The World Society of Emergency Surgery has recommended the use of robotic surgery. It is becoming more common in emergency surgery. The benefits are improved instrument articulation, ergonomics, and 3D visualization. Long operative times, elevated cost, and accessibility are some limitations. A large-scale analysis found that robotic surgery has reduced conversion rates and post-operative stays.
This study examines the results of robotic surgery in urgent and emergency procedures by using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The aim is to understand the role of robotic surgery in emergency colorectal surgery and provide evidence-based recommendations for its applications.
This retrospective study analyzed the outcomes of open, laparoscopic, and robotic colectomy performed in emergency settings by using data from the ACS-NSQIP database from January 2012 to June 2021. The inclusion criteria involved studies approved by an Institutional Review Board with the “Targeted Colectomy” file of identified patients. The exclusion criteria were ambiguous or missing operative data. Emergency cases were determined by special database variables and clinical criteria. Patients were divided into robotic, laparoscopic, and open groups. The main outcomes involved the rate of overall, surgical, and medical complications, hospital stay duration, and conversion to open surgery. Secondary results used the Vector Autoregressive (VAR) models to examine the time pattern for surgical methods and predict future trends. Classification and Regression Trees (CART) are used to assess decision-making factors that influence surgery.
Statistical analyses were done by generalized linear models to address overdispersed data, along with full-match propensity score method, logistic regression, and g-computation to control confounding. Results are intended to evaluate perioperative outcomes across three methods and determine if robotic surgery gives benefits in emergency settings, similar to elective surgery. All statistical analyses were done using R software.
Of the 83,483 patients who underwent emergent or urgent colorectal surgery, 53,731 went for open surgery, 26,649 had laparoscopic procedures, and 3103 went for robotic surgery. Robotic cases had an increased rate of obesity (41.6%). Open surgery had increased comorbidities like heart failure (3.5%), bleeding disorders (12.5%), COPD (10.0%), and an increased rate of sepsis shock (12.3%) and sepsis (25.8%) vs robotic surgery (0.2% shock, 2.4% sepsis). Operative times were long in robotic surgery (223 minutes), then laparoscopic (163 minutes), and open surgery (127 minutes). Robotic surgery was performed for diverticulitis (68.4%), open surgery for obstruction (32.6%), and perforation (32.3%).
Time series analysis projected a decline in open surgeries to 43.2% by 2025, and robotics and laparoscopy will increase and 20.2% and 36.5% respectively. Robotics surgery had the lowest complication risk (odds ratio [OR] 0.65, p<0.001, 95% confidence interval [CI] 0.60 to 0.72), and open surgery had the highest (OR 2.04, p<0.001, 95% CI 1.97 to 2.12). Medical complications followed the same patterns: robotic surgery exhibited reduced risk with laparoscopy (OR 0.79, p=0.005, 95% CI 0.68 to 0.93) and open surgery had elevated risk (OR 1.62, p<0.001, 95% CI 1.54 to 1.70).
Robotic surgery was associated with a shorter length of stay (LOS) (incidence rate ratio [IRR] 0.67, Incidence rate ratio, 95% CI 0.65 to 0.69) as compared to laparoscopic and open surgery, which had the longest LOS (IRR 1.31, p<0.001, 95% CI 1.29 to 1.32). Unadjusted rate of conversion to open surgery was significantly lower for robotic procedures (7.8%) compared to laparoscopic procedures (24.2%).
Robotic surgery is an advantageous and viable method for emergency colorectal surgery with decreased conversion rate and improved postoperative outcomes compared to open and laparoscopic surgery. The technical benefits of robotic surgery persist in complex cases. The projected elevation in robotic utilization is to 20.2% of emergency colorectal procedures by 2025. Successful implementation requires addressing issues such as 24/7 availability of skilled multidisciplinary teams, fast setup protocols, and longer operative times.
Reference: Ferrari D, Violante T, Novelli M, Sassun R, Sileo A, Larson DW. Robotic Surgery in Emergency Colorectal Procedures: Analysis of Outcomes and Future Trends. J Am Coll Surg. doi:10.1097/XCS.0000000000001500
