Does Surgeon Experience Affect Outcomes in Robotic Cholecystectomy for Emergency Biliary Disease? A Statewide Analysis.

BACKGROUND

The use of robotic surgery (RS) as an operative technique in emergency general surgery (EGS) is rapidly growing, with a >3-fold increase in RS-EGS operations since 2011. Prior work has utilized payer claims to evaluate outcomes of RS-cholecystectomy in the EGS setting. However, these studies fail to evaluate how outcomes are affected by surgeon experience or whether there is a learning curve for RS in the EGS setting. We hypothesized that surgeons on the learning curve may have higher rates of complications.

METHODS

EGS collaborative data from 12 hospitals were used to compare the postoperative outcomes of patients undergoing RS-cholecystectomy to those undergoing laparoscopic (LS) cholecystectomy. Unadjusted and adjusted outcomes were compared between the control (LS) and the exposure (RS) groups, using entropy balancing and multivariable analysis. Learning curves were plotted for postoperative outcomes, operative time, and hospital length of stay, using linear spline curve modeling (single knot at case 70) to represent how outcomes change with increasing surgeon experience.

RESULTS

We evaluated 8,221 minimally invasive total cholecystectomy cases, of which 2,141 were performed with RS. RS-cholecystectomy was associated with a lower rate of technical complications, independent of surgeon experience (adjusted odds ratio: 0.38, 95% CI: 0.21-0.69, p=0.002). Operative time was longer, and nontechnical complications were higher for RS-cholecystectomy (+13.1min, 95% CI: 7.3-18.8, p<0.001 and adjusted odds ratio: 1.18, 95% CI: 1.01-1.39, P=0.043, respectively). Adjusted operative time decreased by 14.1 minutes over the first 70 cases (95% CI: -21.8 to -6.4, p<0.001).

CONCLUSIONS

RS-cholecystectomy is not associated with more technical complications, and surgeons with less RS experience did not have a higher likelihood of technical complications for cholecystectomy when compared with LS in an EGS setting. Operative times for RS-cholecystectomy are longer than LS and significantly decrease with increasing surgeon experience.

LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

STUDY TYPE: Prognostic/epidemiological.