Robotic Operation After Interhospital Transfer for Emergency General Surgery: Adoption, Hospital-Level Variation, and National Outcomes

BACKGROUND: Robotic surgery is increasingly used in emergency general surgery (EGS), but its adoption and outcomes after interhospital transfer remain unclear. We evaluated robotic adoption, hospital-level variation, predictors of use, and comparative outcomes among transferred EGS patients. STUDY DESIGN: Using the Nationwide Readmissions Database (2016-2019), we identified adults transferred from acute-care hospitals who underwent EGS procedures. Mixed-effects models evaluated predictors and between-hospital variation in robotic use, summarized by intraclass correlation coefficients (ICC) and median odds ratios (MOR). Multivariable logistic and generalized linear models compared cost, length of stay (LOS), non-home discharge, complications, mortality, and 30-day readmission across robotic, laparoscopic, and open approaches. RESULTS: Robotics was used for ≥1 transferred patient in 8.5% of transfer-receiving hospital-years and 13.7% of robot-capable transfer-receiving hospital-years. Hospital-level variation was substantial for robotic vs laparoscopic selection (MOR 3.59; ICC 35.3%) but modest for robotic vs open selection (MOR 1.31; ICC 2.3%). Investor-owned hospitals and later years were associated with greater odds of robotic use, whereas extreme illness severity and rural residence were associated with lower odds. Compared with laparoscopy, robotics was associated with shorter LOS and higher cost, without statistically significant differences in adjusted clinical outcomes. Compared with open surgery, robotics was associated with shorter LOS, lower cost, and lower odds of non-home discharge and surgical complications. CONCLUSIONS: Robotic surgery after interhospital transfer was uncommon, with substantial hospital-level variation relative to laparoscopy despite similar adjusted clinical outcomes. These findings support defining selection criteria and evaluating equitable access to minimally invasive platforms.