Financial Impact of the Robotic Approach in Liver Surgery: A Comparative Study of Clinical Outcomes and Costs Between the Robotic and Open Technique in a Single Institution.

BACKGROUND: One of the perceived major drawbacks of minimally invasive techniques has always been its cost. This is especially true for the robotic approach and is one of the main reasons that has prevented its wider acceptance among hospitals and surgeons. The aim of our study was to evaluate the clinical outcomes and economic impact of robotic and open liver surgery in a single institution. METHODS: Sixty-eight robotic and 55 open hepatectomies were performed at our institution between January 1, 2009 and December 31, 2013. Demographics, perioperative data, and postoperative outcomes were collected and compared between the two groups. An independent company performed the financial analysis. The economic parameters comprised direct variable costs, direct fixed costs, and indirect costs. RESULTS: Mean estimated blood loss was significantly less in the robotic group (438 versus 727.8 mL; P = .038). Overall morbidity was significantly lower in the robotic group (22% versus 40%; P = .047). Clavien III/IV complications were also lower, with 4.4% in the robotic versus 16.3% in the open group (P = .043). The length of stay in the intensive care unit (ICU) was shorter for patients who underwent a robotic procedure (2.1 versus 3.3 days; P = .004). The average total cost, including readmissions, was $37,518 for robotic surgery and $41,948 for open technique. CONCLUSIONS: Robotic liver resections had less overall morbidity, ICU, and hospital stay. This translates into decreased average costs for robotic surgery. These procedures are financially comparable to open resections and do not represent a financial burden to the hospital.

Perioperative risk assessment in robotic general surgery: lessons learned from 884 cases at a single institution.

OBJECTIVE: To assess factors associated with morbidity and mortality following the use of robotics in general surgery. DESIGN: Case series. SETTING: University of Illinois at Chicago. PATIENTS AND INTERVENTION: Eight hundred eighty-four consecutive patients who underwent a robotic procedure in our institution between April 2007 and July 2010. MAIN OUTCOMES MEASURES: Perioperative morbidity and mortality. RESULTS: During the study period, 884 patients underwent a robotic procedure. The conversion rate was 2%, the mortality rate was 0.5%, and the overall postoperative morbidity rate was 16.7%. The reoperation rate was 2.4%. Mean length of stay was 4.5 days (range, 0.2-113 days). In univariate analysis, several factors were associated with increased morbidity and included either patient-related (cardiovascular and renal comorbidities, American Society of Anesthesiologists score ≥ 3, body mass index [calculated as weight in kilograms divided by height in meters squared] <30, age ≥ 70 years, and malignant disease) or procedure-related (blood loss ≥ 500 mL, transfusion, multiquadrant operation, and advanced procedure) factors. In multivariate analysis, advanced procedure, multiquadrant surgery, malignant disease, body mass index of less than 30, hypertension, and transfusion were factors significantly associated with a higher risk for complications. American Society of Anesthesiologists score of 3 or greater, age 70 years or older, cardiovascular comorbidity, and blood loss of 500 mL or more were also associated with increased risk for mortality. CONCLUSIONS: Use of the robotic approach for general surgery can be achieved safely with low morbidity and mortality. Several risk factors have been identified as independent causes for higher morbidity and mortality. These can be used to identify patients at risk before and during the surgery and, in the future, to develop a scoring system for the use of robotic general surgery

Cost and validity of early postoperative contrast swallow after laparoscopic adjustable gastric banding.

BACKGROUND: To assess the validity and cost of early routine upper gastrointestinal (UGI) studies after laparoscopic adjustable gastric banding (LAGB) at a university hospital in the United States. Today, although there is widespread use of LAGB, and it is considered a safe procedure, it also can result in some specific early complications. In most centers, an UGI series after bariatric surgery is performed to rule out these potentially dangerous complications. METHODS: From March 2006 to July 2010, 183 LAGB procedures were performed by a single surgeon. All data were collected prospectively in a computerized database and reviewed retrospectively. The patients underwent water-soluble UGI studies during the early postoperative phase (2-24 h) to exclude gastrointestinal perforation, obstruction, and gastric band malposition. RESULTS: No intraoperative complications occurred. One conversion to an open procedure was required because of massive adhesions. A total of 21 postoperative complications (11.5%) occurred. None of the 183 patients who underwent an early UGI series experienced leakage, gastric band malposition, or slippage. The only radiologic abnormality was a stomal obstruction (.5%) requiring reoperation. The total cost for the 183 UGI studies was $54,900. The mean hospital stay was .5 day (range .1-5.6). Approximately 90% of patients were discharged within the first 24 hours. CONCLUSION: The fear of acute perforation or obstruction has been the rationale for obtaining UGI studies after LAGB. We found this to be expensive and of limited value in an experienced center and have created a decisional algorithm to determine when its use is appropriate for symptomatic patients.

Traditional versus single-site placement of adjustable gastric banding: a comparative study and cost analysis.

In bariatric surgery, laparoscopic adjustable gastric banding (LAGB) has proven effective in reducing weight and improving obesity-associated comorbidities. Recently, however, laparoendoscopic single-site (LESS) surgery has been proposed to minimize the invasiveness of laparoscopic surgery. The aim of this study is to compare the operative cost and peri-operative outcomes of these two approaches. We undertook a retrospective review of a prospectively maintained database of patients undergoing either LAGB or LESS between March 2006 and October 2009. The outcomes and cost of 25 LESS gastric bandings were compared to 121 standard LAGB. Costs included operative time, consumables, and laparoscopic tower depreciation. Both groups had similar patient demographics, body mass index, and comorbidities; with the exception of age (37 year for single site vs. 44 years for standard; P=0.002). There were no statistical differences for operative time (78 vs. 76 min, P=0.69), blood loss (8.4 vs. 9 ml, P=0.76), pain score (0.81 vs. 0.84 at 1 week, P=0.95) or complication rates (12% vs. 14%, P=1). Length of stay was shorter for the LESS group (0.5 day vs. 1.5 days, P=0.02). The mean operative cost for the LESS banding was $20,502/case vs. $20,346/case for the standard LAGB, with no statistically significant difference between the approaches (P=0.73). Operative costs and peri-operative outcomes of LESS gastric banding are comparable with those of the standard LAGB procedure. As a result, single-site surgery can be proposed as a valid alternative to the standard procedure with cosmetic advantage and comparable complication rate.