Surgery – PICO #1

Brief description of patient problem/setting (summarize the case very briefly)

On the surgery floor you go to talk to a patient about a future appendectomy. The patient has read about robotic-assisted appendectomies. He wonders about if they are a better match for him over doing a laparoscopic appendectomy.

Search Question: Clearly state the question (including outcomes or criteria to be tracked)

In surgical patients undergoing an appendectomy, do robotic-assisted approaches to an appendectomy reduce operative time and time to discharge versus doing a laparoscopic appendectomy?

Question Type: What kind of question is this? (boxes now checkable in Word)

☐Prevalence                             ☐Screening                  ☐Diagnosis

☐Prognosis                              ☒Treatment                 ☒Harms

Assuming that the highest level of evidence to answer your question will be meta-analysis or systematic review, what other types of study might you include if these are not available (or if there is a much more current study of another type)? Please explain your choices.

– If meta-analysis or systematic review are not available, randomized controlled clinical trials will also offer great supporting evidence as they are carefully planned experiments, reduce the potential for bias, and allow for comparison between intervention and control groups.

– Cohort studies could also be used since they allow to follow the patients who have already received a particular treatment forward over time. This is not as reliable as randomized controlled clinical trials since patients might differ in ways other than in the variable that is being observed.

PICO search terms:

AppendectomyRobotic assisted appendectomiesLaparoscopic appendectomiesReduced operative time
Appendectomy Patients  Reduced time to discharge
Appendicitis Patients   
Patients with Appendicitis   

Search tools and strategy used:

Please indicate what data bases/tools you used, provide a list of the terms you searched together in each tool, and how many articles were returned using those terms and filters.
Explain how you narrow your choices to the few selected articles.

Results found:

TRIP Database

  • Robotic assisted appendectomy AND Laparoscopic appendectomy – 53


  • Robotic assisted appendectomy AND Laparoscopic appendectomy (in the last 10 years) – 24

Google Scholar

  • Robotic assisted appendectomy AND Laparoscopic appendectomy (in the last 10 years) – 16,500

Since robotics is a relatively new field of surgical medicine, I could not really find too many articles that much information on robot assisted appendectomies versus laparoscopic ones. There were many articles on open appendectomies versus laparoscopic ones, but going through my surgery rotation, it seems like open appendectomies are on their way out. I included an article on robotic assisted hysterectomies that yielded some great results versus conventional open hysterectomies.

Identify at least 3 articles (or other appropriate reputable sources) that answer your specific question with the highest available level of evidence (you will probably need to look at more than 3 articles to get the 3 most focused and highest-level articles to address your question). Please make sure that they are Medline indexed.

Please post the citation and abstract for each article (to include the journal and authors’ names and date) and say why you chose it.
Please also note what kind of article it is (e.g. meta-analysis, cohort study, or independent blind comparison with gold standard of diagnosis, etc.).

At the bottom of each abstract, please comment on what your key points are from this article (including any points or concepts included in the article, but not present in the abstract – i.e. make the concepts understandable to the reader)

Please note that if the evidence is not in the abstract, you must clearly summarize the evidence in your posting.

Citation: Becker, T., DeLeon, G., Rao, V., & Pei, K. Y. (2023). A comparison of outcomes between laparoscopic and robotic appendectomy among ACS-NSQIP hospitals. Laparoscopic, Endoscopic, and Robotic Surgery, 6(2), 39–42.
Type of article: Retrospective Cohort Study
Abstract   Objective Robotic general surgery remains controversial, with some employing the technology for common laparoscopic procedures such as appendectomies. Very few studies have compared robotic appendectomy (RA) to existing techniques, partly due to the relative scarcity of data. The purpose of this study was to compare outcomes for RA versus laparoscopic appendectomy (LA).   Methods This retrospective cohort study evaluated procedural specific databases of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) for appendectomy between January 2016 and December 2019 and included all available cases at the time of analysis (June 2021). Demographic and surgical outcomes including composite 30-day complications, specific complications, and length of operation were analyzed using a univariate analysis.   Results In total, there were 52,559 appendectomies in the NSQIP database between 2016 and 2019. Analysis was restricted to those who underwent minimally invasive approaches. In total, 49,850 patients were included in the analysis. Of those, 49,800 patients underwent LA, and 50 patients underwent RA. Participants who underwent RA were older (35.8 ± 4.5 y vs. 23.0 ± 0.2 y, p < 0.01). There was no difference in the total number of comorbidities (92.0% vs. 73.4%, p = 0.32) or the severity of appendicitis (p > 0.90) between RA and LA cases. RA had a longer median operation time (71.0 min vs. 46.0 min, p < 0.01) but a shorter postoperative stay (0.7 d vs. 1.3 d, p < 0.01). There was no difference in the frequency of readmission likely related to procedure (4.0% vs. 3.0%, p = 0.88) or complications (18.0% vs. 23.8%, p = 0.88); however, RA was associated with increased 30-day mortality (2.0% vs. <0.1%, p < 0.01) compared to LA.   Conclusion Our results demonstrated that LA and RA had a similar frequency and profile of complications. Robotic procedures took longer but resulted in shorter postoperative stays. Our study revealed that RA constituted a mere 0.1% of all cases, with only 50% showing pathology consistent with appendicitis, despite 92.2% of LA cases presenting with the condition. Despite our findings of RA offering some benefit, more research is necessary, particularly regarding outcomes and value delivery.
Key Points: This retrospective cohort study research was comprised of 49,850 appendectomies49,800 of those appendectomies were done laparoscopically, while 50 of them were done roboticallyPatients who underwent robotic assisted appendectomies had longer operation times than those who underwent laparoscopic appendectomies, but had a shorter post-operative hospital stay timeThere were no differences in perioperative complications There were also as no differences in frequency in readmission
Why I chose it: I chose this article because it was one of the few articles that took on robotic assisted appendectomies versus laparoscopic ones. There were not that many robotic-assisted appendectomies, but it was enough to show that while robotic-assisted appendectomies took longer to complete, it did result in shorter hospital stays for the patient which is both a win for the patient and the hospital.  
Citation: Rifai, A. O., Rembetski, E. M., Stutts, L. C., Mazurek, Z. D., Yeh, J. L., Rifai, K., Bear, R. A., Maquiera, A. J., & Rydell, D. J. (2023). Retrospective analysis of operative time and time to discharge for laparoscopic vs robotic approaches to appendectomy and cholecystectomy. Journal of robotic surgery, 17(5), 2187–2193.
Type of article: Retrospective Cohort Study
Abstract:   Robotic-assisted appendectomies and cholecystectomies are believed to increase cost compared to the gold standard laparoscopic approach. Two equally qualified surgeons performed both approaches over 2 years to evaluate intraoperative duration, time to discharge, conversion to open procedure, and readmission within 30 days. 110 laparoscopic, 81 robotic-assisted appendectomies; and 105 laparoscopic and 165 robotic-assisted cholecystectomies were performed. Intraoperative time; laparoscopic appendectomy was 1.402 vs 1.3615 h for robotic-assisted (P value = 0.304); laparoscopic cholecystectomy was 1.692 vs 1.634 h for robotic-assisted (P value = 0.196). Time to discharge, was 38.26 for laparoscopic vs 28.349 h for robotic-assisted appendectomy (P value = 0.010), and 35.95 for laparoscopic vs 28.46 h for robotic-assisted cholecystectomy (P value = 0.002). Intraoperative conversion to open; only laparoscopic procedures were converted, one appendectomy and nine cholecystectomies. None in the robotic-assisted procedures. Readmissions, none in the appendectomy group and three in the cholecystectomy group. One laparoscopic and two robotic-assisted cholecystectomy patients were readmitted. Intraoperative times for robotic appendectomy and cholecystectomy were not longer than laparoscopic approach. Robotic approach shortened the time to discharge and the likelihood for conversion to open procedure.
Key Points: This article included 191 patients who had appendectomies110 of the patients had conventional laparotomies for their appendicitisThe other 81 patients had robot-assisted appendectomies This study evaluated if there was no difference in time spent in the operating room and the time it took to discharge the patient between both routes of appendectomies Other factors that were also looked at was whether the laparoscopic or robot assisted surgery had to be converted to an open procedure because a situation arose during surgery, as well as looking at readmission for those patients back into the hospital within 30 days Both the laparoscopic and robot assisted appendectomies had similar interoperative times, however patients who had laparoscopic appendectomies took longer to discharge from the hospital than the robotic assisted onesNone of the robotic assisted appendectomies converted into an open surgery, while one of the laparoscopic ones did convert to an open None of the patients who had appendectomies, whether they were laparoscopic or robot assisted, needed to be readmitted back into the hospital because of any complications
Why I chose it: I chose this article because there were many factors that made up the study. There was an almost equal split between the patients who had the surgery laparoscopically versus those who had it with robot assistance. The study itself showed that patients who went through robotic-assisted appendectomies spent less time in the hospital as well as recovered much quicker from the surgery. Additionally, none of the patients had to be converted to an open surgery because of a complication that arose.
Citation: Van Weelden, W. J., Gordon, B. B. M., Roovers, E. A., Kraayenbrink, A. A., Aalders, C. I. M., Hartog, F., & Dijkhuizen, F. P. H. L. J. (2017). Perioperative surgical outcome of conventional and robot-assisted total laparoscopic hysterectomy. Gynecological surgery, 14(1), 5.
Type of article: Retrospective Cohort Study
Abstract Background: To evaluate surgical outcome in a consecutive series of patients with conventional and robot assisted total laparoscopic hysterectomy. Methods: A retrospective cohort study was performed among patients with benign and malignant indications for a laparoscopic hysterectomy. Main surgical outcomes were operation room time and skin to skin operating time, complications, conversions, rehospitalization and reoperation, estimated blood loss and length of hospital stay. Results: A total of 294 patients were evaluated: 123 in the conventional total laparoscopic hysterectomy (TLH) group and 171 in the robot TLH group. After correction for differences in basic demographics with a multivariate linear regression analysis, the skin-to-skin operating time was a significant 18 minutes shorter in robot assisted TLH compared to conventional TLH (robot assisted TLH 92m, conventional TLH 110m, p0.001). The presence or absence of previous abdominal surgery had a significant influence on the skin-to-skin operating time as did the body mass index and the weight of the uterus. Complications were not significantly different. The robot TLH group had significantly less blood loss and lower rehospitalization and reoperation rates. Conclusions: This study compares conventional TLH with robot assisted TLH and shows shorter operating times, less blood loss and lower rehospitalization and reoperation rates in the robot TLH group.
Key Points: This study looked at 294 patients that went through hysterectomies123 of those patients had conventional total laparoscopic hysterectomies171 patients had robotic-assisted total laparoscopic hysterectomiesPatients who had conventional total laparoscopic hysterectomies spent an average of 190 minutes in the OR, while patients who had the robotic-assisted total laparoscopic hysterectomies spent an average of 170 minutes in the ORReadmission to the hospital was significantly more prevalent for the conventional group than the robotic-assisted one. There were 13 patients who had to be readmitted back into the hospital with the conventional group versus 7 patients in the robotic group.The patients who had robotic-assisted total laparoscopic hysterectomies lost an average of 25ml of blood, while the patients who went through the conventional route lost an average of 100ml of bloodPatients who had the conventional surgery stayed an average of 4 days in the hospital recovering, while those who had the robotic-assisted surgery stayed an average of 3 days
Why I chose it: I chose this article because while it did not talk about robotic-assisted appendectomies, it did talk about a more invasive and relatively more complicated surgery. As the field of robotics grows, so will the risks on doing more and more tricky procedures. There was a large group of patients that made up this study and it ultimately showed that robotic-assisted total laparoscopic hysterectomies induced shorter times in the operating room, much less blood loss during the operation itself and much lower readmission rates than going through a conventional total laparoscopic hysterectomy.

What is the clinical “bottom line” derived from these articles in answer to your question?

In the early 2000s, the laparoscopic appendectomy was considered the gold standard over having open surgery. As the years came through, robotic assisted surgeries have gained more traction with more cholecystectomies, appendectomies, hysterectomies, and much more. The field of robotic-assisted surgery is very new, and a lot more information and data are needed to see if it might one day become the gold-standard. From what I could gather, patients who received robotic-assisted appendectomies spent less time in the hospital, and could recover much faster and sooner, than their laparoscopic counterparts. If asked, and if the option was available, I would advise my patient that robotic-assisted appendectomies are a great way to go.

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