outcomes following laparoscopic or robotic assisted ......robotic ventral hernia surgery is safe and...
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Outcomes Following Laparoscopic or Robotic Assisted Ventral Hernia Surgery
Aakash Dheri, Richard Harth, David Marr, Darren Mensch, Pharm D Candidates1,
Clark Gerhart MD2, Marie Roke-Thomas, PhD1
1Wilkes University, Nesbitt School of Pharmacy, 2 Surgical Specialists, Pennsylvania, USA
Objective
Robotic ventral hernia surgery is safe and effective with a significant decrease in recurrence rates and conversion to an open procedure, p<.05. The operative time in the Robotic surgery was significantly longer, p < .05, due to the addition of primary closure which was not used in the laparoscopic technique. Length of stay, complications and pain medication after surgery were lower in the robotic procedure, but not significant p > .05. Potential savings in the Robotic surgery is due to the ability to decrease mesh size with primary closure. Additional benefits are expected as our experience as the number of robotic surgeries increase.
Background
The introduction of minimally invasive surgical techniques for hernia
repair has been shown to be an effective means of preventing post-
surgical complications, smaller and fewer incisions when compared to
open general surgery techniques for the repair of hernias.1 Laparoscopic
surgery requires trans-abdominal sutures and tackers, which is often the
cause of post-operative pain. However, the novel robotic single site
incision procedure uses intracorporeal suturing of the mesh directly to the
fascial edge, bypassing the sutures and tackers associated with pain in
traditional therapy.2 Robotic instrumentation has been developed to allow
the surgery to be performed with greater dexterity due to the wrist action
articulation of the robotic arms in comparison to the rigid trocar used in
traditional laparoscopic surgery. Reports have suggested that robotic
instrumentation allows procedures to be performed with similar
advantages while reducing complications associated with traditional
laparoscopic procedures.3
Method
IRB approval was obtained. 111 patients who underwent daVinci® robotic
surgery and 116 laparoscopic ventral hernia patients were chosen as
subjects. All procedures were performed at the same acute care hospital
and by the same operative surgeon. Patients were excluded from the
study if they had multiple procedures, such as concomitant
appendectomy, gynecological procedures or cholecystectomy, so
comparisons could be made between hernia procedures alone without
factors that may alter surgical time, length of stay, or complication rates.
Patient medical records at both the hospital and surgical practice were
reviewed by medical record number. Information was collected on age,
gender, BMI, anesthesia time, procedure time, complications, discharge
time, etc., and pain medication given in the recovery room. All pain
medication doses were converted to doses of morphine for a true
comparison. Discharge time is time from the end of procedure to discharge.
Results
Robotic (N=111)
Robotic % Lap
(116) Lap % P Value
GENDER
Female 78 70.27 91 78.48 0.078
Male 34 30.63 23 19.82
ASA SCORE
Mild 52 46.84 58 50
0.411 (overall)
Severe 60 54.05 56 48.27
TYPE OF HERNIA
Incisional
Initial 68/95 71.57 86/110 78.18
*Incisional 0.03
Ventral Primary 0.02
Recurrent 27/95 28.42 24/110 21.81
Primary ventral
Initial 16/16 100 6/6 100
Recurrent 0 0 0 0
CONCOMITANT PROCEDURES Yes 36 32.43 45 38.79 0.294
Patient Baseline Characteristics
Cost of Ventral Hernia Repairs
C.Gerhart, WB General Hospital
* The two groups difference both in the number of incisional hernias, as well as the number of ventral primary hernias
Results Continued
Cost Analysis
Primary Outcomes
Variables
Robotic (N=111)
Lap (N=116)
P value
OPERATIVE TIME (min) 92.15± 53.19 60.38±47.85 <0.0001*
BLOOD LOSS (ml) 25.0 (minimal) 25.0 (minimal) --
HOSPITAL STAY (hours) 17.7± 40.29 22.3± 51.7 0.437
REOPERATIONS 6 (5.4%) 7 (6.03%) 0.256
CONVERSIONS 1 (<1%) 7 (6.03%) 0.035*
READMISSIONS 6 (5.4%) 9 (7.76%) 0.297
Variables Robotic (N=111)
Robotic %
Lap (N=116)
Lap % P-value
POSTOPERATIVE COMPLICATION (DISCHARGE
TO 30 DAYS) 2 1.8 4 3.4 0.695
PAIN MEDICATION USE PRIOR TO DISCHARGE
88
79.2
96
82.7
0.372
Primary Safety Outcomes
Surgery Years No. of cases aged 2 years since surgery
0-6 months
6-12
months
13-18 months
19-24 months
Total # of cases recurred up to
24months
% Recurrence
P-value
Lap
2010-2012
61 2 2 2 3 9 14.75 0.038
Robotic
2011-2012
70 2 1
3
4.28
The following cases were chosen based on availability of recurrence data for up to two years following surgical repair.
Recurrences
1. Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M.
Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. Cochrane Database of Systematic Reviews. 2011;(3):1-59.
2. Schluender S, Conrad J, Divino CM, Gurland B. Robot-assisted laparoscopic repair of ventral hernia with intracorporeal suturing. Surg Endosc. 2003 Jun;17:1391-95.
3. Pietrabissa A, Sbrana F, Morelli, Badessi F, Pugliese L, Vinci A, Klersy C, Spinoglio G. Overcoming the challenges of single-incision cholecystectomy with robotic single-site technology. Arch Surg. 2012 Aug; 147(8):709-714.
References
Avg. Size Cost/ cm2 Total Cost
Laparoscopic
286.4 cm2 $4.1 $1,174
Robotic
147.5 cm2 $4.1 $605
Savings
$569
Avg. Size Cost/ cm2 Total Cost
Laparoscopic
286.4 cm2 $4.1 $1,174
Robotic
147.5 cm2 $4.1 $605
Savings
$569
da Vinci 8 mm
da Vinci 5 mm
Lap
Mesh (assume equal) n/a n/a n/a
Fixation (Suture or tackers ) $60
Suture $60
Suture $565 - 1
$1130 - 2
Drapes $200 $200 $0
Trocars (x3 or 4) $80 $80 $150
Hot Shears $340 $0 $0
Harmonic $0 $0 $480
Monopolar or lap tray $0 $0 $120
5 mm Monopolar $0 $227 $0
Needle Driver (2) $440 $400 $0
Total (w/ out mesh) $1,120 $967 $1,315-$1,880
Conclusion
To perform a single-institution, single-investigator, retrospective,
comparative study to evaluate the safety and performance of the da Vinci
S/Si Surgical System for use in robotic-assisted ventral hernia repair,
compared to laparoscopic approach. Comparative variables included
operative time, blood loss, length of hospital stay, re-admissions, intra-
operative complications, postoperative complications, recurrence rates
and pain medication prior to discharge.