Are we gaining value? A national evaluation of robotic versus laparoscopic appendectomy.

INTRODUCTION: Robotic appendectomy is increasingly used to treat acute appendicitis, yet its clinical benefits and resource implications remain unclear. We compared operative outcomes of robotic appendectomy and laparoscopic appendectomy. METHODS: We conducted a retrospective cohort analysis of adults undergoing minimally invasive appendectomy from 2022 to 2023 using the NSQIP database. The primary outcome was operative time. Secondary outcomes included surgical site infection, conversion to open surgery, and postoperative sepsis. We assessed the statistical interaction among operative approach, BMI, and perforation. Adjusted operative times were obtained using multivariable linear regression. RESULTS: Between 2022 and 2023, 85,774 patients with acute appendicitis met the inclusion criteria, and 807 (0.9%) underwent robotic appendectomy. Robotic appendectomy patients were older (42 vs 37 years, p<0.001) than laparoscopic appendectomy patients, had higher mean BMI (30.2 vs 29.1, p<0.001), and were less likely to be septic on presentation (19.3% vs 31.4%, p<0.001), but had higher rates of perforated/complicated appendicitis (32.2% vs 15.3%, p<0.001). Robotic appendectomy was associated with 2.4 times higher odds of conversion than laparoscopic appendectomy (OR 2.4, 95% CI 1.11-5.20, p<0.05). The median operative time was longer with robotic appendectomy (62 vs 44 min; p<0.001), corresponding to a median time penalty of approximately 18 min. Significant interaction effects showed that the operative time difference between robotic appendectomy and laparoscopic appendectomy widened progressively with increasing patient BMI and was most pronounced in cases of perforated appendicitis, where robotic appendectomy added the greatest incremental time. CONCLUSION: Robotic appendectomy required longer operative times than laparoscopic appendectomy, particularly in obese patients and perforated cases. Although robotic appendectomy offers enhanced visualization and dexterity, the increased operative time in acute care surgery raises resource concerns. These findings challenge the value of robotic appendectomy for acute appendicitis and question whether its use truly benefits patients or simply reflects surgeon or institutional preference.