Bullet emboli can prove to be a clinical challenge. Adjuncts such as X-ray, computed tomography, transthoracic, and/or transesophageal echocardiography help establish the emboli location. While observation in the asymptomatic patient is reasonable in some circumstances, most patients undergo removal. Removal of bullet cardiac emboli is safe with the availability of modern techniques.

Introduction Since inception of robotic-assisted surgery (RAS) in 1999, there has been an exponential rise in RAS in both number and complexity of surgical cases performed. The majority of these cases are gynecologic surgery in nature, with only a quarter of them labeled as general surgery. The purpose of this study is to determine if RAS in the Department of Defense (DoD) mirrors these trends. Methods A total of 6,204 RAS cases from across the DoD were reviewed between 01 January 2015 and 30 September 2017 from every Military Treatment Facility (MTF) that employs a robotic surgical device (various models of the da Vinci robotic surgical system by Intuitive Surgical). Specialty, number, and surgeon were recorded for each case. These end points were also examined for trends overtime and compared to similar civilian data. Results The number of MTFs performing robotic surgery and the number of cases performed increased significantly. An average of 373 cases per quarter-year were performed in 2015, 647 in 2016, and 708 in 2017. The number of RAS cases increased by about 10% every quarter-year during this time period. RAS was most commonly performed by general surgery in 10 of the 14 MTFs examined. Conclusions MTFs implemented RAS much later than the civilian world. However, since its implementation, the frequency of RAS use has increased at a faster rate in the DoD than in the civilian world. Possible reasons for this are a younger pool of surgeons in the military and less demands on cost-effective productivity, allowing these younger surgeons to focus on emerging technology rather than maximizing surgical cost efficiency. General surgery constitutes the majority of RAS cases in the DoD. It is unclear why this difference from the civilian world exists.

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The purpose of this study is to update the available literature with information on the current use of robotic assisted surgery (RAS) in the Department of Defense (DoD) compared to the civilian world, and how the coronavirus disease 2019 (COVID-19) pandemic impacted RAS in the DoD. A total of 9,979 RAS cases between 01st October 2017 and 31st December 2020 were reviewed from every DoD Military Treatment Facility (MTF) that meets our inclusion criteria and employs various models of da Vinci robotic surgical systems (Intuitive Surgical). Specialty, number, and facility were recorded for each case. These data were then compared to previously known trends about RAS use in the DoD as well as with civilian trends. Before COVID-19, the use of RAS had increased over time, but not at the same rate as in the civilian sector. General surgery cases constituted most RAS cases in both the DoD and the civilian sector. The arrival of COVID-19 in the United States significantly decreased the use of RAS in the DoD as well as in the civilian sector in all surgical specialties because it led to postponement or cancellation of many non-emergent surgical procedures. In conclusion, the use of RAS has continued to increase, and general surgery cases continue to constitute most of these cases. However, since the COVID-19 pandemic began, there was a significant decline in both DoD and civilian RAS cases, with a more pronounced decline in the DoD.