienced robotic ventral and incisional hernia repair in an emergency setting. 20% of patients were classified as Clavien-Dindo I or II, while about 11% Clavien-Dindo III and IV. Only 3% of the population experienced a recurrence.

Muysoms et al. [ 107 ] performed an extensive analysis of robotic cost. They retrospective evaluate laparoscopic (272 procedures of which 6 were emergency cases) and robotic (404 procedures of which 8 were emergency cases) inguinal hernia repairs. As reported in other literature experiences, authors concluded that Robotic inguinal hernia repair was significantly ( p  < 0.001) more expensive if compared to laparoscopic surgery (mean cost €2612 versus €1963, respectively). Nevertheless, in the robotic group, a larger number of patients were treated as outpatients with lower postoperative complications.

Regarding inguinal and ventral hernia repair, the analysis conducted by Lunardi et al. [ 95 ] showed encouraging data for RS approach: from 2013 to 2021 RS increased of 1.9% per year and 1.1% per year respectively. After propensity score matching, authors reported superimposable data in terms of CCI and BMI, comparing laparoscopic and robotic approaches. Nonetheless, RS showed benefits also in these fields: lower conversion rates were reported both in inguinal hernia repairs (18.1% vs. 3.8%, p  < 0.001) and in ventral hernia repair (16.2% vs. 4.8%, p  < 0.001). In addition, a statistically significant shorter postoperative LOS was registered in the RS group (the mean LOS in the inguinal hernia group was 3.34 vs. 3 days in laparoscopic and robotic approaches respectively, and the mean LOS in the ventral hernia group was 3.87 vs. 3.73 days, respectively).

Other abdominal emergency surgery and future perspectives

A rare indication for urgent RS was post-traumatic splenic bleeding reported by Giulianotti et al. [ 108 ].

Until now, no reports of RS in adhesive intestinal obstruction have been published.

A possible and useful application of RS is represented by telementoring and telesurgery [ 32 , 109 , 110 , 111 ]. The original aim of RS and the recent COVID-19 pandemic gave an important incentive in these directions. The advantage of telementoring and telepresence of an expert surgeon in a virtual way is nowadays possible and may be improved thanks to the modern and future highspeed internet connection (5G networks) as well as the telesurgery in ultra-remote countries, in low-volume centers and in an emergent civil or battlefield surgical scenarios [ 112 , 113 , 114 ].

The development of new modular robotic platforms may contribute to increase RS applications in emergency settings. Nowadays, several different robotic platforms are approved for human use, such as CMR Versius (Cambridge Medical Robotics, Cambridge, UK), Distalmotion Dexter (Distalmotion, Epalinges, Switzerland) and Medtronic Hugo (Medtronic Inc., Minneapolis, USA). Most of them share the opportunity of switching from a conventional laparoscopic setting to a robot-assisted one.

Limitations

The main bias of our study was represented by hospital organisations: RS devices are available in the same building as the General Surgery Unit at San Donato Hospital (Arezzo, Italy) facilitating emergency surgical procedures. On the other hand, Da Vinci Xi is situated in a separate building specifically dedicated to RS at the General and Robotic Surgery Unit of San Giovanni Battista Hospital (Foligno, Italy).

Furthermore, these findings represented a limit when the surgeons’ team wanted to perform a laparoscopic exploration to validate a minimally invasive robotic approach in emergency scenarios.

In our experience, it should also underline that the COVID-19 era has contributed to limiting RS adoption.

Future shreds of evidence from randomized clinical trials with long-term follow-up are required to define the potential role of RS in AES. Nevertheless, the unavailable data on the cost-effectiveness of RS in AES are linked to lower use of robotic devices if compared to laparoscopic approaches. Our experience suggested that RS costs are superimposable to laparoscopic surgery if we analyse LOS and conversion rate data. To optimize the delivery of robotic technology in AES, a well-coordinated effort among health systems, clinicians, payers, and policymakers and dedicated training program for robotic teams are imperative.

Our study demonstrates that RS may be an useful and reliable approach also to emergency surgical procedures, especially when performed in selected patients in very well trained robotic centers allowing a safe managing of surgical challenging procedures as main indications for this technology, reducing the conversion rate when compared to laparoscopy.

As for laparoscopy the patient selection for robotic approach need hemodinamically stable condition and require a sharing of the surgical strategy by all the team: surgeons, nurses and anaesthesiologists. All the staff need to be trained in laparoscopic and robotic elective surgery, including technology functioning. The hybrid use of robotic/laparoscopic technology may be taken into consideration (a laparoscopic exploration may be the first step) to decide the following approach. The robotic approach may be reserved to challenging steps of the operation (suture/microsuture/dissections).

The availability of the device is the sine qua non condition for emergent and of course urgent use. The current organization in which the platform is shared by different teams, represent for the diffusion of its use in the emergent setting.

The cost reduction of platforms and instruments, together with new robotic devices in the health market, may represent a future perspective for emergencies use of robotic technology. So, the robotic technology may be one of the tools available in every operating theatre, to use in selected cases according to patient condition and surgical team experience.

Data availability

No datasets were generated or analysed during the current study.

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Ceccarelli, G., Catena, F., Avella, P. et al. Emergency robotic surgery: the experience of a single center and review of the literature. World J Emerg Surg 19 , 28 (2024). https://doi.org/10.1186/s13017-024-00555-6

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Robot-assisted vascular surgery: literature review, clinical applications, and future perspectives

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• Balazs C. Lengyel 1 , 2 ,
• Ponraj Chinnadurai 1 ,
• Stuart J. Corr 1 ,
• Alan B. Lumsden 1 &
• Charudatta S. Bavare 1  

Although robot-assisted surgical procedures using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA) have been performed in more than 13 million procedures worldwide over the last two decades, the vascular surgical community has yet to fully embrace this approach (Intuitive Surgical Investor Presentation Q3 (2023) https://investor.intuitivesurgical.com/static-files/dd0f7e46-db67-4f10-90d9-d826df00554e . Accessed February 22, 2024). In the meantime, endovascular procedures revolutionized vascular care, serving as a minimally invasive alternative to traditional open surgery. In the pursuit of a percutaneous approach, shorter postoperative hospital stay, and fewer perioperative complications, the long-term durability of open surgical vascular reconstruction has been compromised (in Lancet 365:2179–2186, 2005; Patel in Lancet 388:2366–2374, 2016; Wanhainen in Eur J Vasc Endovasc Surg 57:8–93, 2019). The underlying question is whether the robotic-assisted laparoscopic vascular surgical approaches could deliver the robustness and longevity of open vascular surgical reconstruction, but with a minimally invasive delivery system. In the meantime, other surgical specialties have embraced robot-assisted laparoscopic technology and mastered the essential vascular skillsets along with minimally invasive robotic surgery. For example, surgical procedures such as renal transplantation, lung transplantation, and portal vein reconstruction are routinely being performed with robotic assistance that includes major vascular anastomoses (Emerson in J Heart Lung Transplant 43:158–161, 2024; Fei in J Vasc Surg Cases Innov Tech 9, 2023; Tzvetanov in Transplantation 106:479–488, 2022; Slagter in Int J Surg 99, 2022). Handling and dissection of major vascular structures come with the inherent risk of vascular injury, perhaps the most feared complication during such robotic procedures, possibly requiring emergent vascular surgical consultation. In this review article, we describe the impact of a minimally invasive, robotic approach covering the following topics: a brief history of robotic surgery, components and benefits of the robotic system as compared to laparoscopy, current literature on “vascular” applications of the robotic system, evolving training pathways and future perspectives.

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Introduction

The robotic-assisted laparoscopic approach has transformed many surgical subspecialties; however, it has yet to gain momentum and play a central role in vascular surgery [ 1 , 2 , 3 , 4 ]. Other surgical specialties such as thoracic surgery, general surgery, and urology have embraced robotic technology into clinical routine and now providing minimally invasive surgical options to patients while mastering the vascular skill sets imperative for these procedures. In the meantime, endovascular surgery has revolutionized the field of vascular surgery, delivering the promise of minimally invasive therapeutic options to our patients. However, one could argue that the durability of open surgical vascular reconstruction and repair has been compromised, in this pursuit of percutaneous endovascular technologies, as evidenced by the re-intervention rates for endovascular procedures [ 5 , 6 , 7 ]. The lack of early adoption of surgical robotics could be potentially due to the lack of surgical laparoscopic skills/training among vascular specialists, fear and risk of uncontrolled bleeding, and the inherent difficulties of creating laparoscopic vascular anastomosis.

A surgical procedure can be broadly divided into two parts: firstly, the core therapeutic part (i.e., the only portion which the patient benefits from) and secondly, the delivery system—the part that provides access/conduit to deliver the intended core therapeutic option. For example, to sew in a piece of Dacron into the aorta—as initially described by Dr. DeBakey—is easily the most durable repair described for aortic aneurysmal disease [ 8 ]. However, the delivery system—either a laparotomy thoracotomy or thoracoabdominal incision is very unappealing to most patients and associated with higher perioperative complication rates than endovascular alternatives [ 9 ]. Endovascular aortic repair has a very appealing delivery system namely a small incision or puncture site, however, the core therapeutic part of stent graft placement is fraught with long-term problems and is nowhere near the durability of the Dacron-based vascular reconstruction for abdominal aneurysmal disease [ 8 , 9 ]. These endovascular procedures also became an early target for steerable, robotic catheter technology; however, its routine adoption has been limited and also redirected recently toward image-guided, robotic endobronchial interventions, where it is transforming diagnosis and therapeutic care for patients with malignant lung nodules [ 10 , 11 , 12 ].

The concept that the robotic approach is an equivalent of an open operation delivered with a minimally invasive technique, due to the dynamic wristed instruments, which are essentially mimicking the hand movements of a surgeon, inside the body, makes it dramatically different from the traditional laparoscopic approach. An intriguing question is whether robotic surgery introduced in the vascular surgery world could retain the core therapeutic components that have been validated for decades while at the same time making the delivery of such repairs more acceptable and tolerable to patients. It is this intriguing concept that stimulated us to evaluate the role of robotics.

The outline of this review article is as follows: a brief history of robotic-assisted vascular surgery, components and benefits of the robotic system as compared to laparoscopy, current literature on vascular applications of the robotic system, evolving robotic training pathways of vascular surgeons and future perspectives of robotic vascular surgery with novel techniques/instrumentation.

Brief history of robotic surgical platforms

Early surgical robots were specialty focused, like the Robodoc, which was first developed in the late 1980s, for orthopedic surgery, or another urologic robot—developed for prostate surgery. Later advancements were propelled by the US military, which wanted to develop a telemedical unit that could provide surgical care in close proximity of the battlefield, operated by a surgeon in the safe zone. This led to the pioneering development of the Green Telepresence System, which consisted of a surgeon’s workstation and a remote surgical unit. This robot laid the basis for today’s surgical robotic appliances. Although it was first developed for open surgery, only after one of the developers, Colonel Satava, saw the presentation of Dr. Perrisat on one of the first videotaped laparoscopic cholecystectomy, the system was transitioned toward laparoscopic surgery. Interestingly, the first procedures that have been tested on robotic surgical systems were mostly vascular operations, such as running suture on bovine aorta, patch angioplasty, and PTFE graft anastomosis with the contribution of Jon Bowersox, a vascular surgeon from the Stanford Medical Center. They were all successful attempts, but were significantly slow, due to the lack of wristed instruments in early robots that were only introduced in the mid-1990s. Along with the above-mentioned efforts of the Stanford Research Institute and the Defense Advanced Research Projects Agency (DARPA), two private companies, Computer Motion and Intuitive Surgical, raced for the development of the ultimate surgical robotic system. Their competition ended with merging in 2003. Computer Motion’s Zeus system was discontinued for the sake of Intuitive Surgical’s more versatile robot, the da Vinci. The prototype of the da Vinci surgical system—called Lenny, was developed in 1995. It had to be attached to the surgical table and had fixed instrumentation. Later with the introduction of exchangeable instrumentation, Mona was developed, and was first used in human trials in 1997. It lacked a camera holding arm, so an assistant had to be present manipulating the camera on the instructions of the operating surgeon. Further improvements in visualization and the addition of a stand-alone cart—housing the patient-side components, were revealed one year later, forming the first surgical robot with the name da Vinci. After successful human trials, it received FDA approval in 2000 for general surgery indications in the USA [ 13 , 14 ]. Since then, the surgical robot has gone through significant upgrades and now represents state-of-the-art technology (Fig.  1 ).

Evolution of Intuitive Surgical’s da Vinci Surgical Robot (Intuitive Surgical, Sunnyvale, CA, USA)

Intuitive Surgical reported that by September 2023, more than 13 million procedures were performed on the da Vinci system. More than 8200 da Vinci robots are available worldwide. The industry is exponentially growing and mostly led by general surgeons, urologists, and gynecologists, while other specialists, including vascular surgeons, only take part in a small fraction of procedures performed [ 1 ]. However, many of these procedures include essential vascular techniques, most vascular surgeons are yet to receive training on the robot. It is not only problematic in terms of practicing vascular operations, but also when it comes to treating rare, life-threatening vascular complications using the same robotic platform.

Introduction to the da Vinci surgical robotic system

The most used laparoscopic robot, the da Vinci system can be subdivided into three subsystems, namely the surgeon console, the patient-side cart, and the vision cart. The surgeon who is performing the operation is physically disconnected from the patient, sitting in an ergonomic control unit, controlling a master–slave teleoperation architecture with an intermediary of a computerized control system. The patient-side manipulators are mounted on the transportable patient-side cart. The robot has four arms that work in the sterile field. Each of these can hold either an endoscopic camera or a surgical instrument. Since the input by the surgeon runs through a computer, it can filter out unwanted signals, such as the tremor of the surgeon’s hand, or it can scale motions to facilitate enhanced precision when it is required. But it could go both ways: the robot could inform the surgeon, based on visual or other imaging clues—aiding orientation, giving warning signs on critical steps, and ultimately enhancing patient safety. Certainly, it is the topic of the future, and innovation has limitless potential in this field [ 15 ].

Also contributing to better orientation, the state-of-the-art visualization system offers 3D vision by a stereo endoscopic camera that records in 4 K resolution [ 16 ].

Since the most widely available robotic systems do not support haptic feedback, one of the most important perceptions is lost. This forms huge limitations in vascular procedures, where tactile feedback is often paramount. However, in March 2024, Intuitive Surgical revealed the new, fifth-generation da Vinci robotic system, which will support haptic feedback, a long-awaited feature in robotic surgery. With this, tissue handling, and possibly suture handling, will improve. One of the hardships of today’s robotic instruments is that they can break monofilament sutures like Prolene (Ethicon, Raritan, NJ, USA) very easily, due to handling by the needle drivers, which is why most vascular robotic surgeons use PTFE sutures which are proven to be a bit more durable.

The biggest advantage of robotic surgery in contrast to laparoscopy is the utilization of wristed instruments that can be operated in an ergonomic and intuitive manner. These articulated instruments can allow up to seven degrees of freedom including grasping. These can essentially act as an extension of the surgeon`s arm, allowing a wide range of motion.

In the fourth-generation da Vinci system, visual clues help to overcome the lack of tactile feedback. As opposed to open vascular procedures, where one of the key techniques of locating blood vessels is palpation, on the robotic platform, localization mostly relies on visual clues. One of the existing imaging technologies that could help in the visualization of blood vessels is FireFly®—which is a near-infrared fluorescence imaging technology, where with the intravenous injection of indocyanine green, blood vessels can be highlighted [ 16 ].

The da Vinci Xi robot can be synchronized with the TRUMPF Medical TruSystem 7000dV operating table (TRUMPF Medezin Systeme, Saalfeld, Germany), which allows the surgical team to move the table without redocking the robot. The robot automatically adjusts the gantry and instruments to maintain position relative to the patient`s anatomy. This provides more efficiency and optimal exposure during multi-quadrant operations [ 16 ].

Currently, the most widely used robotic surgical system is represented by the da Vinci Xi robot, which was introduced in 2014. Compared to the previous model—the Si, it offers several advantages. It comes with an endoscopic camera that fits in an 8 mm port and supports 4 k resolution and 3D vision with magnification. A significant improvement over the previous generation is that the endoscope can be mounted on either of the robotic arms, which creates more freedom for port placement. If using the 30-degree optics, the surgeon can flip the camera 180 degrees with a simple touch of the touchscreen, without having the assistant do it manually. The touchscreen on the surgeon console can control the electrocautery and several other functions can be adjusted on the go. The patient-side cart’s top-mounted rotating boom enables multi-quadrant surgery without having to redock the robot. Laser guidance helps the faster docking process. The autotarget function optimizes the position of the robotic arms—which are significantly sleeker and can reach further, so they can move more freely without colliding. A synchronizeable table—as mentioned before, enables table movements during the operation without the need for redocking. All these advancements create a much more intuitive and user-friendly platform than laparoscopy. Along with the technical details, there is great emphasis on training, which in the case of the robotic system can be performed in computer simulation in a structured manner through Intuitive Surgical’s Learning platform.

Advantages and disadvantages of the robotic surgical platforms

The advantages of robot-assisted surgery include the capability of 3D visualization, seven degrees of freedom provided by the Endo-wrist technology, elimination of the fulcrum effect, and physiologic tremors. It also has the ability to scale motions and even to perform telesurgeries if needed. The system allows the surgeon to take up a more ergonomic posture than what traditional laparoscopy would require [ 17 , 18 ]. Although sitting in front of the surgeon console is considered more ergonomic, it has its challenges, like the possible development of upper body fatigue and neck pain; therefore, the correct use of the armrest and individual adjustment of the seating position is important [ 19 ].

One of the main drawbacks of the robotic approach is the lack of tactile or haptic feedback, which is present in laparoscopy. The system requires additionally trained staff to operate and a large enough space for the equipment [ 17 ]. Finally, its long-term outcome benefit is yet to be proven in vascular surgery. Today, only relatively small single-center studies and case series have been published.

A significant limitation of the widespread adoption of robotic surgery is its high cost. The price makes the equipment inaccessible to most hospitals, not to mention the high annual maintenance fees and additional cost of disposable instruments. Its use is generally limited to centers, although it’s sensible, considering the need for high expertise, which can be gained only through a high volume of cases. However, cost issues could be counterbalanced by reduced length of stay, lower morbidity, and better surgical outcomes as reported in urology and colorectal surgery compared to other techniques [ 20 , 21 ].

Besides the most widespread da Vinci robotic system, several other—possibly more cost-effective—robots are either under development or undergoing clinical trials to compete with the current generation. These could eventually create healthy competition in the market leading to lower costs and urging innovations [ 22 ].

In 2010, Stefanidis et al. highlighted the intuitive nature and steep learning curve of robotic procedures with their experiment involving 34 medical students with no prior laparoscopic or robotic experience. They performed suturing tasks using laparoscopy and the da Vinci robot on a live porcine model. Results showed faster suturing, higher assessment scores, and fewer errors per knot with the robot. Laparoscopic performance did not significantly improve over rounds, while robotic assistance led to significant improvement [ 23 ].

Challenges in the adoption of surgical robotic technology in vascular surgery

The da Vinci Surgical System is approved for cardiac, thoracic, urologic, gynecologic, otorhinolaryngologic, colorectal, and general surgical uses. Despite numerous robotic procedures involving core vascular surgical techniques, the vascular application is still considered off-label [ 3 ]. The question is why did most vascular surgeons neglect this technology?

Every surgical specialty aspires to find less invasive ways to treat patients. Vascular surgery is no exception. We use vasculature as a pathway to reach and fix the disease with wires, catheters, balloons, and stents. Endovascular techniques have evolved in such a way, that in many areas of vascular surgery, it became the primary choice of care [ 24 , 25 , 26 , 27 ]. Most notably in cases of aortic aneurysmal disease or aortoiliac occlusive disease (AIOD), endovascular techniques offer less perioperative mortality, shorter hospital stay, comparable long-term durability, and survival. Despite these important factors, endovascular procedures often come with an increased re-intervention rate, and the need for lifelong surveillance, not to mention the elevated costs [ 5 , 6 , 28 ].

Recent studies have pointed out that the better long-term durability and need for less invasive surveillance methods and decreased exposure to radiation because of frequent CTA scans may outweigh the higher perioperative morbidity of open abdominal aortic aneurysm repair, also providing a better quality of life [ 6 ].

Not every patient is fit for open repair, even so in the case of most of the typical population requiring vascular surgery. These patients often have multi-systemic disease, limiting their ability to endure the surgical stress of an open reconstruction, subsequently suffering from high perioperative morbidity and mortality. Besides the possibility of endovascular interventions, robotic reconstruction could be the third operative option to choose from.

The failure of the adoption of laparoscopy in vascular surgery

Although laparoscopic aortic surgery has been available for more than 20 years, only a handful of centers have adopted the technique. The main reasons for it include the lack of interest, focus on endovascular treatment options, required steep learning curve, and most notably the difficulties of creating a vascular anastomosis, subsequently longer clamping times, and prolonged operation times [ 3 ]. Vascular surgical laparoscopy is extremely difficult to master.

Apart from technical difficulties, the laparoscopic approach could retain most of its attributed benefits when used for vascular reconstructions. A comparative study between open abdominal aortic repair and total laparoscopic repair found that there was no significant difference in short-term morbidity and mortality, but with laparoscopy, the operative times were significantly longer, mainly due to a longer anastomosis creation time. Interestingly, more bleeding was observed in laparoscopic cases [ 29 ]. This could be accounted for by several problems, such as the lack of effective tamponade, the negative effect of suction on the pneumoperitoneum, and consequently the loss of visual control. Possibly, the most feared complication of laparoscopy is major vascular injury, which can lead to severe complications, even death of the patient. Perhaps the lack of safe vascular control, mostly derived from the lack of appropriate laparoscopic clamps, was one of the main aversive factors against laparoscopy for the vascular community. This issue is still present in robotic surgery, which is why the development of reliable dedicated robotic vascular instruments is essential for the ability to perform more arterial cases with the robot.

The laparoscopic technique was associated with benefits including shorter hospitalization, reduced need for pain medication, and reduced time of postoperative bowel dysfunction [ 29 ]. Long-term results of laparoscopic aortic reconstruction yielded comparably good results to open repair in terms of survival and need for re-intervention, but with the additional benefit of the lack of laparotomy-related complications [ 30 ].

Despite the above-mentioned results, originating from only a handful of centers worldwide, laparoscopy was not appealing enough for vascular surgeons to invest in, due to inherent technical difficulties and the lack of laparoscopic training in vascular surgical education.

Although the robotic approach is based on the fundamentals of laparoscopy, it is a dramatically different technique. The main difference lies in the wristed robotic instruments and intuitive controls that facilitate surgical manipulation, resulting in shorter learning curves, allowing for faster vascular anastomosis and consequently shorter clamping times [ 31 ].

Current vascular procedures performed with robotic assistance

The following section describes vascular procedures currently performed using the da Vinci system. In terms of procedural volumes, most of these are performed by non-vascular specialists, who have mastered essential vascular surgical skills with the use of the robot. We believe that there are many techniques to be learned from these specialties, to adopt this technology in the vascular field. (Table  1 ).

Robot-assisted infrarenal aortic and aortoiliac aneurysm repair

Performing aortic reconstruction requires the ability to control high-pressure arteries, often heavily calcified. Choosing the right place for clamping heavily relies on preoperative imaging, as haptic feedback is unavailable (except the latest-generation da Vinci robot), although there are some visual clues like the color of the vessel wall or how it reacts to movement and palpation with the instruments, which might help the decision. Clamping can be done either by inserting a laparoscopic clamp through an assist port or by inserting a DeBakey clamp through a small incision. Balloon occlusion of the iliac arteries can be performed as well. However, we have to point out that no specialty-focused vascular robotic instruments, like dedicated aortic robotic clamps, are available so far.

Identification and control of lumbar arteries before opening the aneurysm sac is another key element in the safety of these operations, as uncontrolled bleeding from these can cause major issues. Preoperative imaging and image fusion could play a major role in this topic. There is an extensive need for further research in this regard.

Despite these concerns, Stadler and Lin have published case series with successful surgeries and acceptable operation times, when compared to laparoscopy, with improved clamping times and tolerable bleeding [ 32 , 33 , 34 , 35 , 36 ]. The latest report from Dr. Stadler included 61 patients operated on for aortoiliac aneurysms. The median operation time was 253 min (range, 185–360), the median clamping time was 93 min, and the anastomosis time was 31 min. Conversion to laparotomy was required in eight cases (13%), and median blood loss was 1210 ml. The median hospital stay was 7 days [ 36 ]. Although reported numbers prove that robot-assisted reconstruction is feasible and can be performed with good results, most of the studies come from a few centers and a relatively small number of cases. Further studies are needed to assess the place of robotic surgery in this field as well as to prove whether it has comparable results to open reconstruction and endovascular approaches.

Aortoiliac occlusive disease (AIOD)

There is extensive literature on the results of robotic aortic reconstruction with the indication of AIOD, but mostly from a few centers [ 36 ]. Wisselink and colleagues were the first to publish a successful aortobifemoral bypass with robotic assistance in 2002 [ 37 ]. Later, in 2009 Martinez et al. published the first totally robotic aortobifemoral bypass surgery [ 38 ].

Stadler reported the largest number of cases. During a nine-year period, 224 patients underwent robot-assisted reconstruction with the indication of AIOD. The median operation time was 194 (range, 127–315) min with a median clamping time of 37 min, of which the median anastomosis time was 24 min. Median bleeding was estimated to be 320 ml and the median length of stay was 5 days. According to pooled data including patients operated on aneurysmal disease, perioperative complications rate was 3% and 30-day mortality 0.3% [ 36 ].

In a recent study, early and midterm outcomes of robotic aortoiliac reconstruction were published. Out of 70 cases, conversion was required in three cases, two of which were because of bleeding complications. Early complications occurred in 14 cases, with 10 needing reoperation. Mortality was 1.4% (one out of 70 patients). Primary patency at 12 and 48 months was reported to be 94% and 92%, respectively, while secondary patency was 100% and 98.1% [ 39 ]. Although the above-mentioned results suggest that the operation is feasible and safe, and provides appropriate mid-term durability, it did not reach widespread acceptance; only a few centers made attempts with the technique due to partly technical problems such as missing dedicated vascular instrumentation or legal issues [ 39 ].

Furthermore, such as in the case of aortic aneurysms, in the case of AIOD, endovascular procedures have become more and more practiced with relatively low complication rates and acceptable durability, limiting the attention to other minimally invasive alternatives [ 40 , 41 , 42 ].

Robot-assisted thoracofemoral bypass

Thoracofemoral bypass has better patency rates than axillofemoral bypass, but requires a patient who can tolerate thoracic exposure and clamping of the descending aorta. By using robotic assistance, the time taken for the anastomosis can be shortened. However, this procedure is rarely done, due to the narrow group of ideal patients, and to the advances in endovascular therapy [ 43 ].

Robotic treatment of type II endoleak after endovascular aortic repair (EVAR)

Type II endoleak after EVAR can be a challenging diagnosis. Guidelines recommend re-intervention in the presence of sac enlargement during follow-up [ 24 ]. Most treatment options consist of endovascular techniques, but when these fail, open reconstruction may be required.

In a recent meta-analysis, results of eight studies, comprising 196 patients undergoing semiconversion (open conversion with endograft preservation), were analyzed. In 70% the indication was isolated type II endoleak. In 45.8%, previous endovascular attempts were made to close the endoleak. Aortic clamping was not necessary in 92% of the cases, but the sac was opened in 96%, and ligation or suture of the culprit arteries was performed. 30-Day pooled mortality was a non-negligible 5.3% with major systemic complications in 13.4% of the cases. Recurrence of endoleak was seen in 12.6%. Overall survival rate was 84.6% [ 44 ]. EVAR is generally considered a less durable, but minimally invasive procedure than traditional open repair, and thus offered to more frail patients or because of the intent to avoid high surgical risk. Where the reason for EVAR is to avoid complications associated with open repair, an open reoperation is a contradictory choice. When endovascular options fail, less invasive treatment can be provided by robot-assisted techniques.

There are a few small case series with robot-assisted surgery published on this topic. In 2009, Lin et al. presented a case, with successful robot-assisted ligation of the inferior mesenteric artery, which was the source of a type II endoleak, causing sac enlargement in an 84 old male. The total operation time was 249 min, of which 180 min was the time of robotic assistance. The estimated blood loss was only 50 ml. The patient tolerated the procedure well and was discharged home without complications on the 2nd postoperative day. The 3-month follow-up CT scan confirmed the occlusion of the IMA and the stabilization of the aneurysm sac size [ 45 ].

In 2019, Morelli shared their experience with their first two patients who underwent total robotic type II endoleak repair. They reported promising results. The average length of surgeries was 183 min, and average hospitalization was 2.5 days. The operation consisted of two phases: firstly, the ligation of the IMA and then the posterior mobilization of the aneurysm sac to make the selective clipping of lumbar arteries. Preoperative CTA imaging was used for the identification of feeding vessels in these cases. After target ligation was complete verification of the absence of backflow was carried out with a dedicated US probe, inserted through one of the assistant ports [ 46 ].

The above-mentioned literature shows that robot-assisted type II endoleak repair is feasible and safe, but more studies are required to evaluate its potential among other approaches. One of the biggest challenges lies in identifying the correct feeding vessels on preoperative imaging and translating this finding to the robotic platform. Creating an imaging-based navigation system, possibly with the help of augmented reality, could be an answer. Studies on how existing imaging can help intraoperative navigation and orientation are warranted.

Another challenge is finding an efficient method to expose both the left- and right-sided lumbar arteries, or the medial sacral artery, which often presents as a cause of endoleaks. The modified transperitoneal approach described by Stadler et al. is adequate for exposing the left-sided side branches, but going under an often heavily calcified aorta to reach feeding branches on the other side is a risky maneuver, which can easily result in bleeding complications requiring conversion [ 47 ]. Exposing the aorta from the right side is unlikely the answer to this dilemma due to the closeness of the inferior vena cava and the need for redocking and repositioning of ports, which would make the operation significantly longer and more complex. A hybrid approach mixing robotic exposure with endovascular techniques might present a solution, but this area is still in an experimental phase and needs further studies in terms of feasibility and safety.

Robot-assisted splenic aneurysm repair

Splenic artery aneurysm is the most common type of visceral aneurysm, with a prevalence of around 0.8% in the general population. Generally, diameters exceeding 30 mm are to be treated especially in pregnant women (regardless of the size) and symptomatic cases. The first treatment of choice if feasible is an endovascular procedure, but open reconstructions also provide viable options. Laparoscopic or robotic procedures could be proposed if the patient is not a candidate for endovascular treatment and open surgery predicts poor prognosis [ 48 , 49 ].

Median arcuate ligament syndrome (MALS)

In median arcuate ligament syndrome compression of the celiac artery by the interweaving fibers of the two diaphragmatic pillars causes most typically postprandial epigastric abdominal pain, but can also be an incidentally found radiologic sign, often asymptomatic. Prevalence is 2/100,000 patients and it is more common in women, mainly affecting younger patients. Exclusion of other possible causes of abdominal discomfort is usually part of the evaluation [ 50 ]. Traditionally, the solution was carried out via open surgery, then laparoscopy emerged, offering a minimally invasive alternative. However, operating in tight spaces, the need for thorough clearance of the celiac plexus, controlling bleeding, or even performing vascular anastomosis made these surgeries challenging.

A few studies have presented small to medium amounts of cases of MALS release with robotic assistance. All reports show favorable outcomes and technical feasibility with minimal conversion rates and short in-hospital stays, providing good long-term results in terms of symptom relief and decrease of peak systolic velocity during ultrasound control. Re-interventions may be necessary in relatively small numbers [ 50 , 51 , 52 , 53 ].

In a recent case report, a patient who was not a candidate for open surgical reconstruction presented with pancreaticoduodenal and gastroduodenal artery aneurysm with celiac artery compressive occlusion. A three-step procedure was performed, where the robot-assisted release of the celiac artery was followed by stenting of the celiac artery and coil occlusion of the aneurysms [ 54 ].

Comparison of laparoscopic vs. robotic MAL release resulted in an equally effective decrease in measured PSV (peak systolic velocity) on duplex ultrasound postoperatively. Operative times were longer in the robotic group (mean of 86 min vs. 134 min). This could be attributed to the inherent mechanics of the robotic platform and the extended dissection performed in robotic cases. The latter could be associated with significant relief of postprandial symptoms and chronic nausea compared to laparoscopically operated patients. The authors also pointed out that robotic operations required significantly more junior first assistants and less frequently required second assistants, which can balance out the elevated costs of robotic equipment, while helping with the training of young residents [ 55 ] (Fig.  2 ).

A Intraoperative view of the median arcuate ligament (red arrow) causing a visible compression at the origin of the celiac artery. B 3D CTA reconstruction image of the same patient. The yellow arrow marks the compressed celiac artery

Left renal vein transposition for nutcracker syndrome

Renal nutcracker syndrome is a rare phenomenon characterized by the compression of the left renal vein, causing diverse symptoms, but most notably flank pain, hematuria, pelvic congestion syndrome in women, or left varicocele in men [ 56 ]. Consensus on the standard treatment of this phenomenon has not yet been reached. Several treatment options include open surgical or laparoscopic transposition of the left renal vein, kidney auto-transplantation, endovascular procedures, and recently robot-assisted techniques [ 57 ]. Several small case series were published, reporting favorable outcomes with low complication rates and good clinical outcomes in terms of symptom relief [ 57 , 58 , 59 ]. However renal auto-transplantation, even with robotic techniques is not a complication-free procedure and requires careful patient selection and high level of experience [ 56 ]. (Fig.  3 ).

Steps of a robotic renal vein transposition. A Rommel tourniquet on the supra- and infrarenal IVC, right renal vein, and laparoscopic bulldog clamp on the left renal vein and a lumbar vein. B Closing the defect of the IVC after the transection of the left renal vein. C Creation of the cavorenal anastomosis more distally. D Completed transposition of the left renal vein

Robot-assisted IVC filter removal

Whereas the FDA (US Food and Drug Administration) recommends IVC filter removal once the risk of embolization is gone, the retrieval rate is only around 25–30% in the USA [ 60 ]. Endovascular approach is considered the first choice when an IVC filter is to be removed; however, sometimes these attempts are unsuccessful or considered high risk because of possible extrusion of the filer. Robot-assisted surgery can be an alternative to an open approach, providing a minimally invasive solution. Few case series have been published on robot-assisted IVC filter removal, each of which presents good results, with high success rate, low number of postoperative complications, and short length of stay [ 59 , 61 , 62 ] (Fig.  4 ).

Robot-assisted IVC filter removal. In picture A and B protrusion of the filter’s struts can be appreciated on CT imaging, marked with a red arrow. C Intraoperative view of the infrarenal IVC with the protruding struts of the filter

Robot-assisted first rib resection

A case series of 83 patients undergoing robotic first rib resection with the indication of Paget–Schroetter syndrome was presented in 2018. The robot was used for the dissection of the first rib, disarticulation of the costosternal joint, and division of the scalene muscles. The operative time was 127 min (±20 min). Median hospitalization was 4 days, and no surgical or neurovascular complication was reported [ 63 ].

A systematic review comprising 12 studies of 379 patients with TOS suggested that the robotic technique is an effective method in the treatment of TOS. It offers improved exposure, reduced risk of neurovascular injury, and shorter hospitalization [ 64 ].

Robot-assisted nephrectomy and IVC thrombectomy

The gold standard technique of open radical nephrectomy with inferior vena cava (IVC) thrombectomy for renal cell carcinoma presenting with IVC thrombus is more and more challenged by a robot-assisted approach. Since the first published case series in 2011, a growing number of surgeons attempted to adopt the technique with a promise of an equally effective but less invasive approach [ 65 ]. While this procedure involves dissection and even opening of major vessels, it’s mainly performed by urologists, who have mastered specific vascular surgical skills with the robot. In 2022, a meta-analysis evaluating robotic IVC thrombectomies versus open surgeries concluded that the minimally invasive method is feasible, effective, and safe. It is associated with fever perioperative complications, lower postoperative transfusion rates, and shorter in-hospital stays, although it is still a relatively infrequent procedure apart from a few high-volume centers. Most possibly this is due to the considerable complexity of these cases, involving manipulation of major vessels with a significant risk of major bleeding complications [ 66 ].

One of the main challenges of this operation is to acquire control over the main vessels. Temporary occlusion of the IVC can be done by clamps introduced to the abdomen through an assist port or simple stab incision. Another technique is to apply vessel loops circumferentially and then create a modified Rummel tourniquet using a small rubber tube. This can be later reinforced by the application of laparoscopic bulldog clamps.

Kundavaram et al. described a technique when the temporary occlusion of the IVC is obtained by an intracaval 9 Fr Fogarty catheter inserted through a 5 mm assist port into the abdomen. The IVC is punctured, the catheter is introduced, then inflated. The position of the balloon is either confirmed by laparoscopic ultrasonography or transesophageal echocardiography [ 67 ]. Later, this approach was modified by the insertion of a Reliant compliant balloon (Medtronic, Minneapolis, MN, USA) into the IVC through the right internal jugular vein under fluoroscopic and intraoperative ultrasonographic guidance [ 68 ].

Robot-assisted kidney transplantation

Open kidney transplantation is the gold standard of care in end-stage renal disease. Since first performed in 1954 by Doctor Joseph E. Murray, the technique has not changed much.

In the 1990s, advances in minimally invasive surgery warranted the adoption of these techniques in the field of transplant surgery. The first laparoscopic donor nephrectomy was reported by Ratner et al. in 1995, and not much later it gained widespread acceptance and has become the standard technique for kidney donation. Laparoscopy’s adoption into renal implantation on the other hand was challenging. Since the first laparoscopic kidney transplant in 2009, it was rarely performed, because of the challenge of completing intracorporeal vascular anastomosis with instrumentation lacking articulation, limited movement range, and fulcrum effect. This highly demanding task, requiring high levels of expertise in laparoscopy, was difficult to master and this ultimately led to longer warm ischemia times and poor graft function [ 2 , 69 ].

Robotic assistance, however, has helped overcome the difficulties of laparoscopic renal transplantation. Since its first description, it is now becoming more and more accepted and performed. In a meta-analysis published in 2022, it was demonstrated that robot-assisted kidney transplant is safe and feasible, compared to the open approach it is associated with a lower risk of surgical site infection, less postoperative pain, and shorter length of hospital stay, while there is no difference in renal function, graft, and patient survival. It can be especially beneficial for obese patients due to the assessed lower risk of surgical site infections [ 70 ]. A notable limitation of the procedure for now is that most centers exclude all patients with calcified iliac arteries from the robotic approach, while chronic renal insufficiency is notoriously associated with atherosclerosis. This limits the use of this technique in more frail patients who would possibly benefit most from a minimally invasive approach.

Calcification of the arteries creates a change for robotic surgery because of the potential disastrous complications of vascular injury or inefficient clamping. In an experiment conducted by Le et al. in 2013, it was proven that robotic bulldog clamps exerted significantly less clamp force compared to laparoscopic clamps [ 71 ]. This issue could be potentially overcome by developing more robust robotic vascular clamps.

Robot-assisted lung transplantation

In 2023, as reported by Emerson et al., the first robot-assisted lung transplantation was performed successfully. The robot was used for the removal of the recipient’s diseased right lung and after the donor’s lung was inserted into the chest, the bronchial and the left atrial anastomosis were created with robotic assistance. The pulmonary artery anastomosis was then performed under direct vision due to the longer ischemic time at that point. The patient recovered without any major adverse events and was discharged on the 11th postoperative day. Since then, several more robot-assisted lung transplants have been performed by the team [ 72 ].

Portal vein reconstruction in robot-assisted pancreaticoduodenectomy

Pancreatic cancer is widely recognized as one of the most vicious tumors, with only 5% combined 5-year survival rate. Although surgical therapy is the most effective treatment, a minority of the patients are candidates for it, due to locally invasive disease or the presence of distant metastasis. Pancreaticoduodenectomy (PD) as described by Whipple in 1935 is the gold standard procedure for pancreatic head tumors to this day. It is considered one of the most complex surgeries of the alimentary tract due to the challenge of careful dissection along critical vascular structures and then the restoration of the enteric continuity, requiring three anastomoses (pancreaticojejunostomy, hepaticojejunostomy, and gastrojejunostomy). This demanding operation has high morbidity and mortality rates even at high-volume centers [ 73 ]. Like in the case of many previously described areas, laparoscopy could not gain widespread popularity, although it was first described more than 20 years ago [ 74 ]. The technically challenging requirement of retroperitoneal dissection in close proximity to major vascular structures and the need to perform the reconstruction with laparoscopic instruments made it difficult to master this procedure. Robot-assisted surgery promises to overcome many boundaries of the traditional minimally invasive approach.

When the tumor involves the superior mesenteric or portal vein, portomesenteric resection is now considered the standard of care. A patient is considered a candidate for robotic PD in case of venous involvement is less than 180° circumferentially and the vein is patent [ 75 , 76 ]. After resection is complete, reconstruction is required, which is an essentially vascular surgical procedure, performed with robotic assistance. According to the International Study Group of Pancreatic Surgery (ISGP) classification, types of vein resection can be divided into four categories. Type 1 resection means a small side wall resection, which can be closed with direct suture. In case of type 2 resection, patch closure is required. In the case of type 3 and 4 resections, a complete segmental resection is required, which can be reconstructed with direct repair in the former, and only with interposition in the latter. If the resection involves the splenomesenteric junction, the surgeon has to sew in a mini-Y graft with three robot-assisted anastomoses to preserve the flow [ 76 ]. This requires high-level vascular surgical skills and can be easily considered a “vascular” operation.

Robotic coronary artery bypass grafting

Although the first reported endoscopic bypass grafting was performed in 1998, by a French group, this approach faced similar criticism as other vascular surgical procedures [ 77 ]. These were the lack of haptic feedback, steep learning curve, high costs, lack of standardized training, concerns regarding the conversion rates, difficulties of creating multi-vessel revascularization, and long-term durability [ 78 ]. Recently, Balkhy et al. published their experience with totally endoscopic coronary artery bypass (TECAB) in 544 patients. 56% had multi-vessel revascularization and 242 patients underwent hybrid revascularization. Only one patient required conversion with sternotomy due to bleeding and there were six reoperations (1.1%) with four requiring sternotomies. Early mortality was 0.9% and at a median follow-up of 36 months, cardiac-related mortality was 2.4%, with freedom from MACE being 93% [ 79 ].

One of the critical points of TECAB is the creation of vascular anastomosis. There have been proprietary devices developed to ease this procedure, including the C-Port Flex A distal anastomosis device, and the PAS-port proximal anastomosis device (Cardica, Redwood, CA, USA). Utilization of such an anastomotic device significantly shortened operation times, but did not significantly affect patency compared to the sutured approach in a large single-center retrospective analysis [ 80 ].

Transitioning skills learned and devices developed for cardiac procedures have the potential to advance the adoption of vascular surgical procedures in the realm of robotics.

Training pathway to becoming a vascular robotic surgeon

As previously demonstrated, many “vascular” procedures are constantly being performed, many by other specialties; however, vascular surgery performed with robotic assistance is still considered barred by many. Although these procedures have core vascular surgical elements, the current generation of vascular surgeons receive no training in robotics, which also means they lack the skills to solve occasional vascular complications, without the need for a conversion when called into the OR emergently. That is why setting a training pathway for fellows and vascular surgical residents is of paramount importance. Fellows coming to vascular surgery may have basic training in laparoscopy or even robotic surgery; therefore, their expertise in this field can be built upon.

Our current strategy is to focus on individuals having experience with laparoscopy to train them in robotic surgery through a complex pathway. This includes basic robotic training, simulation on the manufacturer’s platform, wet lab practice, and case observations. This is followed by five robotic cases with the supervision of an external proctor. We determined a graduated increase in case complexity, starting from low complexity high-volume cases, such as peritoneal dialysis catheter insertion with lysis of intraabdominal adhesions through gradually more complex cases like venous repairs to highly complex and more demanding operations, like median arcuate ligament release, visceral aneurysm repair, and type 2 endoleak repair after stentgraft placement. This graduality in case complexity along with the increasing volume of cases allows appropriate experience to be gained to handle the more complex procedures. However, neither vascular robotic surgery nor this method has been accepted by the vascular community. We need further discussion and a concurrent position statement on this topic.

Future perspectives of robotic vascular surgery

Future robotic surgical systems could include the following improvements to the current generation of robotic systems. The concept of “master–slave” controls in robotic systems can be reimagined to reflect the levels of surgical autonomy and provide real-time assistance to surgeons with a smart robotic setup and positioning, including a certain level of automation of repetitive surgical tasks [ 81 ]. The current concept of streaming a set of imagery (laparoscopic camera, patient hemodynamics, preoperative imaging) and letting the surgeon integrate the relevant procedural stage-specific information could be adapted to a surgical-state intelligence system that provides integrated imaging, sensing, and feedback to the surgeon in the console. This could include better visualization of preoperative and intraoperative 3D imagery using novel image visualization systems [ 82 ]. Integration of intraoperative imaging systems for real-time visualization of robotic devices and changes in vascular anatomy can be adopted to improve imaging, visualization, and ‘integrated navigation” of future robotic systems [ 83 ]. Real-time image processing systems can impact how intraoperative imagery is generated and visualized during surgical procedures. This could include automatic tissue/target organ recognition and delineation of surgical tools/steps and complications using machine-learning algorithms. The major difference between conventional open surgery and robotic-assisted laparoscopic surgery is the lack of tactile sensation. Latest-generation robotic systems have been exploring the added clinical value of providing tactile feedback to the user using sensors and trackers built into the robotic instrument [ 84 ]. Automated recognition of surgical gestures, including quantification of surgical performance could be an insightful way of understanding surgical skills, and potentially optimize surgical performance and predict patient outcomes for robotic surgical procedures [ 85 ].

In the field of robotic surgery, there has been a dramatic improvement in technology, technique, and adoption of a wide array of specialties. In vascular surgery, the robotic approach is still in its infancy, despite many “vascular procedures” being performed by non-vascular specialists. Although this technique holds the promise of delivering the core therapeutic elements of an open approach through a keyhole incision, it is still to be determined whether the same durability can be achieved. Promising data originating from only a handful of centers worldwide. There is still a huge need for dedicated robotic vascular instruments, namely forceps and aortic clamps to be developed. In addition, dedicated robotic surgery training pathways for vascular surgeons have to be developed and embraced by the vascular community.

Data availability

No datasets were generated or analyzed during the current study.

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Balazs C. Lengyel, Ponraj Chinnadurai, Stuart J. Corr, Alan B. Lumsden & Charudatta S. Bavare

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Lengyel, B.C., Chinnadurai, P., Corr, S.J. et al. Robot-assisted vascular surgery: literature review, clinical applications, and future perspectives. J Robotic Surg 18 , 328 (2024). https://doi.org/10.1007/s11701-024-02087-2

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DOI : https://doi.org/10.1007/s11701-024-02087-2

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Expanding horizons in cardiac transplant: efficacy and outcomes of circulatory and brain death donor hearts in a newly implemented cardiac transplant program with limited donor accessibility and a literature review.

1. Introduction

2.1. study design, 2.2. organ procurement and management, 2.3. clinical outcomes, 2.4. statistical analysis, 3.1. dcd and dbd recipients, donors, and basal characteristics of procedure, 3.2. survival and secondary outcomes, 3.3. potential impact of adult dcd in the canarian ct program, 4. discussion, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, acknowledgments, conflicts of interest, abbreviations.

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Groba Marco, M.d.V.; Cabrera Santana, M.; Galvan Ruiz, M.; Fernandez de Sanmamed, M.; Romero Lujan, J.L.; Gonzalez Martin, J.M.; Santana Ortega, L.; Espinar, M.V.; Portela Torron, F.; Peña Morant, V.; et al. Expanding Horizons in Cardiac Transplant: Efficacy and Outcomes of Circulatory and Brain Death Donor Hearts in a Newly Implemented Cardiac Transplant Program with Limited Donor Accessibility and a Literature Review. J. Clin. Med. 2024 , 13 , 4972. https://doi.org/10.3390/jcm13174972

Groba Marco MdV, Cabrera Santana M, Galvan Ruiz M, Fernandez de Sanmamed M, Romero Lujan JL, Gonzalez Martin JM, Santana Ortega L, Espinar MV, Portela Torron F, Peña Morant V, et al. Expanding Horizons in Cardiac Transplant: Efficacy and Outcomes of Circulatory and Brain Death Donor Hearts in a Newly Implemented Cardiac Transplant Program with Limited Donor Accessibility and a Literature Review. Journal of Clinical Medicine . 2024; 13(17):4972. https://doi.org/10.3390/jcm13174972

Groba Marco, Maria del Val, Miriam Cabrera Santana, Mario Galvan Ruiz, Miguel Fernandez de Sanmamed, Jose Luis Romero Lujan, Jesus Maria Gonzalez Martin, Luis Santana Ortega, María Vazquez Espinar, Francisco Portela Torron, Vicente Peña Morant, and et al. 2024. "Expanding Horizons in Cardiac Transplant: Efficacy and Outcomes of Circulatory and Brain Death Donor Hearts in a Newly Implemented Cardiac Transplant Program with Limited Donor Accessibility and a Literature Review" Journal of Clinical Medicine 13, no. 17: 4972. https://doi.org/10.3390/jcm13174972

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