Minimally invasive distal pancreatectomy – accepting the cost of conversion

Abstract

Background: Minimally invasive surgery (MIS) has become the preferred approach to distal pancreatectomy at many institutions. More difficult cases are not always attempted, however, due to risk of conversion and attendant additional costs. We hypothesized that these increased costs for conversion would not exceed those of starting with an open approach. Methods: A retrospective review of a prospectively collected single institution pancreas surgery registry (2011–17) was queried for demographic, clinical, and perioperative financial data collected for patients undergoing distal pancreatectomy. Financial data included operating room, room and board, pharmacy, and laboratory charges normalized to Medicare reimbursements based on 2016 Diagnosis Related Groups. Results: There were 80 patients who underwent distal pancreatectomy and had financial data available, including 41 open and 39 MIS operations (11 laparoscopic, 28 robotic). Conversion to open occurred in 14/39 (36%, 3 laparoscopic and 11 robotic). The median age was 63 (24-48) years old. The median length of stay was 6 (3–36) days, and 41/80 (51%) experienced a complication (16% grade 3 or higher). Age and complication rates were similar between the operative groups, but length of stay was significantly shorter for the MIS group (10.0 vs 6.0 days, p = 0.001). Robotic operations had the highest operating room charges (30% higher than open, p = 0.02). Total charges for open operations, however, were significantly higher compared to MIS (p = 0.05), because there were significantly higher room and board (p = 0.007), pharmacy (p = 0.02), and laboratory charges (p = 0.001) (Figure, *p<0.05). MIS cases that converted to open were not significantly more expensive. The MIS cases that were converted to open had operating room charges that were 1% lower, but room and board charges that were 11% higher, pharmacy charges that were 14% higher, and laboratory charges that were 16% higher than MIS completed operations. This resulted in similar total charges for open and MIS converted to open operations (p = 0.28). Conclusion: As MIS distal pancreatectomy becomes the preferred approach, this study demonstrates that there is no significant financial penalty with conversion to the open approach. These data confirm that that when feasible and appropriate, the MIS approach should be pursued, even in the context of higher intraoperative costs for robotic surgery.