eP453 - Impact of Robotic Colorectal Surgery on Healthcare Delivery in a Government Hospital in a Lower Middle-income Country

Purpose/Background: In the dynamic landscape of modern healthcare, the pursuit of optimal patient outcomes while managing expenditure has become imperative. Minimally-invasive surgery (MIS; laparoscopic and robotic surgery) has gained traction due to its inherent benefits and advantages over the open approach reported in literature. Particular to robotic surgery, however, are concerns on cost-effectiveness relating to the patient and the broader healthcare system. In this paper, we explored the cost efficiency of robotic, laparoscopic, and open surgery, aiming to provide valuable insights into their economic dimensions.Methods/Interventions: This was a retrospective cohort study of rectal cancer resections done at the Philippine General Hospital (PGH) from the time of acquisition of the da Vinci® SI robotic system in 2019 until June 2023. This included patients who underwent elective rectal surgery: robotic (R), laparoscopic (L), or open (O). Data on intraoperative outcomes [estimated blood loss (EBL), operative time, and circumferential resection margins (CRM)], postoperative outcomes [postoperative length of stay (LOS), and complication rates], and cost of hospitalization were collected.Results/Outcomes: Among the 210 robotic surgeries conducted between March 2019 to June 30, 2023, 75 were for rectal cancer. These were compared to similar procedures done (O) and (L). (R) had the longest operative time. Compared to (L), (R) had a higher conversion rate (5.3% vs. 3.3%). Positive CRM was highest in (L) (13.6%). However, there was still a higher incidence of positive CRM in (R) compared to (O) (7.9% vs. 4.3%). (R) had higher EBL compared to (L) (509 vs. 322 mL) but the (O) still had the highest EBL. Total LOS among the three approaches were comparable. The total hospital cost of (R) was 164% more than (L), and 197% more than the open.Conclusion/

Discussion: The longer operative time in the study group is consistent with published studies. This can be attributed to the set-up time, docking time, repositioning of the robot arms, as well as the surgeon’s learning curve. The robotic platform enhances surgical precision through tremor reduction, image magnification, and a stable camera. These capabilities are expected to result in reduced tissue trauma and decreased intraoperative blood loss. However, more postoperative complications, higher conversion rate, and higher estimated blood loss can be attributed to the still developing robotic program, and issues related to overcoming the learning curve. We foresee the attainment of the advantages of having a robotic surgery program, which is in its early stages, as considerable experience is achieved.In the context of rectal cancer surgery, concerns have been raised about the laparoscopic approach showing increased positive oncologic margins as compared to the open approach. In our study, aside from experience, difficulty in exposure and retraction may explain findings similar to this. Robotic surgery could potentially offer an advantage in exposure.In the economic aspect, there are still no palpable advantages of the introduction of robotics at the PGH. Within the framework of an LMIC, its true worth may be seen in the setting of a government hospital, where part of the expenditure is subsidized. Robotics is still in its infancy in the country, and its advantages are yet to be fulfilled. An issue in an LMIC where health resources are scarce is proper allocation. This will have to be addressed as we move forward in the use of new technology.Table 1Patient profile, intraoperative outcomes, postoperative outcomes, and cost of hospitalization of patients who underwent surgery for rectal cancer using the robotic, laparoscopic, and open approaches. (PGH, March 2019 to June 2023)