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Page 8 of 10 Nishimura et al. Mini-invasive Surg 2020;4:11 I http://dx.doi.org/10.20517/2574-1225.2019.48

resulting in lower costs. The two studies that unexpectedly demonstrated no significant difference in
adjusted cost of robotic lobectomy compared to VATS were performed at high-volume surgical centers
experienced in robotic surgery. These studies also found no significant difference in cost when comparing
robotic to open lobectomy. Both Si and Xi systems were used and both reported on a more recent study
period with patients evaluated into the year 2017.

There are also non-operating room costs to take into consideration. Postoperative complications have been
[16]
shown to increase costs [16,24] . In Nelson’s study, they reported an association between pulmonary and
cardiovascular complications with increase in mean costs for all approaches. While the majority of studies in
this review did not find a significant difference in overall postoperative major or minor complications between
[24]
robotic and VATS or open groups [7,8,11,14-19,21] , this is a potential area for cost reduction. Kneuertz et al.
performed a retrospective review of patients at our institution who underwent robotic-assisted lobectomy
for NSCLC and evaluated postoperative outcomes on cost. Postoperative complications and prolonged
hospital stay added considerable hospital expenses, which was the largest variability in total cost in the
study.

The studies in this review that reported a difference in postoperative complications between groups were
[9]
multi-institutional database studies . Swanson et al. reported that patients undergoing lobectomy
[1,9]
via robotic approach from 2009 to 2011 were 4.24 times more likely to have a minor event than those
undergoing VATS. In contrast, the study by Subramanian et al. found that, from 2009 to 2014, robotic
[1]
lobectomy compared with VATS was associated with decreased adjusted risk of any minor postoperative
complication, and, when compared with the open approach, had a decreased risk of any major or minor
[8]
postoperative complication. Glenn et al. found no significant difference in overall morbidity between the
robotic group and VATS group from 2010 to 2013; however, they observed that, in the earlier period of
the study (2010-2011), morbidity was significantly higher in the robotic group when compared with VATS
(robotic 42.9% vs. VATS 36.3%, P = 0.004). From 2012 to 2013, there was no longer a significant difference.
Findings in these studies suggest, but do not confirm, that postoperative complications may be higher in
earlier experiences of robotic lobectomy.

Based on the literature comparing all three approaches at single institutions, the cost of robotic lobectomy
appears to be comparable if not less costly than open lobectomy and/or profitable. While OR time
was significantly longer in the robotic group in these studies, length of stay was shorter or similar. The
reduction in length of stay was noted by some authors to account for their findings. From the three studies
that evaluated quality of life in their early experience, it appears that the robotic approach has acceptable
results, although the number of studies and patients evaluated are limited [21-23] .

Many studies in our review compared robotic approach to VATS only, with results consistently
demonstrating higher costs for robotic lobectomy. Interestingly, no study was identified during our
literature search that compared costs for robotic approach to thoracotomy only even when the data suggest
that the continued decline in thoracotomy for lobectomies appears mainly a result from increased adoption
[1,2]
of the robotic platform not from increased use of VATS . While the majority of studies show that robotic
lobectomy has higher hospital costs than VATS, the significance of this finding is unclear. The difference
in index hospital cost is of statistical significance, but its overall impact on patient outcomes and health
economics has not been elucidated and the value of using the robotic platform has not been defined.
Further studies on patient outcomes such as quality of life, recovery time, and morbidity, as well as surgeon
factors, are needed.

Study limitations
There are limitations of this study. Due to the heterogeneity of how costs were defined and analyzed, a
quantitative analysis is not feasible in this study and direct comparisons between studies could not be