Robotic Colectomy Safe but Expensive

By Will Boggs MD

November 07, 2019

NEW YORK (Reuters Health) - Robotic colectomy appears to be only minimally safer than open colectomy (but not laparoscopic colectomy) and is more costly than the other two alternatives, but its use continues to increase, according to new research.

"The most surprising finding here is the replacement of laparoscopic surgery by robotic surgery, especially in centers with high rates of robotic adoption," Dr. Kyle H. Sheetz of the University of Michigan, in Ann Arbor, told Reuters Health by email. "This challenges a common narrative that robotic surgery allows more people to do more minimally invasive surgery."

Advocates for expanding the use of robotics claim that the technology makes common operations safer and more efficacious, and that it increases access to minimally invasive surgery - especially among surgeons and hospitals that have previously favored the open surgical approach.

Dr. Sheetz's team used data from more than 191,000 Medicare patients who underwent robotic colectomy (n=23,022), laparoscopic colectomy (n=80,631), or open colectomy (n=87,639) to evaluate perioperative outcomes and trends in the use of these approaches.

Overall, patients' ages, sex distribution and race were qualitatively similar across all surgical approaches, the researchers report in JAMA Surgery, online October 16. But patients undergoing robotic surgery were slightly more likely to have no documented comorbidities, compared with the other two approaches.

Hospitals performed a higher median annual volume of open surgery than laparoscopic or robotic colectomy, and patients undergoing robotic colectomy were more likely to do so in a hospital with fewer than 250 beds or at a non-teaching hospital.

In conventional risk-adjustment analyses, overall complication rates were significantly lower with robotic colectomy (13.8%) than with open surgery (18.1%). The difference was somewhat attenuated in instrumental variable analysis (17.6% vs. 18.6%), which found the robotic approach to be associated with significantly fewer medical complications and more surgical complications than open surgery.

The incidence of complications was significantly higher with robotic colectomy (10.9%) than with laparoscopic colectomy (10.2%) in conventional risk-adjustment analysis, but not in instrumental variable analysis (11.1% vs. 11.0%).

Hospital length of stay averaged 1.5 days shorter for robotic surgery than for open surgery, but there was no significant difference between robotic and laparoscopic surgery.

The use of robotic colectomy increased from 0.7% of patients in 2010 to 10.9% of patients in 2016.

At hospitals that did not perform robotic colectomy, the use of laparoscopic colectomy increased from 40.7% in 2010 to 45.9% in 2016 while the use of open colectomy declined from 59.3% to 55.1%.

In contrast, at hospitals in the highest quartile of robotic-surgery adoption, increasing use of robotic colectomy was associated with greater decreases in the use of laparoscopic colectomy than of open colectomy.

"Recognizing the substantial added cost of robotic surgery (25% higher and up to $3,000 more expensive than laparoscopic colectomy), these findings also question the relative benefits of robotic colectomy, in that outcomes are only modestly better than open surgery, and robotic procedures primarily replaced laparoscopic operations with equivalent outcomes," the researchers note.

"Based on our results showing comparable outcomes to other more established approaches, it does not appear that robotic surgery is worth the added costs," Dr. Sheetz said.

"New surgical technologies should be carefully evaluated before they fully diffuse into practice," he said. "This study highlights several important considerations when interpreting surgical comparative effectiveness research. Trials in surgery tend to include highly selected patients and surgeons, limiting generalizability. Observational studies are limited by selection bias. The econometric methods we use for this study allowed us to include a wide range of surgeons and patients, but also address selection bias from both measured and unmeasured differences between patients receiving each surgical approach. Therefore, these results reflect the real-world outcomes of robotic surgery."

"Robotic colectomy and laparoscopic colectomy show competitive results in which robotics may provide the same value but at higher costs," write Dr. Wouter J. Born and Dr. Marja A. Boermeester of Amsterdam University Medical Centers in a linked commentary. "Open surgery is still reserved for particularly difficult cases."


JAMA Surg 2019.