Nationwide outcomes and costs of laparoscopic and robotic vs. open hepatectomy

The safety of hepatectomy continues to improve and it holds a key role in the management of benign and malignant hepatic lesions. Laparoscopic and robotic approaches to hepatectomy are increasingly utilized. The purpose of this study was to compare outcomes and costs of laparoscopic and robotic vs. open approaches to hepatectomy and to determine the national nonelective postoperative readmission rate, including readmission to other hospitals. The Nationwide Readmission Database from 2013 to 2014 was queried for all patients undergoing hepatectomy. Patients undergoing laparoscopic and robotic hepatectomies were compared to patients undergoing open hepatectomy. Multivariate logistic regression was implemented to determine the odds ratios (OR) for non-elective readmission within 45days. There were 10,870 patients who underwent hepatectomy from 2013 to 2014 and 724 (6.7%) were approached with laparoscopic or robotic technique. The robotic cohort had lower mean cost of the index admission ($24,983 +/-$18,329 vs. open $32,391 +/-$31,983, p<0.001, 95% CI - 18,292 to 534), shorter LOS (4.5 +/- 3.8 vs. lap 6.8 +/- 6.0 vs. open 7.6 +/- 7.7 days, p<0.01), and were less likely to be readmitted within 45 days (7.9% vs. 13.0% lap vs. 13.8% open, p=0.05). The robotic cohort was slightly younger (mean age 57.5 +/- 13.5 vs. lap 60.1 +/- 13.8 vs. open 58.9 +/- 13.7, p<0.05), and no significant differences were seen by Charlson Comorbidity Index. Anastomosis of hepatic duct to GI tract carried higher odds of mortality (OR 2.87, p<0.01) and higher odds of readmission (OR 1.40, p<0.01). LOS above 7 days increased odds of readmission (OR 2.24, p<0.01). Nearly one-fifth of patients readmitted after hepatectomy present to a different hospital. Robotic hepatectomy was associated with favorable cost and readmission outcomes compared to laparoscopic and open hepatectomy patients, despite similar patient comorbid burdens and patient's age. Length of stay over 7 days and anastomosis of hepatic duct to GI tract are strong risk factors for readmission and mortality.