Elective robotic-assisted bariatric surgery: Is it worth the money? A national database analysis

Is the robotic revolution stunting surgical skills?

This perspective piece aims to examine the impact of the growing utilization of robotic platforms in general and minimally invasive surgery on surgical trainee experience, skill level, and comfort in performing general surgical and minimally invasive procedures following completion of training. We review current literature and explore the application of robotic surgery to surgical training, where minimum case thresholds and breadth distribution are well defined, and where development of surgical technique is historically gained through delicate tissue handling with haptic feedback rather than relying on visual feedback alone. We call for careful consideration as to how best to incorporate robotics in surgical training in order to embrace technological advances without endangering the surgical proficiency of the surgeons of tomorrow.

Key message

The large-scale incorporation of robotics into general and minimally invasive surgical training is something that most, if not all, trainees must grapple with in today's world, and the proportion of robotics is increasing. This shift may significantly negatively affect trainees in terms of surgical skill upon completion of training and must be approached with an appropriate degree of concern and thoughtfulness so as to protect the surgeons of tomorrow.

The downtrending cost of robotic bariatric surgery: a cost analysis of 47,788 bariatric patients

The surgical robot is assumed to be a fixed, indirect cost. We hypothesized rising volume of robotic bariatric procedures would decrease cost per patient over time. Patients who underwent elective, initial gastric bypass (GB) or sleeve gastrectomy (SG) for morbid obesity were selected from Florida Agency for Health Care Administration database from 2017 to 2021. Inflation-adjusted cost per patient was collected. Cost-over-time ($/patient year) and change in cost-over-time were calculated for open, laparoscopic, and robotic cases. Linear regression on cost generated predictive parameters. Density plots utilizing area under the curve demonstrated cost overlap. Among 76 hospitals, 11,472 bypasses (223 open, 6885 laparoscopic, 4364 robotic) and 36,316 sleeves (26,596 laparoscopic, 9724 robotic) were included. Total cost for robotic was approximately 1.5-fold higher (p < 0.001) than laparoscopic for both procedures. For GB, laparoscopic had lower total ($15,520) and operative ($6497) average cost compared to open (total $17,779; operative $9273) and robotic (total $21,756; operative $10,896). For SG, laparoscopic total cost was significantly less than robotic ($10,691 vs. $16,393). Robotic GB cost-over-time increased until 2021, when there was a large decrease in cost (-$944, compared with 2020). Robotic SG total cost-over time fluctuated, but decreased significantly in 2021 (-$490 compared with 2020). While surgical costs rose significantly in 2020 for bariatric procedures, our study suggests a possible downward trend in robotic bariatric surgery as total and operative costs are decreasing at a higher rate than laparoscopic costs.

Robotic versus laparoscopic gastric bypass in bariatric surgery: a systematic review and meta-analysis on perioperative outcomes

BACKGROUND

Robotic-assisted surgery has emerged as a compelling approach to bariatric surgery. However, current literature has not consistently demonstrated superior outcomes to laparoscopic bariatric surgery to justify its higher cost. With its mechanical advantages, the potential gains from the robotic surgical platform are likely to be apparent in more complex cases such as gastric bypass, especially revisional cases.

OBJECTIVE

This systematic review and meta-analysis aimed to summarize the literature and evaluate the peri-operative outcomes of patients with obesity undergoing robotic gastric bypass versus laparoscopic gastric bypass surgery.

SETTING

Systematic review.

METHODS

A literature search of Embase, Medline, Pubmed, Cochrane library, and Google Scholar was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies comparing outcomes of robotic and laparoscopic gastric bypass for obesity were included.

RESULTS

Twenty-eight eligible studies comprised a total of 82,155 patients; 9051 robotic bypass surgery (RBS) versus 73,104 laparoscopic bypass surgery (LBS) were included. All included studies compared Roux-en-Y gastric bypass. RBS was noted to have higher reoperation rate within 30 days (4.4% versus 3.4%; odds ratio 1.31 [95% CI, 1.04-1.66]; P = .027; I2 = 43.5%) than LBS. All other endpoints measured (complication rate, anastomotic leak, anastomotic stricture, surgical site infections, hospital readmission, length of stay, operative time, conversion rate and mortality) did not show any difference between RBS and LBS.

CONCLUSION

This systematic review and meta-analysis showed that there was no significant difference in key outcome measures in robotic versus laparoscopic gastric bypass. RBS was associated with a slightly higher reoperation rate and there was no reduction in overall complication rate with the use of robotic platform.

Robotic Surgery: A Comprehensive Review of the Literature and Current Trends

Robotic surgery (RS) is an evolution of minimally invasive surgery that combines medical science, robotics, and engineering. The first robots approved by the Food and Drug Administration (FDA) were the Da Vinci Surgical System and the ZEUS Robotic Surgical System, which have been improving over time. Through the decades, the equipment applied to RS had undergone a wide transformation as a response to the development of new techniques and facilities for the assembly and implementation of the own. RS has revolutionized the field of urology, enabling surgeons to perform complex procedures with greater precision and accuracy, and many other surgical specialties such as gynecology, general surgery, otolaryngology, cardiothoracic surgery, and neurosurgery. Several benefits, such as a better approach to the surgical site, a three-dimensional image that improves depth perception, and smaller scars, enhance range of motion, allowing the surgeon to conduct more complicated surgical operations, and reduced postoperative complications have made robotic-assisted surgery an increasingly popular approach. However, some points like the cost of surgical procedures, equipment-instrument, and maintenance are important aspects to consider. Machine learning will likely have a role to play in surgical training shortly through "automated performance metrics," where algorithms observe and "learn" individual surgeons' techniques, assess performance, and anticipate surgical outcomes with the potential to individualize surgical training and aid decision-making in real time.

Selection of Robotic Bariatric Surgery Candidates: a Nationwide Analysis

INTRODUCTION

This study aims to identify risk factors associated with 30-day major complications, readmission, and delayed discharge for patients undergoing robotic bariatric surgery.

METHODS

From the metabolic and bariatric surgery and accreditation quality improvement program (2015-2018) datasets, adult patients who underwent elective robotic bariatric operations were included. Predictors for 30-day major complications, readmission, and delayed discharge (hospital stay ≥ 3 days) were identified using univariable and multivariable analyses.

RESULTS

Major complications in patients undergoing robotic bariatric surgery were associated with both pre-operative and intraoperative factors including pre-existing cardiac morbidity (OR = 1.41, CI = [1.09-1.82]), gastroesophageal reflux disease [GERD] (OR = 1.23, CI = [1.11-1.38]), pulmonary embolism (OR = 1.51, CI = [1.02-2.22]), prior bariatric surgery (OR = 1.66, CI = [1.43-1.94]), increased operating time (OR = 1.003, CI = [1.002-1.004]), gastric bypass or duodenal switch (OR = 1.58, CI = [1.40-1.79]), and intraoperative drain placement (OR = 1.28, CI = [1.11-1.47]). With regard to 30-day readmission, non-white race (OR = 1.25, CI = [1.14-1.39]), preoperative hyperlipidemia (OR = 1.16, CI = [1.14-1.38]), DVT (OR = 1.48, CI = [1.10-1.99]), therapeutic anticoagulation (OR = 1.48, CI = [1.16-1.89]), limited ambulation (OR = 1.33, CI = [1.01-1.74]), and dialysis (OR = 2.14, CI = [1.13-4.09]) were significantly associated factors. Age ≥ 65 (OR = 1.18, CI = [1.04-1.34]), female gender (OR = 1.21, CI = [1.10-1.32]), hypertension (OR = 1.08, CI = [1.01-1.15]), renal insufficiency (OR = 2.32, CI = [1.69-3.17]), COPD (OR = 1.49, CI = [1.23-1.82]), sleep apnea (OR = 1.10, CI = [1.03-1.18]), oxygen dependence (OR = 1.47, CI = [1.10-2.0]), steroid use (OR = 1.26, CI = [1.02-1.55]), IVC filter (OR = 1.52, CI = [1.15-2.0]), and BMI ≥ 40 (OR = 1.12, CI = [1.04-1.21]) were risk factors associated with delayed discharge.

CONCLUSION

When selecting patients for bariatric surgery, surgeons early in their learning curve for utilizing robotics should avoid individuals with pre-existing cardiac or renal morbidities, venous thromboembolism, and limited functional status. Patients who have had previous bariatric surgery or require technically demanding operations are at higher risk for complications. An evidence-based approach in selecting bariatric candidates may potentially minimize the overall costs associated with adopting the technology.

Direct medical costs of robotic sleeve gastrectomy compared to laparoscopic approach in a single academic center

BACKGROUND

The use of the robotic platform in bariatric surgery remains controversial because of lack of level I evidence to support its superiority compared to the laparoscopic approach and because of cost concerns. Recently, an extended use program (EUP) for robotic instruments was also introduced at our institution to help reduce the associated direct medical costs of robotic surgery.

OBJECTIVES

 To evaluate the direct medical costs of a robotic sleeve gastrectomy (R-SG) and compare it to a standard laparoscopic approach (L-SG).

SETTING

 Academic, tertiary care center.

METHODS

 The analysis included the last 50 R-SG performed at our institution between June 1st 2019 and October 31st 2020. Those cases were compared to the L-SG cases (29 cases) performed in the same time period. All revisions or conversions were then excluded which resulted in a total of 74 primary SG (R-SG = 45 and L-SG = 29). Direct medical costs included operating room cost, instrument cost, miscellaneous cost, and cost of hospital stay. Direct cost data was generated using the StrataJazz reporting module, which is fed daily from EPIC, our electronic health record system. Patients who underwent a primary SG or a primary SG with a concomitant Paraesophageal Hernia Repair (PEH) were analyzed separately using Mann-Whitney rank sum tests and Student's t tests. An additional analysis and subanalysis of the groups was also performed after applying the potential savings of the Extended Use Program (EUP).

RESULTS

 Overall, the direct medical cost of R-SG was comparable to L-SG ($6330.77 vs $6804.12 respectively, p = 0.07). The direct medical cost of patients undergoing SG alone without PEH was significantly lower in the R-group compared to the L-group ($5927.08 vs $6508.01, respectively, p = 0.04). When applying the EUP savings to our data, the predicted direct medical cost of R-SG becomes significantly lower than L-SG ($6145.77 vs $6804.12 respectively, p = 0.01).

CONCLUSION

 At our academic medical center, we found no difference in direct medical costs between R-SG and L-SG. With the application of the EUP, direct medical costs of R-SG can be significantly lowered compared to L-SG. It is important to consider that cost data are largely dependent upon the academic medical center of interest, and surgeons need to collect their own cost data to evaluate whether robotic surgery is feasible at their institution.

Current Trends in the Utilization of a Robotic Approach in the Field of Bariatric Surgery

PURPOSE

The utilization rate of robotic surgery for bariatric procedures is not well-described. Our study identified the proportion of metabolic and bariatric surgery (MBS) procedures in the United States between 2015 and 2020 performed using a robotic (R-) or laparoscopic (L-) approach.

MATERIALS AND METHODS

A descriptive analysis of the 2015-2020 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant User Data File (PUF) datasets was performed. The primary outcome was (1) surgical cases performed annually and (2) proportion of cases performed using a R- or L- approach. Analysis was done separately for sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPD-DS), and revisional bariatric surgery (RBS). Statistical analysis consisted of means and proportions, fold difference, annual slope, and Student's t tests or chi-square tests as appropriate, with statistical significance set to p < .05.

RESULTS

A total of 1,135, 214 procedures were captured between 2015 and 2020. R-RYGB increased from 2554 to 6198 (6.8% to 16.7%), R-SG increased from 5229 to 17,063 (6.0% to 17.2%), R-RBS increased from 993 to 3386 (4.7% to 17.4%), and R-BPD-DS increased from 221 to 393 (22.0% to 28.4%). The greatest annual increase was observed among R-RBS and R-SG (3.70-fold difference; slope 2.4% per year and 2.87-fold difference; slope 2.2% per year, respectively).

CONCLUSION

There is a nationwide increase in the utilization of a R- approach in bariatric surgery. There are concerns related to the potential increase in healthcare expenditures related to robotics. Further studies are needed to establish key performance indicators along with guidelines for training, adoption and utilization of a R- approach.

Enhancing robotic efficiency through the eyes of robotic surgeons: sub-analysis of the expertise in perception during robotic surgery (ExPeRtS) study

BACKGROUND

Robotic technology affords surgeons many novel and useful features, but two stereotypes continue to prevail: robotic surgery is expensive and inefficient. To identify educational opportunities and improve operative efficiency, we analyzed expert commentary on videos of robotic surgery.

METHODS

Expert robotic surgeons, identified through high case volumes and contributions to the surgical literature, reviewed eight anonymous video clips portraying key portions of two robotic general surgery procedures. While watching, surgeons commented on what they saw on the screen. All interactions with participants were in person, recorded, transcribed, and subsequently analyzed. Using content analysis, researchers double-coded each transcript applying a consensus developed codebook.

RESULTS

Seventeen surgeons participated. The average participant was male (82.4%), 47 (SD = 6.6) years old, had 13.2 (SD = 8.23) years of teaching experience, worked in urban academic hospitals (64.7%) and had performed 643 (SD = 467) robotic operations at the time of interviews. Emphasis on efficiency (or lack thereof) surfaced across three main themes: overall case progression, robotic capabilities, and instrumentation. Experts verbally rewarded purposeful and "ergonomically sound" movements while language reflecting impatience with repetitive and indecisive movements was attributed to presumed inexperience. Efficient robotic capabilities included enhanced visualization, additional robotic arms to improve exposure, and wristed instruments. Finally, experts discussed instrument selection with regards to energy modality, safety features, cost, and versatility.

CONCLUSION

This study highlights three areas for improved efficiency: case progression, robotic capabilities, and instrumentation. Development of education materials within these themes could help surgical educators overcome one of robotic technology's persistent challenges.

Is Robotic Revisional Bariatric Surgery Justified? An MBSAQIP Analysis

BACKGROUND

The laparoscopic approach is utilized in greater than 90% of bariatric surgeries. With the growing prevalence of robotic-assisted surgery in bariatrics, there has been limited consensus on the superiority of either laparoscopic or robotic approaches, especially in revisional procedures (conversion from sleeve gastrectomy (SG) to Roux-en-Y gastric bypass (RYGB)).

METHODS

A retrospective analysis was performed of the MBSAQIP PUF database of patients who underwent conversion from SG to RYGB procedures in either laparoscopic or robotic-assisted approaches. The groups underwent 2:1 propensity matching and primary outcomes included post-conversion days until discharge (POD), conversion operation length, total and major morbidity, 30-day readmission, 30-day reoperation, 30-day reintervention, and 30-day mortality after conversion.

RESULTS

After 2:1 propensity score matching, 3411 patients (2274 laparoscopic vs 1137 robotic) were included in the study. Intraoperatively, no significant difference was found in total morbidity (6.5% lap vs 5.9% robotic) or major morbidity (1.9% lap vs 1.7% robotic); however, the operative times were significantly longer robotically (126 min vs 164 min). Post-operatively, no significant differences were found in discharge day (1.8 lap vs 1.8 robotic), 30-day readmission (7.6% lap vs 8.6% robotic), reoperation rate (2.9% lap vs 3.7% robotic), additional intervention rate (2.5% lap vs 3.3% robotic), or 30-day mortality (0.1% vs 0.1%).

CONCLUSION

There is no significant difference in perioperative or intraoperative outcomes between laparoscopic and robotic-assisted SG to RYGB conversion procedures other than a longer operative time in the robotic approach, suggesting increased efficiency with the laparoscopic approach.

Cost analysis of robotic assisted general surgery cases in a single academic institution

Laparoscopy is currently the standard approach for minimally invasive general surgery procedures. However, robotic surgery is now increasingly being used in general surgery. Robotic surgery provides several advantages such as 3D-visualization, articulated instruments, improved ergonomics, and increased dexterity, but is also associated with an increased overall cost which limits its widespread use. In our institution, the robotic assisted approach is frequently used for the performance of general surgery cases including inguinal hernias, cholecystectomies and paraesophageal hernia (PEH) repairs. The primary aim of the study was to evaluate the differences in cost between a robotic and laparoscopic approach for the above-mentioned cases. With IRB approval, we conducted a retrospective cost analysis of patients undergoing inguinal hernia repairs, cholecystectomies and PEH repairs between June 2018 and November 2020. Patients who had a concomitant procedure, a revisional surgery, or bilateral inguinal hernia repair were excluded from the study. Cost analysis was performed using a micro-costing approach. Statistical significance was denoted by p < 0.05. There were no differences among the different groups in relation to age, gender, ethnicity, and BMI. The overall cost of the robotic (R-) approach compared to a laparoscopic (L-) approach was significantly lower for cholecystectomy ($3,199.96 vs $4019.89, p < 0.05). For inguinal hernia repairs and PEH repairs without mesh, we found no significant difference in overall costs between the R- and L- approach (R- $3835.06 vs L- $3783.50, p = 0.69) and (R- $6852.41 vs L- $6819.69, p = 0.97), respectively. However, the overall cost of PEH with mesh was significantly higher for the R- group compared to the L- group (R- $7,511.09 vs L- $6,443.32, p < 0.05). Based on our institutional cost data, use of a robotic approach when performing certain general surgery cases does not seem to be cost prohibitive.

Australian experience with robot-assisted Roux-en-Y gastric bypass with comparison to a conventional laparoscopic series

BACKGROUND

Robotic surgery is a novel approach to abdominal surgery. In Australia, the uptake of robotic assistance for bariatric surgery has been relatively slow compared to many other countries. The aim of this study is to report the first high volume experience of robotic-assisted Roux-en-Y gastric bypass surgery in Australia (RRYGB) and compare outcomes with a similar laparoscopic group (LRYGB).

METHODS

Retrospective analysis of 100 RRYGB versus 100 LRYGB was carried out over a period of seven years performed by two surgeons. These groups were matched by revisional status. Outcomes recorded included operative times, conversion rate, hospital stay, short-term (30 days) complication rates, and long-term complication rates. Baseline comorbidities of patients were also recorded.

RESULTS

Baseline characteristics of the two groups were similar except for comorbidity rates (higher in LRYGB group). The mean age was 43 (RRYGB) and 44(LRYGB) years, respectively. The mean pre-op BMI was 44.3 in the RRYGB group and 44.7 in the LRYGB group. Mean operating time in the RRYGB group was 208 min compared to 175 min in the LRYGB group. The number of patients with major complications was 1 in the robotic group versus 5 in the laparoscopic group (P: 0.2166). Minor complications were higher in the robotic group (17 vs. 5, P: 0.0054). Median length of stay of patients with RRYGB was 4 days compared to 5 days for the LRYGB group.

CONCLUSION

RRYGB has been successfully implemented in Australia with low complication rates compared to conventional laparoscopic RYGB. Operating times are longer compared to LRYGB which is consistent with most published literature. To justify increased costs generally associated with robotic surgery, better quality studies are needed to accurately assess potential cost savings with length of stay and safety benefits to patients and institutions.

Sleeve Gastrectomy Performed with Single Staple Height and Bioabsorbable Reinforcement in a Single Surgeon > 2500 Consecutive Case Series: Is Smart Technology Necessary?

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is shown to have durable and sustained weight reduction outcomes and improvement in comorbid conditions in patients with severe clinical obesity. Discussions regarding "proper" staple height for various gastric locations continue. We propose a standard approach of consistent use of single staple load height and bioabsorbable staple line reinforcement during the LSG to reduce variability.

METHODS

A retrospective chart review of 2556 consecutive cases of adult patients who underwent LSG evaluated perioperative complications, postoperative leaks or bleeding, and average weight and body mass index (BMI) change and excess weight loss (EWL) at 6, 12, and 24 months. The same green staple load (2.0 mm) and staple line reinforcement were used in all cases for all staple firings, regardless of patient size or gastric location.

RESULTS

Patients were a mean age of 42 years, 87.3% were female, and the mean preoperative weight was 134.2 kg and BMI was 48.2 kg/m². No staple line leak was detected. Three bleeding events occurred but did not require readmission or rehospitalization. Mean EWL and BMI, respectively, were 49.0% and 35.5 kg/m² at 6 months, 69.8% and 29.6 kg/m² at 12 months, and 70.0% and 29.5 kg/m² at 24 months.

CONCLUSION

In this case series of 2556 consecutive LSG performed by a single surgeon, clinically meaningful EWL and decreased BMI were achieved. Streamlining the LSG procedure by utilizing the same staple height and a bioabsorbable staple line reinforcement proved safe with minimal complications.

Robotic Roux-en-Y Gastric Bypass: A Single Surgeon's Experience with 527 Consecutive Patients

Background and Objectives

Robotic bariatric surgery is increasingly adopted by surgeons. We present the surgical results of 527 consecutive patients who underwent robotic Roux-en-Y gastric bypass (RYGB) using the standard technique.

Methods

A retrospective analysis of a prospectively maintained database was performed including 527 consecutive patients who underwent robotic RYGB between January 1, 2018 and December 31, 2021.

Results

The mean age of the patients was 41 years, with a male/female sex distribution of 143/384 (27.1%/72.9%). Type 2 diabetes in the pre-operative period was diagnosed in 31% of patients. The median pre-operative body mass index (BMI) was 44.6 kg/m² (range, 35-64). The mean operation time was 134 min for robotic RYGB, including the docking process. Early (< 30 days) complications included ileus (0.2%), atelectasis (0.2%), thromboembolic (0.2%) events, and surgical-site infection (0.2%). No leakage or bleeding of the gastrojejunal and jejunojejunal anastomoses were recorded. Oral food intake was begun at 1.8 days on average. The average hospital stay was 2 days. Despite a range of BMI values, operation times and gastrojejunal anastomosis times did not show significant differences. There were no significant differences in mean operation time or mean gastrojejunal anastomosis time over the years.

Conclusions

The robotic approach is effective and safe for patients undergoing RYGB. This technique provides satisfactory results with short-term surgical outcomes. However, the real benefits of robotic RYGB should be further evaluated by well-conducted randomized trials. Even in difficult cases with higher BMI values, optimal operation times and similar operative efficiency can be obtained if a standard operation technique is applied.

Developing a Value Framework: Utilizing Administrative Data to Assess an Enhanced Care Initiative

BACKGROUND

There remains no tool to quantify the total value of comparative processes in health care. Hospital administrative data sets are emerging as valuable sources to evaluate performance. Thus, we use a framework to simultaneously assess multiple domains of value associated with an enhanced recovery initiative using national administrative data.

MATERIALS AND METHODS

Risk-stratified clinical pathways for patients undergoing pancreatic surgery were implemented in 2016 at our institution. We used a national administrative database to characterize changes in value associated with this initiative. Value metrics assessed included in-hospital mortality, complication rates, length of stay (LOS), 30-day readmission rates, and institutional costs. We compared our performance with other hospitals both before and after implementation of the pathways. Metrics were graphed on radar charts to assess overall value.

RESULTS

22,660 cases were assessed. Comparing 75 cases at our institution and 5520 cases at all other hospitals before pathway implementation, mean in-hospital LOS was 9.6 versus 10.8 d, in-hospital mortality was 0.0% versus 1.9%, mean costs were $23,585 versus $21,387, 30-day readmission rates were 1.3% versus 7.4%, and complication rates were 8.0% versus 11.2%, respectively. Comparing 334 cases at our institution and 16,731 cases at all other hospitals after pathway implementation, mean in-hospital LOS was 7.7 versus 10.3 d, in-hospital mortality was 0.3% versus 1.6%, mean costs were $19,428 versus $22,032, 30-day readmission rates were 6.6% versus 7.5%, and complication rates were 6.3% versus 10.3%, respectively. Notably, LOS and institutional costs were reduced at our institution after implementation of the enhanced clinical care pathways. Our costs were higher than comparators before implementation, but lower than comparators after implementation.

CONCLUSIONS

Herein, we used an analytic framework and used national administrative data to assess the value of an enhanced care initiative as benchmarked with data from other hospitals. We thus illustrate how to identify and measure opportunities for targeted improvements in health care delivery. We also recognize the limitations of the use of administrative data in a comprehensive assessment of value in health care.