Robotic-assisted versus laparoscopic unilateral inguinal hernia repair: a comprehensive cost analysis

Abstract

Background

Cost-effectiveness of robotic-assisted surgery is still debatable. Robotic-assisted inguinal hernia repair has no clear clinical benefit over laparoscopic repair. We performed a comprehensive cost-analysis comparison between the two approaches for evaluation of their cost-effectiveness in a large healthcare system in the Western United States.

Methods

Health records in 32 hospitals were queried for procedural costs of inguinal hernia repairs between January 2015 and March 2017. Elective robotic-assisted or laparoscopic unilateral inguinal hernia repairs were included. Cost calculations were done using a utilization-based costing model. Total cost included: fixed cost, which comprises medical device and personnel costs, and variable cost, which comprises disposables and reusable instruments costs. Other outcome measures were length of stay (LOS), conversion to open, and operative times. Statistics were done using t test for continuous variables and χ2 test for categorical variables. A p-value < 0.05 was considered significant.

Results

A total of 2405 cases, 734 robotic-assisted (633 Primary: 101 recurrent) and 1671 laparoscopic (1471 Primary: 200 recurrent), were included. The average total cost was significantly higher (p < 0.001) in the robotic-assisted group ($5517) compared to the laparoscopic group ($3269). However, the average laparoscopic variable cost ($1105) was significantly higher (p < 0.001) than the robotic-assisted cost ($933). Whereas there was no significant difference between the two groups for LOS and conversion to open, average operative times were significantly higher in the robotic-assisted group (p < 0.001). Subgroup analysis for primary and recurrent inguinal hernias matched the overall results.

Conclusions

Robotic-assisted inguinal hernia repair has a significantly higher cost and significantly longer operative times, compared to the laparoscopic approach. The study has shown that only fixed cost contributes to the cost difference between the two approaches. Medical device cost plus the longer operative times are the main factors driving the cost difference. Laparoscopic unilateral inguinal hernia repair is more cost-effective compared to a robotic-assisted approach.

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

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

References

  1. 1.

    Ismail I, Wolff S, Gronfier A, Mutter D, Swantröm LL (2015) A cost evaluation methodology for surgical technologies. Surg Endosc 29(8):2423–2432

    Article  Google Scholar 

  2. 2.

    Lau WY (2002) History of treatment of groin hernia. World J Surg 26(6):748–759

    CAS  Article  Google Scholar 

  3. 3.

    Hussain A, Malik A, Halim MU, Ali AM (2014) The use of robotics in surgery: a review. Int J Clin Pract 68(11):1376–1382

    CAS  Article  Google Scholar 

  4. 4.

    Marecik SJ, Chaudhry V, Jan A, Pearl RK, Park JJ, Prasad LM (2007) A comparison of robotic, laparoscopic, and hand-sewn intestinal sutured anastomoses performed by residents. Am J Surg 193(3):349–355

    Article  Google Scholar 

  5. 5.

    Luciani LG, Mattevi D, Mantovani W, Cai T, Chiodini S, Vattovani V et al (2017) Retropubic, laparoscopic, and robot-assisted radical prostatectomy: a comparative analysis of the surgical outcomes in a single regional center. Curr Urol 11(1):36–41

    Article  Google Scholar 

  6. 6.

    Sujenthiran A, Nossiter J, Parry M, Charman S, Aggarwal A, Payne H et al (2017) National cohort study comparing severe medium-term urinary complications following radical prostatectomy: robot-assisted versus laparoscopic versus retropubic open radical prostatectomy. BJU Int 121(3):445–452

    Article  Google Scholar 

  7. 7.

    Niklas C, Saar M, Berg B, Steiner K, Janssen M, Siemer S et al (2016) Da Vinci and open radical prostatectomy: comparison of clinical outcomes and analysis of insurance costs. Urol Int 96(3):287–294

    Article  Google Scholar 

  8. 8.

    Beck TL, Schiff MA, Goff BA, Urban RR (2018) Robotic, laparoscopic, or open hysterectomy—surgical outcomes by approach in endometrial cancer. J Minim Invasive Gynecol 25(6):986–993

    Article  Google Scholar 

  9. 9.

    Shah CA, Beck T, Liao JB, Giannakopoulos NV, Veljovich D, Paley P (2017) Surgical and oncologic outcomes after robotic radical hysterectomy as compared to open radical hysterectomy in the treatment of early cervical cancer. J Gynecol Oncol 28(6):1–10

    Article  Google Scholar 

  10. 10.

    Mäenpää MM, Nieminen K, Tomás EI, Laurila M, Luukkaala TH, Mäenpää JU (2016) Robotic-assisted vs traditional laparoscopic surgery for endometrial cancer: a randomized controlled trial. Am J Obstet Gynecol 215(5):588.e1–588.e7

    Article  Google Scholar 

  11. 11.

    Panteleimonitis S, Pickering O, Abbas H, Harper M, Kandala N, Figueiredo N et al (2018) Robotic rectal cancer surgery in obese patients may lead to better short-term outcomes when compared to laparoscopy: a comparative propensity scored match study. Int J Colorectal Dis. https://doi.org/10.1007/s00384-018-3030-x

    Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Valverde A, Goasguen N, Oberlin O, Svrcek M, Fléjou JF, Sezeur A et al (2017) Robotic versus laparoscopic rectal resection for sphincter-saving surgery: pathological and short-term outcomes in a single-center analysis of 130 consecutive patients. Surg Endosc 31:4085–4091

    Article  Google Scholar 

  13. 13.

    Papanikolaou IG (2014) Robotic surgery for colorectal cancer: systematic review of the literature. Surg Laparosc Endosc Percutan 24:478–483

    Google Scholar 

  14. 14.

    ECRI Institute (2015) Robotic surgery. https://www.ecri.org/Resources/ASG/Robotic_Surgery_Infographic_MS15369_web.pdf. Accessed 5 Dec 2018

  15. 15.

    Nakadi IE, Melot C, Closset J, DeMoor V, Betroune K, Feron P et al (2006) Evaluation of da Vinci Nissen fundoplication clinical results and cost minimization. World J Surg 30(6):1050–1054

    Article  Google Scholar 

  16. 16.

    Breitenstein S, Nocito A, Puhan M, Weber M, Clavien P (2008) Robotic-assisted versus laparoscopic cholecystectomy. Ann Surg 247(6):987–993

    Article  Google Scholar 

  17. 17.

    Higgins RM, Frelich MJ, Bosler ME, Gould JC (2017) Cost analysis of robotic versus laparoscopic general surgery procedures. Surg Endosc 31(1):185–192

    Article  Google Scholar 

  18. 18.

    Bittner IVJG, Cesnik LW, Kirwan T, Wolf L, Guo D (2018) Patient perceptions of acute pain and activity disruption following inguinal hernia repair: a propensity-matched comparison of robotic-assisted, laparoscopic, and open approaches. J Robot Surg. https://doi.org/10.1007/s11701-018-0790-9

    Article  Google Scholar 

  19. 19.

    Arcerito M, Changchien E, Bernal O, Konkoly-Thege A, Moon J (2016) Robotic inguinal hernia repair: technique and early experience. Am Surg 82(10):1014–1017

    PubMed  Google Scholar 

  20. 20.

    Escobar Dominguez JE, Ramos MG, Seetharamaiah R, Donkor C, Rabaza J, Gonzalez A (2016) Feasibility of robotic inguinal hernia repair, a single-institution experience. Surg Endosc 30(9):4042–4048

    Article  Google Scholar 

  21. 21.

    Edelman DS (2017) Robotic inguinal hernia repair. Am Surg 83(12):1418–1421

    PubMed  Google Scholar 

  22. 22.

    Waite KE, Herman MA, Doyle PJ (2016) Comparison of robotic versus laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair. J Robot Surg 10(3):239–244

    Article  Google Scholar 

  23. 23.

    Charles EJ, Mehaffey JH, Tache-Leon CA, Hallowell PT, Sawyer RG, Yang Z (2017) Inguinal hernia repair: is there a benefit to using the robot? Surg Endosc. https://doi.org/10.1007/s00464-017-5911-4

    Article  PubMed  PubMed Central  Google Scholar 

  24. 24.

    Vidovszky TJ, Smith W, Ghosh J, Ali MR (2016) Robotic cholecystectomy: learning curve, advantages, and limitations. J Surg Res 136(2):172–178

    Article  Google Scholar 

  25. 25.

    Hanly EJ, Talamini MA (2004) Robotic abdominal surgery. Am J Surg. 188(4 suppl. 1):19–26

    Article  Google Scholar 

  26. 26.

    Tarr ME, Brancato SJ, Cunkelman JA, Polcari A, Nutter B, Kenton K (2015) Comparison of postural ergonomics between laparoscopic and robotic sacrocolpopexy: a pilot study. J Minim Invasive Gynecol 22(2):234–238

    Article  Google Scholar 

  27. 27.

    Feng X, Morandi A, Boehne M, Imvised T, Ure BM, Kuebler JF et al (2015) 3-Dimensional (3D) laparoscopy improves operating time in small spaces without impact on hemodynamics and psychomental stress parameters of the surgeon. Surg Endosc 29(5):1231–1239

    Article  Google Scholar 

  28. 28.

    Currò G, La Malfa G, Caizzone A, Rampulla V, Navarra G (2015) Three-dimensional (3D) versus two-dimensional (2D) laparoscopic bariatric surgery: a single-surgeon prospective randomized comparative study. Obes Surg 25(11):2120–2124

    Article  Google Scholar 

  29. 29.

    Szold A, Bergamaschi R, Broeders I, Dankelman J, Forgione A, Langø T et al (2015) European Association of Endoscopic Surgeons (EAES) consensus statement on the use of robotics in general surgery. Surg Endosc 29(2):253–288

    Article  Google Scholar 

  30. 30.

    Bailey JG, Hayden JA, Davis PJB, Liu RY, Haardt D, Ellsmere J (2014) Robotic versus laparoscopic Roux-en-Y gastric bypass (RYGB) in obese adults ages 18 to 65 years: a systematic review and economic analysis. Surg Endosc 28(2):414–426

    Article  Google Scholar 

  31. 31.

    Barbash GI, Glied SA (2010) New technology and health care costs—the case of robot-assisted surgery. N Engl J Med 363(8):701–704

    CAS  Article  Google Scholar 

  32. 32.

    Khajanchee YS, Kenyon TAG, Hansen PD, Swanstrom LL (2004) Economic evaluation of laparoscopic and open inguinal herniorrhaphies: the effect of cost-containment measures and internal hospital policy decisions on costs and charges. Hernia 8:196–202

    CAS  Article  Google Scholar 

  33. 33.

    Hagen ME, Pugin F, Chassot G, Huber O, Buchs N, Iranmanesh P et al (2012) Reducing cost of surgery by avoiding complications: the model of robotic Roux-en-Y gastric bypass. Obes Surg 22:52–61

    Article  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Chet W. Hammill.

Ethics declarations

Disclosures

Lee Swanstrom is on the Scientific Advisory board of Olympus and Boston Scientific. Chet Hammill is a Medtronic consultant and Intuitive Surgical proctor. Walaa Abdelmoaty, Christy Dunst, and Chris Neighorn have no conflicts of interest or financial ties to disclose.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Abdelmoaty, W.F., Dunst, C.M., Neighorn, C. et al. Robotic-assisted versus laparoscopic unilateral inguinal hernia repair: a comprehensive cost analysis. Surg Endosc 33, 3436–3443 (2019). https://doi.org/10.1007/s00464-018-06606-9

Download citation

Keywords

  • Inguinal hernia
  • Robotic-assisted
  • Laparoscopic
  • Cost-effective
  • Adoption
  • Cost analysis