title: Comparison of Open, Laparoscopic, and Robotic Colectomies Using a Large National Database: Outcomes and Trends Related to Surgery Center Volume.
abstract: BACKGROUND
  Previous studies have shown that high-volume centers and laparoscopic techniques improve outcomes of colectomy. These evidence-based measures have been slow to be accepted, and current trends are unknown. In addition, the current rates and outcomes of robotic surgery are unknown.
  
  
  OBJECTIVE
  The purpose of this study was to examine current national trends in the use of minimally invasive surgery and to evaluate hospital volume trends over time.
  
  
  METHODS
  This was a retrospective study.
  
  
  METHODS
  This study was conducted in a tertiary referral hospital.
  
  
  METHODS
  Using the National Inpatient Sample, we evaluated trends in patients undergoing elective open, laparoscopic, and robotic colectomies from 2009 to 2012. Patient and institutional characteristics were evaluated and outcomes compared between groups using multivariate hierarchical-logistic regression and nonparametric tests. The National Inpatient Sample includes patient and hospital demographics, admission and treating diagnoses, inpatient procedures, in-hospital mortality, length of hospital stay, hospital charges, and discharge status.
  
  
  METHODS
  In-hospital mortality and postoperative complications of surgery were measured.
  
  
  RESULTS
  A total of 509,029 patients underwent elective colectomy from 2009 to 2012. Of those 266,263 (52.3%) were open, 235,080 (46.2%) laparoscopic, and 7686 (1.5%) robotic colectomies. The majority of minimal access surgery is still being performed at high-volume compared with low-volume centers (37.5% vs 28.0% and 44.0% vs 23.0%; p < 0.001). A total of 36% of colectomies were for cancer. The number of robotic colectomies has quadrupled from 702 in 2009 to 3390 (1.1%) in 2012. After adjustment, the rate of iatrogenic complications was higher for robotic surgery (OR = 1.73 (95% CI, 1.20-2.47)), and the median cost of robotic surgery was higher, at $15,649 (interquartile range, $11,840-$20,183) vs $12,071 (interquartile range, $9338-$16,203; p < 0.001 for laparoscopic).
  
  
  CONCLUSIONS
  This study may be limited by selection bias by surgeons regarding the choice of patient management. In addition, there are limitations in the measures of disease severity and, because the database relies on billing codes, there may be inaccuracies such as underreporting.
  
  
  CONCLUSIONS
  Our results show that the majority of colectomies in the United States are still performed open, although rates of laparoscopy continue to increase. There is a trend toward increased volume of laparoscopic procedures at specialty centers. The role of robotics is still being defined, in light of higher cost, lack of clinical benefit, and increased iatrogenic complications, albeit comparable overall complications, as compared with laparoscopic colectomy.
authors.affiliation: 1 Department of Surgery, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, New York 2 Department of Public Health, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, New York.
authors.forename: Heather L
authors.initials: HL
authors.lastname: Yeo
authors.forename: Abby J
authors.initials: AJ
authors.lastname: Isaacs
authors.forename: Jonathan S
authors.initials: JS
authors.lastname: Abelson
authors.forename: Jeffrey W
authors.initials: JW
authors.lastname: Milsom
authors.forename: Art
authors.initials: A
authors.lastname: Sedrakyan
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003082:Colectomy / Q000379:methods* / Q000401:mortality / Q000706:statistics & numerical data / Q000639:trends; D016208:Databases, Factual; D005260:Female; D017052:Hospital Mortality / Q000639:trends; D061847:Hospitals, High-Volume / Q000706:statistics & numerical data / Q000639:trends; D061846:Hospitals, Low-Volume / Q000706:statistics & numerical data / Q000639:trends; D006801:Humans; D010535:Laparoscopy / Q000706:statistics & numerical data* / Q000639:trends; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications / Q000453:epidemiology; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data / Q000639:trends*; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000706:statistics & numerical data* / Q000639:trends; D014481:United States; D055815:Young Adult