Index cost comparison of laparoscopic vs robotic surgery in colon and rectal cancer resection: a retrospective financial investigation of surgical methodology innovation at a single institution

Abstract

Background
Robotic assisted colorectal cancer resection (R-CR) has become increasingly commonplace in contrast to traditional laparoscopic cancer resection (L-CR). The aim of this study was to compare the total direct costs of R-CR to that of L-CR and to compare the groups with respect to costs related to LOS.Methods
Patients who underwent colon and/or rectal cancer resection via R-CR or L-CR instrumentation between January 1, 2015 and December 31 2018, at our institution, were evaluated and compared. Primary outcomes were overall cost, supply cost, operating time and cost, postoperative length of stay (LOS), and postoperative LOS cost. Secondary outcomes were readmission within 30 days and mortality during the surgery.ResultsTwo hundred forty R-CR (mean age 64.9 ± 12.4 years) and 258 L-CR (mean age 66.4 ± 15.5 years) patients met the inclusion criteria. There was no significant difference in overall mean direct cost between R-CR and L-CR. The mean supply cost per case was significantly higher for R-CR vs L-CR ($3789 vs $2122, p < 0.001). Operating time was also higher for R-CR than L-CR (224 min vs 187 min, p = 0.066) but LOS was slightly lower (5.08 days vs 5.55 days, p = 0.113).Conclusions
Cost is the main obstacle to easy and widespread use of the platform at this junction, though new developments and competition could very well reduce costs. Supply cost was the main reason for increased costs with robotic resection.

Full text

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Techniques in Coloproctology
https://doi.org/10.1007/s10151-022-02703-z
ORIGINAL ARTICLE
Index cost comparison oflaparoscopic vs robotic surgery incolon
andrectal cancer resection: aretrospective financial investigation
ofsurgical methodology innovation atasingle institution
E.U.Ezeokoli1 · R.Hilli2· H.J.Wasvary2
Received: 25 May 2022 / Accepted: 2 September 2022
© Springer Nature Switzerland AG 2022, corrected publication 2022
Abstract
Background Robotic assisted colorectal cancer resection (R-CR) has become increasingly commonplace in contrast to tra-
ditional laparoscopic cancer resection (L-CR). The aim of this study was to compare the total direct costs of R-CR to that
of L-CR and to compare the groups with respect to costs related to LOS.
Methods Patients who underwent colon and/or rectal cancer resection via R-CR or L-CR instrumentation between January
1, 2015 and December 31 2018, at our institution, were evaluated and compared. Primary outcomes were overall cost, supply
cost, operating time and cost, postoperative length of stay (LOS), and postoperative LOS cost. Secondary outcomes were
readmission within 30days and mortality during the surgery.
Results Two hundred forty R-CR (mean age 64.9 ± 12.4years) and 258 L-CR (mean age 66.4 ± 15.5years) patients met the
inclusion criteria. The overall mean direct cost between R-CR and L-CR was significantly higher ($8756 vs $7776 respec-
tively, p=0.001) as well as the supply cost per case ($3789 vs $2122, p < 0.001). Operating time was also higher for R-CR
than L-CR (224min vs 187min, p = 0.066) but LOS was slightly lower (5.08days vs 5.55days, p = 0.113).
Conclusions Cost is the main obstacle to easy and widespread use of the platform at this junction, though new developments
and competition could very well reduce costs. Supply cost was the main reason for increased costs with robotic resection.
Keywords Robotic· Laparoscopic· Cost· Comparison· Cancer· Resection
Introduction
The advantages of laparoscopic colorectal surgery over open
procedures have been well documented in the in the COLOR
trials [1]. Robotic assisted procedures have become increas-
ingly commonplace and the ease of use with the da Vinci
robot has led to widespread acceptance among multiple sur-
gical specialties. Efforts to improve clinical outcomes have
prompted surgeons to adopt minimally invasive innovations
and this has held true for specialists performing colorectal
operations [2–4].
Studies have shown that robotic-assisted colorectal can-
cer resections (R-CR) have postoperative outcomes and con-
version rates that are comparable to laparoscopic colorectal
cancer resections (L-CR), with longer operative times and
relatively shorter lengths of stay (LOS) [2, 5]. To date, there
is no clear consensus as to the superior surgical approach,
but differences between the cost efficiencies of robotic ver-
sus laparoscopic approaches are commonly debated. Multi-
ple specialties including urology, gynecologic oncology, and
cardiac surgery, have noted higher costs for robotic opera-
tions compared with laparoscopic ones [6–9]. The relatively
few studies in the US literature looking at cost comparisons
between R-CR and L-CR have identified higher robotic costs
with equivalent healthcare outcomes [10, 11]. Many of these
cost studies are limited as to how the costs are defined and
the complexities of what is being charged or reimbursed is
not always well explained [12].
One way to accurately assess actual procedure costs is
to use the measurement of the direct costs attributed to the
operation itself. The primary objective of our study was to
* E. U. Ezeokoli
ekenex@gmail.com
1 Oakland University William Beaumont School ofMedicine,
586 Pioneer Dr., Rochester, MI48309, USA
2 Department ofColorectal Surgery, Beaumont Health
Systems, RoyalOak, MI, USA

Techniques in Coloproctology
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compare the total direct costs of R-CR to that of L-CR. Our
secondary objective was to compare the groups with respect
to costs related to LOS.
Materials andmethods
Patient selection
After institutional review board approval and in accordance
with the 1964 Helsinki Declaration and its later amendments
or comparable ethical standards, a prospectively maintained
database at Royal Oak, William Beaumont Hospital was
retrospectively queried to identify patients who underwent
colon or rectal cancer resection between January 1, 2015
and. December 31, 2018. Patients were excluded if the
procedure was not classified as a laparoscopic or robotic
cancer resection. Other exclusion criteria included
minimally invasive procedures converted to open, and/
or an additional procedure from the index surgery was
required during or after the initial surgery. Of the initial 847
patients, 498 patients met the final inclusion criteria. The
term “costs” for this study refers to the actual variable direct
cost to the institution with each individual patient encounter.
“Costs” were NOT the charges to the payor. The overall
direct variable costs for each patient encounter included
direct variable supply costs (including disposables), other
direct variable costs that included operating room (OR)
costs and costs related to time in the OR, and other accrued
direct costs secondary to the patient’s length of stay (LOS)
postoperatively. In a subset analysis costs related to time
spent in the hospital LOS were also compared. Again, all
costs were actual variable direct costs to the institution and
not charges to the payor. Cost variables were acquired from
the director of financial decision and support at Royal Oak,
William Beaumont Hospital.
Cost data acquisition
Costs represent direct variable costs for the patient
encounter, including overall direct costs, direct variable
supply and disposables cost, and other direct variable costs
including operating room (OR) cost and time, and LOS.
All costs were actual variable direct cost to the institution
and not charges to the payor. Cost variables were acquired
from the director of financial decision and support at our
institution.
Cost definitions
Direct costs are thought to be a more accurate representation
of true costs [13]. For this study, total direct costs are the
sum of the variable expenses directly related to patient care.
Variable direct costs represent incremental costs which
would not have occurred if the surgery was not performed.
These costs vary with patient activity (i.e., medications and
medical tests). Included in these costs are labor wages for
all of the personnel required for patient care of each surgical
patient being treated, supplies (gowns, drapes IV equipment,
etc., including robotic instruments), and drugs. To contrast,
fixed direct costs (which were not evaluated in our study)
represent incremental costs that would still have occurred
even if the surgery was not performed. This includes
ongoing equipment costs (depreciation, maintenance
contracts and repairs), consulting fees, and administrative
costs for both personnel (office manager, secretarial staff,
etc.) and the office supplies/furnishings required to support
this staff. Finally, the total direct costs were a summation
of direct supply costs and the direct cost of operative time.
Both variables were evaluated independent of the total cost
and were compared between R-CR and L-CR. LOS costs
were available for a subset of patients and comparisons were
made as appropriate.
The surgeon’s professional expenses were irrelevant to
this analysis given the institution’s private practice model
and thus these expenses are not part of the OR cost. Capital
investment for both laparoscopic and robotic setups were
not included in our summaries. Indirect costs that were not
directly related to individual patient care were not included
in this study.
Surgical technique
All robotic procedures were performed using the Da Vinci
Xi robotic system (Intuitive Surgical Inc., Sunnyvale,
CA, USA). Laparoscopy was performed with the use of a
laparoscopic tower and the associated equipment that was
supplied by Olympus Corp. Stapling devices included those
supplied by Intuitive, Ethicon and Medtronic as contracted
through Beaumont Health and were used at the discretion
of the individual surgeon. Surgeon variability existed, but
surgical approaches, and the equipment used, were identical
for each surgeon regardless of whether the procedure was
accomplished via a laparoscopic or robotic approach. In
other words, a surgeon who created a pneumoperitoneum
via the Veress needle technique would use this same
technique in both robotic and laparoscopic surgeries. This
remained consistent with respect to their choice of staplers,
electrosurgical equipment, and wound retractors. Variability
with respect to the specifics of each surgery existed among
surgeons with regards to mobilization, isolation of the
vessels, methods of reconstruction, and splenic flexure
takedown, but again, each surgeon maintained an identical
standardized approach for their minimally invasive
procedures. The operating time was recorded from time of
the initial skin incision to the time of skin closure.

Techniques in Coloproctology
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Statistical analysis
Primary outcomes were the overall direct internal
costs from the institution to compare the two surgical
approaches. This included direct OR costs and supply
costs. Secondary outcomes included LOS and 30-day
mortality and unexpected readmissions. Costs related
to LOS were also analyzed. For analysis we used
SPSS Version 25 (IBM Corp., Armonk, NY, USA).
Comparisons between surgical types for these variables
were analyzed using a Student’s t test or a gamma
distribution with a log link for skewed distributions. The
categorical variables were analyzed using a Fisher’s exact
test and the other continuous variables were compared
using a two-sample t test. For all analyses, a p value
of < 0.05 was considered statistically significant.
Results
Demographics
Patient demographics are presented in Table1. Mean age for
R-CR (n = 240) and L-CR (n = 258) was 64.9 ± 12.4years
and 66.4 ± 15.5years, respectively (p = 0.212). Mean BMI
for R-CR and L-CR was 28.8 ± 6.4kg/m2 and 28.0 ± 6.3kg/
m2, respectively (p = 0.151). There was a significant
difference in the sex of the surgery recipients with R-CR 53%
male (127), 47% female (113)) and L-CR (42% male (109),
58% female (149)) (p = 0.020). There was no difference in
race/ethnicity or American Society of Anesthesiologists
(ASA) class (p = 0.250, p = 0.955, respectively). There
was a significant difference in the distribution of surgery
performed between the methodologies with 42% (207) of
the procedures being a hemicolectomy or greater of which
more than half (127) were done laparoscopically (Table2).
Table 1 Demographics
Values reported as n (%) unless otherwise indicated
CR cancer resection, BMI body mass index, ASA American Society of Anaesthesiologists physical status classification, SD standard deviation
Characteristics Robotic CR (n = 240) Laparoscopic CR (n = 258) P value Total (n = 498)
Age, years (mean ± SD) 64.9 ± 12.4 66.4 ± 15.5 0.212 65.7 ± 14.1
Sex Male: 127 (53) Male: 109 (42) 0.020 Male: 236 (47)
Female: 113 (47) Female: 149 (58) Female: 262 (53)
Race/Ethnicity White/Caucasian: 182 (76%) White/Caucasian: 201 (78%) 0.250 White/Caucasian: 383 (77)
Black or African/American: 33
(14)
Black or African/American: 40
(16)
Black or African/American: 73 (15)
Other: 25 (10) Other: 17 (7) Other: 42 (8)
Initial BMI (mean ± SD) 28.8 ± 6.4 28.0 ± 6.3 0.151 28.3 ± 6.3
ASA class I–1 (0.3) I–2 (1) 0.955 I–3 (0.6)
II–69 (29) II–78 (30) II–147 (29)
III–152 (63) III–160 (62) III–312 (63)
IV–17 (7) IV–18 (7) IV–35 (7)
V–1 (0.3) V–0 V–1 (0.2)
Table 2 Surgery performed
Values reported as n (%). Bolded values are statistically significant at 95% confidence
CR cancer resection
Surgery type Robotic CR
(n = 240)
Laparoscopic CR
(n = 258)
p value Total (n = 498)
Hemicolectomy or greater 80 (33) 127 (49) < 0.001 207 (42)
Less than hemicolectomy 73 (30) 85 (33) 158 (31)
Total proctectomy 23 (10) 8 (3) 31 (6)
Partial proctectomy 60 (24) 34 (13) 94 (19)
Proctocolectomy 4 (2) 4 (2), 8 (2)

Techniques in Coloproctology
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Primary outcomes
Cost data are presented in Table3. There was a significant
difference in overall mean direct cost between R-CR and
L-CR ($8756 vs $7776 respectively, p = 0.001). There was a
significant difference in mean supply cost of R-CR vs L-CR
($3793 vs $2107, p < 0.001). However, there was no differ-
ence in the mean OR time direct cost for R-CR compared
to L-CR ($1074 vs $1129, p = 0.931).OR time and hospital
LOS data is presented in Table4. There was no difference
between R-CR and L-CR in mean OR duration (227min vs
187min, p = 0.066), LOS (5.08days vs 5.55days, p = 0.113)
or postoperative LOS cost ($1230 vs $1567, p = 0.156).
Secondary outcomes
There were 27 cases of unplanned readmissions in the entire
cohort (5.4%) (Table5). R-CR had a lower case of unplanned
readmissions (n = 11, 5%) than L-CR (n = 16, 6.2%). In the
entire cohort, there were only four mortalities, with all being
in L-CR cases.
Discussion
Laparoscopic surgery comes with limitations, including
limited range of motion, straight nonarticulated instruments,
and two-dimensional imaging. The introduction of robotic
surgery with improved three-dimensional visualization,
remote center technology, better range of motion with
articulated instruments and improved surgeon ergonomics
has made the practice a mainstay in certain surgical
specialties, in particular gynecology and urology [4, 14].
Use in colorectal cancer resection remains controversial
with little evidence to definitively advocate for it as
opposed to conventional laparoscopy [5]. Along with patient
outcomes, the issue of cost is critically important to hospital
administrators and third party payors. As such, our study
primarily looked to evaluate direct costs to an institution
with healthcare outcomes as a secondary outcome.
We found that our institution’s mean variable direct cost
was higher for R-CR compared to L-CR, with the main fac-
tor being the increased supply cost associated with the robot.
Though not significant, robotic surgery led to decreased LOS
by almost a day, but this was not enough to ameliorate the
overall cost. With this clear increased cost associated with
robotic surgery, it is difficult to see a solid economic ration-
ale in advocating for it over laparoscopic cancer resections.
These findings are in line with the general cost analyses
looking at robotic vs laparoscopic methods across specialties
Table 3 OR cost data
Values reported as mean ± SD. Bolded values are statistically significant at 95% confidence
CR cancer resection, OR operating room, LOS length of stay
Robotic CR (n = 240) Laparoscopic CR
(n = 258)
PTotal (n = 498)
Total direct cost $8756 ± 3694 $7776 ± 4457 0.001 $8247 ± 4133
Supplies direct cost $3793 ± 1794 $2107 ± 1729 < 0.001 $2919 ± 1950
OR time direct cost $1070 ± 378 $1067 ± 421 0.931 $1068 ± 401
Average time per case
(minutes)
227 ± 83 213 ± 91 0.066 219 ± 87
Table 4 Hospital LOS
Values reported as mean ± SD
CR cancer resection, LOS length of stay, OR operating room
**Only 99 robotic cases, and 131 laparoscopic cases, had an
associated post-op LOS. Tabulated figures reflect this
Robotic CR (n = 240) Laparoscopic
CR (n = 258)
P
LOS per case (days) 5.09 ± 4.51 5.55 ± 4.45 0.113
Postoperative LOS
cost per case**
$1230 ± 1927 $1597 ± 2879 0.156
Table 5 Readmission and
mortality within 30days
Values reported as n (%)
CR cancer resection
Robotic CR
(n = 240)
Laparoscopic CR
(n = 258)
P value Total (n = 498)
Not readmitted 229 (95) 242 (93.3) 0.553 471 (94.6)
Unplanned readmission 11 (5) 16 (6.2) 27 (5.4)
Mortality 0 4 (0.7) 0.1245 4 (0.8)

Techniques in Coloproctology
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[6–9, 15], and among the limited colorectal cancer resec-
tion cost-analysis studies. In one of the first cost-analysis
studies of rectal cancer, out of Korea, Baek etal. found
increased robotic resection OR costs compared to laparo-
scopic secondary to increased including labor and supply
costs, along with reduced hospital income [16]. Similarly, 2
studies from Taiwan by Lee etal., one looking at colon and
the other at rectal cancer, found equivalent clinical outcomes
with robotic resections with lower LOS but higher costs [10,
11]. An additional study from Korea in 2015 looking at rec-
tal cancer did not find a significant LOS but again found
increased costs associated with robotic resection [17]. There
was no difference in OR time direct cost between R-CR and
L-CR, though it should be noted that our institution did not
track surgeon or anesthesia expense in these variables and it
only accounts for other direct labor costs in the OR.
We did not find a significant difference between R-CR
vs L-CR in OR time (227min vs 213min) or LOS for
(5.09days vs 5.55days). Previous studies have generally
found R-CR to have longer OR times and shorter LOS [18],
but the findings on LOS have been more variable with many
studies finding no difference [2, 5, 10, 19, 20]. We were able
to isolate the LOS cost post-operatively for only 230 patients
in our cohort, looking for variation. There was no significant
difference for cost postoperatively in our cohort.
The price of a da Vinci Xi is approximately $2.0–$2.5M,
with an estimated annual $200,000 service charge in
addition to the cost of the limited-use instrument arms [21].
Even assuming equivalent operative costs and disregarding
maintenance prices, the cost of robot acquisition and
reusable equipment would have to decrease significantly
to maintain economic efficiency. Per the ROLARR trials
there is little potential for additional clinical improvement
with the robot [5]. These additional costs are therefore
absorbed by the healthcare facility, without any increase
in reimbursement, and any advantage related to reduction
in LOS is still unclear. The financial feasibility of robotic
colorectal surgery requires increased volume, a reduction
in the initial cost and reusable equipment, or increased
competition and wider propagation of this newer technology.
Surgeon preference and convenience are other factors. At
our institution, most surgeons who utilize the robot enjoy the
maneuverability and additional ergonomic comfort during
extended cases. Marketing and hospital reputation regarding
use of cutting edge technology, patient perception of robotic
surgery, and recruitment of talented surgeons are various
factors that may play a role in deciding whether introducing
robotic surgery is worthwhile for a specific health care
system. Surgical volumes prior to and after introduction of
the robot may be changed. At this juncture however, there
is no clear economic benefit for the institution, nor additive
positive clinical outcomes for patients.
There are several limitations to the study. Our study is
based on retrospective data and carries with it the standard
weaknesses inherent to this design, including potential for
selection bias and unmeasured confounding or contributing
effects. We minimized this by setting strict inclusion criteria.
Large multicenter randomized trials are more ideal to
characterize robotic colorectal cancer resection. The hospital
database lacks information on specific training, subspecialty
and experience of surgeons, and volume of surgery by
the specific surgeons involved, which may influence the
operative times and complication rates. Additionally, cost
data were not available for all cases, specifically with post-
operative LOS cost; only 230/498 patients had these values
available for retrieval. We did not evaluate longer term
outcomes and costs such as complications and additional
episode of care costs.
Lastly, there are several hidden costs which were not taken
into consideration for robotic surgery such as personnel
training cost, along with robot repair and maintenance.
These costs were not readily obtainable at our institution.
Our results should be interpreted accordingly.
Conclusions
Cost is the main obstacle for easy and widespread use of
the platform at this junction, though new developments
and competition could very well reduce costs. There was
a significant overall direct cost difference at our institution
especially due to supply cost between the two methodologies
(R-CR vs L-CR. Other institutions may need to take a closer
financial look at this more novel instrumentation before
adopting it as common practice.
Acknowledgements We would like to thank Pamela Bucki, Jason
Hafron MD, Samer Kawak MD, and Michelle Jankowski for assistance
with data acquisition and statistical analysis.
Funding The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Declarations
Conflict of interest The author(s) declared no potential conflicts of in-
terest with respect to the research, authorship, and/or publication of
this article.
Ethical and Informed Consent statement After institutional review
board approval and in accordance with the 1964 Helsinki Declaration
and its later amendments or comparable ethical standards, a prospec-
tively maintained database at Royal Oak, William Beaumont Hospital
was retrospectively queried to identify patients who underwent colon
or rectal cancer resection between January 1, 2015 and. December
31, 2018.

Techniques in Coloproctology
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