Minimally invasive surgery (MIS), comprised of laparoscopic surgery and robotic surgery, has been a validated, widely adopted alternative to open surgery for several decades. First reported in 1910, laparoscopic techniques were initially criticized and did not gain traction until much later in the century [1]. Today, approximately 15 million MIS procedures are performed annually, with the United States accounting for nearly 5 million cases [2]. These numbers continue to rise each year, creating a greater demand for MIS platforms, programs, and trained personnel.

MIS has profound benefits compared to open surgery, the most notable being reductions in operative and postoperative complications, hospital stay, recovery time, and postoperative pain [3]. MIS techniques have been implemented across most surgical subspecialties and have become the gold standard approach for the diagnosis and treatment of many thoracic and abdominal disorders. Some commonly performed MIS procedures are cholecystectomy, appendectomy, and hysterectomy [4,5,6]. Historically, these are more frequently performed in the ambulatory setting.

Within MIS, laparoscopic surgery and robotic surgery are comparable in terms of morbidity and mortality outcomes. Some studies have even reported lower total complication rates in patients undergoing robotic surgery, specifically for hysterectomy, gastrectomy, and rectal cancer resection procedures [7]. Though rates of conversion to open surgery and total postoperative length of stay are not significantly different between laparoscopic surgery and robotic surgery as a whole, several studies investigating specific surgical procedures have associated robotic surgery with lower conversion rates and shorter length of stay [8,9,28].

With advancements in minimally invasive surgical techniques, increasingly more procedures are being performed using robotic platforms. Thus, the ability to operate robotically is becoming a vital skillset required of all surgeons. Acute care surgeons are often urgently consulted intraoperatively to evaluate acute pathologies and intervene rapidly. Without surgeon knowledge of robotic systems, patients may be subjected to more invasive procedures, leading to increased morbidity, lengths of stay, and recovery times. Exposure to robotic surgery has become a part of fellowship training in other programs across the country [35] and remains a core component of OSU’s curriculum at both the residency and fellowship levels. Our surgical residents and fellows routinely participate in robotic cases across all years of their training, underscoring the importance of such training in the foundational development of surgeons.

Though robotic surgery has been emerging as a modality for the management of acutely ill patients, the availability of robotic platforms on short notice remains challenging during typical business hours. Scheduled robotics cases often utilize available consoles during working daytime hours – hours which acute care cases do not necessarily conform to. Our experience at OSU has demonstrated the importance of multidisciplinary collaborations to make additional staff and resources available for robotics cases to proceed at any hour. Previous work has demonstrated that robotic procedures like cholecystectomy that occur outside of typical business hours are equally as safe as those that occur during the day [36].

Engaging all participatory parties in the development of OSU’s robotics program was a key component to its early success. Prior to the program’s development, robotic surgery cases were solely performed on an elective basis at OSU. This meant, previously, operating room staff had at least one day to prepare for cases. With the introduction of daily add-on robotics cases, the streamlined, advance preparation of universal robotic case carts by Central Sterile Supply staff members was essential to feasibly integrate additional robotics cases into daily operations. Collaboration between faculty and operating room staff led to the creation of a standardized acute care surgery set that could be applied to most cases completed within the Division of Trauma, Critical Care, and Burns.

Surgical robotics training for not only surgeons but also operating room staff was another crucial component of the program. OSU surgical residents and fellows were provided ample opportunities to practice on robotic platforms through virtual reality simulations and to hone their skills in the operating room during live cases. Current surgical faculty were offered robotics training through an apprenticeship model, derived through a close partnership with colleagues specializing in elective minimally invasive surgery. As surgeons completed cases on an elective basis and gained the confidence and competence necessary to complete cases independently, they graduated from apprentices and became teachers to new apprentices. Interested operating room staff were provided formal training in robotic assistant duties, both by surgical faculty and by the Intuitive Surgical, Inc. Representative. After those who were interested were trained, additional efforts have continued, and all staff are now trained to participate in these cases.

This peer-inclusive, growth-oriented model allowed for a gradual expansion of individuals at OSU with surgical robotics expertise. This subsequently increased the availability of trained individuals and the possibility of completing a robotics procedure at any given time. At first, our institution underwent a three-month trial period where cases were carefully selected with interested staff members as well as our Intuitive, Inc. representative, who all volunteered to be available as a call team when a potential case was identified. This allowed for the early identification of any possible pitfalls which could be addressed before additional expansion. Now, multiple surgical teams can be assembled around the clock for emergent cases, limited only by the availability of a robotic platform and robotically capable operating room. Resources can be quickly organized for emergent add-on robotics cases in the same way they are coordinated for other modalities. Again, we emphasize the importance of a coordinated effort by all invested team members to successfully scale up the team’s robotic proficiency and capacity for additional cases. As a continued effort to provide quality care in this setting, our surgeons and operating room staff work in conjunction to evaluate all cases completed robotically with special attention to cases completed outside of regular business hours to ensure the appropriateness of case selection and utilization of resources during this time. There are limitations to the generalizability of this study as it was performed at a single, large academic medical center. Additionally, we did not distinguish between elective verses non-elective operative cases in our initial assessment of the ability to scale our program.

In conclusion, robotic surgery is a validated, safe method for surgical intervention of many acute care pathologies, and its applications should continue to be expanded. Through implementation of robotic surgery programs such as the one outlined in this study, medical centers may be able to complete both outpatient and emergent robotic surgery cases on a 24-h basis. Collaborating openly with all stakeholders in the robotic operating room environment and working to address unique barriers to completion of safe, standardized robotic cases at each institution will be key to individual programs’ success. Additional studies from our group will seek to compare outcomes from the use of robotics in acute care surgery to more traditional modalities of acute care surgery. Special attention will be given to comparison of cases completed electively through our group as well as add-on or after-hours cases. We hope to use these data to determine which patients may benefit most from robotic surgery intervention as well as how our robotics program can address disparities for patients undergoing acute care surgery.