Cost analysis of robot-assisted choledochotomy and common bile duct exploration as an option for complex choledocholithiasis.

AIM: The aim of this study is to evaluate the clinical outcomes and cost-effectiveness of elective, robot-assisted choledochotomy and common bile duct exploration (RCD/CBDE) compared to open surgery for ERCP refractory choledocholithiasis. METHOD: A prospective database of all RCD/CBDE has been maintained since our first procedure in April 2007 though April 2016. With ethics approval, this database was compared with all contemporaneous elective open procedures (OCD/CBDE) performed since March 2005. Emergency procedures were excluded from analysis. Cost analysis was calculated using a micro-costing approach. Outcomes were analyzed on the basis of intent-to-treat. A p value of 0.05 denoted statistical significance. RESULTS: A total of 80 cases were performed since 2005 compromising 50 consecutive, unselected RCD/CBDE and 30 OCD/CBDE. Comparing RCD/CBDE to OCD/CBDE there were no significant differences between groups with respect to age (65 ± 20 vs. 67 ± 18 years, p = 0.09), gender (14/30 vs. 16/25 male/female, p = 0.52), ASA class or co-morbidities. The mean duration of surgery for RCD/CBDE trended longer compared to OCD/CBDE (205 ± 70 min vs. 174 ± 73 min, p = 0.08). However, there was significant reduction in postoperative complications with RCD/CBDE versus OCD/CBDE (22% vs. 56%, p = 0.002). Median hospital stay was also significantly reduced (6 vs 12 days, p = 0.01). The net overall hospital cost for RCD/CBDE was lower ($8449.88 CAD vs. $11671.2 CAD). CONCLUSION: In this single-centre, cohort study, robotic-assisted CD/CBDE for ERCP refractory common bile duct stones provides the dominating strategy of improved patient outcomes with a reduction of overall cost.

Robot-assisted common bile duct exploration as an option for complex choledocholithiasis.

BACKGROUND: This study aimed to describe the authors' early experience with robot-assisted common bile duct exploration (CBDE) for choledocholithiasis refractory to endoscopic therapy and to compare the outcomes with those of equivalent patients undergoing an open technique. METHODS: At our institution, 55 CBDEs were performed between 2005 and 2010. All 19 robot-assisted cases were unselected elective referrals for stone disease. Of 36 open procedures, emergency cases and exploration not for stone disease were excluded, leaving 18 cases for analysis. Cases were analyzed on an intent-to-treat basis. A P value of 0.05 denoted statistical significance. RESULTS: The patients did not differ in terms of demography, comorbidity, or presenting symptoms. The reasons for endoscopic failure in both groups were similar. The mean operating time was longer for robot-assisted surgery (220 ± 41.26 min) than for open surgery (169 ± 65.81 min) (P = 0.01), but the median hospital stay was shorter (4 vs 11 days; P = 0.02). Four conversions to open surgery (21%) were performed due to severe adhesions. The two groups did not differ statistically in terms of T-tube usage (74 vs 61%; P = 0.414). One death occurred in the robotic group and two in the open cohort. Postoperative complications occurred in seven robotic and ten open cases (P = 0.402). They were mainly respiratory complications in the robot-assisted group, whereas they were cardiac and wound-related complications in the open group. Two of the converted cases had complications similar to those of the open group. Postoperative endoscopic retrograde cholangiopancreatography (ERCP) for retained stones was performed in one open case and three robotic cases. CONCLUSION: Robot-assisted CBDE offers some benefit when ERCP fails. Ideal case selection may enhance success.