Robotic surgery in emergency setting: 2021 WSES position paper
Authors: de’Angelis Nicola , Khan Jim , Marchegiani Francesco , Bianchi Giorgio , Aisoni Filippo , Alberti Daniele , Ansaloni Luca , Biffl Walter , Chiara Osvaldo , Ceccarelli Graziano , Coccolini Federico , Cicuttin Enrico , D’Hondt Mathieu , Di Saverio Salomone , Diana Michele , De Simone Belinda , Espin-Basany Eloy , Fichtner-Feigl Stefan , Kashuk Jeffry , Kouwenhoven Ewout , Leppaniemi Ari , Beghdadi Nassiba , Memeo Riccardo , Milone Marco , Moore Ernest , Peitzmann Andrew , Pessaux Patrick , Pikoulis Manos , Pisano Michele , Ris Frederic , Sartelli Massimo , Spinoglio Giuseppe , Sugrue Michael , Tan Edward , Gavriilidis Paschalis , Weber Dieter , Kluger Yoram , Catena Fausto 
Published: January 2022

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 particularly valuable in emergency situations.

Conclusions
Many hospitals are currently equipped with a robotic surgical platform which needs to be implemented efficiently. The role of robotic surgery for emergency procedures remains under investigation. However, its 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.