Viewpoint 

Laparoscopic Deskilling—The Hidden Risk of Robotic Dominance

Enrico Pazzaglia, Tommaso Violante, Matteo Rottoli, et al

JAMA Surg Published Online: July 29, 2026

doi: 10.1001/jamasurg.2026.3048

Robotic surgery has revolutionized minimally invasive procedures over the last 2 decades. However, its rapid adoption now may inadvertently contribute to the erosion of foundational laparoscopic skills, not just among trainees, but also among experienced surgeons. Since their introduction, robotic platforms have carried well-documented advantages, such as wristed instruments, 3D visualization, and tremor filtration, addressing several technical limitations of conventional laparoscopy and igniting a surge in adoption across multiple surgical specialties.¹ Data from the American College of Surgeons National Surgical Quality Improvement Program for 2012 to 2023 project that robotic colectomy will surpass laparoscopic colectomy by 2026, with similar trends in proctectomy, pancreatectomy, and esophagectomy.² Critically, robotic adoption was associated with a 2:1 replacement of laparoscopic over open procedures, confirming that robotics is cannibalizing existing minimally invasive surgery (MIS) volume, not merely converting open cases.¹ While robotic growth will eventually plateau, the true threat is the current transitional period, where laparoscopic case volumes are falling faster than robotic access is expanding.

This Viewpoint discusses the potential implications of this trend and calls for strategies to preserve laparoscopic proficiency amid robotics’ surge.

In surgical practice, deskilling refers to the progressive deterioration or complete loss of previously acquired motor, cognitive, and procedural abilities when they are not regularly applied.³ This concern is not unprecedented: the transition from open to laparoscopic surgery generated analogous worries about the erosion of open surgical competency, and those lessons should directly inform how we approach the current robotic transition. While technological advancement naturally shifts surgical skill sets, deskilling becomes a critical patient safety concern when surgeons become overly reliant on highly specialized, automated platforms at the expense of versatile, foundational techniques.

Several mechanisms may contribute to laparoscopic skill decay. Conventional laparoscopy requires advanced spatial reasoning to compensate for the fulcrum effect of rigid instruments and limited depth perception associated with 2-dimensional (2D) visualization. It also relies heavily on tactile cues transmitted through the instrument shaft, which help guide tissue handling and dissection. Robotic platforms fundamentally alter these sensory and motor demands, providing enhanced 3D visualization of the operating field, improved ergonomics, and intuitive instrument manipulation. When the specific psychomotor pathways and muscle memory required for standard laparoscopy are not routinely exercised, proficiency may decline, leaving the surgeon vulnerable when traditional techniques are unexpectedly required. Crucially, initial indirect evidence demonstrates that this vulnerability affects even experienced surgeons. An international multicenter crossover study using force-sensing instruments showed that when expert surgeons transitioned from robotic to laparoscopic surgery, tissue handling forces increased by 46%, an objective biomechanical measure of performance variation that persisted even with extensive prior laparoscopic experience.⁴ Additionally, a comprehensive review of 37 studies demonstrated limited evidence for retrograde skill transfer: with only 3 of 11 studies showing positive skill transference from robotic to laparoscopic techniques, the authors asserted that surgeons trained exclusively on robotic platforms cannot be assumed proficient in conventional laparoscopy.⁵ A randomized trial in novice learners further confirmed this directional asymmetry: laparoscopic training positively transferred to robotic performance, but robotic exposure actively hindered subsequent laparoscopic performance, with significantly increased time and errors.⁶ The deskilling of laparoscopy could have important implications for surgical practice, primarily by threatening the minimally invasive “middle ground.” Modern surgical departments operate in high-demand environments in which robotic systems may occasionally be unavailable because of scheduling constraints, maintenance requirements, or unexpected technical malfunction. In these situations, surgeons must revert to conventional laparoscopy as the primary MIS alternative. When laparoscopic experience has not been recently maintained, this scenario may present a clinical dilemma. Surgeons who feel unable to safely perform a standard laparoscopic procedure may instead directly choose open surgery. Although long-term outcomes may be comparable between approaches, bypassing the intermediate option of conventional laparoscopy may expose patients to avoidable consequences, including increased short-term morbidity, longer hospital stays, and a higher risk of surgical site infection.

Beyond clinical outcomes, economic and equity implications reinforce the concern. Robotic platforms carry substantial capital investments and involve ongoing costs related to maintenance, disposable instrumentation, and prolonged room turnover times. If surgeons lose the ability to perform basic procedures laparoscopically, health care systems will become dependent on robotics even for low-complexity procedures like cholecystectomies or inguinal hernia repair. In institutions with limited access to robotic operating time, this dynamic could prevent its use for complex oncology or reconstructive cases where the platform’s advanced capabilities genuinely add value.

This shift could hurt not only senior surgeons, deskilling a versatile technique vital in resource-limited settings, but also trainees and junior consultants, as the lack of capable mentors and access to adequate laparoscopic experience becomes a structural problem that cannot be resolved at the individual level alone. Allowing foundational laparoscopic skills to decay may contribute to disparities in surgical care, potentially fueling a 2-tiered health care system. Surgeons trained primarily in highly resourced academic environments may have limited opportunities to practice conventional laparoscopy, yet many community hospitals, rural centers, and health systems in low- and middle-income countries continue to rely on the cost-effectiveness and portability of standard laparoscopic equipment. Global surgery initiatives depend on these characteristics, and allowing foundational laparoscopic skills to decay could widen disparities in access to MIS worldwide. Addressing this challenge will require a structural renovation of both surgical education and ongoing professional development, calibrated to the resources and intended practice environment of each institution. Residency programs should continue to preserve laparoscopy as the foundational minimally invasive skill in residency curricula, with trainees required to demonstrate proficiency in purely laparoscopic procedures, mastering fundamental port placement, tissue handling, and intracorporeal suturing before transitioning to robotic training. Postponing robotic training after laparoscopic exposure ensures that residents graduate as competent generalists, capable of functioning in any environment, while also maximizing bidirectional skill acquisition.^5,6

Additionally, surgical departments should protect senior surgeons against deskilling through continued exposure to conventional laparoscopy. This could consist in the implementation of mandatory practice requirements, compelling attendings to log a minimum annual volume of low- to middle-complexity laparoscopic cases, balanced case allocation, simulation-based training, and continuing education initiatives.⁷

Lastly, emerging laparoscopic technology, such as 3D-optics, is also narrowing the ergonomic gap with robotic surgery and may help sustain engagement with conventional laparoscopy.

Looking ahead, the availability and affordability of robotic platforms will likely continue to expand. As these systems become more widely accessible, reliance on robotic approaches may further increase, potentially accelerating the decline in routine laparoscopic exposure regardless of immediate interventions. In the longer term, if robotic technology becomes universally available and economically sustainable across health systems in high-income countries, the reduction of basic laparoscopic practice may no longer represent a major systemic problem. In such a scenario, conventional laparoscopy could assume a role similar to that of open surgery today, remaining an important technical foundation while progressively giving way to newer technological platforms.

However, until that technological horizon is reached, we are navigating a critical transitional period, and the gap between the fully robotic ideal and the current reality of resource constraints and technological limitations is wide. The emerging consensus supports treating laparoscopic and robotic training as discrete competencies requiring deliberate, parallel curricula,^5-7 and maintaining proficiency in laparoscopic techniques is essential for preserving the adaptability and resilience of the surgical workforce, one capable of operating effectively and safely, regardless of the environment, preserving patient outcomes, supporting equitable access to MIS, and sustaining the versatility of modern surgical practice.