Value Added Care: Improving Quality with Decreased Costs in Robotic Assisted Colorectal Surgery

Abstract

Diseases of the colon and rectum, such as diverticulitis or cancer, are increasing and occurring in younger populations. Although robotic assisted surgery can be more expensive for the index operation, robotic assisted colorectal surgery decreases length of stay, need for narcotics, and the amount of time needed off work for recovery. Robotic surgery also introduces new opportunities for simulation training which allows developing surgeons to improve their technique without risk to a live patient. These benefits contribute to decreased healthcare costs for the system as a whole as well as mitigate downstream effects on the economy due to loss of productivity and tax revenue. Robotic assisted surgery also facilitates video-based mentorship. Video mentorship can be used to improve surgical care and health equity nationally and internationally. Robotic surgery may also provide future opportunities for integration of CT scans into the operative field or artificial intelligence to improve surgeon performance and accuracy.

1. Introduction

The term “Robot” is defined in Merriam-Webster Dictionary as “a machine that resembles a living creature in being capable of moving independently and performing complex actions”. According to the modern definition, “robotic surgery” would seem to suggest that the technology functions autonomously, which is not accurate. “Robotic surgery” is the term typically referring to the Da Vinci surgical platform used today in various surgical procedures. It would more precisely be described using the term “telepresence”, meaning “transporting one’s awareness to a different location” [1].

Robotic surgery first originated in 1985 with a device called PUMA used to position a stereotactic brain biopsy needle while reducing surgeon tremor and increasing precision. This device evolved into other similar devices used for procedures such as transurethral resection of the prostate, hip replacements, and percutaneous kidney biopsies. The current iteration of robotic surgery began as a Department of Defense and NASA initiative to allow surgeons to begin a life-saving operation while the patient was still being transported from a hostile or unsafe environment with the intention of military use on the battlefield. The first prototype in 1986, called “telepresence surgical system”, which initially targeted microsurgery, evolved over time to address laparoscopy and laparoscopic-specific issues including reducing fulcrum effect, tremor, improving dexterity, and stereoscopic vision. After training simulation and animal model testing, Intuitive Surgical acquired the intellectual property in 1995. Intuitive developed their next generation, da Vinci, and began human trials in 1998. Meanwhile, the first FDA-approved robotic surgical system developed by Computer Motion comprised of a voice-controlled laparoscope. In 2003, after several years of further developments including robotic arms, table positioning, and interchangeable instruments, Computer Motion merged with Intuitive Surgical. Since then, there have been several significant improvements and many new generations of the platform, allowing adoption by multiple surgical specialties. Today, there are more than 5000 da Vinci systems around the world and over 6 million procedures performed, with general surgical procedures being the most widespread application [1]. As the United States performs 70.6% of robotic surgeries globally, the majority of this discussion will involve robotic surgery in the United States [2].

In the United States, more than 600,000 colon surgeries are performed annually [3]. Colorectal cancer is the third most common cancer in men and women, the third most common cancer cause of death, and the most common cancer cause of death for men under the age of 50 [4]. For patients with inflammatory bowel disease, 80% of patients with Crohn’s disease and 30% of ulcerative colitis will require surgery in their lifetime [5]. As colorectal surgeries involve narrow working spaces like the bony pelvis and intricate dissections around vital structures, robotic surgery has been increasing utilized in order to apply advancing technology while maintaining a minimally invasive approach with its proven patient benefits [6].

2. Patient outcomes

The expanding adoption of robotic surgery in the colorectal field has led to increased research into patient outcomes. Many recent studies focusing on short-term outcomes of robotic surgeries are similar or even superior compared to open or laparoscopic approaches. The Robotic versus Laparoscopic Resection for Rectal Cancer (ROLARR) study was the largest international randomized control trial that compared the safety, efficacy, and short- and long-term outcomes of robotic colorectal procedures compared with conventional laparoscopy, and found no statistically significant difference in conversion rates to open laparotomy, circumferential resection margins, mesorectal resection quality, postoperative complications within 30 days, and quality of life on month 6 after operation. Meta-analyses from cohort and case-control studies on the use of robotics in rectal cancer resection suggests benefits in terms of all-cause mortality, surgical site infection, intraoperative blood loss, time to oral diet, postoperative return of gastrointestinal function, preservation of a functional anus, and urinary and sexual function [7].

Urologic and sexual function after surgery is an important area unique to colorectal surgery and not addressed in most studies. Up to 80% of men and 60% of women experience voiding and sexual dysfunction after rectal surgery. Some studies have shown faster recovery to normal urogenital function in robotic compared to laparoscopic groups, however, the ROLARR trial and other large-scale retrospective studies found no significant difference [6].

The benefits of robotic surgery for outcomes after cancer surgery are nuanced. When compared to laparoscopic surgery, robotic surgery has similar margin positivity rates, disease free survival, and overall survival for colon cancer. Robotic surgery has been shown to increase the number of lymph nodes harvested for all areas of the colon and rectum as well as improve radial resection margins in rectal cancer [7]. Conversely, advantages in this patient population were demonstrated in short-term outcomes such as shorter hospital stay and faster return of bowel function [8].

A proposed reason behind these benefits in short-term outcomes is related to decreased post-operative pain. A randomized study by Tolstrup et al. [9] comparing post-operative pain after robotic versus laparoscopic rectal cancer resection found that opioid consumption was significantly lower after robotic surgery compared to the laparoscopic group [10].

While there are many studies that demonstrate patient outcomes with robotic surgery, fewer studies explore patient perceptions and satisfaction. Existing literature reviews have found the majority of patient experiences were positive and patients were satisfied overall. Many perceived the new technology as better, felt that robotic surgery indicated a more technically skilled surgeon, and would recommend robotic surgery to others. Patients who were dissatisfied felt their length of stay shorter than expected [9, 11, 12, 13]. Patients were also more likely to be satisfied and comfortable with a robotic approach if they received preoperative education on the role of the robot during surgery and the maintained participation of the surgeon during their procedure [11, 12]. As patient satisfaction becomes increasingly important for hospital economics and reimbursements, setting appropriate expectations and educating patients on the role of technology during their operation is integral to improve this quality metric.

3. Surgeon outcomes

In a survey of almost 4000 surgeons by the American College of Surgeons in 2020, 13% of surgeons under 60 years of age were considering leaving surgery with only a 51% job satisfaction rate among them [14]. The top three reasons for leaving surgery were overall stress (79%), work time demands (77%), and personal time requirements (73%). With increasing life expectancy of the twenty-first century, there is a predicted shortage of almost 30,000 surgeons by the year 2030 [15]. Attenuating the loss of the surgical work force now will have downstream effects on impending physician shortages. Robotic surgery has the potential to improve job performance for surgeons by decreasing necessary personnel, improving ergonomics with a decrease in hand tremor, and options for decrease in musculoskeletal sequelae of traditional open and laparoscopic methods.

Robotic assisted surgery (RAS) has been shown to have higher task complexity for surgeons when compared to surgical techs and circulating nurses, a potential function of the physical space created by the surgeon console [16]. Aspects such as closed loop communication and situational awareness require more effort when the surgeon is sitting at the console with their head positioned into the eyepieces speaking through a microphone as opposed to standing a few feet away from their surgical scrub. Surgeon control of instruments from the console allows fewer personnel at bedside, potentially lowering healthcare costs in the face of healthcare worker shortage. On the Da Vinci Xi^®, the surgeon essentially doubles his working arms from the traditional two used in laparoscopy to four. There is no longer the need for an assistant to hold the camera or hold a retraction arm as the surgeon, who is the most highly trained person in the operation, can control both the camera and retraction arm while maintaining control of two working arms [8].

Another improvement in surgeon efficiency during robotic versus open and laparoscopic surgery are the ergonomics. The console allows for adjustment tailored to an individual’s body, leaving the variance to wrist motion, which is essentially constant throughout variations in human proportions, as opposed to hand size and height, which vary by surgeon. Physiologic degrees of freedom in the wrist including flexion-extension, radioulnar deviation, and rotation are mimicked in robotic instruments and even improved. When compared to the natural range of motion on the surgeon, the robotic instruments have 7 degrees of freedom and allow for 180 degrees of articulation and 540 degrees of rotation [8]. When observing participants with no surgical training, Prasad et al. found they were 2.5 and 7 times more accurate in moderate and fine motor skills, respectively, when compared to laparoscopic performance (P < 0.001) [17]. They also noted an equalized performance for dominant and non-dominant hands. In laparoscopic and open surgery, longer instruments act as a fulcrum between a surgeon’s hand and the operative field, which serves to amplify tremor. The robot console eliminates this tremor, potentially an explanation for improved functional outcomes after pelvic surgery, such as sexual and bladder function [8].

Work-related musculoskeletal disorders range from 60 to 90% of surgeons based on specialty [18]. Pain from surgical practice also plays a role in less recognized phenomena such as quality of life and burnout which can trigger early retirement and surgeon shortages [19, 20, 21]. In general, it is recommended to maintain neutral positions of the neck and spine in both open and minimally invasive surgery. However, according to Stucky et al., laparoscopic surgeons are three to five times more likely to experience neck and shoulder pain than surgeons performing open procedures [22]. Using instruments that require less movement of the wrist in its physiologic degrees of freedom are recommended, leading to more time spent in awkward positions to accomplish challenging operative tasks. There are also limitations for surgeons with smaller hand sizes as most instruments are designed for glove sizes 6.5 and above and require the table to be lowered to pubic bone level as opposed to elbow level as in open surgery [18]. With the adjustable console and handpieces, these differences in size are eliminated. The height discrepancies between surgical team members to maintain an angle no greater than 30 degrees between eye level and the laparoscopic monitor for favorable neck positioning is also eliminated by having the surgeon at the robot console [23]. Hokenstad et al. have developed an extensive guide to setting up the surgeon console for optimal positioning from angle of neck and back flexion to differences in forehead placement to avoid headaches [24]. Although guides such as this exist, there is concern that training residents and medical students are not exposed to the importance of ergonomics and solutions for “awkward” postures. In a survey sent by the ACGME in 2019, only 1.5% of program directors reported a formal ergonomics curriculum, serving as a missed opportunity to improve potentially detrimental behaviors early in careers and avoid lifelong musculoskeletal pain and early retirement [25].

4. Training/learning curve

The American Board of Surgery, which is the accrediting body responsible for certifying surgeons in the United States, recommends that all trainees have knowledge of robotic surgery, however there is no standardized robotics curriculum and no requirement for robotic cases exists for board eligibility [26]. Although the Board has added the option on the case logging system to declare a case as robotic, the CPT code used for billing and tracking is the same as its laparoscopic counterpart. With the extensive simulation training options and improved ergonomics of robotic surgery, there is a reported shorter learning curve. Studies report a curve of 30–100 cases for laparoscopic surgery vs. 15–44 cases for robotic surgery [8]. For rectal surgery specifically, operative time to perform a total mesorectal excision was significantly reduced within the first 20 robotic cases for surgeons who previously performed the procedure open [27].

In a review of experienced surgeon opinion as they observed robotic case content, Green et al. noted that robotic surgery depends more on visual assessment. This is due to the lack of tactile feedback with an emphasis on risk avoidance [28]. When teaching residents, their surgeons employed strategies such as dual console and simulation with communication of visual information to be the mainstay of teaching. Cope et al. comment on this as a surgical “sensory semiosis” constructed from visual and haptic clues and replacing traditional tactile feedback [29]. While the loss of tactile feedback is often listed as a weakness of the robotic approach, early robotic assisted surgery models developed MIT and Stanford under the original Department of Defense and NASA grant found that surgeons performed with higher accuracy using 3D visualization as opposed to haptic feedback available on earlier robotic prototypes [1]. Despite the differences in sensory feedback between robotic and open surgery, surgeon discussion emphasized the importance of appropriate exposure and tension, themes common to traditional open and laparoscopic surgery as well.

As previously stated, risk avoidance is particularly important in the surgical teaching environment. In order to standardize an approach specific to robotic surgery, Kalipershad and Peristerakis developed a safety protocol with an emphasis on clear communication, situational awareness and role clarity, with the goal of reducing errors in a high-pressured environment. The protocol has two main areas of concentration, the first of which being on human factor simulation training with operative team members. The second area is a step by step plan for “emergency undocking” which would be triggered by the operative surgeon and lead to a cascade of events for patient safety and efficient conversion to open [30].

An interesting trend in training for RAS is the discrepancies in teaching by gender. In a study by Foley et al. comparing console participation time per case, they found that male attending surgeons provided female trainees less console participation than male counterparts (52.1% vs. 59.7%) while female attending surgeons provided same amount of time [31]. When looking specifically at total mesorectal excision, male trainees performed more complete procedures than their female counterparts (57% vs. 42%) [31]. By allowing objective data collection, robotic surgery can also be a tool to support equitable training environments for an increasingly diverse surgical work force.

Simulation is an important part of robotic surgery training for not only residents and medical students but practicing attendings who want to adopt robotic assisted surgery into their practice. While systematic reviews have identified the value of simulation and virtual reality training in laparoscopic skill improvement, little has been proven in robotic skills [32, 33, 34]. Available simulation models include the Fundamentals of Robotic Surgery physical Dome, the da Vinci Simulation System (DVSS), and the dV-Trainer. When comparing performance on these training devices to a control group, all groups significantly improved their performance [35]. Some centers are recommending a “virtual reality warm-up” prior to starting robotic cases [36, 37]. When testing both residents and experienced MIS surgeons improvements were shown in task time, cognitive errors, and intra-corporeal suturing after a 3–5 minute simulator warm up [37].

A concern for the decreased need of bedside assistance during robotic surgery is the loss of medical student involvement. Stimulating medical student interest in the field of surgery is another mechanism to combat the impending surgeon shortage. Specific concerns involve physical separation from the operating attending/resident affecting engagement with the case and the monotony of “just watching” instead of physically participating in the surgery. When surveying fourth year medical students at the Medical College of Wisconsin, Higgins and O’Sullivan found that the visual and audio observation actually enhanced their learning. They were able to hear surgeons more effectively with the microphone feature of the robot and they could follow the case progression on an adjustable screen. Unfortunately, the medical students in the study generally found the robotic surgery learning environment to be demotivating [38]. It is hard to separate if these feelings are specific to the robotic surgery learning environment or generalized recognized themes among medical students such as the lack of self-determination, with no ability to develop their autonomy, motivation through skill competence, or regular communication with the attending surgeon [39].

5. Economic considerations

The introduction of new technology does introduce new costs. Although robotic surgery has existed since 2000, for much of this time period the Intuitive DaVinci system has been the only FDA approved platform in the United States [26]. Although Intuitive has continued to develop new instruments with an increased number of uses and a lease type arrangement, the initial startup cost of a robotic surgery system can still be cost prohibitive for smaller hospitals or low- and middle-income countries [2]. Although Intuitive has maintained substantial market share, the patents for the DaVinci system expired in 2016 which should introduce more competition with a subsequent decrease in cost [40]. When compared to laparoscopic surgery, robotic surgery does have an increased cost for the strict operating room costs for performing an operation by approximately $1–3 thousand dollars [41]. However, healthcare costs are not strictly operating room costs. While many operations are attempted in a minimally invasive fashion, whether laparoscopic or robotic, many operations are converted to a larger open laparotomy incision for a variety of reasons. The conversion to an open surgery is significantly lower for robotic than laparoscopic surgery with a shorter length of inpatient stay [42]. When comparing the cost of a robotic colorectal surgery operation to a laparoscopic surgery converted to an open operation, the cost of the robotic surgery is lower [6]. Across all payers in the United States, 1 day of an inpatient stay costs approximately $1000 [43]. Shorter lengths of stay would increase a hospital system’s ability to admit more patients and generate higher revenues for the system as a whole as well as offset the increase in the original cost of a robotic operation versus a laparoscopic operation. Early discharges, defined as less than or equal to 3 days after a minimally invasive operation are also associated with a decreased risk of post-discharge complications which are another driver of overall increased healthcare expenditure [44]. Hospital cost increases from surgical complications can range anywhere from $3000 to over $100,000 depending on the severity and nature of the complication [45].

As many robotic instruments have a finite number of uses, unlike open instruments which can mostly be sterilized and reused indefinitely, accuracy of documentation and charge capture is increasingly important for cost containment. In newly established robotic programs, error rates of 60% when logging robotic items can occur. By implementing improved peer education, barcode systems, and improved item descriptions, error rates can be decreased by 75% which increases the ability to bill for robotic items. The Intuitive system also directly captures which instruments have been utilized. Although these logs cannot be used directly for billing purposes, they can be compared to operating room documentation as an objective measure of team accuracy and performance [46].

A major limitation of the literature reviewing costs of robotic surgery is variability in the surgeon learning curve. For the treatment of colorectal cancer, robotic technology has been preferentially adopted by high inpatient volume hospitals, teaching hospitals, and has had a quicker rise for treatment of rectal cancer than colon cancer [47]. Higher utilization of robotic surgery is also associated with a higher number of general surgeons, higher hospital density within a service area, higher average income, and a lower proportion of uninsured patients [48]. A major critique of RAS is the increased operating time, which is associated with increased length of stay and more frequent complications in colorectal surgery patients, regardless of the surgical approach [49]. However, when evaluating fellowship trained colorectal surgeons from 2015 to 2019, Johns et al. found that the total cost of hospitalization was 25% greater for the laparoscopic group and the robotic surgeries were shorter in duration than the laparoscopic operations [41]. Looking specifically at abdominoperineal resection for rectal cancer, which involves removing the entire rectum and anus, Gorgun et al. found no difference in overall costs and decreased operative times for the robotic surgeries compared to the laparoscopic surgeries [50].

Cost containment can also occur at the operating room management level by addressing staffing assignments. When applying the NASA task load index to staff within an operating room during a robotic operation, Walters et al. [51] identified that key steps of the operation required highly time dependent effort and physical demands. These key times included room setup, start of the operation, patient preparation for surgery, registered nurse documentation and management of surgical specimens, moving patients at the end of the procedure, and room cleanup. In order to minimize the demands on the more highly paid members of the team, the group recommended that registered nurses do not participate in bedside scrubbing for procedures and identified opportunities to engage non-licensed support staff. Effective use of non-licensed support staff enables more cost-effective staffing models [51].

Changes in disease processes and outcomes also have downstream effects on healthcare costs and patient income. The most common disease processes of the colon and rectum are associated with obesity, a condition which has been steadily increasing throughout the United States [52]. Obesity introduces a new set of surgical challenges, including increased conversion to open and diminished volume of space to operate in a minimally invasive fashion. Robotic surgery has been preferentially applied to pelvic surgery in obese men and been associated with decreased conversion to open, decreased sexual and autonomic dysfunction, and early decrease in associated urinary symptoms [53]. Other oncologic outcomes that are improved in robotic surgery include higher lymph node harvests [7] and improved radial resection margins in rectal cancer [54]. For patients with a complete tumor resection but a lymph node harvest lower than 12, many recommendations include adjuvant chemotherapy, which adds costs for port placement and administration of chemotherapy medications, which often include intravenous infusions, monitoring, and frequent laboratory evaluations. Additionally, male obese patients historically have higher positive radial margins and lower lymph node harvests for rectal cancer. The technological improvements in robotic surgery help mitigate those differences and save downstream costs for this vulnerable patient population [55].

The most common indications for colon resection, diverticulosis and colon cancer, are also occurring in increasingly younger patient populations [56]. Disease processes that typically occurred in ages 50 or above have shifted to those younger than 50. In this population, patients are more likely to be building their careers and have dependent children under the age of 18 living at home [57]. Disruptions in career and potential ability to support a dependent family are more of a personal financial burden for these patients, a cost and quality metric which is not often accounted for in healthcare cost literature. Robotic surgery is not only associated with a shorter length of stay in the hospital but is also associated with a faster return to work by approximately 4 days [58]. This quicker return to work mitigates individual economic stressors for patients.

Another currently theoretical benefit of the improved ergonomics of robotic surgery is career longevity of surgeons. As previously mentioned, the United States is predicted to have a deficit of 23,000 general surgeons by the year 2032. The shortage is due to multiple effects such as surgeon retirement during the COVID-19 pandemic and decreased interest in surgery by medical school graduates [59]. Resident training is also funded by Medicare, which spent $4.5 billion in 2020 for resident education [60]. As physician education is a significant usage of taxpayer dollars, improvements in surgeon longevity not only addresses the impending physician shortage but also improves the return on investment of government spending on physician training.

6. Future directions

Despite the lack of long-term outcomes data, robotic surgery continues to grow in the field of colorectal surgery. The FDA has recently approved the Senhance and Versius systems which will introduce competition into the market, as well as new configurations and features that may offset some of the critiques of the Intuitive systems, such as a closed design that separates the surgeon from the operating team. Although remote surgery was the original intention by the Department of Defense, current remote applications are limited to proctoring which can improve healthcare equity by reducing barriers to training and mentorship. Application of robotic assisted surgery to endoscopy may enable lower insufflation pressures with lower risk of perforation as well as the ability to remove larger tumors without the need for a formal operation. Integration of artificial intelligence (AI) may also enable new tools to improve operative times and accuracy. 3D rendering of CT scan findings may also be rendered onto operative images to facilitate identification of pathology [10].

7. Conclusion

Despite criticism of cost and lack of long-term data, robotic assisted surgery has become an integral part of colorectal surgery. From a health outcomes side, robotic colorectal surgery is associated with decreased pain, decreased length of stay, decreased risk of surgical site infections, increased lymph node harvest for cancer, improved resection margins for obese men with rectal cancer, improved urinary and sexual function, and an expedited return to work. For surgeons, robotic surgery allows for improved ergonomics accommodating a wider variety of body types and potentially a longer career. Robotic systems also enable objective collection of data during surgeries that facilitates systematic approaches to managing necessary services with fewer resources. For surgeons who are less experienced with minimally invasive surgery, robotics allows for quicker adaptation of a minimally invasive approach with fewer conversions to open. For surgeons with fellowship training, robotic colorectal surgery can be performed faster than laparoscopic surgery with lower overall hospitalization costs. When used correctly, robotic assisted surgery adds value for patients, hospital systems, and surgeons.