Deborah S Keller, MS, MD, Juan R Flores-Gonzalez, MD, Madhu Ragupathi, MD, John Paul LeFave, MD, Sergio Ibarra, Ali Mahmood, MD, Thomas B Pickron, MD, Eric M Haas, MD, FACS, FASCRS, FACS, FASCRS. Colorectal Surgical Associates
Introduction: Our goal was to compare operative times and quality across 4 minimally invasive platforms in colorectal surgery. Operative time is increasingly recognized as a quality marker in surgery. The safety and efficacy of these minimally invasive techniques have been proven; however, direct comparison of operative times, outcomes, and resulting quality of care across platforms has not been performed.
Methods and Procedures: Review of a prospective, departmental database identified elective colorectal resections performed using a minimally invasive surgery (MIS) platform between 2008 and 2014. Patients were stratified into multiport laparoscopic, single incision laparoscopic/ single incision laparoscopic + 1 additional port (SILS), and robotic assisted laparoscopic approaches (RALS). Evaluation of demographic, perioperative, and postoperative outcomes variables was performed. The main outcome measures were operative time and surgical quality by operative approach. The HARM score, a validated clinical outcome metric comprised of mortality, readmissions, and LOS, was used to measure surgical quality.
Results: 855 cases were evaluated- 22.81% Multiport, 18.36% RALS, 43.39% SILS, and 15.44% SILS + 1. There were no significant differences in age, BMI, ASA score, or gender distribution across platforms. The primary diagnosis was diverticulitis in multiport (30.3%), rectal cancer in RALS (39.1%), and colon cancer is SILS (27.1%). The main procedure performed was a low anterior resection in multiport (47%) and RALS (77%), and a segmental colectomy in SILS (63%). Conversion to OPEN was significantly higher in multiport (p<0.01). SILS had the shortest operative times, and while RALS had the longest (p<0.01). LOS (p=0.04) and postoperative complications (p<0.01) were significantly higher with multiport, while readmission rates were significantly higher with RALS (p<0.01). Mortality rates were similar across MIS platforms (1.00). All platforms offered high quality (HARM score 0) from overall short LOS, low readmission and mortality rates.
Conclusions: Multiport, RALS, and SILS all offer high quality care with a composite of LOS, readmission, and mortality rates. However, no single MIS platform offered optimal results for every outcome measured. Operative times were directly associated with readmission rates. Further, conversion to open surgery had no significant impact on postoperative outcomes or quality. Future study should focus on operative times to improve patient outcomes.
| Patient Outcomes |
Multiport (195) |
RALS (157) |
SILS (503) |
p-Value |
|---|---|---|---|---|
| Median Operative time (min, Range) |
176.42 (31-521) |
255.51 (85-540) |
156.87 (21-422) |
<0.01* |
| Conversion (n, %) | 36 (18.5%) | 2 (1.3%) | 30 (6.0%) |
<0.01* |
| Median Length of Stay (days, Range) | 3 (1-28) | 3 (1-16) | 3 (1-31) | 0.04* |
| Mean Length of Stay (days, SD) | 5.00 (4.28) | 4.40 (2.99) |
3.85 (2.75) |
0.04* |
| Complications (n, %) | 65 (7.60%) | 49 (5.73%) | 31 (3.63%) |
<0.01* |
| Readmissions (n, %) | 19 (9.7%) | 23 (14.6%) | 8 (2.2%) |
<0.01* |