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Robotic Assisted vs. Laparoscopic Cholecystectomy Outcome and cost analysis in a Case-Matched Control Study
Stefan Breitenstein, Antonio Nocito, Carmen Oggier, Markus Weber, Perre-Alain Clavien; Universitiy Hospital Zurich , Zurich , Switzerland

Background: The advantages of robotic assisted surgical procedures, specifically 3D view, magnification and flexibility of the instruments, are well documented. However, pressure is universally applied to decrease costs, leading to restriction of development and implementation of new technologies. So far, neither outcome nor costs of computer assisted versus laparoscopic cholecystectomies have been analyzed. Methods: From September 2004 to August 2005, data from 50 consecutive patients who underwent robotic assisted cholecystectomy (Da Vinci Robot, Intuitive Surgical) was collected. These patients were matched 1:1 to 50 patients with laparoscopic cholecystectomy (operated from 2001 to 2005) according to age, gender, ASA (American Society of Anesthesiology) histology and the experience of the surgeon. Endpoints constituted morbidity, graded according to a new severity classification, operation time, hospital stay and related costs. Results: Both groups were comparable regarding patient characteristics, co-morbidities and histology. One severe complication occurred in each group (2%). In the robotic group a postoperative bile leak of the cystic duct was treated by endoscopic stenting (severity score 3a). In the laparoscopic group a re-operation due to jejunal perforation (severity score 3b) had to be performed. Operation time (skin-to-skin) for robotic assisted cholecystectomy was significantly shorter than for the laparoscopic approach (75’ vs 98’, p<0.001). In contrast, hospital stay was comparable in both groups (2.6d vs 2.8d, p=0.49). Overall hospitalization costs for robotic assisted cholecystectomy were significantly higher compared to the laparoscopic group (€5881 vs. €5181, p<0.001), basically due to amortisation and consumables for the robotic system (€1451 vs. €387). Variable costs generated in the operating theatre, such as medical and nursing time, were significantly lower in the robotic group (€1522 vs. €1745, p=0.01). Fixed and variable costs generated on the ward were comparable in both groups (€2908 vs. €3060, p=0.67). Excluding amortisation and maintenance costs for the robotic system, the overall hospitalisation costs were similar in both groups (€5285 vs. €5181, p=0.45). Conclusions: Robotic assisted cholecystectomy is a safe and therefore valuable approach. Despite the shorter operation time compared to laparoscopic cholecystectomy, purchase costs and maintenance fees clearly and unequivocally render robotic assisted cholecystectomy the more expensive procedure. Therefore a reduction of these acquisition and maintenance costs is a pre-requisite for a large-scale adoption and implementation of this technology in surgery.


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