Background
Racial disparities in access to optimal care and postoperative outcomes are widely reported. Robotic and laparoscopic procedures have been widely adopted in proctectomies. This study sought to determine any racial disparities in access to minimally invasive proctectomy using a large national database.

Method
The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for proctectomies from 2016 to 2020. Data were evaluated for surgical approach, demographics, and comorbidity, and then compared by race. We sought to assess race as an independent risk factor in determining what type of surgical approach (robotic, laparoscopic, or open) patients received. Surgical approach was determined by the initial surgical operation. Converted cases were included with the initial intended approach. Multivariable logistic regression model with backward elimination accounting for age, sex, race, BMI, hypertension, smoking, and diabetes was built to find predictors of laparoscopic/robotic/open surgeries. The findings are presented as odds ratio (OR) and 95% confidence interval (95%CI).

Results
A total of 17217 patients (1105 Asian, 14962 White, 1150 African American/Black) were included in this analysis (Table 1). Both Asians and Whites had significantly higher rates of laparoscopic proctectomies performed relative to African Americans. Asians also had the highest rate of robotic proctectomies. Conversely, African American/Black patients had significantly higher rates of open proctectomies performed followed by White patients and then, Asians. While Asians had the lowest BMI across all surgical approaches, they had the highest mean age relative to other races. Overall, African Americans display a higher comorbidity burden supported by their morbidity probability and rates of diabetes, hypertension, and smoking use (Table 1). There was no significant difference in mortality probability among the races. , In regression models, given the Asians as the reference category, the OR (95%CI) for laparoscopic proctectomy for White and African/Americans were 0.74 (0.65-0.85) and 0.53 (0.45-0.64), respectively (P<0.001). Similarly, compared to Asians, the OR (95%CI) for robotic proctectomy for White and African/Americans were 1.074 (0.93-1.25) and 0.70 (0.57-0.85), respectively (P<0.001). Finally, compared to Asians, the OR (95%CI) for open proctectomy for White and African/Americans were 1.23 (1.09-1.39) and 2.31 (1.94-2.75), respectively (P<0.001).

Conclusion
The odds of open proctectomy for African Americans patients were 2.3 times more than that in Asian patients. The odds of laparoscopic and robotic protectomies for African American patients were 46.5% and 30.5% less than those in Asians, respectively. Asians had the highest rate of laparoscopic and robotic proctectomies performed, while African Americans had the highest rate of open proctectomies. African American proctectomy patients are less likely to undergo laparoscopic surgery compared to Asian and White patients. Race may be an independent risk factor regarding patients’ access to minimally invasive proctectomies.