title: The first nationwide evaluation of robotic general surgery: a regionalized, small but safe start.
abstract: BACKGROUND
  The purpose of this study was to evaluate the outcomes of the most commonly performed robotic-assisted general surgery (RAGS) procedures in a nationwide database and compare them with their laparoscopic counterparts.
  
  
  METHODS
  The Nationwide Inpatient Sample was queried from October 2008 to December 2010 for patients undergoing elective, abdominal RAGS procedures. The two most common, robotic-assisted fundoplication (RF) and gastroenterostomy without gastrectomy (RG), were individually compared with the laparoscopic counterparts (LF and LG, respectively).
  
  
  RESULTS
  During the study, 297,335 patients underwent abdominal general surgery procedures, in which 1,809 (0.6 %) utilized robotic-assistance. From 2009 to 2010, the incidence of RAGS nearly doubled from 573 to 1128 cases. The top five RAGS procedures by frequency were LG, LF, laparoscopic lysis of adhesions, other anterior resection of rectum, and laparoscopic sigmoidectomy. Eight of the top ten RAGS were colorectal or foregut operations. RG was performed in 282 patients (0.9 %) and LG in 29,677 patients (99.1 %). When comparing RG with LG there was no difference in age, gender, race, Charlson comorbidity index (CCI), postoperative complications, or mortality; however, length of stay (LOS) was longer in RG (2.5 ± 2.4 vs. 2.2 ± 1.5 days; p < 0.0001). Total cost for RG was substantially higher ($60,837 ± 28,887 vs. $42,743 ± 23,366; p < 0.0001), and more often performed at teaching hospitals (87.2 vs. 50.9 %; p < 0.0001) in urban areas (100 vs. 93.0 %; p < 0.0001). RF was performed in 272 patients (3.5 %) and LF in 7,484 patients (96.5 %). RF patients were more often male compared with LF (38.2 vs. 32.3 %; p < 0.05); however, there was no difference in age, race, CCI, LOS, or postoperative complications. RF was more expensive than LF ($37,638 ± 21,134 vs. $32,947 ± 24,052; p < 0.0001), and more often performed at teaching hospitals (72.4 vs. 54.9 %; p < 0.0001) in urban areas (98.5 vs. 88.7 %; p < 0.0001).
  
  
  CONCLUSIONS
  This nationwide study of RAGS exemplifies its low but increasing incidence across the country. RAGS is regionalized to urban teaching centers compared with conventional laparoscopic techniques. Despite similar postoperative outcomes, there is significantly increased cost associated with RAGS.
authors.affiliation: Division of Gastrointestinal and Minimally Invasive Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA, blair.wormer@carolinas.org.
authors.forename: Blair A
authors.initials: BA
authors.lastname: Wormer
authors.forename: Kristian T
authors.initials: KT
authors.lastname: Dacey
authors.forename: Kristopher B
authors.initials: KB
authors.lastname: Williams
authors.forename: Joel F
authors.initials: JF
authors.lastname: Bradley
authors.forename: Amanda L
authors.initials: AL
authors.lastname: Walters
authors.forename: Vedra A
authors.initials: VA
authors.lastname: Augenstein
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Stefanidis
authors.forename: B Todd
authors.initials: BT
authors.lastname: Heniford
mesh_terms: D000328:Adult; D005260:Female; D018662:Fundoplication / Q000191:economics / Q000592:standards*; D005743:Gastrectomy / Q000191:economics / Q000379:methods / Q000592:standards*; D005102:Health Expenditures; D006801:Humans; D010535:Laparoscopy / Q000191:economics / Q000379:methods* / Q000592:standards; D007902:Length of Stay / Q000191:economics / Q000639:trends; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D011183:Postoperative Complications / Q000191:economics; D012189:Retrospective Studies; D012371:Robotics / Q000592:standards*; D014481:United States