Standardization of operative technique in minimally invasive right hepatectomy: improving cost-value relationship through value stream mapping in hepatobiliary surgery

Comparative cost-effectiveness of open, laparoscopic, and robotic liver resection: A systematic review and network meta-analysis

BACKGROUND

This study evaluated the cost-effectiveness of open, laparoscopic, and robotic liver resection.

METHODS

A comprehensive literature review and Bayesian network meta-analysis were conducted. Surface under cumulative ranking area values, mean difference, odds ratio, and 95% credible intervals were calculated for all outcomes. Cluster analysis was performed to determine the most cost-effective clustering approach. Costs-morbidity, costs-mortality, and costs-efficacy were the primary outcomes assessed, with postoperative overall morbidity, mortality, and length of stay associated with total costs for open, laparoscopic, and robotic liver resection.

RESULTS

Laparoscopic liver resection incurred the lowest total costs (laparoscopic liver resection versus open liver resection: mean difference -2,529.84, 95% credible intervals -4,192.69 to -884.83; laparoscopic liver resection versus robotic liver resection: mean difference -3,363.37, 95% credible intervals -5,629.24 to -1,119.38). Open liver resection had the lowest procedural costs but incurred the highest hospitalization costs compared to laparoscopic liver resection and robotic liver resection. Conversely, robotic liver resection had the highest total and procedural costs but the lowest hospitalization costs. Robotic liver resection and laparoscopic liver resection had a significantly reduced length of stay than open liver resection and showed less postoperative morbidity. Laparoscopic liver resection resulted in the lowest readmission and liver-specific complication rates. Laparoscopic liver resection and robotic liver resection demonstrated advantages in costs-morbidity efficiency. While robotic liver resection offered notable benefits in mortality and length of stay, these were balanced against its highest total costs, presenting a nuanced trade-off in the costs-mortality and costs-efficacy analyses.

CONCLUSION

Laparoscopic liver resection represents a more cost-effective option for hepatectomy with superior postoperative outcomes and shorter length of stay than open liver resection. Robotic liver resection, though costlier than laparoscopic liver resection, along with laparoscopic liver resection, consistently exceeds open liver resection in surgical performance.

Counting the cost: financial implications of complications following pancreaticoduodenectomy

BACKGROUND

Morbidity after pancreaticoduodenectomy (PD) has been reported to be about 30-53%. These complications can double hospital costs. We sought to explore the financial implications of complications after PD in a large institutional database.

METHODS

A retrospective analysis of patients undergoing PD from 2010-2017 was performed. Costs for index hospitalization were divided into categories: operating room, postoperative ward, radiology and interventional radiology. Complications were categorized according to the Clavien-Dindo classification. Univariable and mutivariable analysis were performed.

RESULTS

Median cost of index admission for 997 patients who underwent PD was $23,704 (range $10,988-$528,531). Patients with major complications incurred significantly greater median costs compared to those without ($40,005 vs $21,306, p < 0.001). Patients with postoperative pancreatic fistula (POPF) grade A, B and C had progressively increasing costs ($32,164, $50,264 and $102,013, p < 0.001). On multivariable analysis ileus/delayed gastric emptying, respiratory failure, clinically significant POPF, thromboembolic complications, reoperation, duration of surgery >240 minutes and male sex were associated with significantly increased costs.

CONCLUSION

Complications after PD significantly increase hospital costs. This study identifies the major contributors towards increased cost post-PD. Initiatives that focus on prevention of complications could reduce associated costs and ease financial burden on patients and healthcare organizations.

Unravelling the Complexity Myth for Minimally Invasive Right Hepatectomy: Liver Parenchymal Features and their Correlation to Objective Outcomes in Major Anatomical Resections

BACKGROUND

Minimally invasive approaches to major liver resection have been limited by presumed difficulty of the operation. While some concerns arise from mastering the techniques, factors such as tumor size and liver parenchymal features have anecdotally been described as surrogates for operative difficulty. These factors have not been systematically studied for minimally invasive right hepatectomy (MIRH).

METHODS

Seventy-five patients who underwent MIRH during 2007-2016 by the senior author were evaluated; these were compared to control group of open right hepatectomy. Demographics, operative, and post-operative variables were collected. Operative times and estimated blood loss, two objective parameters of operative difficulty were correlated to volume of hepatic resection, parenchymal transection diameter and liver parenchymal features using regression analysis.

RESULTS

Thirty-eight (50.6%) resections were performed for malignant indications. Average tumor size was 5.7 cm (±3.6), mean operative time was 196 min (±74), and mean EBL was 220 mL (±170). Average transection diameter was 10.1 cm (±1.7). There was no correlation between operative difficulty with parenchymal transection diameter or presence of steatosis. Blood loss was higher with increased right hepatic lobe volume and body mass index.

CONCLUSIONS

This analysis of a very defined anatomical resection suggests that the often quoted radiographic and pathologic features indicative of a challenging procedure were not significant in determining operative difficulty.

Economic analysis of open versus laparoscopic versus robotic hepatectomy: a systematic review and meta-analysis

BACKGROUND

Following the publication of reports from landmark international consensuses (Louisville 2008 and Morioka 2014), minimally invasive hepatectomy became widely accepted as a legitimate alternative to open surgery. We aimed to compare the operative, hospitalization, and total economic costs of open (OLR) vs. laparoscopic (LLR) vs. robotic liver resection (RLR).

METHODS

We performed a systematic literature review (end-of-search date: July 3, 2020) according to the PRISMA statement. Random-effects meta-analyses were conducted. Quality assessment was performed with the Cochrane Risk of Bias tool for randomized controlled trials, and the Newcastle-Ottawa Scale for non-randomized studies.

RESULTS

Thirty-eight studies reporting on 3847 patients (1783 OLR; 1674 LLR; 390 RLR) were included. The operative costs of LLR were significantly higher than those of OLR, while subgroup analysis also showed higher operative costs in the LLR group for major hepatectomy, but no statistically significant difference for minor hepatectomy. Hospitalization costs were significantly lower in the LLR group, with subgroup analyses indicating lower costs for LLR in both major and minor hepatectomy series. No statistically significant difference was observed regarding total costs between LLR and OLR both overall and on subgroup analyses in either major or minor hepatectomy series. Meta-analyses showed higher operative, hospitalization, and total costs for RLR vs. LLR, but no statistically significant difference regarding total costs for RLR vs. OLR.

CONCLUSION

LLR's higher operative costs are offset by lower hospitalization costs compared to OLR leading to no statistically significant difference in total costs, while RLR appears to be a more expensive alternative approach.

Computer Vision in the Surgical Operating Room

Background

Multiple types of surgical cameras are used in modern surgical practice and provide a rich visual signal that is used by surgeons to visualize the clinical site and make clinical decisions. This signal can also be used by artificial intelligence (AI) methods to provide support in identifying instruments, structures, or activities both in real-time during procedures and postoperatively for analytics and understanding of surgical processes.

Summary

In this paper, we provide a succinct perspective on the use of AI and especially computer vision to power solutions for the surgical operating room (OR). The synergy between data availability and technical advances in computational power and AI methodology has led to rapid developments in the field and promising advances.

Key Messages

With the increasing availability of surgical video sources and the convergence of technologies around video storage, processing, and understanding, we believe clinical solutions and products leveraging vision are going to become an important component of modern surgical capabilities. However, both technical and clinical challenges remain to be overcome to efficiently make use of vision-based approaches into the clinic.