Robotics In Surgery Is It Worth The Investment?

Robotics In Surgery Is It Worth The Investment?

Robots in Surgery Definition Surgical assisting devices Surgeon-computerinstrument interface Minimally invasive surgery

Da Vinci surgical system NASA Ames research centre - space surgery DARPA battlefield surgery 1994 first robotic operation intestinal anastomosis

Da Vinci surgical system 1994 - Intuitive Surgical 1997 First robotic procedure: cholecystectomy 2000 200 patient trial 2005-350 units sold 2006 70,000 operations done

A matter of cost 1,000,000 initial cost 110,000 maintenance cost per annum Can the benefits of robotic surgery pay for its costs?

Methods Cost benefit analysis Da Vinci For individual surgical procedures Cholecystectomies, adrenalectomies, gastric bypass surgery, cardiac bypass grafting, prostatectomies etc.

Methods Comparison against traditional open surgery and standard minimally invasive surgery Hospital stay, operation time, cost of equipment Pubmed and Google Scholar Nissen fundoplication and Radical retropubic prostatectomy

Results: Initial Costs Item da Vinci system including Surgeon console Surgical cart housing robotic arms 3-D digital camera Installation and testing Endoscopes 0 endoscope 30 endoscope Cost (Euro) 956,550 16,500 16,500 Sony 20 monitor 3,800 Initial purchase cost - 1,031,810 737 per procedure Starter set of multispecialty training instruments 11,815 Starter set of accessories and disposables 16,645 Delivery cost 10,000 TOTAL 1,031,810

Results: Maintenance costs Maintenance costs 110,000 per year 550 per procedure

Theatre, hospital, and convalescence costs Item Surgeons fees* Primary surgeon (1 st year specialist registrar) First assistant (1 st year senior house officer) Anaesthetist fees* (1 st year specialist registrar) Nurses fees Scrub nurse Circulating nurse Cost per hour (Euro) 27.70 17.70 27.70 13.90 13.90 Theatre cost, 100.90 per hour Hospital stay cost, 432 per day Time away from work, 83 per day TOTAL 100.90

Nissen Fundoplication Item (average values) Open method Standard minimally-invasive surgery Robotic surgery Operative time 0.8 hours (50 minutes) 1.0 hours (60 minutes) 1.8 hours (107 minutes) Hospital stay time 6.1 days 2.2 days 2.2 days Convalescence time 35 days 12 days 12 days Disposable equipment costs Not Applicable* 1006 1558 1 Costi, R., Himpens, J., Bruyns, J., Cadiere, G. B.: Robotic Fundoplication: From Theoretic Advantages to Real Problems. J Am Coll Surg. Vol. 197 No.3 Pg. 500-507 Sept 2003 2 Richards, K. F., Fisher K. S., Flores J. H., Christensen B. J.: Laparoscopic Nissen fundoplication: cost, morbidity and outcome compared with open surgery. Surg Laparosc Endosc. Vol. 6 No 2 Pg. 140-143 Apr 1996

Nissen Fundoplication Versus open surgery Shorter hospital stay, shorter time to return to work Longer operating time, cost of disposable equipment, cost of maintenance, cost of initial purchase Cost savings of 647.90 per procedure

Nissen Fundoplication Versus standard minimally invasive surgery No cost benefit Longer operating time, cost of disposable equipment, cost of maintenance, cost of initial purchase Increased cost of 1919.70 per procedure

Radical retropubic prostatectomy Item (average values) Open method Standard minimally-invasive surgery Robotic surgery Operative time 2.7 hours (163 minutes) 4.1 hours (246 minutes) 2.5 hours (148 minutes) Hospital stay time 3.5 days 1.3 days 1.2 days Convalescence time 47 days 47 days 30 days Disposable equipment costs 75 533 1705 1 Lotan, Y., Cadeddu, J. A., Gettman, M. T.: The New Economics of Radical Prostatectomy: Cost Comparison of Open, Laparoscopic and Robot Assisted Techniques. J Urol. Vol. 172 Pg. 1431-1435 Oct 2004 2 Menon, M., Shrivastava, A., Tewari, A.: Laparoscopic Radical Prostatectomy: Conventional and Robotic. J Urol. Vol 66 Pg 101-104. 2005

Radical retropubic prostatectomy Versus open surgery Shorter operating time, shorter hospital stay, shorter time to return to work Cost of disposable equipment, cost of maintenance, cost of initial purchase Cost savings of 492.20 per procedure

Radical retropubic prostatectomy Versus standard minimally invasive surgery Shorter operating time, shorter hospital stay, shorter time to return to work Cost of disposable equipment, cost of maintenance, cost of initial purchase Increased cost of 843.40 per procedure

Discussion Cost effective compared to open surgery Expensive new technology Potential for major improvements

Conclusions Should the CUH buy a da Vinci surgical robot? Probably not advisable Current prices are prohibitive but the technology has tremendous potential