N. Charland1,2, J. Hadaya1,3, Z. K. Tran1,4, N. Y. Cho1,2, S. Mallick1, N. K. Le1,2, P. Benharash1,3 1David Geffen School Of Medicine, University Of California At Los Angeles, Cardiovascular Outcomes Research Laboratories (CORELAB), Los Angeles, CA, USA 2David Geffen School Of Medicine, University Of California At Los Angeles, Los Angeles, CA, USA 3David Geffen School Of Medicine, University Of California At Los Angeles, Department Of Surgery, Los Angeles, CA, USA 4Loma Linda University School Of Medicine, Department Of Surgery, Loma LInda, CA, USA
Introduction: Robot-assisted surgery has seen exponential adoption over the last decade. While the safety and efficacy of robotic surgery in the elective setting has been demonstrated, data regarding robotic emergency general surgery (EGS) remains sparse. In the present study, we evaluated trends in the use of minimally invasive surgery (MIS), including robot-assisted, for 6 key EGS operations and their associated outcomes.
Methods: All adults undergoing non-elective appendectomy, cholecystectomy, small or large bowel resection, perforated ulcer repair, or lysis of adhesions were identified in the 2008-2020 National Inpatient Sample. Temporal trends were analyzed using a rank-based, non-parametric test developed by Cuzick (nptrend). Multivariable regression was used to evaluate the association between surgical technique and in-hospital mortality, perioperative complications, and resource use stratified by operation. To standardize the definition of EGS, operations performed on hospital day 3 or later were excluded from analysis.
Results:
Of an estimated 9,201,209 patients undergoing EGS, 6,180,124 (67.2%) were performed using an MIS approach. Over the study period, MIS utilization increased significantly for all EGS apart from small bowel resection. The robotic proportion of minimally invasive EGS increased significantly overall, with the largest growth seen in robotic large bowel resections (2008 – 5.5%, 2020- 21.1%, nptrend<.001) and perforated ulcer repairs (2016 – 7.8%, 2020 – 19.5%, nptrend<.001).
Patients receiving robot-assisted EGS were older (56 vs 46 years, p=.001), had similar chronic disease burden (Elixhauser Comorbidity Index 3 vs 3, p=0.11) and more commonly cared for at metropolitan teaching hospitals (69.5 vs 59.3%, p<.001). On risk-adjusted analysis, no significant differences in mortality were observed between laparoscopic and robotic techniques. Lower associated odds of perioperative blood transfusion were observed for robotic large bowel resection (0.76, 95% CI 0.70 – 0.83), ulcer repair (0.50, 95% CI 0.32-0.79), cholecystectomy (0.72, 95% CI 0.62-0.84) and lysis of adhesions (0.79, 95% CI 0.72-0.86). For all EGS surgeries, robot use was associated with significantly higher admission costs (β-coefficient $5228, 95% CI $5009 – 5447).
Conclusion: MIS techniques have been increasingly utilized for EGS over the last decade, particularly robot-assisted surgery for large bowel resection and ulcer repair. Robotic techniques had comparable mortality rates to laparoscopy and reduced utilization of blood transfusion, though hospitalization costs were greater. These findings support the safety of robot-assisted surgery for EGS, though further study of cost-benefit relationships is warranted.
