Routine surgical pathology in general surgery

BACKGROUND

Although pathological analysis provides the definitive diagnosis for most resection specimens, recent evidence suggests that such analysis may be omitted for certain routine samples. This was a retrospective analysis of the value of routine histopathological examination performed in daily general surgical practice.

METHODS

All specimens from routine appendicectomies, cholecystectomies, haemorrhoidectomies and inguinal hernia repairs performed between 1993 and 2002 were included. The analysis included a comparison of histological and macroscopic diagnoses, review of preoperative and peroperative findings, and an evaluation of the consequences of routine histopathological assessment on patient management and costs.

RESULTS

With the exception of hernia specimens, the rate of submission for routine pathological evaluation was 100 per cent. No hernia sac specimen from more than 2000 interventions revealed aberrant histological findings. Of 311 haemorrhoidectomy specimens three showed malignancy, all of which had a suspicious macroscopic appearance. Of 1465 appendices, only one (0.1 per cent) had a potentially relevant histological diagnosis that was not suspected macroscopically. Among 1523 cholecystectomy specimens, all adenomas (0.6 per cent) and carcinomas (0.4 per cent) were suspected macroscopically or developed in association with a known disease.

CONCLUSION

The rarity of incidental histological findings relevant to patient management, especially in the absence of macroscopic abnormalities, suggests that routine histological examination of certain specimens may be omitted. A more elementary role for macroscopic examination of the specimen by the surgeon and the pathologist is proposed.

Use of prophylactic antibiotics in a paediatric day-case surgery at NAUTH, Nnewi, Nigeria: a randomized double-blinded study

This was a randomized double-blinded study to assess the need for prophylactic antibiotics in paediatric day-case surgery, as well as the cost implication. Group A received preoperative intravenous ampiclox and vitamin B complex in doses appropriate for weight and age, while group B received only vitamin B complex as a placebo. The study was completed by 138 (95.2%) patients in group A, and by 140 (97.2%) patients in group B. Wound infection was seen in seven (5%) patients in group A and six (4.3%) patients in group B. The average cost of hernia repair in group A was US 43 dollars and US 31.1 dollars in group B.

[Effects and measures of the flat payment system based on the diagnosis procedure combination system in pediatric surgery]

The current status of the flat payment system based on the diagnosis procedure combination (DPC) system was examined in pediatric surgery. Many important diseases especially in neonatal surgery are not listed for the DPC system due to either the small number of cases or variations in hospital stay or cost In our university hospital, however, the DPC system was applied to 286 (90.8%) of 315 admissions. Total scores for the admissions were slightly higher (103.5%) in the DPC system compared with the fee-for-service system. Scores for inguinal hernia by day surgery and one-night stay were also slightly higher (102.2%) in the DPC system. Future measures for the DPC system include the provision that most preoperative evaluations should be performed in outpatient clinics and further elective surgery at a separate admission is recommended for patients with benign disease or in good condition. In cases of surgery for emergencies or malignancies, too many examinations should be avoided. Postoperative treatment using a clinical path without complications should be performed to achieve shortening of hospital stays and reduced cost. Problems in the current DPC system are complicated and inadequate classification, probably due to the unique and cost-unbeneficial nature of pediatric surgery. To establish a better medical fee system, further efforts to improve the DPC system should be continued.

Étude comparative rétrospective de l'impact médicoéconomique d'un renfort innovant dans la cure des éventrations de la paroi abdominale antérieure

STUDY AIM

Determine the gain of hospitalization cost using a new intraperitoneal mesh compared to the retro-muscular pre-fascial implantation of a polyester mesh.

PATIENTS AND METHODS

From January 1998 to June 2000, 52 patients with incisional hernia of the anterior abdominal wall were operated using intraperitoneal Parietex composite Mesh. The cost of surgery, anesthesia and hospitalization in this group were compared to similar data from a group of 21 patient where a Mesrsuture mesh in a prefascial retromuscular position was used.

RESULTS

Parietex Composite Mesh in intraperitoneal position allows a significative reduction in surgery time, anesthesia time and hospitalization. The clinical results were confirmed by cost savings.

CONCLUSION

Using new innovative medical device changing surgery technique insures significant cost saving despite its initial additional cost and increases patient's comfort during hospitalization.

Prospective randomized study of internal oblique aponeurotic flap repair for tension-free reinforcement of the posterior inguinal wall: a new technique

In recent years, Lichtenstein's tension-free hernioplasty has emerged as the gold standard for hernia surgery. However, it entails placement of a mesh and thus is costlier material-wise compared with herniorrhaphies. A new technique of internal oblique aponeurosis flap (IOAF) has been devised by the author that incorporates the advantages of Lichtenstein's technique (low recurrence, less pain) without its additional costs. A prospective study was carried out to compare the two techniques. The mean time for surgery was significantly less for the IOAF repair compared with the Lichtenstein's repair. Complications were fewer with the IOAF repair, especially local heaviness and induration. IOAF repair also had less material cost than Lichtenstein's repair. The technique of IOAF repair for inguinal hernia is fast, safe, and has less material cost compared with the Lichtenstein tension-free repair.

Costs and quality of life after endoscopic repair of inguinal hernia vs open tension-free repair: a review

BACKGROUND

The ongoing debate about the relative merits of endoscopic (EH) vs open mesh herniorrhaphy (OH) prompts the need for comparisons of outcome measures other than recurrence. Therefore, we reviewed data on the costs, time to return to work, quality of life (QoL), and pain associated with EH and OH.

METHODS

Studies comparing EH to OH and explicitly involving costs or QoL were identified and reviewed.

RESULTS

Eighteen studies were included. Direct in-hospital costs were higher for unilateral EH. Direct out-of-hospital costs were lower after EH in some studies. Indirect costs were lower for EH. Total costs were higher for EH in three studies and lower in one study. With EH, QoL was better, pain was less, operating time was longer, and time return to work and other activities was shorter.

CONCLUSION

From a societal perspective, EH entails costs similar to OH but offers extra benefits to the patient in terms of QoL and pain.

Inguinal hernia repair: results using an open preperitoneal approach

BACKGROUND

Laparoscopic surgical approaches to the repair of inguinal hernias have shown the advantages of placing mesh in the preperitoneal space. Despite those advantages, laparoscopic hernia repairs have been associated with increased cost, longer operating times, and advanced laparoscopic skills. An open preperitoneal approach has the benefit of mesh in the preperitoneal position without the disadvantages of a laparoscopic procedure.

METHODS

We present our experience with the use of an open preperitoneal mesh repair (KugelMesh, Bard, Inc.). The study was conducted in a prospective fashion from January 1998 through October 2001. 1072 hernias were repaired in two community hospitals by three general surgeons. Patients with recurrent hernias were excluded if the initial repair was from a preperitoneal approach. Operative time, cost, post-operative pain, and complications were analyzed.

RESULTS

Recurrences occurred in five patients (0.47%) during a mean follow-up time of 23 months (range: 2-47). The average operating time was 32.4 min (range: 16-62). Post-operative narcotic pain medication usage averaged 5.8 pills (range: 0-26) per repair. Average surgical charges were less for the open preperitoneal approach ($2253) than for laparoscopic repairs ($4826).

CONCLUSIONS

The open preperitoneal hernia repair using the Kugel mesh offers many advantages. It is inexpensive, has a low recurrence rate, and allows the surgeon to cover all potential defects with one piece of mesh. Postoperative recovery is short and postoperative pain is minimal.

Reparación de la hernia inguinal primaria: Lichtenstein frente a Shouldice. Estudio prospectivo y aleatorizado sobre el dolor y los costes hospitalarios

INTRODUCTION

Hernia is one of the most widely studied processes, and the search for excellence has become the final aim. However, many controversies remain to be resolved. The objective of the present study was to analyze postoperative pain and costs using two techniques of primary inguinal hernia repair.

PATIENTS AND METHOD

We performed a prospective, randomized study of 54 patients who underwent surgical repair of inguinal hernia through either the Lichtenstein or the Shouldice technique between June 2001 and May 2002. The following variables were analyzed: age, location and type of hernia, evaluation of tolerance to local anesthesia, surgical technique, operating time, pain at days 1, 3 and 5 after surgery, analgesic consumption, days until driving could be resumed, days off work, and occupation.

RESULTS

The patient groups were similar, with no significant differences in age, location or type of hernia. For Lichtenstein hernioplasty, operating time was lower (p < 0.01); pain evaluation showed no significant differences on days 1 and 3 after surgery but was higher on day 5 (p = 0.064). No significant differences were found in analgesic consumption, time before driving could be resumed, or days off work. Freelance patients returned to work earlier, independently of the surgical technique performed. The cost of the Lichtenstein technique was 235 euros compared with 180 euros for the Shouldice technique and this difference was statistically significant (p < 0.05).

CONCLUSION

In the hands of expert surgeons, the Shouldice technique is the procedure of choice in the repair of primary hernias. The results are just as satisfactory as those obtained with Lichtenstein hernioplasty and hospital costs are lower.

[Attempted assessment of the incidence and cost of surgical treatment of inginal hernias in Poland in the years 2001-2002]

A comprehensive, up-to-date assessment of the incidence and treatment cost of inguinal hernias in Poland is made difficult by the lack of a central data registry and insufficient accuracy of the data available. Therefore, research was undertaken in order to evaluate the incidence and cost of inguinal hernia treatment in the years 2001-2002 in Poland. Survey-derived data was collected from Regional Health Funds operating similar data management systems in 2002 and the Regional Branches of the National Health Fund in 2003. The number of inguinal hernia repairs, length of hospital stay, as well as the cost of these procedures and the overall number of insured people in the region were assessed. Data was obtained from 11 units (Regional Health Funds, Branches of the National Health Fund). The length of hospital stay differed between individual Regional Health Funds. The annual cost of inguinal hernia treatment amounts to approximately 100 million PLN.

Randomized Clinical Trial of Fixation vs Nonfixation of Mesh in Total Extraperitoneal Inguinal Hernioplasty

HYPOTHESIS

Mesh fixation in the extraperitoneal space during endoscopic total extraperitoneal inguinal hernioplasty might be related to an increase in postoperative pain, morbidity rate, and hospital costs.

DESIGN

Randomized clinical trial.

SETTING

University teaching hospital.

PATIENTS

From January 1999 to December 2001, 170 patients with inguinal hernia were invited to participate; 85 patients were randomized to each group.

INTERVENTION

Total extraperitoneal inguinal hernioplasty with or without mesh fixation using staples.

MAIN OUTCOME MEASURES

Operating time, morbidity rate, chronic pain, recurrences, and hospital cost were analyzed. Follow-up was considered complete when it included a physical examination at 24 months (mean, 36 +/- 12 months).

RESULTS

The statistical study showed no significant differences with regard to epidemiological factors, hernia type, operating time, morbidity, or recurrences when the mesh was stapled, although the total cost of the process was higher (P<.001).

CONCLUSIONS

Stapling the mesh in total extraperitoneal inguinal hernioplasty offers no advantages and increases the cost of the process. Our results suggest the possibility of limiting the use of mesh fixation in total extraperitoneal inguinal hernioplasty to cases of direct bilateral hernias.

[Tension-free laparoscopic versus open inguinal hernia repair]

AIM

During the last decade laparoscopic techniques have been applied to the treatment of inguinal hernia to combine tension-free technique, esthetic, and functional benefits of mini-invasive surgery. Anyway controversy persists regarding the most effective inguinal hernia repair. The aim of this study is to compare the open technique and the laparoscopic approach concerning: complications, recurrences, recovery time and return to usual activity.

METHODS

A randomized prospective analysis of 121 consecutive inguinal hernia repairs was performed over a 12-month period. Male well-informed patients with primary monolateral inguinal hernia (ASA I-II) were divided into 2 groups and consecutively treated; group A was treated with laparoscopic transabdominal preperitoneal approach (TAPP) (median age 47+/-7 years, 57 patients), group B with open mesh herniorrhaphy (45+/-6 years, 64 patients).

RESULTS

Complication rate was 5.26% for group A (none needed conversion) and 4.68% for group B. All complications were considered minor. No recurrences were observed over a 12-month follow-up in both groups. Post-operative hospital stay and return to activity show statistically significant differences. Median post-hospital stay was 1.7 days for group A while it was longer (2.9 days) for group B. Significant difference was observed in the duration of convalescence too (group A 9.3+/-7.2 days; group B 12.1+/-7. 1 days).

CONCLUSION

On the basis of our experience, even if a longer follow-up is needed, the validity of laparoscopic approach to inguinal hernia is confirmed. General anesthesia and higher costs are reasonable compromises for a shorter period of discomfort in patients with a low ASA index and busy job/sport activity.

Outcome and Cost Comparison of Laparoscopic Transabdominal Preperitoneal Hernia Repair versus Open Lichtenstein Technique

Laparoscopic hernia repair has all the advantages of a tension free repair. This study compares the laparoscopic transabdominal preperitoneal (TAPP) approach with tension-free open hernia repair in terms of operative time, postoperative pain, hospital stay, complications, and cost. Open and TAPP repairs using polypropylene mesh were performed in two groups of 25 male patients. The difference in operative times between the groups was not significant. Mean pain scores (0-100) for the open group were 54.12 +/- 13.06 at 12 hours and 37.24 +/- 11.38 at 24 hours, significantly higher than the corresponding scores of 38.36 +/- 8.21 at 12 hours and 20.92 +/- 8.73 at 24 hours for the TAPP group (P < 0.05). The mean postoperative analgesic dose was 6.72 +/- 2.72 in the TAPP group, which was insignificantly lower than 7.52 +/- 2.00 in the open group. Mean hospital stay was 2.24 +/- 0.97 days in the open group and 1.52 +/- 0.51 in the TAPP group, which was significant (P < 0.05). Twenty patients (80%) in the TAPP group rated themselves highly satisfied with the surgery as compared to 11 patients (44%) in the open group (P < 0.05). There was no recurrence in either group during a mean followup period of 13.5 months (range, 8-28 months). Laparoscopic hernia repair was significantly more expensive than open (1100 US dollars versus 629 US dollars). TAPP repair is superior to open repair in terms of shorter hospital stay, lower postoperative pain, and better patient satisfaction. It is also safe, with no recurrence in a short-term period. This technique will be the operation of choice for the treatment of groin hernia after long-term results have been established in our center.

Cost-effectiveness of alternative methods of surgical repair of inguinal hernia

Objectives:To assess the relative cost-effectiveness of laparoscopic methods of inguinal hernia repair compared with open flat mesh and open non-mesh repair.

Methods:Data on the effectiveness of these alternatives came from three systematic reviews comparing: (i) laparoscopic methods with open flat mesh or non-mesh methods; (ii) open flat mesh with open non-mesh repair; and (iii) methods that used synthetic mesh to repair the hernia defect with those that did not. Data on costs were obtained from the authors of economic evaluations previously conducted alongside trials included in the reviews. A Markov model was used to model cost-effectiveness for a five-year period after the initial operation. The outcomes of the model were presented using a balance sheet approach and as cost per hernia recurrence avoided and cost per extra day at usual activities.

Results:Open flat mesh was the most cost-effective method of preventing recurrences. Laparoscopic repair provided a shorter period of convalescence and less long-term pain compared with open flat mesh but was more costly. The mean incremental cost per additional day back at usual activities compared with open flat mesh was €38 and €80 for totally extraperitoneal and transabdominal preperitoneal repair, respectively.

Conclusions:Laparoscopic repair is not cost-effective compared with open flat mesh repair in terms of cost per recurrence avoided. Decisions about the use of laparoscopic repair depend on whether the benefits (reduced pain and earlier return to usual activities) outweigh the extra costs and intraoperative risks. On the evidence presented here, these extra costs are unlikely to be offset by the short-term benefits of laparoscopic repair.

Economic evaluation of laparoscopic and open inguinal herniorrhaphies: the effect of cost-containment measures and internal hospital policy decisions on costs and charges

BACKGROUND

Totally extraperitoneal (TEP) repairs of inguinal hernias, despite having a favorable clinical outcome are often criticized due to higher costs and charges associated with this approach. We, therefore, present a comparison of direct costs and charges between TEP and open tension-free (OPN) repairs, emphasizing the effect of cost-containment measures on the part of surgeons and the hospital's charging (rate-setting) policies on these measurements.

METHODS

Itemized direct costs, charges, and reimbursements were determined for 41 TEP and 44 OPN unilateral repairs done between January 1997 and December 1999. Multiple sensitivity analyses were done to evaluate the effect of cost-containment measures and the hospital's rate-setting policies on the differences in costs and charges between the two procedures. The hospital's profits were expressed as profit-cost ratios.

RESULTS

The mean direct cost for a TEP repair was $128.58 more than the OPN repair ($795.07[+/-65] vs 666.49 [+/-52]). However, mean charges and hospital reimbursement were $2,139.80 and $1,679.87, respectively, more for the TEP repairs. The profit-cost ratio was significantly higher in the TEP group (2.85:1 vs 1.07:1, P<.001). We found that 79.8% of the difference in direct costs vs 29% of the difference in charges between the two procedures was sensitive to cost-containment measures. Forty-five percent of the difference in charges was due to the hospital's nonuniform rate-setting policies. Long-term follow-up (38 months) showed no recurrence for either procedure.

CONCLUSIONS

The direct cost of TEP repairs with the minimal use of disposable instruments in a high-volume center is comparable to the OPN repair. However, due to differences in the hospital's charging policies, TEP repair would appear to be an expensive alternative from the payer's point of view.

How long do we need teaching in the operating room? The true costs of achieving surgical routine

BACKGROUND

Our aim was to quantify the incremental costs of longer operating times of residents and less-experienced junior consultants when compared with senior consultants on the basis of two surgical routine procedures.

METHODS

We prospectively assessed 246 patients who underwent laparoscopic cholecystectomy and 216 patients who underwent open inguinal hernia repair. Operating times, complication rates and overall costs for these patients were recorded and linked to the attending surgeons.

RESULTS

Most importantly, operating times significantly depend on the surgeon (P<0.001) and on proper supervision of junior surgeons (P<0.001 to P=0.003). When compared with those of senior surgeons, incremental costs for the hospital provider were Euro 200 and Euro 54 per laparoscopic cholecystectomy and Euro 153 and Euro 106 per open hernia repair when carried out by junior consultants and residents, respectively. Overall incremental costs per year for these procedures were Euro 8,370 for residents and Euro 22,922 for junior consultants.

CONCLUSION

Owing to longer operating times for junior consultants the costs of achieving surgical routine are considerably higher than previously estimated. These higher costs derive from junior consultants performing operations without proper supervision from senior consultants. We conclude that prolonged supervision in the operating room is highly cost-effective regardless of higher costs for personal resources per operating-minute.

Spannungsfreie Methoden der Operation prim�rer Leistenbr�che

INTRODUCTION

Surgery of inguinal hernia has fundamentally changed since the concept of "tension-free" laparoscopic and open repair was introduced in the previous decade. Until now, final judgement of the new methods was difficult because of lack of appropriate studies.

METHODS

In a prospective clinical study, we compared the results of endoscopic, total extraperitoneal (TEP) (72 hernias) with Lichtenstein hernioplasty (66 hernias). Follow-up was done daily in the hospital and 6 weeks and 12 months after operation.

RESULTS

Operation time was equal in the case of unilateral hernias, but higher surgical qualification was required in the TEP group. Intraoperative and early postoperative complication rates were without significant difference, but late ( P=0.013) and total ( P=0.031) complication rates were significantly higher in the TEP group. There were no clear advantages for TEP in patient comfort, social criteria, or cosmetic appearance. The costs for TEP were 2,428 Euros, 440 Euros more than for the Lichtenstein operation.

CONCLUSION

As a result of the study, the Lichtenstein operation can be recommended as regular operative therapy of primary inguinal hernia because, compared with TEP, it is a simple, safe, effective and economical procedure.