James P Villamere, MD, Alana Gebhart, BA, Stephen Vu, Ninh T Nguyen, MD. Department of Surgery, University of California, Irvine Medical Center, Orange, CA, USA.
Background: The robotic platform has been shown to be of greatest benefit in enabling surgeons to transition open procedures to laparoscopy. Currently, most gastrointestinal procedures have a high rate of laparoscopic adoption; however, the role for robotic assisted laparoscopic surgery for common general surgical procedures is still unclear. The aim of this study was to compare the utilization and outcome of laparoscopic (Lap) vs. robotic assisted laparoscopic (R-A Lap) techniques for common elective general and bariatric surgical procedures performed at academic medical centers.
Methods: A retrospective, multicenter analysis utilizing a large administrative database was implemented. Using the ICD-9th revision diagnosis and procedure codes, data was obtained between October 2009 and September 2013 from the University HealthSystem Consortium clinical database for all patients who underwent Lap vs. R-A Lap techniques for 8 common elective general surgical procedures (gastric bypass, sleeve gastrectomy, gastric band, antireflux surgery, Heller myotomy, cholecystectomy, colectomy, rectal resection). Outcome measures including demographics, rate of robotic assisted laparoscopy, length of stay (LOS), major complications, in-hospital mortality, 30-day readmission, and cost were compared between groups. Chi-square and t test were used to compare outcome variables.
Results: There were 104,292 Lap and R-A Lap general and bariatric surgical procedures analyzed. For all procedures, the preoperative severity of illness was similar between groups. Utilization of the robotic approach was highest for rectal resection (18.8%), followed by Heller myotomy (7.6%), sleeve gastrectomy (5.0%), antireflux surgery (4.9%), gastric bypass (2.5%), gastric band (1.9%), colectomy (1.6%), and cholecystectomy (1.0%). Compared to laparoscopy, all procedures had a mean 29% higher cost associated with the robotic approach. There was no significant difference in in-hospital mortality or major complications between the two techniques for all procedures. Compared to robotic approach, laparoscopic sleeve gastrectomy and gastric banding had a shorter LOS (2.1±1.4 vs. 2.5±1.0; p < 0.05 for sleeve and 1.3±1.1 vs. 1.5±1.2; p <0.05 for band); laparoscopic gastric banding and laparoscopic antireflux surgery had a lower 30-day readmission (1.05% vs. 3.50%; p <0.05 for band and 1.74% vs. 3.35%; p <0.05 for antireflux surgery). Outcomes were comparable between laparoscopic vs. robotic gastric bypass, colectomy, and rectal resection with the exception of cost. Only two procedures had improved outcome associated with the robotic approach; robotic Heller myotomy and robotic cholecystectomy had a shorter LOS compared to the laparoscopic approach (2.2±1.9 vs. 2.9±3.7; p <0.05 for Heller myotomy and 2.2±1.7 vs. 2.8±2.3 for cholecystectomy). Results were similar after stratification by illness severity and increased body mass index. No significant difference in in-hospital mortality or major complications between techniques persisted for all procedures at stratification. Cost was more comparable between techniques for most surgical procedures in major/extreme illness severity patients.
Conclusion: This nationwide analysis of academic centers showed a low utilization of robotic assisted elective general and bariatric surgical procedures. Compared to conventional laparoscopy, there were no observed clinical benefits associated with the robotic approach but there was a consistently higher cost.