Clinical Advantages of a New Collaborative Assistant Robot (ANSUR Surgical Unit) in Laparoscopic Appendectomy and Cholecystectomy

Clinical Advantages of a New Collaborative Assistant Robot (ANSUR Surgical Unit) in Laparoscopic Appendectomy and Cholecystectomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical Advantages of a New Collaborative Assistant Robot (ANSUR Surgical Unit) in Laparoscopic Appendectomy and Cholecystectomy Toshiya Higashi, Masaki Kimura, Yuki Kumazaki, Takuya Nakashima, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8228632/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Jan, 2026 Read the published version in Journal of Robotic Surgery → Version 1 posted 15 You are reading this latest preprint version Abstract Objective To evaluate the efficacy of ANSUR-assisted laparoscopic appendectomy and cholecystectomy compared with conventional laparoscopic surgery (LS). Background The ANSUR Surgical Unit (ASAHI INTECC CO., LTD., Aichi, Japan) is a new collaborative assistant robot equipped with three arms. However, no studies have reported on ANSUR, and its clinical advantages remain unclear. Methods We retrospectively evaluated the data of 145 patients who underwent laparoscopic appendectomy and 261 patients who underwent laparoscopic cholecystectomy, in both elective and emergency settings, at our institution between January 2023 and June 2025. Results ANSUR-assisted laparoscopic appendectomy was performed in 30 of 145 patients, and ANSUR-assisted laparoscopic cholecystectomy in 36 of 261 patients. In laparoscopic appendectomy, the proportion of complicated appendicitis in the ANSUR-assisted LS group was significantly lower than that in the conventional LS group ( p = 0.006). However, there were no significant differences in the perioperative outcomes between the two groups. In laparoscopic cholecystectomy, the proportion of emergency ANSUR-assisted LS cases was lower than that of conventional LS ( p = 0.041). The intraoperative and postoperative outcomes of ANSUR-assisted LS were comparable to those of conventional LS. No conversion to open surgery occurred in either ANSUR-assisted laparoscopic appendectomy or cholecystectomy. The median setup time—defined as the interval between ANSUR roll-in and the start of surgery—was 5 min for laparoscopic appendectomy and 8 min for laparoscopic cholecystectomy. Conclusions ANSUR is a safe and effective collaborative assistant robot for laparoscopic appendectomy and cholecystectomy. Additionally, ANSUR is expected to have clinical benefit in reducing healthcare manpower constrains. ANSUR surgical unit Collaborative assistant robot Laparoscopic Appendectomy Laparoscopic Cholecystectomy Figures Figure 1 Figure 2 Introduction Advancements in surgery include cost reduction, improved patient satisfaction, enhanced clinical outcomes, and evolving surgical approaches. Surgical techniques have evolved considerably, with minimally invasive surgery (MIS) offering several advantages, such as reduced postoperative pain, fewer complications, shorter hospital stays, and faster recovery across various procedures [ 1 ]. Typical MIS procedures include thoracoscopic, laparoscopic (LS), and robot-assisted surgery (RAS). RAS has advanced significantly since 2000 and is expected to provide surgical benefits, such as three-dimensional visualization, improved dexterity, better ergonomics, and telesurgery, while retaining the perioperative advantages of LS [ 2 ]. Moreover, the routine use of RAS has increased across multiple surgical specialties, with nearly all subspecialties adopting robotic techniques [ 3 ]. However, RAS presents several challenges, including limited evidence quality, high costs, and environmental concerns [ 2 , 4 ]. Two primary types of robotic systems are used in gastroenterological surgery: teleoperated systems, in which the surgeon controls the robotic arm via a console, and collaborative robotic systems, which assist and stabilize instrument manipulation [ 5 ]. Teleoperated robotic surgical systems, such as the da Vinci Surgical System (Intuitive Surgical Inc., CA, USA), are widely used worldwide [ 6 ]. In contrast, collaborative robotic systems have been studied less extensively than teleoperated systems. The ANSUR Surgical Unit (ASAHI INTECC CO., LTD., Aichi, Japan) is a unique collaborative assistant robot that supports the operator during LS by performing assistant functions. It has three arms—one camera arm and two assistant arms (Fig. 1 a)—allowing it to stabilize the camera and appropriately grasp tissue. The operator controls the camera or assistant arm—such as the wave forceps (Fig. 1 b)—using a sensor attached to either side of the instrument (Fig. 1 c) and a foot pedal. Consequently, ANSUR is characterized by its ability to assist surgeons in performing solo LS. In this study, we aimed to compare the perioperative outcomes of ANSUR-assisted LS with conventional LS in appendectomy and cholecystectomy, and to evaluate its advantages, equivalence, and potential implications. ANSUR has three arms that can be initiated and controlled by the surgeon. The arms consist of the camera arm (1), right assistant arm (2), and left assistant arm (3) Wave forceps Attaching sensor (black arrow) positioned on the right-hand or left-hand side of the instrument and trocar censer (black arrowhead) Methods Patient Selection This retrospective study included patients who underwent appendectomy or cholecystectomy, either electively or emergently, at a single center (Matsunami General Hospital, Gifu, Japan) between January 2023 and June 2025. We excluded patients who underwent open procedures or other surgeries simultaneously (Supplemental Fig. 1). All patients provided informed consent through an opt-out process before enrollment in the study. This study was conducted in accordance with the ethical principles of the Declaration of Helsinki and approved by the Matsunami General Hospital Institutional Review Board (approval number: Matsu–I–Rin–658). Training Program The ANSUR training program was developed to include both didactic and hands-on training, incorporating tasks aimed at developing the motor and cognitive skills required to achieve competency in using ANSUR. All surgeons using ANSUR completed this training program and were fully experienced in performing conventional laparoscopic appendectomies and cholecystectomies. Surgical Indications and Procedures The decision to perform open, elective, or emergency surgery was left solely to the operator and was based on clinical judgment and patient safety. At our institution, for ANSUR-assisted laparoscopic appendectomy and cholecystectomy, the patient is placed in the supine position with the right arm tucked against the body to allow room for ANSUR. Laparoscopic appendectomy requires three ports: a 12-mm port in the umbilical region and two 5-mm ports in the left lumbar and hypogastric regions, respectively (Fig. 2 a, b). The monitor is placed on the right side of the operating table, adjacent to the right side of ANSUR. After adjusting the patient's position to a head-down and left-tilted orientation and adjusting the height of the operating table, ANSUR is rolled in from the patient’s right side and docked in position. First, the camera is attached to the camera arm. Next, the camera is inserted into port 2, and its range of motion is checked. Finally, the surgeon's port (port 1) is recognized by ANSUR. The surgeon uses the right hand for port 1 and the left hand for port 3 to perform the surgery according to routine practice. In contrast, laparoscopic cholecystectomy requires two 12-mm ports in the umbilical and epigastric regions and two 5-mm ports in the right hypochondriac and right lumbar regions (Fig. 2 c, d). The monitor is placed over the patient's right shoulder, adjacent to the left side of ANSUR. After adjusting the patient's position to a head-up and left-tilted orientation and adjusting the height of the operating table, ANSUR is rolled in from the patient’s right side and docked in position. First, the camera and wave forceps are attached to the camera and the right assistant arm, respectively. Next, the camera is inserted into port 4, and its range of motion is checked. Then, the wave forceps are inserted into port 3, and their range of motion is checked. Finally, the surgeon's port (port 1) is recognized by ANSUR. The surgeon uses the right hand for port 1 and the left hand for port 2 to perform the surgery according to routine practice. These port arrangements are similar to those used in conventional laparoscopic appendectomies and cholecystectomies. However, to prevent collisions among the patient, the surgeon, the assistant arms of ANSUR, and the external camera arm, several strategies were implemented to facilitate smooth surgical progression. In ANSUR-assisted laparoscopic appendectomy, the camera port (port 2) was shifted a few centimeters medially, particularly in patients with low body mass, to avoid collisions between the patient and the ANSUR camera arm. In ANSUR-assisted laparoscopic cholecystectomy, the port used for the operator’s left forceps (port 2) was shifted a few centimeters toward the patient’s right to avoid collision between the operator’s left arm and the ANSUR camera arm. Moreover, the assistant port (port 3) was shifted a few centimeters toward the foot side to avoid collisions between the patient and the ANSUR assistant arm. conventional laparoscopic appendectomy ANSUR-assisted laparoscopic appendectomy conventional laparoscopic cholecystectomy ANSUR-assisted laparoscopic cholecystectomy Evaluation of Clinicopathological Features and Outcome Measure Evaluation of Clinicopathological Features and Outcome Measure We investigated the patients’ demographic and clinical variables, including age, sex, body mass index, American Society of Anesthesiologists physical status, medical history, and operative and postoperative findings. Setup time was defined as the interval between the roll-in of ANSUR and the start of the surgical procedure. Postoperative complications were defined and classified according to the Clavien–Dindo classification [ 7 ]. Information regarding the resected specimens from pathological examination was collected. Complicated appendicitis was defined as perforated or gangrenous appendicitis, with or without an intra-abdominal abscess [ 8 ]. In this study, the primary endpoint was postoperative complications, while the secondary endpoints were operative time. These were evaluated as additional practical factors potentially influencing the comparison between ANSUR-assisted and conventional LS. Statistical Analysis Patient characteristics were expressed as frequencies and percentages for categorical variables and as medians with ranges or means with standard deviations for continuous variables. Comparisons of continuous variables between the two groups were performed using the Student’s t-test or the Mann–Whitney U test. The chi-squared test was used for categorical variables. Statistical significance was defined as a p -value < 0.05. Statistical analyses were performed using EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan) [ 9 ], a graphical user interface for R (R Foundation for Statistical Computing, Vienna, Austria), which is a modified version of R Commander incorporating statistical functions commonly used in biostatistics. Results Patient Characteristics A total of 421 patients were initially included in the study; however, 15 were excluded because they underwent different procedures (seven cases began as open surgery, and eight laparoscopic procedures were performed simultaneously with other surgical interventions). Thus, 406 patients were included in the final analysis. Of these, 145 patients underwent laparoscopic appendectomy, and 261 underwent laparoscopic cholecystectomy (Supplemental Fig. 1). Supplemental Fig. 1 Flow chart of patient selection Comparison of ANSUR-assisted and Conventional Laparoscopic Appendectomy The clinicopathological characteristics and perioperative outcomes in laparoscopic appendectomy are summarized in Table 1 . ANSUR-assisted LS was performed in 30 of the 145 cases. There were no significant differences between the two groups in clinical characteristics or intraoperative and postoperative outcomes, except for diagnosis. The proportion of patients with complicated appendicitis was 23.3% in the ANSUR-assisted LS group and 42.6% in the conventional LS group, with a significantly higher proportion of complicated appendicitis in the conventional LS group ( p = 0.006). Additionally, no conversions to open surgery were observed in either group. The median setup time for the ANSUR was 5 (range, 3–16) min. Table 2 presents a comparison of the two groups stratified by emergency and elective surgery. In elective cases, ANSUR-assisted LS resulted in fewer cases of complicated appendicitis (9.1% vs. 26.9%) and a higher proportion of other diagnoses (36.4% vs. 3.8%) compared to conventional LS ( p = 0.024). Table 1 Patients’ Characteristics and Perioperative Outcomes in Laparoscopic Appendectomy Variables ANSUR-assisted LS Conventional LS p -value n = 30 n = 115 Age (years), median (range) 50.5 (12–82) 46 (10–91) 0.702 Sex (Male/Female), n (%) 17 (56.7)/13 (43.3) 70 (60.9) / 45 (39.1) 0.834 Body mass index (kg/m 2 ), median (SD) 21.5 (3.2) 22.1 (3.3) 0.349 ASA PS classification (I/II/III/IV/V), n 22 / 7 / 1 / 0 / 0 / 0 63 / 40 / 10 / 1 / 1 0.436 History of abdominal surgery, n (%) 13 (11.3) 4 (13.3) 0.999 Emergency case, n (%) 19 (63.3) 89 (77.4) 0.181 Operating time (min), median (range) 59 (35–91) 70 (26–196) 0.138 Set-up time (min), median (range) 5 (3–16) Blood loss (mL), median (range) 1 (0–20) 1 (0–380) 0.623 Conversion to open surgery, n (%) 0 (0) 0 (0) LOHS (days), median (range) 4 (2–14) 4 (2–30) 0.114 Complications (CD grade ≥ III), n (%) 0 (0) 4 (3.5) 0.699 Diagnosis, n (%) 0.006 Complicated appendicitis 7 (23.3) 49 (42.6) Simple appendicitis 19 (63.3) 64 (55.7) Others 4 (13.3) 2 (1.7) Re-admission, n (%) 0 (0) 0 (0) LS, laparoscopic surgery; SD, standard deviation; ASA PS, American Society of Anesthesiologists’ physical status; LOHS, postoperative length of hospital stay; CD, Clavien–Dindo. Table 2 Patients’ Characteristics and Perioperative Outcomes in Emergency and Elective Laparoscopic Appendectomy Emergency case n = 108 Elective case n = 37 ANSUR-assisted LS n = 19 Conventional LS n = 89 p -value ANSUR-assisted LS n = 11 Conventional LS n = 26 p -value Operating time (min), median (range) 63 (35–91) 70 (28–159) 0.337 58 (38–86) 70 (26–196) 0.287 Blood loss (mL), median (range) 1 (0–20) 1 (0–380) 0.411 1 (0–3) 1 (0–110) 0.691 LOHS (days), median (range) 4 (2–14) 4 (3–30) 0.185 3 (3–5) 3 (2–6) 0.859 Complications (n) 0.813 0.338 CD I SSI (1) CD II Paralytic ileus (2) Paralytic ileus (4) SSI (2) Asthma (1) Paralytic ileus (1) CD IIIa Paralytic ileus (2) SSI (1) CD IVa VT (1) Diagnosis, n (%) 0.392 0.024 Complicated appendicitis 6 (31.6) 42 (47.2) 1 (9.1) 7 (26.9) Simple appendicitis 13 (68.4) 46 (51.7) 6 (54.5) 18 (69.2) Others 0 (0) 1 (1.1) 4 (36.4) 1 (3.8) LS, laparoscopic surgery; LOHS, postoperative length of hospital stay; CD, Clavien–Dindo; SSI, surgical site infection; VT, ventricular tachycardia. Comparison of ANSUR-assisted and Conventional Laparoscopic Cholecystectomy Table 3 summarizes patients’ characteristics and perioperative outcomes for laparoscopic cholecystectomy. ANSUR-assisted LS was performed in 36 of 261 cases. The proportion of emergency surgery cases was 19.4% in ANSUR-assisted LS and 38.7% in the conventional LS group, with a significantly higher proportion in conventional LS ( p = 0.041). ANSUR-assisted LS resulted in significantly less intraoperative blood loss (1 mL vs. 5 mL, p < 0.001) and shorter postoperative hospital stays (4 [range, 2–8] days vs. 4 [range, 2–27] days, p = 0.002). Additionally, there was no conversion to open surgery in ANSUR-assisted LS. The median set-up time for the ANSUR was 8 (range, 3–23) min. Table 4 presents a comparison of the two groups stratified by emergency and elective surgery. In emergency cases, ANSUR-assisted LS resulted in shorter postoperative hospital stays (4.5 days vs. 7.0 days, p = 0.008) and lower complication rates ( p = 0.010) compared to conventional LS. In elective cases, ANSUR-assisted LS resulted in less intraoperative blood loss compared to conventional LS (1 [range, 0–45] mL vs. 1 [range, 0–150] mL, p = 0.001). Table 3 Patients’ Characteristics and Perioperative Outcomes in Laparoscopic Cholecystectomy Variables ANSUR-assisted LS Conventional LS p -value n = 36 n = 225 Age (years), median (range) 63.5 (35–82) 66.0 (22–91) 0.502 Sex (Male/Female), sex, n (%) 20 (55.6) / 16 (44.4) 122 (54.2) / 103 (45.8) 0.999 Body mass index (kg/m 2 ), median (range) 23.9 (15.6–37.3) 24.0 (14.7–40.5) 0.862 ASA PS classification (I/II/III), n (%) 9 / 21 / 6 50 / 131 / 44 0.886 History of abdominal surgery, n (%) 9 (25.7) 71 (31.7) 0.606 Emergency cases, n (%) 7 (19.4) 87 (38.7) 0.041 Preoperative PTGBD, n (%) 0 4 (1.8) 0.940 Operating time (min), median (range) 91.5 (61–141) 98.0 (43–283) 0.230 Set-up time (min), median (range) 8 (3–23) Blood loss (mL), median (range) 1 (0–250) 5 (0–1,200) < 0.001 Conversion to open surgery, n (%) 0 (0) 2 (0.9) 0.999 LOHS (days), median (range) 4 (2–8) 4 (2–27) 0.002 Complications (CD grade ≥ III), n (%) 1 (2.9) 17 (7.6) 0.509 Diagnosis, n (%) 0.105 Choledocholithiasis 8 (22.2) 44 (19.6) Acute cholecystitis 6 (16.7) 83 (36.9) Chronic cholecystitis 19 (52.8) 81 (36.0) Others 3 (8.3) 17 (7.6) Re-admission, n (%) 0 4 (1.8) 0.955 LS, laparoscopic surgery; ASA PS, American Society of Anesthesiologists’ physical status; PTGBD, percutaneous transhepatic gallbladder drainage; LOHS, postoperative length of hospital stay; CD, Clavien–Dindo. Table 4 Patients’ Characteristics and Perioperative Outcomes in Emergency and Elective Laparoscopic Cholecystectomy Emergency case n = 94 Elective case n = 167 ANSUR-assisted LS n = 7 Conventional LS n = 87 p -value ANSUR-assisted LS n = 29 Conventional LS n = 138 p -value Operating time (min), median (range) 115 (68–141) 107 (61–222) 0.966 90 (61–135) 94 (43–283) 0.498 Blood loss (mL), median (range) 3 (0–250) 10 (0–1,200) 0.195 1 (0–45) 1 (0–150) 0.001 LOHS (days), median (range) 4.5 (3–5) 7.0 (3–26) 0.008 3 (2–8) 4 (2–27) 0.251 Complications (n) 0.010 0.883 CD I SSI (1) Liver dysfunction (1) SSI (1) (0) SSI (1) CD II Liver dysfunction (1) Liver dysfunction (2) Atrial fibrillation (2) Paralytic ileus (1) Postoperative bleeding (1) Pneumonia (1) Urinary tract infection (1) (0) Paralytic ileus (2) Drug rash (1) DGE (1) Urinary retention (1) CD IIIa (0) SSI (4) Choledocholithiasis (4) Intra-abdominal abscess (1) SSI (1) SSI (6) Choledocholithiasis (1) Septicemia (1) Diagnosis, n (%) 0.511 0.865 Choledocholithiasis 0 (0) 0 (0) 8 (27.6) 44 (31.9) Acute cholecystitis 6 (85.7) 81 (93.1) 0 (0) 2 (1.4) Chronic cholecystitis 1 (14.3) 4 (4.6) 18 (62.1) 77 (55.8) Others 0 (0) 2 (2.3) 3 (10.3) 15 (10.9) LS, laparoscopic surgery; LOHS, postoperative length of hospital stay; CD, Clavien–Dindo; SSI, surgical site infection; DGE, delayed gastric emptying. Discussion This study demonstrated that there was no significant difference in surgical outcomes between ANSUR-assisted laparoscopic appendectomy and the conventional method. Moreover, intraoperative and postoperative outcomes were largely equivalent between ANSUR-assisted laparoscopic cholecystectomy and the conventional method. No additional ports or conversions to open surgery were required in either ANSUR-assisted laparoscopic appendectomy or cholecystectomy. Additionally, the setup time for ANSUR was short, and no apparent adverse events occurred during ANSUR-assisted LS. Further, this study showed that the proportion of patients with complicated appendicitis in ANSUR-assisted laparoscopic appendectomy was significantly lower than that in the conventional method. Similarly, the proportion of emergency surgery cases in ANSUR-assisted laparoscopic cholecystectomy was significantly lower than that in the conventional method. Furthermore, in laparoscopic cholecystectomy, ANSUR-assisted LS resulted in significantly less intraoperative blood loss, shorter postoperative hospital stays, and a lower incidence of complications in emergency surgery. These results are likely attributable to selection bias and surgeon bias. During the early stages of introducing ANSUR-assisted LS, elective and less complex surgeries were selected to ensure safety, and nearly all procedures using ANSUR were performed by more experienced and highly skilled surgeons. Nevertheless, by selecting appropriate cases and having procedures performed by well-experienced surgeons, ANSUR can be considered safe and capable of achieving outcomes comparable to the conventional method. Collaborative robotic systems in surgery began in 1994, when AESOP (Computer Motion, Santa Barbara, CA, USA) was first used clinically in 1993 and subsequently marketed in 1994 as the first surgical robot approved by the Food and Drug Administration. In gastroenterological surgery, the AESOP 3000 (Computer Motion), introduced in 1998, is a voice-controlled robotic camera holder. AESOP showed no difference in perioperative outcomes compared to human assistance in cholecystectomy and colectomy [ 10 , 11 ]. However, it has been reported that in laparoscopic cholecystectomy and laparoscopic hernioplasty, AESOP 3000 results in reduced surgeon comfort, longer preparation and operation times, despite the advantage of decreased personnel requirements [ 12 ]. EndoAssist (Armstrong Healthcare Ltd., High Wycombe, United Kingdom), introduced in the late 1990s, is a robotic camera holder activated by foot control and operated via a headset-mounted motion axis selection sensor. In laparoscopic cholecystectomy, EndoAssist has been shown to result in significantly shorter operative times compared to human assistance [ 13 ] and has also been introduced in colorectal surgery [ 14 ]. Soloassist and Soloassist II (AKTORmed, Barbing, Germany), introduced in the early-to-mid 2010s, are robotic endoscope holders maneuvered using a joystick. Soloassist has been shown to be safe for use in cholecystectomy without increasing complications, although operating times are longer than with human assistance [ 15 ]. Soloassist II has been associated with fewer participating surgeons and reduced postoperative hospital stays following laparoscopic cholecystectomy [ 16 ]. It has also been shown to reduce operating time compared to human assistance in laparoscopic inguinal hernia repair [ 17 ] and to be as effective as human assistance in laparoscopic colorectal cancer surgery [ 18 , 19 ]. ViKY (EndoControl, Grenoble, France), introduced in 2007, is a robotic laparoscope holder controlled by either a foot pedal or voice activation, providing direct vision control to the surgeon. No differences were observed between ViKY and conventional methods regarding postoperative complications or recurrence following laparoscopic inguinal hernia repair [ 20 ]. FreeHand (FreeHand Ltd., Guildford, United Kingdom), introduced in 2009, is a robotic laparoscope holder positioned alongside the patient and attached to the operating table. The operator directly controls the robotic arm using a foot pedal and a head-mounted radiofrequency communicator that responds to head movements. FreeHand has been reported to be safely used in laparoscopic appendectomy [ 21 ], colectomy [ 22 ], and other gastroenterological surgeries [ 23 ]. These studies demonstrated that FreeHand provides surgical outcomes comparable to conventional LS, a stable image, minimized user discomfort, and reduced the need for additional personnel. EMARO (HOGY Medical, Tokyo, Japan), introduced in 2015, is a freestanding laparoscopic camera holder controlled by infrared signals from a head attachment worn by the operator and reportedly reduces labor costs and postoperative pain [ 24 ]. Maestro (Moon Surgical SAS, Paris, France), introduced in 2022, is a two-arm robotic device that holds and assists in the positioning of laparoscopes and instruments. Maestro has reportedly been used safely in several LS procedures in gastroenterological surgery without conversion to open surgery and has resulted in a high surgeon satisfaction index [ 25 ]. ANSUR is a new type of collaborative assistant robot with three arms that enables it to hold the camera in a stable position and appropriately grasp tissue (Fig. 1 a). The surgeon moves the camera and wave forceps using sensors attached to instruments on either the right- or left-hand side, along with a foot pedal. Sensors attached to the surgeon's instruments and trocars provided feedback to each robotic arm regarding the position and movement of surgical instruments, allowing the camera and wave forceps to move to the desired position (Fig. 1 c). Wave forceps are wave-shaped, double-ended grasping forceps with a 5-mm-diameter shaft that bends at the tip (Fig. 1 b). Therefore, the surgeon can move the wave forceps for proper deployment of the surgical field. Regarding ANSUR’s setup, this study showed that ANSUR had a short setup time and a straightforward setup procedure. Therefore, surgeons can operate the system smoothly after only limited experience. Given its characteristics, ANSUR may provide a stable field of view and facilitate operative field development, allowing surgeons to perform safer and less stressful solo surgical LS, reduce operative time, and minimize physical stress on the patient. However, one issue with ANSUR is that by taking on an assistant role, it may eliminate the role of surgical trainees as assistants, potentially depriving them of opportunities to learn LS. From an educational perspective, similar to teleoperated robotic surgical systems, ANSUR-assisted LS offer the advantage of enabling the supervising surgeon to seamlessly switch with a surgical trainee when necessary without disrupting the surgical field. This facilitates step-by-step instruction while maintaining safety. The primary advantage of ANSUR-assisted LS is its ability to reduce manpower requirements while maintaining applicability in both elective and emergency surgeries. Especially, ANSUR can perform the duties of both an assistant and a scope operator, taking on roles that preciously required one or two staff members. This is expected to improve the work-life balance of medical staff, including surgeons. For surgeons in particular, the time saved by using ANSUR can be allocated to ward duties, reviewing patient records, taking breaks, attending other surgeries, or performing surgeries in parallel. Moreover, ANSUR can be implemented in existing operating rooms without the need for special renovations or complex setup, allowing for flexible responses even in emergency surgeries. Cost remains a major consideration for the adoption of new technologies. Compared to conventional LS, the operative cost of ANSUR-assisted laparoscopic appendectomy was €261 higher per operation, and that of ANSUR-assisted laparoscopic cholecystectomy was €494 higher per operation. The additional cost of ANSUR-assisted LS was calculated based on the total number of consumables (Supplemental Fig. 2). Specifically, this included the sterile covers for the body, assistant arms, and camera arm; the cost of trocars and surgical tool sensors (calculated by dividing the total cost by 30 uses); and the cost of wave forceps (calculated by dividing the total cost by 10 uses). This analysis did not include initial acquisition costs, depreciation, or service contracts for robotic and laparoscopic systems. Nevertheless, the additional costs of ANSUR-assisted laparoscopic appendectomy and cholecystectomy were lower than those reported for teleoperated robotic surgical systems in previous studies [ 26 – 28 ]. Therefore, ANSUR-assisted LS may offer advantages in terms of cost-effectiveness. Supplemental Fig. 2 Consumables. Sterile cover of the assistant arm Sterile cover of the body Sterile cover for camera arm Trocar sensor Surgical tool sensors Wave Forceps This study has some limitations. First, it was a retrospective study conducted at a single institution. Second, the number of enrolled patients, particularly those who underwent ANSUR-assisted LS, was relatively small; therefore, the findings may be biased, with limited generalizability. Third, there was surgeon bias in this study. In ANSUR-assisted LS, almost all procedures were performed by surgeons certified by Endoscopic Surgical Skill Qualification System of the Japan Society for Endoscopic Surgery. In contrast, conventional LS procedures were performed by both certified and non-certified surgeons. Qualified surgeons participated in all surgeries to ensure surgical safety and quality. Nevertheless, to our knowledge, this was the first study to evaluate the feasibility of a new type of collaborative assistant robot for LS. In conclusion, although the cost of ANSUR-assisted LS was slightly higher than that of conventional LS, ANSUR can be considered a safe and effective collaborative assistive robot. In addition, ANSUR is expected to alleviate surgeon shortage, improve community healthcare, and reform the way surgeons work. Declarations Data availability: Data are available upon reasonable request to the corresponding author. Author contributions: T.H.: conception, analysis, and writing of the manuscript. T.H., M.K., Y.K., T.N., K.H., M.K., and K.T.: monitoring the patients. T.S. and S.T.: guidance on the introduction of ANSUR. M.K. and H.M.: critical review of the manuscript for important intellectual content. All Authors approved the final manuscript and agreed to be accountable for its content. Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing interests: ST received grants to his institute from ASAHI INTECC CO., Ltd. All the other authors have no conflicts of interest. Ethics approval: This study was conducted in accordance with the ethical principles of the Declaration of Helsinki and approved by the Matsunami General Hospital Institutional Review Board (approval number: Matsu–I–Rin–658). Consent to participate: All patients provided informed consent through an opt-out process before enrollment in the study. References Mohiuddin K, Swanson SJ (2013) Maximizing the benefit of minimally invasive surgery. J Surg Oncol 108:315–319. https://doi.org/10.1002/jso.23398 Lanfranco AR, Castellanos AE, Desai JP, Meyers WC (2004) Robotic surgery: a current perspective. Ann Surg 239:14–21. https://doi.org/10.1097/01.sla.0000103020.19595.7d Sheetz KH, Claflin J, Dimick JB (2020) Trends in the adoption of robotic surgery for common surgical procedures. 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Surg Endosc 36:1433–1443. https://doi.org/10.1007/s00464-021-08428-8 Charland N, Hadaya J, Mallick S et al (2024) National trends and outcomes of robotic emergency general surgery in the United States. Surgery 176:835–840. https://doi.org/10.1016/j.surg.2024.05.002 Additional Declarations No competing interests reported. Supplementary Files floatimage3.png Supplemental Fig.1 Flow chart of patient selection floatimage4.png Supplemental Fig.2 Consumables. (a) Sterile cover of the assistant arm (b) Sterile cover of the body (c) Sterile cover for camera arm (d) Trocar sensor (e) Surgical tool sensors (f) Wave Forceps Cite Share Download PDF Status: Published Journal Publication published 03 Jan, 2026 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Revision requested 08 Dec, 2025 Reviews received at journal 08 Dec, 2025 Reviewers agreed at journal 08 Dec, 2025 Reviews received at journal 08 Dec, 2025 Reviews received at journal 08 Dec, 2025 Reviews received at journal 07 Dec, 2025 Reviewers agreed at journal 07 Dec, 2025 Reviewers agreed at journal 07 Dec, 2025 Reviewers agreed at journal 07 Dec, 2025 Reviewers agreed at journal 07 Dec, 2025 Reviewers agreed at journal 06 Dec, 2025 Reviewers invited by journal 06 Dec, 2025 Editor assigned by journal 28 Nov, 2025 Submission checks completed at journal 28 Nov, 2025 First submitted to journal 28 Nov, 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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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8228632","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":557046384,"identity":"9aea8aca-ff3e-4997-a36b-8a1337a12fb3","order_by":0,"name":"Toshiya Higashi","email":"","orcid":"","institution":"Matsunami General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Toshiya","middleName":"","lastName":"Higashi","suffix":""},{"id":557046389,"identity":"106e34b1-3ae7-4b92-a745-466660865144","order_by":1,"name":"Masaki 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12:39:32","extension":"html","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":121974,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8228632/v1/5e6ed3237d6311394775d7e4.html"},{"id":97980172,"identity":"be85d85b-7ca1-458a-af44-432e32daa2fc","added_by":"auto","created_at":"2025-12-11 12:39:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":135590,"visible":true,"origin":"","legend":"\u003cp\u003eANSUR Surgical Unit\u003c/p\u003e\n\u003cp\u003e(a) ANSUR has three arms that can be initiated and controlled by the surgeon. The arms consist of the camera arm (1), right assistant arm (2), and left assistant arm (3)\u003c/p\u003e\n\u003cp\u003e(b) Wave forceps\u003c/p\u003e\n\u003cp\u003e(c) Attaching sensor (black arrow) positioned on the right-hand or left-hand side of the instrument and trocar censer (black arrowhead)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8228632/v1/e34149037290a3b5872015d6.png"},{"id":97980201,"identity":"8446d06d-fe71-4862-8a42-b503aa547cd7","added_by":"auto","created_at":"2025-12-11 12:39:32","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":136140,"visible":true,"origin":"","legend":"\u003cp\u003eSet-up position for\u003c/p\u003e\n\u003cp\u003e(a) conventional laparoscopic appendectomy\u003c/p\u003e\n\u003cp\u003e(b) ANSUR-assisted laparoscopic appendectomy\u003c/p\u003e\n\u003cp\u003e(c) conventional laparoscopic cholecystectomy\u003c/p\u003e\n\u003cp\u003e(d) ANSUR-assisted laparoscopic cholecystectomy\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8228632/v1/551ac8ddfedfcebfa4bfe668.png"},{"id":99545438,"identity":"004ceba3-b656-4dd8-b935-09287138e5ca","added_by":"auto","created_at":"2026-01-05 16:07:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1301248,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8228632/v1/5a7e6147-5c6e-4a7e-84b2-801294e46a55.pdf"},{"id":97980176,"identity":"4ba4360d-a454-47fe-9e5d-f20853f45b3a","added_by":"auto","created_at":"2025-12-11 12:39:26","extension":"png","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":49498,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplemental Fig.1\u003c/strong\u003e Flow chart of patient selection\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8228632/v1/d1ea0ba5e1d2e51e526f3529.png"},{"id":97980173,"identity":"c1ba01ea-5a34-4725-af18-6dcb18c57de3","added_by":"auto","created_at":"2025-12-11 12:39:25","extension":"png","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":631128,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplemental Fig.2\u003c/strong\u003e Consumables.\u003c/p\u003e\n\u003cp\u003e(a) Sterile cover of the assistant arm\u003c/p\u003e\n\u003cp\u003e(b) \u0026nbsp;Sterile cover of the body\u003c/p\u003e\n\u003cp\u003e(c) Sterile cover for camera arm\u003c/p\u003e\n\u003cp\u003e(d) Trocar sensor\u003c/p\u003e\n\u003cp\u003e(e) Surgical tool sensors\u003c/p\u003e\n\u003cp\u003e(f) Wave Forceps\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8228632/v1/3b851b8295c13123af60327c.png"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical Advantages of a New Collaborative Assistant Robot (ANSUR Surgical Unit) in Laparoscopic Appendectomy and Cholecystectomy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAdvancements in surgery include cost reduction, improved patient satisfaction, enhanced clinical outcomes, and evolving surgical approaches. Surgical techniques have evolved considerably, with minimally invasive surgery (MIS) offering several advantages, such as reduced postoperative pain, fewer complications, shorter hospital stays, and faster recovery across various procedures [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Typical MIS procedures include thoracoscopic, laparoscopic (LS), and robot-assisted surgery (RAS). RAS has advanced significantly since 2000 and is expected to provide surgical benefits, such as three-dimensional visualization, improved dexterity, better ergonomics, and telesurgery, while retaining the perioperative advantages of LS [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Moreover, the routine use of RAS has increased across multiple surgical specialties, with nearly all subspecialties adopting robotic techniques [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, RAS presents several challenges, including limited evidence quality, high costs, and environmental concerns [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTwo primary types of robotic systems are used in gastroenterological surgery: teleoperated systems, in which the surgeon controls the robotic arm via a console, and collaborative robotic systems, which assist and stabilize instrument manipulation [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Teleoperated robotic surgical systems, such as the da Vinci Surgical System (Intuitive Surgical Inc., CA, USA), are widely used worldwide [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In contrast, collaborative robotic systems have been studied less extensively than teleoperated systems.\u003c/p\u003e\u003cp\u003eThe ANSUR Surgical Unit (ASAHI INTECC CO., LTD., Aichi, Japan) is a unique collaborative assistant robot that supports the operator during LS by performing assistant functions. It has three arms\u0026mdash;one camera arm and two assistant arms (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea)\u0026mdash;allowing it to stabilize the camera and appropriately grasp tissue. The operator controls the camera or assistant arm\u0026mdash;such as the wave forceps (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb)\u0026mdash;using a sensor attached to either side of the instrument (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec) and a foot pedal. Consequently, ANSUR is characterized by its ability to assist surgeons in performing solo LS.\u003c/p\u003e\u003cp\u003eIn this study, we aimed to compare the perioperative outcomes of ANSUR-assisted LS with conventional LS in appendectomy and cholecystectomy, and to evaluate its advantages, equivalence, and potential implications.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eANSUR has three arms that can be initiated and controlled by the surgeon. The arms consist of the camera arm (1), right assistant arm (2), and left assistant arm (3)\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWave forceps\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAttaching sensor (black arrow) positioned on the right-hand or left-hand side of the instrument and trocar censer (black arrowhead)\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePatient Selection\u003c/h2\u003e\u003cp\u003eThis retrospective study included patients who underwent appendectomy or cholecystectomy, either electively or emergently, at a single center (Matsunami General Hospital, Gifu, Japan) between January 2023 and June 2025. We excluded patients who underwent open procedures or other surgeries simultaneously (Supplemental Fig.\u0026nbsp;1). All patients provided informed consent through an opt-out process before enrollment in the study. This study was conducted in accordance with the ethical principles of the Declaration of Helsinki and approved by the Matsunami General Hospital Institutional Review Board (approval number: Matsu\u0026ndash;I\u0026ndash;Rin\u0026ndash;658).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eTraining Program\u003c/h3\u003e\n\u003cp\u003eThe ANSUR training program was developed to include both didactic and hands-on training, incorporating tasks aimed at developing the motor and cognitive skills required to achieve competency in using ANSUR. All surgeons using ANSUR completed this training program and were fully experienced in performing conventional laparoscopic appendectomies and cholecystectomies.\u003c/p\u003e\n\u003ch3\u003eSurgical Indications and Procedures\u003c/h3\u003e\n\u003cp\u003eThe decision to perform open, elective, or emergency surgery was left solely to the operator and was based on clinical judgment and patient safety. At our institution, for ANSUR-assisted laparoscopic appendectomy and cholecystectomy, the patient is placed in the supine position with the right arm tucked against the body to allow room for ANSUR.\u003c/p\u003e\u003cp\u003eLaparoscopic appendectomy requires three ports: a 12-mm port in the umbilical region and two 5-mm ports in the left lumbar and hypogastric regions, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea, b). The monitor is placed on the right side of the operating table, adjacent to the right side of ANSUR. After adjusting the patient's position to a head-down and left-tilted orientation and adjusting the height of the operating table, ANSUR is rolled in from the patient\u0026rsquo;s right side and docked in position. First, the camera is attached to the camera arm. Next, the camera is inserted into port 2, and its range of motion is checked. Finally, the surgeon's port (port 1) is recognized by ANSUR. The surgeon uses the right hand for port 1 and the left hand for port 3 to perform the surgery according to routine practice.\u003c/p\u003e\u003cp\u003eIn contrast, laparoscopic cholecystectomy requires two 12-mm ports in the umbilical and epigastric regions and two 5-mm ports in the right hypochondriac and right lumbar regions (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ec, d). The monitor is placed over the patient's right shoulder, adjacent to the left side of ANSUR. After adjusting the patient's position to a head-up and left-tilted orientation and adjusting the height of the operating table, ANSUR is rolled in from the patient\u0026rsquo;s right side and docked in position. First, the camera and wave forceps are attached to the camera and the right assistant arm, respectively. Next, the camera is inserted into port 4, and its range of motion is checked. Then, the wave forceps are inserted into port 3, and their range of motion is checked. Finally, the surgeon's port (port 1) is recognized by ANSUR. The surgeon uses the right hand for port 1 and the left hand for port 2 to perform the surgery according to routine practice.\u003c/p\u003e\u003cp\u003eThese port arrangements are similar to those used in conventional laparoscopic appendectomies and cholecystectomies. However, to prevent collisions among the patient, the surgeon, the assistant arms of ANSUR, and the external camera arm, several strategies were implemented to facilitate smooth surgical progression. In ANSUR-assisted laparoscopic appendectomy, the camera port (port 2) was shifted a few centimeters medially, particularly in patients with low body mass, to avoid collisions between the patient and the ANSUR camera arm. In ANSUR-assisted laparoscopic cholecystectomy, the port used for the operator\u0026rsquo;s left forceps (port 2) was shifted a few centimeters toward the patient\u0026rsquo;s right to avoid collision between the operator\u0026rsquo;s left arm and the ANSUR camera arm. Moreover, the assistant port (port 3) was shifted a few centimeters toward the foot side to avoid collisions between the patient and the ANSUR assistant arm.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003econventional laparoscopic appendectomy\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eANSUR-assisted laparoscopic appendectomy\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003econventional laparoscopic cholecystectomy\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eANSUR-assisted laparoscopic cholecystectomy\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\n\u003ch3\u003eEvaluation of Clinicopathological Features and Outcome Measure\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eEvaluation of Clinicopathological Features and Outcome Measure\u003c/div\u003e\u003cp\u003eWe investigated the patients\u0026rsquo; demographic and clinical variables, including age, sex, body mass index, American Society of Anesthesiologists physical status, medical history, and operative and postoperative findings. Setup time was defined as the interval between the roll-in of ANSUR and the start of the surgical procedure. Postoperative complications were defined and classified according to the Clavien\u0026ndash;Dindo classification [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Information regarding the resected specimens from pathological examination was collected. Complicated appendicitis was defined as perforated or gangrenous appendicitis, with or without an intra-abdominal abscess [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In this study, the primary endpoint was postoperative complications, while the secondary endpoints were operative time. These were evaluated as additional practical factors potentially influencing the comparison between ANSUR-assisted and conventional LS.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003ePatient characteristics were expressed as frequencies and percentages for categorical variables and as medians with ranges or means with standard deviations for continuous variables. Comparisons of continuous variables between the two groups were performed using the Student\u0026rsquo;s t-test or the Mann\u0026ndash;Whitney U test. The chi-squared test was used for categorical variables. Statistical significance was defined as a \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Statistical analyses were performed using EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], a graphical user interface for R (R Foundation for Statistical Computing, Vienna, Austria), which is a modified version of R Commander incorporating statistical functions commonly used in biostatistics.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003ePatient Characteristics\u003c/h2\u003e\u003cp\u003eA total of 421 patients were initially included in the study; however, 15 were excluded because they underwent different procedures (seven cases began as open surgery, and eight laparoscopic procedures were performed simultaneously with other surgical interventions). Thus, 406 patients were included in the final analysis. Of these, 145 patients underwent laparoscopic appendectomy, and 261 underwent laparoscopic cholecystectomy (Supplemental Fig.\u0026nbsp;1).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSupplemental Fig.\u0026nbsp;1\u003c/b\u003e Flow chart of patient selection\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eComparison of ANSUR-assisted and Conventional Laparoscopic Appendectomy\u003c/h3\u003e\n\u003cp\u003eThe clinicopathological characteristics and perioperative outcomes in laparoscopic appendectomy are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. ANSUR-assisted LS was performed in 30 of the 145 cases. There were no significant differences between the two groups in clinical characteristics or intraoperative and postoperative outcomes, except for diagnosis. The proportion of patients with complicated appendicitis was 23.3% in the ANSUR-assisted LS group and 42.6% in the conventional LS group, with a significantly higher proportion of complicated appendicitis in the conventional LS group (\u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.006). Additionally, no conversions to open surgery were observed in either group. The median setup time for the ANSUR was 5 (range, 3\u0026ndash;16) min. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents a comparison of the two groups stratified by emergency and elective surgery. In elective cases, ANSUR-assisted LS resulted in fewer cases of complicated appendicitis (9.1% vs. 26.9%) and a higher proportion of other diagnoses (36.4% vs. 3.8%) compared to conventional LS (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.024).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatients\u0026rsquo; Characteristics and Perioperative Outcomes in Laparoscopic Appendectomy\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eANSUR-assisted LS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eConventional LS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;30\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;115\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years), median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50.5 (12\u0026ndash;82)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46 (10\u0026ndash;91)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.702\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex (Male/Female), n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (56.7)/13 (43.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70 (60.9) / 45 (39.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.834\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBody mass index (kg/m\u003csup\u003e2\u003c/sup\u003e), median (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21.5 (3.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.1 (3.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.349\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eASA PS classification (I/II/III/IV/V), n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22 / 7 / 1 / 0 / 0 / 0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63 / 40 / 10 / 1 / 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.436\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistory of abdominal surgery, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (11.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (13.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmergency case, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19 (63.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e89 (77.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.181\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperating time (min), median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59 (35\u0026ndash;91)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70 (26\u0026ndash;196)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.138\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSet-up time (min), median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (3\u0026ndash;16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood loss (mL), median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (0\u0026ndash;20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (0\u0026ndash;380)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.623\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConversion to open surgery, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLOHS (days), median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (2\u0026ndash;14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (2\u0026ndash;30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.114\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplications (CD grade\u0026thinsp;\u0026ge;\u0026thinsp;III), n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (3.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.699\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiagnosis, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplicated appendicitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (23.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49 (42.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSimple appendicitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19 (63.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64 (55.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (13.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (1.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRe-admission, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eLS, laparoscopic surgery; SD, standard deviation; ASA PS, American Society of Anesthesiologists\u0026rsquo; physical status; LOHS, postoperative length of hospital stay; CD, Clavien\u0026ndash;Dindo.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatients\u0026rsquo; Characteristics and Perioperative Outcomes in Emergency and Elective Laparoscopic Appendectomy\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eEmergency case\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;108\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003eElective case\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;37\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eANSUR-assisted LS\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;19\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eConventional LS\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;89\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eANSUR-assisted LS\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;11\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eConventional LS\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;26\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperating time (min), median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e63 (35\u0026ndash;91)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70 (28\u0026ndash;159)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.337\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e58 (38\u0026ndash;86)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e70 (26\u0026ndash;196)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.287\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood loss (mL), median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (0\u0026ndash;20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (0\u0026ndash;380)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.411\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1 (0\u0026ndash;3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1 (0\u0026ndash;110)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.691\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLOHS (days), median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (2\u0026ndash;14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (3\u0026ndash;30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.185\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3 (3\u0026ndash;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3 (2\u0026ndash;6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.859\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplications (n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.813\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.338\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCD I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSSI (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCD II\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eParalytic ileus (2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eParalytic ileus (4)\u003c/p\u003e\u003cp\u003eSSI (2)\u003c/p\u003e\u003cp\u003eAsthma (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eParalytic ileus (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCD IIIa\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eParalytic ileus (2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSSI (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCD IVa\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVT (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiagnosis, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.392\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.024\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplicated appendicitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (31.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42 (47.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1 (9.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e7 (26.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSimple appendicitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (68.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46 (51.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6 (54.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e18 (69.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4 (36.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1 (3.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eLS, laparoscopic surgery; LOHS, postoperative length of hospital stay; CD, Clavien\u0026ndash;Dindo; SSI, surgical site infection; VT, ventricular tachycardia.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eComparison of ANSUR-assisted and Conventional Laparoscopic Cholecystectomy\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarizes patients\u0026rsquo; characteristics and perioperative outcomes for laparoscopic cholecystectomy. ANSUR-assisted LS was performed in 36 of 261 cases. The proportion of emergency surgery cases was 19.4% in ANSUR-assisted LS and 38.7% in the conventional LS group, with a significantly higher proportion in conventional LS (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.041). ANSUR-assisted LS resulted in significantly less intraoperative blood loss (1 mL vs. 5 mL, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and shorter postoperative hospital stays (4 [range, 2\u0026ndash;8] days vs. 4 [range, 2\u0026ndash;27] days, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002). Additionally, there was no conversion to open surgery in ANSUR-assisted LS. The median set-up time for the ANSUR was 8 (range, 3\u0026ndash;23) min. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e presents a comparison of the two groups stratified by emergency and elective surgery. In emergency cases, ANSUR-assisted LS resulted in shorter postoperative hospital stays (4.5 days vs. 7.0 days, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.008) and lower complication rates (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.010) compared to conventional LS. In elective cases, ANSUR-assisted LS resulted in less intraoperative blood loss compared to conventional LS (1 [range, 0\u0026ndash;45] mL vs. 1 [range, 0\u0026ndash;150] mL, \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatients\u0026rsquo; Characteristics and Perioperative Outcomes in Laparoscopic Cholecystectomy\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eANSUR-assisted LS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eConventional LS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;36\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;225\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years), median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e63.5 (35\u0026ndash;82)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66.0 (22\u0026ndash;91)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.502\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex (Male/Female), sex, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (55.6) / 16 (44.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e122 (54.2) / 103 (45.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBody mass index (kg/m\u003csup\u003e2\u003c/sup\u003e), median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.9 (15.6\u0026ndash;37.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.0 (14.7\u0026ndash;40.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.862\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eASA PS classification (I/II/III), n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 / 21 / 6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50 / 131 / 44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.886\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistory of abdominal surgery, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (25.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71 (31.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.606\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmergency cases, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (19.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e87 (38.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.041\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreoperative PTGBD, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (1.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.940\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperating time (min), median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e91.5 (61\u0026ndash;141)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e98.0 (43\u0026ndash;283)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.230\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSet-up time (min), median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (3\u0026ndash;23)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood loss (mL), median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (0\u0026ndash;250)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (0\u0026ndash;1,200)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConversion to open surgery, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (0.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLOHS (days), median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (2\u0026ndash;8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (2\u0026ndash;27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplications (CD grade\u0026thinsp;\u0026ge;\u0026thinsp;III), n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (7.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.509\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiagnosis, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.105\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCholedocholithiasis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (22.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44 (19.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcute cholecystitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (16.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e83 (36.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChronic cholecystitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19 (52.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e81 (36.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (8.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (7.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRe-admission, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (1.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.955\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eLS, laparoscopic surgery; ASA PS, American Society of Anesthesiologists\u0026rsquo; physical status; PTGBD, percutaneous transhepatic gallbladder drainage; LOHS, postoperative length of hospital stay; CD, Clavien\u0026ndash;Dindo.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatients\u0026rsquo; Characteristics and Perioperative Outcomes in Emergency and Elective Laparoscopic Cholecystectomy\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eEmergency case\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;94\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003eElective case\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;167\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eANSUR-assisted LS\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;7\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eConventional LS\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;87\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eANSUR-assisted LS\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;29\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eConventional LS\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;138\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperating time (min), median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e115 (68\u0026ndash;141)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e107 (61\u0026ndash;222)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.966\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e90 (61\u0026ndash;135)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e94 (43\u0026ndash;283)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.498\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood loss (mL), median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (0\u0026ndash;250)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (0\u0026ndash;1,200)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.195\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1 (0\u0026ndash;45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1 (0\u0026ndash;150)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLOHS (days), median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.5 (3\u0026ndash;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.0 (3\u0026ndash;26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.008\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3 (2\u0026ndash;8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4 (2\u0026ndash;27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.251\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplications (n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.010\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.883\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCD I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSSI (1)\u003c/p\u003e\u003cp\u003eLiver dysfunction (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSSI (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSSI (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCD II\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLiver dysfunction (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLiver dysfunction (2)\u003c/p\u003e\u003cp\u003eAtrial fibrillation (2)\u003c/p\u003e\u003cp\u003eParalytic ileus (1)\u003c/p\u003e\u003cp\u003ePostoperative bleeding (1)\u003c/p\u003e\u003cp\u003ePneumonia (1)\u003c/p\u003e\u003cp\u003eUrinary tract infection (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eParalytic ileus (2)\u003c/p\u003e\u003cp\u003eDrug rash (1)\u003c/p\u003e\u003cp\u003eDGE (1)\u003c/p\u003e\u003cp\u003eUrinary retention (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCD IIIa\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSSI (4)\u003c/p\u003e\u003cp\u003eCholedocholithiasis (4)\u003c/p\u003e\u003cp\u003eIntra-abdominal abscess (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSSI (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSSI (6)\u003c/p\u003e\u003cp\u003eCholedocholithiasis (1)\u003c/p\u003e\u003cp\u003eSepticemia (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiagnosis, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.511\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.865\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCholedocholithiasis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e8 (27.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e44 (31.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcute cholecystitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (85.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e81 (93.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2 (1.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChronic cholecystitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (14.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (4.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e18 (62.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e77 (55.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3 (10.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e15 (10.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eLS, laparoscopic surgery; LOHS, postoperative length of hospital stay; CD, Clavien\u0026ndash;Dindo; SSI, surgical site infection; DGE, delayed gastric emptying.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrated that there was no significant difference in surgical outcomes between ANSUR-assisted laparoscopic appendectomy and the conventional method. Moreover, intraoperative and postoperative outcomes were largely equivalent between ANSUR-assisted laparoscopic cholecystectomy and the conventional method. No additional ports or conversions to open surgery were required in either ANSUR-assisted laparoscopic appendectomy or cholecystectomy. Additionally, the setup time for ANSUR was short, and no apparent adverse events occurred during ANSUR-assisted LS.\u003c/p\u003e\u003cp\u003eFurther, this study showed that the proportion of patients with complicated appendicitis in ANSUR-assisted laparoscopic appendectomy was significantly lower than that in the conventional method. Similarly, the proportion of emergency surgery cases in ANSUR-assisted laparoscopic cholecystectomy was significantly lower than that in the conventional method. Furthermore, in laparoscopic cholecystectomy, ANSUR-assisted LS resulted in significantly less intraoperative blood loss, shorter postoperative hospital stays, and a lower incidence of complications in emergency surgery. These results are likely attributable to selection bias and surgeon bias. During the early stages of introducing ANSUR-assisted LS, elective and less complex surgeries were selected to ensure safety, and nearly all procedures using ANSUR were performed by more experienced and highly skilled surgeons. Nevertheless, by selecting appropriate cases and having procedures performed by well-experienced surgeons, ANSUR can be considered safe and capable of achieving outcomes comparable to the conventional method.\u003c/p\u003e\u003cp\u003eCollaborative robotic systems in surgery began in 1994, when AESOP (Computer Motion, Santa Barbara, CA, USA) was first used clinically in 1993 and subsequently marketed in 1994 as the first surgical robot approved by the Food and Drug Administration. In gastroenterological surgery, the AESOP 3000 (Computer Motion), introduced in 1998, is a voice-controlled robotic camera holder. AESOP showed no difference in perioperative outcomes compared to human assistance in cholecystectomy and colectomy [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, it has been reported that in laparoscopic cholecystectomy and laparoscopic hernioplasty, AESOP 3000 results in reduced surgeon comfort, longer preparation and operation times, despite the advantage of decreased personnel requirements [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEndoAssist (Armstrong Healthcare Ltd., High Wycombe, United Kingdom), introduced in the late 1990s, is a robotic camera holder activated by foot control and operated via a headset-mounted motion axis selection sensor. In laparoscopic cholecystectomy, EndoAssist has been shown to result in significantly shorter operative times compared to human assistance [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and has also been introduced in colorectal surgery [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSoloassist and Soloassist II (AKTORmed, Barbing, Germany), introduced in the early-to-mid 2010s, are robotic endoscope holders maneuvered using a joystick. Soloassist has been shown to be safe for use in cholecystectomy without increasing complications, although operating times are longer than with human assistance [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Soloassist II has been associated with fewer participating surgeons and reduced postoperative hospital stays following laparoscopic cholecystectomy [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. It has also been shown to reduce operating time compared to human assistance in laparoscopic inguinal hernia repair [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and to be as effective as human assistance in laparoscopic colorectal cancer surgery [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eViKY (EndoControl, Grenoble, France), introduced in 2007, is a robotic laparoscope holder controlled by either a foot pedal or voice activation, providing direct vision control to the surgeon. No differences were observed between ViKY and conventional methods regarding postoperative complications or recurrence following laparoscopic inguinal hernia repair [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFreeHand (FreeHand Ltd., Guildford, United Kingdom), introduced in 2009, is a robotic laparoscope holder positioned alongside the patient and attached to the operating table. The operator directly controls the robotic arm using a foot pedal and a head-mounted radiofrequency communicator that responds to head movements. FreeHand has been reported to be safely used in laparoscopic appendectomy [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], colectomy [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and other gastroenterological surgeries [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. These studies demonstrated that FreeHand provides surgical outcomes comparable to conventional LS, a stable image, minimized user discomfort, and reduced the need for additional personnel.\u003c/p\u003e\u003cp\u003eEMARO (HOGY Medical, Tokyo, Japan), introduced in 2015, is a freestanding laparoscopic camera holder controlled by infrared signals from a head attachment worn by the operator and reportedly reduces labor costs and postoperative pain [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Maestro (Moon Surgical SAS, Paris, France), introduced in 2022, is a two-arm robotic device that holds and assists in the positioning of laparoscopes and instruments. Maestro has reportedly been used safely in several LS procedures in gastroenterological surgery without conversion to open surgery and has resulted in a high surgeon satisfaction index [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eANSUR is a new type of collaborative assistant robot with three arms that enables it to hold the camera in a stable position and appropriately grasp tissue (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea). The surgeon moves the camera and wave forceps using sensors attached to instruments on either the right- or left-hand side, along with a foot pedal. Sensors attached to the surgeon's instruments and trocars provided feedback to each robotic arm regarding the position and movement of surgical instruments, allowing the camera and wave forceps to move to the desired position (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec). Wave forceps are wave-shaped, double-ended grasping forceps with a 5-mm-diameter shaft that bends at the tip (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb). Therefore, the surgeon can move the wave forceps for proper deployment of the surgical field. Regarding ANSUR\u0026rsquo;s setup, this study showed that ANSUR had a short setup time and a straightforward setup procedure. Therefore, surgeons can operate the system smoothly after only limited experience. Given its characteristics, ANSUR may provide a stable field of view and facilitate operative field development, allowing surgeons to perform safer and less stressful solo surgical LS, reduce operative time, and minimize physical stress on the patient. However, one issue with ANSUR is that by taking on an assistant role, it may eliminate the role of surgical trainees as assistants, potentially depriving them of opportunities to learn LS. From an educational perspective, similar to teleoperated robotic surgical systems, ANSUR-assisted LS offer the advantage of enabling the supervising surgeon to seamlessly switch with a surgical trainee when necessary without disrupting the surgical field. This facilitates step-by-step instruction while maintaining safety.\u003c/p\u003e\u003cp\u003eThe primary advantage of ANSUR-assisted LS is its ability to reduce manpower requirements while maintaining applicability in both elective and emergency surgeries. Especially, ANSUR can perform the duties of both an assistant and a scope operator, taking on roles that preciously required one or two staff members. This is expected to improve the work-life balance of medical staff, including surgeons. For surgeons in particular, the time saved by using ANSUR can be allocated to ward duties, reviewing patient records, taking breaks, attending other surgeries, or performing surgeries in parallel. Moreover, ANSUR can be implemented in existing operating rooms without the need for special renovations or complex setup, allowing for flexible responses even in emergency surgeries.\u003c/p\u003e\u003cp\u003eCost remains a major consideration for the adoption of new technologies. Compared to conventional LS, the operative cost of ANSUR-assisted laparoscopic appendectomy was \u0026euro;261 higher per operation, and that of ANSUR-assisted laparoscopic cholecystectomy was \u0026euro;494 higher per operation. The additional cost of ANSUR-assisted LS was calculated based on the total number of consumables (Supplemental Fig.\u0026nbsp;2). Specifically, this included the sterile covers for the body, assistant arms, and camera arm; the cost of trocars and surgical tool sensors (calculated by dividing the total cost by 30 uses); and the cost of wave forceps (calculated by dividing the total cost by 10 uses). This analysis did not include initial acquisition costs, depreciation, or service contracts for robotic and laparoscopic systems. Nevertheless, the additional costs of ANSUR-assisted laparoscopic appendectomy and cholecystectomy were lower than those reported for teleoperated robotic surgical systems in previous studies [\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Therefore, ANSUR-assisted LS may offer advantages in terms of cost-effectiveness.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSupplemental Fig.\u0026nbsp;2\u003c/b\u003e Consumables.\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eSterile cover of the assistant arm\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eSterile cover of the body\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eSterile cover for camera arm\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTrocar sensor\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eSurgical tool sensors\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWave Forceps\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eThis study has some limitations. First, it was a retrospective study conducted at a single institution. Second, the number of enrolled patients, particularly those who underwent ANSUR-assisted LS, was relatively small; therefore, the findings may be biased, with limited generalizability. Third, there was surgeon bias in this study. In ANSUR-assisted LS, almost all procedures were performed by surgeons certified by Endoscopic Surgical Skill Qualification System of the Japan Society for Endoscopic Surgery. In contrast, conventional LS procedures were performed by both certified and non-certified surgeons. Qualified surgeons participated in all surgeries to ensure surgical safety and quality. Nevertheless, to our knowledge, this was the first study to evaluate the feasibility of a new type of collaborative assistant robot for LS.\u003c/p\u003e\u003cp\u003eIn conclusion, although the cost of ANSUR-assisted LS was slightly higher than that of conventional LS, ANSUR can be considered a safe and effective collaborative assistive robot. In addition, ANSUR is expected to alleviate surgeon shortage, improve community healthcare, and reform the way surgeons work.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability:\u003c/strong\u003e Data are available upon reasonable request to the corresponding author.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e T.H.: conception, analysis, and writing of the manuscript. T.H., M.K., Y.K., T.N., K.H., M.K., and K.T.: monitoring the patients. T.S. and S.T.: guidance on the introduction of ANSUR. M.K. and H.M.: critical review of the manuscript for important intellectual content. All Authors approved the final manuscript and agreed to be accountable for its content.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e ST received grants to his institute from ASAHI INTECC CO., Ltd. All the other authors have no conflicts of interest.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e This study was conducted in accordance with the ethical principles of the Declaration of Helsinki and approved by the Matsunami General Hospital Institutional Review Board (approval number: Matsu\u0026ndash;I\u0026ndash;Rin\u0026ndash;658).\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u003c/strong\u003e All patients provided informed consent through an opt-out process before enrollment in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMohiuddin K, Swanson SJ (2013) Maximizing the benefit of minimally invasive surgery. 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Surgery 176:835\u0026ndash;840. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.surg.2024.05.002\u003c/span\u003e\u003cspan address=\"10.1016/j.surg.2024.05.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"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":"ANSUR surgical unit, Collaborative assistant robot, Laparoscopic Appendectomy, Laparoscopic Cholecystectomy","lastPublishedDoi":"10.21203/rs.3.rs-8228632/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8228632/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eTo evaluate the efficacy of ANSUR-assisted laparoscopic appendectomy and cholecystectomy compared with conventional laparoscopic surgery (LS).\u003c/p\u003e\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe ANSUR Surgical Unit (ASAHI INTECC CO., LTD., Aichi, Japan) is a new collaborative assistant robot equipped with three arms. However, no studies have reported on ANSUR, and its clinical advantages remain unclear.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe retrospectively evaluated the data of 145 patients who underwent laparoscopic appendectomy and 261 patients who underwent laparoscopic cholecystectomy, in both elective and emergency settings, at our institution between January 2023 and June 2025.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eANSUR-assisted laparoscopic appendectomy was performed in 30 of 145 patients, and ANSUR-assisted laparoscopic cholecystectomy in 36 of 261 patients. In laparoscopic appendectomy, the proportion of complicated appendicitis in the ANSUR-assisted LS group was significantly lower than that in the conventional LS group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.006). However, there were no significant differences in the perioperative outcomes between the two groups. In laparoscopic cholecystectomy, the proportion of emergency ANSUR-assisted LS cases was lower than that of conventional LS (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.041). The intraoperative and postoperative outcomes of ANSUR-assisted LS were comparable to those of conventional LS. No conversion to open surgery occurred in either ANSUR-assisted laparoscopic appendectomy or cholecystectomy. The median setup time\u0026mdash;defined as the interval between ANSUR roll-in and the start of surgery\u0026mdash;was 5 min for laparoscopic appendectomy and 8 min for laparoscopic cholecystectomy.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eANSUR is a safe and effective collaborative assistant robot for laparoscopic appendectomy and cholecystectomy. Additionally, ANSUR is expected to have clinical benefit in reducing healthcare manpower constrains.\u003c/p\u003e","manuscriptTitle":"Clinical Advantages of a New Collaborative Assistant Robot (ANSUR Surgical Unit) in Laparoscopic Appendectomy and Cholecystectomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-11 12:38:25","doi":"10.21203/rs.3.rs-8228632/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-08T14:08:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-08T12:36:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"40994901594508872583214819834278371793","date":"2025-12-08T11:05:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-08T10:44:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-08T10:23:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-08T01:54:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"305363241500355737654481669650726094037","date":"2025-12-07T18:21:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"297383223157604522037543347081906087142","date":"2025-12-07T11:46:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"203937324335081101922365669299899018504","date":"2025-12-07T05:34:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"105131382404090711347537091002701162044","date":"2025-12-07T05:09:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"276259005946409320007510509678573944567","date":"2025-12-07T03:36:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-07T03:31:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-28T12:40:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-28T11:26:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2025-11-28T08:52:40+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":"2d637a6c-f091-4293-834d-5403f28d255d","owner":[],"postedDate":"December 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-05T16:03:44+00:00","versionOfRecord":{"articleIdentity":"rs-8228632","link":"https://doi.org/10.1007/s11701-025-03102-w","journal":{"identity":"journal-of-robotic-surgery","isVorOnly":false,"title":"Journal of Robotic Surgery"},"publishedOn":"2026-01-03 15:58:03","publishedOnDateReadable":"January 3rd, 2026"},"versionCreatedAt":"2025-12-11 12:38:25","video":"","vorDoi":"10.1007/s11701-025-03102-w","vorDoiUrl":"https://doi.org/10.1007/s11701-025-03102-w","workflowStages":[]},"version":"v1","identity":"rs-8228632","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8228632","identity":"rs-8228632","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}