An early laparoscopic Whipple for Dr. Kendrick also took approximately 10 hours, "but within 20-30 cases, it was down to 4 or 5 hours, sometimes 6," he said. "There’s a lower average operative time for laparoscopic Whipple ... but [in the end], is that really an important factor if the patient still gains the benefits of [the minimally invasive surgery]?"
Gynecologic Surgery
In gynecologic oncology, where robotic surgery in recent years has been rapidly embraced as a tool for performing minimally invasive endometrial cancer staging, operating time and cost are factors in an "ongoing debate in over whether robotics provides an advantage over laparoscopy for lymph node dissection," said Dr. James E. Delmore, director of gynecologic oncology for the University of Kansas, Wichita.
At least a half-dozen studies have found that robotic-assisted hysterectomy and lymphadenectomy for endometrial cancer results in significantly shorter hospital stays as well as fewer wound infections and postoperative complications compared with an open approach, according to Dr. Delmore, who has served as a proctor for Intuitive. However, fewer studies have compared all three approaches (robotic assisted, traditional laparoscopy, and open).
"It’s hard to determine and analyze procedure costs in many hospital systems," he said. But "from what we can tell thus far, purely laparoscopic hysterectomy with removal of the lymph nodes is the least expensive approach, followed by robotics and then abdominal."
Such cost differentials were demonstrated in a study comparing the outcomes and cost of endometrial cancer staging performed via traditional laparotomy, standard laparoscopy, and robotic techniques. Dr. Maria C. Bell performed all of the procedures (40 robotic, 40 laparotomy, and 30 laparoscopic) at the Sanford Clinic in Sioux Falls, S.D.
Robotic hysterectomy took about an hour longer to perform than did hysterectomy completed via laparotomy (with no significant difference in operating time, compared with pure laparoscopy), but resulted in the lowest complication rate of the three approaches and the shortest average return to normal activity. Estimated blood loss and average length of stay were both significantly reduced for the robotic cohort, compared with laparotomy, and were comparable to laparoscopy. There were no differences in lymph node retrieval among the three groups (Gyn. Oncol. 2008;111:407-11).
When both direct and indirect costs were considered (including a measure by the Lewin Group of "societal/productivity" costs and the cost of the robot on a 5-year amortization schedule), the total average costs for hysterectomy with staging were $12,943 with laparotomy, $7,569 for standard laparoscopy, and $8,212 for robotic assistance.
The overall decreased cost for robotic surgery was unexpected and could be a result of money "invested up front [being] recouped by less time rounding ... and less time taking care of complications," as well as lower societal costs, wrote Dr. Bell, also of the University of South Dakota, Vermillion.
"I was very surprised that laparotomy was the most costly to the hospital," Dr. Bell said in an interview. (One of the coauthors of the report, Usha Seshadri-Kreaden, is employed by Intuitive, and Dr. Bell is a proctor for Intuitive, but the company did not sponsor the study.)
Other investigators who have compared robotic-assisted and conventional laparoscopic hysterectomies have reported higher per-case hospital costs with the robot. With hysterectomy having surpassed prostatectomy in 2010 as the highest-volume procedure for the da Vinci Surgical System, according to its manufacturer, the value of robotics for routine hysterectomy may well be increasingly scrutinized.
The da Vinci is used to treat more than 90% of endometrial cancer patients at Dr. Bell’s and Dr. Delmore’s institutions, but both surgeons are quick to emphasize the need for more data on outcomes and cost-effectiveness. "The temptation of ‘the patient wants it, so we need to offer it’ needs to be tempered with the question ‘are we making progress doing it?’ " said Dr. Delmore.
Training Needs
Institutions are individually grappling with how best to train residents in robotic-assisted surgery. The University of Kansas model includes an online tutorial, training with inanimate objects, animal lab training, and bedside assistance in real robotic-assisted hysterectomies. Dr. Delmore and his colleagues have a study underway to look at how graduate ob.gyns. use this training.
Within the realm of hepatobiliary and pancreatic surgery, where a minimally invasive approach is younger and where training models for the open Whipple procedure are still deliberated, "there is a dramatic appetite for minimally invasive skills," Dr. Kendrick said. HBP fellows at the Mayo Clinic currently are exposed to minimally invasive surgery, but "our goal over the next 2 years is to incorporate an even more significant focus" on robotics and laparoscopy, he said.