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P047: CLINICAL, FINANCIAL, AND EDUCATIONAL IMPLICATIONS OF IMPLEMENTATION OF ROBOTIC SURGERY IN A COMPLEX ABDOMINAL WALL RECONSTRUCTION PROGRAM AT A HIGH-VOLUME ACADEMIC MEDICAL CENTER
Joseph M Blankush; Albert Kim; Sriram Cyr; Monica Polcz; Joan Kaiser; Jose Diaz; Myrick Shinall; Chetan Aher; Meredith Duke; Richard A Pierce; Joseph R Broucek; Vanderbilt University Medical Center
INTRODUCTION: Robot-assisted retromuscular ventral hernia repair (RVHR), including the enhanced-view totally extraperitoneal (eTEP) approach, continues to gain popularity for surgical treatment of ventral hernias. Previous studies have shown comparable outcomes between open and robotic retromuscular ventral hernia repair (oRVHR and rRVHR), specifically in terms of durability of repair and post-operative complications. However, integration of this technique remains guarded at large academic institutions where educational and financial restrictions are oft-cited reasons for resistance to widespread adoption. Here we present patient outcomes, financial implications, and trainee involvement during the implementation of robotic techniques in an abdominal wall reconstruction program at a large academic institution.
METHODS: Following IRB approval, financial outcomes were reviewed for the first 14 months (July 2018 – August 2019) of rRVHR adoption. The first 51 patients to undergo eTEP ventral hernia repair were evaluated for clinical outcomes. Clinical outcomes were benchmarked against AHSQC data and previous literature detailing outcomes for oRVHR and rRVHR. Financial data was aggregated comparing oRVHR and rRVHR reimbursement rates, intra-operative and hospitalization costs, bed turnover, post-operative complications, and readmissions. US dollar values were normalized to $1 representative of oRVHR average variable direct costs (VDC) and contribution margin (CM) for subsequent financial comparisons.
RESULTS: Of the 51 patients included in the analysis, 20% underwent surgery for primary ventral hernia while 80% underwent incisional hernia repair. A transversus abdominis release (TAR) was included in 18% of cases (6% bilateral) and posterior sheath closure was achieved in all cases. Average defect size was 34 cm2 with average mesh coverage of 317 cm2. Comparing eTEP patient outcomes against published data for rVHR, median LOS for inpatient procedures (1.2 days vs. 2.0 days), incidence of surgical site infections (2% vs. 2%), hematoma (4% vs. 3%), readmissions (8% vs. 6%), and reoperation (2% vs. 2%) were consistent with published benchmarks. 73% of cases involved intra-operative resident console time with time on console closely related to resident level and increasing in both frequency and duration as program implementation has continued. Intra-operative costs were higher for eTEP ($0.41 vs. $0.33), but total hospitalization VDC were $0.15 less largely due to reduced LOS. Reduced cost led to $0.16 higher baseline CM per inpatient eTEP and $0.61 increased CM when considering additional margin attributable to increased bed turnover. In outpatient cases, robotic procedures demonstrated an average CM increase of $0.22. Implementation of eTEP did increase the percentage of outpatient cases (12% to 58%), which reimburse at lower rates than inpatient cases and therefore initially results in a $0.19 decrease in total program CM. However, when considering additional bed availability and turnover due to the outpatient shift, total CM increases by $0.28. Of note, the payor mix included 46% covered by Medicare / Medicaid.
CONCLUSION: Adoption of rRVHR, specifically the eTEP technique, in a high-volume academic medical center is feasible from both a clinical and educational standpoint and can increase overall profitability in the context of a high-volume medical center.
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