Robotic surgery for small bowel obstruction: a propensity score-matched analysis of the ACS-NSQIP database.

BACKGROUND: Robotic surgery (RS) has expanded across elective surgical disciplines, yet its role in emergency general surgery remains poorly defined. Small bowel obstruction (SBO) is one of the most common indications for emergency abdominal surgery, and while laparoscopic surgery (LS) has demonstrated advantages over open surgery (OS), in appropriately selected patients at experienced centers, no large-scale study has evaluated robotic outcomes for this condition, partly because dedicated robotic identification variables in national databases have only recently become available. This study aimed to compare perioperative outcomes across robotic, laparoscopic, and open approaches for SBO using a nationally representative database. METHODS: A retrospective cohort study was conducted using the ACS-NSQIP database (2022-2023). Patients undergoing surgery for adhesive SBO were identified by ICD-10 codes and classified by surgical approach. Demographics, comorbidities, 30-day complications, mortality, length of stay (LOS), and operative time (OT) were analyzed. In the unmatched cohort, multinomial logistic regression assessed factors associated with approach selection. Propensity score matching (PSM) in a 1:1:1 ratio was performed to compare outcomes across balanced groups. RESULTS: Of 22,177 SBO operations, 15,246 (68.7%) were open, 6224 (28.1%) laparoscopic, and 707 (3.2%) robotic. After PSM (n = 701 per group), RS achieved the shortest median LOS (2 vs 3 vs 6 days, p < 0.001) but had the longest OT (130 vs 76 vs 109 min, p < 0.001). Thirty-day mortality was comparable across groups (RS 0.9%, LS 0.7%, OS 1.6%; p = 0.241). Both minimally invasive approaches demonstrated significantly lower rates of organ space SSI, superficial SSI, wound dehiscence, and 30-day readmission compared to OS (all p < 0.001). ASA classification, ascites, disseminated cancer, and age were among the factors significantly associated with surgical approach. CONCLUSION: In this propensity score-matched national analysis, robotic surgery for SBO was associated with the shortest hospitalization and a safety profile comparable to laparoscopic surgery in selected patients. Both minimally invasive approaches demonstrated advantages over open surgery across multiple endpoints. These findings support the continued evaluation of robotic surgery as a feasible option for SBO at experienced centers.