Standardisation in Robotic Surgery for Inflammatory Bowel Disease: A Systematic Review

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However, its role in inflammatory bowel disease (IBD) remains poorly defined, with existing studies limited by variability and lack of standardisation. This systematic review aimed to evaluate the reproducibility, operative detail, outcome reporting, and procedural consistency in the current literature on robotic-assisted surgery for IBD. Methods A systematic review was conducted following PRISMA 2020 guidelines and registered on PROSPERO (CRD42024514488). Comprehensive searches of five databases and grey literature from January 2015 to April 2024 were performed. Studies involving robotic surgery in adult IBD patients were included. Methodological quality was assessed using the Newcastle–Ottawa Scale. Results Sixteen studies involving 614 patients met inclusion criteria. Most were retrospective (81.3%) and single-arm (62.5%), with robotic ileocolic resection being the most common procedure (50%). Significant heterogeneity existed in port placement, docking, and intraoperative techniques. Technical reporting, particularly on robotic setup, was inconsistent. Definitions of postoperative outcomes, including complications and conversion rates, varied across studies. Enhanced Recovery After Surgery protocols were used in 18.8% of studies, with minimal reporting of patient-reported outcomes. While risk of bias was generally low, limited follow-up and absence of comparator arms reduced the strength of conclusions. Conclusions Current evidence on robotic surgery in Crohn’s disease is methodologically variable and poorly standardised, particularly regarding technical setup and outcome definitions. Future research should focus on prospective, multicentre studies with detailed intraoperative data, standardised outcomes, and long-term follow-up. robotic surgery inflammatory bowel disease Crohn’s disease ulcerative colitis surgical standardisation systematic review Figures Figure 1 Introduction Despite significant advances in medical therapy, surgical intervention remains a cornerstone in the management of inflammatory bowel disease (IBD) with up to 80% of patients with Crohn’s disease (CD) requiring surgery during their lifetime. 1 The operative management of CD presents unique and persistent challenges due to the recurrent, transmural, and often multifocal nature of the disease, which leads to complex surgical fields marked by dense adhesions, active inflammation, and the consequences of prior resections. Traditionally, open surgery has been the default approach in these scenarios due to such complexity. However, this approach is associated with significant drawbacks, including higher perioperative morbidity, increased risk of surgical site infections, prolonged convalescence, and a negative biopsychosocial impact. Minimally invasive surgery (MIS), particularly laparoscopic techniques, has demonstrated meaningful clinical benefits in colorectal procedures more broadly, including reduced postoperative pain, shorter hospital stays, and improved cosmetic outcomes. 2 Nonetheless, the application of MIS in IBD has been variable and frequently limited. This inconsistency is largely attributable to the technical demands of operating in a chronically inflamed, anatomically distorted field, often complicated by dense adhesions, fistulas, mesenteric foreshortening, and fibrotic tissue planes. 3 Robotic-assisted surgery, which offers enhanced dexterity, superior three-dimensional visualisation, tremor filtration, and increased degrees of instrument articulation, represents an intuitively advantageous platform for addressing the unique anatomical and pathological challenges encountered in CD. These features may offer distinct advantages in complex reoperative or anatomically confined fields. Despite this, the uptake of robotic platforms in IBD remains modest and inconsistent 4 . While robotic systems have gained widespread traction in oncological colorectal surgery, their use in IBD—despite their theoretical benefits—has lagged considerably. The disparity in adoption between malignant and benign colorectal pathology suggests a lack of robust evidence specific to the inflammatory pathology of IBD. Therefore, we aim to systematically review the current evidence base regarding robotic-assisted surgery for IBD with a focus on the consistency of outcome reporting, technical detail, and degree of procedural standardisation in the existing literature. Methods This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. 5 To ensure methodological transparency and facilitate reproducibility, the review protocol was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42024514488. 6 A comprehensive literature search was performed across five major electronic databases: Cochrane Library, MEDLINE, PubMed, Web of Science, and Google Scholar, covering the period from January 2015 to the present. No restrictions were applied with respect to language, publication status, or article type, in order to maximise search sensitivity and minimise selection bias. The inclusion of studies from 2015 onwards was intended to reflect contemporary surgical practice following widespread adoption of robotic platforms in colorectal surgery. In addition to peer-reviewed databases, grey literature sources were systematically explored. This included searches of clinical trial registries and relevant conference proceedings from 2022 onwards, chosen to capture the most recent data in this rapidly evolving field. The search strategy employed a combination of Medical Subject Headings (MeSH), free-text terms, and Boolean operators (‘AND’, ‘OR’). Core search terms included: “inflammatory bowel disease,” “Crohn’s disease,” “ulcerative colitis,” “pouch,” “robotic surgery,” “port placement,” and “trocar” . Reference lists of included studies and relevant review articles were manually screened for additional eligible publications. Study screening and selection were conducted using Covidence software (Veritas Health Innovation, Melbourne, Australia), with automatic deduplication of records. Detailed eligibility criteria are summarised in Table 1. Two independent reviewers performed title and abstract screening, followed by full-text review of potentially eligible studies. Disagreements regarding study inclusion or data extraction were resolved through discussion with an independent third reviewer and subsequent group consensus. A PRISMA-compliant flow diagram summarising the study selection process is presented in Fig. 1 . For data extraction, a customised extraction form was developed in Microsoft Excel, informed by the methodology outlined in the Cochrane Handbook for Systematic Reviews of Interventions. 7 The form was piloted on a subset of included studies to ensure clarity, consistency, and relevance, and refined accordingly prior to full data collection. The data extraction framework captured variables across four core domains: Study characteristics – including author publication history, year of publication, country of origin, and study design; Patient demographics – including age, sex, BMI, and prior surgical history; Surgical technique – with emphasis on operative approach, robotic platform used, and port placement strategy; Primary clinical outcomes – including intraoperative conversion rates, postoperative complication rates, and markers of functional recovery Extracted data were tabulated and subjected to descriptive synthesis. Quantitative data were analysed using Microsoft Excel. Continuous variables were summarised with mean (standard deviation [SD]) and median (interquartile range [IQR]) for parametric and non-parametric data, respectively, while categorical data were presented as frequencies and percentages. All included studies were observational in design. Methodological quality was assessed using the Newcastle–Ottawa Scale (NOS) 8 , which applies a star-based scoring system across three domains: selection, comparability, and outcome assessment. Studies were classified as: Low risk of bias (score = 9), Moderate risk (score = 7–8), High risk (score < 6). Where appropriate, a one-point penalty was applied for major methodological limitations (e.g., lack of control group or incomplete outcome data), while minor concerns (e.g., limited baseline matching) warranted a half-point deduction. Full scoring criteria and rationales are provided in Appendix 1. Results Study Characteristics and Patient Demographics The initial search yielded 404 records, of which 16 studies met the inclusion criteria following de-duplication and screening (Fig. 1 ). The majority of studies were retrospective in design (81.3%, n = 13) 9–19,22,24 and conducted in the United States (56.3%, n = 9). 9–15,20,21 First authors predominantly (93.8%, n = 15) had established publication history in robotic surgery. 9 – 15 , 20 , 21 , 23 , 24 Sample sizes within robotic cohorts ranged from 6 to 109 patients ( median = 31; IQR = 46). CD was the primary indication in 75% ( n = 12) 9,11–17,21-24 , UC in 50% ( n = 8) 10,15,18–20,23,24 , of which 25% ( n = 4) 15,20,23,24 included mixed IBD cohorts. Robotic ileocolic resection (ICR) was the most performed procedure (50%, n = 8) 9–14 . Comparator arms included laparoscopic surgery (31.3%, n = 5) 15,18,19,21,22 , open surgery (6.3%, n = 1) 9 , while 62.5% ( n = 10) were single-arm studies 10 – 14 , 16 , 17 , 20 , 23 , 24 . All studies reported age and sex. Pooled mean patient age was 41.15 years (SD = 7.82), mean body mass index (BMI) was 23.62 kg/m² ( SD = 2.07; reported in 14 studies) 9 – 12 , 14 – 20 , 23 , 24 , and males constituted 49.5% ( SD = 19.5%) of cohorts. Prior abdominal surgery was reported in half ( n = 8) 10–15,18,19 , though details were inconsistently documented. Only one study (6.3%) reported on surgeon training, noting that cases were performed during the surgeons’ robotic learning curve 19 . Risk of bias assessment indicated 14 studies at low risk and 2 at moderate risk, common limitations included short follow-up (≤ 30 days) and inadequate baseline matching. Surgical Setup The da Vinci platform was predominantly used (93.75%); one employed the Medtronic Hugo system (6.25%). 24 Preoperative planning was described in five studies (31.3%) 15,19,20,22,23 , with platform selection driven primarily by robotic availability in 12.5% ( n = 2) 15,19 . Preoperative imaging guided surgical planning in three studies (18.8%) 20,22,23 . For colectomy and ICR, patient positioning was reported in 25% ( n = 4) 10,20,22,23 , the most common being modified lithotomy ( n = 2) 18,22 , left lateral decubitus ( n = 1) 20 , and Trendelenburg ( n = 1) 10 . Robotic docking strategies were specified in 18.8% ( n = 3) 21,22,23 , all utilising left-sided approaches. Double-docking was employed in 12.5% ( n = 2) 22,23 ; the remainder used single-docking techniques. Port placements were comprehensively detailed in 31.3% ( n = 5) 16,19,20,22,23 , with no consistent approach identified. Intraoperative Techniques Technical details were inconsistently reported and varied widely: dissection of target anatomy 10 , 13 , 15 – 17 , 20 , 24 and bowel mobilisation 14 , 16 – 18 , 20 , 22 , 24 were described in 43.8% ( n = 7) each and vascular control in 56.3%, ( n = 9) 10,14,15,16–19,20,24 . No common operative approach emerged. Extraction site was reported in 50% ( n = 8) 10,14,15–17,20,22,23 , most frequently as Pfannenstiel incisions (25%, n = 4) 10,14,17,23 . Anastomotic technique was described in 75% ( n = 12) 10,14–20,24,25 ; one study applied a BMI-based approach 20 . Side-to-side anastomosis was preferred ( n = 4) 10,14,16,16 , including one series using fully intracorporeal anastomosis (ICA) 14 and another comparing intra- versus extracorporeal anastomosis (ECA) 10 ; alongside stapled J-pouch formation ( n = 3) 15–17 and the Kono-S technique ( n = 1). 24 Postoperative Outcomes Enhanced Recovery After Surgery (ERAS) protocols were reported in 18.8% ( n = 3). 10,14,15 Postoperative outcomes were variably reported and are summarised in Table 2. Ulcerative Colitis Subgroup Analysis Of the eight studies (50%) including patients with ulcerative colitis (UC), the most frequently performed procedures were proctocolectomies with or without IPAA, either as single-stage or staged approaches. 15 – 20 Robotic-assisted proctocolectomy was associated with acceptable perioperative outcomes, including low conversion rates (range: 0–13%) and comparable complication profiles to laparoscopic and open approaches. 15 – 18 , 20 Reported postoperative morbidity included anastomotic leaks (0-10.3%) 17–20 , pouch failure ( MEAN = 0%) 15,19 , and 30-day reoperation rates (0-17.2%). 15,17,18 Functional outcomes, specifically, time to stool/stoma function was reported in two studies, with no significant difference between robotic and laparoscopic cohorts. 15 , 16 Descriptions of perioperative care and use of ERAS protocols were seen in 0% of UC studies, with compliance and individual component adherence were unclear. Long-term outcome data and patient-reported measures were limited or absent across studies. Discussion This systematic review identified persistent limitations across the current body of literature on robotic surgery for IBD. Most included studies were retrospective in design, frequently lacking detailed descriptions of operative technique and exhibiting substantial heterogeneity in outcome reporting. Such variability precludes meaningful meta-analysis and impedes the development of evidence-based consensus guidelines. The prevailing “binary” approach seen in the literature towards robotic adoption, wherein surgeons either utilise the robot in all or none of their cases, highlights the urgent need for a more nuanced, phenotype-based surgical strategy. A recurring theme was the disproportionate focus on technically “simpler” IBD cohorts—particularly patients with normal-range body mass indices and limited disease complexity. 25 This introduces selection bias and limits the generalisability of reported outcomes to the broader IBD population, which more typically includes individuals with prior surgical interventions, malnutrition, steroid use, and complex or penetrating disease phenotypes. Furthermore, follow-up intervals were frequently truncated, thereby weakening the interpretability of long-term outcomes such as reoperation rates and disease recurrence—critical endpoints given the chronic, relapsing nature of IBD. Geographic bias also emerged as a salient issue, with the majority of studies originating from high-income countries, particularly the United States. This reflects disparities in access to robotic surgical platforms, which remain concentrated in well-resourced, high-volume tertiary centres. 26 In contrast, low- and middle-income settings face substantial barriers to implementation due to the capital-intensive nature of robotic infrastructure. These systemic inequities—rarely addressed in the current literature—raise concerns about the broader applicability and equity of robotic surgical innovation. There was also substantial variability in reported intraoperative strategies across studies, encompassing differences in port placement, docking preferences, anastomotic configurations, and approaches to bowel mobilisation. However, a consistent limitation throughout the literature is the poor granularity in technical descriptions—particularly concerning access strategies, trocar positioning, and robotic system docking. These omissions are especially problematic given that robotic surgery in IBD remains a relatively new and evolving technique. Access and setup steps are critical determinants of procedural success, and in this context, where disease distribution and prior operations often necessitate nuanced and flexible configurations; limited detail in reporting of these domains significantly limits reproducibility. It also inhibits meaningful comparison across centres and ultimately hinders the development of training and standardised approaches. Robotic surgery may hold particular value in the management of UC, particularly in procedures such as restorative proctocolectomy with IPAA which demand precise pelvic dissection within this confined anatomical region. The robotic platform’s enhanced visualisation and greater instrument articulation are well suited to facilitate nerve preservation, improve accuracy in mesorectal dissection, and secure anastomosis formation. In contrast to the anatomical variability and complexity seen in CD presentations, surgical intervention for UC is typically more standardised, localised and anatomically predictable. This may support the development of reproducible robotic workflows and make UC a suitable appropriate target for establishing consensus guidelines and procedural benchmarks. Further prospective studies focusing specifically on UC’s technical standardisation and functional outcomes are warranted to explore these potential advantages and optimise implementation. Furthermore, definitions of postoperative outcomes remain inconsistent or are omitted altogether, with key clinical endpoints (e.g., ‘pouch failure’) often subjectively defined and unstandardised. This lack of uniformity impedes accurate benchmarking and synthesis of results across studies. Several studies highlighted the potential advantages of robotic platforms in technically complex scenarios. For instance, Calini et al. demonstrated comparable rates of ileus, length of stay, and overall complications between patients undergoing intracorporeal and extracorporeal anastomoses, despite the extracorporeal cohort being significantly more comorbid (higher rates of American Society of Anaesthesiologists Score 3). 10 These benefits are especially relevant in CD, where dense adhesions, mesenteric foreshortening, and inflammation complicate laparoscopic dissection. Notably, conversion rates from robotic to open surgery were substantially higher in patients with complex or recurrent CD, reaching up to 37% in some series, compared to approximately 14% in less complicated cases. 27 Despite this, studies in this review studies suggest that robotic reoperations in IBD can be performed with safety and efficacy comparable to primary procedures. These favourable outcomes are largely attributed to individualised operative planning—particularly preoperative imaging to guide trocar placement and the use of dual docking strategies to facilitate multi-quadrant access. 13,23 Preoperative optimisation remains underemphasised in the current literature. IBD patients—particularly those with CD—frequently present in catabolic states with significant nutritional deficiencies, which are risk factors for poor postoperative outcomes. Current European Crohn's and Colitis Organisation (ECCO) guidelines recommend multidisciplinary preoperative optimisation, including nutritional support and inflammatory control, yet few studies included in this review reported detailed perioperative care protocols. 28 This is particularly important given the well-established relationship between thorough preoperative enteral nutrition leading to reduced postoperative morbidity. 29 Importantly, adherence to ERAS protocols has been associated with reduced rates of anastomotic leak, postoperative sepsis, and shorter hospital stays—even in reoperative IBD cases. 12,13 These results are strengthened by rigorous study designs, including the use of validated classification systems such as Montreal and Clavien-Dindo classifications and the exclusion of confounding factors. 30,31 Despite these clear benefits, ERAS compliance was inconsistently reported and suboptimally implemented across the included studies. Given the well-documented positive impact of ERAS on perioperative outcomes in colorectal surgery more broadly, 32-35 greater emphasis on ERAS in this specific context is needed in the literature. Wider adoption and standardised reporting of ERAS components are warranted to improve postoperative recovery in this high-risk cohort. While robotic surgery appears to offer modest short-term advantages—such as reduced conversion rates and expedited functional recovery—definitive evidence of clinical superiority over laparoscopy remains debated. 35 Moreover, these benefits may be offset by significantly higher procedural costs, largely driven by increased operative time and capital expenses. 36 However, current cost-effectiveness analyses are limited in scope, often focusing solely on intraoperative or immediate postoperative metrics. There is a need for comprehensive economic evaluations that incorporate long-term outcomes such as disease recurrence, reoperation rates, quality-adjusted life years (QALYs), and return to work—particularly relevant in CD, where patients often face a high lifetime surgical burden. A notable gap in the literature is the absence of validated patient-reported outcome measures (PROMs). Given the chronic, quality-of-life-altering nature of CD and the supportive, rather than curative, role of surgery, PROMs are essential to evaluating the real-world impact of surgical intervention. The inclusion of standardised PROMs assessing psychological well-being, functional capacity, and overall satisfaction would enhance the patient-centredness of future research. Future research should prioritise the establishment of multicentre, prospective registries, capturing granular intraoperative data and perioperative variables across high-risk subgroups—including patients with prior operations, fistulising disease, or pelvic sepsis. Further adherence to rigorous reporting standards that incorporate detailed intraoperative methodologies, including port mapping and docking strategies, alongside consistent outcome definitions, extended follow-up, and adjustment for key confounders are needed. Coupled with PROMs and long-term follow-up, such datasets would meaningfully inform both technical refinement and policy development in robotic IBD surgery. Conclusions The robotic surgical literature in IBD remains limited by methodological heterogeneity, geographic and selection biases, and inconsistent outcome reporting. The lack of procedural standardisation and underutilisation of patient-centred and long-term endpoints significantly constrains the ability to draw generalisable, clinically meaningful conclusions. Addressing these deficiencies through prospective, multicentre studies with standardised protocols, validated PROMs, and long-term follow-up is critical to fully characterising the role of robotic surgery in the management of CD. Declarations Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests The authors have no relevant financial or non-financial interests to disclose. Author Contributions All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Ayesha Unadkat, Shobhit Arya and Valerio Celentano. The first draft of the manuscript was written by Ayesha Unadkat, and all authors commented on previous versions of the manuscript. 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Supplementary Files Appendix.docx Tables.docx Cite Share Download PDF Status: Published Journal Publication published 21 Feb, 2026 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Revision requested 02 Jan, 2026 Reviews received at journal 02 Jan, 2026 Reviews received at journal 31 Dec, 2025 Reviewers agreed at journal 26 Dec, 2025 Reviewers agreed at journal 18 Dec, 2025 Reviewers agreed at journal 18 Dec, 2025 Reviewers agreed at journal 16 Dec, 2025 Reviewers invited by journal 16 Dec, 2025 Editor assigned by journal 08 Dec, 2025 Submission checks completed at journal 08 Dec, 2025 First submitted to journal 06 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Unadkat","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtUlEQVRIiWNgGAWjYJACZiCWY+AhVYsx6VoSG4jWwj8j+fDngprD6fN7zhgw/KjYRliLxI20NOkZxw7nbjjbY8DYc+Y2EdbcyDFj5mEDauHnMWBmbCNCi/yN/M+fef4dTpfvJ1aLwY0cBmnetsMJDECHEafF8MwzM2nevnTDDWeOFRwkyi9yx5Mff+b5Zi0v35O88cGPCmK8L5AAY3EYHCBCPRDww9WxPyBOxygYBaNgFIw4AABF1TwFS4OA5gAAAABJRU5ErkJggg==","orcid":"","institution":"Imperial College London","correspondingAuthor":true,"prefix":"","firstName":"Ayesha","middleName":"","lastName":"Unadkat","suffix":""},{"id":562018111,"identity":"a203c24c-fd56-4a10-b45f-d7eef902787d","order_by":1,"name":"Shobhit Arya","email":"","orcid":"","institution":"Imperial College London","correspondingAuthor":false,"prefix":"","firstName":"Shobhit","middleName":"","lastName":"Arya","suffix":""},{"id":562018115,"identity":"2bc60c34-eeef-423f-b6dc-c4649a75d3df","order_by":2,"name":"Aliki Rompou","email":"","orcid":"","institution":"Chelsea and 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12:31:28","extension":"png","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":332117,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-8296594/v1/34c416865e7f2638da09c4b7.png"},{"id":98780256,"identity":"a5ddccdc-0b46-4350-b84d-69231f8bc657","added_by":"auto","created_at":"2025-12-22 12:31:11","extension":"xml","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":91098,"visible":true,"origin":"","legend":"","description":"","filename":"8b1edaf7175b4c378bee0c884c6e984a1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8296594/v1/db6174cd7ee579ce18d0c792.xml"},{"id":98759685,"identity":"b547e134-a2ac-4166-9516-a0e21c1d60aa","added_by":"auto","created_at":"2025-12-22 09:49:45","extension":"html","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":101045,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8296594/v1/64c9d6ed717695bbdc25acc6.html"},{"id":98779064,"identity":"e728b11a-a0b2-499b-ab23-10d250af0839","added_by":"auto","created_at":"2025-12-22 12:29:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":913244,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA 2020 flow diagram illustrating the study selection process for inclusion in the systematic review on robotic surgery for inflammatory bowel disease.\u003c/p\u003e\n\u003cp\u003eA total of 405 records were initially identified; following de-duplication and screening for eligibility, 16 studies met the inclusion criteria and were subsequently included in the final review.\u003c/p\u003e\n\u003cp\u003eIBD indicates inflammatory bowel disease.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8296594/v1/8720867b7a53d9a7c1a4a978.png"},{"id":103251501,"identity":"73297f8e-a484-4a73-9c66-45f434771760","added_by":"auto","created_at":"2026-02-23 16:09:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1437262,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8296594/v1/3f522f1c-d897-41d0-ba7c-e8e1de8c05ad.pdf"},{"id":98759673,"identity":"913fb27a-e40f-4996-bef0-98025a635d07","added_by":"auto","created_at":"2025-12-22 09:49:44","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":299722,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-8296594/v1/2b0e209b447fc4b518129a0f.docx"},{"id":98779081,"identity":"5b9adff9-1999-4b1c-aa55-ee421aa71f75","added_by":"auto","created_at":"2025-12-22 12:29:56","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":487087,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8296594/v1/76f1678ce7bfaa7147a0d176.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Standardisation in Robotic Surgery for Inflammatory Bowel Disease: A Systematic Review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDespite significant advances in medical therapy, surgical intervention remains a cornerstone in the management of inflammatory bowel disease (IBD) with up to 80% of patients with Crohn\u0026rsquo;s disease (CD) requiring surgery during their lifetime.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The operative management of CD presents unique and persistent challenges due to the recurrent, transmural, and often multifocal nature of the disease, which leads to complex surgical fields marked by dense adhesions, active inflammation, and the consequences of prior resections. Traditionally, open surgery has been the default approach in these scenarios due to such complexity. However, this approach is associated with significant drawbacks, including higher perioperative morbidity, increased risk of surgical site infections, prolonged convalescence, and a negative biopsychosocial impact. Minimally invasive surgery (MIS), particularly laparoscopic techniques, has demonstrated meaningful clinical benefits in colorectal procedures more broadly, including reduced postoperative pain, shorter hospital stays, and improved cosmetic outcomes.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eNonetheless, the application of MIS in IBD has been variable and frequently limited. This inconsistency is largely attributable to the technical demands of operating in a chronically inflamed, anatomically distorted field, often complicated by dense adhesions, fistulas, mesenteric foreshortening, and fibrotic tissue planes.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eRobotic-assisted surgery, which offers enhanced dexterity, superior three-dimensional visualisation, tremor filtration, and increased degrees of instrument articulation, represents an intuitively advantageous platform for addressing the unique anatomical and pathological challenges encountered in CD. These features may offer distinct advantages in complex reoperative or anatomically confined fields. Despite this, the uptake of robotic platforms in IBD remains modest and inconsistent\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWhile robotic systems have gained widespread traction in oncological colorectal surgery, their use in IBD\u0026mdash;despite their theoretical benefits\u0026mdash;has lagged considerably. The disparity in adoption between malignant and benign colorectal pathology suggests a lack of robust evidence specific to the inflammatory pathology of IBD. Therefore, we aim to systematically review the current evidence base regarding robotic-assisted surgery for IBD with a focus on the consistency of outcome reporting, technical detail, and degree of procedural standardisation in the existing literature.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e To ensure methodological transparency and facilitate reproducibility, the review protocol was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42024514488.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eA comprehensive literature search was performed across five major electronic databases: Cochrane Library, MEDLINE, PubMed, Web of Science, and Google Scholar, covering the period from January 2015 to the present. No restrictions were applied with respect to language, publication status, or article type, in order to maximise search sensitivity and minimise selection bias. The inclusion of studies from 2015 onwards was intended to reflect contemporary surgical practice following widespread adoption of robotic platforms in colorectal surgery.\u003c/p\u003e \u003cp\u003eIn addition to peer-reviewed databases, grey literature sources were systematically explored. This included searches of clinical trial registries and relevant conference proceedings from 2022 onwards, chosen to capture the most recent data in this rapidly evolving field.\u003c/p\u003e \u003cp\u003eThe search strategy employed a combination of Medical Subject Headings (MeSH), free-text terms, and Boolean operators (\u0026lsquo;AND\u0026rsquo;, \u0026lsquo;OR\u0026rsquo;). Core search terms included: \u003cem\u003e\u0026ldquo;inflammatory bowel disease,\u0026rdquo; \u0026ldquo;Crohn\u0026rsquo;s disease,\u0026rdquo; \u0026ldquo;ulcerative colitis,\u0026rdquo; \u0026ldquo;pouch,\u0026rdquo; \u0026ldquo;robotic surgery,\u0026rdquo; \u0026ldquo;port placement,\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;trocar\u0026rdquo;\u003c/em\u003e. Reference lists of included studies and relevant review articles were manually screened for additional eligible publications.\u003c/p\u003e \u003cp\u003eStudy screening and selection were conducted using Covidence software (Veritas Health Innovation, Melbourne, Australia), with automatic deduplication of records. Detailed eligibility criteria are summarised in Table\u0026nbsp;1. Two independent reviewers performed title and abstract screening, followed by full-text review of potentially eligible studies. Disagreements regarding study inclusion or data extraction were resolved through discussion with an independent third reviewer and subsequent group consensus.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA PRISMA-compliant flow diagram summarising the study selection process is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFor data extraction, a customised extraction form was developed in Microsoft Excel, informed by the methodology outlined in the Cochrane Handbook for Systematic Reviews of Interventions.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e The form was piloted on a subset of included studies to ensure clarity, consistency, and relevance, and refined accordingly prior to full data collection.\u003c/p\u003e \u003cp\u003eThe data extraction framework captured variables across four core domains:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eStudy characteristics \u0026ndash; including author publication history, year of publication, country of origin, and study design;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePatient demographics \u0026ndash; including age, sex, BMI, and prior surgical history;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSurgical technique \u0026ndash; with emphasis on operative approach, robotic platform used, and port placement strategy;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePrimary clinical outcomes \u0026ndash; including intraoperative conversion rates, postoperative complication rates, and markers of functional recovery\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eExtracted data were tabulated and subjected to descriptive synthesis. Quantitative data were analysed using Microsoft Excel. Continuous variables were summarised with mean (standard deviation [SD]) and median (interquartile range [IQR]) for parametric and non-parametric data, respectively, while categorical data were presented as frequencies and percentages.\u003c/p\u003e \u003cp\u003eAll included studies were observational in design. Methodological quality was assessed using the Newcastle\u0026ndash;Ottawa Scale (NOS)\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, which applies a star-based scoring system across three domains: selection, comparability, and outcome assessment. Studies were classified as:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eLow risk of bias (score\u0026thinsp;=\u0026thinsp;9),\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eModerate risk (score\u0026thinsp;=\u0026thinsp;7\u0026ndash;8),\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHigh risk (score\u0026thinsp;\u0026lt;\u0026thinsp;6).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eWhere appropriate, a one-point penalty was applied for major methodological limitations (e.g., lack of control group or incomplete outcome data), while minor concerns (e.g., limited baseline matching) warranted a half-point deduction. Full scoring criteria and rationales are provided in Appendix 1.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Characteristics and Patient Demographics\u003c/h2\u003e \u003cp\u003eThe initial search yielded 404 records, of which 16 studies met the inclusion criteria following de-duplication and screening (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The majority of studies were retrospective in design (81.3%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;13)\u003csup\u003e9\u0026ndash;19,22,24\u003c/sup\u003e and conducted in the United States (56.3%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9).\u003csup\u003e9\u0026ndash;15,20,21\u003c/sup\u003e First authors predominantly (93.8%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;15) had established publication history in robotic surgery.\u003csup\u003e\u003cspan additionalcitationids=\"CR10 CR11 CR12 CR13 CR14\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Sample sizes within robotic cohorts ranged from 6 to 109 patients (\u003cem\u003emedian\u003c/em\u003e\u0026thinsp;=\u0026thinsp;31; \u003cem\u003eIQR\u003c/em\u003e\u0026thinsp;=\u0026thinsp;46).\u003c/p\u003e \u003cp\u003eCD was the primary indication in 75% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12)\u003csup\u003e9,11\u0026ndash;17,21-24\u003c/sup\u003e, UC in 50% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8)\u003csup\u003e10,15,18\u0026ndash;20,23,24\u003c/sup\u003e, of which 25% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4)\u003csup\u003e15,20,23,24\u003c/sup\u003e included mixed IBD cohorts. Robotic ileocolic resection (ICR) was the most performed procedure (50%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8)\u003csup\u003e9\u0026ndash;14\u003c/sup\u003e. Comparator arms included laparoscopic surgery (31.3%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5)\u003csup\u003e15,18,19,21,22\u003c/sup\u003e, open surgery (6.3%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1)\u003csup\u003e9\u003c/sup\u003e, while 62.5% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;10) were single-arm studies\u003csup\u003e\u003cspan additionalcitationids=\"CR11 CR12 CR13\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. All studies reported age and sex. Pooled mean patient age was 41.15 years (SD\u0026thinsp;=\u0026thinsp;7.82), mean body mass index (BMI) was 23.62 kg/m\u0026sup2; (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.07; reported in 14 studies)\u003csup\u003e\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18 CR19\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e, and males constituted 49.5% (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;19.5%) of cohorts. Prior abdominal surgery was reported in half (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8)\u003csup\u003e10\u0026ndash;15,18,19\u003c/sup\u003e, though details were inconsistently documented. Only one study (6.3%) reported on surgeon training, noting that cases were performed during the surgeons\u0026rsquo; robotic learning curve\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Risk of bias assessment indicated 14 studies at low risk and 2 at moderate risk, common limitations included short follow-up (\u0026le;\u0026thinsp;30 days) and inadequate baseline matching.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical Setup\u003c/h3\u003e\n\u003cp\u003eThe da Vinci platform was predominantly used (93.75%); one employed the Medtronic Hugo system (6.25%).\u003csup\u003e24\u003c/sup\u003e Preoperative planning was described in five studies (31.3%)\u003csup\u003e15,19,20,22,23\u003c/sup\u003e, with platform selection driven primarily by robotic availability in 12.5% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2)\u003csup\u003e15,19\u003c/sup\u003e. Preoperative imaging guided surgical planning in three studies (18.8%)\u003csup\u003e20,22,23\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFor colectomy and ICR, patient positioning was reported in 25% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4)\u003csup\u003e10,20,22,23\u003c/sup\u003e, the most common being modified lithotomy (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2)\u003csup\u003e18,22\u003c/sup\u003e, left lateral decubitus (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1)\u003csup\u003e20\u003c/sup\u003e, and Trendelenburg (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1)\u003csup\u003e10\u003c/sup\u003e. Robotic docking strategies were specified in 18.8% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3)\u003csup\u003e21,22,23\u003c/sup\u003e, all utilising left-sided approaches. Double-docking was employed in 12.5% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2)\u003csup\u003e22,23\u003c/sup\u003e; the remainder used single-docking techniques. Port placements were comprehensively detailed in 31.3% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5)\u003csup\u003e16,19,20,22,23\u003c/sup\u003e, with no consistent approach identified.\u003c/p\u003e\n\u003ch3\u003eIntraoperative Techniques\u003c/h3\u003e\n\u003cp\u003eTechnical details were inconsistently reported and varied widely: dissection of target anatomy\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e and bowel mobilisation\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e were described in 43.8% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7) each and vascular control in 56.3%, (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9)\u003csup\u003e10,14,15,16\u0026ndash;19,20,24\u003c/sup\u003e. No common operative approach emerged. Extraction site was reported in 50% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8)\u003csup\u003e10,14,15\u0026ndash;17,20,22,23\u003c/sup\u003e, most frequently as Pfannenstiel incisions (25%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4)\u003csup\u003e10,14,17,23\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAnastomotic technique was described in 75% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12)\u003csup\u003e10,14\u0026ndash;20,24,25\u003c/sup\u003e; one study applied a BMI-based approach\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Side-to-side anastomosis was preferred (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4)\u003csup\u003e10,14,16,16\u003c/sup\u003e, including one series using fully intracorporeal anastomosis (ICA)\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e and another comparing intra- versus extracorporeal anastomosis (ECA)\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e; alongside stapled J-pouch formation (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3)\u003csup\u003e15\u0026ndash;17\u003c/sup\u003e and the Kono-S technique (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1).\u003csup\u003e24\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003ePostoperative Outcomes\u003c/h3\u003e\n\u003cp\u003eEnhanced Recovery After Surgery (ERAS) protocols were reported in 18.8% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3).\u003csup\u003e10,14,15\u003c/sup\u003e Postoperative outcomes were variably reported and are summarised in Table\u0026nbsp;2.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eUlcerative Colitis Subgroup Analysis\u003c/h2\u003e \u003cp\u003eOf the eight studies (50%) including patients with ulcerative colitis (UC), the most frequently performed procedures were proctocolectomies with or without IPAA, either as single-stage or staged approaches.\u003csup\u003e\u003cspan additionalcitationids=\"CR16 CR17 CR18 CR19\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Robotic-assisted proctocolectomy was associated with acceptable perioperative outcomes, including low conversion rates (range: 0\u0026ndash;13%) and comparable complication profiles to laparoscopic and open approaches.\u003csup\u003e\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Reported postoperative morbidity included anastomotic leaks (0-10.3%)\u003csup\u003e17\u0026ndash;20\u003c/sup\u003e, pouch failure (\u003cem\u003eMEAN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0%)\u003csup\u003e15,19\u003c/sup\u003e, and 30-day reoperation rates (0-17.2%).\u003csup\u003e15,17,18\u003c/sup\u003e Functional outcomes, specifically, time to stool/stoma function was reported in two studies, with no significant difference between robotic and laparoscopic cohorts.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Descriptions of perioperative care and use of ERAS protocols were seen in 0% of UC studies, with compliance and individual component adherence were unclear. Long-term outcome data and patient-reported measures were limited or absent across studies.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003eThis systematic review identified persistent limitations across the current body of literature on robotic surgery for IBD. Most included studies were retrospective in design, frequently lacking detailed descriptions of operative technique and exhibiting substantial heterogeneity in outcome reporting. Such variability precludes meaningful meta-analysis and impedes the development of evidence-based consensus guidelines. The prevailing \u0026ldquo;binary\u0026rdquo; approach seen in the literature towards robotic adoption, wherein surgeons either utilise the robot in all or none of their cases, highlights the urgent need for a more nuanced, phenotype-based surgical strategy.\u003c/p\u003e\n\u003cp\u003eA recurring theme was the disproportionate focus on technically \u0026ldquo;simpler\u0026rdquo; IBD cohorts\u0026mdash;particularly patients with normal-range body mass indices and limited disease complexity.\u003csup\u003e25\u0026nbsp;\u003c/sup\u003eThis introduces selection bias and limits the generalisability of reported outcomes to the broader IBD population, which more typically includes individuals with prior surgical interventions, malnutrition, steroid use, and complex or penetrating disease phenotypes. Furthermore, follow-up intervals were frequently truncated, thereby weakening the interpretability of long-term outcomes such as reoperation rates and disease recurrence\u0026mdash;critical endpoints given the chronic, relapsing nature of IBD.\u003c/p\u003e\n\u003cp\u003eGeographic bias also emerged as a salient issue, with the majority of studies originating from high-income countries, particularly the United States. This reflects disparities in access to robotic surgical platforms, which remain concentrated in well-resourced, high-volume tertiary centres.\u003csup\u003e26\u003c/sup\u003e In contrast, low- and middle-income settings face substantial barriers to implementation due to the capital-intensive nature of robotic infrastructure. These systemic inequities\u0026mdash;rarely addressed in the current literature\u0026mdash;raise concerns about the broader applicability and equity of robotic surgical innovation.\u003c/p\u003e\n\u003cp\u003eThere was also substantial variability in reported intraoperative strategies across studies, encompassing differences in port placement, docking preferences, anastomotic configurations, and approaches to bowel mobilisation. However, a consistent limitation throughout the literature is the poor granularity in technical descriptions\u0026mdash;particularly concerning access strategies, trocar positioning, and robotic system docking. These omissions are especially problematic given that robotic surgery in IBD remains a relatively new and evolving technique. Access and setup steps are critical determinants of procedural success, and in this context, where disease distribution and prior operations often necessitate nuanced and flexible configurations; limited detail in reporting of these domains significantly limits reproducibility. It also inhibits meaningful comparison across centres and ultimately hinders the development of training and standardised approaches.\u003c/p\u003e\n\u003cp\u003eRobotic surgery may hold particular value in the management of UC, particularly in procedures such as restorative proctocolectomy with IPAA which demand precise pelvic dissection within this confined anatomical region. The robotic platform\u0026rsquo;s enhanced visualisation and greater instrument articulation are well suited to facilitate nerve preservation, improve accuracy in mesorectal dissection, and secure anastomosis formation. In contrast to the anatomical variability and complexity seen in CD presentations, surgical intervention for UC is typically more standardised, localised and anatomically predictable. This may support the development of reproducible robotic workflows and make UC a suitable appropriate target for establishing consensus guidelines and procedural benchmarks. Further prospective studies focusing specifically on UC\u0026rsquo;s technical standardisation and functional outcomes are warranted to explore these potential advantages and optimise implementation.\u003c/p\u003e\n\u003cp\u003eFurthermore, definitions of postoperative outcomes remain inconsistent or are omitted altogether, with key clinical endpoints (e.g., \u0026lsquo;pouch failure\u0026rsquo;) often subjectively defined and unstandardised. This lack of uniformity impedes accurate benchmarking and synthesis of results across studies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSeveral studies highlighted the potential advantages of robotic platforms in technically complex scenarios. For instance, Calini et al. demonstrated comparable rates of ileus, length of stay, and overall complications between patients undergoing intracorporeal and extracorporeal anastomoses, despite the extracorporeal cohort being significantly more comorbid (higher rates of American Society of Anaesthesiologists Score 3).\u003csup\u003e10\u003c/sup\u003e These benefits are especially relevant in CD, where dense adhesions, mesenteric foreshortening, and inflammation complicate laparoscopic dissection. Notably, conversion rates from robotic to open surgery were substantially higher in patients with complex or recurrent CD, reaching up to 37% in some series, compared to approximately 14% in less complicated cases.\u003csup\u003e27\u0026nbsp;\u003c/sup\u003eDespite this, studies in this review studies suggest that robotic reoperations in IBD can be performed with safety and efficacy comparable to primary procedures. These favourable outcomes are largely attributed to individualised operative planning\u0026mdash;particularly preoperative imaging to guide trocar placement and the use of dual docking strategies to facilitate multi-quadrant access.\u003csup\u003e13,23\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003ePreoperative optimisation remains underemphasised in the current literature. IBD patients\u0026mdash;particularly those with CD\u0026mdash;frequently present in catabolic states with significant nutritional deficiencies, which are risk factors for poor postoperative outcomes. Current European Crohn\u0026apos;s and Colitis Organisation (ECCO) guidelines recommend multidisciplinary preoperative optimisation, including nutritional support and inflammatory control, yet few studies included in this review reported detailed perioperative care protocols.\u003csup\u003e28\u0026nbsp;\u003c/sup\u003eThis is particularly important given the well-established relationship between thorough preoperative enteral nutrition leading to reduced postoperative morbidity.\u003csup\u003e29\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eImportantly, adherence to ERAS protocols has been associated with reduced rates of anastomotic leak, postoperative sepsis, and shorter hospital stays\u0026mdash;even in reoperative IBD cases.\u003csup\u003e12,13\u0026nbsp;\u003c/sup\u003eThese results are strengthened by rigorous study designs, including the use of validated classification systems such as Montreal and Clavien-Dindo classifications and the exclusion of confounding factors.\u003csup\u003e30,31\u003c/sup\u003e Despite these clear benefits, ERAS compliance was inconsistently reported and suboptimally implemented across the included studies. Given the well-documented positive impact of ERAS on perioperative outcomes in colorectal surgery more broadly,\u003csup\u003e32-35\u003c/sup\u003e greater emphasis on ERAS in this specific context is needed in the literature. Wider adoption and standardised reporting of ERAS components are warranted to improve postoperative recovery in this high-risk cohort.\u003c/p\u003e\n\u003cp\u003eWhile robotic surgery appears to offer modest short-term advantages\u0026mdash;such as reduced conversion rates and expedited functional recovery\u0026mdash;definitive evidence of clinical superiority over laparoscopy remains debated.\u003csup\u003e35\u0026nbsp;\u003c/sup\u003eMoreover, these benefits may be offset by significantly higher procedural costs, largely driven by increased operative time and capital expenses.\u003csup\u003e36\u003c/sup\u003e However, current cost-effectiveness analyses are limited in scope, often focusing solely on intraoperative or immediate postoperative metrics. There is a need for comprehensive economic evaluations that incorporate long-term outcomes such as disease recurrence, reoperation rates, quality-adjusted life years (QALYs), and return to work\u0026mdash;particularly relevant in CD, where patients often face a high lifetime surgical burden.\u003c/p\u003e\n\u003cp\u003eA notable gap in the literature is the absence of validated patient-reported outcome measures (PROMs). Given the chronic, quality-of-life-altering nature of CD and the supportive, rather than curative, role of surgery, PROMs are essential to evaluating the real-world impact of surgical intervention. The inclusion of standardised PROMs assessing psychological well-being, functional capacity, and overall satisfaction would enhance the patient-centredness of future research.\u003c/p\u003e\n\u003cp\u003eFuture research should prioritise the establishment of multicentre, prospective registries, capturing granular intraoperative data and perioperative variables across high-risk subgroups\u0026mdash;including patients with prior operations, fistulising disease, or pelvic sepsis. Further adherence to rigorous reporting standards that incorporate detailed intraoperative methodologies, including port mapping and docking strategies, alongside consistent outcome definitions, extended follow-up, and adjustment for key confounders are needed. Coupled with PROMs and long-term follow-up, such datasets would meaningfully inform both technical refinement and policy development in robotic IBD surgery.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe robotic surgical literature in IBD remains limited by methodological heterogeneity, geographic and selection biases, and inconsistent outcome reporting. The lack of procedural standardisation and underutilisation of patient-centred and long-term endpoints significantly constrains the ability to draw generalisable, clinically meaningful conclusions. Addressing these deficiencies through prospective, multicentre studies with standardised protocols, validated PROMs, and long-term follow-up is critical to fully characterising the role of robotic surgery in the management of CD.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Ayesha Unadkat, Shobhit Arya and Valerio Celentano. The first draft of the manuscript was written by Ayesha Unadkat, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is a systematic review. No ethical approval was required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCarter MJ, Lobo AJ, Travis SPL (2004) Guidelines for the management of inflammatory bowel disease in adults. 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J Gastrointest Surg 16:587\u0026ndash;594\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\u003e\n\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"robotic surgery, inflammatory bowel disease, Crohn’s disease, ulcerative colitis, surgical standardisation, systematic review","lastPublishedDoi":"10.21203/rs.3.rs-8296594/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8296594/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRobotic-assisted surgery offers technical advantages over laparoscopy, including improved dexterity and visualisation. However, its role in inflammatory bowel disease (IBD) remains poorly defined, with existing studies limited by variability and lack of standardisation. This systematic review aimed to evaluate the reproducibility, operative detail, outcome reporting, and procedural consistency in the current literature on robotic-assisted surgery for IBD.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e A systematic review was conducted following PRISMA 2020 guidelines and registered on PROSPERO (CRD42024514488). Comprehensive searches of five databases and grey literature from January 2015 to April 2024 were performed. Studies involving robotic surgery in adult IBD patients were included. Methodological quality was assessed using the Newcastle\u0026ndash;Ottawa Scale.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSixteen studies involving 614 patients met inclusion criteria. Most were retrospective (81.3%) and single-arm (62.5%), with robotic ileocolic resection being the most common procedure (50%). Significant heterogeneity existed in port placement, docking, and intraoperative techniques. Technical reporting, particularly on robotic setup, was inconsistent. Definitions of postoperative outcomes, including complications and conversion rates, varied across studies. Enhanced Recovery After Surgery protocols were used in 18.8% of studies, with minimal reporting of patient-reported outcomes. While risk of bias was generally low, limited follow-up and absence of comparator arms reduced the strength of conclusions.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eCurrent evidence on robotic surgery in Crohn\u0026rsquo;s disease is methodologically variable and poorly standardised, particularly regarding technical setup and outcome definitions. Future research should focus on prospective, multicentre studies with detailed intraoperative data, standardised outcomes, and long-term follow-up.\u003c/p\u003e","manuscriptTitle":"Standardisation in Robotic Surgery for Inflammatory Bowel Disease: A Systematic Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-22 09:49:40","doi":"10.21203/rs.3.rs-8296594/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-03T00:39:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-02T18:11:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-01T00:52:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"329184310765434810784375644401434561582","date":"2025-12-26T18:42:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"223415216196939617397282181091369061026","date":"2025-12-18T21:17:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"305107264769248685114974648775152398287","date":"2025-12-18T13:50:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"57292841393194350170770851000406944291","date":"2025-12-16T14:01:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-16T13:40:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-08T14:04:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-08T12:35:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2025-12-06T19:26:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"522cbc7c-f890-40bb-8d8b-90deb7810567","owner":[],"postedDate":"December 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T16:06:47+00:00","versionOfRecord":{"articleIdentity":"rs-8296594","link":"https://doi.org/10.1007/s11701-026-03194-y","journal":{"identity":"journal-of-robotic-surgery","isVorOnly":false,"title":"Journal of Robotic Surgery"},"publishedOn":"2026-02-21 15:58:53","publishedOnDateReadable":"February 21st, 2026"},"versionCreatedAt":"2025-12-22 09:49:40","video":"","vorDoi":"10.1007/s11701-026-03194-y","vorDoiUrl":"https://doi.org/10.1007/s11701-026-03194-y","workflowStages":[]},"version":"v1","identity":"rs-8296594","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8296594","identity":"rs-8296594","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}