The modern era of advanced laparoscopic surgery is the direct result of the disruptive work of Prof. Dr. Erich Mühe with laparoscopic cholecystectomy in 1985 [1]. Since his original work in the field of minimally invasive surgery has incorporated diverse and aggressive refinements of instrumentation and techniques for many operative indications [1]. These efforts at reducing surgical stress while improving cosmesis have included reductions in port size/number, altered extraction sites, attempts at hand assistance, and ultimately single port access [2]. The ultimate goal of all these innovations is to provide our patients with high quality surgical care while maintaining high value.

Robotic-assisted laparoscopic surgery has been the most recent attempt to further refine minimally invasive procedures. The device features EndoWrist instruments, providing seven degrees of freedom for instrument movement and tremor filtering. It allows surgeons to be in a seated posture for long operation tolerance and permits three-dimensional imaging, real-time radiographic correlation, and easy suture maneuvering [3, 4]. Hyung suggested that the application of robotic technology for general surgery is technically feasible and safe, improves dexterity, allows for better visualization, and attains a high level of precision [5]. However, the widespread adoption is limited by the absence of tactile sensation and the extremely high cost for acquisition and utilization of the technology [5]. The recent appearance in the market of three-dimensional laparoscopic cameras at substantially lower costs further erodes the potential benefits of the robotic platform.

Robotic-assisted laparoscopic surgery has been adopted to perform many general surgical procedures including cholecystectomy, Nissen fundoplication, Heller myotomy, and Roux-en-Y gastric bypass. More recently, colorectal procedures [5, 6] are being incorporated into an ever-growing number of robotic-assisted indications. The da Vinci robot is postulated to provide improved visualization due to incorporation of the three-dimensional viewing system, mitigate surgeon tremor and improve ergonomics [7]. The available data from robotic-assisted laparoscopic procedures, confirms that the majority of patient outcome benefits associated with laparoscopic surgery are maintained, albeit consistently at higher costs.

Robotic-assisted procedures have been widely adopted in urology and increasingly in gynecologic surgery, due to the shorter learning curve for advanced suturing compared to conventional laparoscopy. This is especially true in confined spaces due to the added articulation and the three-dimensional visualization. One of the limitations of conventional laparoscopic surgery results from working with long instruments through a fixed entry point on the surface of the body while watching a screen. This leads to reduced tactile feedback, diminished fine motor control, tremor amplification, and difficult hand–eye coordination [8]. There have been only limited assessments of the recently available three-dimensional laparoscopes; however, the improved visualization contributes significantly to suturing skills compared to traditional two-dimensional optics.

Although both laparoscopic prostatectomy and hysterectomy were described in the 1990s, the percentage of prostatectomies and hysterectomies performed laparoscopically was insignificant until the advent of the surgical robotics. This delay in the adoption of minimally invasive techniques in these two very common pelvic surgeries is directly related to their degree of technical difficulty associated with conventional laparoscopy, especially with laparoscopic intracorporeal suturing. However, it is possible to master the requisite laparoscopic skills without robotic assistance. Therefore, it is imperative that rigorous assessment of cost efficiency and possible reduction in learning curve associated with robotic surgery is performed before widespread adoption of robotics is recommended.

There are significant financial obstacles to universal adoption of robotic-assisted laparoscopic surgery: high cost of the robotic platform, disposable instruments, and annual service contracts. The robotic systems are sold to hospitals for a cost of $1.0–$2.3 million, depending on the model. Mandatory annual service agreements range from $100,000 to $170,000 per year. There are also significant costs related to mandatory training at the manufacturer’s facility ($3–4000) and the often required proctoring by an outside surgeon for 3–5 cases ($3000 per session). While the acquisition cost of the da Vinci robotic system is compelling ($1.2–2.4 million), the cost could be offset by the institution if other sources of cost savings can be achieved. However, robotic surgery requires significant costs for disposable or limited use instruments (e.g., shears, needle drivers, graspers, forceps) at a cost of approximately US$1–2000 per instrument every 10 surgeries [9]. These costs are generally higher when compared to the mostly reusable instruments in standard laparoscopic surgery. The available literature suggests that robotic surgery takes consistently longer than open or laparoscopic surgery, thus there is no cost savings in operating room or anesthesia time. This leaves the only potential for cost savings in a decreased length of hospital stay when compared to open. Other limitations to robotic-assisted laparoscopic surgery include the lack of tactile feedback [10], the large and cumbersome footprint of the robot, the fixed positioning of the operating table after the robot has been docked, the longer operative time compared to open surgery, and the limited outcomes data.

Several cost comparison studies have evaluated the relative cost drivers of robotic surgery versus open surgery. The largest cost comparison study was recently published in European Urology by Bolenz et al. [9]. The study compared operating costs (not including maintenance and equipment purchase) of robotic (RALP), laparoscopic (LRP), and open radical prostatectomy (ORP) for prostate cancer in a sample of 643 consecutive patients. Results showed that the cost of RALP was 50 % higher than the cost of ORP even before the cost of purchasing and maintaining the robot was factored in to the calculations. The median cost for the RALP was $6752, followed by LRP at $5687 and RRP at $4437 (all adjusted to 2007 US dollars). RALP had higher surgical supply costs and higher OR cost due to increased average length of procedure. The one cost benefit for RALP was the shorter average length of hospital stay (1 day) relative to LRP and ORP (2 days). However, the shorter RALP hospital stay relative to LRP and ORP did not make up for the RALP higher operating costs, even before considering the additional cost for the purchase and maintenance of the robot. It is also unclear if the all study groups followed the same postoperative plan because both RALP and LRP groups’ patients should have had the same minimally invasive advantage. The additional cost for the purchase and maintenance of the robot ($340,000 per year when amortized over a presumed 7 years life of the robot) would add an additional $2698 per patient undergoing a RALP (assuming 126 cases per year) [9].

A similar cost comparison study was recently completed for robotic versus open radical cystectomy for bladder cancer at the University of North Carolina at Chapel Hill. In this study, the 20 most recent cases of robotic cystectomy were compared with the 20 most recent cases of open cystectomy. The total cost (including base OR costs, OR disposable equipment costs, amortized purchase cost of the robot distributed over 5 years, and yearly maintenance costs) of the robotic radical cystectomy was $1640 more than the open radical cystectomy ($16,248 versus $14,608). In the breakdown of the costs, the majority of the difference came from the higher mean fixed OR costs for robotic cases (OR disposable equipment costs, amortized purchase cost, and yearly maintenance cost distributed over 288 cases per year). The OR variable costs were also slightly higher for the robotic cystectomy due to the increased length of these cases.

Similar to the robotic prostatectomy cost data, there was some cost savings due to a shorter postoperative stay as well as a lower frequency of postoperative transfusion after open cystectomy. While these savings were not enough to overcome the increased OR costs of the robotic cystectomy, the cost differential of $1640 per surgery was much closer than the robotic prostatectomy cost study [11].

The field of robotic-assisted laparoscopic surgery is being actively assessed for a variety of applications as demonstrated by the rapid growth and dissemination of the applications for the approach. Yet with the rising cost of health care becoming a critical element in the assessment of value-based health care, one cannot dismiss the need for cost efficiency. At this point in time, the only argument in favor of robotic-assisted laparoscopy from the cost perspective is the reduction in length of stay compared to open surgery. This creates a very high bar when the technology must compete against established laparoscopic procedures performed by trained and highly skilled laparoscopic surgeons. This contention was eloquently presented in a recent review by Satava [12] where the entire cost benefit or adopting robotics was based upon the ability of an institution to create capacity for other sources of revenue generation by other surgical admissions. Under no scenario assessed, did the robotic platform create positive cash flow for the facility.