Robotic Cholecystectomy in Acute Care Surgery—More Money, Less Problems?

Author(s):
Kirollos Malek; Joshua Farnsworth; Xian Luo-Owen; Jeffrey Quigley; Daniel Srikureja; Kaushik Mukherjee

Background:

Robotic techniques have the potential for improved visualization and improved instrument control.  We sought to determine if utilizing robotic techniques could reduce the rate of conversion for cholecystectomy (CCY), with concomitant decrease in length of stay and complications.

Hypothesis:

We hypothesized that using robotic surgery would result in increased operative cost but decrease the rate of conversion to open CCY.

Methods:

We reviewed a prospectively collected Acute Care Surgery registry at a large (>500 bed) adult university hospital over 18 months.  Cases from three surgeons with privileges for open, laparoscopic, and robotic cases were included.  Operative technique (laparoscopic versus robotic) could not be randomized as trained robotic personnel are available only on weekdays.  We collected data on demographics, indication for surgery, nutritional status, comorbidities, OR time, postoperative complications, length of stay, and operating room costs.  We analyzed our data in SPSS 22 (IBM Inc., Armonk NY) and utilized Student’s T test and Chi-Square analysis.  We also performed a linear regression analysis to determine the effect of OR time, robotic surgery, diagnosis, age, ASA score, and body mass index on operating room costs and postoperative length of stay.

Results:

120 laparoscopic and 28 robotic CCY were performed.  Demographic parameters (age, gender, medical comorbidities, preoperative albumin and BMI, surgical history and smoking) were comparable.  Primary diagnosis was significantly different (Chi-square 0.02), driven by more acute cholecystitis in the laparoscopic group.  0/28 robotic cases and 7/120 (5.8%, p = 0.348 by Fisher’s exact test) laparoscopic cases were converted to open (4 for adhesions and 3 for visualization of anatomy).  There was no difference in the incidence of postoperative complications.    Operative time was similar (146±49 min [robot]vs. 127±74 min [lap], p = 0.101).  Postoperative length of stay was 2.1 days in both groups.  Robotic procedures had higher unadjusted OR costs ($3979±$1333 vs. $2484±$1282, p < 0.001).  After multivariable analysis, robotic surgery was associated with a $1131 increase in costs [95%CI $723, $1540, p < 0.001]; OR time and BMI were also associated with increased cost.  ASA score and BMI were associated with increased postoperative length of stay.

Conclusions:

Robotic CCY can be safely performed on an ACS service with minimal risk of conversion, although a larger study would be required to determine if robotic CCY independently reduces the risk of conversion.  Further study to optimize the cost efficiency of robotic surgery may be beneficial.