The impact of robotic cholecystectomy on private practice in a community teaching hospital.

BACKGROUND: Recently, through aggressive marketing, robotic cholecystectomy has been gaining popularity. The purpose of this study was to evaluate the impact of this technology on private practice and hospital cost and volume. METHODS: From November 2012 to April 2014, all elective cholecystectomies were evaluated for procedure type, operative time (OR), insurance type and payment, hospital length of stay, and volume. Data were analyzed using the Chi-square test, Student t test and the Mann-Whitney U test. RESULTS: Of 338 patients, 246 had complete financial records. Of these patients, 84.1% (207) patients were female with mean age of 45.4 ± 17.1 years. Patients were divided into 2 groups; group 1: 220(89.4%) patients had laparoscopic cholecystectomy (LC) and group 2: 26(10.6%) patients had robotic cholecystectomy (RC). The mean direct cost was higher in the robotic group $2,704.08 ± 308.40 vs $1,712.51 ± 379.50; P < .0001. The median gross margin; however, was not statically different (RC: $1,593.00 (Interquartile range $3,936) vs LC: $1,726.00 (Interquartile range $1,480); P = .85). Both case time and OR were higher in the robotic group; case time (RC: 121 ± 15.4 vs LC: 98.4 ± 27.5 minutes, P < .0001); OR (RC: 86.6 ± 14.3 vs LC: 63.9 ± 25.9 minutes, P < .0001). There was no appreciable change over time in either surgeon or hospital volume. CONCLUSIONS: There was a statistically significant increase in direct cost in RC vs. LC but not in margin. There was no impact in private practice on the number of cases being done robotically, nor there was an increase in hospital volume. This analysis did not include the purchase cost or maintenance of the robot.

Extra-adrenal myelolipoma presenting as efferent limb obstruction.

Myelolipomas are rare benign lesions composed of mature adipose tissue and immature hematopoetic cells. The adrenal gland is the most common location for these lesions, but cases of extra-adrenal myelolipomas have been described. The predominant location for extra-adrenal myelolipomas is the retroperitoneum, and very few reported cases describe these lesions in the peritoneal cavity. Typically these lesions are incidental findings and asymptomatic, but occasionally can present with symptoms secondary to mass effect. We present the case of a 72 year old man presenting with a gastric outlet obstruction secondary to an epigastric mass. The mass was resected and pathology was consistent with myelolipoma. This case illustrates an atypical location and presentation of a myelolipoma. These are rare tumors with only 5 intra-abdominal myelolipomas reported in the literature. This article is a review of the surgical literature and a discussion on myelolipomas. Knowledge of these rare entities can help ensure proper management of these patients, which may include early surgical intervention.