The First Nationwide Evaluation of Robotic General Surgery – A Regionalized, Small, But Safe Start

Blair A Wormer, MD, Joel F Bradley, MD, Kristopher B Williams, MD, Amanda L Walters, MS, Vedra A Augenstein, MD, Kristian T Dacey, MHA, Brant T Heniford, MD

Carolinas Medical Center

Introduction:
The purpose of this study was to evaluate the most commonly performed robotic-assisted General Surgery (RAGS) procedures in a nationwide database and compare them to their laparoscopic counterparts.

Methods:
The Nationwide Inpatient Sample, which captures approximately 20% of all US inpatient admissions, was queried from October 2008 (the inception of the robotic ICD-9-CM code) to December 2010 for patients undergoing the most common, elective, abdominal RAGS procedures. The two most common, robotic fundoplication (RF) and robotic gastroenterostomy without gastrectomy for bypass (RG), were individually compared to those performed laparoscopically (LF and LG respectively).

Results:
During the study period, 295,155 elective, abdominal, general surgery operations were performed in total, 1680(0.6%) were RAGS. From 2009 to 2010 the incidence of RAGS nearly doubled from 536 to 1039. When evaluating primary procedure codes, the ten most commonly reported elective RAGS procedures were: 1. LG, 2. LF, 3. anterior rectal resection 4. esophagomyotomy, 5. gastric banding, 6. sigmoidectomy, 7. diaphragmatic hernia repair, 8. abdominoperineal resection, 9. loop ileostomy, 10. right hemicolectomy.
LF was performed in 11,556 (97.5%) and RF in 291 (2.5%). When comparing RF to LF, RF patients were more often Caucasian (91% v. 83%; p=0.0097), however there was no difference in age, gender, Charlson Comorbidity Index (CCI), Length of stay (LOS), or postoperative complications which include: infection, ileus, obstruction, thromboembolism, enterotomy, or mortality. Total cost for RF was slightly more than LF ($38,974±23,758 v. $37,4540±50,141; p<0.0001), and it was more often performed in zip codes with median income >$45k (78% v. 52%; p<0.0001), at teaching hospitals (73% v. 59%; p<0.0001), and in urban areas (99% v. 90%; p<0.0001). There was no difference in the proportion of medicare versus private insurance when evaluating RF and LF.
LG was performed in 41,800 (99.3%) and RG in 296 (0.7%). When comparing RG to LG there was no difference in race, age, gender, CCI, postoperative complications, or mortality; however, LOS was somewhat longer in RG (2.6±2.5days v. 2.4±3.0days; p<0.0001). Total cost for RG was substantially more ($62,734±32,480 v. $43,646±50,141; p<0.0001), and it was more often performed in zip codes with median income >$45k (70% v. 50%;p<0.0001), at teaching hospitals (88% v. 51%;p<0.0001), and in urban areas (100% v. 94%;p<0.0001). There was no difference in the proportion of medicare versus private insurance when evaluating RG and LG.

Conclusions:
This first nationwide study of robotic-assisted General Surgery operations exemplifies its low, but increasing incidence across the country. Robotics in General Surgery is regionalized to urban, teaching centers in higher income areas compared to its laparoscopic counterpart. Although the postoperative outcomes for elective robotic and laparoscopic General Surgery are similar, there is an increased cost associated with robotic cases.

Session: Podium Presentation

Program Number: S120