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Nishimura et al. Mini-invasive Surg 2020;4:11 I http://dx.doi.org/10.20517/2574-1225.2019.48 Page 7 of 10

surgery, resulting in a mean PCS score of 40 and MCS score of 44. They found an association between
pain and PCS scores, where PCS scores were significantly lower in patients with moderate pain (51.6 ±
14.2) than those with mild (69.4 ± 17.7) or no pain (67.8 ± 16.1) (P = 0.05). They concluded that QOL was
satisfactory in their early experience for robotic lobectomy and was related to the pain level.

[21]
In the study by Worrell et al. , costs and quality of life outcomes were evaluated during the initiation of
their robotic lobectomy program. They compared their first 25 robotic assisted lobectomies with 73 VATS
lobectomies, which were performed from 2010 to 2012. The European Organization for Research and
Treatment of Cancer quality of life questionnaire (QLQ-30) was used to assess QOL with responses from
29 of the 98 patients, 9 robotic and 20 VATS, at a median follow-up of 65 months. This study found no
significant difference between the robotic and VATS groups in their global health status and symptom scale
median scores.

[23]
In a retrospective study, Cerfolio et al. reported a consecutive series of patients with clinically apparent
resectable non-small cell lung cancer (NSCLC) from February 2010 to April 2011 who underwent
attempted completely portal robot lobectomy using the four-arm technique. This group was compared
against propensity-matched controls who underwent nerve- and rib-sparing thoracotomy. The study was
performed by a single surgeon at a single institution. Quality of life information was obtained at two time
points, three weeks and four months after surgery, and was measured by the Short Form Health Survey (SF-12)
with supplemental questions about pain control. The robotic lobectomy group had a significantly higher
average mental quality of life (MCS) score at three weeks when compared with the thoracotomy controls
(53.5 vs. 40.3; P < 0.001). A trend for higher physical quality of life (PCS) score at three weeks was observed
with the robotic group, although it was not of statistical significance (40.3 vs. 43.1; P = 0.07). There was
no significant difference observed for mental or physical quality of life at four months. The authors in this
study noted that there may have been bias introduced in the surveys since the patients were informed that
the robotic approach was a new and “less invasive” technique.

DISCUSSION
The hospital cost of robotic lobectomy during initiation of a robotic lobectomy program and/or early
experiences at an institution has consistently been shown to be higher when compared to VATS
lobectomy [11,18,20,21] . There were many factors observed to affect total hospital cost, one of which was
intraoperative cost. Studies that disclosed OR time during early experiences reported a significantly longer
time for robotic lobectomies when compared to VATS [Table 3] [11,18,20,21] . Two of these studies observed
a decrease in operating time with more experience, which translated into a difference in intraoperative
[11]
cost [11,20] . Kaur et al. found that, based on their micro-costing analysis, anatomic resections using
the robotic approach cost more than VATS by $3116 per case. They considered significantly higher
intraoperative times to be a main contributor to this difference, and reported that OR time using the
robotic platform decreased over time. There was a mean difference of 71 min (P = 0.004) when comparing
the first 20 robotic resections with the remaining 22 robotic resections, which resulted in an intraoperative
[20]
cost difference of $883.38, reducing the total hospital cost. In their study, Spillane et al. attributed higher
associated hospital charges for robotic-assisted lobectomies to increased cost of OR time. They also found a
trend in a decrease in intraoperative duration with the robotic approach over time. In their study, Bao et al.
[18]
noted that longer operative time for the robotic group may be due to the limited robotic experience of the
surgeon.

This review also includes studies performed at centers with established robotic programs with high robotic
surgical case volume. Case volume and surgeon experience may influence hospital costs. The amortized
cost of robotic equipment is directly dependent on the number of cases performed, with higher volume