Surgical Innovation in the Era of Global Surgery

A Network Analysis

George Garas, MD, FRCS; Isabella Cingolani, PhD; Vanash Patel, MD, PhD, FRCS; Pietro Panzarasa, PhD; Derek Alderson, MD, FRCS; Ara Darzi, MD, KBE, FRCS; Thanos Athanasiou, MD, PhD, MBA, FRCS


Annals of Surgery. 2020;271(5):868-874. 

In This Article

Abstract and Introduction


Objective: To present a novel network-based framework for the study of collaboration in surgery and demonstrate how this can be used in practice to help build and nurture collaborations that foster innovation.

Background: Surgical innovation is a social process that originates from complex interactions among diverse participants. This has led to the emergence of numerous surgical collaboration networks. What is still needed is a rigorous investigation of these networks and of the relative benefits of various collaboration structures for research and innovation.

Methods: Network analysis of the real-world innovation network in robotic surgery. Hierarchical mixed-effect models were estimated to assess associations between network measures, research impact and innovation, controlling for the geographical diversity of collaborators, institutional categories, and whether collaborators belonged to industry or academia.

Results: The network comprised of 1700 organizations and 6000 links. The ability to reach many others along few steps in the network (closeness centrality), forging a geographically diverse international profile (network entropy), and collaboration with industry were all shown to be positively associated with research impact and innovation. Closed structures (clustering coefficient), in which collaborators also collaborate with each other, were found to have a negative association with innovation (P < 0.05 for all associations).

Conclusions: In the era of global surgery and increasing complexity of surgical innovation, this study highlights the importance of establishing open networks spanning geographical boundaries. Network analysis offers a valuable framework for assisting surgeons in their efforts to forge and sustain collaborations with the highest potential of maximizing innovation and patient care.


As a result of recent technological and computational advances and the exponential rate at which new knowledge is generated, the "lone innovator" model no longer represents a suitable paradigm for scientific production.[1] In the modern world, innovation is increasingly the outcome of a collaborative process.[2] This is especially the case for surgical innovation that has been unfolding at a global scale, within a complex network of international collaborations.[3–5]

The aim of collaborative efforts is the generation of social capital. The definition and generative mechanisms of social capital have long been the subject of debates and controversies within the social sciences.[6,7] Typically, scholars tend to converge on the idea that social capital refers to the value that individuals, groups, or organizations can derive from the underlying social relations.[8] In the context of surgical research, social capital can relate to accessing data, expertise, knowledge, or any other type of resources that become available through specific collaborative patterns and facilitate knowledge creation and innovation.

Surgical innovation networks are complex systems, typically consisting of hundreds or thousands of organizations dispersed across the globe forging various types of relationships with one another.[5] Network science offers a theoretical and methodological backdrop that has recently been widely used to study collaboration and innovation in a variety of fields. However, a network approach to examining surgical innovation has been largely neglected.[9,10]

This study applied network analysis to a real-world global collaboration network in robotic surgery. The aim was to familiarize surgeons with network analysis and demonstrate how this approach can be used to devise effective strategies toward the establishment of partnerships that can enhance research impact, facilitate innovation, and advance patient care.