Value of robotic colorectal surgery

Surgeons and the healthcare systems in which they work are increasingly required to provide evidence of value in the services they offer to patients. Value, the ratio of outcomes to costs, is a global measure that focuses not only on discrete outcomes (such as 5year survival rates) but also on patientcentred outcomes, such as duration of disability and the effects of unnecessary treatment1. Optimizing value requires the surgeon to achieve the best possible outcomes for patients as well as thoughtful use of resources, so that expenditure creates the most benefit. The excitement surrounding the introduction of robotic colorectal surgery echoes that generated by the introduction of laparoscopic surgery. Potential advantages include a stable visual field, three-dimensional views, increased degrees of freedom of movement that allow for ‘wristed’ instrumentation to improve dexterity, elimination of physiological tremor and improved ergonomics. Just as laparoscopic colorectal surgery was controversial early on, robotic colorectal surgery is now provoking debate. One of the main concerns is whether or not this approach provides value: does it improve outcomes and what are the effects on the cost of care? Even more than other novel technologies, robotic surgery comes with a very high price tag. The few studies addressing this topic suggest that it costs an additional €1425 to €3900 per procedure (based on an exchange rate of 0⋅75 euros to 1 US dollar)2,3, while still failing to take into account either the initial purchase price of the robot (€450 000 to €1⋅875 million) or annual maintenance costs (€75 000 to €127 500)4. Nor did these studies include the time and resources needed to train surgeons and staff in robotic techniques, or the time and resources devoted to the common practice of performing more straightforward operations (such as right colectomies) with the robot rather than laparoscopically to gain robotic experience. Despite its costs, robotic colorectal surgery would still provide value if it led to significant clinical benefit or reduced the costs of other elements of care. The introduction of laparoscopic colorectal surgery provides an interesting parallel. Increased operating room and equipment costs (compared with those of open surgery) were soon offset by decreased hospital costs and a speedier recovery after discharge5. With robotic prostatectomy, a study6 using cost–utility modelling suggested that improved outcomes may justify its increased cost. The study did, however, conclude that considerable uncertainty persists in the absence of directly comparative randomized data. Even fewer such data are presently available for robotic colorectal surgery. A meta-analysis7 of the four published randomized clinical trials comparing robotic and laparoscopic colorectal surgery has demonstrated decreased blood loss, a lower conversion rate to open surgery and quicker return of bowel function with the robotic approach. The magnitude of the observed differences, however, was small and other important outcomes, including length of hospital stay, complication rates, circumferential margin positivity and lymph node harvest, did not differ significantly. The recently presented results of the randomized ROLARR (Robotic versus Laparoscopic Resection for Rectal Cancer) trial8 showed no significant differences in conversion rate, quality of mesorectal excision, circumferential margin positivity, lymph node yield, complications and 30-day mortality between laparoscopic and robotic approaches. These findings are broadly similar to those reported in non-randomized comparative studies. The only conclusion that can be drawn at the moment is that significant benefits for patients undergoing robotic versus laparoscopic colorectal surgery have yet to be proven. There are perhaps unforeseen benefits. Robotic surgery could find a role by benefiting the surgeon rather than the patient. Operations on the colon and rectum – particularly those with a high splenic flexure, narrow pelvis or in obese patients – can be physically taxing for the surgeon. If the robot facilitates surgery in these specific situations, and thereby allows the surgeon to do more operations in a day or to have a longer career, it would have a profound effect on the overall cost side of the value equation. Surgical training is expensive, in the order of US $1 million per surgeon in the USA. As the population ages and more people develop conditions requiring colonic or rectal resection, the demand for colorectal surgeons will increase9. This means