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Robotics in Hernia Repair - another fad and way too expensive
- 1. The Robot in Hernia Repair- another fad and way too expensive Andrew S. Wright MD University of Washington @andrewswright
- 3. Experience UW Biorobotics Lab • RAVEN Surgical Robot • Telerobotics • NASA/Military application Clinical Robotics Experience • 70+ robotic cases (primarily foregut)
- 4. Experience UW Biorobotics Lab • RAVEN Surgical Robot • Telerobotics • NASA/Military application Clinical Robotics Experience • 70+ robotic cases (primarily foregut) • Quit using robot due to lack of benefit/increased OR time/increased cost
- 5. Experience Director, UW Medicine Hernia Center • 80+ Inguinal hernia/yr – 80% TEP – 10% TAPP – 10% Open • 60+ Incisional/Ventral/yr – 50% lap – 50% open AWR • 2 partners who do robot-assisted TAPP/umbilical/IPOM
- 6. Defining Value Value = Outcomes Cost
- 7. Defining Value Value = Outcomes Cost Value to whom? • Patient (pain/recurrence/return to work) • Surgeon (ergonomics/marketing/reimbursement) • Hospital (marketing/cost/income) • Insurer (cost) • Health Care System (cost/outcomes)
- 8. What’s wrong with lap inguinal?
- 9. What’s wrong with open inguinal?
- 11. What are Downsides to Robot?
- 12. What are Downsides to Robot? • Lack of haptics/tissue feel
- 13. What are Downsides to Robot? • Lack of haptics/tissue feel • Need for bedside assist • ? Need for 3rd arm/extra port • Lack of adequate instruments
- 14. What are Downsides to Robot? • Lack of haptics/tissue feel • Need for bedside assist • ? Need for 3rd arm/extra port • Lack of adequate instruments • Learning Curve
- 15. What are Downsides to Robot?
- 16. What are Downsides to Robot?
- 17. What are Downsides to Robot?
- 18. Possible Benefits of Robot • Visualization • Stable platform • Dexterity
- 19. Possible Benefits of Robot • Visualization • Stable platform • Dexterity • Cool factor • Marketing • Practice expansion
- 20. Where is the Evidence for Robot Inguinals?
- 21. Where is the Evidence for Robot Inguinals?
- 22. Where is the Evidence for Robot Inguinals?
- 23. What about robot incisional/TAR/AWR? • Cool videos!
- 24. What about robot incisional/TAR/AWR? • Cool videos! • No Data
- 25. Cautionary Tale
- 26. What about robot incisional/TAR/AWR? • Cool videos! • No Data • Possible overuse of TAR – Lot of videos of roboTAR for 6-8cm defects
- 27. What about lap incisional/TAR/AWR? • Possible lap too! From Igor Belyansky
- 28. What about costs? • OR Times – Lap Inguinal • 127 mixed lap inguinal hernia, 6 surgeons • Case time 96±38 (min 27, max 188) • Room time 127±39 (min 57, max 213) – Robot Inguinal • 44 mixed robot inguinal hernia, 2 surgeons • Case time 82±22 (min 50, max 143) • Room time 114±21 (min 77, max 173)
- 29. What about costs? • OR Times – Lap Inguinal • 127 mixed lap inguinal hernia, 6 surgeons • Case time 96±38 (min 27, max 188) • Room time 127±39 (min 57, max 213) – Robot Inguinal • 44 mixed robot inguinal hernia, 2 surgeons • Case time 82±22 (min 50, max 143) • Room time 114±21 (min 77, max 173) • Contribution to Margin – $2400 less per case – Exclusive of cost of robot
- 30. What about cost of robot? • Accounting basis – 5-year lease, $2 Million – Amortized at $51/case • Cost allocated to entire department
- 31. What about cost of robot? • Accounting basis – 5-year lease, $2 Million – Amortized at $51/case • Cost allocated to entire department – Amortize only to robot cases • $1042/case
- 32. What about cost of robots? • Only 25% cases done w/ robot – To get to 100% would need to lease 2 additional machines
- 33. What about cost of robots? • Only 25% cases done w/ robot – To get to 100% would need to lease 2 additional machines – $167k/month
- 34. What about societal cost? • 37 Hospitals in WA state with robot – Pullman Regional 25 beds
- 35. What about societal cost? • 37 Hospitals in WA state with robot – Pullman Regional 25 beds • 40 robots = $80 million
- 36. What about societal cost? 750k inguinal hernia repairs annually (US) 60 robot cases/month/robot $30k/month/robot
- 37. What about societal cost? 750k inguinal hernia repairs annually (US) 60 robot cases/month/robot $30k/month/robot $375 Million/year
- 38. Is there value in robot hernia repair? Value = Outcomes Cost Patient – no evidence Surgeon – maybe Hospital – probably not
- 39. Is there value in robot hernia repair? Value = Outcomes Cost Patient – no evidence Surgeon – maybe Hospital – probably not Insurance Companies – nope
- 40. Is there value in robot hernia repair? Value = Outcomes Cost Patient – no evidence Surgeon – maybe Hospital – probably not Insurance Companies – nope Health Care System/Society – Hell no!
- 41. Robotic Hernia Repair Cannot Be Sustained Twitter: @andrewswright Email: awright2@uw.edu