Innovation, cost, and evidence: a critical appraisal of robotic surgery in head and neck and endocrine surgery : A structured critical review of the evidence, with attention to lower-resource settings.

Robotic platforms have expanded rapidly across head and neck and endocrine surgery - from transoral robotic surgery (TORS) for oropharyngeal cancer to remote-access thyroid and parathyroid approaches - often driven by patient demand, hospital branding, and industry marketing rather than by evidence, with particular equity implications in lower- and middle-income countries (LMICs). We conducted a structured critical review of the highest-level available evidence, identified from PubMed/MEDLINE and the Cochrane Library and by reference-list hand-searching up to mid-2026, prioritising randomised controlled trials, systematic reviews and meta-analyses, large cohort studies, health-economic analyses, and multisociety consensus statements. Because the clinical questions span oncologic, functional, economic, and health-systems domains, evidence was synthesised narratively and graded by level within each domain. Across indications, robotic surgery demonstrates outcomes equivalent to - not superior to - conventional surgery. Level I randomised evidence exists for oropharyngeal TORS, whereas robotic thyroidectomy and parathyroidectomy rest on observational series subject to selection bias. The principal demonstrated benefits are cosmetic for remote-access thyroidectomy and avoidance of open access for selected TORS. Formal cost-effectiveness analysis shows robotic approaches frequently exceed accepted willingness-to-pay thresholds, especially in LMICs, where robot-free alternatives such as the transoral endoscopic thyroidectomy vestibular approach (TOETVA) are relevant. A four-pillar value-based framework - oncologic outcomes, functional outcomes, patient-reported outcomes, and cost-effectiveness - supports selective, transparent, case-by-case adoption rather than uncritical uptake.