The Early (2009-2017) Experience With Robot-assisted Cholecystectomy in New York State

Association between hospital participation in Medicare Shared Savings Program and hospital use of robotic surgical approach

BACKGROUND

In 2012, Medicare introduced Shared Savings Program (MSSP) accountable care organizations (ACO) model to improve the value of health care services as a part of the national comprehensive Accountable Care Act. While the effect of the MSSP on primary care has been extensively analyzed, little is known about the effect of the MSSP on cost and quality of surgical care, in particular the use of high-cost robotic surgical modalities. Hospitals routinely market robotic procedures as an indicator of high quality, despite limited evidence of their clinical value. This study examines the relationship between hospital participation in the MSSP and use of robotic surgery.

METHODS

We conducted a retrospective analysis using 2016-2019 publicly available data on hospital MSSP participation and use of robotic-assisted procedures in New York State. Using bivariate and multivariate approaches, we identified hospital characteristics associated with the use of robotic technique and hospital quality.

RESULTS

Of the 157 general hospitals in NYS, 83 (53%) offered robotic surgery and 73 (47%) participated in the MSSP. MSSP-affiliated hospitals were more selective in the type of robotic procedures than non-MSSP hospitals, favoring procedures with stronger evidence-base such as prostatectomies. Hospitals that performed robotic surgery selectively had significantly lower spending per patient (p = 0.04). Higher volume of robotic procedures correlated with higher hospital ranking.

CONCLUSIONS

MSSP participation is associated with more selective use of robotic procedures and lower hospital spending. More research is needed to understand the relationship between hospital investments in quality improvement, use of robotic surgery and hospital performance rankings.

Safety and Feasibility of Cholecystectomy with the HugoTM RAS: Proof of Setup Guides and First-In-Human German Experience

Introduction

The Hugo RAS robotic platform by Medtronic was recently certified for human use in Europe. Several centers have gained initial experience with this system in urology and gynecology. However, few data about its feasibility and safety in general surgery have been published.

Methods

The first-in-human surgical procedures with the Hugo RAS in Germany were performed at our hospital in February 2023. We report our early experience with robotic cholecystectomy using this new platform. The primary aim was to test the setup guides of the manufacturer and to evaluate the safety and feasibility of Hugo RAS for this procedure.

Results

A modified setup with two 11-mm ports and two 8-mm ports without an assistant port was used in 14 consecutive cases. A 30° or a 0° camera, a bipolar grasper or a Maryland on the left arm, a monopolar scissors on the right arm, and a double-fenestrated grasper on the additional arm were mounted. Clip application and gallbladder extraction were performed by the bedside assistant through the right arm 11-mm port. There were no complications, no adverse events, and no conversions. Arm collisions were reduced through slight corrections in trocar positions.

Conclusion

Robotic-assisted cholecystectomy with the Hugo RAS was safe and feasible. The modularity of robotic arms allows individual setup modifications which may be of advantage for patients and surgeons.

Indocyanine green (ICG) fluorescence in robotic hepatobiliary surgery: A systematic review

BACKGROUND

Indocyanine green fluorescence (ICG-F) stains hepatic tumours and delineates vascular and biliary structures in real-time. We detail the efficacy of ICG-F in robotic hepatobiliary surgery.

METHODS

PubMed, EMBASE, Web of Science, and Cochrane Central were searched for original articles and meta-analyses detailing the outcomes of ICG-F in robotic hepatobiliary surgery.

RESULTS

214 abstracts were reviewed; 16 studies are presented. One single-institution study reported ICG-F in robotic right hepatectomy reduced postoperative bile leakage (0% vs. 12%, p = 0.023), R1 resection (0% vs. 16%, p = 0.019), and readmission (p = 0.023) without prolonging operative time (288 vs. 272 min, p = 0.778). Improved visualisation aided in attainment of R0 resection in partial hepatectomies and radical gallbladder adenocarcinoma resections. Fewer ICG-F-aided robotic cholecystectomies were converted to open procedure compared to laparoscopic cholecystectomies (2.1% vs. 8.9%, p = 0.03; 0.15% vs. 2.6%, p < 0.001).

CONCLUSIONS

ICG-F improves clinical outcomes in robotic hepatobiliary surgery without prolonging operative time. There is an opportunity to standardise ICG administration protocols, especially for hepatectomies.

The impact of disclosure of conflicts of interest in studies comparing robot-assisted and laparoscopic cholecystectomies-a persistent problem

INTRODUCTION

Accurate disclosure of conflicts of interest (COI) is critical to interpretation of study results, especially when industry interests are involved. We reviewed published manuscripts comparing robot-assisted cholecystectomy (RAC) and laparoscopic cholecystectomy (LC) to evaluate the relationship between COI disclosures and conclusions drawn on the procedure benefits and safety profile.

METHODS

Searching Pubmed and Embase using key words "cholecystectomy", laparoscopic" and "robotic"/"robot-assisted" retrieved 345 publications. Manuscripts that compared benefits and safety of RAC over LC, had at least one US author and were published between 2014 and 2020 enabling verification of disclosures with reported industry payments in CMS's Open Payments database (OPD) (up to 1 calendar year prior to publication) were included in the analysis (n = 37).

RESULTS

Overall, 26 (70%) manuscripts concluded that RAC was equivalent or better than LC (RAC +) and 11 (30%) concluded that RAC was inferior to LC (RAC-). Six manuscripts (5 RAC + and 1 RAC-) did not have clearly stated COI disclosures. Among those that had disclosure statements, authors' disclosures matched OPD records among 17 (81%) of RAC + and 9 (90%) RAC- papers. All 11 RAC- and 17 RAC + (65%) manuscripts were based on retrospective cohort studies. The remaining RAC + papers were based on case studies/series (n = 4), literature review (n = 4) and clinical trial (n = 1). A higher proportion of RAC + (85% vs 45% RAC-) manuscripts used data from a single institution. Authors on RAC + papers received higher amounts of industry payments on average compared to RAC- papers.

CONCLUSIONS

It is imperative for authors to understand and accurately disclose their COI while disseminating scientific output. Journals have the responsibility to use a publicly available resource like the OPD to verify authors' disclosures prior to publication to protect the process of scientific authorship which is the foundation of modern surgical care.

Robotic single-site cholecystectomy is better in reducing postoperative pain than single-incision and conventional multiport laparoscopic cholecystectomy

BACKGROUND

To compare the short-term outcomes of robotic single-site cholecystectomy (RSSC) with single-incision laparoscopic cholecystectomy (SILC) and conventional multiport laparoscopic cholecystectomy (CMLC), focusing on postoperative pain outcomes.

METHODS

This single-center retrospective study included consecutive patients with benign gallbladder disease who underwent cholecystectomy by a single surgeon between June 2019 and December 2021. Exclusion criteria were acute cholecystitis (AC) and other combined surgeries. One-to-one propensity score matching was performed between the RSSC and SILC or CMLC.

RESULTS

Of the 157 patients included, 39 (24.8%) underwent RSSC, 32 (20.4%) underwent SILC, and 86 (54.8%) underwent CMLC. In a propensity score-matched cohort between RSSC and SILC (32 patients in each group), the number of additional analgesic injections was significantly lower in the RSSC group than in the SILC group (0.7 vs. 1.3, p = 0.002), and postoperative pain scores were also significantly lower at 6 h (2.8 vs. 3.6, p = 0.004) and 24 h (2.6 vs. 3.3, p = 0.021) after surgery in the RSSC group than in the SILC group. In a propensity score-matched cohort between RSSC and CMLC (23 patients in each group), the number of additional analgesic injections was significantly lower in the RSSC group than in the CMLC group (0.7 vs. 1.3, p = 0.005), and postoperative pain scores were also significantly lower at 6 h after surgery (2.9 vs. 3.7, p = 0.025) in the RSSC group than in the CMLC group.

CONCLUSION

This study demonstrated that RSSC is helpful in reducing postoperative pain and the use of additional analgesics compared to both SILC and CMLC.

Outcomes following robot-assisted versus laparoscopic sleeve gastrectomy: the New York State experience

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) represents more than half of all bariatric procedures in the USA, and robot-assisted sleeve gastrectomy (RSG) is becoming increasingly common. There is a paucity of evidence regarding postoperative surgical outcomes (> 30 days) in RSG patients, especially as these patients move between multiple hospital systems.

METHODS

Using 2012-2018 New York State's inpatient and ambulatory data from the Statewide Planning and Research Cooperative System, bivariate and multivariate analyses were employed to examine patient long-term outcomes, postoperative complications, and charges following RSG versus LSG in unmatched and propensity score-matched (PSM) samples.

RESULTS

Among the 72,157 minimally invasive sleeve gastrectomies identified, 2365 (2.6%) were RSGs. In the PSM sample (2365 RSG matched to 23,650 LSG), RSG cases were more likely to be converted to an open procedure (2.3% vs 0.2% LSG patients, p < 0.01) and had a longer mean length of stay (LOS; 2.1 vs. 1.8 days LSG, p < 0.01). Postoperative complications were not different between RSG and LSG patients, but the proportion of emergency room visits resulting in inpatient readmissions was higher among RSG patients (5.5% vs. 4.2% in LSG patients, p < .01). Among the super obese (body mass index ≥ 50) patients, conversions to open procedure and LOS were also significantly higher for RSG versus LSG cases. Average hospital charges for the index admission ($47,623 RSG vs $35,934 LSG) and cumulative changes for 1 year from the date of surgery ($57,484 RSG vs $43,769 LSG) were > 30% higher for RSG patients.

CONCLUSIONS

RSG patients were more likely to have conversions to open procedures, longer postoperative stay, readmissions, and higher charges for both the index admission and beyond, compared to LSG patients. No clear advantages emerged for the utilization of the robotic platform for either average risk or extremely obese patients.

Surgeon Variation in the Application of Robotic Technique for Abdominal Hernia Repair: A Mixed-Methods Study

INTRODUCTION

Although the utilization of robotic technique for abdominal hernia repair has increased rapidly, there is no consensus as to when it should be applied for optimal outcomes. High variability exists within surgeon practices regarding how they use this technology, and the factors that drive robotic utilization remain largely unknown. This study aims to explore the motivating factors associated with surgeons' decisions to utilize a robotic approach for abdominal hernia repair.

METHODS

An exploratory mixed-methods approach was utilized. Surgeons who performed abdominal hernia repairs were interviewed to identify impactful themes motivating surgical approach. This informed a retrospective analysis of ventral hernia repairs performed in 2020 within the Michigan Surgical Quality Collaborative. Surgeon robotic utilization rates were calculated. Among selective robotic users, multivariable regression evaluated the patient and hernia factors associated with robotic utilization.

RESULTS

Qualitative analysis of 21 interviews revealed three dominant themes in the decision to utilize robotic technology: access and resources, surgeon comfort, and market factors. Among 71 surgeons caring for 1174 hernia patients, robotic utilization rates ranged from 0% to 98% of cases. There were 27 surgeons identified as selective robotic users, who cared for 423 patients. Multivariable regression revealed that hernia location was the only factor associated with robotic technique, with non-midline hernias associated with a 4.47 (95% confidence interval 1.34-14.88) higher odds of robotic repair than epigastric hernias.

CONCLUSIONS

Major drivers of robotic technique for hernia repair were found to be perceived benefits and availability, rather than patient or hernia characteristics. These data will contribute to an understanding of surgeon decision-making and help develop improvements to patient care.