Cost-Benefit Performance Simulation of Robot-Assisted Thoracic Surgery As Required for Financial Viability under the 2016 Revised Reimbursement Paradigm of the Japanese National Health Insurance System

Development of a robot-assisted thoracic surgery (RATS) program. Lessons learned after 2500 cases

Robotic surgery provides significant advantages in terms of an optimal three-dimensional and magnified view of the surgical field, superior maneuverability of surgical instruments, removal of surgeon's tremor and excellent ergonomics. Nonetheless, the adoption of this technology in thoracic surgery has been slower than in other specialties such as urology, gynecology or digestive surgery. In this article we describe our institution's experience in robotic-assisted thoracic surgery (RATS) in the span from 2012 to 2020. During this time the average annual growth of the program has been 55%. Among the most frequently procedures performed were lobectomies, wedge resection and segmentectomies. Surgical time and length of stay decreased as the number of procedures performed increased, relative to the learning curve. Additional important elements considered relevant to the success of the program are the resources available, leadership, motivation of the surgical team, adequate and stepwise training, as well as the collection of data for periodic analysis of results. All those initiatives have led to a relevant improvement of financial variables reflecting a cost reduction.

Proposed training pathway with initial experience to set up robotic hepatobiliary and pancreatic service

Although robot-assisted hepatobiliary and pancreatic (HPB) surgery has gained momentum over the last 2 decades, only a handful of units in the world perform major robotic resections. Adaptation of robotic surgery in the UK lags behind its European counterparts and this is mainly because of cost implications in a publicly funded National Health Service (NHS). We describe our experience of setting up a robotic HPB programme with clinical outcomes and propose a training pathway that would help prospective centres in setting up their own robotic HPB service with robust clinical governance oversight. After gaining colleagues' and departmental support, approval from the hospital clinical governance, finance department and new intervention procedure committee was sought. A team of two consultant surgeons, three assistants and three theatre staff went through a structured training programme sponsored mainly by the industry. Surgeon training consisted of online modules, simulation, wet lab, cadaveric training, case observations, proctored procedures followed by independent practice. All major cases were recorded and videos reviewed to improve performance. A total of 111 procedures were successfully completed with robotic assistance between April 2018 and March 2020. The programme started with robot-assisted cholecystectomy as index procedure and progressed on to more complex liver and pancreatic resections including major hepatectomy and Whipple's procedure. The training pathway followed by our team has been effective in setting up a safe robotic HPB programme and could be considered as a roadmap to start new Robotic HPB services.

Robotic-assisted repair of complex ventral hernia: can it pay off?

Pressure on health care providers is growing due to capping of remuneration for medical services in most Western European countries. We wanted to investigate, if robotic-assisted ventral hernia repair is reasonable from an economic point of view in our setting. Patients undergoing open or robotic-assisted repair for complex abdominal wall hernia using a Transversus Abdominis Release (TAR) between September 2017 and January 2019 were included. Procedure-related costs were calculated exact to the minute and cost unit accounting for the postoperative in-patient stay was done. Abdominal wall reconstruction using the TAR-technique was done in a total of 26 (10 female) patients via an open (n = 10) or robotic-assisted (n = 16) approach. No significant difference was seen in regard to age, BMI and ASA scores between subgroups. Time for operation was longer (253.5 vs 211.5 min; p = 0.0322), while postoperative hospital stay was shorter for patients operated with a robotic-assisted approach (4.5 vs 12.5 days; p < 0.005). Procedure-related costs were 2.7-fold higher when a robotic-assisted reconstruction was done (EUR 5397 vs. 1989), while total costs for in-patient stay were about 60% lower (EUR 2715 vs 6663). Currently, revenues by national insurance account for a total of EUR 9577 leading to a profit of EUR 1465 and 925 for the robotic-assisted and open myofascial release, respectively. In addition, 30-day re-admission rate was in favor of the robotic-assisted approach as well (6.3% vs 20%). From an economic point of view, robotic-assisted TAR for complex ventral hernia repair is a viable option in our setting. Higher procedure-related costs are offset by a significant shorter hospital stay. The economic advantage goes along with improvement in outcome of patients.

Current status of robot-assisted thoracoscopic surgery for lung cancer

The robotic surgical system was designed to overcome the drawbacks of conventional endoscopic surgery. Since national health insurance in Japan began covering robotic-assisted thoracoscopic surgery (RATS) for malignant lung and mediastinal tumors in 2018, the number of RATS procedures being performed domestically has increased rapidly. This review evaluates the advantages and disadvantages of RATS for patients with lung cancers, based on an electronic literature search of PubMed. The main advantages of RATS are its ability to achieve excellent lymph-node removal with low morbidity and mortality, and minimal postoperative pain. Conversely, its disadvantages include a long operation time and the need for specialized instruments. However, the learning curve for RATS is reported to be shorter than that for VATS: some studies recommend that a surgeon needs to perform 18-22 robotic operations to attain sufficient skill. RATS for lung cancer is more expensive than VATS and the cost of training is high. Although the main disadvantage of RATS is that it reduces operator's tactile senses, the endoscope, which is directly manipulated by the surgeon at the console, using various magnifications, and 3D HD images on the monitor, may compensate for this. Ultimately, RATS offers better maneuverability, accuracy, and stability over VATS.