Robotic surgery in gastrointestinal emergency settings: A systematic review

Abstract

BACKGROUND

Robotic-assisted surgery has become an established component of elective minimally invasive surgery, yet its role in emergency gastrointestinal surgery remains uncertain. Emergency procedures pose unique challenges, including time-critical decision-making, complex anatomy, and limited opportunities for extensive preoperative planning.

AIM

To evaluate the current evidence regarding the feasibility, safety, and clinical outcomes of robotic surgery in the emergency gastrointestinal setting.

METHODS

A systematic literature search of PubMed, Scopus, and the Cochrane Library was performed for studies published through June 15, 2026, following PRISMA guidelines. Eligible studies evaluated robotic-assisted emergency gastrointestinal procedures in adult patients and reported perioperative or clinical outcomes. Study selection, data extraction, and quality assessment were independently performed by two reviewers using validated appraisal tools. Owing to substantial methodological heterogeneity, a descriptive synthesis with pooled weighted means was conducted.

RESULTS

Thirty-two studies met the inclusion criteria, comprising predominantly retrospective cohort studies with additional case series and case reports. Acute cholecystitis represented the most extensively investigated indication (13242 patients), followed by acute appendicitis (475 patients), emergency colorectal surgery (326 patients), abdominal wall hernias (138 patients), perforated peptic ulcer (25 patients), abdominal trauma, and other rare emergency conditions. Across selected patients, robotic surgery demonstrated high technical feasibility, low conversion rates, acceptable operative times, and favorable postoperative recovery. The largest evidence base concerned acute cholecystitis (13242 patients). Among the subset of studies reporting conversion outcomes, conversion to open surgery occurred in 5 of 792 patients (0.6%). However, evidence for other emergency indications remained limited by small sample sizes, retrospective study designs, heterogeneous patient selection, and inconsistent outcome reporting. High acquisition costs, limited platform availability, prolonged setup times, and the need for specialized surgical teams remain important barriers to widespread implementation.

CONCLUSION

Robotic surgery is safe and feasible in carefully selected, hemodynamically stable patients when performed in high-volume centres. However, it does not currently represent a paradigm shift in emergency general surgery compared to standard laparoscopy, primarily due to logistical constraints, prolonged operative times, and higher costs. High-quality prospective multicenter studies and randomized trials are required to define appropriate indications, evaluate cost-effectiveness, and establish the role of robotic technology within modern emergency surgical practice.

Key Words: Emergency general surgery; Robotic surgical procedures; Gastrointestinal surgical procedures

Core Tip: Robotic surgery is an emerging option in emergency gastrointestinal surgery, demonstrating feasibility and safety in carefully selected, hemodynamically stable patients. Current evidence supports its use mainly for acute cholecystitis, while data for other indications remain limited. High costs, logistical barriers, and low-quality evidence currently preclude routine adoption.

INTRODUCTION

Robotic-assisted surgery has transformed the landscape of minimally invasive surgery by providing enhanced three-dimensional visualization, improved instrument articulation, tremor filtration, and superior surgeon ergonomics[1,2]. These technological advantages have led to its widespread adoption across numerous elective surgical specialties, where robotic platforms have demonstrated excellent safety profiles and favorable perioperative outcomes. In contrast, the role of robotic surgery in emergency gastrointestinal surgery (EGS) remains considerably less well defined, with its application largely confined to selected centers and specific clinical scenarios[3-5].

EGS presents unique technical and organizational challenges that distinguish it from elective practice. Patients frequently present with acute inflammation, distorted anatomy, sepsis, bowel obstruction, perforation, or hemorrhage, requiring rapid diagnosis and timely surgical intervention. In these time-sensitive situations, operative strategy is primarily driven by the need for prompt source control and physiological stabilization, factors that have traditionally favored conventional laparoscopy or open surgery[6]. Moreover, the logistical requirements associated with robotic surgery-including platform availability, operating room setup, and the need for specialized surgical teams-have limited its widespread implementation in emergency settings[7-9].

Despite these challenges, continuous advances in robotic technology, increasing surgeon experience, and the expansion of dedicated robotic emergency surgery programs have renewed interest in the use of robotic platforms for acute care surgery (ACS)[10,11]. The enhanced dexterity and visualization offered by robotic systems may be particularly advantageous in complex emergency procedures involving severe inflammation or difficult anatomical dissection[12]. Early clinical reports have suggested that robotic surgery is technically feasible in selected emergency gastrointestinal conditions and may be associated with low conversion rates, acceptable perioperative outcomes, and the preservation of the well-established benefits of minimally invasive surgery[6,8,13-15]. However, the available evidence remains fragmented, consisting predominantly of retrospective observational studies, small case series, and isolated case reports, with considerable heterogeneity in patient selection, operative indications, and reported outcomes.

Given the growing interest in robotic surgery for emergency gastrointestinal disease and the absence of robust evidence defining its clinical role, a comprehensive synthesis of the current literature is warranted.

EGS encompasses the urgent or emergent surgical management of acute abdominal conditions requiring time-sensitive intervention. Within the broader ACS model, EGS is integrated with trauma and surgical critical care. In the present review, EGS is used to describe non-traumatic emergency abdominal surgery, whereas trauma-related robotic procedures are considered separately within the broader ACS framework. This distinction was adopted to ensure terminological consistency while preserving the comprehensive scope of the review. Simultaneously, robotic surgical platforms have evolved from early multi-port systems (e.g., da Vinci Si, Xi) to single-port (SP) platforms and emerging novel systems (e.g., Micro Hand S).

Previous publications have addressed robotic surgery in emergency settings from complementary perspectives. The 2022 WSES position paper[1] primarily provided expert-based guidance on the potential role and implementation of robotic surgery in emergency practice, whereas the 2024 systematic review by Anyomih et al[8] focused on comparative robotic and laparoscopic general surgery in the emergency setting. The present review extends these contributions by incorporating more recent evidence, including studies published through 2026, and by providing an indication-specific synthesis across a broader spectrum of emergency abdominal procedures. Attention is given to outcome denominators, patient selection, institutional requirements, and the distinction between technical feasibility and demonstrated comparative benefit.

The aim of this systematic review was to critically evaluate the available evidence regarding the feasibility, safety, perioperative outcomes, and current indications of robotic-assisted surgery in emergency gastrointestinal and acute care settings. Furthermore, this review seeks to identify existing knowledge gaps, discuss the practical and organizational challenges limiting broader implementation, and highlight priorities for future research to better define the role of robotic technology in modern emergency surgical practice. Specifically, the review addressed the following question: In adult patients requiring emergency abdominal surgery, what evidence is available regarding the feasibility, safety, and perioperative outcomes of robotic-assisted surgery, compared with laparoscopic or open surgery where comparative data are available? Prespecified outcomes of interest included operative time, conversion to open surgery, postoperative morbidity and mortality, reoperation, length of hospital stays (LOS), and, when reported, economic and organizational outcomes.

MATERIALS AND METHODS

A systematic search was conducted across PubMed, Scopus, and the Cochrane Library on June 15, 2026. The search strategy combined Medical Subject Headings terms and free-text keywords, including “Robotic Surgical Procedures”, “Emergency Surgery”, “Trauma Surgery”, and “Minimally Invasive Surgery” using Boolean operators (“AND”, “OR”). Language was restricted to English, with no limits on publication date. The full electronic search strategy, including the specific search strings and filters applied for each database, is provided in Supplementary material. Additional records were identified by manually screening the reference lists of included studies and relevant reviews. The protocol for this systematic review was prospectively registered in the PROSPERO under registration number CRD420261484796 and was conducted in strict accordance with the PRISMA guidelines.

Inclusion and exclusion criteria

Studies included in this review focused on robotic-assisted surgery performed in EGS and acute care settings. Eligible studies reported outcomes such as feasibility, safety, efficacy, or clinical and economic impacts. Only articles involving human participants aged 18 years or older and published in peer-reviewed journals were considered.

For the purposes of this review, the scope was not restricted to luminal gastrointestinal procedures, but encompassed emergency abdominal conditions managed within contemporary EGS/ACS practice. Accordingly, abdominal wall emergencies, diaphragmatic and hiatal hernias, and selected abdominal trauma cases were considered eligible when the robotic procedure involved emergency abdominal surgical management. These uncommon indications were retained to provide a comprehensive overview of the reported applications of robotic technology in the acute care setting and were analysed separately from the core gastrointestinal indications.

Studies exclusively addressing elective robotic surgeries, non-human or preclinical research, abstracts without full-text data, and articles in languages other than English were excluded. Additionally, conference proceedings, editorials, and commentaries without original research data were omitted.

Study selection, evaluation and quality assessment

Two independent reviewers screened the titles and abstracts for relevance and reviewed full texts of potentially eligible studies against the inclusion and exclusion criteria. Any disagreements were resolved through discussion or by consulting a third senior reviewer (Brisinda G) to ensure consensus.

The quality of included studies was appraised using standardized tools appropriate to the study design. Randomized controlled trials were evaluated with the Cochrane Risk of Bias Tool, observational studies with the Newcastle-Ottawa Scale, and case series or reports with the Joanna Briggs Institute Critical Appraisal Tools. The detailed methodological quality and risk of bias assessment for the included retrospective cohort studies are summarized in Table 1, while the quality profile for the selected case series and case reports according to Murad et al[16] is detailed in Table 2.

Table 1 Quality assessment for the selected retrospective cohort studies according to the Newcastle Ottawa Scale.

Ref.	Selection	Comparability	Outcome	Total score	Quality threshold
Choi et al[18]	+++	+	++	6	Moderate
Kubat et al[22]	+++	+	+++	7	High
Choudhry et al[19]	++++	++	+++	9	High
Robinson et al[28]	+++	+	++	6	Moderate
Yi et al[27]	+++	+	++	6	Moderate
Rifai et al[24]	++++	+	+++	8	High
Becker et al[29]	+++	+	+++	7	High
Kudsi et al[37]	+++	+	+++	7	High
Campbell et al[17]	++++	++	+++	9	High
Bou-Ayash et al[36]	+++	+	++	6	Moderate
Latif et al[25]	+++	+	+++	7	High
Hosein et al[41]	++++	+	+++	8	High
Sanderfer et al[2]	++++	+	+++	8	High
Anderson et al[30]	+++	+	++	6	Moderate
Kudsi et al[35]	+++	+	+++	7	High
Arnott et al[31]	+++	+	++	6	Moderate
Kaoukabani et al[21]	+++	+	+++	7	High
Grimsley et al[20]	++++	++	+++	9	High
Iaquinandi et al[43]	+++	++	++	6	Moderate
Shen et al[26]	+++	+	+++	7	High
Klein et al[12]	++++	+	+++	8	High
Murgante Testa et al[38]	+++	+	++	6	Moderate

Table 2 Quality assessment for the selected case series/case reports.

Ref.	Selection	Ascertainment	Causality	Reporting	Overall score
Pedraza et al[34]	+	++	++	+	6/8
Smith et al[46]	+	++	+	+	5/8
Felli et al[33]	+	++	++	+	6/8
Milone et al[23]	+	++	++	+	6/8
Ceccarelli et al[40]	+	++	++	+	6/8
Cubas et al[44]	+	++	++	+	6/8
Maertens et al[32]	+	++	++	+	6/8
Shchatsko et al[39]	+	++	++	+	6/8
Conticchio et al[45]	+	++	+	+	5/8
Jambhekar et al[42]	+	++	++	+	6/8

Data extraction

Data were extracted using a standardized form that included study characteristics, patient demographics, surgical indications, robotic systems used, operative time, complications, mortality, and LOS. This was performed independently by two reviewers to maintain accuracy. To prevent double counting of patient populations deriving from identical institutional registries or multi-centre databases within overlapping timeframes, only the most comprehensive dataset or the study with the largest sample size was included.

Outcomes of interest

The primary outcomes assessed were feasibility and safety, as well as clinical metrics like morbidity, mortality, and LOS. Secondary outcomes included the economic impact and comparative advantages of robotic-assisted techniques over laparoscopic or open approaches in emergency settings.

Statistical analysis

Due to substantial clinical, methodological, and statistical heterogeneity across the included studies-primarily stemming from variations in patient acuity, surgical indications, and institutional protocols-a formal meta-analysis was deemed inappropriate. Instead, a descriptive narrative synthesis was performed. For descriptive purposes, continuous variables (e.g., age, operative time, LOS) were reported as pooled means,

Meanpooled=∑Meani×Ni∑Ni

weighted by study sample size where sufficient raw data were available. These weighted averages are intended purely as summary descriptors of the aggregated cohort rather than inferential estimates of effect size and should be interpreted with caution given the underlying study heterogeneity. Categorical variables were summarized as absolute frequencies and percentages.

Ethical considerations

As this review involved only published literature and did not involve direct patient contact, ethical approval was not required.

RESULTS

The details of the literature search, screening, and selection process are illustrated in the updated PRISMA 2020 flow diagram (Figure 1). Finally, 32 studies met all eligibility criteria and were included in the review.

Figure 1  PRISMA flow chart of the studies.

The characteristics of the studies reported in this systematic review are shown in Table 3. Acute cholecystitis was the most frequently reported disease, with evidence derived from 13 retrospective studies[2,12,17-27]. Perforated peptic ulcer was described in 2 retrospective studies[27,28], while acute appendicitis was evaluated in 5 retrospective studies[2,20,24,27,29]. Colorectal emergency procedures were reported in 3 retrospective studies[2,30,31], one case series[32], and two case reports[33,34]. Regarding abdominal wall pathology, the literature included 5 retrospective studies[2,35-38]. Abdominal trauma was represented by a single case report[39]. For diaphragmatic and hiatal hernia, evidence comprised one case series on giant hiatal hernia[40], one retrospective study on hiatal hernia[41], one case report about Bochdalek hernia[42], one retrospective study about para-esophageal hernias[43] and one case report about incarcerated Morgagni hernia[44]. Finally, rare applications included the rupture of a hepatocellular carcinoma[45] and gallstone ileus[46].

Table 3 Characteristics of the included studies in the systematic review.

Ref.	Study design	Country	Aim of the study	Robot type	Indication	Procedure performed	Number of patients
Felli et al[33]	Case report	Italy	Description, feasibility	Da Vinci system	Bleeding neoplasm	Right hemicolectomy	1
Cubas et al[44]	Case report	United States	Description, feasibility and safety	Da Vinci Xi system	Incarcerated morgagni hernia	Mesh hernia repair	1
Ceccarelli et al[13]	Case series	Italy	Feasibility and safety	Da Vinci Xi system	Hiatal hernias	Direct or mesh repair with Nissen/Toupet	3
Maertens et al[32]	Case series	United Kingdom	Patient outcomes	Da Vinci Xi system	Gastrointestinal emergency	Colectomy, Hartmann’s procedure	10
Shchatsko et al[39]	Case report	United States	Feasibility and safety	Da Vinci system	Abdominal wall penetrating trauma	Direct primary repair	1
Milone et al[23]	Case report	Italy	Description, feasibility and safety	Da Vinci system	Acute cholecystitis	Cholecystectomy	3
Pedraza et al[34]	Case report	United States	Description, feasibility and safety	Da Vinci system	Iatrogenic sigmoid perforation	Primary repair	1
Conticchio et al[45]	Case report	Italy	Description, feasibility and safety	Not specified	Ruptured hepatocellular carcinoma	Resection of segment 3	1
Yi et al[27]	Retrospective cohort study	China	Safety and effectiveness	Micro Hand S	Gastrointestinal and gallbladder emergency	Direct ulcer repair, appendectomy, cholecystectomy, colectomy	10
Jambhekar et al[42]	Case report	United States	Description, feasibility and safety	Da Vinci system	Bochdalek hernia	Direct diaphragmatic repair	1
Smith et al[46]	Case report	United States	Description, feasibility and safety	NR	Gallstone ileus	Enterotomy	1
Becker et al[29]	Retrospective cohort study	United States	Comparison of postoperative outcomes	NR	Acute appendicitis	Appendectomy	50
Kudsi et al[37]	Retrospective cohort study	United States	Comparison of postoperative outcomes	NR	Ventral hernia	Mesh and direct repair	35
Rifai et al[24]	Retrospective cohort study	United States	Evaluation of operative time and post-operative length of stay	NR	Acute cholecystitis and acute appendicitis	Appendectomy and cholecystectomy	246
Campbell et al[17]	Retrospective cohort study	United States	Comparison of post-operative outcomes	NR	Acute cholecystitis, biliary pancreatitis, CBD stones and cholangitis	Cholecystectomy	10019
Choi et al[18]	Retrospective cohort study	Vietnam	Comparison of outcomes of different robotic systems	Si, Xi, SP da Vinci system	Acute cholecystitis	Cholecystectomy	300
Bou-Ayash et al[36]	Retrospective cohort study	United States	Clinical outcomes	Da Vinci system	Incarcerated inguinal hernias	TAPP repair	19
Latif et al[25]	Retrospective cohort study	United Kingdom	Clinical outcomes	Da Vinci X system	Acute cholecystitis	Cholecystectomy, CBD exploration	23
Kubat et al[22]	Retrospective cohort study	United States	Clinical outcomes	Da Vinci Si system	Acute cholecystitis	Cholecystectomy	74
Hosein et al[41]	Retrospective cohort study	United States	Feasibility and safety	NR	Hiatal hernia	Hiatal hernia repair	131
Robinson et al[28]	Retrospective cohort study	United States	Feasibility and safety	Da Vinci Si and Xi system	Perforated peptic ulcers	Direct repair	24
Sanderfer et al[2]	Retrospective cohort study	United States	Description, feasibility and safety	NR	Appendicitis, acute cholecystitis, incarcerated inguinal hernia, colon bleeding, acute diverticulitis, complicated ventral hernia	Appendectomy, cholecystectomy, inguinal hernia repair, colectomy, ventral hernia repair	133
Anderson et al[30]	Retrospective cohort study	United States	Description, feasibility and safety	Da Vinci Xi system	Acute ulcerative colitis	Subtotal colectomy	6
Kudsi et al[35]	Retrospective cohort study	United States	Feasibility	Da Vinci system	Incarcerated ventral/incisional hernia	IPOM, TAPP, Rives-Stoppa, TAR	34
Arnott et al[31]	Retrospective cohort study	United States	Evaluation of short-term outcomes	NR	Acute complicated diverticulitis	Left hemicolectomy	20
Kaoukabani et al[21]	Retrospective cohort study	United States	Outcomes in the elderly	NR	Acute cholecystitis	Cholecystectomy	157
Grimsley et al[20]	Retrospective cohort study	United States	Outcomes and hospital costs	NR	Acute appendicitis, acute cholecystitis, complicated inguinal hernia	Appendectomy, cholecystectomy, inguinal hernia repair	2747
Choudhry et al[19]	Retrospective cohort study	United States	Description, feasibility and safety	Da Vinci Xi system	Acute cholecystitis	Cholecystectomy	135
Iaquinandi et al[43]	Retrospective cohort study	Switzerland	Safety and feasibility	NR	Para-esophageal hernias	Repair of para-esophageal hernias	17
Shen et al[26]	Retrospective cohort study	United States	To assess safety and feasibility	Da Vinci Xi system	Acute cholecystitis	Cholecystectomy	62
Klein et al[12]	Retrospective cohort study	United States	Safety and feasibility	NR	Acute cholecystitis	Cholecystectomy	130
Murgante Testa et al[38]	Retrospective cohort study	Switzerland	Feasibility and safety	NR	Incarcerated inguinal hernia	TAPP repair	15

NR: Not reported; CBD: Common biliary duct; IPOM: Intra-peritoneal onlay mesh; TAPP: Trans-abdominal pre-peritoneal; TAR: Transverus abdominis release.

Acute cholecystitis

Thirteen studies reporting robotic cholecystectomy were included[2,12,17-27], comprising a total of 13242 patients. The pooled mean age, available from nine studies[12,17-26], was 50.3 years, while 62.3% of patients were female. Body mass index (BMI) (mean value of 28.8 kg/m²) was reported in only one study[26]. The pooled mean operative time was 126.1 minutes, whereas the pooled mean LOS was 3.3 days. Conversion to open surgery was reported in five studies[12,18,22,24,26] and occurred in 5 of 792 patients, corresponding to a pooled conversion rate of 0.6% within this specific sub-cohort. Postoperative morbidity was reported in one large study and was 10.5%[20].

Regarding the surgical technologies, specific platform data were available in four studies, with the da Vinci Xi system being explicitly utilized across 3 of them for a total of 212 procedures: Kubat et al[22] reported 74 procedures performed with the da Vinci Xi system, Choudhry et al[19] reported 135 emergency cholecystectomies using the da Vinci Xi platform, and Milone et al[23] reported 3 da Vinci Xi procedures. Furthermore, Choi et al[18] reported 118 procedures performed dynamically with the da Vinci Si/Xi systems, alongside 216 procedures executed with a SP platform.

Perforated peptic ulcer

Two studies reporting robotic repair of perforated peptic ulcer were included[27,28], comprising a total of 25 patients. One study reported a mean age of 50.2 years and 70.8% female patients[28]. Regarding the technology employed, the da Vinci Xi system was utilized in one study for a total of 24 procedures, accounting for most of the collective cohort[28]. In contrast, the remaining study employed the Micro Hand S platform for a single patient[27]. The pooled mean operative time was 87.4 minutes, and the pooled mean LOS was 4.9 days. Conversion to open surgery was reported by only one study[28], with no conversions occurring in the robotic cohort.

Acute appendicitis

Five studies reporting robotic appendectomy for acute appendicitis were included[2,20,24,27,29], comprising a total of 475 patients. The pooled mean age, available from two studies[24,29], was 40.3 years, while 50.8% of patients were female according to data reported in two studies. BMI data were not available for quantitative analysis. The pooled mean operative time, derived from three studies[24,27,29], was 74.5 minutes, whereas the pooled mean LOS, reported in four studies[20,24,27,29], was 2.2 days. Conversion to open surgery was reported only by Rifai et al[24], with no conversions occurring in the robotic cohort. Based on the two studies reporting postoperative complications, the pooled morbidity rate was approximately 13.6%[20,29]. Regarding the surgical devices used, no specific data or details about the robotic platform models (such as the da Vinci Xi or other brands) were mentioned or detailed within the narrative text of the primary studies for this indication.

Colorectal procedures

Six studies reporting emergency robotic colorectal surgery were included, comprising a total of 326 patients. The pooled mean age, available from five studies[30-34], was 59.6 years, and 59.7% of patients were female. BMI was reported in two studies, yielding a pooled mean value of 20.6 kg/m²[30,31]. The pooled operative time was 238.4 minutes, whereas the pooled LOS was 6.0 days[30-34]. Conversion to open surgery was reported in one large series and occurred in 34 of 297 patients (11.4%)[30]. The pooled reoperation rate, based on two studies[30,31] was 5.3%, while the anastomotic leak rate reported in the largest study was 2.4%[31]. Regarding the specific surgical devices used, no technical details or data regarding the robotic platform models were explicitly stated or reported within the narrative text of the primary studies for these colorectal interventions.

Abdominal wall

Five studies reporting emergency robotic hernia repair were included, comprising a total of 138 patients. The pooled mean age, derived from four studies including 103 patients, was 64.9 years. Female sex distribution was available in four studies, with women accounting for 48.5% of the cohort. BMI was reported in four studies, yielding a pooled mean value of 31.0 kg/m²[35-38].

Operative time was available in four studies, with a pooled mean of 123.5 minutes[35-38]. LOS was reported in three studies, resulting in a pooled mean of 2.6 days. Hernia type was described in four studies, with ventral/incisional hernias representing 59.4% of cases and inguinal hernias 40.6%[35-38]. None of the studies reported conversion or reoperation rates. Specific robotic platform models were not reported for this indication.

Abdominal trauma

Only one case report was identified[39]. The study described a 20-year-old male patient with obesity (BMI = 46 kg/m²) who sustained a stab wound to the left flank and was hemodynamically stable on admission. Computed tomography demonstrated a penetrating soft-tissue injury with an oblique trajectory extending from the posterior axillary line into the abdominal cavity, associated with omental herniation. To assess for potential intra-abdominal injuries and simultaneously repair the abdominal wall defect, a robotic-assisted laparoscopic approach using the da Vinci platform was performed. The wound was irrigated and closed before abdominal insufflation, allowing maintenance of pneumoperitoneum during the procedure. No additional cases, comparative studies, or specific model details were identified in the trauma setting.

Other emergency applications

Seven studies reporting emergency robotic surgery were included, comprising a total of 26 patients, predominantly case reports and small case series[40-45]. The most common indication was incarcerated hiatal or paraesophageal hernia (76.9%), followed by rare complex conditions including Morgagni and Bochdalek hernias, gallstone ileus, hepatic rupture and adhesive disease. Most patients were male (96%). The pooled mean operative time, derived from two studies[43,44], was 177.8 minutes, while the pooled LOS was 7.0 days. Conversion to open surgery was not reported in any case. Specific robotic platform details were not reported for these miscellaneous indications.

DISCUSSION

The present systematic review provides a comprehensive synthesis of the available evidence on robotic-assisted surgery in emergency gastrointestinal practice and highlights both the potential and the current limitations of this evolving approach.

Although robotic surgery has become an established component of elective minimally invasive surgery, its application in emergency settings remains limited and is supported predominantly by retrospective studies, case series, and isolated case reports, resulting in an overall low level of evidence[10,11]. Nevertheless, the literature consistently demonstrates that robotic surgery is feasible and safe in carefully selected, hemodynamically stable patients when performed by experienced surgeons within institutions equipped with dedicated robotic programs[1,2,47].

The principal finding of this review is that robotic surgery has been successfully applied across a wide spectrum of emergency conditions, including acute cholecystitis, perforated peptic ulcer, appendicitis, emergency colorectal disease, incarcerated abdominal wall hernias, diaphragmatic and paraesophageal hernias, trauma, and other uncommon emergencies (Table 4). However, the strength of evidence differs substantially among these indications and remains insufficient to demonstrate clear clinical superiority over conventional laparoscopy. Another key limitation of this synthesis stems from the nature of the included literature, which consists predominantly of retrospective observational studies, case series, and small single-centre cohorts. As highlighted by our quality assessment using the Newcastle-Ottawa Scale and Joanna Briggs Institute Critical Appraisal tools, retrospective designs carry an inherent risk of selection, indication, and reporting biases. Emergency robotic procedures are often selected for hemodynamically stable patients or specific anatomical conditions, introducing potential selection bias that may overestimate safety and feasibility. Consequently, while the preliminary findings demonstrate promising outcomes, the overall strength of evidence remains low to moderate, and the conclusions should be interpreted as hypothesis-generating rather than definitive proof of superiority.

Table 4 Pooled clinical outcomes by surgical indication.

Indication	Number of patients	Ref.	Pooled mean operative time (minute)	Pooled mean LOS (days)	Documented conversion rate (sub-cohort)	Dominant identified platform
Acute cholecystitis	13242	[2,12,17-27]	126.1	3.3	0.6%	da Vinci Xi
Perforated peptic ulcer	25	[27,28]	87.4	4.9	0.0%	da Vinci Xi
Acute appendicitis	475	[2,20,24,27,29]	74.5	2.2	0.0%[24]	NR
Colorectal procedures	326	[2,30-34]	238.4	6.0	11.4%	NR
Abdominal wall (hernia)	138	[2,35-38]	123.5	2.6	NR	NR
Abdominal trauma	1	[39]	NR	NR	0.0%	da Vinci
Other applications	26	[40-45]	177.8	7.0	0.0%	NR

NR: Not reported; LOS: Length of stay.

Acute cholecystitis currently represents the best-supported indication because it combines technical reproducibility with the largest clinical experience[2,10,12]. In this setting, robotic technology may facilitate dissection in difficult inflammatory conditions through enhanced three-dimensional visualization, articulated instruments, and superior ergonomics, potentially reducing conversion to laparotomy in selected patients[17,20,47-51]. However, most available studies originate from high-volume referral centres and include carefully selected patients, making it difficult to distinguish the true effect of the robotic platform from the influence of institutional expertise and selection bias.

Similar considerations apply to other emergency procedures. Robotic repair of perforated peptic ulcer, emergency colorectal disease, and complex abdominal wall hernias appears technically advantageous, particularly when advanced intracorporeal suturing, precise dissection, or complex reconstruction are required[28,30-32,35-37]. For relatively straightforward procedures such as appendectomy, the currently available evidence is insufficient to establish a clinically meaningful advantage of robotic surgery over conventional laparoscopy, which remains an established minimally invasive approach[29]. Likewise, reports describing robotic management of trauma, diaphragmatic defects, ruptured hepatocellular carcinoma, gallstone ileus, inflammatory bowel disease, bowel obstruction, and other rare emergencies demonstrate technical versatility rather than superiority and should therefore be interpreted cautiously[13,39,41,42,44].

The marked heterogeneity of the literature further limits interpretation. Differences in patient populations, disease severity, operative techniques, surgeon experience, robotic platforms, and outcome reporting preclude robust comparisons and explain the absence of high-quality pooled evidence. Moreover, clinically relevant outcomes-including postoperative quality of life, functional recovery, long-term recurrence, surgeon ergonomics, and overall cost-effectiveness-remain inconsistently evaluated. The lack of prospective randomized trials, although understandable given the logistical and ethical challenges inherent to emergency surgery, represents a major limitation of the current literature.

Selection bias and clinical feasibility vs superiority

A consistent finding across the available literature is that patient selection remains the principal determinant of successful robotic emergency surgery. Nearly all published series involve hemodynamically stable patients without diffuse peritonitis or uncontrolled haemorrhage, whereas critically ill patients continue to undergo conventional open surgery because rapid source control and damage-control principles remain the overriding priorities. Consequently, favourable perioperative outcomes reported for robotic surgery probably reflect appropriate case selection as much as technological advantages. As highlighted by our quality assessment, retrospective designs carry an inherent risk of selection, indication, and reporting biases. Therefore, while robotic surgery is feasible and safe, current evidence does not demonstrate broad clinical superiority over conventional laparoscopy. Laparoscopy remains the gold standard for most emergency abdominal interventions due to its rapid deployment, widespread availability, and proven efficacy. Robotic surgery should currently be viewed as a complementary tool in acute settings rather than a replacement for standard minimally invasive approaches.

Learning curve and surgeon expertise

Surgeon expertise remains fundamental, as robotic proficiency should complement rather than replace advanced laparoscopic and open surgical skills, ensuring timely conversion whenever patient safety requires it[4,11]. The integration of robotics into emergency surgery is deeply intertwined with the surgeon’s learning curve. Emergency settings demand rapid decision-making and swift execution, which are compromised if the operating surgeon has not surpassed the robotic learning curve in elective procedures. High proficiency in elective robotic surgery is a strict prerequisite before applying this technology to EGS. Furthermore, the lack of standardized credentialing and training curricula specific to acute care robotic surgery currently limits its widespread and safe adoption.

Institutional volume effect

The successful implementation of robotic EGS has predominantly been reported in high-volume tertiary centers with established robotic programs and trained operating-room teams. Whether these outcomes can be reproduced in lower-volume institutions remains uncertain. Limited staff experience, platform availability, and setup requirements may represent greater barriers in time-sensitive emergency procedures, but comparative evidence across institutions with different robotic volumes remains limited.

After-hours logistics

Off-hours availability represents an important potential barrier to routine robotic EGS because emergency procedures frequently occur during nights and weekends, when dedicated robotic nursing staff and technical support may be less consistently available. The magnitude of this limitation is likely to vary substantially according to institutional organization and resources, and current evidence is insufficient to generalize across centers.

Financial considerations

Beyond clinical metrics, widespread implementation of robotic emergency surgery faces significant economic and organizational barriers. High capital costs, maintenance contracts, single-use instrumentation, OR logistics, and the need for specialized multidisciplinary teams restrict routine adoption, particularly outside high-volume tertiary centers[20,52]. Cost-effectiveness varies with institutional surgical volume, case mix, and regional reimbursement models. Although reductions in length of stay, conversion to open surgery, or postoperative complications may partially offset procedural costs in selected high-volume settings[2,11,53], the current literature does not permit robust conclusions. Dedicated economic evaluations using standardized costing methods and emergency-specific cohorts are required.

Based on the available evidence, robotic emergency surgery may currently be considered within an indication- and context-specific framework. Potentially appropriate candidates are hemodynamically stable patients in whom minimally invasive surgery is otherwise indicated, particularly when complex dissection or intracorporeal suturing may be required and when an experienced robotic surgeon and trained team are immediately available. Conversely, robotic surgery should be approached cautiously when rapid source control is paramount, in hemodynamic instability, uncontrolled haemorrhage, or when robotic setup could introduce clinically relevant delay. For several uncommon indications, current evidence remains insufficient to support recommendations beyond individualized case selection.

Future developments will likely depend not only on improvements in robotic technology but also on integration with artificial intelligence, fluorescence imaging, computer-assisted navigation, and digital surgery, which may improve anatomical recognition, intraoperative decision-making, and operative precision[54-58]. However, technological innovation alone is unlikely to justify broader adoption without high-quality evidence demonstrating meaningful improvements in patient-centred outcomes and healthcare value. To bridge this gap, future research must prioritize well-designed prospective comparative studies, the implementation of standardized outcome reporting frameworks, and the establishment of international multicentre registries capable of generating robust, real-world evidence[59]. Such initiatives are essential to identify the specific emergency conditions and patient cohorts that derive genuine benefit from robotic platforms. Overall, current evidence supports robotic surgery as a feasible and safe alternative for selected emergency gastrointestinal procedures in high-volume centres but does not justify its routine adoption over conventional laparoscopy[60]. Until stronger comparative data become available, surgical approach selection should remain tailored to patient physiology, disease severity, surgeon expertise, and institutional resources rather than technology availability alone.

Limitations

This review has several strengths. It provides one of the most comprehensive contemporary syntheses of robotic surgery in emergency gastrointestinal practice, incorporates multiple emergency indications, evaluates methodological quality using validated assessment tools, and summarizes pooled perioperative outcomes across diverse clinical scenarios. By integrating recent evidence from large multicenter databases alongside institutional experiences, this review offers a broad overview of the current state of robotic emergency surgery.

Several limitations should also be acknowledged: (1) The predominance of retrospective observational studies, introducing inherent selection and indication biases; (2) Potential language bias due to the exclusion of non-English literature; (3) The exclusion of grey literature, which may introduce publication bias; (4) A paucity of long-term follow-up data and validated patient-reported outcome measures; and (5) Methodological constraints of descriptive weighted-average pooling in place of formal meta-analysis.

Additional limitations arise from the inclusion of case reports and small case series for uncommon indications, which increase susceptibility to publication and reporting bias. Some primary studies included mixed urgent/emergent populations or heterogeneous indications, limiting the ability to isolate emergency-specific effects. Furthermore, large administrative and institutional datasets may contain partially overlapping patient populations. Although overlapping cohorts were screened and the most comprehensive dataset was preferentially retained when overlap could be identified, residual overlap cannot be completely excluded.

CONCLUSION

Current evidence suggests that robotic-assisted surgery is technically feasible and can be performed safely in carefully selected, hemodynamically stable patients undergoing emergency gastrointestinal and abdominal procedures, particularly in high-volume centers with established robotic expertise. However, the available evidence is predominantly retrospective, heterogeneous, and subject to substantial selection bias, and is therefore insufficient to establish the superiority of robotic surgery over conventional laparoscopy or to support its routine adoption in emergency practice. The strength of evidence varies considerably by indication, with acute cholecystitis representing the most extensively studied application, whereas evidence for colorectal emergencies, abdominal wall procedures, perforated peptic ulcer, trauma, and other uncommon indications remains limited. Accordingly, the choice of surgical approach should currently be individualized according to patient physiology, disease severity, procedural complexity, surgeon expertise, and institutional resources. Prospective multicenter comparative studies, standardized outcome reporting, and dedicated economic evaluations are required to identify the indications and patient populations in which robotic surgery may provide clinically meaningful benefit.