Automation angst in robotic surgical emergencies: A discussion paper
DOI:
https://doi.org/10.26550/2209-1092.1403Keywords:
robotic surgery, patient safety, communication, simulation-based training, perioperative nurseAbstract
Introduction: The inclusion of a surgical robot as a team member adds yet another level of intricacy to the already complex environment and roles for perioperative nurses. Over the last twenty years, robotic-assisted surgery (RAS) has gained popularity due to its many benefits, including operative precision, decreased length of stay, and reduced blood loss.
Aim: This discussion paper aims to provide a greater understanding of robotic surgery for perioperative nurses by offering an overview of the incidence and types of intraoperative robotic surgical emergencies and some technical and non-technical responses to these emergency situations.
Discussion: Like all surgical procedures, RAS has inherent risks, with adverse surgical emergencies creating stress, ‘automation angst’, for the perioperative team members, particularly those who are not familiar or well-practiced with these procedures.
Following thematic analysis of the reviewed literature, this discussion will be presented under the emerging themes, namely, ‘Robotic surgical emergencies’, ‘Non-technical skills for the multidisciplinary team’, ‘Simulation-based training for crisis management’, and ‘Implications for perioperative nurses’.
Conclusion: While robotic surgical emergencies are not common, they do occur, and perioperative nurses need to be prepared. During emergency situations, communication must be at a premium, and the lessons from human factors and situational awareness are well documented.
An ongoing message running through the literature was surrounding the need for education, emphasising that continuous education is required to achieve competence of surgical team members in preparing for emergency situations. Simulation may play an important role in this education. Also important will be the development and implementation of an emergency robotic undocking protocol (ERUP) to guide the team when conversion to open or speedy access to the patient is required.
References
1. Gillespie BM, Gillespie J, Boorman RJ, Granqvist K, Stranne J, Erichsen‑Andersson A. The impact of robotic‑assisted surgery on team performance: a systematic mixed studies review. Hum Factors. 2021[cited 2026 May 31];63(8):1352–1379. doi:10.1177/0018720820928624.
2. Myklebust MV, Storheim H, Hartvik M, Dysvik E. Anesthesia professionals' perspectives of teamwork during robotic‑assisted surgery. AORN J. 2020 [cited 2025 May 5];111(1):87–96. doi:10.1002/aorn.12897.
3. McBride K, Steffens D, Stanislaus C, Solomon M, Anderson T, Thanigasalam R, et al. Detailed cost of robotic‑assisted surgery in the Australian public health sector: from implementation to a multi‑specialty caseload. BMC Health Serv Res. 2021[cited 2025 May 5];21(1):108. doi:10.1186/s12913‑021‑06105‑z..
4. Sakalkale A, Satheakeerthy S, Yeung JMC, Reid F. Robots down‑under: the current climate of robotic‑assisted surgery education in Australia. J Robot Surg. 2024[cited 2025 May 5];18(1):246. doi:10.1007/s11701‑024‑01994‑8.
5. England EC, Spear CR, Huang DD, Weinberg J, Bogert JN, Gillespie T, et al. REBOA as a rescue strategy for catastrophic vascular injury during robotic surgery. J Robot Surg. 2020 [cited 2025 May 5];14(3):473–477. doi:10.1007/s11701‑019‑01011‑3.
6. Sınmaz T, Kara Ö, Seyhan Ak E, Özbaş A. Experiences of robotic surgery nurses regarding technostress: a qualitative study. J Robot Surg. 2025[cited 2025 May 5];19(1):154. doi:10.1007/s11701‑025‑02320‑6.
7. Çelik SS, Koken ZO, Canda AE, Esen T. Experiences of perioperative nurses with robotic‑assisted surgery: a systematic review of qualitative studies. J Robot Surg. 2023[cited 2025 May 5];17(3):785–795. doi:10.1007/s11701‑022‑01511‑9.
8. Hibberson M, Lawton J, Whitehead D. Multidisciplinary simulation training for Australian perioperative teams: a qualitative descriptive exploratory study. J Perioper Nurs. 2023[cited 2025 May 5];36(4):e14–e35. doi:10.26550/2209‑1092.1261.
9. Russell B. Understanding the role of the scrub nurse during robotic surgery. Nurs Stand. 2022;37(12):71–75. doi:10.7748/ns.2022.e12003.
10. Pilz da Cunha G, Sijberden JP, Gobardhan P, Lips DJ, Terkivatan T, Marsman HA, et al. Risk factors and outcomes of conversions in robotic and laparoscopic liver resections: a nationwide analysis. Surgery. 2025[cited 2025 May 5];178:108820. doi:10.1016/j.surg.2024.09.004.
11. Slavin M, Ross SB, Sucandy I, Saravanan S, Crespo KL, Syblis CC, et al. Unplanned conversions of robotic pancreaticoduodenectomy: short‑term outcomes and suggested stepwise approach for a safe conversion. Surg Endosc. 2024[cited 2025 May 5];38(2):964–974. doi:10.1007/s00464‑023‑10527‑7.
12. Buffi NM, Piccolini A, Moretto S, Paciotti M, Finocchiaro A, Cella L, et al. Reliability of the da Vinci robotic surgical system: a systematic review and pooled analysis of technical failures. World J Urol. 2025[cited 2025 May 5];43(1):348. doi:10.1007/s00345‑025‑05732‑z.
13. Ogihara A, Omata M, Shidei H, Mitsuboshi S, Aoshima H, Isaka T, et al. Intraoperative robotic surgical system‑related problems in robot‑assisted thoracoscopic surgery. Gen Thorac Cardiovasc Surg. 2024[cited 2025 May 5];72(9):593–598. doi:10.1007/s11748‑024‑02013‑1.
14. Watkins AA, Ricard C, Hoagland D, Shehata D, Price M, Trant CJ, et al. Emergency conversion from robotic thoracoscopy to thoracotomy: a safe, reproducible, and effective technique. Oper Tech Thorac Cardiovasc Surg. 2025[cited 2025 May 5];30(1):67–74. doi:10.1053/j.optechstcvs.2024.10.005.
15. Abd El Aziz MA, Grass F, Behm KT, D'Angelo AL, Mathis KL, Dozois EJ, et al. Trends and consequences of surgical conversion in the United States. Surg Endosc. 2022[cited 2025 May 5];36(1):82–90. doi:10.1007/s00464‑020‑08240‑w.
16. Manfredini B, Zirafa CC, Romano G, Bagalà E, Cariello C, Davini F, et al. Intraoperative catastrophes during robotic lung resection: a single‑center experience and review of the literature. Life (Basel). 2023[cited 2025 May 5];13(1):215. doi:10.3390/life13010215.
17. Restaino S, Paparcura F, Arcieri M, Pellecchia G, Poli A, Gallotta V, et al. Employing the aviation model to reduce errors in robotic gynecological surgery: a narrative review. Healthcare (Basel). 2024[cited 2025 May 5];12(16):1614. doi:10.3390/healthcare12161614.
18. Clanahan JM, Awad MM. How does robotic‑assisted surgery change OR safety culture? AMA J Ethics. 2023[cited 2025 May 5];25(8):E615–E623. doi:10.1001/amajethics.2023.615.
19. Mahendran V, Turpin L, Boal M, Francis NK. Assessment and application of non‑technical skills in robotic‑assisted surgery: a systematic review. Surg Endosc. 2024[cited 2025 May 5];38(4):1758–1774. doi:10.1007/s00464‑024‑10713‑1.
20. Wood TC, Rahman R, Bainton T, Ahmed J, Raza A. The importance of non‑technical skills in robot‑assisted surgery in gynaecology. J Robot Surg. 2024[cited 2025 May 5];18(1):192. doi:10.1007/s11701‑024‑01956‑0.
21. Sutkin G, Steele C, Brommelsiek M, Simonson RJ, Chan YYR, Davies A, et al. Speech communication interference in the robotic operating room. J Robot Surg. 2024[cited 2025 May 5];18(1):406. doi:10.1007/s11701‑024‑02157‑5.
22. Cofran L, Cohen T, Alfred M, Kanji F, Choi E, Savage S, et al. Barriers to safety and efficiency in robotic surgery docking. Surg Endosc. 2022[cited 2025 May 5];36(1):206–215. doi:10.1007/s00464‑020‑08258‑0.
23. Gros E, Shi R, Hasty B, Anderson T, Schmiederer I, Roman‑Micek T, et al. In situ interprofessional operating room simulations: empowering learners in crisis resource management principles. Surgery. 2021[cited 2025 May 5];170(2):432–439. doi:10.1016/j.surg.2021.02.011.
24. Redondo‑Sáenz D, Cortés‑Salas C, Parrales‑Mora M. Perioperative nursing role in robotic surgery: an integrative review. J Perianesth Nurs. 2023[cited 2025 May 5];38(4):636–641. doi:10.1016/j.jopan.2022.11.001.
25. Çelik SS, Tunçbilek Z, Sarıköse S, Topaktaş G, Canda AE. Roles, experience and views of nurses working in robotic surgery settings: a mixed‑methods study. J Perioper Pract. 2024[cited 2025 May 5];34(7–8):248–256. doi:10.1177/17504589241231100.
26. Kalipershad SNR, Peristerakis I. The introduction of an emergency safety protocol coupled with simulation training in robotic surgery has enabled a more cohesive and efficient response to emergencies. Surgeon. 2022[cited 2025 May 5];20(3):151–156. doi:10.1016/j.surge.2021.03.007.
27. de Almeida TFP, Campos MEC, de Castro PR, Garcia DPC, Junger G, Faria e Silva R, et al. Training in the protocol for robotic undocking for life emergency support (RULES) improves team communication, coordination and reduces the time required to decouple the robotic system from the patient. Int J Med Robot. 2022[cited 2025 May 5];18(6):e2454. doi:10.1002/rcs.2454.
28. Chan YY, Zhong J, Jacobs MA, Peters CA. Emergent robot‑to‑open conversion – multidisciplinary simulation training in crisis management. J Pediatr Urol. 2024[cited 2025 May 5];20(4):751–758. doi:10.1016/j.jpurol.2024.06.010.
29. Kadlec KE, Thompson J, Brogdon S, Muckler VC. Developing and implementing an emergency robotic undocking protocol at a community hospital. J Interprof Educ Pract. 2020[cited 2025 May 5];21:100385. doi:10.1016/j.xjep.2020.100385.
30. Dunnahoo FC, Thompson J, Muckler VC. Developing an emergency robotic undocking protocol using simulation. J Interprof Educ Pract. 2021[cited 2025 May 5];24:100464. doi:10.1016/j.xjep.2021.100464.
31. Saba P, Shuler N, Shepard L, Holler T, Wu G, Rashid H, et al. Design and implementation of an emergency undocking curriculum for robotic surgery utilizing a 3D printing hydrogel bleeding vascular model. Urol Video J. 2022[cited 2025 May 5];16:100186. doi:10.1016/j.urolvj.2022.100186.
32. Møller L, Olsen RG, Jørgensen L, Hertz P, Petersson J, Røder A, et al. Training and education of operating room nurses in robot‑assisted surgery: a systematic review. Surg Endosc. 2024[cited 2025 May 5];38(12):7024–7036. doi:10.1007/s00464‑024‑11335‑3.
