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Page 4 of 8 Kavalukas et al. Mini-invasive Surg 2020;4:61 I http://dx.doi.org/10.20517/2574-1225.2020.71

A few studies have been successful in evaluating the cost differences between robotic and laparoscopic
[24]
surgery examining only the charges specific to the procedure. Ramji et al. found the intraoperative
robotic costs to be twice as much compared to laparoscopic costs Some evidence exists that increased
[7]
experience over time leads to fewer charges with robotic procedures. Al-Mazrou et al. found that, despite
a significantly higher cost with the robot over a span of three years, the cost difference reduced over time
for the robotic group: $2698 in 2012, $2235 in 2013, and $1402 in 2014. Given the lack of significant
differences in many perioperative parameters between the two groups, the cost associated with the robotic
procedure is the one consistent metric upon which improvements can be made.

POSTOPERATIVE OUTCOMES
Pain
Robotic and laparoscopic surgery share similar incisions via trocar and specimen extraction sites.
A robotic right colectomy typically involves an intracorporeal anastomosis, allowing for extraction
through a Pfannenstiel incision at the conclusion of the procedure. Investigating this theory of a less
painful incision, Kelley et al. reported a 50% lower use of postoperative narcotics in the robotic group
[25]
compared to laparoscopic right hemicolectomies. Within the literature specific to rectal procedures, there
are no statistically significant differences in postoperative pain scores or analgesic use between the two
interventions [18,26] .

Ileus
There were no observed differences in several independent studies of laparoscopic vs. robotic rectal
resections in terms of postoperative ileus. Pooled data from eight studies with 854 patients failed to reach
significance regarding the incidence of prolonged ileus between the two groups, nor was there a difference
[27]
[11]
in time to resumption of regular diet . Feinberg et al. reported ileus rates of 9.5% for robotic vs. 10.4%
for laparoscopic rectal resections, which was not statistically significant. While the rates of ileus were as
high as 12%-17% in another study, comparisons between laparoscopic and robotic surgery continued to
show no difference. Conversely, a meta-analysis of over 125,989 patients undergoing colectomies did show
a statistically significant faster time to recovery of bowel function in the robotic group, though these groups
[28]
were vastly uneven (121,055 laparoscopic patients vs. 4,934 robotic patients) . Given the plethora of case-
matched, well-performed studies listed previously, there is no clear difference in ileus rates between the two
methods.

Surgical infection and anastomotic leak
Surgical site infection and anastomotic leak rates were not shown to be different between the robotic and
laparoscopic surgery groups for rectal cancer in the ROLARR randomized clinical trial . The results
[29]
from this international, multi-institutional study support the findings of four other independent studies
demonstrating no significant difference between the two arms [9,11,30,31] .

Length of stay
Multiple studies have shown no difference in the length of stay between robotic and laparoscopic
proctectomy [9,32] . While two studies claim statistically significant differences in data (0.6 days and 0.4 days,
both favouring robotic surgery), this does not translate into clinical relevance [12,33] . Additionally, it is also
hard to determine if the cost of hospitalization is affected due to the time difference. Many confounding
variables can account for differences this diminutive, including wait times while admitted in holding
prior to the procedure, operative times, and availability of transportation home on the day of discharge.
[21]
A comprehensive review of the National Impatient Sample database by Alharthi et al. did show a
meaningful difference of 4.8 days for robotic vs. 5.7 days for laparoscopic approach. This study is the
only one to also look at hospital charges, and despite a shorter length of stay the robotic group still had
significantly higher hospital charges.