Top

Surgical Endoscopy

Published in:

01-06-2023 | Laparoscopy

Economic evaluation of robotic and laparoscopic paraesophageal hernia repair

Authors: Neal S. Panse, Vishnu Prasath, Patrick L. Quinn, Ravi J. Chokshi

Published in: Surgical Endoscopy | Issue 9/2023

Abstract

Background

Robotic approach in paraesophageal hernia (PEH) repair may improve outcomes over laparoscopic approach, though at additional cost. This study aimed to compare cost-effectiveness of robotic and laparoscopic PEH repair.

Methods

A decision tree was created analyzing cost-effectiveness of robotic and laparoscopic PEH repair. Costs were obtained from 2021 Medicare data and were accumulated within 60 months after surgery. Effectiveness was measured in quality-adjusted life-years (QALYs). Branch-point probabilities and costs of robotic surgery consumables were obtained from published literature. The primary outcome of interest was incremental cost-effectiveness ratio (ICER). One-way, two-way, and probabilistic sensitivity analyses were performed. A secondary analysis including attributable capital and maintenance costs of robotic surgery was conducted as well.

Results

Laparoscopic repair yielded 3.660 QALYs at $35,843.82. Robotic repair yielded 3.661 QALYs at $36,342.57, with an ICER of $779,488.62/QALY. Robotic repair was favored when rates of open conversion and symptom recurrence were low, or with reduced cost of robotic instruments. A probabilistic sensitivity analysis favored laparoscopic repair in 100% of simulations. When accounting for costs of robotic technology, robotic approach was preferred only in unrealistic clinical scenarios.

Conclusions

Laparoscopic repair is likely more cost-effective for most institutions, though results were relatively similar. With experienced surgeons who surpass the initial learning curve, robotic surgery may improve outcomes enough to be cost-effective, but only when excluding capital and maintenance fees.

Antiporda M, Veenstra B, Jackson C, Kandel P, Daniel Smith C, Bowers SP (2017) Laparoscopic repair of giant paraesophageal hernia: are there factors associated with anatomic recurrence? Surg Endosc. https://doi.org/10.1007/s00464-017-5770-zCrossRefPubMed

Karmali S, McFadden S, Mitchell P, Graham A, Debru E, Gelfand G, Graham J, Martin S, Tiruta C, Grondin S (2008) Primary laparoscopic and open repair of paraesophageal hernias: a comparison of short-term outcomes. Dis Esophagus. https://doi.org/10.1111/j.1442-2050.2007.00740.xCrossRefPubMed

Mungo B, Molena D, Stem M, Feinberg RL, Lidor AO (2014) Thirty-day outcomes of paraesophageal hernia repair using the NSQIP database: should laparoscopy be the standard of care? J Am Coll Surg. https://doi.org/10.1016/j.jamcollsurg.2014.02.030CrossRefPubMed

Nguyen NT, Christie C, Masoomi H, Matin T, Laugenour K, Hohmann S (2011) Utilization and outcomes of laparoscopic versus open paraesophageal hernia repair. Am Surg. https://doi.org/10.1177/000313481107701018CrossRefPubMed

Jutric Z, Louie BE (2013) Laparoscopic paraesophageal hernia repair. Surg Laparosc Endosc Percutan Tech. https://doi.org/10.1097/SLE.0b013e3182a12666CrossRefPubMed

Lara FJP, Zubizarreta Jimenez R, Moya Donoso FJ, Hernández Gonzalez JM, Prieto-Puga Arjona T, Del Rey MA, Pitarch Martinez M (2021) Preoperative calculation of angles of vision and working area in laparoscopic surgery to treat a giant hiatal hernia. World J Gastrointest Surg. https://doi.org/10.4240/wjgs.v13.i12.1638CrossRefPubMedPubMedCentral

Leal Ghezzi T, Campos Corleta O (2016) 30 Years of robotic surgery. World J Surg. https://doi.org/10.1007/s00268-016-3543-9CrossRefPubMed

Pernar LIM, Robertson FC, Tavakkoli A, Sheu EG, Brooks DC, Smink DS (2017) An appraisal of the learning curve in robotic general surgery. Surg Endosc. https://doi.org/10.1007/s00464-017-5520-2CrossRefPubMed

Esposito C, Autorino G, Castagnetti M, Cerulo M, Coppola V, Cardone R, Esposito G, Borgogni R, Escolino M (2021) Robotics and future technical developments in pediatric urology. Semin Pediatr Surg. https://doi.org/10.1016/j.sempedsurg.2021.151082CrossRefPubMed

10.

Gerull WD, Cho D, Arefanian S, Kushner BS, Awad MM (2020) Favorable peri-operative outcomes observed in paraesophageal hernia repair with robotic approach. Surg Endosc. https://doi.org/10.1007/s00464-020-07700-7CrossRefPubMed

11.

Soliman BG, Nguyen DT, Chan EY, Chihara RK, Meisenbach LM, Graviss EA, Kim MP (2019) Robot-assisted hiatal hernia repair demonstrates favorable short-term outcomes compared to laparoscopic hiatal hernia repair. Surg Endosc. https://doi.org/10.1007/s00464-019-07055-8CrossRefPubMed

12.

Hosein S, Carlson T, Flores L, Armijo PR, Oleynikov D (2020) Minimally invasive approach to hiatal hernia repair is superior to open, even in the emergent setting: a large national database analysis. Surg Endosc. https://doi.org/10.1007/s00464-020-07404-yCrossRefPubMed

13.

Stringfield SB, Parry LA, Eisenstein SG, Horgan SN, Kane CJ, Ramamoorthy SL (2021) Experience with 10 years of a robotic surgery program at an academic medical center. Surg Endosc. https://doi.org/10.1007/s00464-021-08478-yCrossRefPubMedPubMedCentral

14.

Turchetti G, Palla I, Pierotti F, Cuschieri A (2011) Economic evaluation of da Vinci-assisted robotic surgery: a systematic review. Surg Endosc. https://doi.org/10.1007/s00464-011-1936-2CrossRefPubMed

15.

Abdelmoaty WF, Dunst CM, Neighorn C, Swanstrom LL, Hammill CW (2018) Robotic-assisted versus laparoscopic unilateral inguinal hernia repair: a comprehensive cost analysis. Surg Endosc. https://doi.org/10.1007/s00464-018-06606-9CrossRefPubMed

16.

Albright BB, Witte T, Tofte AN, Chou J, Black JD, Desai VB, Erekson EA (2016) Robotic versus laparoscopic hysterectomy for benign disease: A systematic review and meta-analysis of randomized trials. J Minim Invasive Gynecol. https://doi.org/10.1016/j.jmig.2015.08.003CrossRefPubMed

17.

Quinn PL, Arjani S, Ahlawat SK, Chokshi RJ (2020) Cost-effectiveness of palliative emergent surgery versus endoscopic stenting for acute malignant colonic obstruction. Surg Endosc. https://doi.org/10.1007/s00464-020-07637-xCrossRefPubMed

18.

Higgins RM, Frelich MJ, Bosler ME, Gould JC (2017) Cost analysis of robotic versus laparoscopic general surgery procedures. Surg Endosc. https://doi.org/10.1007/s00464-016-4954-2CrossRefPubMed

19.

Ho C, Tsakonas E, Tran K, Cimon K, Severn M, Mierzwinski-Urban M, Corcos J, Pautler S (2011) Robot-assisted surgery compared with open surgery and laparoscopic surgery: clinical effectiveness and economic analyses. Canadian Agency for Drugs and Technologies in Health; 2011 Sep. (CADTH Technology Report, No. 137.) https://www.ncbi.nlm.nih.gov/books/NBK168912/.

20.

Attema AE, Brouwer WBF, Claxton K (2018) Discounting in economic evaluations. Pharmacoeconomics. https://doi.org/10.1007/s40273-018-0672-zCrossRefPubMedPubMedCentral

21.

Stylopoulos N, Gazelle GS, Rattner DW (2002) Paraesophageal hernias: operation or observation? Ann Surg. https://doi.org/10.1097/00000658-200210000-00012CrossRefPubMedPubMedCentral

22.

Morrow EH, Chen J, Patel R, Bellows B, Nirula R, Glasgow R, Nelson RE (2018) Watchful waiting versus elective repair for asymptomatic and minimally symptomatic paraesophageal hernias: a cost-effectiveness analysis. Am J Surg. https://doi.org/10.1016/j.amjsurg.2018.07.037CrossRefPubMedPubMedCentral

23.

Petro CC, Zolin S, Krpata D, Alkhatib H, Tu C, Rosen MJ, Prabhu AS (2020) Patient-reported outcomes of robotic vs laparoscopic ventral hernia repair with intraperitoneal mesh: the PROVE-IT randomized clinical trial. JAMA Surg. https://doi.org/10.1001/jamasurg.2020.4569CrossRefPubMedCentral

24.

Juszczak K, Gastecka A, Adamowicz J, Adamczyk P, Pokrywczyńska M, Drewa T (2020) Health-related quality of life is not related to laparoscopic or robotic technique in radical cystectomy. Adv Clin Exp Med. https://doi.org/10.17219/acem/121937CrossRefPubMed

25.

Ubel PA, Hirth RA, Chernew ME, Fendrick AM (2003) What is the price of life and why doesn’t it increase at the rate of inflation? Arch Intern Med. https://doi.org/10.1001/archinte.163.14.1637CrossRefPubMed

26.

Washington K, Watkins JR, Jeyarajah DR (2019) The first year is the hardest: a comparison of early versus late experience after the introduction of robotic hiatal hernia repair. J Robot Surg. https://doi.org/10.1007/s11701-019-00967-6CrossRefPubMed

27.

Vasudevan V, Reusche R, Nelson E, Kaza S (2017) Robotic paraesophageal hernia repair: a single-center experience and systematic review. J Robot Surg. https://doi.org/10.1007/s11701-017-0697-xCrossRefPubMed

28.

Galvani CA, Loebl H, Osuchukwu O, Samamé J, Apel ME, Ghaderi I (2016) Robotic-assisted paraesophageal hernia repair: initial experience at a single institution. J Laparoendosc Adv Surg Tech A 26(4):290–295CrossRefPubMed

29.

Gerull WD, Cho D, Kuo I, Arefanian S, Kushner BS, Awad MM (2020) Robotic approach to paraesophageal hernia repair results in low long-term recurrence rate and beneficial patient-centered outcomes. J Am Coll Surg. https://doi.org/10.1016/j.jamcollsurg.2020.07.754CrossRefPubMed

30.

Arcerito M, Perez MG, Kaur H, Annoreno KM, Moon JT (2020) Robotic fundoplication for large paraesophageal hiatal hernias. JSLS. https://doi.org/10.4293/JSLS.2019.00054CrossRefPubMedPubMedCentral

31.

Nason KS, Luketich JD, Qureshi I, Keeley S, Trainor S, Awais O, Shende M, Landreneau RJ, Jobe BA, Pennathur A (2008) Laparoscopic repair of giant paraesophageal hernia results in long-term patient satisfaction and a durable repair. J Gastrointest Surg. https://doi.org/10.1007/s11605-008-0712-7CrossRefPubMed

32.

Williamson WA, Ellis FH Jr, Streitz JM Jr, Shahian DM (1993) Paraesophageal hiatal hernia: is an antireflux procedure necessary? Ann Thorac Surg 56(3):447–452CrossRefPubMed

33.

Lin EL, Sibona A, Peng J, Singh PN, Wu E, Michelotti MJ (2021) Cumulative summation analysis of learning curve for robotic-assisted hiatal hernia repairs. Surg Endosc. https://doi.org/10.1007/s00464-021-08665-xCrossRefPubMedPubMedCentral

34.

Ruurda JP, Draaisma WA, van Hillegersberg R, Borel Rinkes IH, Gooszen HG, Janssen LW, Simmermacher RK, Broeders IA (2005) Robot-assisted endoscopic surgery: a four-year single-center experience. Dig Surg. https://doi.org/10.1159/000088628CrossRefPubMed

35.

Diez Del Val I, Martinez Blazquez C, Loureiro Gonzalez C, Vitores Lopez JM, Sierra Esteban V, Barrenetxea Asua J, Del Hoyo AI, Perez de Villarreal P, Bilbao Axpe JE, Mendez Martin JJ (2013) Robot-assisted gastroesophageal surgery: usefulness and limitations. J Robot Surg. https://doi.org/10.1007/s11701-013-0435-yCrossRefPubMed

36.

Seetharamaiah R, Romero RJ, Kosanovic R, Gallas M, Verdeja JC, Rabaza J, Gonzalez AM (2013) Robotic repair of giant paraesophageal hernias. JSLS 17(4):570–577CrossRefPubMedPubMedCentral

37.

Sarkaria IS, Latif MJ, Bianco VJ, Bains MS, Rusch VW, Jones DR, Rizk NP (2016) Early operative outcomes and learning curve of robotic assisted giant paraesophageal hernia repair. Int J Med Robot. https://doi.org/10.1002/rcs.1730CrossRefPubMedPubMedCentral

38.

Sowards KJ, Holton NF, Elliott EG, Hall J, Bajwa KS, Snyder BE, Wilson TD, Mehta SS, Walker PA, Chandwani KD, Klein CL, Rivera AR, Wilson EB, Shah SK, Felinski MM (2019) Safety of robotic assisted laparoscopic recurrent paraesophageal hernia repair: insights from a large single institution experience. Surg Endosc. https://doi.org/10.1007/s00464-019-07291-yCrossRefPubMed

39.

Okrainec A, Ferri LE, Feldman LS, Fried GM (2010) Defining the learning curve in laparoscopic paraesophageal hernia repair: a CUSUM analysis. Surg Endosc. https://doi.org/10.1007/s00464-010-1321-6CrossRefPubMed

40.

Tartaglia N, Pavone G, Di Lascia A, Vovola F, Maddalena F, Fersini A, Pacilli M, Ambrosi A (2020) Robotic voluminous paraesophageal hernia repair: a case report and review of the literature. J Med Case Rep. https://doi.org/10.1186/s13256-020-2347-6CrossRefPubMedPubMedCentral

41.

Draaisma WA, Gooszen HG, Consten EC, Broeders IA (2008) Mid-term results of robot-assisted laparoscopic repair of large hiatal hernia: a symptomatic and radiological prospective cohort study. Surg Technol Int 17:165–170PubMed

42.

Ekeke CN, Vercauteren M, Baker N, Sarkaria I (2019) Surgical techniques for robotically-assisted laparoscopic paraesophageal hernia repair. Thorac Surg Clin. https://doi.org/10.1016/j.thorsurg.2019.06.001CrossRefPubMedPubMedCentral

43.

Kaan HL, Ho KY (2019) Endoscopic robotic suturing: the way forward. Saudi J Gastroenterol. https://doi.org/10.4103/sjg.SJG_12_19CrossRefPubMedPubMedCentral

44.

O’Connor SC, Mallard M, Desai SS, Couto F, Gottlieb M, Ewing A, Cobb WS, Carbonell AM, Warren JA (2020) Robotic versus laparoscopic approach to hiatal hernia repair: results after 7 years of robotic experience. Am Surg. https://doi.org/10.1177/0003134820943547CrossRefPubMed

45.

Howell RS, Liu HH, Petrone P, Anduaga MF, Servide MJ, Hall K, Barkan A, Islam S, Brathwaite CEM (2020) Short-term outcomes in patients undergoing paraesophageal hiatal hernia repair. Sci Rep. https://doi.org/10.1038/s41598-020-61566-2CrossRefPubMedPubMedCentral

46.

Witek TD, Luketich JD, Pennathur A, Awais O (2019) Management of recurrent paraesophageal hernia. Thorac Surg Clin. https://doi.org/10.1016/j.thorsurg.2019.07.011CrossRefPubMed

47.

Kao AM, Otero J, Schlosser KA, Marx JE, Prasad T, Colavita PD, Heniford BT (2018) One more time: redo paraesophageal hernia repair results in safe durable outcomes compared with primary repairs. Am Surg. https://doi.org/10.1177/000313481808400727CrossRefPubMed

48.

Wennergren J, Levy S, Bower C, Miller M, Borman D, Davenport D, Plymale M, Scott Roth J (2015) Revisional paraesophageal hernia repair outcomes compare favorably to initial operations. Surg Endosc. https://doi.org/10.1007/s00464-015-4688-6CrossRefPubMed

49.

Zahiri HR, Weltz AS, Sibia US, Paranji N, Leydorf SD, Fantry GT, Park AE (2017) Primary versus redo paraesophageal hiatal hernia repair: a comparative analysis of operative and quality of life outcomes. Surg Endosc. https://doi.org/10.1007/s00464-017-5583-0CrossRefPubMed

50.

Tolboom RC, Draaisma WA, Broeders IA (2016) Evaluation of conventional laparoscopic versus robot-assisted laparoscopic redo hiatal hernia and antireflux surgery: a cohort study. J Robot Surg. https://doi.org/10.1007/s11701-016-0558-zCrossRefPubMedPubMedCentral

51.

Lekarczyk A, Sinha H, Dvir D, Goyert J, Airhart A, Reddy RM (2022) Similar hospital profits with robotic-assisted paraesophageal hiatal hernia repair, despite higher or supply costs. Surg Endosc. https://doi.org/10.1007/s00464-022-09513-2CrossRefPubMed

52.

Munshower E, Ren E, Bauerle WB, Ruland J, Stoltzfus J, McDonald M, Baillie DR, Chaar ME (2022) Cost analysis of robotic assisted general surgery cases in a single academic institution. J Robot Surg. https://doi.org/10.1007/s11701-022-01434-5CrossRefPubMed

53.

Quijano Y, Nuñez-Alfonsel J, Ielpo B, Ferri V, Caruso R, Durán H, Díaz E, Malavé L, Fabra I, Pinna E, Isernia R, Hidalgo Á, Vicente E (2020) Robotic versus laparoscopic surgery for rectal cancer: a comparative cost-effectiveness study. Tech Coloproctol. https://doi.org/10.1007/s10151-020-02151-7CrossRefPubMed

54.

De Pastena M, Esposito A, Paiella S, Surci N, Montagnini G, Marchegiani G, Malleo G, Secchettin E, Casetti L, Ricci C, Landoni L, Bovo C, Bassi C, Salvia R (2021) Cost-effectiveness and quality of life analysis of laparoscopic and robotic distal pancreatectomy: a propensity score-matched study. Surg Endosc. https://doi.org/10.1007/s00464-020-07528-1CrossRefPubMedPubMedCentral

55.

Simianu VV, Gaertner WB, Kuntz K, Kwaan MR, Lowry AC, Madoff RD, Jensen CC (2020) Cost-effectiveness evaluation of laparoscopic versus robotic minimally invasive colectomy. Ann Surg. https://doi.org/10.1097/SLA.0000000000003196CrossRefPubMed

Title: Economic evaluation of robotic and laparoscopic paraesophageal hernia repair
Authors: Neal S. Panse
Vishnu Prasath
Patrick L. Quinn
Ravi J. Chokshi
Publication date: 01-06-2023
Publisher: Springer US
Keyword: Laparoscopy
Published in: Surgical Endoscopy / Issue 9/2023
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI: https://doi.org/10.1007/s00464-023-10119-5

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Economic evaluation of robotic and laparoscopic paraesophageal hernia repair

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 9/2023

Not deep enough: Modeling the effect of shallow placement of the DaVinci Xi “bariatric” long trocar on the muscular abdominal wall

Three-year survival and distribution of lymph node metastases in gastric cancer following neoadjuvant chemotherapy: results from a European randomized clinical trial

Just five more minutes, mom: why video games could make you a better endoscopist

Residents perform better technically, have less stress and workload, and prefer robotic to laparoscopic technique during inanimate simulation

Comparison of Zenker’s per-oral endoscopic myotomy (Z-POEM) with standard flexible endoscopic septotomy for Zenker’s diverticulum: a prospective study with 2-year follow-up

The role of diabetes severity scores in predicting disease remission in patients with BMI > 50 kg/m2 undergoing Roux-En-Y gastric bypass and sleeve gastrectomy: a multi-centered study