Cost-Effectiveness of Laparoscopic Sleeve Gastrectomy for Chinese Patients.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most popular bariatric surgery procedure in China. However, its cost-effectiveness in Chinese patients is currently unknown. OBJECTIVES: This study aims to assess the cost-effectiveness of LSG vs no surgery in Chinese patients with severe and complex obesity, taking into account both healthcare expenses and the potential improvement in health-related quality of life (HRQoL). METHODS: A retrospective cohort study was conducted, encompassing 135 Chinese patients who underwent LSG between January 3, 2022 and December 29, 2022, at a major bariatric center. The study evaluated the cost-effectiveness from a healthcare service perspective, employing the incremental cost-effectiveness ratio (ICER) for quality-adjusted life years (QALYs) gained. The analyses compared LSG with the alternative of not undergoing surgery over a 1-year period, using actual data, and extended to a lifetime horizon by projecting costs and utilities at an annual discount rate of 3.0%. Subgroup analyses were undertaken to explore cost-effectiveness variations across different sex, age and BMI categories, and diabetes status, employing a one-way analysis of variance (ANOVA). To ensure the reliability of the findings, one-way and probabilistic sensitivity analyses were executed. RESULTS: The results indicated that 1-year post-LSG, patients achieved an average total weight loss (TWL) of (32.7 ± 7.3)% and an excess weight loss (EWL) of (97.8 ± 23.1)%. The ICER for LSG compared to no surgery over a lifetime was $4,327/QALY, significantly below the willingness-to-pay (WTP) threshold for Chinese patients with severe and complex obesity. From a lifetime perspective, LSG proved to be cost-effective for all sex and age groups, across all BMI categories, and for both patients with and without diabetes. Notably, it was more cost-effective for younger patients, patients with higher BMI, and patients with diabetes. CONCLUSIONS: LSG is a highly cost-effective intervention for managing obesity in Chinese patients, delivering substantial benefits in terms of HRQoL improvement at a low cost. Its cost-effectiveness is particularly pronounced among younger individuals, those with higher BMI, and patients with diabetes.

Hospital charges for laparoscopic sleeve gastrectomy compared to robotic sleeve gastrectomy: a multicenter study.

BACKGROUND: Sleeve gastrectomy has become a gold standard in addressing medically refractory obesity. Robotic platforms are becoming more utilized, however, data on its cost-effectiveness compared to laparoscopy remain controversial (1-3). At NYU Langone Health, many of the bariatric surgeons adopted robotic surgery as part of their practices starting in 2021. We present a retrospective cost analysis of laparoscopic sleeve gastrectomy (LSG) vs. robotic sleeve gastrectomy (RSG) at New York University (NYU) Langone Health campuses. METHODS: All adult patients ages 18-65 who underwent LSG or RSG from 202 to 2023 at NYU Langone Health campuses (Manhattan, Long Island, and Brooklyn) were evaluated via electronic medical records and MBSAQIP 30-day follow-up data. Patients with prior bariatric surgery were excluded. Complication-related ICD-10/CPT codes are collected and readmission costs will be estimated from ICD codes using the lower limit of CMS transparent NYU standard charges (3). Direct charge data for surgery and length of stay cost data were also obtained. Statistical T-test and chi-squared analysis were used to compare groups. RESULTS: Direct operating cost data at NYU Health Campuses demonstrated RSG was associated with 4% higher total charges, due to higher OR charges, robotic-specific supplies, and more post-op ED visits. CONCLUSIONS: RSG was associated with higher overall hospital charges compared to LSG, though there are multiple contributing factors. More research is needed to identify cost saving measures. This study is retrospective in nature, and does not include indirect costs nor reimbursement. Direct operating costs, per contractual agreement with suppliers, are only given as percentages. Data are limited to 30-day follow-up.

A systematic review on the effectiveness of robot-assisted minimally invasive gastrectomy.

BACKGROUND: Robot-assisted minimally invasive gastrectomy (RAMIG) is increasingly used as a surgical approach for gastric cancer. This study assessed the effectiveness of RAMIG and studied which stages of the IDEAL-framework (1 = Idea, 2A = Development, 2B = Exploration, 3 = Assessment, 4 = Long-term follow-up) were followed. METHODS: The Cochrane Library, Embase, Pubmed, and Web of Science were searched for studies on RAMIG up to January 2023. Data collection included the IDEAL-stage, demographics, number of participants, and study design. For randomized controlled trials (RCTs) and long-term studies, data on intra-, postoperative, and oncologic outcomes, survival, and costs of RAMIG were collected and summarized. RESULTS: Of the 114 included studies, none reported the IDEAL-stage. After full-text reading, 18 (16%) studies were considered IDEAL-2A, 75 (66%) IDEAL-2B, 4 (4%) IDEAL-3, and 17 (15%) IDEAL-4. The IDEAL-stages were followed sequentially (2A-4), with IDEAL-2A studies still ongoing. IDEAL-3 RCTs showed lower overall complications (8.5-9.2% RAMIG versus 17.6-19.3% laparoscopic total/subtotal gastrectomy), equal 30-day mortality (0%), and equal length of hospital stay for RAMIG (mean 5.7-8.5 days RAMIG versus 6.4-8.2 days open/laparoscopic total/subtotal gastrectomy). Lymph node yield was similar across techniques, but RAMIG incurred significantly higher costs than laparoscopic total/subtotal gastrectomy ($13,423-15,262 versus $10,165-10,945). IDEAL-4 studies showed similar or improved overall/disease-free survival for RAMIG. CONCLUSION: During worldwide RAMIG implementation, the IDEAL-framework was followed in sequential order. IDEAL-3 and 4 long-term studies showed that RAMIG is similar or even better to conventional surgery in terms of hospital stay, lymph node yield, and overall/disease-free survival. In addition, RAMIG showed reduced postoperative complication rates, despite higher costs.

Low-cost wound protector for laparoscopic surgeries.

The role of wound protectors in laparoscopic surgeries is highly controversial in the literature. Some studies demonstrate their benefit in reducing the rate of surgical site infections; however, these results are not reproducible across all procedures. In addition to protecting the operative wound, these devices can be used at sites of surgical specimen extraction in laparoscopic procedures. Several commercially available devices serve this purpose but are scarcely available in resource-limited settings. One of the reasons for this limitation is the cost of the device. In this technical note, we aim to provide a cost-effective option utilizing materials readily available in the operating room and with a simple fabrication process.

A retrospective cohort study of intra-corporeal versus extra-corporeal anastomosis for right hemicolectomy with cost-effectiveness analysis.

BACKGROUND: We aimed to compare outcomes and cost effectiveness of extra-corporeal anastomosis (ECA) versus intra-corporeal anastomosis (ICA) for laparoscopic right hemicolectomy using the National Surgical Quality Improvement Programme data. METHODS: Patients who underwent elective laparoscopic right hemicolectomy for colon cancer from January 2018 to December 2022 were identified. Non-cancer diagnoses, emergency procedures or synchronous resection of other organs were excluded. Surgical characteristics, peri-operative outcomes, long-term survival and hospitalisation costs were compared. Incremental cost-effectiveness ratio (ICER) was used to evaluate cost-effectiveness. RESULTS: A total of 223 patients (175 ECA, 48 ICA) were included in the analysis. Both cohorts exhibited comparable baseline patient, comorbidity, and tumour characteristics. Distribution of pathological TMN stage, tumour largest dimension, total lymph node harvest and resection margin lengths were statistically similar. ICA was associated with a longer median operative duration compared with ECA (255 min vs. 220 min, P < 0.001). There was a quicker time to gastrointestinal recovery, with a shorter median hospital stay in the ICA group (4.0 versus 5.0 days, P = 0.001). Overall complication rates were comparable. ICA was associated with a higher surgical procedure cost (£6301.57 versus £4998.52, P < 0.001), but lower costs for ward accommodation (£1679.05 versus £2420.15, P = 0.001) and treatment (£3774.55 versus £4895.14, P = 0.009), with a 4.5% reduced overall cost compared with ECA. The ICER of -£3323.58 showed ICA to be more cost effective than ECA, across a range of willingness-to-pay thresholds. CONCLUSION: ICA in laparoscopic right hemicolectomy is associated with quicker post-operative recovery and may be more cost effective compared with ECA, despite increased operative costs.

Inpatient Hospital Costs and Route of Hysterectomy for Management of Benign Uterine Disease in the 90-Day Global Billing Period.

OBJECTIVE: To compare inpatient hospital costs and complication rates within the 90-day global billing period among routes of hysterectomy. METHODS: The Premier Healthcare Database was used to identify patients who underwent hysterectomy between 2000 and 2020. Current Procedural Terminology codes were used to group patients based on route of hysterectomy. Comorbidities and complications were identified using International Classification of Diseases codes. Fixed, variable, and total costs for inpatient care were compared. Fixed costs consist of costs that are set for the case, such as operating room time or surgeon costs. Variable costs include disposable and reusable items that are billed additionally. Total costs equal fixed and variable costs combined. Data were analyzed using analysis of variance, t test, and χ 2 test, as appropriate. Factors independently associated with increased total costs were assessed using linear mixed effects models. Multivariate logistic regression was performed to evaluate associations between the route of surgery and complication rates. RESULTS: A cohort of 400,977 patients were identified and grouped by route of hysterectomy. Vaginal hysterectomy demonstrated the lowest inpatient total cost ($6,524.00 [interquartile range $4,831.60, $8,785.70]), and robotic-assisted laparoscopic hysterectomy had the highest total cost ($9,386.80 [interquartile range $6,912.40, $12,506.90]). These differences persisted with fixed and variable costs. High-volume laparoscopic and robotic surgeons (more than 50 cases per year) had a decrease in the cost difference when compared with costs of vaginal hysterectomy. Abdominal hysterectomy had a higher rate of complications relative to vaginal hysterectomy (adjusted odds ratio [aOR] 1.52, 95% CI, 1.39-1.67), whereas laparoscopic (aOR 0.85, 95% CI, 0.80-0.89) and robotic-assisted (aOR 0.92, 95% CI, 0.84-1.00) hysterectomy had lower rates of complications compared with vaginal hysterectomy. CONCLUSION: Robotic-assisted hysterectomy is associated with higher surgical costs compared with other approaches, even when accounting for surgeon volume. Complication rates are low for minimally invasive surgery, and it is unlikely that the robotic-assisted approach provides an appreciable improvement in perioperative outcomes.

Robotic surgery versus conventional laparoscopy in sigmoid colectomy for diverticular disease-a comparison of operative trauma and cost-effectiveness: retrospective, single-center analysis.

PURPOSE: Robotic assisted surgery is an alternative, fast evolving technique for performing colorectal surgery. The primary aim of this single center analysis is to compare elective laparoscopic and robotic sigmoid colectomies for diverticular disease on the extent of operative trauma and the costs. METHODS: Retrospective analysis from our prospective clinical database to identify all consecutive patients aged ≥ 18 years who underwent elective minimally invasive left sided colectomy for diverticular disease from January 2016 until December 2020 at our tertiary referral institution. RESULTS: In total, 83 patients (31 female and 52 male) with sigmoid diverticulitis underwent elective minimally invasive sigmoid colectomy, of which 42 underwent conventional laparoscopic surgery (LS) and 41 robotic assisted surgery (RS). The mean C-reactive protein difference between the preoperative and postoperative value was significantly lower in the robotic assisted group (4,03 mg/dL) than in the laparoscopic group (7.32 mg/dL) (p = 0.030). Similarly, the robotic´s hemoglobin difference was significantly lower (p = 0.039). The first postoperative bowel movement in the LS group occurred after a mean of 2.19 days, later than after a mean of 1.63 days in the RS group (p = 0.011). An overview of overall charge revealed significantly lower total costs per operation and postoperative hospital stay for the robotic approach, 6058 € vs. 6142 € (p = 0,014) not including the acquisition and maintenance costs for both systems. CONCLUSION: Robotic colon resection for diverticular disease is cost-effective and delivers reduced intraoperative trauma with significantly lower postoperative C-reactive protein and hemoglobin drift compared to conventional laparoscopy.

Outcomes of Robot-Assisted Versus Laparoscopic Surgery for Colorectal Cancer in Adults Aged 75 Years and Older: A Propensity Score-Matched Analysis of the US Nationwide Inpatient Sample.

BACKGROUND: Robot-assisted surgery has been increasingly adopted in colorectal cancer resection. OBJECTIVE: The study aimed to compare the inpatient outcomes of robot-assisted versus conventional laparoscopic colorectal cancer resection in patients aged 75 years and older. DESIGN: A retrospective, population-based study. SETTINGS: This study analyzed data from the United States Nationwide Inpatient Sample from 2005 to 2018. PATIENTS: Patients with colorectal cancer aged 75 years and older and who underwent robot-assisted or conventional laparoscopic resection. MAIN OUTCOME MEASURES: Postoperative complications, prolonged length of stay, and total hospital costs were assessed. RESULTS: Data from 14,108 patients were analyzed. After adjustment, any postoperative complications (adjusted OR = 0.87; 95% CI, 0.77-0.99; p = 0.030) and prolonged length of stay (adjusted OR = 0.78; 95% CI, 0.67-0.91; p = 0.001) were significantly less in the robotic than the laparoscopic group. In addition, robotic surgery was associated with significantly higher total hospital costs (26.06 USD greater cost; 95% CI, 21.35-30.77 USD; p < 0.001). LIMITATIONS: The analysis was limited by its retrospective and observational nature, potential coding errors, and the lack of intraoperative factors, such as operative time, laboratory measures, and information on surgeons' experience. CONCLUSIONS: In the United States, in patients with colorectal cancer aged 75 years and older who were undergoing tumor resections, compared to conventional laparoscopic surgery, robotic surgery is associated with better inpatient outcomes in terms of complication rate and risk of prolonged length of stay. This finding is especially true among patients with colon cancer. However, robotic surgery is associated with higher total hospital costs. See Video Abstract . RESULTADOS DE LA CIRUGA ASISTIDA POR ROBOT FRENTE A LA CIRUGA LAPAROSCPICA PARA EL CNCER COLORRECTAL EN ADULTOS AOS DE EDAD UN ANLISIS EMPAREJADO POR PUNTUACIN DE PROPENSIN DE LA MUESTRA NACIONAL DE PACIENTES HOSPITALIZADOS DE ESTADOS UNIDOS: ANTECEDENTES:La cirugía asistida por robot se ha adoptado cada vez más en la resección del cáncer colorrectal.OBJETIVO:El estudio tuvo como objetivo comparar los resultados hospitalarios de la resección del cáncer colorrectal asistida por robot versus la laparoscópica convencional en pacientes ≥ 75 años.DISEÑO:Estudio retrospectivo de base poblacional.AJUSTES:Este estudio analizó datos de la Muestra Nacional de Pacientes Hospitalizados de Estados Unidos de 2005 a 2018.PACIENTES:Pacientes con cáncer colorrectal ≥ 75 años y sometidos a resección laparoscópica convencional o asistida por robot.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluaron las complicaciones posoperatorias, la duración prolongada de la estancia hospitalaria y los costos hospitalarios totales.RESULTADOS:Se analizaron datos de 14.108 pacientes. Después del ajuste, cualquier complicación posoperatoria (aOR = 0,87; IC del 95 %: 0,77-0,99, p = 0,030) y duración prolongada de la estancia hospitalaria (aOR = 0,78; IC del 95 %: 0,67-0,91, p = 0,001) fueron significativamente menores en el grupo robótico que el grupo laparoscópico. Además, la cirugía robótica se asoció con costos hospitalarios totales significativamente mayores ($26,06 USD mayor costo; IC 95%: 21,35-30,77 USD, p < 0,001).LIMITACIONES:El análisis estuvo limitado por su naturaleza retrospectiva y observacional, posibles errores de codificación y la falta de factores intraoperatorios como el tiempo operatorio, medidas de laboratorio e información sobre la experiencia de los cirujanos.CONCLUSIONES:En Estados Unidos, los pacientes con cáncer colorrectal ≥ 75 años que se sometieron a resecciones tumorales, en comparación con la cirugía laparoscópica convencional, la cirugía robótica se asocia con mejores resultados hospitalarios en términos de tasa de complicaciones y riesgo de estadía prolongada, especialmente entre pacientes con cáncer de colon. Sin embargo, la cirugía robótica se asocia a costes hospitalarios totales más elevados. (Traducción-Yesenia Rojas-Khalil ).

Healthcare cost expenditure for robotic versus laparoscopic liver resection: a bottom-up economic evaluation.

BACKGROUND: Minimally invasive liver surgery (MILS) is increasingly performed via the robot-assisted approach but may be associated with increased costs. This study is a post-hoc comparison of healthcare cost expenditure for robotic liver resection (RLR) and laparoscopic liver resection (LLR) in a high-volume center. METHODS: In-hospital and 30-day postoperative healthcare costs were calculated per patient in a retrospective series (October 2015-December 2022). RESULTS: Overall, 298 patients were included (143 RLR and 155 LLR). Benefits of RLR were lower conversion rate (2.8% vs 12.3%, p = 0.002), shorter operating time (167 min vs 198 min, p = 0.044), and less blood loss (50 mL vs 200 mL, p < 0.001). Total per-procedure costs of RLR (€10260) and LLR (€9931) were not significantly different (mean difference €329 [95% bootstrapped confidence interval (BCI) €-1179-€2120]). Lower costs with RLR due to shorter surgical and operating room time were offset by higher disposable instrumentation costs resulting in comparable intraoperative costs (€5559 vs €5247, mean difference €312 [95% BCI €-25-€648]). Postoperative costs were similar for RLR (€4701) and LLR (€4684), mean difference €17 [95% BCI €-1357-€1727]. When also considering purchase and maintenance costs, RLR resulted in higher total per-procedure costs. DISCUSSION: In a high-volume center, RLR can have similar per-procedure cost expenditure as LLR when disregarding capital investment.

Robotic surgery versus Laparoscopic surgery for anti-reflux and hiatal hernia surgery: a short-term outcomes and cost systematic literature review and meta-analysis.

PURPOSE: The objective of this study is to compare the operative time, intraoperative complications, length of stay, readmission rates, overall complications, mortality, and cost associated with Robotic Surgery (RS) and Laparascopic Surgery (LS) in anti-reflux and hiatal hernia surgery. METHODS: A comprehensive literature search was conducted using MEDLINE (via PubMed), Web of Science and Scopus databases. Studies comparing short-term outcomes and cost between RS and LS in patients with anti-reflux and hiatal hernia were included. Data on operative time, complications, length of stay, readmission rates, overall complications, mortality, and cost were extracted. Quality assessment of the included studies was performed using the MINORS scale. RESULTS: Fourteen retrospective observational studies involving a total of 555,368 participants were included in the meta-analysis. The results showed no statistically significant difference in operative time, intraoperative complications, length of stay, readmission rates, overall complications, and mortality between RS and LS. However, LS was associated with lower costs compared to RS. CONCLUSION: This systematic review and meta-analysis demonstrates that RS has non-inferior short-term outcomes in anti-reflux and hiatal hernia surgery, compared to LS. LS is more cost-effective, but RS offers potential benefits such as improved visualization and enhanced surgical techniques. Further research, including randomized controlled trials and long-term outcome studies, is needed to validate and refine these findings.

Comparative cost-effectiveness of open, laparoscopic, and robotic liver resection: A systematic review and network meta-analysis.

BACKGROUND: This study evaluated the cost-effectiveness of open, laparoscopic, and robotic liver resection. METHODS: A comprehensive literature review and Bayesian network meta-analysis were conducted. Surface under cumulative ranking area values, mean difference, odds ratio, and 95% credible intervals were calculated for all outcomes. Cluster analysis was performed to determine the most cost-effective clustering approach. Costs-morbidity, costs-mortality, and costs-efficacy were the primary outcomes assessed, with postoperative overall morbidity, mortality, and length of stay associated with total costs for open, laparoscopic, and robotic liver resection. RESULTS: Laparoscopic liver resection incurred the lowest total costs (laparoscopic liver resection versus open liver resection: mean difference -2,529.84, 95% credible intervals -4,192.69 to -884.83; laparoscopic liver resection versus robotic liver resection: mean difference -3,363.37, 95% credible intervals -5,629.24 to -1,119.38). Open liver resection had the lowest procedural costs but incurred the highest hospitalization costs compared to laparoscopic liver resection and robotic liver resection. Conversely, robotic liver resection had the highest total and procedural costs but the lowest hospitalization costs. Robotic liver resection and laparoscopic liver resection had a significantly reduced length of stay than open liver resection and showed less postoperative morbidity. Laparoscopic liver resection resulted in the lowest readmission and liver-specific complication rates. Laparoscopic liver resection and robotic liver resection demonstrated advantages in costs-morbidity efficiency. While robotic liver resection offered notable benefits in mortality and length of stay, these were balanced against its highest total costs, presenting a nuanced trade-off in the costs-mortality and costs-efficacy analyses. CONCLUSION: Laparoscopic liver resection represents a more cost-effective option for hepatectomy with superior postoperative outcomes and shorter length of stay than open liver resection. Robotic liver resection, though costlier than laparoscopic liver resection, along with laparoscopic liver resection, consistently exceeds open liver resection in surgical performance.

Cost-effectiveness of open versus laparoscopic pancreatectomy: A nationwide, population-based study.

BACKGROUND: Laparoscopic pancreatic resection is comparable to open pancreatic resection; however, cost-effectiveness analyses of laparoscopic pancreatic resection are scarce. The authors performed a population-based study investigating the cost-effectiveness of laparoscopic pancreatic resection versus open pancreatic resection. METHODS: Data from 9,256 patients who received pancreaticoduodenectomy (66.8%) and distal pancreatectomy (33.2%) from 2016 to 2018 were retrieved from the Korean National Health Insurance Service. Events after pancreatectomy were categorized as no complication, complication, and death. Probabilities of each event and average cost during index admission and 1 year were utilized to calculate incremental cost-effectiveness ratio, the cost difference between two interventions divided by quality-adjusted life year. Quality-adjusted life year, a function of length and quality of life, was measured with utility values determined by researching literature. RESULTS: Laparoscopic pancreatic resection was performed in 12.4% of pancreaticoduodenectomies and 53.4% of distal pancreatectomies. For pancreaticoduodenectomy, laparoscopic pancreatic resection was associated with an increase of 0.0022 quality-adjusted life years for index admission and 0.0023 quality-adjusted life years for 1 year compared with open pancreatic resection. The incremental cost was $321 for index admission and -$1,414 for 1 year, leading to an incremental cost-effectiveness ratio of $147,429 per quality-adjusted life year gained for index admission and -$614,965 per quality-adjusted life year gained for 1 year. For distal pancreatectomy, laparoscopic pancreatic resection improved 0.0131 quality-adjusted life years for index admission and 0.0285 quality-adjusted life years for index admission. The incremental cost was -$1,240 for index admission and -$5,875 for 1 year, leading to an incremental cost-effectiveness ratio of -$94,519 per quality-adjusted life year gained for index admission and -$206,351 for 1 year. CONCLUSION: laparoscopic pancreatic resection was a cost-effective alternative to open pancreatic resection for pancreaticoduodenectomy and distal pancreatectomy, except for the higher cost of index admission for pancreaticoduodenectomy.

Excess use of surgical supplies in minimally invasive benign gynecology surgery: an observational study.

BACKGROUND: Single-use materials and equipment are regularly opened by the surgical team during procedures but left unused, potentially resulting in superfluous costs and excess environmental waste. OBJECTIVE: This study aimed to estimate the excess use of surgical supplies in minimally invasive benign gynecologic surgeries. STUDY DESIGN: This is a prospective observational study conducted at a university-affiliated single tertiary medical center. Designated study personnel were assigned to observe surgical procedures performed during July to September 2022. Surgical teams were observed while performing surgeries for benign indications. The teams were not informed of the purpose of the observation to avoid potential bias. Disposable materials and equipment opened during the procedure were documented. Excess supplies were defined as those opened but left unused before being discarded. Costs per item of the excess supplies were estimated on the basis of material and equipment costs provided by the hospital. RESULTS: A total of 99 surgeries were observed, including laparoscopic (32%), robotic (39%), hysteroscopic (14%), vaginal (11%), and laparotomy procedures (3%). Excess use of surgical supplies was documented in all but one procedure. The total cost across all surgeries reached $6357. The contained tissue extraction bag was the most expensive item not used (Applied Medical, Rancho Santa Margarita, CA; $390 per unit) in 4 procedures, contributing 25.54% to the total cost. Raytec was the most common surgical waste, with a total of n=583 opened but unused (average n=5.95 per surgery). A significant difference was found in the rate of excess supplies across the surgical approaches, with robotic surgery contributing 52.19% of the total cost (P=.01). CONCLUSION: Excess use of disposable materials and equipment is common in minimally invasive benign gynecologic surgeries and contributes to superfluous costs and excess environmental waste. It is predominantly attributed to the opening of inexpensive materials that are left unused during the procedure. Increased awareness of costs and generated waste may reduce excess use of surgical supplies and should be further explored in future research.

[Robotic vs. laparoscopic right hemicolectomy-An analysis of costs]. / Robotische vs. laparoskopische Hemikolektomie rechts ­ eine Kostenanalyse.

The use of robotic surgical methods for performing right-sided hemicolectomy has been somewhat controversial, primarily due to concerns related to costs. The purpose of this study is to document the initial robotic right hemicolectomies conducted at our institution and to compare them with a laparoscopic reference group. A significant focus of this study is the detailed analysis of the costs associated with both techniques within the German healthcare system.Surgical and cost-related data for 34 cases each for robotic and laparoscopic right-sided hemicolectomy performed at Nürnberg Hospital were compared. This comparison was conducted through a retrospective single-center case-matched analysis. Cost analysis was carried out following the current guidelines provided by the Institute for the Hospital Remuneration System (InEK) of Germany.The average age of the patient cohort was 70 years, with a male patient proportion of 57.4%. Analysis of perioperative parameters indicated similar outcomes for both surgical techniques. Regarding the incidence of complications of Clavien-Dindo stages III-V (8.8% vs. 17.6%; p = 0.48), a positive trend towards robotic surgery was observed. The cost analysis showed nearly identical total costs for the selected cases in both groups (mean €13,423 vs. €13,424; p = 1.00), with the most significant cost difference noted in surgical (operative) costs (€5,779 vs. €3,521; p < 0.01). The lower costs for laparoscopic cases were primarily due to the reduced material costs (mean €2,657 vs. €702; p < 0.05).In conclusion, both surgical approaches are clinically equivalent, with only minor differences in the total case costs.

Effect of IWATE laparoscopic difficulty score on postoperative outcomes and costs for robotic hepatectomy: Are complex resections more expensive?

BACKGROUND: The IWATE criteria, a four-level classification system for laparoscopic hepatectomy, measures technical complexity but lacks studies on its impact on outcomes and costs, especially in robotic surgeries. This study evaluated the effects of technical complexity on perioperative outcomes and costs in robotic hepatectomy. METHODS: Since 2013, we prospectively followed 500 patients who underwent robotic hepatectomy. Patients were classified into four levels of IWATE scores; (low [0-3], intermediate [4-6], advanced [7-9], and expert [10-12]) determined by tumor characteristics, liver function and resection extent. Perioperative variables were analyzed with significance accepted at a p-value ≤.05. RESULTS: Among 500 patients, 337 (67%) underwent advanced to expert-level operations. Median operative duration was 213 min (range: 16-817 min; mean ± SD: 240 ± 116.1 min; p < .001) and estimated blood loss (EBL) was 95 mL (range: 0-3500 mL; mean ± SD:142 ± 171.1 mL; p < .001). Both operative duration and EBL showed positive correlations with increasing IWATE scores. Median length of stay (LOS) of 3 days (range: 0-34; mean ± SD:4 ± 3.0 days; p < .001) significantly correlated with IWATE score. Total cost of $25 388 (range: $84-354 407; mean ± SD: 29752 ± 20106.8; p < .001) also significantly correlated with operative complexity, however hospital reimbursement did not. No correlation was found between IWATE score and postoperative complications or mortality. CONCLUSIONS: Clinical variables such as operative duration, EBL, and LOS correlate with IWATE difficulty scores in robotic hepatectomy. Financial metrics such as costs but not reimbursement received by the hospital correlate with IWATE scores.

Evaluating the economic efficiency of open, laparoscopic, and robotic distal pancreatectomy: an updated systematic review and network meta-analysis.

BACKGROUND: This study compared the cost-effectiveness of open (ODP), laparoscopic (LDP), and robotic (RDP) distal pancreatectomy (DP). METHODS: Studies reporting the costs of DP were included in a literature search until August 2023. Bayesian network meta-analysis was conducted, and surface under cumulative ranking area (SUCRA) values, mean difference (MD), odds ratio (OR), and 95% credible intervals (CrIs) were calculated for outcomes of interest. Cluster analysis was performed to examine the similarity and classification of DP approaches into homogeneous clusters. A decision model-based cost-utility analysis was conducted for the cost-effectiveness analysis of DP strategies. RESULTS: Twenty-six studies with 29,164 patients were included in the analysis. Among the three groups, LDP had the lowest overall costs, while ODP had the highest overall costs (LDP vs. ODP: MD - 3521.36, 95% CrI - 6172.91 to - 1228.59). RDP had the highest procedural costs (ODP vs. RDP: MD - 4311.15, 95% CrI - 6005.40 to - 2599.16; LDP vs. RDP: MD - 3772.25, 95% CrI - 4989.50 to - 2535.16), but incurred the lowest hospitalization costs. Both LDP (MD - 3663.82, 95% CrI - 6906.52 to - 747.69) and RDP (MD - 6678.42, 95% CrI - 11,434.30 to - 2972.89) had significantly reduced hospitalization costs compared to ODP. LDP and RDP demonstrated a superior profile regarding costs-morbidity, costs-mortality, costs-efficacy, and costs-utility compared to ODP. Compared to ODP, LDP and RDP cost $3110 and $817 less per patient, resulting in 0.03 and 0.05 additional quality-adjusted life years (QALYs), respectively, with positive incremental net monetary benefit (NMB). RDP costs $2293 more than LDP with a negative incremental NMB but generates 0.02 additional QALYs with improved postoperative morbidity and spleen preservation. Probabilistic sensitivity analysis suggests that LDP and RDP are more cost-effective options compared to ODP at various willingness-to-pay thresholds. CONCLUSION: LDP and RDP are more cost-effective than ODP, with LDP exhibiting better cost savings and RDP demonstrating superior surgical outcomes and improved QALYs.

Robotic versus laparoscopic anterior resection for the treatment of stage II and III sigmoid colon cancer: a propensity score-matched analysis.

Robot-assisted laparoscopic anterior resection is a novel technique. However, evidence in the literature regarding the advantages of robot-assisted laparoscopic surgery (RLS) is insufficient. The aim of this study was to compare the outcomes of RLS versus conventional laparoscopic surgery (CLS) for the treatment of sigmoid colon cancer. We performed a retrospective study at the Northern Jiangsu People's Hospital. Patients diagnosed with sigmoid colon cancer and underwent anterior resection between January 2019 to September 2023 were included in the study. We compared the basic characteristics of the patients and the short-term and long-term outcomes of patients in the two groups. A total of 452 patients were included. Based on propensity score matching, 212 patients (RLS, n = 106; CLS, n = 106) were included. The baseline data in RLS group was comparable to that in CLS group. Compared with CLS group, RLS group exhibited less estimated blood loss (P = 0.015), more harvested lymph nodes (P = 0.005), longer operation time (P < 0.001) and higher total hospitalization costs (P < 0.001). Meanwhile, there were no significant differences in other perioperative or pathologic outcomes between the two groups. For 3-year prognosis, overall survival rates were 92.5% in the RLS group and 90.6% in the CLS group (HR 0.700, 95% CI 0.276-1.774, P = 0.452); disease-free survival rates were 91.5% in the RLS group and 87.7% in the CLS group (HR 0.613, 95% CI 0.262-1.435, P = 0.259). Compared with CLS, RLS for sigmoid colon cancer was found to be associated with a higher number of lymph nodes harvested, similar perioperative outcomes and long-term survival outcomes. High total hospitalization costs of RLS did not translate into better long-term oncology outcomes.

Transforming surgical landscapes: obstacles in the integration of robotic surgery in Pakistan -is cost the only limiting factor?

The advantages of Robotic Assisted Surgery (RAS) over laparoscopic surgery encompass enhanced precision, improved ergonomics, shorter learning curves, versatility in complex procedures, and the potential for remote surgery. These benefits contribute to improved patient outcomes which have led to a paradigm shift in robotic surgery worldwide and it is now being hailed as the future of surgery. Robotic surgery was introduced in Pakistan in 2011, but widespread adoption has been limited. The future of RAS in Pakistan demands a strategic and comprehensive plan due to the substantial investment in installation and maintenance costs. Considering Pakistan's status as a low to middle-income country, a well-designed economic model compatible with the existing health system is imperative. The debate over high investments in robotic surgery amid unmet basic surgical needs underscores the complex dynamics of healthcare challenges in the country. In this review, we discuss the potential benefits of robotics over other surgical techniques, where robotic surgery stands in Pakistan and the possible hurdles and barriers limiting its use along with solutions to overcome this in the future.

Clinical and economic comparison of laparoscopic versus open hepatectomy for primary hepatolithiasis: a propensity score-matched cohort study.

BACKGROUND: It is unclear whether laparoscopic hepatectomy (LH) for hepatolithiasis confers better clinical benefit and lower hospital costs than open hepatectomy (OH). This study aim to evaluate the clinical and economic value of LH versus OH. METHODS: Patients undergoing OH or LH for primary hepatolithiasis at Yijishan Hospital of Wannan Medical College between 2015 and 2022 were divided into OH group and LH group. Propensity score matching (PSM) was used to balance the baseline data. Deviation-based cost modelling and weighted average median cost (WAMC) were used to assess and compare the economic value. RESULTS: A total of 853 patients were identified. After exclusions, 403 patients with primary hepatolithiasis underwent anatomical hepatectomy (OH n=143; LH n=260). PSM resulted in 2 groups of 100 patients each. Although LH required a longer median operation duration compared with OH (285.0 versus 240.0 min, respectively, P<0.001), LH patients had fewer wound infections, fewer pre-discharge overall complications (26 versus 43%, respectively, P=0.009), and shorter median postoperative hospital stays (8.0 versus 12.0 days, respectively, P<0.001). No differences were found in blood loss, major complications, stone clearance, and mortality between the two matched groups. However, the median overall hospital cost of LH was significantly higher than that of OH (CNY¥52,196.1 versus 45,349.5, respectively, P=0.007). Although LH patients had shorter median postoperative hospital stays and fewer complications than OH patients, the WAMC was still higher for the LH group than for the OH group with an increase of CNY¥9,755.2 per patient undergoing LH. CONCLUSION: The overall clinical benefit of LH for hepatolithiasis is comparable or even superior to that of OH, but with an economic disadvantage. There is a need to effectively reduce the hospital costs of LH and the gap between costs and diagnosis-related group reimbursement to promote its adoption.