robotics in hernia repair - another fad and way too expensive

The Robot in Hernia Repair-another fad and way too expensive

Andrew S. Wright MDUniversity of Washington

@andrewswright

Disclosures

None

Experience

UW Biorobotics Lab

• RAVEN Surgical Robot

• Telerobotics

• NASA/Military application

Clinical Robotics Experience

• 70+ robotic cases (primarily foregut)

Experience

UW Biorobotics Lab

• RAVEN Surgical Robot

• Telerobotics

• NASA/Military application

Clinical Robotics Experience

• 70+ robotic cases (primarily foregut)

• Quit using robot due to lack of benefit/increased OR time/increased cost

Experience

Director, UW Medicine Hernia Center

• 80+ Inguinal hernia/yr– 80% TEP

– 10% TAPP

– 10% Open

• 60+ Incisional/Ventral/yr– 50% lap

– 50% open AWR

• 2 partners who do robot-assisted TAPP/umbilical/IPOM

Defining Value

Value = OutcomesCost

Defining Value


Value to whom?

• Patient (pain/recurrence/return to work)

• Surgeon (ergonomics/marketing/reimbursement)

• Hospital (marketing/cost/income)

• Insurer (cost)

• Health Care System (cost/outcomes)

What’s wrong with lap inguinal?

What’s wrong with open inguinal?

What are Downsides to Robot?


• Lack of haptics/tissue feel



• Need for bedside assist

• ? Need for 3rd arm/extra port

• Lack of adequate instruments



• Need for bedside assist

• ? Need for 3rd arm/extra port

• Lack of adequate instruments

• Learning Curve

Possible Benefits of Robot

• Visualization

• Stable platform

• Dexterity

Possible Benefits of Robot

• Visualization

• Stable platform

• Dexterity

• Cool factor

• Marketing

• Practice expansion

Where is the Evidence for Robot Inguinals?

What about robot incisional/TAR/AWR?

• Cool videos!


• Cool videos!

• No Data

Cautionary Tale


• Cool videos!

• No Data

• Possible overuse of TAR

– Lot of videos of roboTAR for 6-8cm defects

What about lap incisional/TAR/AWR?

• Possible lap too! From Igor Belyansky

What about costs?

• OR Times– Lap Inguinal

• 127 mixed lap inguinal hernia, 6 surgeons• Case time 96±38 (min 27, max 188)• Room time 127±39 (min 57, max 213)

– Robot Inguinal• 44 mixed robot inguinal hernia, 2 surgeons• Case time 82±22 (min 50, max 143)• Room time 114±21 (min 77, max 173)

What about costs?

• OR Times– Lap Inguinal

• 127 mixed lap inguinal hernia, 6 surgeons• Case time 96±38 (min 27, max 188)• Room time 127±39 (min 57, max 213)

– Robot Inguinal• 44 mixed robot inguinal hernia, 2 surgeons• Case time 82±22 (min 50, max 143)• Room time 114±21 (min 77, max 173)

• Contribution to Margin– $2400 less per case– Exclusive of cost of robot

What about cost of robot?

• Accounting basis

– 5-year lease, $2 Million

– Amortized at $51/case

• Cost allocated to entire department

What about cost of robot?

• Accounting basis

– 5-year lease, $2 Million

– Amortized at $51/case

• Cost allocated to entire department

– Amortize only to robot cases

• $1042/case

What about cost of robots?

• Only 25% cases done w/ robot

– To get to 100% would need to lease 2 additional machines

What about cost of robots?

• Only 25% cases done w/ robot

– To get to 100% would need to lease 2 additional machines

– $167k/month

What about societal cost?

• 37 Hospitals in WA state with robot

– Pullman Regional 25 beds


• 37 Hospitals in WA state with robot

– Pullman Regional 25 beds

• 40 robots = $80 million


750k inguinal hernia repairs annually (US)

60 robot cases/month/robot

$30k/month/robot


750k inguinal hernia repairs annually (US)

60 robot cases/month/robot

$30k/month/robot

$375 Million/year

Is there value in robot hernia repair?


Patient – no evidence

Surgeon – maybe

Hospital – probably not




Surgeon – maybe


Insurance Companies – nope




Surgeon – maybe


Insurance Companies – nope

Health Care System/Society – Hell no!

Robotic Hernia Repair Cannot Be Sustained

Twitter: @andrewswrightEmail: [email protected]

robotics in hernia repair - another fad and way too expensive

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