This literature review, authored by Dr. Reza Lankarani, offers a comprehensive overview of current trends and challenges in modern surgery. It highlights significant issues such as the variable quality of evidence in surgical literature, with a notable lack of high-level evidence, and critical global disparities in access to surgical care, particularly in lower and middle-income countries. The review also examines the burgeoning integration of robotics and AI in surgery, alongside associated adoption barriers, and emphasizes the need for international collaboration to address these complex issues and foster equitable access to advanced surgical practices worldwide.

Access inequality in global surgery is a profound challenge, with basic surgical care remaining out of reach for an estimated 5 billion people globally. This situation is likened to a lack of emergency services in remote areas.

The sources highlight several critical barriers that contribute to this pervasive access inequality:

Unsustainable financing models: Catastrophic expenditures associated with surgical care affect 33 million individuals annually, indicating a severe lack of financial protection. In Low- and Middle-Income Countries (LMICs), only 28% of surgical costs are covered, compared to 89% in high-income countries, where the target for financial protection is 100%.

Workforce shortages: LMICs face significant deficits in surgical personnel, with fewer than 5 surgeons per 100,000 people, far below the World Health Organization (WHO) target of 20 surgeons per 100,000. High-income countries, in contrast, have a much higher surgeon density of 56.2 per 100,000. This disparity also correlates with higher postoperative mortality rates in LMICs (5.8%) compared to high-income countries (0.8%), against a WHO target of less than 1%.

Infrastructure gaps: Despite the WHO Resolution 76.2 in 2023, surgery remains excluded from 70% of national health plans, which severely limits the development of necessary infrastructure for surgical care.

Methodological Tensions and Policy-Practice Misalignment also exacerbate access inequality:

The literature reveals a "persistent evidence hierarchy crisis," where high-impact journals are still dominated by retrospective studies, even as global surgery appropriately emphasizes access equity. This means that while the focus is on equity, the research guiding policy may not always be of the highest rigor, with only 1 in 6 surgical studies meeting gold-standard rigor.

The Lancet's financing recommendations often overlook the realities of micro-implementation, which contributes to the policy-practice misalignment.

The high cost of advanced technologies like the da Vinci 5 surgical robot, at $2 million, remains prohibitive for LMICs, further exacerbating surgical inequities, especially when this amount could fund 100 community surgical clinics.

To address these disparities, several policy and practical approaches are being pursued and recommended:

National Surgical Plans (NSOAPs): These plans are crucial and necessitate local workforce pipelines, such as Ethiopia's "Saving Lives Through Safe Surgery" (SaLTS) program which trains non-physician surgeons, tiered equipment frameworks (like the WHO's 3-tier surgical device list), and outcome-linked financing. Ethiopia has been a pioneer in this regard, being the first in Africa to establish NSOAPs since 2016.

Community-Led Adaptation of Global Models: Mexico's NIHR Global Surgery Unit (GSU) hub in Veracruz focuses on community engagement, adapting models like India's ASHA worker program for rural outreach and translating materials into indigenous languages (e.g., Nahuatl) to overcome linguistic barriers.

International Collaboration and South-South Learning: Mexico's adaptation of India's community health model and Ethiopia's NSOAP influencing neighboring African nations (e.g., Zambia, Rwanda) demonstrate effective south-south learning. North-South mentorship, such as the UK's NIHR funding and technical support for GSU hubs, also plays a role in enabling robust research.

Language Localization: Mexico and Ethiopia prioritize translating surgical guidelines into indigenous languages (e.g., Oromo, Mixtec) to improve accessibility and overcome linguistic barriers.

Policy Recommendations for Policymakers: It is recommended to rebalance innovation portfolios to include scalable solutions (e.g., single-port robotics, AI triage), mandate Level I-II evidence for FDA-cleared surgical devices, adopt "surgical equity impact statements" for new technologies, and expand NIH Study Sections for global surgical health services research. This emphasizes that "The scalpel's future lies not in its sharpness, but in its reach".

These efforts aim to bridge the significant gaps in access to surgical care, ensuring that technological advancements and policy frameworks contribute to equitable access rather than widening existing disparities.

Evidence gaps in global surgery policy refer to the lack of high-quality, rigorous research and data needed to inform effective decision-making, particularly concerning equitable access, technology adoption, and financial sustainability. These gaps pose a significant challenge to bridging innovation with equity in surgical care.

Here's a breakdown of the key evidence gaps identified in the sources:

Prevalence of Lower-Quality Evidence: A review of 273 studies from top surgical journals (JAMA Surgery, International Journal of Surgery, British Journal of Surgery) reveals a significant imbalance in evidence quality.

60% (n=164) of publications constitute Level III evidence, meaning they are based on retrospective cohorts.

In contrast, only 17.6% (n=48) represent Level I evidence, which includes randomized controlled trials (RCTs), considered the gold standard for clinical research.

The average evidence level across these studies is 2.5±0.8, indicating only marginal improvement historically and persistent methodological limitations.

Dominance of Case Series in Specific Fields: In pediatric surgery, an analysis of 327 studies on congenital tracheal stenosis (CTS) shows an overwhelming dominance of single-center case series (93.27%). Furthermore, only 4% of this research addressed key innovation areas like biomechanical airway stents or computational fluid dynamics simulations.

"Persistent Evidence Hierarchy Crisis": The literature points to a "persistent evidence hierarchy crisis". This means that while global surgery appropriately emphasizes access equity, high-impact journals remain dominated by retrospective studies. This creates a "two-tier evidence ecosystem", where resource-rich settings generate incremental technical advances, but fundamental care gaps persist globally, partly due to the lack of robust clinical trial frameworks for modern surgical innovations (e.g., biodegradable tracheal stents).

Lack of Cost-Effectiveness Analyses: A critical evidence gap exists in the absence of cost-effectiveness analyses comparing robotic investments with basic equipment scale-up. This is particularly relevant when considering that the $2 million price tag of a da Vinci 5 surgical robot could alternatively fund 100 community surgical clinics. Without such analyses, it's difficult for policymakers to make informed decisions about resource allocation that truly support equitable access.

Impact on Decision-Making: For patients and the public, this translates to a critical issue: only 1 in 6 surgical studies meets gold-standard rigor, meaning many decisions rely on limited data.

To address these significant evidence gaps, policymakers are advised to:

Mandate Level I-II evidence for FDA-cleared surgical devices. This would ensure that new technologies are rigorously evaluated before widespread adoption.

Expand NIH Study Sections for global surgical health services research. This would help generate more high-quality research focused on the unique challenges and needs of global surgical health.

These policy changes are essential to ensure that surgical care advancements are based on robust evidence and contribute to equitable access rather than widening existing disparities.

Global Surgery Policy is a critical area that addresses access to surgical care, financing, infrastructure, and workforce development globally.

Here's a discussion of global surgery policy based on the provided sources:

Critical Barriers to Surgical Care Access

A review of "Global Surgery Policy Priorities" identifies three major barriers to accessing surgical care:

Unsustainable financing models: Catastrophic expenditures affect 33 million annually. Workforce shortages:

Low- and middle-income countries (LMICs) have fewer than 5 surgeons per 100,000 people.

Infrastructure gaps: Despite the WHO Resolution 76.2 (2023), surgery remains excluded from 70% of national health plans.

Global Surgery Metrics Comparison

The sources provide a comparison of key indicators:

Surgeon Density/100,000: In high-income countries, it's 56.2, while in LMICs, it's 3.8. The WHO target is 20.

Postoperative Mortality: High-income countries have 0.8% postoperative mortality, whereas LMICs experience 5.8%. The WHO target is less than 1%.

Financial Protection: 89% of surgical costs are covered in high-income countries, compared to only 28% in LMICs. The target is 100%.

Methodological Tensions and Policy-Practice Misalignment

The literature indicates a "persistent evidence hierarchy crisis," where high-impact journals are still dominated by retrospective studies, even as global surgery appropriately emphasizes access equity.

Financing Recommendations: The Lancet's financing recommendations often overlook the realities of micro-implementation.

National Surgical Plans: These plans necessitate:

Local workforce pipelines, such as Ethiopia's SaLTS program, which trains non-physician surgeons.

Tiered equipment frameworks, like the WHO's 3-tier surgical device list.

Outcome-linked financing.

Cost-effectiveness Analyses: Current literature is lacking cost-effectiveness analyses that compare robotic investments with basic equipment scale-up.

Key Issues for Patients and the Public

Despite modern surgery becoming safer and more precise through technology, three key issues persist:

Access Inequality: Basic surgical care is out of reach for 5 billion people, akin to a lack of emergency services in remote areas.

Evidence Quality: Only 1 in 6 surgical studies meet gold-standard rigor, meaning many decisions rely on limited data.

Cost vs. Value: While robots facilitate minimally invasive procedures, their $2 million price tag could alternatively fund 100 community surgical clinics.

Global Surgery Representation and International Collaboration

Research highlights international collaborations from various countries:

Mexico: Focuses on community-led adaptation of global models, with a NIHR Global Surgery Unit (GSU) hub in Veracruz. Initiatives include implementing India's ASHA worker model for rural outreach, adapting materials into indigenous languages (e.g., Nahuatl), and partnering with industry (e.g., Sempra, Nuvoil) and support groups (e.g., Grupo Reto, AMANC) for health workshops and cancer patient guidance.

Ethiopia: A pioneer in policy-driven research, spearheading "Saving Lives Through Safe Surgery" (SaLTS) and being the first in Africa to establish National Surgical Obstetric Anesthesia Plans (NSOAPs) since 2016. There's an upcoming research summit in November 2024 to address urban-rural workforce disparities and surgical infrastructure gaps. Ethiopia is also part of the Southern African Development Community (SADC) surgical partnership, harmonizing standards.

Turkey: Serves as a nexus for Euro-Asian knowledge exchange, hosting multiple surgery conferences in August 2025 (e.g., Istanbul) focusing on minimally invasive techniques and surgical AI. Turkey contributed to global ENT research during COVID-19 and participates in training initiatives with European colleges for joint training programs.

Saudi Arabia: An emerging scholarly influence, ranked among top Middle Eastern contributors to ENT surgery research during COVID-19. Saudi Arabia is a key sponsor of August 2025 surgery conferences in Riyadh, emphasizing robotic surgery and disaster response in resource-limited settings.

Cross-Cutting Themes in International Collaboration:

South-South Learning: Mexico adapts India's community health model, and Ethiopia's NSOAP influences neighboring African nations.

North-South Mentorship: The UK's NIHR provides funding and technical support for GSU hubs, enabling Randomized Controlled Trials (RCTs) like CHEETAH.

Digital Equity Gaps: LMIC representation in social media engagement for global surgery remains low (only 1.4% of posts originated from Mexico or Ethiopia).

Industry-Academia Synergy: Saudi energy sector funds surgical robotics research, and Mexican industry partnerships scale health interventions for workers.

Future Directions and Challenges:

Language Localization: Mexico and Ethiopia prioritize translating surgical guidelines into indigenous languages (e.g., Oromo, Mixtec) to improve accessibility.

Climate Resilience: Integrating surgical care into climate-disaster response, inspired by WHO's 2023 Resolution 76.2.

Equitable Publishing: Addressing bibliometric disparities; for instance, Ethiopia produced 27 ENT surgery publications (2020–2021) versus 1,616 from the US.

Recommendations for Colleagues and Policymakers:

To bridge innovation with equity and foster ethically grounded technology adoption, policymakers must:

Rebalance innovation portfolios to include scalable solutions (e.g., single-port robotics, AI triage).

Mandate Level I-II evidence for FDA-cleared surgical devices.

Adopt "surgical equity impact statements" for new technologies.

Expand NIH Study Sections for global surgical health services research.

These policy considerations emphasize that "The scalpel's future lies not in its sharpness, but in its reach".

Dr Reza Lankarani, General Surgeon

Founder | Surgical Pioneering Newsletter and Podcast Series

Editorial Board Member | Genesis Journal of Surgery and Medicine

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