eP231 - Achieving Quality Outcomes and Cost Efficiency in Robotic Rectal Cancer Surgery: Tertiary Center Experience with 330 Robotic Rectal Cancer Resections

Purpose/Background: The treatment for Rectal Cancer has been standardized with Preoperative Chemoradiotherapy followed by Total Mesorectal Excision surgery. Over the last three decades Laparoscopic Surgery (LS) has been adopted for TME, more recently Robotic Surgery (RS) for TME is gaining acceptance. Compared to LS, Robotic Surgery offers exceptional ergonomics, 3D visualization, and precise movements during complex pelvic surgeries particularly for ultralow or intersphincteric resections of the rectum. But one of the major challenges for adoption of RS is additional per patient cost for using the robotic system, instruments and maintenance of the robotic system (approx. $9000 in India and $20628 in the USA per procedure cost). To address this, at our institute we have standardized three important aspects of rectal cancer surgery. Firstly subspecialization of the surgeons in colorectal surgery, secondly standardization of the RS TME technique and thirdly cost efficiency steps with improvement of patient outcomes. The aim of this retrospective study was to assess if we can improve surgical outcomes while achieving cost efficiency in robotic rectal cancer surgery.Methods/Interventions: This retrospective study (March 2015 to June 2023) examined 330 robotic rectal cancer surgeries performed by single colorectal surgeon at our institute since the adoption of robotics for rectal cancer surgery using the Intuitive DaVinci robotic system. All cancers involving the rectum were included (ie upto 15cm from the anorectal margin) as the setup, instrumentation, stapling techniques were the same. Strategies involved in achieving cost efficiency included minimizing the number of robotic arms ie three robotic arm – two instrument technique (one for camera and two for instruments with only two robotic instruments monopolar hot shears and bipolar graspers used, avoiding additional energy devices, standardizing the procedure, ensuring a trained versatile team, and following ERAS protocols.Results/Outcomes: During the study period, 330 robotic rectal cancer procedures were performed which included abdominoperineal resections, anterior resection, low anterior resection, ultra-low anterior resection, and intersphincteric resection in 78 (23.6%), 97 (29.4%), 74 (22.4%), 48 (14.5%), and 31 (9.3%) patients, respectively. Pelvic exenteration for locally advanced disease was done for 2 patients. Positive circumferential resection margins were found in 15 cases (4.7%), with only two patients (0.6%) showing positive margins. The nodal harvest rates were 13.89 and wound infection (SSI) rates were reported at 1.4%. Clinically significant anastomotic leaks which required intervention occurred in three patients (0.9%), and there were three conversions to open procedure (0.9%). There were no unplanned blood transfusions. The average cost was INR Rs 4,50,315 ($ 5397), and hospital stay ranged from 5 to 7 days. Readmission rates were 1.9%.Conclusion/

Discussion: RS effectively overcomes the limitations of LS for TME for Rectal cancer. Establishing a specialized robotic colorectal team improves surgical outcomes and efficiency. Based on our standardized approach, robotic rectal cancer TME surgery can be performed at a lower cost while achieving excellent surgical outcomes. We have shown that with subspecialization, standardization of TME technique and cost efficiency steps, RS can be safely adopted for TME for Rectal Cancer with improved surgical quality outcomes and lower cost