Abstrakt Ostatní Červenec 2010

“Toward adaptive stereotactic robotic brachytherapy for prostate cancer: demonstration of an adaptive workflow incorporating inverse planning and an MR stealth robot.”

Adam Cunha, J., I. C. Hsu, et al. (2010).

Minim Invasive Ther Allied Technol 19(4): 189-202.


To translate any robot into a clinical environment, it is critical that the robot can seamlessly integrate with all the technology of a modern clinic. MRBot, an MR-stealth brachytherapy delivery device, was used in a closed-bore 3T MRI and a clinical brachytherapy cone beam CT suite. Targets included ceramic dummy seeds, MR-Spectroscopy-sensitive metabolite, and a prostate phantom. Acquired DICOM images were exported to planning software to register the robot coordinates in the imager’s frame, contour and verify target locations, create dose plans, and export needle and seed positions to the robot. The coordination of each system element (imaging device, brachytherapy planning system, robot control, robot) was validated with a seed delivery accuracy of within 2 mm in both a phantom and soft tissue. An adaptive workflow was demonstrated by acquiring images after needle insertion and prior to seed deposition. This allows for adjustment if the needle is in the wrong position. Inverse planning (IPSA) was used to generate a seed placement plan and coordinates for ten needles and 29 seeds were transferred to the robot. After every two needles placed, an image was acquired. The placed seeds were identified and validated prior to placing the seeds in the next two needles. The ability to robotically deliver seeds to locations determined by IPSA and the ability of the system to incorporate novel needle patterns were demonstrated. Shown here is the ability to overcome this critical step. An adaptive brachytherapy workflow is demonstrated which integrates a clinical anatomy-based seed location optimization engine and a robotic brachytherapy device. Demonstration of this workflow is a key element of a successful translation to the clinic of the MRI stealth robotic delivery system, MRBot.




“Establishing cutoff scores on assessments of surgical skills to determine surgical competence.”

Jelovsek, J. E., M. D. Walters, et al. (2010).

American Journal of Obstetrics and Gynecology 203(1).


Objective: The aim of this study was to establish minimum cutoff scores on intraoperative assessments of surgical skills to determine surgical competence for vaginal hysterectomy. Study Design: Two surgical rating scales, the Global Rating Scale of Operative Performance and the Vaginal Surgical Skills Index, were used to evaluate trainees while performing vaginal hysterectomy. Cutoff scores were determined using the Modified Angoff method. Results: Two hundred twelve evaluations were analyzed on 76 surgeries performed by 27 trainees. Trainees were considered minimally competent to perform vaginal hysterectomy if total absolute scores (95% confidence interval) on Global Rating Scale = 18 (16.5-20.3) and Vaginal Surgical Skills Index = 32 (27.7-35.5). On average, trainees met new cutoffs after performing 21 and 27 vaginal hysterectomies, respectively. With the new cutoffs applied to the same cohort of fourth-year obstetrics and gynecology trainees, all residents achieved competency in performing vaginal hysterectomy by the end of their gynecology rotations. Conclusion: Standard-setting methods using cutoff scores may be used to establish competence in vaginal surgery. © 2010 Mosby, Inc. All rights reserved.




“Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): Short-term outcomes of an open-label randomised controlled trial.”

Kang, S. B., J. W. Park, et al. (2010).

The Lancet Oncology 11(7): 637-645.


Background: The safety and short-term efficacy of laparoscopic surgery for rectal cancer after preoperative chemoradiotherapy has not been demonstrated. The aim of the randomised Comparison of Open versus laparoscopic surgery for mid and low REctal cancer After Neoadjuvant chemoradiotherapy (COREAN) trial was to compare open surgery with laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy. Methods: Between April 4, 2006, and Aug 26, 2009, patients with cT3N0-2 mid or low rectal cancer without distant metastasis after preoperative chemoradiotherapy were enrolled at three tertiary-referral hospitals. Patients were randomised 1:1 to receive either open surgery (n=170) or laparoscopic surgery (n=170), stratified according to sex and preoperative chemotherapy regimen. Short-term outcomes assessed were involvement of the circumferential resection margin, macroscopic quality of the total mesorectal excision specimen, number of harvested lymph nodes, recovery of bowel function, perioperative morbidity, postoperative pain, and quality of life. Analyses were based on the intention-to-treat population. Patients continue to be followed up for the primary outcome (3-year disease-free survival). This study is registered with ClinicalTrials.gov, number NCT00470951. Findings: Two patients (1·2%) in the laparoscopic group were converted to open surgery, but were included in the laparoscopic group for analyses. Estimated blood loss was less in the laparoscopic group than in the open group (median 217·5 mL [150·0-400·0] in the open group vs 200·0 mL [100·0-300·0] in the laparoscopic group, p=0·006), although surgery time was longer in the laparoscopic group (mean 244·9 min [SD 75·4] vs 197·0 min [62·9], p<0·0001). Involvement of the circumferential resection margin, macroscopic quality of the total mesorectal excision specimen, number of harvested lymph nodes, and perioperative morbidity did not differ between the two groups. The laparoscopic surgery group showed earlier recovery of bowel function than the open surgery group (time to pass first flatus, median 38·5 h [23·0-53·0] vs 60·0 h [43·0-73·0], p<0·0001; time to resume a normal diet, 85·0 h [66·0-95·0] vs 93·0 h [86·0-121·0], p<0·0001; time to first defecation, 96·5 h [70·0-125·0] vs 123 h [94·0-156·0], p<0·0001). The total amount of morphine used was less in the laparoscopic group than in the open group (median 107·2 mg [80·0-150·0] vs 156·9 mg [117·0-185·2], p<0·0001). 3 months after proctectomy or ileostomy takedown, the laparoscopic group showed better physical functioning score than the open group (0·501 [n=122] vs -4·970 [n=128], p=0·0073), less fatigue (-5·659 [n=122] vs 0·098 [n=129], p=0·0206), and fewer micturition (-2·583 [n=122] vs 4·725 [n=129], p=0·0002), gastrointestinal (-0·400 [n=122] vs 4·331 [n=129], p=0·0102), and defecation problems (0·535 [n=103] vs 5·327 [n=99], p=0·0184) in repeated measures analysis of covariance, adjusted for baseline values. Interpretation: Laparoscopic surgery after preoperative chemoradiotherapy for mid or low rectal cancer is safe and has short-term benefits compared with open surgery; the quality of oncological resection was equivalent. Funding: The National Cancer Center, South Korea. © 2010 Elsevier Ltd.




“Multipurpose surgical robot as a laparoscope assistant.”

Nelson, C. A., X. Zhang, et al. (2010).

Surgical Endoscopy 24(7): 1528-1532.


BACKGROUND: This study demonstrates the effectiveness of a new, compact surgical robot at improving laparoscope guidance. Currently, the assistant guiding the laparoscope camera tends to be less experienced and requires physical and verbal direction from the surgeon. Human guidance has disadvantages of fatigue and shakiness leading to inconsistency in the field of view. This study investigates whether replacing the assistant with a compact robot can improve the stability of the surgeon’s field of view and also reduce crowding at the operating table. METHODS: A compact robot based on a bevel-geared “spherical mechanism” with 4 degrees of freedom and capable of full dexterity through a 15-mm port was designed and built. The robot was mounted on the standard railing of the operating table and used to manipulate a laparoscope through a supraumbilical port in a porcine model via a joystick controlled externally by a surgeon. The process was videotaped externally via digital video recorder and internally via laparoscope. Robot position data were also recorded within the robot’s motion control software. RESULTS: The robot effectively manipulated the laparoscope in all directions to provide a clear and consistent view of liver, small intestine, and spleen. Its range of motion was commensurate with typical motions executed by a human assistant and was well controlled with the joystick. CONCLUSIONS: Qualitative analysis of the video suggested that this method of laparoscope guidance provides highly stable imaging during laparoscopic surgery, which was confirmed by robot position data. Because the robot was table-mounted and compact in design, it increased standing room around the operation table and did not interfere with the workspace of other surgical instruments. The study results also suggest that this robotic method may be combined with flexible endoscopes for highly dexterous visualization with more degrees of freedom.




“Review of methods for objective surgical skill evaluation.”

Reiley, C. E., H. C. Lin, et al. (2010).

Surgical Endoscopy.


BACKGROUND: Rising health and financial costs associated with iatrogenic errors have drawn increasing attention to the dexterity of surgeons. With the advent of new technologies, such as robotic surgical systems and medical simulators, researchers now have the tools to analyze surgical motion with the goal of differentiating the level of technical skill in surgeons. METHODS: The review for this paper is obtained from a Google Scholar and PubMed search of the key words “objective surgical skill evaluation.” Only studies that included motion analysis were used. RESULTS: In this paper, we provide a clinical motivation for the importance of surgical skill evaluation. We review the current methods of tracking surgical motion and the available data-collection systems. We also survey current methods of surgical skill evaluation and show that most approaches fall into one of three methods: (1) structured human grading; (2) descriptive statistics; or (3) statistical language models of surgical motion. We discuss the need for an encompassing approach to model human skill through statistical models to allow for objective skill evaluation.




“Ergonomics in laparoscopic surgery.”

Supe, A. N., G. V. Kulkarni, et al. (2010).

Journal of Minimal Access Surgery 6(2): 31-36.


Laparoscopic surgery provides patients with less painful surgery but is more demanding for the surgeon. The increased technological complexity and sometimes poorly adapted equipment have led to increased complaints of surgeon fatigue and discomfort during laparoscopic surgery. Ergonomic integration and suitable laparoscopic operating room environment are essential to improve efficiency, safety, and comfort for the operating team. Understanding ergonomics can not only make life of surgeon comfortable in the operating room but also reduce physical strains on surgeon.




“Patient safety: Make it a priority for your organization!”

Wertz Evans, E. M. (2010).

Journal of Medical Practice Management 25(6): 373-378.


Ten years have passed since the Institute of Medicine released its landmark report To Err is Human-Building a Safer Health System. Creating public awareness that tens of thousands of Americans were dying every year because of medical errors led to the establishment of multiple agencies and efforts to address this problem. Research on patient safety had originally focused on systems within the hospital setting, and now more attention is directed toward studying processes in the ambulatory setting (e.g., physician practices). This article reviews the research and other took that are available to help leaders, executives, and providers create safer systems of care for patients seen throughout the physician practice environment. Copyright © 2010 by Greenbranch Publishing LLC.




“Patient’s point of view on surgical innovations: For less traumatic surgery and enhanced recovery.”

Bucher, P., F. Pugin, et al. (2010).

Innovations chirurgicales et point de vue du patient: Vers une chirurgie moins traumatisante et une réhabilitation accélérée 6(254): 1292-1297.


Surgical innovations (associating LESS, NOTES, robotics, images software and Fast-track surgery) will allow a less and less invasive surgery. While these advances could be view as surgical or industrial marketing, or compared to the laparoscopic revolution, they simply answer patients’ demand in a society changing its standard regarding: medical care, body image, recovery and rehabilitation. We will in this paper, according to results of a Google Survey analyzing population expectations of surgery, evaluate the interest of these surgical innovations. While, these innovations at least in part answers patients expectation, their therapeutic validity will have to be proved. It is our job, to foresee the future of surgery in accordance with health care system needs and patients expectation for adequate implementation of these innovations.




“Randomized trials in robotic surgery: a practical impossibility?”

Collins, S. and P. Tulikangas (2010).

International Urogynecology Journal and Pelvic Floor Dysfunction 21(9): 1045-1047.




“Surgery in space: the future of robotic telesurgery.”

Haidegger, T., J. Sandor, et al. (2010).

Surgical Endoscopy.


BACKGROUND: The origins of telemedicine date back to the early 1970s, and combined with the concept of minimally invasive surgery, the idea of surgical robotics was born in the late 1980s based on the principle of providing active telepresence to surgeons. Many research projects were initiated, creating a set of instruments for endoscopic telesurgery, while visionary surgeons built networks for telesurgical patient care, demonstrated transcontinental surgery, and performed procedures in weightlessness. Long-distance telesurgery became the testbed for new medical support concepts of space missions. METHODS: This article provides a complete review of the milestone experiments in the field, and describes a feasible concept to extend telemedicine beyond Earth orbit. With a possible foundation of an extraplanetary human outpost either on the Moon or on Mars, space agencies are carefully looking for effective and affordable solutions for life-support and medical care. The major challenges of surgery in weightlessness are also discussed. RESULTS: Teleoperated surgical robots have the potential to shape the future of extreme health care both in space and on Earth. Besides the apparent advantages, there are some serious challenges, primarily the difficulty of latency with teleoperation over long distances. Advanced virtualization and augmented-reality techniques should help human operators to adapt better to the special conditions. To meet safety standards and requirements in space, a three-layered architecture is recommended to provide the highest quality of telepresence technically achievable for provisional exploration missions. CONCLUSION: Surgical robotic technology is an emerging interdisciplinary field, with a great potential impact on many areas of health care, including telemedicine. With the proposed three-layered concept-relying only on currently available technology-effective support of long-distance telesurgery and human space missions are both feasible.




“Suture damage after grasping with EndoWrist of the da Vinci Surgical System.”

Hirano, Y., N. Ishikawa, et al. (2010).

Minimally Invasive Therapy and Allied Technologies 19(4): 203-206.


Robotic surgery using the da Vinci Surgical System promises to extend the capabilities of minimally invasive surgery and many surgical specialties are applying this new technology. With the progress of robotic surgery, we have many opportunities to perform intracorporeal anastomosis and knotting. In these procedures, we use needle drivers, and we sometimes experience collapse of sutures after grasping them due to the lack of tactile feedback. In this study, we evaluated the relationship between the decrease of durability and robotic manipulation and whether a difference in endurance can be observed using different types of robotic instruments or needle drivers for conventional laparoscopic surgery. We held 4-0 mono-filament sutures with three types of EndoWrist: Large Needle Driver (LND), Cadiere Forceps (CF) and Debaky Forceps (DF) of the da Vinci surgical system once or three times and measured the decrease of durability of the suture. The mean tensions of the suture were significantly decreased after robotic manipulation with LND. The mean tension after holding three times with LND was significantly less than that with the CF. During intracorporeal anastomosis and knotting in robotic surgery, it is important to decrease the necessity to hold the suture directly with EndoWrist. If needed, the best EndoWrist to use is CF or DF, but not LND. © 2010 Informa UK Ltd.




“Multi-objective optimization of end-to-end sutured anastomosis for robot-assisted surgery.”

Liu, Y., S. Wang, et al. (2010).

Int J Med Robot.


BACKGROUND: Due to differences in surgical operations between free-hand and robot-assisted vessel anastomosis, there exist new challenges in applying the manipulation criteria of free-hand surgery to robot-assisted surgery in order to guarantee successful completion of the surgical procedure. METHODS: A mathematical model is established to optimize the process variables in vessel anastomosis. The distance between entry point and cross-section, suture tension and the number of individual sutures are selected as design variables. The allowable range of suture tension and the difference between longitudinal stresses of vessel tissue on transverse sections are used as the objective functions. Simulation experiments are carried out to obtain the allowable range of suture tension and tissue stress distribution, based on numerical analysis. RESULTS: For a vessel in anastomosis with 4 mm diameter, a larger distance between the entry point and the cross-section and/or more sutures can result in less tissue deformation and a tighter joint between the two vessel ends. The allowable range of suture tension is a function of the number of individual sutures and increases with the decrease of the distance between entry point and cross-section. The optimal designs providing the suture configuration of distance between entry point and cross-section and the number of individual sutures are presented in the case that the performance of robot-assisted anastomosis can be guaranteed without strong control of suture tension. CONCLUSIONS: The work provides meaningful results for the optimal design of the suturing procedure in robot-assisted vascular anastomosis when the robotic system does not allow tactile feedback. Copyright (c) 2010 John Wiley & Sons, Ltd.




“[Recent advances of urological laparoscopic surgery in Japan].”

Matsuda, T., T. Inoue, et al. (2010).

Nippon Rinsho (Japanese Journal of Clinical Medicine) 68(7): 1371-1375.


Urologic laparoscopic surgeries started with varicocelectomies, pelvic lymphadenectomies and nephrectomies in 1989-90. According to the nation-wide survey in Japan, the percentages of surgeries performed laparoscopically are 43, 17 and 21% among all adrenalectomies, radical nephrectomies and partial nephrectomies, respectively. The incidence of complications and open conversion reduced significantly during these 20 years from 9.7 to 5.3% and from 5.2 to 2.6%, respectively. The perioperative mortality rate among 25,393 urologic laparoscopic surgeries was 0.047%. A surgical robot, da Vinci was accepted by the Japanese Government in 2009. Robotic-assisted laparoscopic surgeries and laparoendoscopic single-site surgeries will be the major progress in Japan.




“Multidisciplinary development of robotic surgery in a University Tertiary Hospital: Organization and outcomes.”

Ortiz Oshiro, E., A. Ramos Carrasco, et al. (2010).

Desarrollo multidisciplinario de la cirugía robótica en un hospital universitario de tercer nivel: organización y resultados. 87(2): 95-100.


BACKGROUND: Da Vinci system (Intuitive Surgical) is a surgical telemanipulator providing many technical advantages over conventional laparoscopic approach (3-D vision, ergonomics, highly precise movements, endowrist instrumentation…) and it is currently applied to several specialties throughout the world since 2000. The first Spanish public hospital incorporating this robotic technology was Hospital Clinico San Carlos (HCSC) in Madrid, in July 2006. We present the multidisciplinary organization and clinical, research and training outcomes of the Robotic Surgery Plan developed in the HCSC. MATERIAL AND METHODS: Starting from joint management and joint scrub nurses team, General and Digestive Surgery, Urology and Gynaecology Departments were progressively incorporated into the Robotic Surgery Plan, with several procedures increasing in complexity. A number of intra and extra-hospital teaching and information activities were planned to report on the Robotic Surgery Plan. RESULTS: Between July 2006 and July 2008, 306 patients were operated on: 169 by General Surgery, 107 by Urology and 30 by Gynaecology teams. The outcomes showed feasibility and a short learning curve. The educational plan included residents and staff interested in robotic technology application. CONCLUSION: The structured and gradual incorporation of robotic surgery throughout the PCR-HCSC has made it easier to learn, to share designed infrastructure, to coordinate information activities and multidisciplinary collaboration. This preliminary experience has shown the efficiency of an adequate organization and motivated team. Copyright 2009 AEC. Published by Elsevier Espana. All rights reserved.




“Diminished Suture Strength After Robotic Needle Driver Manipulation.”

Ricchiuti, D., J. Cerone, et al. (2010).

Journal of Endourology.


Abstract Robot-assisted minimally invasive surgery has become a routine surgical option for the treatment of prostate cancer. Despite its technical advancements, the da Vinci((R)) Surgical System still lacks haptic feedback to the surgeon, resulting in a maximally applied compressive force by the robotic needle driver during every grasping maneuver. Without this perceptional sense of touch and grip control, repetitive robotic needle driver manipulation may unknowingly lead to irreparable damage to fine sutures used during delicate anastomotic repairs. For robotic prostatectomy, any such loss of integrity can potentially lead to premature breakdown of the urethrovesical anastomosis and urine extravasation, especially important for a less-than-perfectly fashioned anastomotic repair. Although it has already been established that overhandling of sutures using handheld laparoscopic instruments can lead to reduced suture strength, it has not been established to what extent this may occur after robotic surgical procedures. We present analytical data and analyses concerning the failure strength of fine sutures commonly used for urethrovesical anastomotic repair during robotic prostatectomy, after repetitive robotic needle driver manipulation. When compared with noncompromised monofilament suture controls, the average maximal failure force after repetitive robotic manipulation was significantly reduced by 35% (p < 0.0001). Similarly, the average maximal failure force of braided sutures was significantly reduced after repetitive robotic manipulation by 3% (p = 0.009). This work demonstrates that significant reductions in monofilament and braided suture strength integrity can occur after customary repetitive manipulation by robotic needle drivers in an ex vivo model, with further research warranted in the in vivo setting.




“The negative effect of distraction on performance of robot-assisted surgical skills in medical students and residents.”

Suh, I. H., J. H. Chien, et al. (2010).

Int J Med Robot.


BACKGROUND: Modern surgical practice often requires multitasking in operating rooms, generally full of distractions. The purpose of this research was to investigate the effect of distraction on robot-assisted surgical skill performance in medical students and residents. METHODS: Fourteen subjects performed a suture-tying task with the da Vinci() surgical system with distractive secondary tasks simultaneously. The time to task completion, speed and the total distance travelled were analysed. Two-way repeated-measures ANOVA were applied. The scores of secondary tasks were analysed. RESULTS: A significant secondary task effect was found with an increase of the time to task completion (p = 0.003) and decreased average speed (p < 0.001). The performance of secondary task for residents was significantly better than students. CONCLUSIONS: The performance of a robot-assisted surgical task was negatively affected by secondary tasks. However, residents with more surgical experience demonstrated a larger attention capacity for multitasking. Therefore, understanding how medical trainees respond to the distractive secondary tasks while performing robot-assisted surgical task is important in developing a surgical training programme based on the concept of attention. Copyright (c) 2010 John Wiley & Sons, Ltd.




“Hybrid operating theater – A future multifunctional therapyroom.”

Tscheliessnigg, K. H. (2010).

Der hybrid-op-saal als multifunktionaler therapieraum der zukunft – Interdisziplinarität, bildgeführte therapie, integration medizinischer technologie wie CT, angiographie, navigation und robotic 17(7-8): 285-292.


Interventional rooms of the present are with few exceptions either imaging-interventional suites or sterile operating rooms. Procedures are restricted to either percutaneous procedures or to two-staged image-guided surgery without intra-operative imaging control. Since Surgery of the future will be minimally invasive and since minimally invasive therapy is essentially image-guided therapy, a new physical place for these activities has to be devised: the multifunctional therapy room of the future integrates sophisticated imaging and image guidance modalities together with advanced surgical and life-support equipment in a sterile environment. Even given a high degree of integration, this will be a complex and costly piece of medical technology. Yet another dimension of multifunctionality and cooperation will be introduced and a significant impact on the care of vitally threatened patients will be exerted by using this room not only for elective image-guided therapy but also for emergent one-stop diagnosis and treatment. The way in the future for cardiology and heart surgery.




“Developing a successful robotic surgery program in a rural hospital.”

Zender, J. and C. Thell (2010).

AORN Journal 92(1): 72-83; quiz 84-76.


Robotic surgery has become a standard in many large hospitals across the United States and the world. The surgical robot offers the surgeon a three-dimensional view and increased dexterity in addition to providing the benefits of laparoscopic surgery to the patient (eg, shorter hospital stays, decreased pain, fewer postoperative complications). The next progression for robotic surgery is a move to rural venues. For many small, rural hospitals, however, obtaining a robot may be cost prohibitive, and these facilities may need to explore sources of funding for the program. Developing a robotics program requires intense training by surgeons and all surgical team members. Effective marketing of the program and the dedication and hard work of surgical team members and administrators are vital to ensure the success of the program.



“Robotic vascular surgery, 150 cases.”

Stadler, P., L. Dvoracek, et al. (2010).

Int J Med Robot.


BACKGROUND: Based on their experience of 150 robot-assisted vascular reconstructions, the authors not only reflect on the current uses of the da Vinci robotic system in vascular surgery, but also discuss options for the further expansion of this cutting-edge technology in their area of expertise. METHODS: To date there has not been the same level of development in laparoscopy in vascular surgery as in general surgery and, despite the numbers of published studies showing interesting results, laparoscopic vascular surgery has never been generally accepted. Robot-assisted surgery represents a new stage of progress in mini-invasive methods. During the period November 2005-September 2009, the authors performed 150 robot-assisted vascular reconstructions in the aortoiliac area. The most significant include aortofemoral reconstructions and surgery on aneurysms of the abdominal aorta, the pelvic arteries and the splenic artery, as well as their first attempts to perform hybrid interventions. RESULTS: Four cases (2.7%) required conversion to standard surgery and four patients (2.7%) experienced more serious postoperative complications. On one occasion (0.7%) the robotic equipment broke down during the operation and surgery had to be completed laparoscopically. In one case (0.7%) the operation had to be abandoned because the finding on the aorta proved to be inoperable. In the cohort under consideration, the median operating time was 228 min, the median time taken to suture the anastomosis was 27 min and the median clamp time was 39 min. CONCLUSIONS: Robotic operating systems improve the precision, control and dexterity of the surgical procedure and offer patients a higher quality of operating interventions. Copyright (c) 2010 John Wiley & Sons, Ltd.




“An analysis of the differences in the acute hospitalization charges following minimally invasive versus open posterior lumbar interbody fusion: Presented at the 2009 Joint Spine Section Meeting – Clinical article.”

Wang, M. Y., M. D. Cummock, et al. (2010).

Journal of Neurosurgery: Spine 12(6): 694-699.


Object. Minimally invasive spine (MIS) procedures are increasingly being recognized as equivalent to open procedures with regard to clinical and radiographic outcomes. These techniques are also believed to result in less pain and disability in the immediate postoperative period. There are, however, little data to assess whether these procedures produce their intended result and even fewer objective data to demonstrate that they are cost effective when compared with open surgery. Methods. The authors performed a retrospective analysis of hospital charges for 1- and 2-level MIS and open posterior interbody fusion for lumbar spondylotic disease, disc degeneration, and spondylolisthesis treated at a single academic medical center. Patients presenting with bilateral neurological symptoms were treated with open surgery, and those with unilateral symptoms were treated with MIS. Overall hospital charges and surgical episode-related charges, length of stay (LOS), and discharge status were obtained from the hospital finance department and adjusted for multi-/single-level surgeries. Results. During a 14-month period, 74 patients (mean age 55 years) were treated. The series included 59 single-level operations (75% MIS and 25% open), and 15 2-level surgeries (53% MIS and 47% open). The demographic profile, including age and Charlson Comorbidity Index, were similar between the 4 groups. The mean LOS for patients undergoing single-level surgery was 3.9 and 4.8 days in the MIS and open cases, respectively (p = 0.017). For those undergoing 2-level surgery, the mean LOS was 5.1 for MIS versus 7.1 for open surgery (p = 0.259). With respect to hospital charges, single-level MIS procedures were associated with an average of $70,159 compared with $78,444 for open surgery (p = 0.027). For 2-level surgery, mean charges totalled $87,454 for MIS versus $108,843 for open surgery (p = 0.071). For single-level surgeries, 5 and 20% of patients undergoing MIS and open surgery, respectively, were discharged to inpatient rehabilitation. For 2-level surgeries, the rates were 13 and 29%, respectively. Conclusions. While hospital setting, treatment population, patient selection, and physician expectation play major roles in determining hospital charges and LOS, this pilot study at an academic teaching hospital shows trends for quicker discharge, reduced hospital charges, and lower transfer rates to inpatient rehabilitation with MIS. However, larger multicenter studies are necessary to validate these findings and their relevance across diverse US practice environments.