Robotic approaches may offer benefit in colorectal procedures, more controversial in other areas: a review of 166,790 cases

Maria S Altieri, MD, Dana A Telem, MD, Jie Yang, PhD, Jiawen Zhu, Caitlin Halbert, DO, Mark Talamini, MD, Aurora D Pryor, MD. Stony Brook University Hospital

Introduction:

Laparoscopy has become the standard of care, although not adopted by all surgeons for many procedures. The use of robotic-assisted surgery (RAS) has been cited as a significant technological advancement in the area of minimally invasive surgery. While the penetrance of robotic surgery into field of urology and gynecology has been significant, general surgeons have been slower adopters, citing higher intraoperative cost and considerable learning curve compared to conventional laparoscopy. We sought to compare laparoscopy and RAS among five different general surgical procedures with various penetrance of laparoscopy.

Methods:

Following IRB approval, the New York Statewide Planning and Research Cooperative System (SPARCS) administrative data was used to identify five common laparoscopic general surgery procedures: Cholecystectomy, Colectomy, Esophageal Fundoplication (EF), Roux-en-Y Gastric Bypass (RYGB) and Sleeve gastrectomy (SG) between 2008-2012. SPARCS is a comprehensive data reporting system which collects patient level detail on patient characteristics, diagnoses, treatment, and complications for every hospital charge in the New York State. ICD-9 codes were used to select laparoscopic versus robotic procedures. Patients with missing identification code, age<18 years, patients with multiple procedures in one record, and those with open procedures were excluded. Procedures were compared based on overall complication (yes vs no) and hospital length of stay (HLOS). Following univariate analysis, propensity score analysis was used to estimate the marginal differences between patients who underwent robotic-assisted and laparoscopic procedures. P-values <0.05 were considered significant.

Results:

There were 1458 patients who had undergone robotic assisted surgery and 165332 patients who had undergone laparoscopic surgery among the five procedures between 2008-2012. Of the 1458 robotic cases, 186 were cholecystectomy, 307 were RYGB, 118 were SG, 288 were esophageal fundoplication, and 559 were colectomy. Initial univariate analysis showed a significantly higher rate of overall complications and HLOS in the laparoscopic group compared to the robotic (19.28% versus 16.32%, p=0.0041 and 5.18 versus 3.92 days, p<0.0001). Laparoscopic colectomy had a significantly higher rate of complications and longer length of stay compared to robotic approaches (32.26% versus 22.9% p<0.0001 and 6.76 versus 5.11 days, p<0.001). No difference in complications or HLOS was seen in the cholecystectomy group (20.59% versus 20.43%, p=1 and 4.92 versus 5.7 days, p=0.2371); RYGB group (6.32% versus 4.23%,p=0.1557 and 2.49 versus 2.5 days, p=0.9197); SG group (4.97% versus 4.24%, p=1 and 2.33 versus 2.37 days, p=0.64); EF group (14.87% versus 18.75%, p=0.0887 and 3.35 versus 3.13 days, p=0.3737). Following Propensity Score analysis patients who had undergone robotic-assisted colectomy had significantly lower rate of complications compared to those who underwent conventional laparoscopic procedure (P-value=0.0022). In addition, patients who underwent robotic assisted SG had on average 0.33 days longer HLOS (P-value =0.0037) (Table 1).

Conclusion:

RAS exhibited non-superiority to laparoscopy in common laparoscopic procedures in terms of complications and HLOS. It may, however, present a safe and effective alternative to conventional laparoscopy in colorectal surgery, where penetrance of conventional laparoscopy has not been that prominent and complication rates are high. Robotic approaches may facilitate safer adoption of laparoscopy in these areas.