Solo surgeon ambulatory magnetic-assisted robotic surgery (MARS): initial 51 cases with high patient satisfaction

A retrospective review of a prospectively maintained database identified all patients who underwent outpatient reduced port laparoscopic cholecystectomy assisted by MARS for treatment of symptomatic cholelithiasis between January 2024 and August 2024 at a tertiary care hospital located in Santiago, Chile. All cholecystectomies were performed independently by four experienced laparoscopic surgeons without a surgical assistant. Each surgeon had participated in the clinical trial that led to eventual FDA clearance of the robotic system and were experienced in using the robot. The learning curve for each surgeon on the system was comparable to the results published by Larenas et al., who found that the learning curve of the system for use in urologic procedures was four cases [11]. Ethics approval was obtained from the Scientific Ethics Committee of the Metropolitan Eastern Health Service prior to the start of the study (approval code: SSMOriente291024-6).

Table 1 details the results of the modified patient satisfaction survey. Forty patients (78.4%) completed the survey at 30 days postoperatively. Regarding postoperative pain management, 87.5% of participants were satisfied, with only 5% expressing dissatisfaction with pain control in the hospital and at home. Similarly, most patients were satisfied with the amount of time needed to return to normal daily activities (90.0%), work (90.0%), and a normal exercise routine (95.0%). 95.0% of patients were satisfied with the results of surgery, 87.5% would undergo the surgery again, and 97.5% would recommend the surgery to someone else.

The additional MARS-specific questions also showed strong positive feedback. 97.5% of patients were satisfied with their surgeon using a new robotic system designed to reduce the number of incisions. 87.5% of patients were satisfied with the care provided by their surgeon, with a small percentage expressing neutral or unsatisfied responses. Of the patients who were neutral or unsatisfied with their surgical experience, five were able to be contacted for further clarification. Four patients had administrative issues related to discharge and problems with follow-up scheduling. One patient would not recommend the procedure due to experiencing postoperative diarrhea during the three weeks following surgery.

This study demonstrates the safety and feasibility of the MARS platform for use in outpatient reduced port laparoscopic cholecystectomy by a solo surgeon with high patient satisfaction. Of the 51 procedures performed with MARS, there were no postoperative complications or readmissions within 30 days. In addition, operative efficiency was maintained with MARS despite the lack of a surgical assistant, with a mean operative time of less than 60 min. This was likely enabled by the ability of the operating surgeon to simultaneously control the laparoscopic camera and gallbladder retraction with the robot as needed. Our study builds upon previous literature demonstrating the utility of magnetic-assisted surgery in reduced port MIS and is the first to report a cholecystectomy cases series performed by a solo surgeon with the MARS system.

Surgical procedures in the US and abroad are increasingly shifting to outpatient and non-hospital locations. According to the 2024 US Ambulatory Surgery Center Market Report published by the Health Industry Distributors Association (HIDA), the 2024 ASC market is valued at $45.6 billion and projected to grow 21% to $55.3 billion by 2029 as procedures become less invasive. Outpatient surgical volumes are projected to reach 109.6 million cases by 2033, representing an 18% increase from 2023 levels [14]. Technological advances, increasing patient demand, and potential cost savings are driving the shift of numerous procedures across specialties to the outpatient setting. This shift also comes amid critical staffing shortages, particularly among nurses and surgical technologists, which has prompted facilities to adopt strategies like workflow automation and flexible scheduling to attract and retain staff. The 2024 HIDA report stated that nearly 70% of ASC leaders reported increased difficulty recruiting staff in 2023 compared to 2022. Hospitals have also faced a decrease of approximately 94,000 healthcare workers since February 2020, with vacancy rates for nurses increasing by up to 30% in some locations [15]. Robotic surgery may offer a partial solution to these challenges by reducing the need for specialized surgical staff, alleviating some pressure caused by workforce shortages while addressing growing procedural demands. Enabling surgeons to perform solo procedures with a surgeon-controlled robotic assistant will likely aid in these efforts.

Several studies have demonstrated the use of robotic surgical systems to perform solo surgery, particularly robotic camera holders [16‐22]. These investigations have shown that robotic camera assistance is safe and feasible for a range of minimally invasive procedures, including laparoscopic cholecystectomy, hysterectomy, colon resection, bariatrics, and foregut surgery. Robotic camera holders can provide a stable view of the operative field and may also improve surgeon ergonomics [23, 24]. It follows that eliminating the need for a camera assistant could reduce the amount of time spent in a suboptimal field of view, unintended rotation of the camera horizon, tissue contact, tremor, and undesired camera movements. Two randomized controlled trials evaluated the application of a robotic camera holder on cholecystectomy specifically and found that robotic holders were practical, reliable, and can reduce operative personnel [16, 25]. Previous studies have also shown that solo surgery with robotic camera holders can be cost beneficial [16‐20, 26, 27]. Stott et al. found that the use of a robotic camera holder provided cost savings compared with surgical trainees and nurse assistants during laparoscopic liver resections [28]. In addition to providing camera control, the MARS system enables concurrent surgeon control of tissue retraction, permitting even more precise intraoperative maneuvers and visualization. Further studies are warranted to investigate the influence of MARS on operative efficiency compared to standard laparoscopy, particularly regarding operative time and economy of motion.

Effective pain management is an essential component of postoperative care. Inadequately controlled pain negatively affects quality of life and functional recovery and can potentially require unplanned inpatient admission after ambulatory surgery [29, 30]. Persistent incisional pain in particular is a common and problematic postoperative complication occurring in approximately 1 in 30 patients [31]. The majority of patients who develop persistent incisional pain report interference across aspects of daily life and more than half will seek analgesic use, which can result in increased medication side effects and personal healthcare costs. Efforts to reduce the size and number of incisions required to perform surgery have been a key driving force in surgical innovation, from advanced endoscopic techniques to natural orifice transluminal endoscopic surgery (NOTES) [32]. The MARS system’s use of magnetic attraction to provide incisionless retraction represents another advancement. Welsh et al. used the Levita magnetic system in place of an externally mounted Nathanson liver retractor in a series of minimally invasive bariatric procedures and found that use of the magnetic system resulted in decreased postoperative pain scores and decreased hospital length of stay compared to a control cohort [12]. Previous studies of this magnetic system in laparoscopic cholecystectomy have also demonstrated low postoperative pain scores and no apparent trauma to the abdominal wall from the external magnet at 6 h postoperatively [7]. While we do not directly compare postoperative pain control with the MARS system to standard laparoscopy, the majority of patients in this study were satisfied with their pain control in the hospital and at home. Additional studies are necessary to rigorously investigate the pain control benefits of reduced port laparoscopic surgery across a range of procedures and patient populations.

Patient satisfaction is increasingly recognized as an important metric that influences both postoperative outcomes and healthcare reimbursement models. Studies have shown that patients with higher satisfaction levels are more likely to adhere to postoperative care instructions, report reduced levels of stress, and experience fewer complications and readmissions, all of which contribute to improved postoperative recovery [33‐35]. Moreover, efficient and high-quality surgical care is associated with higher patient satisfaction scores [33]. Insurance providers and healthcare systems have incorporated patient satisfaction metrics into physician and hospital reimbursement structures, emphasizing the need for patient-centered care. Notably, in 2012, the Department of Health and Human Services tied a percentage of Medicare reimbursement to patient satisfaction scores as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, thus incentivizing hospitals to improve patient perceptions of the care they receive [36]. Robotic surgery and other technological advances like the MARS system may be utilized to enhance the surgical experience for patients. In a prospective study of 51 patients who underwent minimally invasive bariatric surgery with the magnetic system, 90% of patients believed that reduced incision magnet-assisted surgery would provide superior cosmetic results compared to standard laparoscopy [37]. The results of our survey further support these findings, as the overwhelming majority of patients in our cohort were satisfied with the use of new technology designed to reduce surgical incisions. The majority of patients in our study were also satisfied with the surgical experience overall.

This study is limited by its retrospective, single-center design, and lack of a direct comparison to standard laparoscopy. In addition, all cholecystectomies were performed by surgeons with extensive experience using the MARS system, which could limit the generalizability of our findings. We also did not objectively account for additional pain medications patients may have requested postoperatively outside of the standard regimen. However, we plan to conduct a randomized prospective study to compare postoperative pain between the reduced port technique with MARS and the conventional four-port technique for laparoscopic cholecystectomy. Additional work is also needed to validate our modifications to the SSQ-8. Further studies are warranted to evaluate the operative efficiency, learning curve, and cost-effectiveness of the MARS system for solo laparoscopic cholecystectomy. Use of the system for solo surgery should also be investigated for additional procedures across surgical disciplines.

This study is the first to demonstrate the safety and feasibility of the MARS platform for use in outpatient reduced port laparoscopic cholecystectomy by a solo surgeon with high patient satisfaction. MARS was particularly useful for simultaneous gallbladder retraction and laparoscopic camera manipulation by the operating surgeon, thus eliminating the need for a surgical assistant. These results also showcase the potential benefits of the MARS platform for other surgical procedures. Furthermore, due to high patient satisfaction with this technique, MARS may improve the patient experience and strengthen the patient–surgeon relationship.