Surgeon Volume and Clinical Outcomes After Robotic Elective and Emergency General Surgery

Importance: Robotic-assisted surgery is increasingly used in acute care surgery, but the impact of individual surgeon robotic case volume on outcomes for both elective and emergency general surgery procedures remains uncertain. Objective: To evaluate the association between annual surgeon robotic case volume and patient outcomes following robotic-assisted elective and emergency general surgery. Design, Setting, and Participants: This retrospective cohort study used data from the Premier Healthcare Database (PHD), a large US all-payer hospital database, from January 2021 to December 2023. The PHD aggregates data from nonprofit, community, and teaching hospitals across rural and urban areas, representing 25% of all US inpatient admissions. Adult patients (aged ≥18 years) undergoing robotic-assisted cholecystectomy, colectomy, appendectomy, small bowel resection, or ventral hernia repair were included. Exposure: Annual surgeon-level robotic case volume, categorized as low (≤25), intermediate (26-75), high (76-150), or very high (≥151). Main Outcomes and Measures: The primary outcome was conversion to open surgery; secondary outcomes included postoperative complications, intensive care unit (ICU) admission, 30-day readmission, operative time, hospital length of stay, total hospital cost, and in-hospital mortality. Multivariable logistic and linear regression models, respectively, were used to estimate adjusted odds ratios (AORs) and mean ratios with 95% CIs. Models adjusted for patient demographics, hospital characteristics, and surgeon specialty. Results: Among 185 924 patients undergoing robotic procedures (137 879 elective and 48 045 emergency), most (58.2%) were female (57.1% of elective and 61.5% of emergency cases). Mean (SD) patient age was 54.9 (16.6) years overall (55.6 [15.8] years for elective and 53.0 [18.5] years for emergency procedures). In elective procedures, increasing annual surgeon volume was associated with stepwise improvements across most outcomes; compared with low volume surgeons, very high volume surgeons had lower odds of conversion to open surgery (AOR, 0.45; 95% CI, 0.36-0.56), complications (AOR, 0.87; 95% CI, 0.79-0.96), readmission (AOR, 0.79; 95% CI, 0.68-0.91), and ICU admission (AOR, 0.61; 95% CI, 0.46-0.82). Operative time (mean ratio, 0.77; 95% CI, 0.75-0.79), hospital length of stay (mean ratio, 0.89; 95% CI, 0.88-0.91), and costs (mean ratio, 0.83; 95% CI, 0.82-0.84) were also significantly lower. In emergency procedures, very high vs low surgeon volume was associated with lower odds of conversion to open surgery (AOR, 0.73; 95% CI, 0.54-1.00) and modest reductions in operative time (mean ratio, 0.88; 95% CI, 0.85-0.91) and cost (mean ratio, 0.92; 95% CI, 0.89-0.94). No association was observed between surgeon volume and in-hospital mortality in either cohort. Conclusions and Relevance: In this cohort study, greater annual surgeon robotic case volume was associated with better patient outcomes in elective general surgery and, to a lesser degree, in emergency procedures. These findings highlight the importance of surgeon-specific experience in robotic surgery and may inform training, credentialing, and strategies for safe expansion of robotic capabilities in acute care surgery.