title: Robot-assisted versus laparoscopic rectal resection for cancer in a single surgeon's experience: a cost analysis covering the initial 50 robotic cases with the da Vinci Si.
abstract: OBJECTIVE
  The aim of this study is to compare surgical parameters and the costs of robotic surgery with those of laparoscopic approach in rectal cancer based on a single surgeon's early robotic experience.
  
  
  METHODS
  Data from 25 laparoscopic (LapTME) and the first 50 robotic (RobTME) rectal resections performed at our institution by an experienced laparoscopic surgeon (>100 procedures) between 2009 and 2014 were retrospectively analyzed and compared. Patient demographic, procedure, and outcome data were gathered. Costs of the two procedures were collected, differentiated into fixed and variable costs, and analyzed against the robotic learning curve according to the cumulative sum (CUSUM) method.
  
  
  RESULTS
  Based on CUSUM analysis, RobTME group was divided into three phases (Rob1: 1-19; Rob2: 20-40; Rob3: 41-50). Overall median operative time (OT) was significantly lower in LapTME than in RobTME (270 vs 312.5 min, p = 0.006). A statistically significant change in OT by phase of robotic experience was detected in the RobTME group (p = 0.010). Overall mean costs associated with LapTME procedures were significantly lower than with RobTME (p < 0.001). Statistically significant reductions in variable and overall costs were found between robotic phases (p < 0.009 for both). With fixed costs excluded, the difference between laparoscopic and Rob3 was no longer statistically significant.
  
  
  CONCLUSIONS
  Our results suggest a significant optimization of robotic rectal surgery's costs with experience. Efforts to reduce the dominant fixed cost are recommended to maintain the sustainability of the system and benefit from the technical advantages offered by the robot.
authors.affiliation: General Surgery Unit, Department of Oncology Transplantation and New Technologies, University of Pisa, Pisa, Italy. luca.morelli@unipi.it.|EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy. luca.morelli@unipi.it.
authors.forename: Luca
authors.initials: L
authors.lastname: Morelli
authors.affiliation: General Surgery Unit, Department of Oncology Transplantation and New Technologies, University of Pisa, Pisa, Italy.
authors.forename: Simone
authors.initials: S
authors.lastname: Guadagni
authors.affiliation: Institute of ManagementScuola Superiore Sant'Anna, Pisa, Italy.
authors.forename: Valentina
authors.initials: V
authors.lastname: Lorenzoni
authors.affiliation: General Surgery Unit, Department of Oncology Transplantation and New Technologies, University of Pisa, Pisa, Italy.
authors.forename: Gregorio
authors.initials: G
authors.lastname: Di Franco
authors.affiliation: General Surgery Unit, Department of Oncology Transplantation and New Technologies, University of Pisa, Pisa, Italy.
authors.forename: Luigi
authors.initials: L
authors.lastname: Cobuccio
authors.affiliation: General Surgery Unit, Department of Oncology Transplantation and New Technologies, University of Pisa, Pisa, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Palmeri
authors.affiliation: General Surgery Unit, Department of Oncology Transplantation and New Technologies, University of Pisa, Pisa, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Caprili
authors.affiliation: General Surgery Unit, Department of Oncology Transplantation and New Technologies, University of Pisa, Pisa, Italy.
authors.forename: Cristiano
authors.initials: C
authors.lastname: D'Isidoro
authors.affiliation: EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Moglia
authors.affiliation: EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Ferrari
authors.affiliation: General Surgery Unit, Department of Oncology Transplantation and New Technologies, University of Pisa, Pisa, Italy.
authors.forename: Giulio
authors.initials: G
authors.lastname: Di Candio
authors.affiliation: EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy.
authors.forename: Franco
authors.initials: F
authors.lastname: Mosca
authors.affiliation: Institute of ManagementScuola Superiore Sant'Anna, Pisa, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Turchetti
mesh_terms: D000368:Aged; D003365:Costs and Cost Analysis; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000191:economics*; D059032:Learning Curve; D008297:Male; D015999:Multivariate Analysis; D061646:Operative Time; D011182:Postoperative Care; D012004:Rectal Neoplasms / Q000191:economics* / Q000601:surgery*; D012371:Robotics / Q000191:economics*; D066231:Surgeons
keywords: Colorectal surgery; Cumulative sum analysis; Learning curve; Robotic surgery