How Robotic-Assisted Techniques Changed Outpatient Surgical Care

For most of the 20th century, major surgery meant a hospital admission. Surgeons opened the body wide enough to see and reach the target tissue, and patients spent days recovering on a hospital ward. Over roughly four decades, robotic-assisted and minimally invasive techniques moved a steady stream of procedures into outpatient settings, where patients go home the same day. Smaller incisions and more precise instruments made the change possible. 

That shift also changed how patients find care. When a procedure no longer requires a hospital stay, patients can compare specialty practices directly, and the first phone call or web inquiry often decides where they book. Patient Prism’s Revenue Activation System helps medical practices turn those inquiries into scheduled consultations. Dr. Josef Geldwert, founder of the Geldwert Bunion Center, built his practice around this outpatient model, and this article traces how bunion correction became part of the same shift.

Surgical robots started in neurosurgery and hip replacement

Surgeons performed the first documented robot-assisted procedure in 1985. They used a modified industrial arm, the PUMA 560, to guide a needle along a planned path during a CT-guided brain biopsy.1

Orthopedics followed in 1992 with ROBODOC, a system built to mill the femur for a hip implant.2 Surgeons had long shaped the bone cavity by hand with rasps. ROBODOC cut the cavity to match a plan built from preoperative CT images, and the system received FDA 510(k) clearance in 2008.3

The da Vinci Surgical System reached the market in 2000, when the U.S. Food and Drug Administration (FDA) cleared it for general laparoscopic procedures.4 A surgeon operates da Vinci from a console and controls wristed instruments inserted through a few small ports. Urologists and gynecologists adopted the system early for prostate and uterine surgery.

Smaller incisions made same-day discharge possible

Outpatient surgery predates surgical robots. Two physicians opened the first freestanding ambulatory surgery center (ASC) in Phoenix, Arizona, in 1970.5 Early centers focused on short, low-risk procedures.

Minimally invasive and robotic techniques expanded the list of operations an ASC could safely perform. A smaller incision damages less muscle and soft tissue, so patients often have less pain and lose less blood. Operating times do not always shrink, but hospital stays do, and patients recover sooner.6,7 Together, those effects shorten the time a patient needs under medical observation.

The numbers show the scale of the shift. Hospitals performed about 54% of their surgeries on an outpatient basis in 1992, and about 65% by 2012.8 Today, more than 6,400 Medicare-certified ASCs operate in the United States.9

Joint replacement moved out of the hospital

Knee and hip replacements were among the last major orthopedic procedures to leave the inpatient ward. Robotic-arm systems such as Stryker’s Mako give surgeons haptic boundaries during bone preparation.10 The arm resists movement outside the planned cut, which protects nearby ligaments and soft tissue. Accurate cuts and less soft-tissue trauma helped surgeons send joint replacement patients home sooner.

Medicare payment rules followed the clinical results. The Centers for Medicare & Medicaid Services (CMS) removed total knee arthroplasty from its inpatient-only list in 2018, so hospitals could bill the procedure as outpatient care.11 For 2020, CMS added total knee arthroplasty to the list of procedures covered in ASCs.12 The same rule removed total hip arthroplasty from the inpatient-only list.12 Under the new rules, health systems and surgery centers expanded outpatient joint replacement programs.

Foot and ankle surgery followed the same path

Bunion correction shows how the shift reached smaller joints. A bunion, or hallux valgus, is a deformity in which the big toe angles toward the second toe and a bony bump forms at the base of the joint. About 23% of adults have one.13

Traditional correction relies on an osteotomy. The surgeon cuts and repositions the first metatarsal bone, then fixes it in place with screws or plates. Recovery varies by procedure, but patients typically walk on the heel in a protective shoe, with crutches for balance, for about six weeks.14,15 Studies of minimally invasive bunion techniques report shorter operating and hospital times.16

As robotic-assisted and minimally invasive techniques pushed a growing share of orthopedic procedures out of the hospital and into single-day outpatient visits, foot and ankle surgeons adapted the same principles to the forefoot. The HyperFlex® Bunion Correction Device, developed by Dr. Josef Geldwert, founder of the Geldwert Bunion Center, as a minimally invasive outpatient approach to bunion correction.

Weighing the cost and long-term results of same-day surgery 

Outpatient surgery avoids the cost of an overnight hospital stay, which lowers the total bill for many procedures. Robotic systems add their own expenses, including the purchase price, service contracts, and single-use instruments. Hospitals and surgery centers weigh those costs against case volume and shorter stays.

Research on long-term outcomes also varies by specialty. Randomized trials of robotic spine surgery remain few, and a 2022 meta-analysis of 11 trials found no conclusive benefit over freehand screw placement.17 Surgeons and payers continue to track complication rates and implant survival as more procedures move to same-day settings.

The direction over the past four decades has been consistent. Each advance in surgical precision has shortened recovery, and each reduction in recovery time has moved another group of procedures out of the hospital.

 

References

1. Encyclopaedia Britannica. “PUMA 560.” https://britannica.com/technology/PUMA-560
2. Smithsonian Magazine. “Why This Robotic Medical Device Belongs in a Museum.” November 30, 2016. https://www.smithsonianmag.com/smithsonian-institution/why-this-robotic-medical-device-belongs-in-a-museum-180961220/
3. Citeline MedTech Insight. “Robodoc’s Surgical System Cleared by FDA.” August 14, 2008. https://insights.citeline.com/MT042761/Robodocs-surgical-system-cleared-by-FDA
4. ScienceDaily. “FDA Approves New Robotic Surgery Device.” July 17, 2000. https://www.sciencedaily.com/releases/2000/07/000717072719.htm
5. American College of Surgeons. “Timeline: 1970.” https://timeline.facs.org/1970.html
6. Li X, et al. “Laparoscopic Versus Conventional Appendectomy: A Meta-Analysis of Randomized Controlled Trials.” BMC Gastroenterology, November 3, 2010. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2988072/
7. Jiang J, et al. “The Comparison of Short- and Long-Term Outcomes for Laparoscopic Versus Open Gastrectomy for Patients With Advanced Gastric Cancer: A Meta-Analysis of Randomized Controlled Trials.” Frontiers in Oncology, 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9016843/
8. Agency for Healthcare Research and Quality. “HCUP Statistical Brief #188: Surgeries in Hospital-Owned Outpatient Facilities, 2012.” 2015. https://hcup-us.ahrq.gov/reports/statbriefs/sb188-Surgeries-Hospital-Outpatient-Facilities-2012.jsp
9. Becker’s ASC Review. “The Number of ASCs in All 50 States.” July 4, 2025. https://www.beckersasc.com/new-asc-development/the-number-of-ascs-in-all-50-states-2/
10. Stryker. “The Role of Haptics in Robotic-Arm Assisted TKA.” https://www.stryker.com/us/en/joint-replacement/test/the-role-of-haptics-in-robotic-arm-assisted-tka.html
11. Hall Render. “CMS Removes Total Knee Replacement from Inpatient Only List.” November 28, 2017. https://hallrender.com/2017/11/28/cms-removes-total-knee-replacement-from-inpatient-only-list/
12. American Association of Hip and Knee Surgeons. “CMS Releases CY2020 OPPS and ASC Payment Systems Final Rule.” https://www.aahks.org/advocacy/cy2020-opps-asc-pr/
13. Nix S, Smith M, Vicenzino B. “Prevalence of Hallux Valgus in the General Population: A Systematic Review and Meta-Analysis.” Journal of Foot and Ankle Research, September 27, 2010. https://pmc.ncbi.nlm.nih.gov/articles/PMC2955707/
14. Royal Berkshire NHS Foundation Trust. “Scarf Osteotomy Bunion Repair.” December 2023. https://royalberkshire.nhs.uk/media/qsdn15fo/scarf-osteotomy-bunion-repair_dec23.pdf
15. Riverside Health System. “Post-Operative Foot and Ankle Protocol.” https://www.riversideonline.com/-/media/medical-services/orthopedics/rhealth_protocol-post-op_fa_self-print.pdf
16. Ji L, et al. “Minimally Invasive vs. Open Surgery for Hallux Valgus: A Meta-Analysis.” Frontiers in Surgery, March 21, 2022. https://pubmed.ncbi.nlm.nih.gov/35388365/
17. Luengo-Matos S, et al. “Efficacy and Safety of Robotic Spine Surgery: Systematic Review and Meta-Analysis.” Journal of Orthopaedics and Traumatology, October 15, 2022. https://pmc.ncbi.nlm.nih.gov/articles/PMC9569281