Robotic approach together with an enhanced recovery programme improve the perioperative outcomes for complex hepatectomy

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.

From morbidity reduction to cost-effectiveness: Enhanced recovery after surgery (ERAS) society recommendations in minimal invasive liver surgery

PURPOSE

Minimal-invasive liver surgery (MILS) reduces surgical trauma and is associated with fewer postoperative complications. To amplify these benefits, perioperative multimodal concepts like Enhanced Recovery after Surgery (ERAS), can play a crucial role. We aimed to evaluate the cost-effectiveness for MILS in an ERAS program, considering the necessary additional workforce and associated expenses.

METHODS

A prospective observational study comparing surgical approach in patients within an ERAS program compared to standard care from 2018-2022 at the Charité - Universitätsmedizin Berlin. Cost data were provided by the medical controlling office. ERAS items were applied according to the ERAS society recommendations.

RESULTS

537 patients underwent liver surgery (46% laparoscopic, 26% robotic assisted, 28% open surgery) and 487 were managed by the ERAS protocol. Implementation of ERAS reduced overall postoperative complications in the MILS group (18% vs. 32%, p = 0.048). Complications greater than Clavien-Dindo grade II incurred the highest costs (€ 31,093) compared to minor (€ 17,510) and no complications (€13,893; p < 0.001). In the event of major complications, profit margins were reduced by a median of € 6,640.

CONCLUSIONS

Embracing the ERAS society recommendations in liver surgery leads to a significant reduction of complications. This outcome justifies the higher cost associated with a well-structured ERAS protocol, as it effectively offsets the expenses of complications.

Comparative study of operative expenses: robotic vs. laparoscopic vs. open liver resections at a university hospital in the UK

Robotic liver resections (RLR) are increasingly being performed and has previously been considered more costly. The aim is to explore the cost of RLR compared with laparoscopic and open liver resection in a single National Health Service (NHS) hospital. A retrospective review of patients who underwent RLR, LLR, and OLR from April 2014 to December 2022 was conducted. The primary outcomes were the cost of consumables and median income, and the secondary outcomes were the overall length of stay and mortality at 90 days. Overall, 332 patients underwent liver resections. There were 204 males (61.4%) and 128 females (38.6%), with a median age of 62 years (IQR: 51-77 years). Of these, 60 patients (18.1%) underwent RLR, 21 patients (6.3%) underwent LLR, and 251 patients (75.6%) underwent OLR. Median consumables cost per case was £3863 (IQR: £3458-£5061) for RLR, £4326 (IQR: £4273-£4473) for LLR, and £4,084 (IQR: £3799-£5549) for the OLR cohort (p = 0.140). Median income per case was £7999 (IQR: £4509-£10,777) for RLR, £7497 (IQR: £2407-£14,576) for LLR, and £7493 (IQR: £2542-£14,121) for OLR. The median length of stay (LOS) for RLR was 3 days (IQR: 2-4.7 days) compared to 5 days for LLR (IQR: 4.5-7 days) and 6 days for OLR (IQR: 5-8 days, p < 0.001). Within the NHS, RLR has consumable costs comparable to OLR and LLR. It is also linked with a shorter LOS and generates similar income for patients undergoing OLR and LLR.