1 SUBMITTED 22 JAN 23 1 REVISION REQ. 20 MAR 23; REVISION RECD. 2 APR 23 2 ACCEPTED 16 MAY 23 3 ONLINE-FIRST: JULY 2023 4 DOI: https://doi.org/10.18295/squmj.7.2023.043 5 6 Robotic Appendicectomy 7 A review of feasibility 8 Hossein Arang1 and *Michael El Boghdady2,3 9 10 1King’s College NHS Foundation Trust, London, UK; 2Department of General Surgery, Guys’ 11 and St Thomas’ Hospital NHS Foundation Trust, London, UK; 3University of Edinburgh, 12 Scotland, UK. 13 *Corresponding Author’s e-mail: michael.elboghdady@nhs.net 14 15 Abstract 16 Acute appendicitis is one of the most common abdominal emergencies. There has been an 17 increasing trend in the use of robotic surgery in abdominal surgery. However, it remains 18 underutilised in emergency surgeries. We aimed to systematically review robotic 19 appendicectomies (RA) feasibility. A 20-year systematic review was performed in 20 compliance with PRISMA guidelines. MERSQI score was applied for quality assessment. 21 The research protocol was registered with PROSPERO. The search resulted in 1242 citations, 22 of which 9 articles were included. Quality scores mean:10.72(SD=2.56). The endpoints 23 across the studies were: rate of conversion to open surgery, length of hospital stay, blood loss 24 and operative time. RA is safe and feasible technique in elective and emergency settings with 25 minimal blood loss. The operating time and the hospital stay were within acceptable limits. 26 The major drawback of robotic surgery is its high cost and limited availability. Future studies 27 are recommended to evaluate RA with a focus on its application during emergency and on its 28 cost-effectiveness. 29 Keywords: Robot Surgery; Robotic-Assisted Surgery; Robot Enhanced Surgery; Robotic 30 Surgical Procedure; Appendectomy; Appendicectomy; Robotic Appendicectomy; 31 Gastrointestinal Surgical Procedure. 32 33 2 Introduction 34 Acute appendicitis is known to be the most common abdominal surgical emergency in the 35 world, with around 50,000 acute appendicectomies performed annually in the UK.1 36 Laparoscopic appendicectomy (LA) is considered the gold-standard management and is 37 recommended over open appendectomy in all patient groups.2,3 However, the COVID-19 38 pandemic brought a new challenge for surgeons undertaking laparoscopic procedures, with its 39 safety being debated out of fear of contaminated aerosol transmission to healthcare 40 workers.4,5 41 42 Over the last decade, there has been an increasing trend in the routine use of robotic surgery 43 in several surgical specialties and nearly all surgical subspecialties have adopted it.6,7 The use 44 of the robotic system is known to improve precision, visualisation, spatial flexibility, and 45 stability, compared with traditional laparoscopic techniques.8,9 In particular, robotic surgery 46 has shown to reduce the risk of potential viral transmission to the surgeons and theatre staff 47 as it allows them to be remote from the patient and each other.4,10,11 Although routinely used 48 in elective cases, robotic surgery remains generally unexplored and potentially underutilised 49 in emergency surgeries.9,12,13 50 51 This study aimed to systematically review robotic appendicectomy (RA) procedures in 52 elective and emergency settings and study its indications and feasibility. 53 54 Methods 55 This study was registered with PROSPERO register for systematic reviews. The systematic 56 review was performed in compliance with the PRISMA guidelines.14 57 58 Search strategy 59 A 20-year literature search using the search terms’’ robotic appendectomy’’ and ‘’robotic 60 appendicectomy’’ was carried out on PubMed, ScienceDirect and Cochrane databases for 61 articles published from 2002 to April 2022 [Figure 1]. Mesh terms were used and did not 62 reveal any new relevant citations. 63 64 Inclusion and exclusion criteria 65 All citations directly related to robotic appendicectomy were included in this study. 66 Conference abstracts, letters to editors and non-English publications were excluded. 67 3 68 Procedure 69 The procedure comprised of two authors for citations inspection, which were systematically 70 reviewed against the inclusion and exclusion criteria. The final list of citations was completed 71 in consensus between the two authors. The search items were studied from the nature of the 72 article, the date of publication, the aims and findings of the studies in relation to the robotic 73 appendicectomy procedures and the type of robotic system used. In case the type of robotic 74 system was not clearly mentioned in the manuscripts, corresponding authors were contacted 75 for confirmation of the included type of robotic surgery. In only one study, the type of the 76 used robotic system was not clearly mentioned, and authors were not reachable. 77 78 Quality assessment and synthesis 79 The retrieved citations were read for further assessment for eligibility. Our method for 80 identifying and evaluating data complied with the PRISMA checklist and has been reported 81 in line with assessing the methodological quality of systematic reviews (AMSTAR 2).15 82 There was a good compliance with Amstar 2 tool. Reporting ‘’Yes’’ in 11 criteria and 83 ‘’partial yes’’ in two. The ‘’no’’ were related to meta-analysis, which was not applicable in 84 this study. 85 86 The Medical Education Research Study Quality Instrument (MERSQI) was used for quality 87 assessments of studies.16 This score contains 10 items that reflect 6 domains of study quality 88 including study design, sampling, type of data, validity, level of data analysis, and outcomes. 89 The score represented the mean of two independent assessors’ quality estimations of each 90 citation. MERSQI’s maximum score was 18 with a potential range from 5 to 18. The 91 maximum score for each domain was 3. The mean quality score was calculated to be 10.72 92 (SD= 2.56) = Moderate quality score of citation ~ 11. High quality score was ≥13 and Low-93 quality score was 5-9. 94 95 Risk of bias within and across studies 96 The risk of bias was assessed in a blind manner; and we calculated the mean score between 97 two raters if the scores did not match. We also controlled for accumulated risk of bias by 98 grading the body of evidence of the findings according to MERSQI score. 99 100 4 Results 101 Citation selection and characteristics 102 This 20-year systematic search resulted in 1346 citations. After scanning the titles and 103 abstracts, relevant citations were extracted (Fig. 1). The inclusion and exclusion criteria were 104 applied, duplicated and irrelevant citations were excluded. A final list of 9 citations was 105 suitable to the research rationale. The full texts of the articles were read by two authors for 106 further evaluation. The tabular analysis of the citations for RA procedures is presented in 107 Table 1, which comprises details about studies such as the published journals, aims and 108 findings of the studies, robotic system, quality scores and evidence grades of the studies.17 to 109 25 110 111 Risk of bias within and across studies 112 We applied MERSQI scores in our systematic review as it has been demonstrated to be a 113 reliable and valid instrument for measuring methodological quality in research.16 In addition, 114 to decrease the risk of bias within studies in our systematic review, we excluded 115 recommendations, letters to editors, abstracts and commentaries. The full texts of the 116 retrieved citations were read for further assessment for eligibility. There was risk of bias 117 within studies, which consisted of the small number of papers that studied RA procedures; 118 however, there was a good number of RA procedures included in the included cohort studies. 119 120 Results of quality and evidence-grade assessments 121 For the included citations, the mean quality score was calculated to be 10.72 (SD= 2.56) and 122 the scores ranged from 6.5 to 13.5, with 4 high quality, 2 moderate and 3 low quality studies. 123 124 Results of individual studies 125 A total of 174 procedures were included in this review, 161 elective, 12 emergency and one 126 interval RA. Four citations reached high quality through MERSQI scores. Only one study did 127 not specify the exact number of the included RA procedures. 128 129 Akl et al.’s retrospective analysis of 107 patients underwent elective RA in conjunction with 130 other robotic gynaecological procedures between 2004 and 2007 was performed. The main 131 objective was to evaluate the feasibility and safety of RA. The patients had a postoperative 132 follow-up period of at least six weeks. The researchers encountered no perioperative 133 complications related to concomitant during gynaecological procedures with no conversion 134 5 required in any of the procedures. Additionally, the researchers found that RA could be 135 performed effectively without significantly affecting the operative time. 136 137 Bütter et al.’s study aimed to measure the outcome of the first paediatric da Vinci surgery 138 programme in Canada among 41 children. All the procedures were completed without the 139 need for conversion to open or laparoscopic surgery. The researchers found that the use of the 140 robotic system offered them a significant advantage compared to laparoscopic surgery. These 141 included: markedly enhanced magnification and 3D visualisation, increased instrument 142 dexterity and improved precision and ease of suturing. 143 144 Hüttenbrink et al.’s study aimed to investigate the safety and benefit for 53 patients 145 undergoing incidental RA during robotic-assisted laparoscopic radical prostatectomy 146 (RALRP) between 2012 and 2014. The findings supported the consideration of the 147 coincidental RA as no intraoperative or postoperative complications were encountered. In 148 addition, the median hospital stay was 5 days, which was similar when compared to other 149 RALRP procedures during the same period. 150 151 Quilici et al.’s citation included a cohort study of 34,984 patients in which the value, cost and 152 fiscal impact of robotic procedures for abdominal surgeries were compared to open and 153 laparoscopic counterparts. The cost of RA was significantly higher compared to the 154 laparoscopic technique with an average total cost per case of $13,210 versus $7709 for LA, 155 respectively. In addition, the mean duration of robotic surgery was longer when compared to 156 laparoscopic technique in abdominal surgery. However, this study contained few RA 157 procedures, which made it difficult to obtain a valid comparison between the different 158 surgical approaches. Furthermore, the use of robotic technology for abdominal surgical 159 procedures provided no significant difference in clinical outcomes versus the other surgical 160 techniques. 161 162 Synthesis of the studies 163 There was difference in the endpoints across the studies. These included: rate of conversion 164 to open surgery, length of postoperative hospital stays, intraoperative blood loss and 165 operative time. The length of hospital stay mean was 5.2 and estimated blood loss 22.5 ml. 166 167 6 Conversion rate and intra-operative complications 168 Akl et al. evaluated the safety and feasibility of elective RA during gynecologic robotic 169 surgery.17 In this study of 107 patients, none required conversion to laparoscopic or open 170 surgery. Another study by Hüttenbrink et al. reported on 53 patients who underwent elective 171 RA during robotic-assisted laparoscopic prostatectomy (RALRP).22 The researchers reported 172 no intraoperative or postoperative complications related to incidental RA and encouraged its 173 consideration for patients scheduled for robotic-assisted prostate surgery. 174 175 Length of stay 176 Kelkar et al. aimed to analyse the safety and effectiveness of the Versius surgical system in 177 its first-in-human use of 30 patients undergoing gynaecological or general surgical 178 procedures.24 Four patients with acute appendicitis underwent emergency RA with an average 179 length of hospital stay of 4 days (2-7 days). 180 181 Yao et al. evaluated the feasibility and safety of the surgical robot, Micro Hand S. Between a 182 total of 81 cases of robotic surgery, 3 patients had emergency RA for acute appendicitis with 183 an average postoperative hospital stay of 6.3 days. 23 184 185 Hüttenbrink et al. reported an average postoperative hospital stay of 5 days for elective RA 186 during RALRP vs 6 days for all other RALRP performed in the same period of time.22 187 188 Estimated Blood loss 189 Kelkar et al.reported that the estimated blood loss was negligible (<5ml) in all four patients 190 who had an emergency RA for acute appendicitis.24 Yao et al. reported an intraoperative 191 blood loss of 40.0 ml amongst the 3 patients who had emergency RA. 23 192 193 Operative time 194 Kelkar et al. reported a median operative time of 105 min (80-135 min) amongst the four 195 emergency RA with Yao et al. reporting a similar operative time of 130.0 min between the 196 emergency RA cases.23, 24 197 198 Akl et al. reported an average time of 3.4 min (range 2-6) for RA after measuring the 199 operative time of 10 consecutive robotic cases.17 The authors concluded that RA can be 200 performed effectively without any significant difference in the operative time. 201 7 202 On the other hand, Quillici et al. concluded that the mean duration of robotic surgery was 203 significantly longer when compared to laparoscopic surgery; however, there were too few RA 204 to obtain a valid comparison between the different surgical approaches. 25 205 206 Discussion 207 To our knowledge, this is the first review to study robotic appendicectomy procedures. Our 208 study showed that RA can be considered as a feasible and safe technique, mainly in elective 209 settings. Indications of RA were acute and chronic appendicitis, mucocele resection, as well 210 as being performed in conjunction with other robotic gynaecological and urological 211 procedures. 212 213 Laparoscopic appendicectomy remains the gold standard for the management of appendicitis, 214 due to its benefits such as the lower incidence of wound infections, less postoperative pain 215 and shorter hospital stay in comparison to open appendicectomy.26 Whilst the available 216 literature on the use of robotic surgery in appendicectomy is somewhat limited, surgeons 217 have reported more dexterity, greater precision, better visualisation and improved range of 218 motion with its utilisation in abdominal surgery.8, 9, 27 These major features have led to its 219 widespread adoption in difficult operative access and technically challenging procedures.28 220 221 Particularly in light of the Covid-19 pandemic, surgeons considered robotic surgery as a safe 222 alternative to clear the backlog of operations whilst reducing the risk of potential viral 223 transmission. The offered advantages of robotic surgery include operating with lower 224 pneumoperitoneum pressures, reducing the length of hospital stay and minimising contact 225 between the patient and healthcare workers during surgery after trocars placement.11, 29, 30 226 227 Despite the advantages, drawbacks of robotic surgery still include limited availability and 228 additional specialised surgical robotic training. In addition, the increased cost of robotic 229 surgery remains one of its main limitations when compared to laparoscopic or open surgery. 230 The robotic surgery requires specialised training and its cost of acquiring, operating and 231 maintaining a surgical robotic system is significantly more expensive when compared to 232 other surgical techniques.25, 31, 32 233 234 8 Our study included three robotic systems: the da Vinci robot, the Versius and the Micro Hand 235 S. The da Vinci robot launched in 1999 and has remained the predominant robotic surgical 236 system for over 20 years. However, with a cost of £1.7 million per robot, £1,000 per patient 237 for disposables and £140,000 maintenance fees per year, newer cost-effective systems have 238 emerged to improve on the da Vinci.33, 34 The novel Micro Hand S has demonstrated 239 significantly lower hospitalisation and operative costs in comparison to the da Vinci robotic 240 system, (p< 0.05). The surgical instruments of the Micro Hand S have unlimited use whereas 241 the instruments of the da Vinci surgical robot have a 10-use limit. Furthermore, the surgical 242 instruments of the Micro hand S robot cost about 1,000 yuan per set which is roughly 243 equivalent to £119 vs 2,000 yuan per set for the da Vinci, which is roughly equivalent to 244 £239.35, 36 The Versius surgical system is the first UK built surgical robot and is said to be the 245 next major rival to the da Vinci. Although reports are limited about specific costs of the novel 246 system, the Versius robot offers the advantages of being smaller, more versatile and more 247 portable, improving its cost-effectiveness.34 248 249 The main limitation of this review was the limited number of citations that studied RA and 250 the absence of randomised trials during this 20-year period. However, there was a good 251 number of procedures in the cohort studies included in this review. Future research is needed 252 to further evaluate the strengths and weaknesses of each robotic surgical system in 253 appendicectomy, with a particular focus on its application during emergency settings and on 254 its cost-effectiveness. 255 256 Conclusion 257 The present review included studies revealing robotic appendicectomy as a safe and feasible 258 technique. RA could be performed effectively without the need for conversion and minimal 259 blood loss. The operating time and the hospital stay were within acceptable limits. However, 260 the major drawback of robotic surgery is its high cost. Future studies are recommended to 261 further evaluate the different robotic surgical systems in appendicectomies, with a focus on 262 its application during emergency procedures and on its cost-effectiveness. 263 264 References 265 1. Baird, D., Simillis, C., Kontovounisios, C., Rasheed, S., & Tekkis, P. P. (2017). Acute 266 appendicitis. BMJ (Clinical research ed.), 357, j1703. 267 https://doi.org/10.1136/bmj.j1703 268 https://doi.org/10.1136/bmj.j1703 9 2. Sauerland, S., Jaschinski, T., & Neugebauer, E. A. (2010). Laparoscopic versus open 269 surgery for suspected appendicitis. The Cochrane database of systematic reviews, 270 (10), CD001546. https://doi.org/10.1002/14651858.CD001546.pub3 271 3. Page, A. J., Pollock, J. D., Perez, S., Davis, S. S., Lin, E., & Sweeney, J. F. (2010). 272 Laparoscopic versus open appendectomy: an analysis of outcomes in 17,199 patients 273 using ACS/NSQIP. Journal of gastrointestinal surgery : official journal of the Society 274 for Surgery of the Alimentary Tract, 14(12), 1955–1962. 275 https://doi.org/10.1007/s11605-010-1300-1 276 4. El Boghdady M, Ewalds-Kvist BM. Laparoscopic Surgery and the debate on its 277 safety during COVID-19 pandemic: A systematic review of recommendations. 278 Surgeon. 2021 Apr;19(2):e29-e39. doi: 10.1016/j.surge.2020.07.005. Epub 2020 Aug 279 11. PMID: 32855070; PMCID: PMC7418789. 280 5. BJS Commission Team, BJS commission on surgery and perioperative care post-281 COVID-19, British Journal of Surgery, Volume 108, Issue 10, October 2021, Pages 282 1162–1180, https://doi.org/10.1093/bjs/znab307 283 6. Sheetz, K. H., Claflin, J., & Dimick, J. B. (2020). Trends in the Adoption of Robotic 284 Surgery for Common Surgical Procedures. JAMA network open, 3(1), e1918911. 285 https://doi.org/10.1001/jamanetworkopen.2019.18911 . 286 7. de'Angelis, N., Khan, J., Marchegiani, F., Bianchi, G., Aisoni, F., Alberti, D., 287 Ansaloni, L., Biffl, W., Chiara, O., Ceccarelli, G., Coccolini, F., Cicuttin, E., 288 D'Hondt, M., Di Saverio, S., Diana, M., De Simone, B., Espin-Basany, E., Fichtner-289 Feigl, S., Kashuk, J., Kouwenhoven, E., … Catena, F. (2022). Robotic surgery in 290 emergency setting: 2021 WSES position paper. World journal of emergency surgery : 291 WJES, 17(1), 4. https://doi.org/10.1186/s13017-022-00410-6 292 8. Ran, L., Jin, J., Xu, Y., Bu, Y., & Song, F. (2014). Comparison of robotic surgery 293 with laparoscopy and laparotomy for treatment of endometrial cancer: a meta-294 analysis. PloS one, 9(9), e108361. https://doi.org/10.1371/journal.pone.0108361 295 9. Roh, H. F., Nam, S. H., & Kim, J. M. (2018). Robot-assisted laparoscopic surgery 296 versus conventional laparoscopic surgery in randomized controlled trials: A 297 systematic review and meta-analysis. PloS one, 13(1), e0191628. 298 https://doi.org/10.1371/journal.pone.0191628 299 10. Kimmig, R., Verheijen, R., Rudnicki, M., & for SERGS Council (2020). Robot 300 assisted surgery during the COVID-19 pandemic, especially for gynecological cancer: 301 https://doi.org/10.1002/14651858.CD001546.pub3 https://doi.org/10.1007/s11605-010-1300-1 https://doi.org/10.1093/bjs/znab307 https://doi.org/10.1001/jamanetworkopen.2019.18911 https://doi.org/10.1186/s13017-022-00410-6 https://doi.org/10.1371/journal.pone.0108361 https://doi.org/10.1371/journal.pone.0191628 10 a statement of the Society of European Robotic Gynaecological Surgery (SERGS). 302 Journal of gynecologic oncology, 31(3), e59. https://doi.org/10.3802/jgo.2020.31.e59 303 11. Moawad, G. N., Rahman, S., Martino, M. A., & Klebanoff, J. S. (2020). Robotic 304 surgery during the COVID pandemic: why now and why for the future. Journal of 305 robotic surgery, 14(6), 917–920. https://doi.org/10.1007/s11701-020-01120-4 306 12. Sudan, R., & Desai, S. S. (2012). Emergency and weekend robotic surgery are 307 feasible. Journal of robotic surgery, 6(3), 263–266. https://doi.org/10.1007/s11701-308 011-0289-0 309 13. Osagiede, O., Spaulding, A. C., Cochuyt, J. J., Naessens, J. M., Merchea, A., 310 Crandall, M., & Colibaseanu, D. T. (2019). Factors Associated With Minimally 311 Invasive Surgery for Colorectal Cancer in Emergency Settings. The Journal of 312 surgical research, 243, 75–82. https://doi.org/10.1016/j.jss.2019.04.089 313 14. Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & PRISMA Group (2009). 314 Preferred reporting items for systematic reviews and meta-analyses: the PRISMA 315 statement. BMJ (Clinical research ed.), 339, b2535. 316 https://doi.org/10.1136/bmj.b2535 317 15. Shea, B. J., Reeves, B. C., Wells, G., Thuku, M., Hamel, C., Moran, J., ... & Henry, 318 D. A. (2017). AMSTAR 2: a critical appraisal tool for systematic reviews that include 319 randomised or non-randomised studies of healthcare interventions, or both. bmj, 358. 320 16. Reed, D. A., Cook, D. A., Beckman, T. J., Levine, R. B., Kern, D. E., & Wright, S. 321 M. (2007). Association between funding and quality of published medical education 322 research. JAMA, 298(9), 1002–1009. https://doi.org/10.1001/jama.298.9.1002 323 17. Akl, M. N., Magrina, J. F., Kho, R. M., & Magtibay, P. M. (2008). Robotic 324 appendectomy in gynaecological surgery: technique and pathological findings. The 325 international journal of medical robotics + computer assisted surgery : MRCAS, 4(3), 326 210–213. https://doi.org/10.1002/rcs.198 327 18. Yi, B., Wang, G., Li, J., Jiang, J., Son, Z., Su, H., & Zhu, S. (2016). The first clinical 328 use of domestically produced Chinese minimally invasive surgical robot system 329 "Micro Hand S". Surgical endoscopy, 30(6), 2649–2655. 330 https://doi.org/10.1007/s00464-015-4506-1 331 19. Yi, B., Wang, G., Li, J., Jiang, J., Son, Z., Su, H., Zhu, S., & Wang, S. (2017). 332 Domestically produced Chinese minimally invasive surgical robot system "Micro 333 Hand S" is applied to clinical surgery preliminarily in China. Surgical endoscopy, 334 31(1), 487–493. https://doi.org/10.1007/s00464-016-4945-3 335 https://doi.org/10.3802/jgo.2020.31.e59 https://doi.org/10.1007/s11701-020-01120-4 https://doi.org/10.1007/s11701-011-0289-0 https://doi.org/10.1007/s11701-011-0289-0 https://doi.org/10.1016/j.jss.2019.04.089 https://doi.org/10.1136/bmj.b2535 https://doi.org/10.1001/jama.298.9.1002 https://doi.org/10.1002/rcs.198 https://doi.org/10.1007/s00464-015-4506-1 https://doi.org/10.1007/s00464-016-4945-3 11 20. Bütter, A., Merritt, N., & Dave, S. (2017). Establishing a pediatric robotic surgery 336 program in Canada. Journal of robotic surgery, 11(2), 207–210. 337 https://doi.org/10.1007/s11701-016-0646-0 338 21. Orcutt, S. T., Anaya, D. A., & Malafa, M. (2017). Minimally invasive appendectomy 339 for resection of appendiceal mucocele: Case series and review of the literature. 340 International journal of surgery case reports, 37, 13–16. 341 https://doi.org/10.1016/j.ijscr.2017.05.027 342 22. Hüttenbrink, C., Hatiboglu, G., Simpfendörfer, T., Radtke, J. P., Becker, R., Teber, 343 D., Hadaschik, B., Pahernik, S., & Hohenfellner, M. (2018). Incidental appendectomy 344 during robotic laparoscopic prostatectomy-safe and worth to perform?. Langenbeck's 345 archives of surgery, 403(2), 265–269. https://doi.org/10.1007/s00423-017-1630-5 346 23. Yao, Y., Liu, Y., Li, Z., Yi, B., Wang, G., & Zhu, S. (2020). Chinese surgical robot 347 micro hand S: A consecutive case series in general surgery. International journal of 348 surgery (London, England), 75, 55–59. https://doi.org/10.1016/j.ijsu.2020.01.013 349 24. Kelkar, D., Borse, M. A., Godbole, G. P., Kurlekar, U., & Slack, M. (2021). Interim 350 safety analysis of the first-in-human clinical trial of the Versius surgical system, a 351 new robot-assisted device for use in minimal access surgery. Surgical endoscopy, 352 35(9), 5193–5202. https://doi.org/10.1007/s00464-020-08014-4 353 25. Quilici, P. J., Wolberg, H., & McConnell, N. (2022). Operating costs, fiscal impact, 354 value analysis and guidance for the routine use of robotic technology in abdominal 355 surgical procedures. Surgical endoscopy, 36(2), 1433–1443. 356 https://doi.org/10.1007/s00464-021-08428-8 357 26. Jaschinski, T., Mosch, C. G., Eikermann, M., Neugebauer, E. A., & Sauerland, S. 358 (2018). Laparoscopic versus open surgery for suspected appendicitis. The Cochrane 359 database of systematic reviews, 11(11), CD001546. 360 https://doi.org/10.1002/14651858.CD001546.pub4 361 27. Lanfranco, A. R., Castellanos, A. E., Desai, J. P., & Meyers, W. C. (2004). Robotic 362 surgery: a current perspective. Annals of surgery, 239(1), 14–21. 363 https://doi.org/10.1097/01.sla.0000103020.19595.7d 364 28. Köckerling F. (2014). Robotic vs. Standard Laparoscopic Technique - What is 365 Better?. Frontiers in surgery, 1, 15. https://doi.org/10.3389/fsurg.2014.00015 366 29. Huddy, J. R., Crockett, M., Nizar, A. S., Smith, R., Malki, M., Barber, N., & Tilney, 367 H. S. (2022). Experiences of a "COVID protected" robotic surgical centre for 368 https://doi.org/10.1007/s11701-016-0646-0 https://doi.org/10.1016/j.ijscr.2017.05.027 https://doi.org/10.1007/s00423-017-1630-5 https://doi.org/10.1016/j.ijsu.2020.01.013 https://doi.org/10.1007/s00464-020-08014-4 https://doi.org/10.1007/s00464-021-08428-8 https://doi.org/10.1002/14651858.CD001546.pub4 https://doi.org/10.1097/01.sla.0000103020.19595.7d https://doi.org/10.3389/fsurg.2014.00015 12 colorectal and urological cancer in the COVID-19 pandemic. Journal of robotic 369 surgery, 16(1), 59–64. https://doi.org/10.1007/s11701-021-01199-3 370 30. Sparwasser, P., Brandt, M. P., Haack, M., Dotzauer, R., Boehm, K., Gheith, M. K., 371 Mager, R., Jäger, W., Ziebart, A., Höfner, T., Tsaur, I., Haferkamp, A., & Borgmann, 372 H. (2021). Robotic surgery can be safely performed for patients and healthcare 373 workers during COVID-19 pandemic. The international journal of medical robotics + 374 computer assisted surgery : MRCAS, 17(4), e2291. https://doi.org/10.1002/rcs.2291 375 31. Amodeo, A., Linares Quevedo, A., Joseph, J. V., Belgrano, E., & Patel, H. R. (2009). 376 Robotic laparoscopic surgery: cost and training. Minerva urologica e nefrologica = 377 The Italian journal of urology and nephrology, 61(2), 121–128. 378 32. Gkegkes, I. D., Mamais, I. A., & Iavazzo, C. (2017). Robotics in general surgery: A 379 systematic cost assessment. Journal of minimal access surgery, 13(4), 243–255. 380 https://doi.org/10.4103/0972-9941.195565 381 33. Bennett, K. (2012). Robotic Surgery: da Vinci® and beyond. The Bulletin of the 382 Royal College of Surgeons of England, 94(1), 8-9. 383 10.1308/147363512X13189526438431 384 34. Khandalavala, K., Shimon, T., Flores, L., Armijo, P. R., & Oleynikov, D. (2020). 385 Emerging surgical robotic technology: a progression toward microbots. Ann Laparosc 386 Endosc Surg, 5, 3-3. DOI10.21037/ales.2019.10.02 387 35. Zeng, Y., Wang, G., Li, Z., Lin, H., Zhu, S., & Yi, B. (2021). The Micro Hand S vs. 388 da Vinci Surgical Robot-Assisted Surgery on Total Mesorectal Excision: Short-Term 389 Outcomes Using Propensity Score Matching Analysis. Frontiers in surgery, 8, 390 656270. https://doi.org/10.3389/fsurg.2021.656270 391 36. Luo, D., Liu, Y., Zhu, H., Li, X., Gao, W., Li, X., Zhu, S., & Yu, X. (2020). The 392 MicroHand S robotic-assisted versus Da Vinci robotic-assisted radical resection for 393 patients with sigmoid colon cancer: a single-center retrospective study. Surgical 394 endoscopy, 34(8), 3368–3374. https://doi.org/10.1007/s00464-019-07107-z 395 396 https://doi.org/10.1007/s11701-021-01199-3 https://doi.org/10.1002/rcs.2291 https://doi.org/10.4103/0972-9941.195565 https://doi.org/10.3389/fsurg.2021.656270 https://doi.org/10.1007/s00464-019-07107-z 13 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 Figure 1: Flow diagram of the systematic search 438 439 440 441 442 443 444 445 446 Records identified through database searching Pubmed (n =73) Science Direct (n=1268) Cochrane Library (n=5) S cr e e n in g In cl u d e d E li g ib il it y Id e n ti fi ca ti o n Records screened (n =1239) Records excluded** (n = 1228) Case reports, recommendations, conference abstracts, letters, editorials, reviews, commentaries, out of scope citations and non-English Full-text articles assessed for eligibility (n = 11) Full-text articles excluded (n = 2) Studies included in qualitative synthesis (n = 9) 14 Table 1: Tabular analysis of included citations 447 Author (year) Journal Type of study Objective Patients (n) Indications Robotic system Findings/outcomes MERSQI scores* (quality) Akl et al. (2008) The Internation al Journal of Medical Robotics and Computer Assisted Surgery Cohort study To assess the feasibility, safety and pathological findings of incidental RA in patients undergoing robotic gynecological surgery. Altogether Elective RA 107 patients. Chronic pelvic pain and gynecological malignancies. Da Vinci robotic system Incidental RA was performed safely and effectively in conjunction with other robotic gynecological procedures with no perioperative complications related to appendicectomy. 13 (high) Yi et al. (2015) Surgical Endoscopy Case series To assess the safety and feasibility of the chinese minimally invasive surgical robot system “Micro Hand S” in its first clinical use Altogether 3 patients (Emergenc y RA=2) Acute appendicitis Micro Hand S robotic surgery The robot system “Micro Hand S” was safe and effective with no intraoperative complications or technical problems being encountered with its use. At three-month follow up, patients had no adverse reactions. 8 (low) Yi et al. (2016) Surgical Endoscopy Case report To develop and validate one low-cost and easy-use minimally invasive surgical robot system “Micro Hand S” that surgeons can use to resolve the complicated surgeries challenge. Altogether 10 patients (Emergenc y RA=3) Acute appendicitis Micro Hand S robotic surgery No intraoperative complications or technical problems were encountered with the use of the domestic produced “Micro Hand S” All patients recovered and were discharged from hospital without complications. 8 (low) Bütter et al. (2016) Journal of Robotic Surgery Cohort study To present the results of the first pediatric robotic surgery program in Canada. Altogether 41 children Interval RA=1 Interval appendicectom y. Da Vinci robotic system All robotic procedures were completed without conversion, with no technical failures due to the robotic system. 13 (high) Orcutt et al. (2017) Internation al journal of surgery Case series To present cases with appendiceal mucoceles that Altogether 2 patients Mucocele of appendix Unclear The robotic approach allowed meticulous dissection and 6.5 (low) 15 case reports were successfully treated with minimally invasive approaches. Elective RA=1 intact removal of appendiceal mucocele with no intra or postoperative complications. Hüttenbri nk et al. (2017) Langenbec k’s Archives of Surgery Cohort study To investigate the safety and patients benefit of incidental appendicectomy during RALRP. Altogether 53 patients Elective RA=53 Histopathol ogy: inconspicu ous=33, postinflam matory changes=1 1, chronic appendiciti s=4, appendiciti s=3 and neoplasia= 2 RALRP with incidental appendicectom y. Da Vinci robotic system Incidental appendicectomy during RALRP is a feasible and safe procedure and could be considered for patients scheduled for robot-assisted prostate surgery. 13.5 (high) Yao et al. (2020) Internation al Journal of Surgery Cohort study To evaluate the feasibility and safety of the Micro Hand S surgical robot in general surgery. Altogether 81 patients (Emergenc y RA=3) Acute appendicitis Micro Hand S robotic surgery RA was successfully performed in all 3 patients. The operation time(min) 130.0, blood loss (ml) 40.0 and hospital stay (day) 6.3 11 (moderate) Kelkar et al. (2020) Surgical Endoscopy Cohort study To provide an initial safety analysis of the first 30 surgical procedures performed using the Versisus Surgical System. Altogether 30 patients (Emergenc y RA=4) Acute appendicitis Versius Surgical System RA was successfully carried out in all 4 patients. The operation time ranged between 80- 135 minutes and estimated intraoperative blood loss was negligible. 10 (moderate) Quilici et al. (2021) Surgical Endoscopy Cohort study To define the value, cost, and fiscal impact of robotic-assisted procedures in abdominal surgery and Altogether 34,984 patients (few unspecified number RA) Abdominal surgery including AA. Da Vinci surgical system RA were performed at a higher cost vs laparoscopic appendicectomy, with an average total cost per case $13,210 vs $7709. 13.5 (high) 16 provide clinical guidance for its routine use. Robotic technology for gastrointestinal pro cedures is significantly more expensive than other surgical techniques. 448 RA = robotic appendicectomy; AA = acute appendicitis; RALRP = robot-assisted radical 449 prostatectomy. 450 *MERSQI 451 • Low quality 5-9 452 • Moderate quality 10-12 453 • High quality ≥13 454