Applications of Reinforcement Learning for Autonomous Surgical Robotics: A Systematic Review

Reinforcement learning (RL) has emerged as a promising approach for autonomous surgical robotic subtasks. Recent advances include deep reinforcement learning (DRL), imitation learning (IL), and vision-language-action (VLA) models. However, current evidence remains fragmented across simulation benchmarks, task-specific demonstrations, and limited clinical studies. Existing reviews primarily focus on RL algorithms, while the broader pathway from algorithm development to clinically deployable surgical autonomy has not been comprehensively synthesised. This PRISMA 2020-guided systematic review examines RL, IL, safe RL, simulation-to-real (sim-to-real) transfer, foundation models, VLA systems, and regulatory readiness in surgical robotics. We searched IEEE Xplore, PubMed/MEDLINE, Embase, Scopus, Web of Science, the Cochrane Library, ACM Digital Library, arXiv, and medRxiv for studies published between January 2015 and March 2026, with additional studies identified through backward citation tracing. Eligible studies proposed novel RL, imitation learning, or foundation-model approaches for surgical robotics with empirical validation in simulation or on physical robotic platforms. Two reviewers independently extracted data using a predefined coding scheme, and a third reviewer resolved disagreements. Owing to substantial heterogeneity in platforms, tasks, and outcome measures, a quantitative meta-analysis was not feasible; therefore, the evidence was synthesised narratively using a comparative framework. A total of 220 studies met the inclusion criteria, covering eleven active surgical RL platforms, seven paired sim-to-real studies, emerging foundation-model architectures, and three FDA-cleared robotic systems exhibiting Level 3 autonomy. Available comparative studies suggest that hierarchical approaches can outperform flat policies in long-horizon tasks, while language-conditioned models demonstrated promising multi-step surgical capabilities. Seven paired simulation-to-real studies were identified, encompassing tissue retraction, guidewire navigation, and surgical cutting tasks. Sim-to-real performance gaps varied substantially by task and metric, with success-rate gaps ranging from -10 to 50 percentage points (negative values indicating better real-world than simulated performance), while paired mean spatial errors differed by at most 0.61 mm. Most studies employed domain randomization or visual domain adaptation; hierarchical reinforcement learning demonstrated advantages over flat policies in multi-step surgical tasks. Explicit safety-constrained methods (CPO, CBF, and SER), formal verification, and regulatory-aligned evaluation were reported in fewer than 3% of applied studies. Most evidence remained simulation-based, with no reported autonomous RL execution in vivo in humans. Overall, RL-based surgical robotics appears mature at the simulation stage but remains preclinical for autonomous clinical deployment. Future progress requires stronger sim-to-real validation, multimodal safety-aware architectures, alignment with IEC 62304, ISO 14971, FDA guidance, and the EU AI Act, and open benchmarks that jointly evaluate performance, safety, and surgeon trust.