Abstract
Background
This study was designed to define the value, cost, and fiscal impact of robotic-assisted procedures in abdominal surgery and provide clinical guidance for its routine use.
Methods
34,984 patients who underwent an elective cholecystectomy, colectomy, inguinal hernia repair, hysterectomy, or appendectomy over a 24-month period were analyzed by age, BMI, risk class, operating time, LOS and readmission rate. Average Direct and Total Cost per Case (ADC, TCC) and Net Margin per Case (NM) were produced for each surgical technique, i.e., open, laparoscopic, and robotic assisted (RA).
Results
All techniques were shown to have similar clinical outcomes. 9412 inguinal herniorrhaphy were performed (48% open with $2138 ADC, 29% laparoscopy with $3468 ADC, 23% RA with $6880 ADC); 8316 cholecystectomies (94% laparoscopy with $2846 ADC, 4.4% RA with a $7139 ADC, 16% open with a $3931 ADC); 3432 colectomies (42% open with a $12,849 ADC, 38% laparoscopy with a $10,714, 20% RA with a $15,133); 12,614 hysterectomies [42% RA with a $8213 Outpatient (OP) ADC, 39% laparoscopy $5181 OP ADC, 19% open $4894 OP ADC]. Average Global NM is − 1% for RA procedures and only positive with commercial payors.
Conclusion
RA techniques do not produce significant clinical enhancements than similar surgical techniques with identical outcomes while their costs are much higher. The produced value analysis does not support the routine use of RA techniques for inguinal hernia repair and cholecystectomy. RA techniques for hysterectomies and colectomies are also performed at much higher cost than open and laparoscopic techniques, should only be routinely used with appropriate clinical justification and by cost efficient surgical providers.
Similar content being viewed by others
References
Gkegkes ID, Mamais IA, Iavazzo C (2017) Robotics in general surgery: a systematic cost assessment. J Minim Access Surg 13(4):243–255
Khorgami Z, Li WT, Jackson TN, Anthony Howard C, Sclabas GM (2019) The cost of robotics: an analysis of the added costs of robotic-assisted versus laparoscopic surgery using the National Inpatient Sample. Surg Endosc 33(7):2217–2221
Higgins RM, Frelich MJ, Bosler ME, Gould JC (2017) Cost analysis of robotic versus laparoscopic general surgery procedures. Surg Endosc 31(1):185–192
National Institute for Health and Care Excellence (2015) Developing NICE Guidelines: the manual. Process and Methods Guides No. 20. National Institute for Health and Care Excellence (NICE), London
Quilici PJ, Greaney EM Jr, Quilici J, Anderson S (2000) Laparoscopic inguinal hernia repair: optimal technical variations and results in 1700 cases. Am Surg 66(9):848–852
Dirksen CD, Beets GL, Go PMNYH et al (1998) Bassini repair compared with laparoscopic repair for primary inguinal hernia: a randomized controlled trial. Eur J Surg 164:439–447
James G, Bittner IV, 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 12(4):625–632
Pirolla EH, Patriota GP, Pirolla FJC, Ribeiro FPG, Rodrigues MG, Ismail LR, Ruano RM (2018) Inguinal hernia repair via robotic-assisted technique: a literature review. Arq Bras Cir Dig 31(4):e1408
Saito T, Fukami Y, Uchino T, Kurahashi S, Matsumura T, Osawa T, Arikawa T, Komatsu S, Kaneko K, Sano T (2020) Preliminary results of robotic inguinal hernia repair following its introduction in a single-center trial. Ann Gastroenterol Surg 4(4):441–447
The HerniaSurge Group (2018) International guidelines for groin hernia management. Hernia 22(1):1–165
Pedroso LM, de-Melo RM, da-Silva-JR NJ (2017) Comparative study of postoperative pain between the lichtenstein and laparoscopy surgical techniques for the treatment of unilateral primary inguinal hernia. Arq Bras Cir Dig 30(3):173–176
Reiner MA, Bresnahan ER (2016) Laparoscopic total extraperitoneal hernia repair outcomes. JSLS 20(3):e2016.00043
Podolsky D, Novitsky Y (2020) Robotic inguinal hernia repair. Surg Clin North Am 100(2):409–415
Abdelmoaty WF, Dunst CM, Neighorn C, Swanstrom LL, Hammill CW (2019) Robotic-assisted versus laparoscopic unilateral inguinal hernia repair: a comprehensive cost analysis. Surg Endosc 33(10):3436–3443
Miguel PR, Reusch M, daRosa ALM, Carlos JRB (1998) Laparoscopic hernia repair—complications. JSLS 2(1):35–40
Khoraki J et al (2020) Perioperative outcomes and cost of robotic-assisted versus laparoscopic inguinal hernia repair. Surg Endosc 34(8):3496–3507
Sheetz KH, Claflin J, Dimick JB (2020) Trends in the adoption of robotic surgery for common surgical procedures. JAMA Netw Open 3(1):e1918911
Nolan H, Glenn J (2018) Minimally invasive pediatric cholecystectomy: a comparison of robotic and laparoscopic single and multiport techniques. J Laparoendosc Adv Surg Tech A 28(6):770–773
Huang Y, Chua TC, Maddern GJ, Samra JS (2017) Robotic cholecystectomy versus conventional laparoscopic cholecystectomy: a meta-analysis. Surgery 161(3):628–636
Rosemurgy A, Ryan C, Klein R, Sukharamwala P, Wood T, Ross S (2015) Does the cost of robotic cholecystectomy translate to a financial burden? Surg Endosc 29(8):2115–2120
Sheetz KH, Norton EC, Dimick JB, Regenbogen SE (2019) Perioperative outcomes and trends in the use of robotic colectomy for medicare beneficiaries from 2010 through 2016. JAMA Surg 155(1):41–49
Yeo HL, Isaacs AJ, Abelson JS, Milsom JW, Sedrakyan A (2016) Comparison of open, laparoscopic, and robotic colectomies using a large national database: outcomes and trends related to surgery center volume. Dis Colon Rectum 59(6):535–542
Sivathondan PC, Fellow C, Unit JGC, Leeds DGJ (2018) The role of robotics in colorectal surgery. Ann R Coll Surg Engl 100(Suppl 7):42–53
Zelhart M, Kaiser AM (2018) Robotic versus laparoscopic versus open colorectal surgery: towards defining criteria to the right choice. Surg Endosc 32(1):24–38
Papanikolaou IG (2014) Robotic surgery for colorectal cancer: systematic review of the literature. Surg Laparosc Endosc Percutan Tech 24(6):478–483
Moghadamyeghaneh Z et al (2016) Comparison of open, laparoscopic, and robotic approaches for total abdominal colectomy. Surg Endosc 30(7):2792–2798
Bastawrous A, Baer C, Rashid L, Neighorn C (2018) Higher robotic colorectal surgery volume improves outcomes. Am J Surg 215:874–878
Rashidi L, Neighorn C, Bastawrous A (2017) Outcome comparisons between high-volume robotic and laparoscopic surgeons in a large healthcare system. Am J Surg 213:901–905
Ji-Chan Nie MD, An-Qi Yan MD, Xi-Shi Liu MD (2017) Robotic-assisted radical hysterectomy results in better surgical outcomes compared with the traditional laparoscopic radical hysterectomy for the treatment of cervical cancer. Int J Gynecol Cancer 27(9):1990–1999
Kimmig R, Ind T (2018) Minimally invasive surgery for cervical cancer: consequences for treatment after LACC Study. J Gynecol Oncol 29(4):e75
Pennington KP, Urban RR, Gray HJ (2019) Revisiting minimally invasive surgery in the management of early-stage cervical cancer. J Natl Compr Canc Netw 17(1):86–90
Qin M, Siyi Li, Huang H-F, Yan Li YuGu, Wang W, Shan Y, Yin J, Wang Y-X, Cai Y, Chen J-Y, Jin Y, Ling-Ya Pan A (2020) Comparison of laparoscopies and laparotomies for radical hysterectomy in stage IA1–IB1 cervical cancer patients: a single team with 18 years of experience. Front Oncol 10:1738
Yuan Z, Cao D, Yang J, Yu M, Shen K, Yang J, Zhang Y, Zhou H (2019) Laparoscopic vs. open abdominal radical hysterectomy for cervical cancer: a single-institution, propensity score matching study in China. Front Oncol 9:1107
Varghese A, Doglioli M, Fader AN (2019) Updates and controversies of robotic-assisted surgery in gynecologic surgery. Clin Obstet Gynecol 62(4):733–748
Clair KH, Tewari KS (2020) Robotic surgery for gynecologic cancers: indications, techniques and controversies. J Obstet Gynaecol Res 46(6):828–843
Wright JD, Cham S, Chen L, Burke WM, Hou JY, Tergas AI, Desai V, Hu JC, Ananth CV, Neugut AI, Hershman DL (2017) Utilization of sentinel lymph node biopsy for uterine cancer. Am J Obstet Gynecol 216(6):594.e1-594.e13
Iavazzo C, Papadopoulou EK, Gkegkes ID (2014) Cost assessment of robotics in gynecologic surgery: a systematic review. J Obstet Gynaecol Res 40(11):2125–2134
Sarlos D, Kots L, Stevanovic N, Schaer G (2010) Robotic hysterectomy versus conventional laparoscopic hysterectomy: outcome and cost analyses of a matched case-control study. Eur J Obstet Gynecol Reprod Biol 150(1):92–96
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Disclosures
The authors, Dr. P J. Quilici, Mr. Harry Wolberg and Mr. Nathaniel McConnell have no conflict of interest or financial ties to disclose.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Quilici, P.J., Wolberg, H. & McConnell, N. Operating costs, fiscal impact, value analysis and guidance for the routine use of robotic technology in abdominal surgical procedures. Surg Endosc 36, 1433–1443 (2022). https://doi.org/10.1007/s00464-021-08428-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-021-08428-8