Abstract
Robotically assisted operations are the state of the art in laparoscopic general surgery. They are established predominantly for elective operations. Since laparoscopy is widely used in urgent general surgery, the significance of robotic assistance in urgent operations is of interest. Currently, there are few data on robotic-assisted operations in urgent surgery. The aim of this study was to collect and classify the existing studies. A two-stage, PRISMA-compliant literature search of PubMed and the Cochrane Library was conducted. We analyzed all articles on robotic surgery associated with urgent general surgery resp. acute surgical diseases of the abdomen. Gynecological and urological diseases so as vascular surgery, except mesenterial ischemia, were excluded. Studies and case reports/series published between 1980 and 2021 were eligible for inclusion. In addition to a descriptive synopsis, various outcome parameters were systematically recorded. Fifty-two studies of operations for acute appendicitis and cholecystitis, hernias and acute conditions of the gastrointestinal tract were included. The level of evidence is low. Surgical robots in the narrow sense and robotic camera mounts were used. All narrow-sense robots are nonautonomous systems; in 82%, the Da Vinci® system was used. The most frequently published emergency operations were urgent cholecystectomies (30 studies, 703 patients) followed by incarcerated hernias (9 studies, 199 patients). Feasibility of robotic operations was demonstrated for all indications. Neither robotic-specific problems nor extensive complication rates were reported. Various urgent operations in general surgery can be performed robotically without increased risk. The available data do not allow a final evidence-based assessment.
Keywords: General surgery, Minimally invasive surgery, Robotic surgery, Emergency surgery, Urgent surgery
Introduction
Laparoscopic interventions are established in general surgery for urgent, acute diseases of the abdominal organs. For acute appendicitis and cholecystitis, laparoscopic operations are the standard of care and are recommended in guidelines [1, 2]. Many surgical departments also operate on gastrointestinal perforations, incarcerated hernias and bowel obstruction laparoscopically on a regular basis.
However, robotic surgery has been an integral part of general surgery for over two decades and is becoming increasingly widespread. From 2012 to 2018, an increase in general surgical robotic interventions by more than a factor of 8 was described, reaching up to 15.1% of all general surgical operations in the USA [3]. This raises the question of the significance of robotic surgery in urgent surgery. Recently, this led to the publication of a position paper by the World Society of Emergency Surgery (WSES) [4].
We can distinguish two groups of robots as follows: surgical robots (SRs) in a narrower sense and robotic camera mounts (RCMs). SRs in the stricter definition are nonautonomous systems, which are controlled by a surgeon via a console. The main representative of this group of robots is the Da Vinci® system from Intuitive Surgery Inc. (Sunnyvale, CA, USA) since the products from Computer Motion (ZEUS, AESOP; Santa Barbara, CA, USA) were discontinued after Computer Motion and Intuitive merged in 2003. Recently, the Da Vinci® system has faced competition from other manufacturers (e.g., CMR Surgical Versius®, Cambridge, UK; Hugo®, Medtronic, Dublin, Ireland; and Microhand S, China; Dexter®, Distalmotion, Switzerland).
A number of advantages are accredited to robotic surgical systems as follows: systems such as the Da Vinci® system should help to overcome the disadvantages of laparoscopic surgery, such as physiological tremors and restricted degrees of freedom. RCMs, such as Soloassist® II (AKTORmed, Barbing, Germany), promise the liberation of the physician acting as a surgical assistant. However, these operations are very similar to “classic” laparoscopy. All robotic systems also advertise improved ergonomics and optimized visualization. Whether these properties lead to advantages over traditional laparoscopy is the subject of debate. All robotic systems are theoretically predisposed for technical malfunctions that may cause harm to the patient. Several publications report on better outcomes of robotic surgery, e.g., conversion rates, morbidity (including postoperative ileus) and postoperative stay in colorectal surgery [5, 6]. However, almost all publications examine elective operations. Against the background and known advantages of laparoscopic operations in urgent operations, the possible benefit of surgical robots in urgent general surgery must be examined and discussed. The aim of this review is to analyze and classify the available data on this topic.
Methods
Literature search
Two of the authors (AR and JL) independently searched PubMed (1980-present) and the Cochrane Library (1980-present). The systematic review was performed according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines [7].
A two-stage analysis was conducted. First, a preliminary search and screening of 500 results was performed on October 26th and 27th, 2020, to elaborate the principles of the further analysis. The results of this first search indicated that the number of publications of interest was very limited. Therefore, we decided to include case reports and case series in the systematic analysis. Furthermore, this first search showed a massive heterogeneity of data. To give the reader a full overview of the topic, we decided not to attempt a meta-analysis since a meta-analysis would have limited the useable studies to only a few. A strict systematic review or a meta-analysis would necessarily have meant that most urgent surgical diseases could not have been analyzed. The primary goal of this work, however, was to cover robotic-assisted operations in urgent surgery as broadly as possible, which was only possible through a partially descriptive evaluation.
The second definitive search was run on December 31st, 2021.
The following search terms were used in combination with “robotic” and “robotic surgery”: adhesiolysis, appendectomy, appendicitis, bowel obstruction, cholecystectomy, cholecystitis, diverticular disease, diverticulitis, hernia, incarceration, perforation, peritonitis, ulcer, urgency and emergency (Appendix 1).
The search terms were partially truncated to include as many grammatical variables as possible.
Inclusion criteria
All studies, case reports and case series describing urgent general and visceral surgical procedures in connection with robotic surgery were included. Manuscripts were included in which typical general or visceral surgical operations were described; inclusion was not decided by which specialty the operation performed. If study populations were published multiple times, the more recent publication was included.
Exclusion criteria
Publications that did not report the original data were excluded, as were those with overlapping study populations (see above). Urological, gynecological or vascular surgery emergency interventions were excluded. Reports on the thoracoscopic robotic treatment of diaphragmatic hernias were also excluded. If the full text was not available, the study was also excluded.
Evaluation
If the specified information was extractable, complications were classified according to the Clavien–Dindo classification, whenever applicable [8]. In all other cases and biliary complications in cholecystectomies, the complications were mentioned separately.
Outcomes of interest
All included manuscripts were examined with a focus on the following factors: (a) primary objective of the study and technical aspects, (b) complications (see above) and whether these complications could be related to the use of the robot, (c) pros and cons of the use of the robotic operation, (d) financial aspects, (e) factors related to the acute/urgent situation and (f) further outcomes of interest.
Results
The literature search resulted in a total of 3072 (+ 5, see below) findings, of which 219 were eliminated (duplicates, letters, replies, guidelines, etc.). A total of 2853 papers were analyzed. The review of the references of the analyzed full texts led to the inclusion of five additional studies. A total of 2645 publications were excluded since the title and/or abstract did not meet the inclusion criteria. The full texts of 208 studies met the criteria and were further analyzed. No unpublished studies were obtained. The full-text analysis revealed that 155 of these studies did not contain data of interest for this review, and one full text was unavailable. Three similar case reports were combined into a case series [9–11]. In total, 52 studies were included, five of which were evaluated for more than one indication (Fig. 1) [12–16]. Apart from one paper on a spleen hematoma, all reports on urgent robotic operations could be assigned to four classic general surgical fields: appendectomies, cholecystectomies, hernias (partly with intestinal obstruction) and gastrointestinal procedures [15].
Of the included papers, 15 were case reports or case series. None of the studies were randomized, and 24 were controlled. Six studies were prospective, and the remaining studies were retrospective [17–22]. Only four retrospective and none of the prospective studies explicitly examined urgent robotic operations, and two of these were controlled studies [23–26].
Two studies focused on the use robotic camera mounts (RCM), and they included 302 urgently operated patients [14, 21]. All other 50 studies examined the use of surgical robots in the narrow sense (SR). In these studies, 955 urgently operated patients were included. A total of 655 of these patients (68.6%) were treated using the Da Vinci® system (41 studies, 82% of the SR studies). Hosein et al. and Gangemi et al. did not specify the type of SR, and the 261 patients included in their studies accounted for 27.4% of the SR patients [27, 28]. An alternative SR was utilized in only 39 operations (3.6%).
Complication rates were listed in all but one study, but with varying degrees of accuracy [29]. Some studies reported complications only above a certain degree of severity, i.e., Clavien–Dindo grade ≥ 3. It should be noted that only 22 of the 52 studies differentiated whether the complication occurred in the subgroup of emergency robotic procedures, and 12 of these were case reports. In most of the included studies, only the complication rate of the entire robotic group was listed. In addition, there was no strict distinction between intra- and postoperative complications, while the follow-up periods differed greatly.
Since urgent operations were neither an interest, endpoint nor variable in the majority of the studies, evidence grading, e.g., the Newcastle–Ottawa Quality Assessment Scale, cannot be applied meaningfully. Regarding urgent operations, the levels of evidence for almost all included studies must be assessed as low, which was true particularly for case series and case reports. One paper was excluded because it was a duplicate publication of a more or less identical patient group [26].
Appendectomies
Seven papers reported on urgent appendectomies using robotic surgery in a total of 196 patients (Table 1). The vast majority of patients (n = 185) were analyzed in two studies, both using RCM. Three more publications were case reports or case series. As a result, only 11 patients were urgently appendectomized using an SR. No complications or conversions were reported.
Table 1.
References | Study design | Outcome | Further notes | |||||||
---|---|---|---|---|---|---|---|---|---|---|
Design | Study period |
n (urgent, robotic) |
n (non-urgent) | Primary study objective | Robot | Differentiated urgent vs. non-urgent | Complications conversions |
Further outcomes of interest | ||
n (other) | ||||||||||
Cadiére et al. [16] | R-NRNC | 3/1997–2/2001 | 1 | – | Feasibility | Da Vinci | No | No complications | See also cholecystitis | |
145 | No conversions | |||||||||
Kelkar et al. [22] | P-NRNC | 3/2019–4/2019 | 4 | – | Feasibility | Versius | No | No complications | ||
26 | No conversions | |||||||||
Kibar et al. [51] | CR | n.d | 1 | – | – | Da Vinci | Yes | No complications | Appendicovesical fistula | |
– | No conversions | |||||||||
Mittal et al. [21] | P-NRNC | n.d | 22 | – | Feasibility/usefulness |
FreeHand RCM |
No | No complications | Liberation of the surgical assistant | |
– | No conversions | |||||||||
Ohmura et al. [14] | R-NRC | 12/2014–3/2017 | 163 | 3 | feasibility |
Soloassist RCM |
No | “No device-related complications” | Liberation of the surgical assistant | See also cholecystitis and hollow organs |
783 | No conversions | |||||||||
Yi et al. [12] | CS | 3/2014 | 2 | – | Feasibility | Micro Hand S | Yes | No complications | See also hollow organs | |
1 | No conversions | |||||||||
Yi et al. [13] | CS | 4/2014–5/2014 | 3 | 1 | Feasibility | Micro Hand S | No | No complications | 2 patients withdrawn | See also cholecystitis and hollow organs |
6 | No conversions |
CR Case report, CS Case series, n.d. not documented, P-NRNC prospective, non-randomized, non-controlled, R-NRC retrospective, non-randomized, controlled, R-NRNC retrospective, non-randomized, non-controlled, RCM Robotic camera mount
The three case reports/case series specified closure of the appendix stump (sutures), and the other studies did not provide any information on this. There were no reports of robotic single-incision appendectomies.
Cholecystectomies
Thirty publications reported on urgent robotic cholecystectomies, none of which were randomized (Table 2). Three studies were prospectively controlled, and 14 were retrospectively controlled. Of the uncontrolled studies, three were prospective, and six were retrospective. Four case reports or case series have been summarized in the table for better clarity [13, 30–32].
Table 2.
References | Study design | Outcome | Further notes | |||||||
---|---|---|---|---|---|---|---|---|---|---|
Design | Study period |
n (urgent, robotic) |
n (non-urgent) | Primary study objective | Robot | Differentiated urgent vs. non-urgent | Complications conversions |
Further outcomes of interest | ||
n (other) | ||||||||||
Ayloo et al. [52] | R-NRC | 9/2005–6/2012 | 45 | 134 | MIRC vs. MILC | Da Vinci | No | 1.7% CD ≥ 3; 1.7% CD < 3” |
3 conversions in MILC; OT longer in MIRC |
|
147 | no conversions | |||||||||
Balachandran et al. [53] | R-NRC | 10/2011–7/2014 | 76 | 339 | SIRC vs. MILC | Da Vinci | No | 1% ileus 0.2% bile leakage |
6.5% hernias in SIRC LOS shorter SIRC |
All performed by 1 surgeon |
263 | 2.9% to MILC, 3.2% to open | |||||||||
Bibi et al. [33] | R-NRNC | 6/2012–1/2013 | 31 | 71 | Safety of SIRC | Da Vinci | No | 4% CD < 3 | 50% of conversions due to inflammation | |
– | 3.9% conversions | |||||||||
Buzad et al. [17] | P-NRC | 1/2012–5/2012 | 2 | 18 | SIRC vs. SILC | Da Vinci | No | No complications | No differences in OT and costs | SILC reviewed retrospectively |
10 | No conversion | |||||||||
Cadiére et al. [16] | R-NRNC | 3/1997–2/2001 | 4 | 44 | Feasibility | Da Vinci | No | 25% (n = 1) CD 2 | See also appendicitis | |
98 | no conversions | |||||||||
Chung et al. [29] | R -NRC | 8/2013–1/2015 | 7 | 63 | SILC vs. MILC | Da Vinci | No | n.d | 2.8% 30 d readmission | |
70 | 1.4% conversion to open | |||||||||
Daskalaki et al. [54] | R-NRNC | 7/2011–2/2013 | 28 | 156 | ICG Cholangio-graphy | Da Vinci | No | 1% CD ≥ 3; 2.2% CD < 3 | cholangiography > 94% | |
– | no conversions | |||||||||
Gangemi et al. [28] | R- NRC | 2008–2015 | 130 | 546 | Risk factors for conversion | n.d | N.d | n.d | ||
289 | 0.15% (n = 1) conversions | |||||||||
Giulianotti et al. [15] | R-NRNC | 10/2000–11/2002 | 7 | 45 | Descriptive; RC vs. LC | Da Vinci | No | 1.9% (n = 1) complications n.d | ||
123 | 1.9% (n = 1) conversions | |||||||||
Gonzalez et al. [55] | R-NRC | 1/2012–9/2012 | 20 | 146 | SILC vs. SIRC vs. SPIDER | Da Vinci | No | 1.2% CD ≥ 3; 0.6% CD < 3 | OT for SIRC longer than SILC/SPIDER | |
335 | No (3 additional incisions) | |||||||||
Honaker et al. [56] | R-NRC | 3/2013–2/2014 | 1 | 17 | MIRC vs. MILC | Da Vinci | No | No complications | LOS shorter MIRC | |
40 | No conversions | |||||||||
Jeong Jang et al. [57] | R-NRNC | 4/2019–8/2020 | 2 (5) | 72 (69) | Feasibility of SIRC | Da Vinci | No | 1.35% CD 1 | 3 acute cholecystitis diagnosed intraoperatively | |
– | No conversions | |||||||||
Kalteis et al. [58] | R-NRC | 4/2002–11/2004 | 20 | 52 | Safety and effectiveness | AESOP | No | 1.4% CD < 3 | Liberation of the surgical assistant | |
72 | No conversions | |||||||||
Konstantinidis et al. [18] | P-NRNC | 3/2011–7/2011 | 4 | 41 | Feasibility and effectiveness | Da Vinci | No | 2.2.% CD 3b, 5.3% < CD 3 | 20% intraoperative gallbladder-ruptures | |
– | No conversions | |||||||||
Kornprat et al. [19] | P-NRC | 2001–2006 | 2 | 18 | MIRC vs. MILC | Zeus | No | No complications | OT longer in MIRC | |
26 | No conversions | |||||||||
Kubat et al. [23] | R-NRC | 5/2012–8/2013 | 74 | 76 | Urgent vs. non-urgent MIRC | Da Vinci | Yes | 12% complications in urgent, incl. 1.5% (n = 1) BD injury |
LOS longer in urgent, overall complications + SSI no differences |
|
– | 1.5% (n = 1) conversions | |||||||||
Kulaylat et al. [36] | R-NRC | 1/2015–12/2018 | 10 | 69 | SIRC/MIRC vs. SILC/MILC | Da Vinci | No | “No differences in complications” | OT longer in robotic, costs higher in robotic | Pediatric patients |
220 | No conversions | |||||||||
Li et al. [42] | R-NRC | 8/2013–12/2015 | 17 | 61 | Safety, resources SIRC vs. MILC | Da Vinci | No | 3.8% < CD 3 (20% in MILC) | 1.9% conversion rate in MILC | OT, LOS and costs higher in SIRC |
367 | No conversions | |||||||||
Mattei et al. [59] | R-NRNC | 2013–? | 1 | 19 | Feasibility in pediatric patients | Da Vinci | No | 20% seromas (CD < 3) | OT longer, LOS shorter | |
– | No conversions | |||||||||
Ohmura et al. [14] | R-NRC | 12/2014–3/2017 | 101 | 172 | Feasibility | Soloassist RCM | No | “No device-related complications” | LOS shorter; liberation of surgical assistant | See also appendicitis and hollow organs |
848 | No conversions | |||||||||
Rosales-Velderrain et al. [60] | P-NRNC | 3/2013–5/2015 | 4 | 10 | Safety, feasibility in pediatric patients | Da Vinci | No | 7% (n = 1) seroma | ||
– | No conversions | |||||||||
Schertz et al. [35] | R-NRC | 8/2013–4/2018 | 3/6 | 101/99 | SIRC vs. MIRC | Da Vinci | No | 1 enterotomy (MIRC), 2.9% hernias (SIRC) | OT, LOS in SIRC shorter | |
– | Excluded | |||||||||
Su et al. [61] | R-NRC | 2/2014–9/2015 | 10 | 41 | SIRC vs. SILC | Da Vinci | No | No complications |
OT in urgent longer Pain lower in SIRC |
|
63 | No conversions | |||||||||
Svoboda et al. [20] | P-NRC | 11/2012–2/2014 | 159 | 112 | SIRC in BMI ≥ 30 vs. < 30 | Da Vinci | No | 0.9% (n = 1), incisional hernia | OT longer in obese patients | Inconclusive data |
– | no conversions | |||||||||
Tao et al. [62] | R- NRC | 1/2006–2/2020 | 13 | 161 | MILC vs. MIRC | Da Vinci | No | 12.3% overall in RC | RC vs. LC CD 1 > , CD 2 < , CD 3 equal, no CD IV | All acute cholecystitis diagnosed intraoperatively |
441 | No conversion | |||||||||
Vidovszky et al. [34] | P-NRNC | 1/2012–1/2013 | 13 | 82 | apPlicability of SIRC | Da Vinci | No | 4.2% CD 3; 2.1% < CD 3 |
One disruption of DC 4 technical problems |
5 inflammations diagnosed intraoperatively |
– | 8.4%; 1 due to inflammation | |||||||||
Case Series Case Reports |
CS/CR | 2001–2021 | 11 | Feasibility | Da Vinci (3), Microhand S (1) | No | No complications | Bustos et al. [31]; Hanisch et al. [30]; Milone et al. [32]; Yi et al. [13] | ||
No conversions |
Only statistically significant differences listed
BMI Body mass index, CD Clavien-Dindo classification of complications [8], CR Case report, CS Case series, DC Ductus cysticus, LC laparoscopic cholecystectomy, LOS length of stay, MILC Multi-incision laparoscopic cholecystectomy, MILC Multi-incision robotic cholecystectomy, n.d. not documented, OT Operation Time, P-NRC prospective, non-randomized, controlled, P-NRNC prospective, non-randomized, non-controlled, RC Robotic cholecystectomy, R-NRC retrospective, non-randomized, controlled, R-NRNC retrospective, non-randomized, non-controlled, RCM robotic camera mount, SI Single-Incision, SILC Single-incision laparoscopic cholecystectomy, SIRC Single-incision robotic cholecystectomy
A total of 804 urgent cholecystectomies were performed with robotic assistance, 101 of them with an RCM. The remaining 703 patients underwent surgical intervention with an SR. The Da Vinci® system was used in 546 (77.7%) patients; the robot type was not reported for 130 patients. One study explicitly analyzed urgent operations as the main interest [23].
Eleven publications reported cholecystectomies using the single-incision robotic technique (SIRC).
The reports of complications differed greatly, as did the follow-up periods (0–6 months). Kubat et al. showed 12% complications in urgent cholecystectomies, including one (1.5%) biliary tract injury [23]. The highest reported complication rate was 20% (including seromas), and 9 studies stated that no complications occurred. The incidence of Clavien–Dindo grade ≥ 3 complications varied between 1.7 and 4.2%. Biliary tract problems (injury, leakage) were demonstrated in three studies, each with one patient. Hernias represented a particular complication of single-site operations; these were described in three studies, with an incidence of 0.9–6.5%. Conversion to a laparoscopic procedure or to open surgery was reported in 7 studies, and two studies indicated that conversion was necessary due to inflammation [33, 34]. In one study, conversions were an exclusion criterion [35]. Six authors reported a prolonged operation time and one reported a decreased operation time in the robotic group compared to laparoscopic cholecystectomies. One study reported higher costs for robotically operated patients [36].
Gastrointestinal procedures
Urgent gastrointestinal operations were investigated in 12 studies (Table 3). There were three studies in this group of topics that specifically investigated urgent operations: Anderson et al., Beltzer et al. and, most recently, Robinson et al. [24, 37, 38]. The publication by Ohmura et al. on the use of an RCM evaluated for appendicitis and cholecystitis also reports on the operation of 16 perforations in the upper gastrointestinal tract [14]. Three very similar case reports of Kudsi et al. were combined into a case series [9–11].
Table 3.
References | Study design | Outcome | Further notes | |||||||
---|---|---|---|---|---|---|---|---|---|---|
Design | Study period | n (urgent, robotic) | n (non-urgent) | primary study objective | Robot | Differentiated urgent vs. non-urgent | Complications conversions |
Further outcomes of interest | ||
n (other) | ||||||||||
Anderson et al. [24] | R-NRC | 2/2015–2/2017 | 6 | – | Urgent subtotal colectomy: robotic vs. Laparoscopic | Da Vinci | Yes | 20% (n = 1) CD 2 | OT longer in robotic | 2 dockings |
13 | No conversions | |||||||||
Beltzer et al. [37] | R-NRC | 10/2013–11/2018 | 2 | 58 | Diverticular disease: robotic vs. Laparoscopic | Da Vinci | No | 15% cd ≥ 3; 15% < 3 | Length of postop ileus in robotic group shorter | Urgency unclear, used: CDD Type 2c |
46 | 1.7% (n = 1) conversions | |||||||||
Felli et al. [63] | CR | n.d | 1 | – | Hemicolectomy for hemorrhagic cancer | Da Vinci | Yes | No complications | Double-barreled ileocolostomy; oncologic resection | |
– | No conversion | |||||||||
Guerra et al. [64] | CR | n.d | 1 | – | Acute large bowel malignant obstruction | Da Vinci | Yes | No complications | Oncological resection of a splenic flexure tumor | |
– | No conversions | |||||||||
Kudsi et al. [9–11] | 3 CR | 2019–2020 | 3 | – | 3 colon resections | Da Vinci | Yes | No complications | All with hand sutured anastomosis | 3 video vignettes |
– | No conversions | |||||||||
Ohmura et al. [14] | R-NRC | 12/2014–3/2017 | 16 | – | Feasibility | Soloassist RCM | No | “No device-related complications” | LOS shorter liberation of surgical assistant | See also appendicitis and cholecystitis |
933 | No conversions | |||||||||
Pedraza et al. [65] | CR | n.d | 1 | – | Iatrogenic colonic perforation; | Da Vinci | Yes | No complications | Primary repair | |
– | No conversions | |||||||||
Robinson et al. [38] | R-NRC | 2015–2019 | 24 | – | Perforated gastrojejunal ulcera | Da Vinci | Yes | 8.3%, median cd-score 2.2 | Complications similar to laparoscopic group | Robotic vs. laparoscopic; higher costs in robotic |
20 | No conversions | |||||||||
Sudan et al. [66] | CR | n.d | 1 | – | Duodenal stump insufficiency | Da Vinci | Yes | No complications | 5 d after BPD-DS, biliary peritonitis | |
– | No conversions | |||||||||
Sun et al. [67] | CR | 3/2014 | 1 | – | Gastric perforations | Microhand S | Yes | No complications | ||
– | No conversions | |||||||||
Yi et al. [12] | CS | 3/2014 | 1 | – | Repair of gastric perforation | Microhand S | No | No complications | See also appendicitis and cholecystitis | |
1 | No conversions | |||||||||
Yi et al. [13] | CS | 4/2014–5/2014 | 1 | – | Repair of gastric perforation | Microhand S | No | No complications | Withdrawal of 2 patients | See also appendicitis and cholecystitis |
7 | No conversions |
Only statistically significant differences listed
BPD biliopancreatic diversion with duodenal switch, CD Clavien-Dindo classification of complications [8], CDD classification of diverticular disease [39], CR Case report, CS Case series, LOS length of stay, n.d. not documented, OT Operation time, RCM Robotic camera mount, R-NRC retrospective, non-randomized, controlled
It remains unclear how many of the 60 robotically operated patients reported by Beltzer et al. were treated in an emergency situation. For this review, we accepted two of the 60 patients with diverticulitis type IIc of classification of diverticular disease (CDD) since they undoubtedly belonged to the group of urgent operations [39]. The study did not distinguish the complications between urgent and elective operations. The overall complication rate was 30%, with percentages of 8.3% for Clavien–Dindo grade 3b complications and 6.7% for anastomotic leakage. One fatality (Clavien–Dindo grade 5), and the need for conversion in another case were described [37]. Anderson et al. listed a complication rate of 20%, though with no further specifications (n = 1) [24]. Robinsons’ primary focus was on a typical urgent operation: perforated gastrojejunal ulcers. He reported noninferiority to the laparoscopic approach but dramatically higher costs for robotic operations. None of the case reports/case series reported any complications.
Hernias/miscellaneous
SRs are commonly used in hernia surgery; however, the urgency of these operations arises from the incarceration of the hernia, which is often associated with intestinal obstruction. We identified eight reports of urgent robotic operations for hernias (Table 4). Four studies retrospectively analyzed urgent hernia operations, two of which were controlled studies [25, 40, 41]. In addition, we identified a database analysis that included urgent robotic hiatal hernia operations [27]. A rare indication for urgent robotic surgery was the operation of posttraumatic splenic bleeding reported by Giulianotti et al. [15]. No reports on the use of an SR in adhesive intestinal obstruction were found.
Table 4.
References | Study design | Outcome | Further notes | |||||||
---|---|---|---|---|---|---|---|---|---|---|
Design | Study period | n (urgent, robotic) | n (non-urgent) | Primary study objective | Robot | Differentiated urgent vs. non-urgent | Complications | Further outcomes of interest | ||
n (control) | Conversions | |||||||||
Bou-Ayash et al. [25] | R-NRNC | 2/2013–5/2020 | 19 | – | Incarcerated inguinal hernia | Da Vinci | Yes | 5.3% CD IVa (n = 1; hypercarbia); 10.6% CD < 3 | ||
– | No conversions | |||||||||
Cubas et al. [68] | CR | n.d | 1 | – | Incarcerated morgagni hernia | Da Vinci | Yes | No complication | ||
– | No conversion | |||||||||
Ceccarelli et al. [69] | CS | 12/2009–12/2019 | 3 | – | Strangulated hiatal hernias | Da Vinci | Yes | 33% (n = 1) CD 3 | ||
2 lap | No conversions | |||||||||
Giulianotti et al. [15] | R-NRNC | 10/2000–11/2002 | 1 | 192 | Feasibility; here: posttraumatic spleen hematoma | Da Vinci | No | No complications | One CD V in non-urgent patients | |
– | No conversions | |||||||||
Hosein et al. [27] | database query | 2015–2017 | 131 | 704 | Hiatal hernia repair: robotic vs. Lap. Vs. Open | n.d | No | 2% overall complications; 0.1% (n = 1) CD V | More urgent and severe ill cases in open; robotic less complication than lap/open | |
1488 open 6774 lap | n.d | |||||||||
Muhonen et al. [70] | CS | n.d | 1 | – | Incarcerated paraduodenal hernia | Da Vinci | Yes | No complications | ||
2 lap | No conversions | |||||||||
Muysoms et al. [41] | R-NRC | 1/2016–12/2019 | 8 | 396 | Robotic vs. Lap. Inguinal hernia | Da Vinci | No | 3.5% CD II, 0.2% CD IIIb | Shorter hospital stay, higher costs in robotic group | |
272 | No conversions | |||||||||
Kudsi et al. [40] | R-NRC | 2013–2019 | 34 | – | Incarcerated hernia robotic vs. Open | Da Vinci | Yes | 23.3% < CD 3; 13.3% ≥ CD 3; 3.2% recurrence | OT shorter in open, more CD ≥ 3 in open, more SSI in open | IPOM & TAPP |
43 | No conversions | |||||||||
Smith et al. [71] | CR | n.d | 1 | – | Incarcerated inguinal hernia | Da Vinci | Yes | No complications | TAPP | |
– | No conversion |
Only statistically significant differences listed
CD Clavien-Dindo classification of complications, CS Case series, lap laparoscopic, IPOM intraperitoneal only mesh, n.d. not documented, OT operation time, R-NRC non-randomized, controlled, R-NRNC retrospective, non-randomized, not controlled, SSI surgical site infections, TAPP transabdominal pre-peritoneal hernia repair
For urgent robotic hernia operations, the published complication rates were very heterogeneous; the database analysis of Hosein et al. reported one death (0.1%) and an overall complication rate of 2% [27]. Muysoms et al. reported 3.5% minor and 0.2% major complications [41]. Kudsi et al. published a complication rate of 36.6% (23% minor and 13% major complications); however, this rate was significantly lower than that in the open surgery subgroup of Clavien–Dindo grade ≥ 3 complications [26]. A further interesting outcome was the significantly shorter hospital stay but higher costs and the recurrence rate of 3.2% reported by Myosoms et al. [41]. All studies emphasized that the interventions were technically feasible using an SR.
Discussion
General considerations and assessment of evidence
To date, there is only limited research on urgent robotic operations in general surgery; therefore, the data available are still very limited. Against this background, we consider a review such as ours, which systematically collects and examines the existing data and presents it descriptively, to be as comprehensive as possible and to be valuable and necessary.
Our review gives clear indications that robotic surgery has not yet arrived in urgent general surgery on a larger scale. A randomized controlled trial has not yet been performed, which is not totally unexpected given that randomized trials dealing with emergency and urgent surgery are generally very rare. However, even the nonrandomized studies offer specific data only to a limited extent: only six studies named urgent operations as a main interest or important variable [23–27, 38]. This makes a systematic assessment of the evidence complicated and a meta-analysis practically impossible. It can be stated that there is only a low level of evidence regarding robotic surgery in the context of urgent operations. Nevertheless, we were able to identify and summarize a notable number of publications covering a wide range of diseases.
Case reports and series are sources with limited evidence and are not suitable for a meta-analysis. In the absence of sources with better evidence, these are nevertheless presented in our study, as these reports fulfill the function of documenting the technical feasibility of certain interventions in the sense of a proof of concept.
With the recently published position paper of the WSES, the topic of urgent robotic operations was highlighted for the first time. De’Angelis et al. also conducted an extensive literature search. The number of papers screened was comparable to our study, but de’Angelis et al. used only ten manuscripts for their analysis: five retrospective cohort studies, and five case reports/case series [4]. We decided against reducing the number of publications used through a stricter assessment since we wanted to provide a maximum amount of information about robotic emergency operations. Nevertheless, our presentation goes beyond a purely narrative review, as, under verifiable conditions, we offer the first complete overview of the published data. However, the conclusions the authors of the WSES statement published are very similar to our findings, though we covered a wider field of operations [4]. The combination of de’Angelis et al. and our work creates, for the first time, a deeper impression of the significance of robotic operations in urgent surgery.
The main indications for robotic emergency interventions were gallbladder, hernias, and gastrointestinal surgery, as well as appendectomies. Some common aspects can be identified. First, there are supposedly higher costs of robotic interventions. Our review shows that robotic operations are significantly more expensive than laparoscopic surgeries [36, 38, 41, 42]. To date, there are no data that demonstrate the amortization of the extra costs by a reduction in the length of stay or complications that stem from the use of an SR. Moreover, the abovementioned studies that showed a cost increase per procedure did not take the considerable acquisition costs of the systems into account. The option of refunding by additional charges for the use of an SR is not possible in all health systems. Second, an often cited counterargument against robotic emergency interventions is the increased time requirements due to longer preparation or operation times. Here, the data were ambiguous and ranged from lengthening to shortening of time intervals with a tendency toward increased operative time. Minimally invasive surgery is primarily intended for stable patients, which of course also applies to robotic operations. Thus, even the moderate increases in operating time described above do not seem to be a contraindication for robotic operations.
Robotic camera mounts (RCM)
RCMs can be classified as robotic surgery only to a limited extent. However, they offer some of the alleged advantages, in particular a stable image and ergonomic advantages. However, there are also might be disadvantages, e.g., complications due to technical malfunctions.
According to this review, this type of surgery seems to be not very widespread, especially in urgent surgery, as only two publications have described the use of these systems [14, 21].
No clear statements about the advantages and disadvantages of RCMs can be drawn from the data presented here, but it can be stated that this type of surgery is undoubtedly more similar to laparoscopic than to robotic surgery. However, it seems important that no RCM-associated complications are reported.
Appendectomies
Appendectomy is a very frequent operation, although there have been very few studies that deal with robotic operations for acute appendicitis. This is of particular interest since appendicitis was one of the diseases that significantly led to the development of modern laparoscopy, initially starting with the confirmation of the diagnosis and the first laparoscopic appendectomy by Semm in 1983 [43]. Today, laparoscopic appendectomy is the therapy of choice for appendicitis [2].
There may be various reasons for the lack of studies on SR for appendicitis: The presumed high costs of robotic operations have been discussed since the start of robotic surgery [30]. Most likely, a “minor” procedure such as an appendectomy with correspondingly low remuneration is estimated as economically unreasonable and will therefore not become part of clinical routine for robotic surgery. It is also conceivable that the advantages of robotic operations for an often rather simple operation without complex preparation are not regarded as sufficient to implement this technique. An urgent appendectomy with the Da Vinci® system was reported in only two cases, while this robot system has been generally used most often. The feasibility of appendectomies with the Da Vinci® system was shown by several studies reporting on appendectomies in the context of other operations [44, 45].
An option to make a robotic appendectomy economically worth considering is to overthink the closure of the appendix stump: the use of the stapler or clip applicator for the Da Vinci® system causes relevant costs. This could be circumvented by closing the stump with a Roeder loop or suture. However, a current meta-analysis showed that stump closure with staples is superior in terms of postoperative complications [46].
In the overall view, appendectomy via SR is technically possible, but the additional expense compared to laparoscopic appendectomy most likely cannot be justified.
Cholecystectomies
Regarding this indication, the number of published studies is better, although far from satisfactory. However, against the background of more available studies, a case report analysis was less necessary. In addition to the fact that one of these case reports was among the first publications on robotic surgery in general surgery (Hanisch et al.), these reports did not provide any crucial information [30]. The statements regarding the advantages and disadvantages of the robotic approach in urgent cholecystectomies were very heterogeneous without a clear trend.
Remarkably, many studies compared single-incision robotic cholecystectomy (SIRC) with nonrobotic surgical procedures. Therefore, we assume a reporting bias: multi-incision robotic cholecystectomy (MIRC) was primarily examined in studies that were published before 2010, and acute cholecystitis was often an exclusion criterion [19]. However, the scientific perception of robotic cholecystectomy may have changed in two aspects: MIRC appears to be such a standard procedure that it is less examined in studies. At the same time, and based on their increased robotic experience, more researchers have opted to include acute cholecystectomy in their studies. In our estimation, these interventions are currently often performed as SIRC since this technique is assumed to be more innovative. Furthermore, there is another inaccuracy in the analysis: a number of studies reported robotic surgery for acute cholecystitis, with acute inflammation diagnosed intraoperatively. Therefore, this might not be labeled “urgent surgery” correctly in the narrower sense. The subject of this analysis is not the question of single- vs. multi-incision operations. The currently most up-to-date Practice Guideline on Safe Cholecystectomy votes for MIRC, in particular due to an increased rate of biliary tract injuries in the single-incision group [47]. Regarding the literature analyzed in our study, there was one biliary tract injury during an operation for acute cholecystitis using the SIRC technique. The data on complications and conversions were heterogeneous, as were the statements on the possible advantages and disadvantages of robotic operations. Biliary tract problems were reported in three patients, which resulted in a biliary complication rate of 0.4% among all patients operated on with an SR, which was within the expected range. Except for one study, these complications were not differentiated between urgent and elective operations. Notably, Kulaylat et al. reported an increase in hospital costs of 38% for the robotic procedure compared to laparoscopic cholecystectomy [36]. In summary, at the moment, neither the advantages nor the risks of robotic operations in urgent, acute cholecystectomies can be adequately assessed. However, no clear contraindications for the use of robots in this situation were found in this review.
Gastrointestinal procedures
The advantage of robotic surgery in acute conditions of the gastrointestinal tract, especially perforations, seems obvious: since a robot provides a significant advantage for suturing and tying knots, perforations and ruptures can be closed excellently. Furthermore, robotic operations for benign and malignant diseases of the colon or the upper gastrointestinal tract are clinical routine, with an increasing proportion being performed in the elective setting [48]. Our review shows that for urgent operations, there are hardly any data available. However, our own experience and the case reports/series listed demonstrate that these interventions were definitely possible in an urgent setting.
Beltzer et al. summarized that there was no advantage in using the robot for surgical procedures in diverticular disease [37]. Anderson et al. also did not state any explicit advantages and reported a longer operation time [24]. There are currently no data that propagate the use of SR in this indication group for a better outcome in a population operated urgently.
Robinson et al. presented a study primarily focused on urgent robotic surgery for perforated gastrojejunal perforations [38]. The authors were able to show that robotic surgery was not inferior to laparoscopic surgery. In addition, they reported two interesting aspects that otherwise hardly received attention: (1) the immediate preparation time in the OR was even shorter than that with laparoscopic operations; and (2) 54% of the operations were performed on weekends or during the evening, night or early morning. This invalidates some of the arguments that have been put forward against robotic emergency operations.
As mentioned above, in regard to surgery of the gastrointestinal tract, the cost disadvantages of SRs matter again: stapler and sealing devices in addition to draping, scissors, forceps, etc., are significant cost factors. Schiergens et al. showed that the use of an SR for an elective sigma resection increases the cost of surgical supplies by more than a factor of 4 compared to open surgery and by more than a factor of 2 compared to laparoscopic surgery. These numbers were very comparable to the cost increase reported by Robison et al. for urgent gastrojejunal ulcers [38, 49].
Hernias/miscellaneous
SRs are used regularly in minimally invasive hernia surgery [3]. This may contribute to the fact that there are quite a few studies on urgent robotic hernia surgery. Even if the evidence cannot be described as satisfactory, the overall picture is similar to those of the other indication groups: robotic interventions are feasible in incarcerated hernias and in urgent situations. The complication and conversion rates were low and comparable to those of nonrobotic, minimally invasive procedures. To date, however, no clear advantages of the robotic technique have been demonstrated.
The situation is different in hiatal hernias: in most cases, hiatal hernias are technically more demanding than inguinal or ventral hernias. The sutures required to reconstruct the hiatus and to create the fundoplication as well as the preparation make this operation ideal for the use of an SR. Current studies showed fewer complications and a shorter hospital stay for robotic hiatus hernia surgery in the elective setting [50]. Even if no data are available for urgent hiatoplasty, it is quite likely that such effects can be observed here.
The report of a splenectomy for bleeding (along with several reports of elective splenectomies) indicated that this operation is also possible with an SR. If the patient’s circulatory system remains stable and a minimally invasive procedure is conceivable, the procedure can also be carried out with an SR if the appropriate expertise is available.
Conclusion
A particular value of our work is that it provides a well-founded summary of the existing data for surgeons and researchers who are interested in urgent abdominal robotic surgery. Based on this, the specific studies needed can be initiated in the future. Furthermore, our review may help to establish framework conditions for a register for urgent robotic interventions.
With this review, we provide the most complete overview of the current literature on robotic surgery for urgent general surgical operations. Our analysis of the literature gives the impression that, in particular, robotic cholecystectomies in acute cholecystitis and operations on impacted hernias are feasible and rational and can be carried out without increased risk. Initial studies on urgent robotic operations in the gastrointestinal tract have thus far shown ambivalent results but have been proven technically feasible. High costs remain a significant burden for these operations.
Appendix 1
Search algorithm
#1 (“robot*”[MeSH Terms] AND “robot*”[Title/Abstract]) OR “robotic surgery” OR “robot-assisted” OR “robot assisted”
#2 #1 AND adhesiolysis
#3 #1 AND (appendicitis OR append*)
#4 #1 AND bowel obstruction
#5 #1 AND (cholecystitis OR cholecystectomy OR cholecyst*)
#6 #1 AND diverticular disease
#7 #1 AND diverticulitis
#8 #1 AND “emergency”
#9 #1 AND “emergencies”
#10 #1 AND hernia
#11 #1 AND (incarcerated OR incarcerat*)
#12 #1 AND “ischaemia”
#13 #1 AND perforation
#14 #1 AND peritonitis
#15 #1 AND ulc*
#16 #1 AND urgency
#17 #1 AND urgent
#2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17
Author contributions
All authors contributed to the study conception and design. Data acquisition was performed by AR and JL, and analysis and interpretation of the data were performed by AR, JL, WP and FU. Critical revision was performed by WP and FU. The first draft of the manuscript was written by AR and JL, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Funding
Open Access funding enabled and organized by Projekt DEAL. The authors declare that no funds, grants or other support was received during the preparation of this manuscript.
Declarations
Conflict of interest
Alexander Reinisch declares no financial or nonfinancial interests to disclose. Juliane Liese declares no financial or nonfinancial interests to disclose. Winfried Padberg declares no financial or nonfinancial interests to disclose. Frank Ulrich declares no financial or nonfinancial interests to disclose.
Ethical approval
Not applicable.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Alexander Reinisch and Juliane Liese have contributed equally to this work.
Winfried Padberg and Frank Ulrich have contributed equally to this work.
References
- 1.Wakabayashi G, Iwashita Y, Hibi T, Takada T, Strasberg SM, Asbun HJ, Endo I, Umezawa A, Asai K, Suzuki K, Mori Y, Okamoto K, Pitt HA, Han HS, Hwang TL, Yoon YS, Yoon DS, Choi IS, Huang WS, Giménez ME, Garden OJ, Gouma DJ, Belli G, Dervenis C, Jagannath P, Chan ACW, Lau WY, Liu KH, Su CH, Misawa T, Nakamura M, Horiguchi A, Tagaya N, Fujioka S, Higuchi R, Shikata S, Noguchi Y, Ukai T, Yokoe M, Cherqui D, Honda G, Sugioka A, de Santibañes E, Supe AN, Tokumura H, Kimura T, Yoshida M, Mayumi T, Kitano S, Inomata M, Hirata K, Sumiyama Y, Inui K, Yamamoto M. Tokyo guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos) J Hepatobiliary Pancreat Sci. 2018;25(1):73–86. doi: 10.1002/jhbp.517. [DOI] [PubMed] [Google Scholar]
- 2.Gorter RR, Eker HH, Gorter-Stam MA, Abis GS, Acharya A, Ankersmit M, Antoniou SA, Arolfo S, Babic B, Boni L, Bruntink M, van Dam DA, Defoort B, Deijen CL, DeLacy FB, Go PM, Harmsen AM, van den Helder RS, Iordache F, Ket JC, Muysoms FE, Ozmen MM, Papoulas M, Rhodes M, Straatman J, Tenhagen M, Turrado V, Vereczkei A, Vilallonga R, Deelder JD, Bonjer J. Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. Surg Endosc. 2016;30(11):4668–90. doi: 10.1007/s00464-016-5245-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Sheetz KH, Claflin J, Dimick JB. Trends in the adoption of robotic surgery for common surgical procedures. JAMA Netw Open. 2020;3(1):e1918911. doi: 10.1001/jamanetworkopen.2019.18911. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.de Angelis N, Khan J, Marchegiani F, Bianchi G, Aisoni F, Alberti D, Ansaloni L, Biffl W, Chiara O, Ceccarelli G, Coccolini F, Cicuttin E, D'Hondt M, Di Saverio S, Diana M, De Simone B, Espin-Basany E, Fichtner-Feigl S, Kashuk J, Kouwenhoven E, Leppaniemi A, Beghdadi N, Memeo R, Milone M, Moore E, Peitzmann A, Pessaux P, Pikoulis M, Pisano M, Ris F, Sartelli M, Spinoglio G, Sugrue M, Tan E, Gavriilidis P, Weber D, Kluger Y, Catena F. Robotic surgery in emergency setting: 2021 WSES position paper. World J Emerg Surg. 2022;17(1):4. doi: 10.1186/s13017-022-00410-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Ng KT, Tsia AKV, Chong VYL. Robotic versus conventional laparoscopic surgery for colorectal cancer: a systematic review and meta-analysis with trial sequential analysis. World J Surg. 2019;43(4):1146–1161. doi: 10.1007/s00268-018-04896-7. [DOI] [PubMed] [Google Scholar]
- 6.Tan A, Ashrafian H, Scott AJ, Mason SE, Harling L, Athanasiou T, Darzi A. Robotic surgery: disruptive innovation or unfulfilled promise? A systematic review and meta-analysis of the first 30 years. Surg Endosc. 2016;30(10):4330–52. doi: 10.1007/s00464-016-4752-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700. doi: 10.1136/bmj.b2700. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–213. doi: 10.1097/01.sla.0000133083.54934.ae. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Kudsi OY, Gokcal F. Urgent robotic mesocolic excision for obstructing proximal transverse colon cancer—a video vignette. Colorectal Dis. 2019;21(9):1093–1094. doi: 10.1111/codi.14714. [DOI] [PubMed] [Google Scholar]
- 10.Kudsi OY, Bou-Ayash N. Bleeding sigmoid diverticulosisurgent stapleless totally robotic sigmoidectomy-a video vignette. Colorectal Dis. 2020;22(9):1205. doi: 10.1111/codi.15051. [DOI] [PubMed] [Google Scholar]
- 11.Kudsi OY, Bou-Ayash N. Caecal volvulus—urgent totally robotic right colectomy—a video vignette. Colorectal Dis. 2020;22(10):1448–1449. doi: 10.1111/codi.15068. [DOI] [PubMed] [Google Scholar]
- 12.Yi B, Wang G, Li J, Jiang J, Son Z, Su H, Zhu S. The first clinical use of domestically produced Chinese minimally invasive surgical robot system "micro hand S". Surg Endosc. 2016;30(6):2649–55. doi: 10.1007/s00464-015-4506-1. [DOI] [PubMed] [Google Scholar]
- 13.Yi B, Wang G, Li J, Jiang J, Son Z, Su H, Zhu S, Wang S. Domestically produced Chinese minimally invasive surgical robot system "micro hand S" is applied to clinical surgery preliminarily in China. Surg Endosc. 2017;31(1):487–93. doi: 10.1007/s00464-016-4945-3. [DOI] [PubMed] [Google Scholar]
- 14.Ohmura Y, Nakagawa M, Suzuki H, Kotani K, Teramoto A. Feasibility and usefulness of a joystick-guided robotic scope holder (soloassist) in laparoscopic surgery. Visc Med. 2018;34(1):37–44. doi: 10.1159/000485524. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Giulianotti PC, Coratti A, Angelini M, Sbrana F, Cecconi S, Balestracci T, Caravaglios G. Robotics in general surgery: personal experience in a large community hospital. Arch Surg. 2003;138(7):777–84. doi: 10.1001/archsurg.138.7.777. [DOI] [PubMed] [Google Scholar]
- 16.Cadière GB, Himpens J, Germay O, Izizaw R, Degueldre M, Vandromme J, Capelluto E, Bruyns J. Feasibility of robotic laparoscopic surgery: 146 cases. World J Surg. 2001;25(11):1467–1477. doi: 10.1007/s00268-001-0132-2. [DOI] [PubMed] [Google Scholar]
- 17.Buzad FA, Corne LM, Brown TC, Fagin RS, Hebert AE, Kaczmarek CA, Pack AN, Payne TN. Single-site robotic cholecystectomy: efficiency and cost analysis. Int J Med Robot. 2013;9(3):365–370. doi: 10.1002/rcs.1507. [DOI] [PubMed] [Google Scholar]
- 18.Konstantinidis KM, Hirides P, Hirides S, Chrysocheris P, Georgiou M. Cholecystectomy using a novel Single-Site(®) robotic platform: early experience from 45 consecutive cases. Surg Endosc. 2012;26(9):2687–94. doi: 10.1007/s00464-012-2227-2. [DOI] [PubMed] [Google Scholar]
- 19.Kornprat P, Werkgartner G, Cerwenka H, Bacher H, El-Shabrawi A, Rehak P, Mischinger HJ. Prospective study comparing standard and robotically assisted laparoscopic cholecystectomy. Langenbecks Arch Surg. 2006;391(3):216–221. doi: 10.1007/s00423-006-0046-4. [DOI] [PubMed] [Google Scholar]
- 20.Svoboda S, Qaqish TR, Wilson A, Park H, Youssef Y. Robotic single-site cholecystectomy in the obese: outcomes from a single institution. Surg Obes Relat Dis. 2015;11(4):882–885. doi: 10.1016/j.soard.2014.11.016. [DOI] [PubMed] [Google Scholar]
- 21.Mittal R, Sbaih M, Motson RW, Arulampalam T. Use of a robotic camera holder (FreeHand) Minim Invasive Ther Allied Technol. 2020;29(1):56–60. doi: 10.1080/13645706.2019.1576052. [DOI] [PubMed] [Google Scholar]
- 22.Kelkar D, Borse MA, Godbole GP, Kurlekar U, Slack M. Interim safety analysis of the first-in-human clinical trial of the Versius surgical system, a new robot-assisted device for use in minimal access surgery. Surg Endosc. 2020 doi: 10.1007/s00464-020-08014-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Kubat E, Hansen N, Nguyen H, Wren SM, Eisenberg D. Urgent and elective robotic single-site cholecystectomy: analysis and learning curve of 150 consecutive cases. J Laparoendosc Adv Surg Tech A. 2016;26(3):185–191. doi: 10.1089/lap.2015.0528. [DOI] [PubMed] [Google Scholar]
- 24.Anderson M, Lynn P, Aydinli HH, Schwartzberg D, Bernstein M, Grucela A. Early experience with urgent robotic subtotal colectomy for severe acute ulcerative colitis has comparable perioperative outcomes to laparoscopic surgery. J Robot Surg. 2020;14(2):249–253. doi: 10.1007/s11701-019-00968-5. [DOI] [PubMed] [Google Scholar]
- 25.Bou-Ayash N, Gokcal F, Kudsi OY. Robotic inguinal hernia repair for incarcerated hernias. J Laparoendosc Adv Surg Tech A. 2020 doi: 10.1089/lap.2020.0607. [DOI] [PubMed] [Google Scholar]
- 26.Kudsi OY, Gokcal F, Bou-Ayash N, Chang K. Comparison of midterm outcomes between open and robotic emergent ventral hernia repair. Surg Innov. 2020 doi: 10.1177/1553350620971182. [DOI] [PubMed] [Google Scholar]
- 27.Hosein S, Carlson T, Flores L, Armijo PR, Oleynikov D. Minimally invasive approach to hiatal hernia repair is superior to open, even in the emergent setting: a large national database analysis. Surg Endosc. 2021;35(1):423–8. doi: 10.1007/s00464-020-07404-y. [DOI] [PubMed] [Google Scholar]
- 28.Gangemi A, Danilkowicz R, Bianco F, Masrur M, Giulianotti PC. Risk factors for open conversion in minimally invasive cholecystectomy. JSLS. 2017 doi: 10.4293/JSLS.2017.00062. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Chung PJ, Huang R, Policastro L, Lee R, Schwartzman A, Alfonso A, Sugiyama G. Single-site robotic cholecystectomy at an inner-city academic center. JSLS. 2015 doi: 10.4293/JSLS.2015.00033. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Hanisch E, Markus B, Gutt C, Schmandra TC, Encke A. Robot-assisted laparoscopic cholecystectomy and fundoplication–initial experiences with the Da Vinci system. Chirurg. 2001;72(3):286–288. doi: 10.1007/s001040051307. [DOI] [PubMed] [Google Scholar]
- 31.Bustos R, Mashbari H, Gangemi A. First report of gallbladder volvulus managed with a robotic approach. Case Rep Surg. 2019;2019:2189890. doi: 10.1155/2019/2189890. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Milone M, Vertaldi S, Bracale U, D'Ambra M, Cassese G, Manigrasso M, De Palma GD. Robotic cholecystectomy for acute cholecystitis: three case reports. Medicine (Baltimore) 2019;98(30):e16010. doi: 10.1097/MD.0000000000016010. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Bibi S, Rahnemai-Azar AA, Coralic J, Bayoumi M, Khorsand J, Farkas DT, Prasad LM. Single-site robotic cholecystectomy: the timeline of progress. World J Surg. 2015;39(10):2386–2391. doi: 10.1007/s00268-015-3135-0. [DOI] [PubMed] [Google Scholar]
- 34.Vidovszky TJ, Carr AD, Farinholt GN, Ho HS, Smith WH, Ali MR. Single-site robotic cholecystectomy in a broadly inclusive patient population: a prospective study. Ann Surg. 2014;260(1):134–141. doi: 10.1097/SLA.0000000000000295. [DOI] [PubMed] [Google Scholar]
- 35.Schertz P, Misra S, Livert D, Mulligan J, Rohatgi C. Comparison of intraoperative outcomes between single-incision robotic cholecystectomy and multi-incision robotic cholecystectomy. Cureus. 2019;11(8):e5386. doi: 10.7759/cureus.5386. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Kulaylat AN, Richards H, Yada K, Coyle D, Shelby R, Onwuka AJ, Aldrink JH, Diefenbach KA, Michalsky MP. Comparative analysis of robotic-assisted versus laparoscopic cholecystectomy in pediatric patients. J Pediatr Surg. 2020 doi: 10.1016/j.jpedsurg.2020.11.013. [DOI] [PubMed] [Google Scholar]
- 37.Beltzer C, Knoerzer L, Bachmann R, Axt S, Dippel H, Schmidt R. Robotic versus laparoscopic sigmoid resection for diverticular disease: a single-center experience of 106 cases. J Laparoendosc Adv Surg Tech A. 2019;29(11):1451–1455. doi: 10.1089/lap.2019.0451. [DOI] [PubMed] [Google Scholar]
- 38.Robinson TD, Sheehan JC, Patel PB, Marthy AG, Zaman JA, Singh TP. Emergent robotic versus laparoscopic surgery for perforated gastrojejunal ulcers: a retrospective cohort study of 44 patients. Surg Endosc. 2022;36(2):1573–1577. doi: 10.1007/s00464-021-08447-5. [DOI] [PubMed] [Google Scholar]
- 39.Lembcke B. Diagnosis, differential diagnoses, and classification of diverticular disease. Viszeralmedizin. 2015;31(2):95–102. doi: 10.1159/000380833. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Kudsi OY, Bou-Ayash N, Chang K, Gokcal F. Perioperative and midterm outcomes of emergent robotic repair of incarcerated ventral and incisional hernia. J Robot Surg. 2020 doi: 10.1007/s11701-020-01130-2. [DOI] [PubMed] [Google Scholar]
- 41.Muysoms F, Vierstraete M, Nachtergaele F, Van Garsse S, Pletinckx P, Ramaswamy A. Economic assessment of starting robot-assisted laparoscopic inguinal hernia repair in a single-centre retrospective comparative study: the EASTER study. BJS Open. 2021 doi: 10.1093/bjsopen/zraa046. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Li YP, Wang SN, Lee KT. Robotic versus conventional laparoscopic cholecystectomy: a comparative study of medical resource utilization and clinical outcomes. Kaohsiung J Med Sci. 2017;33(4):201–206. doi: 10.1016/j.kjms.2017.01.010. [DOI] [PubMed] [Google Scholar]
- 43.Semm K. Endoscopic appendectomy. Endoscopy. 1983;15(2):59–64. doi: 10.1055/s-2007-1021466. [DOI] [PubMed] [Google Scholar]
- 44.Hüttenbrink C, Hatiboglu G, Simpfendörfer T, Radtke JP, Becker R, Teber D, Hadaschik B, Pahernik S, Hohenfellner M. Incidental appendectomy during robotic laparoscopic prostatectomy-safe and worth to perform? Langenbecks Arch Surg. 2018;403(2):265–269. doi: 10.1007/s00423-017-1630-5. [DOI] [PubMed] [Google Scholar]
- 45.Akl MN, Magrina JF, Kho RM, Magtibay PM. Robotic appendectomy in gynaecological surgery: technique and pathological findings. Int J Med Robot. 2008;4(3):210–213. doi: 10.1002/rcs.198. [DOI] [PubMed] [Google Scholar]
- 46.Mannu GS, Sudul MK, Bettencourt-Silva JH, Cumber E, Li F, Clark AB, Loke YK. Closure methods of the appendix stump for complications during laparoscopic appendectomy. Cochrane Database Syst Rev. 2017;11:CD006437. doi: 10.1002/14651858.CD006437.pub3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 47.Brunt LM, Deziel DJ, Telem DA, Strasberg SM, Aggarwal R, Asbun H, Bonjer J, McDonald M, Alseidi A, Ujiki M, Riall TS, Hammill C, Moulton CA, Pucher PH, Parks RW, Ansari MT, Connor S, Dirks RC, Anderson B, Altieri MS, Tsamalaidze L, Stefanidis D, Group tPoBDICW Safe cholecystectomy multi-society practice guideline and state of the art consensus conference on prevention of bile duct injury during cholecystectomy. Ann Surg. 2020;272(1):3–23. doi: 10.1097/SLA.0000000000003791. [DOI] [PubMed] [Google Scholar]
- 48.Konstantinidis IT, Ituarte P, Woo Y, Warner SG, Melstrom K, Kim J, Singh G, Lee B, Fong Y, Melstrom LG. Trends and outcomes of robotic surgery for gastrointestinal (GI) cancers in the USA: maintaining perioperative and oncologic safety. Surg Endosc. 2020;34(11):4932–4942. doi: 10.1007/s00464-019-07284-x. [DOI] [PubMed] [Google Scholar]
- 49.Schiergens TS, Sienel WGR, Werner J. Implementation of new technologies in the DRG system under economic aspects. Chirurg. 2020;91(7):561–566. doi: 10.1007/s00104-020-01184-w. [DOI] [PubMed] [Google Scholar]
- 50.Soliman BG, Nguyen DT, Chan EY, Chihara RK, Meisenbach LM, Graviss EA, Kim MP. Robot-assisted hiatal hernia repair demonstrates favorable short-term outcomes compared to laparoscopic hiatal hernia repair. Surg Endosc. 2020;34(6):2495–502. doi: 10.1007/s00464-019-07055-8. [DOI] [PubMed] [Google Scholar]
- 51.Kibar Y, Yalcin S, Kopru B, Kaya E, Topuz B, Ebiloglu T. Robot-assisted laparoscopic repair of spontaneous appendicovesical fistula. J Endourol Case Rep. 2016;2(1):111–113. doi: 10.1089/cren.2016.0063. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 52.Ayloo S, Roh Y, Choudhury N. Laparoscopic versus robot-assisted cholecystectomy: a retrospective cohort study. Int J Surg. 2014;12(10):1077–1081. doi: 10.1016/j.ijsu.2014.08.405. [DOI] [PubMed] [Google Scholar]
- 53.Balachandran B, Hufford TA, Mustafa T, Kochar K, Sulo S, Khorsand J. A comparative study of outcomes between single-site robotic and multi-port laparoscopic cholecystectomy: an experience from a tertiary care center. World J Surg. 2017;41(5):1246–1253. doi: 10.1007/s00268-016-3799-0. [DOI] [PubMed] [Google Scholar]
- 54.Daskalaki D, Fernandes E, Wang X, Bianco FM, Elli EF, Ayloo S, Masrur M, Milone L, Giulianotti PC. Indocyanine green (ICG) fluorescent cholangiography during robotic cholecystectomy: results of 184 consecutive cases in a single institution. Surg Innov. 2014;21(6):615–621. doi: 10.1177/1553350614524839. [DOI] [PubMed] [Google Scholar]
- 55.Gonzalez AM, Rabaza JR, Donkor C, Romero RJ, Kosanovic R, Verdeja JC. Single-incision cholecystectomy: a comparative study of standard laparoscopic, robotic, and SPIDER platforms. Surg Endosc. 2013;27(12):4524–31. doi: 10.1007/s00464-013-3105-2. [DOI] [PubMed] [Google Scholar]
- 56.Honaker MD, Paton BL, Stefanidis D, Schiffern LM. Can robotic surgery be done efficiently while training residents? J Surg Educ. 2015;72(3):377–380. doi: 10.1016/j.jsurg.2014.11.008. [DOI] [PubMed] [Google Scholar]
- 57.Jeong Jang E, Kang SH, Kim KW. Early outcomes of robotic single site cholecystectomy using the DaVinci Xi® system. JSLS. 2021 doi: 10.4293/JSLS.2020.00082. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 58.Kalteis M, Pistrich R, Schimetta W, Pölz W. Laparoscopic cholecystectomy as solo surgery with the aid of a robotic camera holder: a case-control study. Surg Laparosc Endosc Percutan Tech. 2007;17(4):277–282. doi: 10.1097/SLE.0b013e31806030ae. [DOI] [PubMed] [Google Scholar]
- 59.Mattei P. Single-site robotic-assisted laparoscopic cholecystectomy in children and adolescents: a report of 20 cases. Surg Endosc. 2018;32(5):2402–8. doi: 10.1007/s00464-017-5939-5. [DOI] [PubMed] [Google Scholar]
- 60.Rosales-Velderrain A, Alkhoury F. Single-port robotic cholecystectomy in pediatric patients: single institution experience. J Laparoendosc Adv Surg Tech A. 2017;27(4):434–437. doi: 10.1089/lap.2016.0484. [DOI] [PubMed] [Google Scholar]
- 61.Su WL, Huang JW, Wang SN, Lee KT. Comparison study of clinical outcomes between single-site robotic cholecystectomy and single incision laparoscopic cholecystectomy. Asian J Surg. 2017;40(6):424–428. doi: 10.1016/j.asjsur.2016.03.005. [DOI] [PubMed] [Google Scholar]
- 62.Tao Z, Emuakhagbon VS, Pham T, Augustine MM, Guzzetta A, Huerta S. Outcomes of robotic and laparoscopic cholecystectomy for benign gallbladder disease in Veteran patients. J Robot Surg. 2021;15(6):849–857. doi: 10.1007/s11701-020-01183-3. [DOI] [PubMed] [Google Scholar]
- 63.Felli E, Brunetti F, Disabato M, Salloum C, Azoulay D, De'angelis N. Robotic right colectomy for hemorrhagic right colon cancer: a case report and review of the literature of minimally invasive urgent colectomy. World J Emerg Surg. 2014;9:32. doi: 10.1186/1749-7922-9-32. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 64.Guerra F, Petrelli F, Stortoni P, Patriti A. Acute large bowel malignant obstruction of the splenic flexure: fully robotic resection with central ligation and intracorporeal anastomosis—a video vignette. Colorectal Dis. 2021;23(1):325. doi: 10.1111/codi.15384. [DOI] [PubMed] [Google Scholar]
- 65.Pedraza R, Ragupathi M, Martinez T, Haas EM. Robotic-assisted laparoscopic primary repair of acute iatrogenic colonic perforation: case report. Int J Med Robot. 2012;8(3):375–378. doi: 10.1002/rcs.1447. [DOI] [PubMed] [Google Scholar]
- 66.Sudan R, Desai SS. Emergency and weekend robotic surgery are feasible. J Robot Surg. 2012;6(3):263–266. doi: 10.1007/s11701-011-0289-0. [DOI] [PubMed] [Google Scholar]
- 67.Sun L, Tang S. Perioperative nursing for gastric perforation repair operation performed by the first domestic surgical robot. Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2015;40(4):453–456. doi: 10.11817/j.issn.1672-7347.2015.04.019. [DOI] [PubMed] [Google Scholar]
- 68.Cubas R, Garcia M, Mukherjee K. Robotic repair of incarcerated morgagni hernia in an adult on the acute care surgery service. Rev Fac Cien Med Univ Nac Cordoba. 2021;78(1):91–94. doi: 10.31053/1853.0605.v78.n1.28299. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 69.Ceccarelli G, Pasculli A, Bugiantella W, De Rosa M, Catena F, Rondelli F, Costa G, Rocca A, Longaroni M, Testini M. Minimally invasive laparoscopic and robot-assisted emergency treatment of strangulated giant hiatal hernias: report of five cases and literature review. World J Emerg Surg. 2020;15(1):37. doi: 10.1186/s13017-020-00316-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 70.Muhonen J, Hsu M, Strudivant M, Unger A, Dexter D, Giuseppucci P, Esper C. Identification and repair of left-sided paraduodenal hernia using both laparoscopic and robotic techniques. Case Rep Surg. 2020;2020:7569530. doi: 10.1155/2020/7569530. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 71.Smith MT, Wong NC, Coleman JA. Inguinal hernia of the distal ureter causing hydronephrosis: a rare case. Urol Case Rep. 2021;35:101549. doi: 10.1016/j.eucr.2020.101549. [DOI] [PMC free article] [PubMed] [Google Scholar]