de’Angelis et al. World Journal of Emergency Surgery (2022) 17:4 https://doi.org/10.1186/s13017-022-00410-6 REVIEW Open Access Robotic surgery in emergency setting: 2021 WSES position paper Nicola de’Angelis1,2* , Jim Khan3, Francesco Marchegiani4, Giorgio Bianchi1, Filippo Aisoni1, Daniele Alberti5, Luca Ansaloni6, Walter Biffl7, Osvaldo Chiara8, Graziano Ceccarelli9, Federico Coccolini10, Enrico Cicuttin10, Mathieu D’Hondt11, Salomone Di Saverio12, Michele Diana13,14, Belinda De Simone15, Eloy Espin‑Basany16, Stefan Fichtner‑Feigl17, Jeffry Kashuk18, Ewout Kouwenhoven19, Ari Leppaniemi20, Nassiba Beghdadi1,2, Riccardo Memeo21, Marco Milone22, Ernest Moore23, Andrew Peitzmann24, Patrick Pessaux25,26,27, Manos Pikoulis28, Michele Pisano29, Frederic Ris30, Massimo Sartelli31, Giuseppe Spinoglio32, Michael Sugrue33, Edward Tan34, Paschalis Gavriilidis35, Dieter Weber36, Yoram Kluger37 and Fausto Catena38 Abstract Background: Robotics represents the most technologically advanced approach in minimally invasive surgery (MIS). Its application in general surgery has increased progressively, with some early experience reported in emergency settings. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a systematic review of the literature to develop consensus statements about the potential use of robotics in emergency general surgery. Methods: This position paper was conducted according to the WSES methodology. A steering committee was constituted to draft the position paper according to the literature review. An international expert panel then critically revised the manuscript. Each statement was voted through a web survey to reach a consensus. Results: Ten studies (3 case reports, 3 case series, and 4 retrospective comparative cohort studies) have been published regarding the applications of robotics for emergency general surgery procedures. Due to the paucity and overall low quality of evidence, 6 statements are proposed as expert opinions. In general, the experts claim for a strict patient selection while approaching emergent general surgery procedures with robotics, eventually considering it for hemodynamically stable patients only. An emergency setting should not be seen as an absolute contraindication for robotic surgery if an adequate training of the operating surgical team is available. In such conditions, robotic surgery can be considered safe, feasible, and associated with surgical outcomes related to an MIS approach. However, there are some concerns regarding the adoption of robotic surgery for emergency surgeries associated with the following: (i) the availability and accessibility of the robotic platform for emergency units and during night shifts, (ii) expected longer operative times, and (iii) increased costs. Further research is necessary to investigate the role of robotic surgery in emergency settings and to explore the possibility of performing telementoring and telesurgery, which are particu‑ larly valuable in emergency situations. Conclusions: Many hospitals are currently equipped with a robotic surgical platform which needs to be imple‑ mented efficiently. The role of robotic surgery for emergency procedures remains under investigation. However, its *Correspondence: nic.deangelis@yahoo.it 1 Unit of Digestive, Hepatobiliary, and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), Créteil, France Full list of author information is available at the end of the article © The Author(s) 2022. 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The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​ mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. de’Angelis et al. World Journal of Emergency Surgery (2022) 17:4 Page 2 of 12 use is expanding with a careful assessment of costs and timeliness of operations. The proposed statements should be seen as a preliminary guide for the surgical community stressing the need for reevaluation and update processes as evidence expands in the relevant literature. Keywords: Emergency surgery, Robotic surgery, General surgery, Minimally invasive surgery Background [14] and was reported according to the Preferred Report- Robotics represents the most technologically advanced ing Items for Systematic Reviews and Meta-Analyses approach in minimally invasive surgery (MIS). Its appli- (PRISMA) statement [15]. cation has progressively gained acceptance in several The focus question was the following: what are the surgical fields, being routinely used for elective urol- applications and outcomes of robotics for general surgery ogy, gynecology, digestive, and hepato-bilio-pancreatic in emergency settings? surgery [1–8]. Conversely, robotic surgery in the emer- Studies reporting the use of a robotic surgical plat- gency setting has not been explored, although some early form to manage general surgery emergencies and urgen- experience has been reported in the literature [9–12]. cies were searched in the following databases on June 30, Consequently, the issue regarding the role and poten- 2021: MEDLINE (through PubMed), Embase, and the tial applications of robotics for emergency procedures Cochrane Library. A specific research query was formu- remains open. However, it deserves to be continuously lated for each database, using the following keywords and monitored and updated in the future as evidence would MeSH terms: emergency, emergency surgery, emergency emerge. setting, urgent, robotic surgery, robotic, robotics, robot- assisted, minimally invasive surgery, and minimally inva- sive surgery procedures. Project rationale and design According to the PICOS format, the following items The present position paper is supported by the World were used as selection criteria for articles emerging from Society of Emergency Surgery (WSES) and aims to pro- the literature search: vide a systematic review of the literature investigating the use of robotics in emergency general surgery to develop P, population: adult patients requiring surgery in consensus statements based on the currently available emergent/urgent settings. evidence and practice. The present document should be I, intervention: robotic or robot-assisted general sur- seen as a preliminary guide for the surgical community gery intervention. stressing the need for reevaluation and update processes C, comparisons: laparoscopy or open surgery or no as evidence expands in the relevant literature. comparison. For the purpose of this WSES position paper, the O, outcome(s): operative and postoperative surgical organizing committee (composed of Fausto Catena, outcomes. Nicola de’Angelis, and Jim Khan) constituted a steering S, study design: due to the expected paucity of studies committee (made up of 16 experts), who had the task of on the topic, all types of comparative study, but also drafting the present position paper, and an international case series and case reports were considered aiming expert panel composed of 21 experts who were asked to to provide the most exhaustive picture of the current critically revise the manuscript and position statements. evidence and practice in robotic emergency general The position paper was conducted according to the surgery. WSES methodology [13]. We shall present the systematic review of the literature and provide the derived state- The research was limited to studies published in ments upon which a consensus was reached, specifying English. the quality of the supporting evidence and suggesting The literature search and selection were performed future research directions. by two independent reviewers (GB and FM), who also screened the reference list of the selected articles to potentially include additional studies. First, all records Systematic review from merged searches were reviewed for relevance con- Methods cerning title and abstract. Records were removed when Review question, selection criteria, and search strategy both reviewers excluded them. Otherwise, the disagree- The systematic review of the literature was performed ment was resolved via discussion or with the intervention following the Cochrane Collaboration specific protocol of a tiebreaker (NdeA). Both reviewers then performed de’Angelis et al. World Journal of Emergency Surgery (2022) 17:4 Page 3 of 12 an independent full-text analysis, which allowed to finally Study characteristics include or exclude the preselected article. The selected 10 studies were published between 2012 and 2021. They consisted of 5 cohort studies and 5 case reports conducted in Europe (n = 3) and North America Data extraction and synthesis (n = 7). The characteristics of the examined studies are Data extraction was performed by filling in an electronic summarized in Table 1. Overall, they considered 279 spreadsheet, which included the following items: first patients. author’s name, year of publication, scientific journal, type Three studies reported interventions of colorectal sur- of study, number of patients, pathological state requiring gery [9, 10, 19], two studies reported on hiatal hernia sur- surgical intervention, type of surgical intervention, surgi- gery [20, 21], two studies reported on gallbladder surgery cal approach, operative surgical outcomes, and postop- [22, 23], two studies reported on bariatric surgery [12, erative surgical outcomes. The risk of bias in the selected 24], and one study reported on abdominal wall surgery studies was assessed by using validated systems accord- [25]. Only one case was a cancer-related emergency [10]. ing to the type of study design [16–18]. Qualitative synthesis of the literature Results Literature search and selection 1. Robotics in emergency colorectal surgery The initial search yielded 3767 results; after removing duplicates, 3662 articles were screened for eligibility An early preliminary report of an emergent robotic based on title and abstract, and 31 articles were retrieved repair of a colonic iatrogenic perforation was published for a full-text evaluation. A total of 10 studies fulfilled the by Pedraza et al. in 2012 [19]. The authors showed that selection criteria and were finally included in the review such a procedure was feasible and successful. In 2014, (Fig. 1). Felli et al. [10] described the case of an 86-year old Fig. 1 Flowchart of the literature search and selection Table 1 Studies reporting on urgent/emergent general surgery interventions performed with a robotic approach References Study design Nb. of patients Time period Pathology Intervention Robotic platform Outcomes Results Comparative studies Hosein et al. [21] Retrospective 131 robotic cases January 2015– Hiatal hernia Hiatal hernia repair Unknown Perioperative Trend towards better cohort study 719 open cases December 2017 outcomes outcomes in mini‑ 1517 laparoscopic mally invasive surgery cases (laparoscopic and robotic) as compared to open approach Kubat et al. [22] Retrospective 76 robotic (elective) May 2001–August Acute cholecystitis, Robotic single-site Intuitive Surgical da Perioperative out‑ Robotic single-site cohort study cases 2013 choledocholithi‑ cholecystectomy Vinci Si™ comes and learning cholecystectomy 74 robotic (urgent) asis, severe chronic curve is safe and can be cases cholecystitis applied to urgent and elective settings with acceptable periop‑ de’Angelis et al. World Journal of Emergency Surgery erative outcomes. Learning curve of 50 cases Robinson et al. [12] Retrospective 4 robotic cases 2015–2019 Perforated gas‑ Repairs of perfo‑ Intuitive Surgical da Perioperative Outcomes are cohort study 0 laparoscopic cases trojejunal ulcers rated gastrojejunal Vinci Si™/Xi™ outcomes non-inferior to (2022) 17:4 following Roux-en-Y ulcers laparoscopy with gastric bypass the use of the robot. surgery In-room-to-surgery time is reduced in the robotic group. Costs are greater in the robotic group Anderson et al. [9] Retrospective 6 robotic cases February 2015–Feb‑ Severe acute ulcera‑ Subtotal colectomy Intuitive Surgical da Feasibility and Robotic subtotal cohort study on 13 laparoscopic ruary 2017 tive colitis Vinci Xi™ perioperative colectomy has a prospective cases outcomes similar periop‑ database erative outcomes of laparoscopic subtotal colectomy Case series and case reports Kudsi et al. [25] Case series 34 robotic cases February 2013– Ventral hernia Robotic ventral Intuitive Surgical da Perioperative Robotic ventral her‑ November 2019 hernia repair Vinci™ outcomes and mid- nia repair is effective term follow-up in the emergency setting Ceccarelli et al. [21] Case series 3 robotic cases December 2009– Giant hiatal hernia Hernia repair ± fun‑ Intuitive Surgical da Perioperative Uneventful post‑ December 2019 doplication Vinci Xi™ outcomes operative course in patients, one patient developed an antrum stenosis due to preoperative mucosal ischemia Page 4 of 12 de’Angelis et al. World Journal of Emergency Surgery Table 1 (continued) References Study design Nb. of patients Time period Pathology Intervention Robotic platform Outcomes Results Milone et al. [23] Case series 3 robotic cases 2019 Moderate acute cal‑ Robotic cholecys‑ Intuitive Surgical da Perioperative Uneventful postop‑ culous cholecystitis tectomy Vinci Si™ outcomes erative course (2022) 17:4 Sudan et al. [24] Case report Robotic cases 2001 Complications of Robotic stricture‑ Intuitive Surgical da Perioperative Uneventful postop‑ biliopancreatic plasty Vinci Si™ outcomes erative course diversion with Robotic suture of duodenal switch duodenal stump Felli et al. [10] Case report 1 robotic case 2014 Hemorrhagic right Robotic right Intuitive Surgical da Perioperative Uneventful postop‑ colon cancer colectomy with Vinci Si™ outcomes erative course. At double-barreled 5 months of follow- ileocolostomy up, no recurrence was noted Pedraza et al. [19] Case report 1 robotic case 2001 Iatrogenic colonos‑ Robotic color‑ Intuitive Surgical da Perioperative Uneventful postop‑ copy perforation rhaphy Vinci Si™ outcomes erative course Page 5 of 12 de’Angelis et al. World Journal of Emergency Surgery (2022) 17:4 Page 6 of 12 woman who underwent a robotic right colectomy for a to preserve the benefits of the previous MIS approach. bleeding ascending colon neoplasia. The surgery was The authors highlighted how the adoption of the robotic uneventful and the reported postoperative outcomes platform was useful in a patient in order to identify the were excellent. More recently, Anderson et al. [9] pub- damage and to repair it. More recently, Robinson et al. lished a matched case–control study focusing on the use [12] published a retrospective cohort study comparing of robotics for urgent subtotal colectomies in patients emergent laparoscopic and robotic gastrojejunal ulcer presenting with ulcerative colitis. The results showed repair. The authors showed that in-room-to-surgery- similar short-term outcomes for robotic and laparoscopic start time was significantly reduced in the robotic group. approaches. Additionally, perioperative outcomes were in favor of the robotic approach, although not significantly different. 2. Robotics in emergency hiatal hernia surgery However, robotic surgery was significantly more expen- sive than laparoscopy. Over the last years, two groups published their early experience with robotic surgery for emergency hiatal 5. Robotics in emergency abdominal wall surgery hernia repair. In a case series of 3 patients undergoing robotic surgery for complicated giant hiatal hernia, Cec- In 2020, Kudsi et al. [25] published an article on the carelli et al. [21] showed that postoperative outcomes perioperative and mid-term outcomes of 34 patients were good. The authors suggested that the potential who underwent emergency robotic ventral hernia repair advantages of robotics over a conventional laparoscopic with different techniques between 2013 and 2019. With approach were mainly related to the surgeon’s comfort a 20.5% rate of minor postoperative complications (Cla- and precision during the intervention. Hosein et al. [20] vien-Dindo grades I-II), a 11.7% rate of major postop- performed a cohort-based analysis using data from the erative complications (Clavien-Dindo grades III-IV), and 2015–2017 Vizient clinical database, which included only one (2.9%) patient experiencing hernia recurrence, inpatient data from over 300 hospitals in the USA. Trend the authors concluded that robotic ventral hernia repair analysis demonstrated that laparoscopy was the most was associated with promising results and overall feasi- common approach in emergency hiatal hernia repair, bility in emergency settings, to be tested in further long- representing 64.09% of cases, followed by the open term follow-up studies. (30.38%) and the robotic approach (5.53%). Concerning operative and postoperative outcomes, a trend was also Evaluation of the quality of evidence observed for better outcomes in case of MIS (laparos- Five out of 10 selected studies were retrospective cohort copy or robotic) hiatal hernia repair as compared to open studies and were evaluated according to the NOS [18]. surgery. Two studies received a score of 8/9 [9, 12], one study was graded 7/9 [20], and two studies had a score of 6/9 3. Robotics in emergency gallbladder surgery [22, 25] (Table 2). The remaining studies were evalu- ated according to the tool described by Murad et al. [16]. In 2016, Kubat et al. [22] published a retrospective case All studies received a score of 6/8 [10, 19, 21, 23, 24] series of 76 elective and 74 urgent robotic single-site (Table 3). cholecystectomies. The authors reported good periop- erative outcomes, concluding that this approach was safe Position statements and efficient. In 2019, Milone et al. [23] described a case Following a comprehensive literature review and the series of 3 patients who underwent robotic cholecystec- summary of current scientific evidence on the applica- tomy for acute cholecystitis. The reported perioperative tions of robotics for emergency general surgery proce- outcomes were excellent and the authors recommended dures, the following position statements (PS) were put the introduction of robotics in emergency settings in forward. For each statement, the supporting literature, order to validate their preliminary results. the level of evidence, and the strength of the consensus are indicated. The level of evidence is classified accord- 4. Robotics in emergency bariatric surgery ing to the GRADE system (https://​train​ing.​cochr​ane.​ org/​intro​ducti​on-​grade). For each statement, the con- The first report of robotic emergency surgery after sensus was assessed through a web survey (by means complicated robotic biliopancreatic diversion with duo- of a Google Form) open to all members of the steering denal switch was published by Sudan et al. in 2012 [24]. committee and panel of experts and to the members The robotic approach was preferred over open surgery in of the Board of Governors of the WSES. If a statement the management of postoperative complications in order reached < 70% of agreement, it was rediscussed via email de’Angelis et al. World Journal of Emergency Surgery (2022) 17:4 Page 7 of 12 Table 2 Quality assessment for the selected retrospective the need for a safe and efficient strategy starting from cohort studies according to the Newcastle Ottawa Scale (NOS) the standardization of the robotic platform setting and References Selection Comparability Outcome/ Overall score docking, up to the execution of the surgical procedure. exposure In order to successfully perform emergency cases with a robotic system, the on-call surgical team must be ade- Kubat et al. *** – *** 6/9 [22] quately trained with robotic technology. As reported by Anderson **** * *** 8/9 Robinson et al. [12] in a case series of 24 robotic emer- et al. [9] gency bariatric surgeries, which were compared to 20 Kudsi et al. *** – *** 6/9 laparoscopic procedures, the surgeon who adopted the [25] robotic approach was the same in all cases. It is the proof Hosein et al. *** * *** 7/9 that a specific attitude of the operator is fundamental. [21] However, it also highlights the need for a “can do” atti- Robinson **** * *** 8/9 et al. [12] tude from the entire surgical team [28]. The importance of the shared viewpoint is reinforced by Sudan et al. [24] who described the adoption of the robotic platform dur- ing the night and during the weekend in order for the or videoconference, modified, and resubmitted to the staff to be comfortable with this technology. In addi- experts’ vote until a consensus was reached. tion, proper team work and communication in such a The experts involved were also asked to describe their challenging workspace are required [29] as much as the current practice. The great majority (82.6%) worked in a completion of the learning curve for the entire surgical hospital equipped with a robotic surgical platform. How- team [30]. The ideal operating room team in an emer- ever, the access to the robotic surgical system for emer- gency setting should be made up of the first operating gency procedures appeared to be limited, with difficult surgeon with an extensive expertise in robotic surgery, availability (39.1%) only during the day (13%), or not an assisting surgeon familiar with the robotic technology, available at all (43.5%). and a scrub nurse dedicated to the robotic program. All PS-1. Robotic surgery in emergency settings is highly team members should work in a simulation environment dependent on the surgeon’s experience and should only before starting a robotic emergency surgery program. be performed in an appropriately equipped operating Limitations linked to the adoption of robotic surgery room with trained nursing staff. in emergency settings are related to the time required Supporting literature for robotic setting and docking and the accessibility of Robotic surgery requires a high level of technical the robotic platform for emergency surgical units. Con- expertise when compared to open or even laparoscopic cerning the time issue, Robinson et al. [12] reported that, surgery. A complete specialized training is required to be when the entire team is appropriately trained and pre- proficient in performing standardized surgical interven- pared, the in-room-to-surgery-start time is reduced and tions associated with acceptable operative and postop- has no significant impact on the overall duration of the erative outcomes [26]. In a recent article, Thomas et al. scheduled emergency procedure. However, in this study, [27] analyzed the robotic colorectal surgery activity of a the authors highlighted how the majority of the staff were tertiary colorectal unit and concluded that success relies familiar with the robotic technology, and there were no on a structured training curriculum, a dedicated surgical limitations to its accessibility. This may not be the case team, the institution’s support, and many other variables for all emergency care units, and trained nursing staff in addition to the training at the robotic console itself. may not be always available during night shifts. A good The adoption of the robot in the emergency setting does coordination between the hospital administration, the not change the rules of the game. Rather, it enhances surgeons, and the staff is the key point to have an efficient Table 3 Quality assessment for the selected case series/case reports according to Murad et al. [16] References Selection Ascertainment Causality Reporting Overall score Pedraza et al. [19] * ** ** * 6/8 Sudan et al. [24] * ** ** * 6/8 Felli et al. [10] * ** ** * 6/8 Milone et al. [23] * ** ** * 6/8 Ceccarelli et al. [21] * ** ** * 6/8 de’Angelis et al. World Journal of Emergency Surgery (2022) 17:4 Page 8 of 12 and extensive organization for the use of robotic technol- obstruction, a laparoscopic approach may be beneficial ogy, also in emergency surgery scenarios. despite the considerable risk of conversion to open sur- gery and the higher probability of bowel injuries [37]. In Level of evidence: case reports and case series → all of the abovementioned pathological states, the prereq- expert opinion uisite for a safe minimally invasive treatment is the selec- Strength of consensus (based on the survey evalua- tion of a stable patient. tion): 100% In terms of anesthetic management in emergency set- tings, the robotic approach can be considered as an alter- PS-2. Robotic surgery in emergency settings may be native to laparoscopy because it does not change the risk considered in highly selected clinically stable patients exposure but it may be associated with longer operative only. times if the surgical team is not properly trained. Addi- Supporting literature tional costs must also be considered. Further studies are Due to the very limited evidence in the literature and necessary in order to clarify the future role of a low pres- the consensus that robotic surgery required a high level sure pneumoperitoneum in emergency robotic surgery of expertise for the operating surgeon and the entire sur- [38]. gical team, particularly if performed in emergency set- tings, it should be considered for clinically stable patients Level of evidence: case reports and case series → only. expert opinion A recent review [31] on the anesthetic aspects of Strength of consensus: 94.6% robotic surgery suggested that when the surgical team gains confidence, even more complex operations or PS-3. Robotic surgery may be considered in challeng- patients with comorbidities can be considered candidates ing situations, which are foreseen as a reason for con- for the robotic approach. A precise preoperative assess- version to open surgery if operating in laparoscopy. ment based on a case-by-case evaluation, and multidis- Supporting literature ciplinary decision-making are crucial to guarantee the The available literature suggests that the main poten- choice of the most indicated surgical strategy. Even if a tial advantages of robotic surgery over laparoscopy are comprehensive preoperative assessment is not always related to suturing and dissection. In case of emergency possible in emergency situations, a careful patient selec- robotic surgery, the published studies described the fol- tion is advised in order not to expose frail or unstable lowing procedural steps: hiatoplasties [20, 21], ventral patients to longer emergency procedures or unnecessary suturing or mesh fixations [25], colonic suturing [19], complications related to the surgical technique. duodenal stump suturing [24], strictureplasty [24], and Indeed, in unstable patients or patients with cardio- dissection of inflamed gallbladder [22, 23] or colon [9]. pulmonary comorbidities, the adoption of MIS with All of these tasks are particularly challenging in lapa- the need for carbon dioxide insufflation may result in a roscopic surgery and they often lead to conversion to higher intra-abdominal pressure and hypercarbia with open surgery, which can also be a source of postopera- metabolic and respiratory changes which may be del- tive complications [39, 40]. The technological advances of eterious [32]. Osagiede et al. [11] showed that the pres- the robotic surgical platform, such as deep magnification, ence of a metastatic disease and the higher number of 3D stereoscopic vision, a stable field with elimination of comorbidities negatively influenced the adoption of MIS physiological tremors, motion scaling, and improved in emergency colorectal cancer surgery. Likewise, Arnold ergonomics as compared to laparoscopy, may contribute et al. [33] demonstrated that the adoption of MIS is con- to facilitate the performance of some difficult procedural fined to physiologically clinically stable patients while steps and reduce the risk of conversion. However, this those with abdominal gross contamination or severe remains to be proven, especially for surgical interven- infectious processes are more prone to undergo open tions performed in emergency settings. surgery. Despite this selection bias, when the results are corrected for preoperative risk factors, the adoption of Level of evidence: case reports and case series → laparoscopy is associated with a reduced wound infection expert opinion. rate, risk of death, and length of hospital stay. Strength of consensus: 83.8% (based on the survey Recently, emergency laparoscopy was evaluated as a evaluation) valid approach to the treatment of perforated diverticu- litis with generalized peritonitis [34], iatrogenic colo- PS-4. In a near future, robotic surgery may offer the noscopy perforations [35], and perforated peptic ulcers advantage of telementoring and telesurgery, which [36]. In addition, in simple cases of adhesive small bowel could be useful to promote a safe and standardized de’Angelis et al. World Journal of Emergency Surgery (2022) 17:4 Page 9 of 12 application of robotics, also in low-volume centers or be justified in the context of an efficient implementa- specific environments. tion of robotic surgery. Currently, the availability and Supporting literature accessibility of the robotic platforms for emergency One of the limitations of laparoscopic surgery is the care surgical units are very limited. absence of telementoring during a difficult procedure. Supporting literature Even if communicating systems dedicated to telemen- A consistently growing number of hospitals, mainly ter- toring are available, no opportunity for the direct con- tiary care and university-based hospitals, are acquiring a trol of movements is present in laparoscopy. In robotic robotic surgical platform in order to satisfy daily requests surgery, an in-person mentoring can be performed if a and advertise the most advanced technology. The robotic second robotic console is present in the hospital (such platform is often shared between different specialties, as telestration or tele-assisted surgery). In a near future, subsequently limited in terms of availability for a single it can be expected to perform telementoring during surgical field and not adaptable to changing schedules. In elective and emergency robotic procedures. After the this perspective, several reports suggested that the use of first transatlantic robot-assisted surgery performed by the robotic surgical platform by experienced teams could Jacques Marescaux in 2001 [41], the surgical community be prolonged to night hours and even to the weekend. was waiting for a routine use of telesurgery which, how- This approach was called “after hours” by Sudan et al. ever, was not feasible due to technical limitations. Today, [24], whose report aimed to highlight the potential of a thanks to the evolution of telecommunications, namely robotic system which is available 24 h/7 days per week. fifth generation (5G) networks, there is a growing oppor- The availability of the platform during the night shift tunity for a surgeon with a proven expertise in the field to could potentially favor a more cost-effective use of the remotely operate on a distant patient [42, 43]. A digital robotic system. However, this remains very limited and, connection with a reference center which can evaluate as previously highlighted, a proper attitude and excellent the case, suggest a solution, and eventually manage the training of the entire team are key to guarantee surgical surgical situation if need be, represents a powerful tool, proficiency and efficiently implement robotic surgery for especially in emergency settings. Indeed, in emergency emergency procedures. surgery where a maximal experience improves outcomes, Concerns for the adoption of robotics for emergency it would be beneficial to have a mentor observing and surgeries also persist in relation to the increased costs remotely participating in the intervention. Additionally, that a robotic surgical procedure implies also need to be this technology could be applied to provide surgical care justified in the context of an efficient implementation of to rural areas, to establish surgical collaborations, and to robotic surgery. eliminate the shortage of surgeons. This is also applicable for specific environments, such as in the space station, Level of evidence: case reports and case series → where an emergency medical condition has to be man- expert opinion aged by a trained component of the crew, or close to a Strength of consensus: 89.2% (based on the survey battlefield, where the surgeon may operate at a safe dis- evaluation) tance, or again at the bottom of the ocean [44]. Telesur- gery could well be an option in such situations. PS-6. The development of new modular robotic plat- However, these applications conceal some limitations forms may contribute to increase the applications of in terms of global network development, legal and ethical robotic surgery in emergency settings. issues, costs, and cyber security. These issues are under Supporting literature examination. However, despite the current skepticism, it The surgical marketplace was recently enhanced with is unquestionable that robotic surgery can have a pivotal several different robotic platforms either approved for role in developing telemedicine and telesurgery [45, 46]. human use, such as the CMR Versius (Cambridge Medi- cal Robotics, Cambridge, UK) and the Distalmotion Level of evidence: case reports and case series → Dexter (Distalmotion, Epalinges, Switzerland) or under expert opinion approval, such as the Medtronic Hugo (Medtronic Inc., Strength of consensus: 89.2% (based on the survey Minneapolis, USA). Most of them share the opportunity evaluation) of switching from a conventional laparoscopic setting to a robot-assisted one. This key point, which could be PS-5. The use of robotic surgery for unscheduled less relevant in elective surgery, should be carefully con- and urgent operations needs to be implanted without sidered when approaching emergency surgery. In fact, creating scheduling conflicts in the occupation of the when no specific port placement is required, the surgeon operating room. Moreover, the increased costs need to can simply use a different approach depending on the de’Angelis et al. World Journal of Emergency Surgery (2022) 17:4 Page 10 of 12 procedural step and on his/her own ability. In addition, The establishment of a dedicated registry is also man- these robotic platforms offer an improved vision with datory to perform a deep analysis on this technique, advanced near-infrared imaging, not routinely available in order to define the following: characteristics of the in laparoscopic surgery. The objective evaluation of tis- patient candidate for emergency robotic procedures, sue anatomy or perfusion could limit the surgical bias in operative and postoperative outcomes, PROMs, mini- emergency settings by mitigating the personal opinion mum requisites in terms of personnel and equipment, [47, 48]. cost-effectiveness, and ethical issues. In the future, advances in surgical technologies will offer multiple new opportunities, which are currently under development, like hyperspectral imaging [49] and Discussion robotic single-port surgery [50]. Their potential appli- Hospitals that are currently equipped with a robotic sur- cations and outcomes in emergency surgery need to be gical platform need to implement it efficiently. The role of evaluated and updated once evidence is available. robotic surgery for emergency procedures remains under investigation. However, its use is expanding despite the Level of evidence: case reports and case series → lack of evidence-based guidelines. In this scenario, the expert opinion WSES wished to provide this position paper to the sur- Strength of consensus: 94.6% (based on the survey gical community. This position paper summarizes the evaluation) current evidence and practice and proposes consensus statements to be reevaluated and updated as the evidence in the supporting literature emerges. For now, the experts recommend a strict patient selection while approach- Research agenda ing emergent general surgery procedures with robotics. The experts recognized that there is a substantial lack However, an emergency setting should not be seen as a of evidence to support the use of robotic surgery for contraindication for robotic surgery if adequate training emerging general surgery procedures. For this reason, a of the operating surgical team is available. When such research agenda has been proposed. prerequisites are met, robotic surgery can be considered safe and feasible, and surgical outcomes related to an • Observational (cohort study, case–control) and MIS approach are expected. Finally, the application of the interventional studies are anticipated to investigate robotic surgical platform may grow with improvements the applications and outcomes of robotic surgery in in telementoring and telesurgery, which are particularly emergency settings and to compare them with those valuable in emergency settings. obtained with laparoscopy and open surgery. • Future studies should evaluate patient preferences Abbreviations considering patient-related outcome measures MIS: Minimally invasive surgery; NOS: Newcastle–Ottawa Scale; PROM: Patient- (PROMs), including pain evaluation and mid-/long- related outcome measures; PS: Position statements; WSES: World Society of Emergency Surgery. term quality of life. • Future studies should evaluate the cost-effectiveness Acknowledgements of robotic surgery implementation in emergency set- The authors are grateful to Guy Temporal and Christopher Burel, professionals in medical English proofreading, for their valuable help. tings at hospital level (e.g., scheduling conflict alle- viation) and at the level of the healthcare system (e.g., Authors’ contributions length of hospital stay, productivity losses, reim- GB, FM, and NdeA conducted the systematic review of the literature and wrote the first draft of the manuscript. All authors were involved in the state‑ bursement systems). ment evaluation and consensus process. All authors critically reviewed the • Future studies should evaluate the applicability of the manuscript and approved the final version. All authors read and approved the robotic surgical platforms to perform telementoring final manuscript. and telesurgery, which are theoretically promising Funding technologies to expand the applications of robotic No funding or resources was received for the preparation of this article. The surgery. authors received a WSES institutional waiver for this publication. Availability of data and materials With the aim to enrich the available evidence and fill There are no data from individual authors that reach the criteria for availability. knowledge gaps, the WSES plans to launch an open reg- istry on emergency robotic general surgery. 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