Introducing the E100: will the improvement make a significant difference? Financial analysis based on sleeve gastrectomy

Robotic-assisted surgery has been shown to offer significant benefits for both patients and surgeons. However, the high cost of the equipment remains a major barrier to its widespread adoption in the medical field. To ensure cost-effectiveness of these procedures, it is important to implement strategies that can help reduce the costs involved. One potential strategy to reduce costs is to compare the performance of different generators used in these procedures. In this study, we compared the performance of two generators: the E100 (Intuitive Surgical, Inc.) and the ERBE VIO dV 2.0 (Elektromedizin GmbH). The analysis focused on several key metrics, including the number of times the generators were activated, the average time per seal, total sealing time, and console time. The financial impact of transitioning to the E100 was also evaluated based on annual volume. We analyzed a total of 1457 sleeve gastrectomies, with 746 performed using the ERBE generator and 711 performed using the E100. There were no significant differences in preoperative BMI or bleeding complication rates between the two groups. The average activation of the generator per case was similar in both groups. However, the sealing time was 42.3% lower, and the average console time was 8 min shorter in cases where the E100 was used. Based on our financial analysis, transitioning to the E100 generator would result in cost savings of approximately $33–$34 K per year. This suggests that introducing the new generator is a successful strategy for reducing costs associated with robotic-assisted procedures.


Introduction
Robotic-assisted surgery was born from the desire to improve surgical procedures, aiming to optimize the overall procedure and outcome by enhancing the surgeon's abilities [1]. The two main benefits of robotic-assisted surgery are increased range of motion, the highest degrees of freedom in minimally invasive surgery, and improved visibility through tridimensional images with high-definition optics [2,3]. Additionally, it confers surgeons' dexterity, steadiness, and superior ergonomic benefits compared to conventional or laparoscopic surgery [4].
These benefits apply to many surgical specialties, including bariatric surgery, in which the ergonomic benefits of robotic assistance portend a huge advantage by minimizing the physical strain and procedural difficulties inherent to the patient's BMI. Even though there has been controversy in the past regarding the benefits of robotic-assisted surgery in bariatrics, recent studies show significant advantages, such as decreased infectious rate, readmissions, interventions, and transfusions [5,6].
Despite the benefits of robotic-assisted surgery, it is yet to be accepted for its elevated costs. Therefore, every approach to reduce it during surgery in robotic-assisted procedures should be recognized and implemented [7,8]. The OR time plays one of the most relevant roles in this, by reducing it, the surgery becomes more cost-effective, which could be accomplished with the introduction of the E100 generator (Intuitive Surgical, Inc.) [9].
The VIO dV 2.0 (Erbe Elektromedizin GmbH) was the generator of choice to power the sealing instruments throughout the procedures in robotic-assisted surgeries, but in 2019, Intuitive released the E100, an internal generator that improves the sealing times at lower temperatures than the ERBE [10]. In robotic procedures, the generators are used constantly and activated countless times, consequently decreasing seconds in sealing time could have an important impact on the OR time, making the procedure shorter and less expensive.
The goal of this paper is to analyze the impact of the new generator, as a strategy to reduce costs during bariatric surgery specifically in sleeve gastrectomy.

Materials and methods
This is a retrospective study that included patients that underwent robotic sleeve gastrectomy between January 2019 and July 2022 at Orlando Regional Medical Center. The patients from January 2019 to December 2020 were operated on with the ERBE generator, while the patients from January 2021 to July 2022 were operated on using the E100 generator. The following variables were studied for each group: energy activation per case, time per seal, total sealing time per case and console time. Data was obtained from DaVinci Xi procedural log (Intuitive Surgical). The collected data was analyzed as descriptive statistics and was presented as a mean standard deviation. A t-test was used to compare both groups. P < 0.05 was considered significant. The data was analyzed using excel (Microsoft Excel Spreadsheet Software, Microsoft Office) and organized in graphs using tableau (Tableau Software, LLC. Seattle, Washington. 2003-2022). Since this study does not involve human research, institutional review board approval is unnecessary.

Results
The study included a total of 1457 procedures, of which 746 were performed with the ERBE generator and 711 with the new E100 generator. There were no significant differences in preoperative BMI, ASA Classification, or postoperative bleeding complication rates between the two groups ( Table 1).
The number of times that the generator was activated to complete the surgery was similar in both groups, with 56 ± 20 activations with the ERBE system and 62 ± 20 activations with the E100 (Table 2). However, the sealing time was significantly lower with the E100 at 2.09 ± 0.28 s compared to 3.92 ± 0.42 s with the ERBE (p < 0.05) (Fig. 1).
This resulted in a significant reduction in the total sealing time to complete the procedure of the vessel sealer, which dropped by 42.3% from 219.50 s with the ERBE to 126.53 s with the E100 (p < 0.05) (Fig. 2).
The average console time was also significantly lower with the E100 at 30 ± 13 min compared to 38 ± 15 min with the ERBE. Based on a sleeve gastrectomy volume of 600 + cases in 2021, the total saved time using the E100 reached 930 s. Considering the estimated OR cost per minute in the US of between $36 and $37, the total savings using the new generator were estimated to be between $33-$34 K per year [9] (Table 3).

Discussion
Bariatric surgery has become the gold standard treatment for morbid obesity and the best long-term solution, being the sleeve gastrectomy the most common procedure performed. Even though minimal invasive surgery has proven to be a significant advance in the surgical field, robotic assistance is still very controversial in many surgical specialties, such as bariatrics, for its elevated costs [11].
The elevated costs associated with robotic-assisted surgery represent one of the main limitations to its endorsement in hospitals worldwide, making it available only in certain hospitals that can afford the newest technology. Therefore, decreasing the costs related to the procedure has become a priority, since the robotic approach has proven to have a good clinical outcome with fewer complications compared to the conventional laparoscopic approach [5,6]. For these reasons, any strategy that can be implemented to reduce the cost associated with robotic surgery will be advantageous since it will make it more accessible in the healthcare system [12,13].
In an attempt to reduce costs, new technology has been developed to improve surgical procedures while making them cost-effective. With that in mind, the E100 generator was released in 2019. With its new software and hardware, the E100 seems to be superior to older generators due to its amplified performance, precise control, and most importantly, its rapid sealing time while increasing efficiency throughout the procedure. The E100 can speed activation time, in the present study it was able to save up to 42% of the time per activation. In addition to this E100 keeps a lower thermal profile and has a quicker cooling time; minimizing thermal spread, and providing greater force gripping tissue with its textured jaws [10].
The study found no significant difference in bleeding complication rates between the two groups, indicating that both generators are similarly safe. The console time was significantly reduced by 20% with the E100 generator. While it is true that the generator contributes to a reduction in sealing time, which in turn reduces OR time, it is important to note that the reduced OR time cannot be solely attributed to the generator. Surgeons' accumulated experience may also play a role in improving their performance and reducing OR time.
However, the study did find that the time per seal was significantly lower with the E100 generator, which is an important factor in the overall reduction in time during procedures.
With the newest inventions comes initial investments. While the generator implies an investment that could seem expensive, in the long run, it pays off, comparing the E100 to  the ERBE, the generator pays itself within the year. E100 is a valuable tool that will make a significant strategy to reduce cost during the surgery.
The new generator has proven to be a great addition to the OR, with the added benefit of reducing costs during procedures making it an ideal strategy for hospitals to increase their cost-effectiveness during surgery as it increases satisfaction in our surgeons due to the reduced sealing time since they were able to perform at a better speed with the same results.

Conclusion
The E100 generator effectively reduces costs in roboticassisted surgery by decreasing sealing time and, thus, procedure durations. Since time means expenses in an OR, saving minutes in sealing minimizes the costs of robotic-assisted sleeve gastrectomies which will increase hospital savings.