C2B - 06: THE COST OF A “LEAN START-UP” ROBOTIC TRANSABDOMINAL PRE-PERITONEAL INGUINAL HERNIA REPAIR IN A SURGICAL TRAINING PROGRAM.
Nathan S Rubalcava, MD, Sharjeel Israr, MD, Jordan Weinberg, MD, Ronald Gagliano, MD, Scott Petersen, MD, Thomas Gillespie, MD; St. Joseph's Hospital and Medical Center

The adoption of robotic surgery has been expensive.  Surgical residencies have a responsibility to train residents in leading edge technologies.  We have already paid the price for the extremely steep learning curve of transabdominal extra-peritoneal (L-TEP) inguinal hernia repairs (IHR).  The learning curve to train residents to do robotic transabdominal pre-peritoneal (R-TAPP) is unknown.  The “lean start-up” methodology is a build-measure-learn feedback loop used to begin learning as quickly as possible when initiating new processes.  Principles include immediate cost analysis, “minimal viable product”, small batch analysis and establishment of a baseline for comparison.  Can applying the lean start-up methodology to training surgical residents have the same results?

A small batch retrospective cost comparison of a single surgical educator’s teaching experience of his “last 12 taught” L-TEPs and his “first 12 taught” R-TAPPs was performed using the “lean start-up” methodology. Total consumable materials cost, including cost of the mesh and “per use” of robotic instruments per procedure was incorporated in the analysis.  So too was “skin to skin” surgical time.  Statistical analysis was performed using a t-test.  Statistical significance was defined as p<0.05.

24 bilateral IHRs (12 R-TAPPs and 12 L-TEPs) were evaluated.  The average cost per R-TAPP was $1,850.92 and $1659.81 for L-TEP.  Mean cost difference was $230.11. Average case duration for R-TAPP was 149.7 vs 115.4 minutes for L-TEP (p=0.008).

Launching new operations can be hit or miss.  There have been a lot of misses with the advent of robotic surgery.  The cost of acquiring our first 12 taught R-TAPPs was $230.11 and 23% more OR time than our last 12 taught R-TEPs.  This investment negatively impacts the acquisition cost and return on investment.  Using the lean start-up methodology, however, we have demonstrated that robotic surgical training can be accomplished at a lower cost of acquisition and with less increased operating time than previously published.  Lean start-up methodology, which allows for real-time incremental adjustments to processes, may ensure the long-term sustainability of academic robotic programs.