Robotics In Surgery

Is It Worth The Investment?

Robots in Surgery
• Definition
• Surgical assisting
devices
• Surgeon-computer-
instrument 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 Cost (Euro)

da Vinci™ system including 956,550

• Initial
•
•
Surgeon console
Surgical cart housing robotic arms purchase
• 3-D digital camera
• Installation and testing cost -
€1,031,810
Endoscopes 16,500
•
•
0° endoscope
30° endoscope
16,500 • €737 per
procedure
Sony 20’ monitor 3,800

Starter set of multispecialty training 11,815

instruments

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

TOTAL 100.90
 Nissen Fundoplication
Item (average values) Open method Standard minimally-invasive Robotic surgery
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 Robotic surgery
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