Skip to main content

Advertisement

SpringerLink
Log in

Economic evaluation of robotic and laparoscopic paraesophageal hernia repair

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Robotic approach in paraesophageal hernia (PEH) repair may improve outcomes over laparoscopic approach, though at additional cost. This study aimed to compare cost-effectiveness of robotic and laparoscopic PEH repair.

Methods

A decision tree was created analyzing cost-effectiveness of robotic and laparoscopic PEH repair. Costs were obtained from 2021 Medicare data and were accumulated within 60 months after surgery. Effectiveness was measured in quality-adjusted life-years (QALYs). Branch-point probabilities and costs of robotic surgery consumables were obtained from published literature. The primary outcome of interest was incremental cost-effectiveness ratio (ICER). One-way, two-way, and probabilistic sensitivity analyses were performed. A secondary analysis including attributable capital and maintenance costs of robotic surgery was conducted as well.

Results

Laparoscopic repair yielded 3.660 QALYs at $35,843.82. Robotic repair yielded 3.661 QALYs at $36,342.57, with an ICER of $779,488.62/QALY. Robotic repair was favored when rates of open conversion and symptom recurrence were low, or with reduced cost of robotic instruments. A probabilistic sensitivity analysis favored laparoscopic repair in 100% of simulations. When accounting for costs of robotic technology, robotic approach was preferred only in unrealistic clinical scenarios.

Conclusions

Laparoscopic repair is likely more cost-effective for most institutions, though results were relatively similar. With experienced surgeons who surpass the initial learning curve, robotic surgery may improve outcomes enough to be cost-effective, but only when excluding capital and maintenance fees.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Antiporda M, Veenstra B, Jackson C, Kandel P, Daniel Smith C, Bowers SP (2017) Laparoscopic repair of giant paraesophageal hernia: are there factors associated with anatomic recurrence? Surg Endosc. https://doi.org/10.1007/s00464-017-5770-z

    Article  PubMed  Google Scholar 

  2. Karmali S, McFadden S, Mitchell P, Graham A, Debru E, Gelfand G, Graham J, Martin S, Tiruta C, Grondin S (2008) Primary laparoscopic and open repair of paraesophageal hernias: a comparison of short-term outcomes. Dis Esophagus. https://doi.org/10.1111/j.1442-2050.2007.00740.x

    Article  PubMed  Google Scholar 

  3. Mungo B, Molena D, Stem M, Feinberg RL, Lidor AO (2014) Thirty-day outcomes of paraesophageal hernia repair using the NSQIP database: should laparoscopy be the standard of care? J Am Coll Surg. https://doi.org/10.1016/j.jamcollsurg.2014.02.030

    Article  PubMed  Google Scholar 

  4. Nguyen NT, Christie C, Masoomi H, Matin T, Laugenour K, Hohmann S (2011) Utilization and outcomes of laparoscopic versus open paraesophageal hernia repair. Am Surg. https://doi.org/10.1177/000313481107701018

    Article  PubMed  Google Scholar 

  5. Jutric Z, Louie BE (2013) Laparoscopic paraesophageal hernia repair. Surg Laparosc Endosc Percutan Tech. https://doi.org/10.1097/SLE.0b013e3182a12666

    Article  PubMed  Google Scholar 

  6. Lara FJP, Zubizarreta Jimenez R, Moya Donoso FJ, Hernández Gonzalez JM, Prieto-Puga Arjona T, Del Rey MA, Pitarch Martinez M (2021) Preoperative calculation of angles of vision and working area in laparoscopic surgery to treat a giant hiatal hernia. World J Gastrointest Surg. https://doi.org/10.4240/wjgs.v13.i12.1638

    Article  PubMed  PubMed Central  Google Scholar 

  7. Leal Ghezzi T, Campos Corleta O (2016) 30 Years of robotic surgery. World J Surg. https://doi.org/10.1007/s00268-016-3543-9

    Article  PubMed  Google Scholar 

  8. Pernar LIM, Robertson FC, Tavakkoli A, Sheu EG, Brooks DC, Smink DS (2017) An appraisal of the learning curve in robotic general surgery. Surg Endosc. https://doi.org/10.1007/s00464-017-5520-2

    Article  PubMed  Google Scholar 

  9. Esposito C, Autorino G, Castagnetti M, Cerulo M, Coppola V, Cardone R, Esposito G, Borgogni R, Escolino M (2021) Robotics and future technical developments in pediatric urology. Semin Pediatr Surg. https://doi.org/10.1016/j.sempedsurg.2021.151082

    Article  PubMed  Google Scholar 

  10. Gerull WD, Cho D, Arefanian S, Kushner BS, Awad MM (2020) Favorable peri-operative outcomes observed in paraesophageal hernia repair with robotic approach. Surg Endosc. https://doi.org/10.1007/s00464-020-07700-7

    Article  PubMed  Google Scholar 

  11. Soliman BG, Nguyen DT, Chan EY, Chihara RK, Meisenbach LM, Graviss EA, Kim MP (2019) Robot-assisted hiatal hernia repair demonstrates favorable short-term outcomes compared to laparoscopic hiatal hernia repair. Surg Endosc. https://doi.org/10.1007/s00464-019-07055-8

    Article  PubMed  Google Scholar 

  12. Hosein S, Carlson T, Flores L, Armijo PR, Oleynikov D (2020) Minimally invasive approach to hiatal hernia repair is superior to open, even in the emergent setting: a large national database analysis. Surg Endosc. https://doi.org/10.1007/s00464-020-07404-y

    Article  PubMed  Google Scholar 

  13. Stringfield SB, Parry LA, Eisenstein SG, Horgan SN, Kane CJ, Ramamoorthy SL (2021) Experience with 10 years of a robotic surgery program at an academic medical center. Surg Endosc. https://doi.org/10.1007/s00464-021-08478-y

    Article  PubMed  PubMed Central  Google Scholar 

  14. Turchetti G, Palla I, Pierotti F, Cuschieri A (2011) Economic evaluation of da Vinci-assisted robotic surgery: a systematic review. Surg Endosc. https://doi.org/10.1007/s00464-011-1936-2

    Article  PubMed  Google Scholar 

  15. Abdelmoaty WF, Dunst CM, Neighorn C, Swanstrom LL, Hammill CW (2018) Robotic-assisted versus laparoscopic unilateral inguinal hernia repair: a comprehensive cost analysis. Surg Endosc. https://doi.org/10.1007/s00464-018-06606-9

    Article  PubMed  Google Scholar 

  16. Albright BB, Witte T, Tofte AN, Chou J, Black JD, Desai VB, Erekson EA (2016) Robotic versus laparoscopic hysterectomy for benign disease: A systematic review and meta-analysis of randomized trials. J Minim Invasive Gynecol. https://doi.org/10.1016/j.jmig.2015.08.003

    Article  PubMed  Google Scholar 

  17. Quinn PL, Arjani S, Ahlawat SK, Chokshi RJ (2020) Cost-effectiveness of palliative emergent surgery versus endoscopic stenting for acute malignant colonic obstruction. Surg Endosc. https://doi.org/10.1007/s00464-020-07637-x

    Article  PubMed  Google Scholar 

  18. Higgins RM, Frelich MJ, Bosler ME, Gould JC (2017) Cost analysis of robotic versus laparoscopic general surgery procedures. Surg Endosc. https://doi.org/10.1007/s00464-016-4954-2

    Article  PubMed  Google Scholar 

  19. Ho C, Tsakonas E, Tran K, Cimon K, Severn M, Mierzwinski-Urban M, Corcos J, Pautler S (2011) Robot-assisted surgery compared with open surgery and laparoscopic surgery: clinical effectiveness and economic analyses. Canadian Agency for Drugs and Technologies in Health; 2011 Sep. (CADTH Technology Report, No. 137.) https://www.ncbi.nlm.nih.gov/books/NBK168912/.

  20. Attema AE, Brouwer WBF, Claxton K (2018) Discounting in economic evaluations. Pharmacoeconomics. https://doi.org/10.1007/s40273-018-0672-z

    Article  PubMed  PubMed Central  Google Scholar 

  21. Stylopoulos N, Gazelle GS, Rattner DW (2002) Paraesophageal hernias: operation or observation? Ann Surg. https://doi.org/10.1097/00000658-200210000-00012

    Article  PubMed  PubMed Central  Google Scholar 

  22. Morrow EH, Chen J, Patel R, Bellows B, Nirula R, Glasgow R, Nelson RE (2018) Watchful waiting versus elective repair for asymptomatic and minimally symptomatic paraesophageal hernias: a cost-effectiveness analysis. Am J Surg. https://doi.org/10.1016/j.amjsurg.2018.07.037

    Article  PubMed  PubMed Central  Google Scholar 

  23. Petro CC, Zolin S, Krpata D, Alkhatib H, Tu C, Rosen MJ, Prabhu AS (2020) Patient-reported outcomes of robotic vs laparoscopic ventral hernia repair with intraperitoneal mesh: the PROVE-IT randomized clinical trial. JAMA Surg. https://doi.org/10.1001/jamasurg.2020.4569

    Article  PubMed Central  Google Scholar 

  24. Juszczak K, Gastecka A, Adamowicz J, Adamczyk P, Pokrywczyńska M, Drewa T (2020) Health-related quality of life is not related to laparoscopic or robotic technique in radical cystectomy. Adv Clin Exp Med. https://doi.org/10.17219/acem/121937

    Article  PubMed  Google Scholar 

  25. Ubel PA, Hirth RA, Chernew ME, Fendrick AM (2003) What is the price of life and why doesn’t it increase at the rate of inflation? Arch Intern Med. https://doi.org/10.1001/archinte.163.14.1637

    Article  PubMed  Google Scholar 

  26. Washington K, Watkins JR, Jeyarajah DR (2019) The first year is the hardest: a comparison of early versus late experience after the introduction of robotic hiatal hernia repair. J Robot Surg. https://doi.org/10.1007/s11701-019-00967-6

    Article  PubMed  Google Scholar 

  27. Vasudevan V, Reusche R, Nelson E, Kaza S (2017) Robotic paraesophageal hernia repair: a single-center experience and systematic review. J Robot Surg. https://doi.org/10.1007/s11701-017-0697-x

    Article  PubMed  Google Scholar 

  28. Galvani CA, Loebl H, Osuchukwu O, Samamé J, Apel ME, Ghaderi I (2016) Robotic-assisted paraesophageal hernia repair: initial experience at a single institution. J Laparoendosc Adv Surg Tech A 26(4):290–295

    Article  PubMed  Google Scholar 

  29. Gerull WD, Cho D, Kuo I, Arefanian S, Kushner BS, Awad MM (2020) Robotic approach to paraesophageal hernia repair results in low long-term recurrence rate and beneficial patient-centered outcomes. J Am Coll Surg. https://doi.org/10.1016/j.jamcollsurg.2020.07.754

    Article  PubMed  Google Scholar 

  30. Arcerito M, Perez MG, Kaur H, Annoreno KM, Moon JT (2020) Robotic fundoplication for large paraesophageal hiatal hernias. JSLS. https://doi.org/10.4293/JSLS.2019.00054

    Article  PubMed  PubMed Central  Google Scholar 

  31. Nason KS, Luketich JD, Qureshi I, Keeley S, Trainor S, Awais O, Shende M, Landreneau RJ, Jobe BA, Pennathur A (2008) Laparoscopic repair of giant paraesophageal hernia results in long-term patient satisfaction and a durable repair. J Gastrointest Surg. https://doi.org/10.1007/s11605-008-0712-7

    Article  PubMed  Google Scholar 

  32. Williamson WA, Ellis FH Jr, Streitz JM Jr, Shahian DM (1993) Paraesophageal hiatal hernia: is an antireflux procedure necessary? Ann Thorac Surg 56(3):447–452

    Article  CAS  PubMed  Google Scholar 

  33. Lin EL, Sibona A, Peng J, Singh PN, Wu E, Michelotti MJ (2021) Cumulative summation analysis of learning curve for robotic-assisted hiatal hernia repairs. Surg Endosc. https://doi.org/10.1007/s00464-021-08665-x

    Article  PubMed  PubMed Central  Google Scholar 

  34. Ruurda JP, Draaisma WA, van Hillegersberg R, Borel Rinkes IH, Gooszen HG, Janssen LW, Simmermacher RK, Broeders IA (2005) Robot-assisted endoscopic surgery: a four-year single-center experience. Dig Surg. https://doi.org/10.1159/000088628

    Article  PubMed  Google Scholar 

  35. Diez Del Val I, Martinez Blazquez C, Loureiro Gonzalez C, Vitores Lopez JM, Sierra Esteban V, Barrenetxea Asua J, Del Hoyo AI, Perez de Villarreal P, Bilbao Axpe JE, Mendez Martin JJ (2013) Robot-assisted gastroesophageal surgery: usefulness and limitations. J Robot Surg. https://doi.org/10.1007/s11701-013-0435-y

    Article  PubMed  Google Scholar 

  36. Seetharamaiah R, Romero RJ, Kosanovic R, Gallas M, Verdeja JC, Rabaza J, Gonzalez AM (2013) Robotic repair of giant paraesophageal hernias. JSLS 17(4):570–577

    Article  PubMed  PubMed Central  Google Scholar 

  37. Sarkaria IS, Latif MJ, Bianco VJ, Bains MS, Rusch VW, Jones DR, Rizk NP (2016) Early operative outcomes and learning curve of robotic assisted giant paraesophageal hernia repair. Int J Med Robot. https://doi.org/10.1002/rcs.1730

    Article  PubMed  PubMed Central  Google Scholar 

  38. Sowards KJ, Holton NF, Elliott EG, Hall J, Bajwa KS, Snyder BE, Wilson TD, Mehta SS, Walker PA, Chandwani KD, Klein CL, Rivera AR, Wilson EB, Shah SK, Felinski MM (2019) Safety of robotic assisted laparoscopic recurrent paraesophageal hernia repair: insights from a large single institution experience. Surg Endosc. https://doi.org/10.1007/s00464-019-07291-y

    Article  PubMed  Google Scholar 

  39. Okrainec A, Ferri LE, Feldman LS, Fried GM (2010) Defining the learning curve in laparoscopic paraesophageal hernia repair: a CUSUM analysis. Surg Endosc. https://doi.org/10.1007/s00464-010-1321-6

    Article  PubMed  Google Scholar 

  40. Tartaglia N, Pavone G, Di Lascia A, Vovola F, Maddalena F, Fersini A, Pacilli M, Ambrosi A (2020) Robotic voluminous paraesophageal hernia repair: a case report and review of the literature. J Med Case Rep. https://doi.org/10.1186/s13256-020-2347-6

    Article  PubMed  PubMed Central  Google Scholar 

  41. Draaisma WA, Gooszen HG, Consten EC, Broeders IA (2008) Mid-term results of robot-assisted laparoscopic repair of large hiatal hernia: a symptomatic and radiological prospective cohort study. Surg Technol Int 17:165–170

    PubMed  Google Scholar 

  42. Ekeke CN, Vercauteren M, Baker N, Sarkaria I (2019) Surgical techniques for robotically-assisted laparoscopic paraesophageal hernia repair. Thorac Surg Clin. https://doi.org/10.1016/j.thorsurg.2019.06.001

    Article  PubMed  PubMed Central  Google Scholar 

  43. Kaan HL, Ho KY (2019) Endoscopic robotic suturing: the way forward. Saudi J Gastroenterol. https://doi.org/10.4103/sjg.SJG_12_19

    Article  PubMed  PubMed Central  Google Scholar 

  44. O’Connor SC, Mallard M, Desai SS, Couto F, Gottlieb M, Ewing A, Cobb WS, Carbonell AM, Warren JA (2020) Robotic versus laparoscopic approach to hiatal hernia repair: results after 7 years of robotic experience. Am Surg. https://doi.org/10.1177/0003134820943547

    Article  PubMed  Google Scholar 

  45. Howell RS, Liu HH, Petrone P, Anduaga MF, Servide MJ, Hall K, Barkan A, Islam S, Brathwaite CEM (2020) Short-term outcomes in patients undergoing paraesophageal hiatal hernia repair. Sci Rep. https://doi.org/10.1038/s41598-020-61566-2

    Article  PubMed  PubMed Central  Google Scholar 

  46. Witek TD, Luketich JD, Pennathur A, Awais O (2019) Management of recurrent paraesophageal hernia. Thorac Surg Clin. https://doi.org/10.1016/j.thorsurg.2019.07.011

    Article  PubMed  Google Scholar 

  47. Kao AM, Otero J, Schlosser KA, Marx JE, Prasad T, Colavita PD, Heniford BT (2018) One more time: redo paraesophageal hernia repair results in safe durable outcomes compared with primary repairs. Am Surg. https://doi.org/10.1177/000313481808400727

    Article  PubMed  Google Scholar 

  48. Wennergren J, Levy S, Bower C, Miller M, Borman D, Davenport D, Plymale M, Scott Roth J (2015) Revisional paraesophageal hernia repair outcomes compare favorably to initial operations. Surg Endosc. https://doi.org/10.1007/s00464-015-4688-6

    Article  PubMed  Google Scholar 

  49. Zahiri HR, Weltz AS, Sibia US, Paranji N, Leydorf SD, Fantry GT, Park AE (2017) Primary versus redo paraesophageal hiatal hernia repair: a comparative analysis of operative and quality of life outcomes. Surg Endosc. https://doi.org/10.1007/s00464-017-5583-0

    Article  PubMed  Google Scholar 

  50. Tolboom RC, Draaisma WA, Broeders IA (2016) Evaluation of conventional laparoscopic versus robot-assisted laparoscopic redo hiatal hernia and antireflux surgery: a cohort study. J Robot Surg. https://doi.org/10.1007/s11701-016-0558-z

    Article  PubMed  PubMed Central  Google Scholar 

  51. Lekarczyk A, Sinha H, Dvir D, Goyert J, Airhart A, Reddy RM (2022) Similar hospital profits with robotic-assisted paraesophageal hiatal hernia repair, despite higher or supply costs. Surg Endosc. https://doi.org/10.1007/s00464-022-09513-2

    Article  PubMed  Google Scholar 

  52. Munshower E, Ren E, Bauerle WB, Ruland J, Stoltzfus J, McDonald M, Baillie DR, Chaar ME (2022) Cost analysis of robotic assisted general surgery cases in a single academic institution. J Robot Surg. https://doi.org/10.1007/s11701-022-01434-5

    Article  PubMed  Google Scholar 

  53. Quijano Y, Nuñez-Alfonsel J, Ielpo B, Ferri V, Caruso R, Durán H, Díaz E, Malavé L, Fabra I, Pinna E, Isernia R, Hidalgo Á, Vicente E (2020) Robotic versus laparoscopic surgery for rectal cancer: a comparative cost-effectiveness study. Tech Coloproctol. https://doi.org/10.1007/s10151-020-02151-7

    Article  PubMed  Google Scholar 

  54. De Pastena M, Esposito A, Paiella S, Surci N, Montagnini G, Marchegiani G, Malleo G, Secchettin E, Casetti L, Ricci C, Landoni L, Bovo C, Bassi C, Salvia R (2021) Cost-effectiveness and quality of life analysis of laparoscopic and robotic distal pancreatectomy: a propensity score-matched study. Surg Endosc. https://doi.org/10.1007/s00464-020-07528-1

    Article  PubMed  PubMed Central  Google Scholar 

  55. Simianu VV, Gaertner WB, Kuntz K, Kwaan MR, Lowry AC, Madoff RD, Jensen CC (2020) Cost-effectiveness evaluation of laparoscopic versus robotic minimally invasive colectomy. Ann Surg. https://doi.org/10.1097/SLA.0000000000003196

    Article  PubMed  Google Scholar 

Download references

Funding

The authors (Neal S. Panse, Vishnu Prasath, Patrick L. Quinn, Ravi J. Chokshi) have not received funding from any public or private sources.

Author information

Authors and Affiliations

  1. Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, 185 South Orange Avenue, Newark, NJ, 07103, USA

    Neal S. Panse & Ravi J. Chokshi

  2. Rutgers New Jersey Medical School, 185 South Orange Avenue, Newark, NJ, 07103, USA

    Vishnu Prasath

  3. Department of Surgery, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Columbus, OH, 43210, USA

    Patrick L. Quinn

Authors
  1. Neal S. Panse
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Vishnu Prasath
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Patrick L. Quinn
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ravi J. Chokshi
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ravi J. Chokshi.

Ethics declarations

Disclosure

Neal S. Panse, Vishnu Prasath, Patrick L. Quinn, Ravi J. Chokshi have no conflicts of interest or financial disclosures to declare.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Panse, N.S., Prasath, V., Quinn, P.L. et al. Economic evaluation of robotic and laparoscopic paraesophageal hernia repair. Surg Endosc 37, 6806–6817 (2023). https://doi.org/10.1007/s00464-023-10119-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-023-10119-5

Keywords

Search

Navigation