National trends and outcomes of inpatient robotic-assisted versus laparoscopic cholecystectomy

doi:10.1016/j.surg.2020.06.018

Surgery

Volume 168, Issue 4, October 2020, Pages 625-630

Presented at the 15th Annual Academic Surgical Congress in Orlando, Florida, February 2020.

https://doi.org/10.1016/j.surg.2020.06.018 Get rights and content

Abstract

Background

Laparoscopic cholecystectomy has reached nearly universal adoption in the management of gallstone-related disease. With advances in operative technology, robotic-assisted cholecystectomy has been used increasingly in many practices, but few studies have examined the adoption of robotic assistance for inpatient cholecystectomy and the temporal outcomes on a national scale. The present study aimed to identify trends in utilization, as well as outcomes and factors associated with the use of robotic-assisted cholecystectomy.

Methods

The 2008 to 2017 database of the National Inpatient Sample was used to identify patients undergoing inpatient cholecystectomy. Independent predictors of the use of robotic assistance for cholecystectomy were identified using multivariable logistic regression adjusting for patient and hospital characteristics.

Results

Of an estimated 3,193,697 patients undergoing cholecystectomy, 98.7% underwent laparoscopic cholecystectomy and 1.3% robotic-assisted cholecystectomy. Rates of robotic-assisted cholecystectomy increased from 0.02% in 2008 to 3.2% in 2017 (nptrend < .001). Compared with laparoscopic cholecystectomy, patients undergoing robotic-assisted cholecystectomy had a greater burden of comorbidities as measured by the Elixhauser index (2.2 vs 1.9, P < .001). Although mortality rates were similar, robotic-assisted cholecystectomy was associated with greater complication rates (15.5% vs 11.7%, P < .001), most notably gastrointestinal-related complications (3.7% vs 1.5%, P < .001). On multivariable regression, robotic-assisted cholecystectomy was associated with increased costs of hospitalization (β: $2,398, P < .001).

Conclusion

Using the largest national database available, we found a dramatic increase in the use of robotic-assisted cholecystectomy with no difference in mortality or duration of hospital stay, but there was a statistically significant increase in complications and costs. These findings warrant further investigation.

Introduction

Laparoscopic cholecystectomy (LC) has reached nearly universal adoption for the operative management of gallstone disease, gradually replacing open cholecystectomy since its introduction in 1987.¹ Over the past few decades, LC has become the standard of care when technically safe and feasible. Although the patient population undergoing laparoscopic compared with open cholecystectomy is likely different, LC is associated with improved outcomes and decreased costs.²^,³ Similarly, with rapid advances in operative technology and formal education on robotic techniques, robotic-assisted operations are being utilized with increasing frequency in many different fields of surgery.4, 5, 6, 7

Although LC is the most common approach to cholecystectomy, robotic-assisted cholecystectomy (RC) is being taught and performed increasingly, especially at institutions that have access to this technology. Few studies have examined the adoption of inpatient RC and its outcomes on a national scale, while none to date have incorporated time-trend analyses of RC compared with other modalities. The present study aimed to identify trends in usage, outcomes, and factors associated with the selection of RC using a nationally representative sample. We hypothesized similar clinical outcomes between inpatient RC and LC but increased costs with the use of robotic technology.

Section snippets

Data source and study population

Discharge information for all inpatient hospitalizations for cholecystectomy was obtained from the 2008 to 2017 database of the National Inpatient Sample (NIS) using best practices reported by Khera et al.⁸ The NIS is the largest, all-payer inpatient database, sampling 20% of all hospitalizations in the United States. Using validated methodology and survey-weighting algorithms, the NIS provides accurate national estimates for 97% of all US hospitalizations, drawing information from all states

Patient and hospital characteristics

Of an estimated 3,193,697 patients undergoing inpatient cholecystectomy during the study period, 42,018 (1.3%) underwent RC, and 3,146,454 (98.7%) underwent LC. Rates of RC increased from 0.02% of total cases in 2008 to 3.2% in 2017 (nptrend < .001) (Fig 1). There were no important differences in sex (females 66.3% vs 65.1%) or age (53.0 years vs 52.1 years; Table I). Patients undergoing RC, on average, had a somewhat greater burden of comorbidities as measured by the Elixhauser comorbidity

Discussion

In the present study, we analyzed the temporal use of inpatient RC and LC and their in hospital outcomes over a decade. We observed increased adoption of RC, with RC being used in 3.2% of cases by 2017. LC and RC yielded low but similar mortality, while RC was associated with increased overall complications, both of which remained stable throughout the study period. Moreover, the costs of hospitalization were notably greater for RC on both univariate and multivariable analyses. The disparity in

Funding/Support

Dean’s Leadership in Health and Science Scholarship at the David Geffen School of Medicine at UCLA.

Conflict of interest/Disclosure

The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this manuscript.

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National analysis of cost disparities in robotic-assisted versus laparoscopic abdominal operations
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Although the use of robotic-assisted surgery continues to expand, the cost-effectiveness of this platform remains unclear. The present study aimed to compare hospitalization costs and clinical outcomes between robotic-assisted surgery and laparoscopic approaches for major abdominal operations.
All adults receiving minimally invasive gastrectomy, cholecystectomy, colectomy (right, left, transverse, sigmoid), ventral hernia repair, hysterectomy, and abdominoperineal resection were identified in the 2012 to 2019 National Inpatient Sample. Records with concurrent operations were excluded. Multivariable linear and logistic regressions were developed to examine the association of the operative approach with costs, length of stay, and complications. An interaction term between the year and operative approach was used to analyze cost differences over time.
Of an estimated 1,124,450 patients, 75.8% had laparoscopic surgery, and 24.2% had robotic-assisted surgery. Compared to laparoscopic, patients with robotic-assisted operations were younger and more commonly privately insured. The average hospitalization cost for laparoscopic cases was $16,000 ± 14,800 and robotic-assisted cases was $18,300 ± 13,900 (P < .001). Regardless of procedure type, all robotic-assisted operations had higher costs compared to laparoscopic operations. Risk-adjusted trend analysis revealed that the discrepancy in costs between laparoscopic and robotic-assisted surgery persisted and widened over time from $1,600 in 2012 to $2,600 in 2019. Compared to laparoscopic procedures, robotic procedures had a 2.2% reduction in complications (9.4 vs 11.6%, P < .001) and a 0.7-day decrement in the length of stay (95% confidence interval −0.8 to −0.7).
Disparities in costs between robotic and laparoscopic abdominal operations have persisted over time. Given the modest decrement in adverse outcomes, further investigation into the clinical benefits of robotic surgery is warranted to justify its greater costs.
Cost-effectiveness analysis of robotic cholecystectomy in the treatment of benign gallbladder disease
2023, Surgery (United States)
Laparoscopic cholecystectomy is the current standard of care treatment for benign gallbladder disease. Robotic cholecystectomy is another approach for performing cholecystectomy that offers a surgeon better dexterity and visualization. However, robotic cholecystectomy may increase cost without sufficient evidence to suggest an improvement in clinical outcomes. The purpose of this study was to construct a decision tree model to compare cost-effectiveness of laparoscopic cholecystectomy and robotic cholecystectomy.
Complication rates and effectiveness associated with robotic cholecystectomy and laparoscopic cholecystectomy over a 1-year time frame were compared using a decision tree model populated with data from the published literature. Cost was calculated using Medicare data. Effectiveness was represented by quality-adjusted life-years. The primary outcome of the study was incremental cost-effectiveness ratio, which compares the cost per quality-adjusted life-year of the 2 interventions. The willingness-to-pay threshold was set at $100,000/quality-adjusted life-year. Results were confirmed with 1-way, 2-way, and probabilistic sensitivity analyses varying branch-point probabilities.
The studies used in our analysis included 3,498 patients who underwent laparoscopic cholecystectomy, 1,833 patients who underwent robotic cholecystectomy, and 392 patients who required conversion to open cholecystectomy. Laparoscopic cholecystectomy produced 0.9722 quality-adjusted life-years, costing $9,370.06. Robotic cholecystectomy produced an additional 0.0017 quality-adjusted life-years at an additional $3,013.64. These results equate to an incremental cost-effectiveness ratio of $1,795,735.21/quality-adjusted life-year. This exceeds the willingness-to-pay threshold, making laparoscopic cholecystectomy the more cost-effective strategy. Sensitivity analyses did not alter results.
Traditional laparoscopic cholecystectomy is the more cost-effective treatment modality for benign gallbladder disease. At present, robotic cholecystectomy is not able to improve clinical outcomes enough to justify its added cost.
The effectiveness of extremely low-pressure pneumoperitoneum on pain reduction after robot-assisted cholecystectomy
2023, Asian Journal of Surgery
Citation Excerpt :
Especially, the laparoscopic cholecystectomy (LC) has already been established as the standard treatment for benign gallbladder disease. With the introduction of robotic surgery in 2000, some technical limitations in laparoscopic surgery have been overcome, and the proportion of robotic surgery in MIS is gradually increasing.1 Whether robot-assisted or laparoscopic surgery, the first step in MIS is to establish pneumoperitoneum using carbon dioxide to create an adequate working space in the abdominal cavity.
The robot-assisted cholecystectomy could provide a sufficient surgical field with the extremely low-pressure pneumoperitoneum (ELPP; 4 mmHg) by the robot arm lifting the abdominal wall upward. This study aimed to investigate the effect of ELPP on the postoperative outcomes in benign gallbladder disease.
A retrospective study was designed to compare the postoperative pain in addition with operation time, estimated blood loss, length of hospital stay, and complication of three types of cholecystectomy for benign gallbladder disease: 75 ELPP single site robot-assisted cholecystectomy (SSRC), 114 standard-pressure pneumoperitoneum (SPP) SSRC and 110 SPP conventional laparoscopic cholecystectomy (CLC).
There was no difference in whole operation time between ELPP SSRC and SPP SSRC group (p = 0.159). Postoperative pain score was significantly less in ELPP SSRC group as compared to SPP SSRC or SPP CLC group at 6, 12, and 24 h postoperatively (p = 0.004, p = 0.004, and p = 0.013 respectively). The incidence of shoulder pain was also significantly lower in ELPP SSRC group (p < 0.001). The rate of postoperative complication and length of stay were not different among the three groups.
This study shows that ELPP technique using robot is feasible without increasing postoperative complications in the process of cholecystectomy and the use of the ELPP can reduce postoperative pain and shoulder pain compared to the use of the SPP.
Trends in Robot-Assisted Procedures for General Surgery in the Veterans Health Administration
2022, Journal of Surgical Research
Implementation of robot-assisted procedures is growing. Utilization within the country's largest healthcare network, the Veterans Health Administration, is unclear.
A retrospective cohort study using data from the Department of Veterans Affairs Corporate Data Warehouse from January 2015 through December 2019. Trends in robot utilization for cholecystectomy, ventral hernia repair, and inguinal hernia repair were characterized nationally and regionally by Veterans Integrated Services Network. Patients, who underwent laparoscopic repairs for these procedures and open hernia repairs, were included to determine proportion performed robotically.
We identified 119,191 patients, of which 5689 (4.77%) received a robotic operation. The proportion of operations performed robotically increased from 1.49% to 10.55% (7.08-fold change; slope, 2.14% per year; 95% confidence interval [0.79%, 3.49%]). Ventral hernia repair had the largest growth in robotic procedures (1.51% to 13.94%; 9.23-fold change; slope, 2.86% per year; 95% confidence interval [1.04%, 4.68%]). Regions with the largest increase in robotic utilization were primarily along the Northeast, Midwest, and West Coast.
Robot utilization in general surgery is increasing at different rates across the United States in the Veterans Health Administration. Future studies should investigate the regional disparities and drivers of this approach.
Robotic-assisted cholecystectomy: Current status and future application
2022, Laparoscopic, Endoscopic, and Robotic Surgery
Citation Excerpt :
Studies have been performed in adult patients of varying ethnicities and with a range of comorbidities. Indications include symptomatic cholelithiasis, complicated cholelithiasis (acute cholecystitis, choledocholithiasis, gallstone pancreatitis), biliary dyskinesia, biliary sludge, gallbladder polyps, and cholangitis.2,6,7,12,15–19 Similar contraindications for both techniques include patients with previous major upper abdominal surgery or multiple previous abdominal operations, as the presence of adhesions may limit completion via a minimally invasive modality.2,6,7,12,15–19
Robotic-assisted cholecystectomy (RC) is increasingly common. However, its exact role remains undefined, with multiport conventional laparoscopic cholecystectomy (LC) being regarded as the established gold standard. This review aims to provide an overview of the evidence for RC and to define its current and future role. A literature search was performed on the PubMed and Medline databases to identify relevant articles published between 1994 and February 2022. The evidence obtained was summarised in a narrative style. Greater emphasis was placed on recent 10-year articles and studies of higher methodological quality. RC is noninferior to LC. The robotic platform facilitates the application of minimally invasive surgery in a way conventional laparoscopy cannot. LC remains appropriate for the majority of patients requiring cholecystectomy. The advantages of RC include inherent technical benefits, facilitating the learning of new surgical technology and its potential to reduce the risk of open conversion and bile leakage in certain populations (Mirizzi syndrome, complicated calculous disease, chronic liver disease and possibly malignancy). It also has increasing applicability to related biliary surgery. The limitations include cost, loss of tactile feedback and the learning curve associated with initial implementation. Future applications of robotic surgical systems include utilisation in difficult cholecystectomy, cases of biliary malignancy, telerobotic surgery and telementoring.
Continued Relevance of Minimum Volume Standards for Elective Esophagectomy: A National Perspective
2022, Annals of Thoracic Surgery
Despite minimum volume recommendations, the majority of esophagectomies are performed at centers with fewer than 20 annual cases. The present study examined the impact of institutional esophagectomy volume on in-hospital mortality, complications, and resource use after esophageal resection.
The 2010-2018 Nationwide Readmissions Database was queried to identify all adult patients undergoing esophagectomy for malignancy. Hospitals were categorized as a high-volume hospital (HVH) if performing at least 20 esophagectomies annually and as a low-volume hospital (LVH) if performing fewer than 20 esophagectomies annually. Multivariable models were developed to study the impact of volume on outcomes of interest, which included in-hospital mortality, complications, duration of hospitalization, inflation adjusted costs, readmissions, and nonhome discharge.
Of an estimated 23,176 hospitalizations, 45.6% occurred at HVHs. Incidence of esophagectomy increased significantly along with median institutional caseload over the study period, while the proportion on hospitals considered HVHs remained steady at approximately 7.4%. After adjusting for relevant patient and hospital characteristics, HVH status was associated with decreased mortality (AOR, 0.65), length of stay (β = -1.83), pneumonia (AOR, 0.69), prolonged ventilation (AOR, 0.50), sepsis (AOR, 0.80), and tracheostomy (AOR, 0.66) but increased odds of nonhome discharge (AOR, 1.56; all P < .01), with LVH status as reference.
Many clinical outcomes of esophagectomy are improved with no increment in costs when performed at centers with an annual caseload of at least 20, as recommended by patient advocacy organizations. These findings suggest that centralization of esophageal resections to high-volume centers may be congruent with value-based care models.

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Bile Duct/GallbladderPresented at the Academic Surgical Congress 2020National trends and outcomes of inpatient robotic-assisted versus laparoscopic cholecystectomy

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Data source and study population

Patient and hospital characteristics

Discussion

Funding/Support

Conflict of interest/Disclosure

Am J Surg

J Gastrointest Surg

J Surg Res

Am J Surg

Twenty years of laparoscopic cholecystectomy: Philippe Mouret-March 17, 1987

J Soc Laparoendosc Surg

Multivariate comparison of complications after laparoscopic cholecystectomy and open cholecystectomy

Ann Surg

First human surgery with a novel single-port robotic system: cholecystectomy using the da Vinci Single-Site platform

Surg Endosc

Robotic-assisted versus laparoscopic cholecystectomy

Ann Surg

Adherence to methodological standards in research using the National Inpatient Sample

JAMA

Healthcare Cost and Utilization Project (HCUP). NIS description of data elements; 2018

Comorbidity measures for use with administrative data

Med Care

Bile Duct/Gallbladder
Presented at the Academic Surgical Congress 2020
National trends and outcomes of inpatient robotic-assisted versus laparoscopic cholecystectomy