**4. Costs of robotic surgery**

Despite the increasing popularity of robotic-assisted approaches worldwide, concerns have been raised regarding the high costs of acquiring and maintaining robotic systems [16]. In addition, stapling devices in robotic surgery often come at a high price, necessitating many centres to use standard manual or electronic stapling devices by the table surgeon instead of the console surgeon. Several studies have attempted to perform cost-analysis studies of robotic surgery compared to open and laparoscopic/thoracoscopic approaches. However, there are often significant

discrepancies between these studies, mainly due to different definitions of cost (console and robot; maintenance; instruments; stapling devices) and differences in healthcare and insurance regulations between countries [10]. A large-scale analysis of the NIS database showed that median costs of RATS were significantly higher than conventional VATS [74]. Similar findings were reported in an analysis of the Premier registry by Swanson et al. However, there is evidence to suggest that RATS is comparable or even less expensive than open surgery, mainly due to reduced operative times and shorter hospital LOS [75]. Furthermore, previous studies have shown that as programmes adopt and perform more robotic operations, the overall costs of hospitalisation will decrease [71]. These costs will likely decrease even more over time with the introduction of upcoming competitors' surgical robotic platforms [1].
