Does the cost of robotic cholecystectomy translate to a financial burden?

Trends in industry payments and volume and distribution of robot-assisted surgeries

BACKGROUND

Considerable evidence links pharmaceutical industry payments to health providers' over-prescribing behavior. In response, public policies were enacted to mitigate this effect. However, there is limited evidence examining surgical device industry payments and surgeons' utilization of robot-assisted surgeries (RAS). This study assessed the relationship between industry payments to healthcare providers and the usage of RAS.

METHODS

Using 2015-2020 data from the CMS "Sunshine" Open Payments Database and New York State's (NYS) Statewide hospital discharge databases, we assessed temporal and spatial relationships between industry payments to hospitals and surgeons and volumes of RAS.

RESULTS

During 2015-2020, general surgery robotic device manufacturers paid providers more than $236 M nationwide. The highest proportion of payments was made toward "Education and training" (66.6%) and "Food and travel" (20.6%). In NYS, gastrointestinal (GI) RAS volume steadily increased by 182% (2015-2019, p < 0.01), while there was a 150% increase in general surgeon payments. Genitourinary (GU) and gynecological (GYN) surgeon payments remained unchanged but GU and GYN RAS volume increased by 17% and 75%, respectively, during this period (p < 0.05). Approximately, 93% of payments and 98% of abdomen and pelvic RAS in NYS were concentrated in metropolitan or non-rural counties.

CONCLUSIONS

With increasing payments from robotic device companies toward surgeon education and training, the use of RAS is likely to continue to rise in the long term. Unbiased and non-industry-funded studies examining RAS effect on surgeon behavior and patient outcomes are imperative to ensure system efficiency and patient safety.

Patient Complexity and Bile Duct Injury After Robotic-Assisted vs Laparoscopic Cholecystectomy

Importance

Recent evidence suggests higher bile duct injury rates for patients undergoing robotic-assisted cholecystectomy compared with laparoscopic cholecystectomy. Proponents of the robotic-assisted approach contend that this may be due to selection of higher-risk and more complex patients being offered robotic-assisted cholecystectomy.

Objective

To evaluate the comparative safety of robotic-assisted cholecystectomy and laparoscopic cholecystectomy among patients with varying levels of risk for adverse postoperative outcomes.

Design, Setting, and Participants

This retrospective cohort study assessed fee-for-service Medicare beneficiaries aged 66 to 99 years who underwent cholecystectomy between January 1, 2010, and December 31, 2021. Data analysis was performed between June and August 2024. Medicare beneficiaries were separated into model training and experimental cohorts (60% and 40%, respectively). Random forest modeling and least absolute shrinkage and selection operator techniques were then used in a risk model training cohort to stratify beneficiaries based on their risk of a composite outcome of postoperative adverse events consisting of 90-day postoperative complications, serious complications, reoperations, and rehospitalization in an independent experimental cohort.

Exposures

Robotic-assisted vs laparoscopic cholecystectomy.

Main Outcomes and Measures

The primary outcome of interest was bile duct injury requiring operative intervention after cholecystectomy. Secondary outcomes were composite outcomes from cholecystectomy composed of any complications, serious complications, reoperations, and readmissions.

Results

A total of 737 908 individuals (mean [SD] age, 74.7 [9.9] years; 387 563 [52.5%] female) were included, with 295 807 in an experimental cohort and 442 101 in a training cohort. Bile duct injury was higher among patients undergoing robotic-assisted compared with laparoscopic cholecystectomy in each subgroup (low-risk group: relative risk [RR], 3.14; 95% CI, 2.35-3.94; medium-risk group: RR, 3.13; 95% CI, 2.35-3.92; and high-risk group: RR, 3.11; 95% CI, 2.34-3.88). Overall, composite outcomes between the 2 groups were similar for robotic-assisted cholecystectomy compared with laparoscopic cholecystectomy (RR, 1.09; 95% CI, 1.07-1.12), aside from reoperation, which was overall higher in the robotic-assisted group compared with the laparoscopic group (RR, 1.47; 95% CI, 1.35-1.59).

Conclusions and Relevance

In this cohort study of Medicare beneficiaries, bile duct injury rates were higher among low-, medium-, and high-risk surgical candidates after robotic-assisted cholecystectomy. These findings suggest that patient selection may not be the cause of differences in bile duct injury rates among patients undergoing robotic-assisted vs laparoscopic cholecystectomy.

Evolution of minimally invasive cholecystectomy: a narrative review

BACKGROUND

Laparoscopic cholecystectomy, being a prevalent abdominal surgical procedure, has transitioned through various innovative stages aimed at reducing the procedure's invasiveness. These stages encompass Single-Incision Laparoscopic Cholecystectomy (SILC), Mini Laparoscopic Cholecystectomy (MLC), Natural Orifice Transluminal Endoscopic Surgery (NOTES), and Robotic-Assisted Laparoscopic Cholecystectomy (RALC). The purpose of this review is to trace the evolution of minimally invasive cholecystectomy techniques, assess their status, and identify emerging trends and challenges in the field.

METHOD

An extensive review was performed to explore the evolution and characteristics of SILC, MLC, NOTES, and RALC. The approach involved an in-depth examination of literature available on PubMed, coupled with a critical assessment of surgical outcomes, associated complications, and technical hurdles posed by these methods.

RESULTS

SILC, despite its potential for reduced scarring, exhibits an elevated risk of bile duct damage and incisional hernia occurrences. MLC, mirroring the standard technique closely, presents minor benefits without amplifying postoperative complications, hence, positing itself as a feasible choice for routine elective cholecystectomy. NOTES, although still facing technical challenges, the hybrid transvaginal procedure is gaining clinical interest. RALC, heralded for its augmented precision and dexterity, emerges as a potential future avenue, although necessitating further exploration to ascertain its efficacy and safety.

CONCLUSION

The progression of laparoscopic cholecystectomy methodologies embodies the surgical society's aspiration to minimize invasiveness whilst enhancing patient outcomes. This review endeavors to offer a structured discourse on SILC, MLC, NOTES, and RALC, aspiring to aid the ongoing deliberation on the judicious selection of surgical techniques in clinical practice.

Comparative Safety of Robotic-Assisted vs Laparoscopic Cholecystectomy

Importance

Robotic-assisted cholecystectomy is rapidly being adopted into practice, partly based on the belief that it offers specific technical and safety advantages over traditional laparoscopic surgery. Whether robotic-assisted cholecystectomy is safer than laparoscopic cholecystectomy remains unclear.

Objective

To determine the uptake of robotic-assisted cholecystectomy and to analyze its comparative safety vs laparoscopic cholecystectomy.

Design, Setting, and Participants

This retrospective cohort study used Medicare administrative claims data for nonfederal acute care hospitals from January 1, 2010, to December 31, 2019. Participants included 1 026 088 fee-for-service Medicare beneficiaries 66 to 99 years of age who underwent cholecystectomy with continuous Medicare coverage for 3 months before and 12 months after surgery. Data were analyzed August 17, 2022, to June 1, 2023.

Exposure

Surgical technique used to perform cholecystectomy: robotic-assisted vs laparoscopic approaches.

Main Outcomes and Measures

The primary outcome was rate of bile duct injury requiring definitive surgical reconstruction within 1 year after cholecystectomy. Secondary outcomes were composite outcome of bile duct injury requiring less-invasive postoperative surgical or endoscopic biliary interventions, and overall incidence of 30-day complications. Multivariable logistic analysis was performed adjusting for patient factors and clustered within hospital referral regions. An instrumental variable analysis was performed, leveraging regional variation in the adoption of robotic-assisted cholecystectomy within hospital referral regions over time, to account for potential confounding from unmeasured differences between treatment groups.

Results

A total of 1 026 088 patients (mean [SD] age, 72 [12.0] years; 53.3% women) were included in the study. The use of robotic-assisted cholecystectomy increased 37-fold from 211 of 147 341 patients (0.1%) in 2010 to 6507 of 125 211 patients (5.2%) in 2019. Compared with laparoscopic cholecystectomy, robotic-assisted cholecystectomy was associated with a higher rate of bile duct injury necessitating a definitive operative repair within 1 year (0.7% vs 0.2%; relative risk [RR], 3.16 [95% CI, 2.57-3.75]). Robotic-assisted cholecystectomy was also associated with a higher rate of postoperative biliary interventions, such as endoscopic stenting (7.4% vs 6.0%; RR, 1.25 [95% CI, 1.16-1.33]). There was no significant difference in overall 30-day complication rates between the 2 procedures. The instrumental variable analysis, which was designed to account for potential unmeasured differences in treatment groups, also showed that robotic-assisted cholecystectomy was associated with a higher rate of bile duct injury (0.4% vs 0.2%; RR, 1.88 [95% CI, 1.14-2.63]).

Conclusions and Relevance

This cohort study's finding of significantly higher rates of bile duct injury with robotic-assisted cholecystectomy compared with laparoscopic cholecystectomy suggests that the utility of robotic-assisted cholecystectomy should be reconsidered, given the existence of an already minimally invasive, predictably safe laparoscopic approach.

Development and validation of a novel nomogram to predict the risk of the prolonged postoperative length of stay for lumbar spinal stenosis patients

BACKGROUND

Lumber spinal stenosis (LSS) is the increasingly reason for spine surgery for elder patients since China is facing the fastest-growing aging population. The aim of this research was to create a model to predict the probabilities of requiring a prolonged postoperative length of stay (PLOS) for lumbar spinal stenosis patients, minimizing the healthcare burden.

METHODS

A total of 540 LSS patients were enrolled in this project. The outcome was a prolonged PLOS after spine surgery, defined as hospitalizations ≥ 75th percentile for PLOS, including the day of discharge. The least absolute shrinkage and selection operator (LASSO) was used to identify independent risk variables related to prolonged PLOS. Multivariable logistic regression analysis was utilized to generate a prediction model utilizing the variables employed in the LASSO approach. The receiver operating characteristic (ROC) curve's area under the curve (AUC) and the calibration curve's respective curves were used to further validate the model's calibration with predictability and discriminative capabilities. By using decision curve analysis, the resulting model's clinical effectiveness was assessed.

RESULTS

Among 540 individuals, 344 had PLOS that was within the usual range of P75 (8 days), according to the interquartile range of PLOS, and 196 had PLOS that was above the normal range of P75 (prolonged PLOS). Four variables were incorporated into the predictive model, named: transfusion, operation duration, blood loss and involved spine segments. A great difference in clinical scores can be found between the two groups (P < 0.001). In the development set, the model's AUC for predicting prolonged PLOS was 0.812 (95% CI: 0.768-0.859), while in the validation set, it was 0.830 (95% CI: 0.753-0.881). The calibration plots for the probability showed coherence between the expected probability and the actual probability both in the development set and validation set respectively. When intervention was chosen at the potential threshold of 2%, analysis of the decision curve revealed that the model was more clinically effective.

CONCLUSIONS

The individualized prediction nomogram incorporating five common clinical features for LSS patients undergoing surgery can be suitably used to smooth early identification and improve screening of patients at higher risk of prolonged PLOS and minimize health care.

Short-term outcomes and costs analysis of robotic-assisted versus laparoscopic cholecystectomy-a retrospective single-center analysis

PURPOSE

Robotic-assisted surgery is an alternative technique for patients undergoing minimal invasive cholecystectomy (CHE). The aim of this study is to compare the outcomes and costs of laparoscopic versus robotic CHE, previously described as the major disadvantage of the robotic system, in a single Austrian tertiary center.

METHODS

A retrospective single-center analysis was carried out of all patients who underwent an elective minimally invasive cholecystectomy between January 2010 and August 2020 at our tertiary referral institution. Patients were divided into two groups: robotic-assisted CHE (RC) and laparoscopic CHE (LC) and compared according to demographic data, short-term postoperative outcomes and costs.

RESULTS

In the study period, 2088 elective minimal invasive cholecystectomies were performed. Of these, 220 patients met the inclusion criteria and were analyzed. One hundred ten (50%) patients underwent LC, and 110 patients RC. There was no significant difference in the mean operation time between both groups (RC: 60.2 min vs LC: 62.0 min; p = 0.58). Postoperative length of stay was the same in both groups (RC: 2.65 days vs LC: 2.65 days, p = 1). Overall hospital costs were slightly higher in the robotic group with a total of €2088 for RC versus €1726 for LC.

CONCLUSIONS

Robotic-assisted cholecystectomy is a safe and feasible alternative to laparoscopic cholecystectomy. Since there are no significant clinical and cost differences between the two procedures, RC is a justified operation for training the whole operation team in handling the system as a first step procedure. Prospective randomized trials are necessary to confirm these conclusions.

Intraoperative and postoperative outcomes of robot-assisted cholecystectomy: a systematic review

BACKGROUND

Rapid adoption of robotic-assisted general surgery procedures, particularly for cholecystectomy, continues while questions remain about its benefits and utility. The objective of this study was to compare the clinical effectiveness of robot-assisted cholecystectomy for benign gallbladder disease as compared with the laparoscopic approach.

METHODS

A literature search was performed from January 2010 to March 2020, and a narrative analysis was performed as studies were heterogeneous.

RESULTS

Of 887 articles screened, 44 met the inclusion criteria (range 20-735,537 patients). Four were randomized controlled trials, and four used propensity-matching. There were variable comparisons between operative techniques with only 19 out of 44 studies comparing techniques using the same number of ports. Operating room time was longer for the robot-assisted technique in the majority of studies (range 11-55 min for 22 studies, p < 0.05; 15 studies showed no difference; two studies showed shorter laparoscopic times), while conversion rates and intraoperative complications were not different. No differences were detected for the length of stay, surgical site infection, or readmissions. Across studies comparing single-port robot-assisted to multi-port laparoscopic cholecystectomy, there was a higher rate of incisional hernia; however, no differences were noted when comparing single-port robot-assisted to single-port laparoscopic cholecystectomy.

CONCLUSIONS

Clinical outcomes were similar for benign, elective gallbladder disease for robot-assisted compared with laparoscopic cholecystectomy. Overall, the rates of complications were low. More high-quality studies are needed as the robot-assisted technique expands to more complex gallbladder disease, where its utility may prove increasingly beneficial.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020156945.

Operating costs, fiscal impact, value analysis and guidance for the routine use of robotic technology in abdominal surgical procedures

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.

Robotic compared with laparoscopic cholecystectomy: A propensity matched analysis

BACKGROUND

As robotic surgery becomes more ubiquitous, determining clinical benefit is necessary to justify the cost and time investment required to become proficient. We hypothesized that robotic cholecystectomy would be associated with improved clinical outcomes but also increased cost as compared with standard laparoscopic cholecystectomy.

MATERIALS AND METHODS

All patients undergoing robotic or laparoscopic cholecystectomy at a single academic hospital between 2007 and 2017 were identified using an institutional clinical data repository. Patients were stratified by operative approach (robotic versus laparoscopic) for comparison and propensity score matched 1:10 based on relevant comorbidities and demographics. Categorical variables were analyzed by the χ² test and continuous variables using the Mann-Whitney U test.

RESULTS

A total of 3,255 patients underwent cholecystectomy during the study period. We observed no differences in demographics or body mass index, but greater rates of diabetes mellitus, hypertension, and gastroesophageal reflux disease were present in the laparoscopic group. After matching (n = 106 robotic, n = 1,060 laparoscopic), there were no differences in preoperative comorbidities. Patients who underwent robotic cholecystectomy had lesser durations of stay (robotic: 0.1 ± 0.7 versus laparoscopic: 0.8 ± 1.9, P < .0001) and lesser 90-day readmission rates (robotic: 0% [0], laparoscopic: 4.1% [43], P = 0.035); however, both operative and hospital costs were greater compared with laparoscopic cholecystectomy.

CONCLUSION

Robotic cholecystectomy is associated with lesser duration of stay and lesser readmission rate within 90 days of the index operation, but also greater operative duration and hospital cost compared with laparoscopic cholecystectomy. Hospitals and surgeons need to consider the improved clinical outcomes but also the monetary and time investment required before pursuing robotic cholecystectomy.

Which Cholecystectomy do Medical Students Prefer?

Introduction:

This study was undertaken to identify which minimally invasive technique medical students prefer for cholecystectomy and what factors determine their decision.

Methods:

Brazilian medical students watched a video reviewing the advantages and disadvantages of six different surgical approaches to cholecystectomy: open surgery, conventional laparoscopy, mini-laparoscopy (MINI), single-incision laparoscopic surgery, natural-orifice transluminal endoscopic surgery, and robotic surgery. Respondents then answered questions about hypothetical situations in which the participants would be submitted to elective cholecystectomy.

Results:

One hundred eleven medical students completed the survey, 60 females (54%) and 51 males (46%). Most students were 19–26 years old. When asked whether they would consider an open cholecystectomy if minimally invasive surgery (MIS) techniques were available, only 9% answered yes. Senior medical students were the least willing to consider open surgery (P = .036). When asked if they would prefer conventional laparoscopy, MINI, or robotic surgery for their cholecystectomy, 85% of the women and 63% of the men chose MINI (P = .025). When asked if they would consider a single-incision laparoscopic surgery or natural-orifice transluminal endoscopic surgery approach, 94 respondents (84%) answered no. When asked to rank which factors they consider the most important when choosing a surgical technique, they ranked safety of the procedure first (58%) and surgeon experience second (30%).

Conclusion:

When Brazilian medical students were asked to select a surgical approach for cholecystectomy, most chose MINI. The preference for MINI was strongest amongst female medical students. Both female and male medical students ranked safety as the most important factor.

Total 5-mm port approach: a feasible technique for both elective and emergency laparoscopic cholecystectomy

BACKGROUND

The laparoscopic approach is considered the standard of care for cholecystectomy. Attempts to minimize incisions with single site and natural orifice approaches have shown promise but also have limitations. Technological advances have facilitated decreased port size, which may have a variety of benefits. The aim of this study was to determine the feasibility of an all 5-mm port approach for patients undergoing both elective and emergency laparoscopic cholecystectomy.

METHODS

A consecutive series of laparoscopic cholecystectomies at three different hospitals using all 5-mm ports was prospectively evaluated. Recorded outcomes included operative findings, procedural difficulties, the need to extend the umbilical incision during extraction, operative time, length of stay and post-operative complications.

RESULTS

A total of 101 patients were included and all had a successful cholecystectomy without the need for additional ports. The umbilical incision was extended for gallbladder extraction in 29 (29%) patients. Eight (8%) patients experienced minor post-operative complications and there were no major complications. Cholangiography was performed in 98% of cases and three patients underwent successful common bile duct exploration without requiring additional ports. In a small number of cases, there was difficulty with the quality of the view through the 5-mm laparoscope but this was rectified by removing old or damaged laparoscopes from the circulating stock.

CONCLUSION

This study demonstrates that laparoscopic cholecystectomy using all 5-mm ports is both feasible and safe, and is comparable to published outcomes after conventional laparoscopic cholecystectomy. Further work is needed to determine whether this approach can also improve short- and long-term outcomes.

[Robotic approach to hepatobiliary surgery. German version]

Robot-assisted hepatobiliary surgery has been steadily growing in recent years. It represents an alternative to the open and laparoscopic approaches in selected patients. Endowristed instruments and enhanced visualization provide important advantages in terms of selective bleeding control, microsuturing, and dissection. Cholecystectomies and minor hepatectomies are being performed with comparable results to open and laparoscopic surgery. Even complex procedures, such as major and extended hepatectomies, can have excellent outcomes, in expert hands. The addition of indocyanine green fluorescence provides an additional advantage for recognition of the vascular and biliary anatomy. Future innovations will allow for expanding its use and indications. Robotic surgery has become a very important component of modern minimally invasive surgery and the development of new robotic technology will facilitate a broader adoption of this technique.

Value-based assessment of robotic pancreas and liver surgery

Current healthcare economic evaluations are based only on the perspective of a single stakeholder to the healthcare delivery process. A true value-based decision incorporates all of the outcomes that could be impacted by a single episode of surgical care. We define the value proposition for robotic surgery using a stakeholder model incorporating the interests of all groups participating in the provision of healthcare services: patients, surgeons, hospitals and payers. One of the developing and expanding fields that could benefit the most from a complete value-based analysis is robotic hepatopancreaticobiliary (HPB) surgery. While initial robot purchasing costs are high, the benefits over laparoscopic surgery are considerable. Performing a literature search we found a total of 18 economic evaluations for robotic HPB surgery. We found a lack of evaluations that were carried out from a perspective that incorporates all of the impacts of a single episode of surgical care and that included a comprehensive hospital cost assessment. For distal pancreatectomies, the two most thorough examinations came to conflicting results regarding total cost savings compared to laparoscopic approaches. The most thorough pancreaticoduodenectomy evaluation found non-significant savings for total hospital costs. Robotic hepatectomies showed no cost savings over laparoscopic and only modest savings over open techniques. Lastly, robotic cholecystectomies were found to be more expensive than the gold-standard laparoscopic approach. Existing cost accounting data associated with robotic HPB surgery is incomplete and unlikely to reflect the state of this field in the future. Current data combines the learning curves for new surgical procedures being undertaken by HPB surgeons with costs derived from a market dominated by a single supplier of robotic instruments. As a result, the value proposition for stakeholders in this process cannot be defined. In order to solve this problem, future studies must incorporate (I) quality of life, survival, and return to independent function alongside data such as (II) intent-to-treat analysis of minimally-invasive surgery accounting for conversions to open, (III) surgeon and institution experience and operative time as surrogates for the learning curve; and (IV) amortization and maintenance costs as well as direct costs of disposables and instruments.

Robotic versus conventional laparoscopic cholecystectomy: A comparative study of medical resource utilization and clinical outcomes

Conventional laparoscopic cholecystectomy (CLC) is currently the standard of surgical procedure for gallstone disease. Robotic cholecystectomy (RC) has revolutionized the field of minimally invasive surgery; it is safe and ergonomic, but expensive. The aim of this study is to compare the medical resource utilization and clinical outcomes between the two procedures. This study was conducted retrospectively by assessing data of the clinical outcomes and medical resource of 78 patients receiving RC and 367 patients receiving CLC. We reviewed the data of operation times, length of hospital stay, hospital charges, outpatient department visits, outpatient department service charges, and postoperative complications, which were retrieved from the health information system (HIS) database in this hospital. Patients in both groups had similar demographic and clinical features. The RC group had longer length of hospital stay (p=0.056), significantly longer operation time (p=0.035), and much more hospital charges (p=0.001). The RC group, however, experienced less postoperative complication rates (average 3.8% vs. 20.4%, p=0.001). Conversion rate was 1.9% in the CLC group versus 0% in the RC group (p=0.611). Most complications were mild, and following the Clavien-Dindo classification, there were two cases (2.5%) Grade I for the RC group; 50 cases (13.6%) Grade I and 14 cases (3.81%) Grade II for the CLC group (p<0.001 and 0.001, respectively). Procedure-related complications of Grade IIIa status were encountered in nine patients (2.45%) in the CLC group and none in the RC group (p=0.002).The RC group consumed more medical resources in the index hospitalization; however, they experienced significantly less postoperative complications.

Urgent and Elective Robotic Single-Site Cholecystectomy: Analysis and Learning Curve of 150 Consecutive Cases

BACKGROUND

The use of robotic single-site cholecystectomy has increased exponentially. There are few reports describing the safety, efficacy, and operative learning curve of robotic single-site cholecystectomy either in the community setting or with nonelective surgery.

MATERIALS AND METHODS

We performed a retrospective review of a prospective database of our initial experience with robotic single-site cholecystectomy. Demographics and perioperative outcomes were evaluated for both urgent and elective cholecystectomy. Cumulative sum analysis was performed to determine the surgeon's learning curve.

RESULTS

One hundred fifty patients underwent robotic single-site cholecystectomy. Seventy-four (49.3%) patients underwent urgent robotic single-site cholecystectomy, and 76 (50.7%) underwent elective robotic single-site cholecystectomy. Mean total operative time for robotic single-site cholecystectomy was 83.3 ± 2.7 minutes. Mean operative time for the urgent cohort was significantly longer than for the elective cohort (95.0 ± 4.4 versus 71.9 ± 2.6 minutes; P < .001). There was one conversion in the urgent cohort and none in the elective cohort. There was one bile duct injury (0.7%) in the urgent cohort. Perioperative complications occurred in 8.7% of patients, and most consisted of superficial surgical-site infections. There were no incisional hernias detected. The surgeon's learning curve, inclusive of urgent and elective cases, was 48 operations.

CONCLUSIONS

Robotic single-site cholecystectomy can be performed safely and effectively in both elective and urgent cholecystectomy with a reasonable learning curve and acceptable perioperative outcomes.

Financial modeling of current surgical robotic system in outpatient laparoscopic cholecystectomy: how should we think about the expense?

INTRODUCTION

More than 500,000 robotically assisted procedures were performed worldwide in 2013. Despite broad adoption, there remains a lack of clarity concerning the added cost of the robotic system to the procedure especially in light of an increasing number of ambulatory procedures which are now marketed by hospitals, surgeons and the manufacturer. These procedures are associated with much less reimbursement than inpatient procedures. It is unclear whether these added expenses can be absorbed in these scenarios. Reports vary in opinion concerning the added net costs during robotically assisted laparoscopic hernia or cholecystectomy.

METHODS

The worldwide revenues, procedures, and the installed base of robotic system data were reviewed and reanalyzed from the 2013 Intuitive Surgical Investors report. This provided an opportunity to look cost per case projections from the vantage point of actual revenue.

RESULTS

This analysis was based on revenue of 2.27 billion US dollars in the three categories of capital acquisition, instrumentation and accessories, and service revenue. These revenues were then spread across 523,000 cases with varying assumptions. Without regard to expense offsets, the additional cost ranges from $2908 to $8675 depending on what system was purchased and the ability to distribute costs against case volume. Estimates of commercial and government revenue were then compared against these expenses.

CONCLUSION

The use of the extraordinary technology in the face of low-morbidity low-cost established minimally invasive procedures needs to withstand scrutiny of outcome assessment, revenue and expense considerations and appropriateness review in order to create financially viable approaches to high-volume minimally invasive procedures. Revenue estimates associated with outpatient reimbursement make it difficult to support these expenses, recognizing inpatient procedures represent a different net financial picture.

Robotic general surgery: current practice, evidence, and perspective

BACKGROUND

Robotic technology commenced to be adopted for the field of general surgery in the 1990s. Since then, the da Vinci surgical system (Intuitive Surgical Inc, Sunnyvale, CA, USA) has remained by far the most commonly used system in this domain. The da Vinci surgical system is a master-slave machine that offers three-dimensional vision, articulated instruments with seven degrees of freedom, and additional software features such as motion scaling and tremor filtration. The specific design allows hand-eye alignment with intuitive control of the minimally invasive instruments. As such, robotic surgery appears technologically superior when compared with laparoscopy by overcoming some of the technical limitations that are imposed on the surgeon by the conventional approach.

PURPOSE

This article reviews the current literature and the perspective of robotic general surgery.

CONCLUSIONS

While robotics has been applied to a wide range of general surgery procedures, its precise role in this field remains a subject of further research. Until now, only limited clinical evidence that could establish the use of robotics as the gold standard for procedures of general surgery has been created. While surgical robotics is still in its infancy with multiple novel systems currently under development and clinical trials in progress, the opportunities for this technology appear endless, and robotics should have a lasting impact to the field of general surgery.