Laparoscopy versus laparotomy in the management of benign unilateral adnexal masses

STUDY OBJECTIVE

To compare operative characteristics and charges of laparoscopy and laparotomy for women with a benign unilateral adnexal mass 7 cm or less in greatest diameter.

DESIGN

Historical cohort study (Canadian Task Force classification II-2).

SETTING

Clinic department of obstetrics and gynecology.

PATIENTS

One hundred six women.

INTERVENTION

Unilateral oophorectomy or unilateral salpingo-oophorectomy performed by laparoscopy or laparotomy.

MEASUREMENTS AND MAIN RESULTS

When patients were compared on an intent to treat basis, no differences in greatest mass diameter (4.2 vs 4.5 cm), patient age (49.2 vs 46.4 yrs), or body mass index (26.0 vs 27.0 kg/m(2)) were found between 62 laparoscopies and 44 laparotomies. Laparoscopy was associated with longer operating times (94 vs 63 min, p <0.001), shorter hospital stay (1.6 vs 2.5 days, p <0.001), higher sterile supply charges ($1031 vs $40, p <0.001), and lower hospital room charges ($672 vs $1351, p <0.0001). No significant differences in total hospital charges, febrile morbidity, or transfusion rates were identified.

CONCLUSION

Patient charges and early operative morbidity are similar for laparoscopy and laparotomy. Therefore, patient and surgeon preference should be a primary consideration when deciding on operative approach in carefully selected women with a unilateral adnexal mass.

Medical or surgical therapy for erosive reflux esophagitis: cost-utility analysis using a Markov model

OBJECTIVE

To compare the cost and utility of healing and maintenance regimens of omeprazole and laparoscopic Nissen fundoplication (LNF) in the framework of the Canadian medical system.

SUMMARY BACKGROUND DATA

Medical therapy with proton pump inhibitors for endoscopically proven reflux esophagitis is a safe and effective treatment option. Of late, the surgical treatment of choice for this disease has become LNF.

METHODS

The authors' base case was a 45-year-old man with erosive reflux esophagitis refractory to H2-blockers. A cost-utility analysis was performed comparing the two strategies. A two-stage Markov model (healing and maintenance phases) was used to estimate costs and utilities with a time horizon of 5 years. Discounted direct costs were estimated from the perspective of a provincial health ministry, and discounted quality-of-life estimates were derived from the medical literature. Sensitivity analyses were performed to test the robustness of the model to the authors' assumptions and to determine thresholds. A Monte Carlo simulation of 10,000 patients was used to estimate variances and 95% interpercentile ranges.

RESULTS

For the 5-year period studied, LNF was less expensive than omeprazole (3519.89 dollars vs. 5464.87 dollars per patient) and became the more cost-effective option at 3.3 years of follow-up. The authors found that 20 mg/day omeprazole would have to cost less than 38.60 dollars per month before medical therapy became cost effective; conversely, the cost of LNF would have to be more than 5,273.70 dollars or the length of stay more than 4.2 days for medical therapy to be cost effective. Estimates of quality-adjusted life-years did not differ significantly between the two treatment options, and the incremental cost for medical therapy was 129,665 dollars per quality-adjusted life-years gained.

CONCLUSIONS

For patients with severe esophagitis, LNF is a cost-effective alternative to long-term maintenance therapy with proton pump inhibitors.

[Comparative study between laparoscopic "TEP" and "tension-free" repair of groin hernia]

The "Tension free" and TEP (total preperitoneal repair) of groin hernia gained more popularity in surgical practice in the last five years. The aim of the study was to reveal our experience with these two surgical techniques. The TEP procedure was done in 29 cases, till "Tension free" herniorraphy was performed at 32 cases. Postoperative complications in the group with TEP hernia repair were found in 1 case. Two complications were observed in the "Tension free" group. The follow up of the patients revealed I recurrence in the group of TEP herniorraphy and no recurrence in "Tension free" group. These two techniques for repair of groin hernias had several advantages and in spite of increased operating theater costs should be adopted on a routine basis in some cases than conventional techniques for repair of groin hernia.

Surgical management of open versus laparoscopic adrenalectomy: outcome analysis

PURPOSE

The authors sought to compare the outcome of children undergoing open versus laparoscopic adrenalectomy for an adrenal tumor.

METHODS

Medical records of children that underwent an adrenalectomy from 1990 through 1999 were reviewed. Sixty-four adrenalectomies were performed: 27 pheochromocytomas, 36 neuroblastomas, and 1 virilizing tumor. Sixty adrenalectomies were performed open and 4 laparoscopically. The patient's age, surgical length of stay, operative charge, hospital cost, operating time, blood loss, and outcome were examined.

RESULTS

Mean age for an open procedure was 8.9 +/- 0.9 years and 14 +/- 1.1 for laparoscopic (P =.019). Surgical length of stay for open was 5.4 +/-.38 days and 2.7 +/-.62 days for laparoscopic (P =.006). Patient operative charges were $12,941 +/- 676 for laparoscopic and $4,714 +/- 411 for open (P <.001). When total estimated patient cost, including hospital stay, were compared between groups there was no significant difference. Similar mean operating times and blood loss were noted. There were no deaths or complications in children with a pheochromocytoma. The mortality rate in children with neuroblastoma was 28%.

CONCLUSIONS

Adrenalectomy for benign tumors can be performed safely. In selected children a laparoscopic procedure can be expected to decrease the surgical length of stay without increasing operating time or complications.

Laparoscopic donor nephrectomy: why not?

OBJECTIVES

Laparoscopic donor nephrectomy has undergone explosive worldwide growth as the method of choice for removal of living donor kidneys. However, the method does have some distinct disadvantages as well. The objective is to define real and potential difficulties with the generalized uncritical acceptance of this surgical technique.

METHODS

The literature and personal experience at the largest laparoscopic donor program were reviewed and consolidated. Critical areas of technique and management were analyzed.

RESULTS

Laparoscopic living donor nephrectomy has increased the pool of willing potential renal donors. In experienced has the recipient renal function results are equivalent to open nephrectomy.

CONCLUSIONS

There are risks in performing the operation to the donor and to the allograft. These risks are potentially catastrophic and mitigate against any casual attitudes about embarking on a laparoscopic donor nephrectomy program.

Hand-assisted laparoscopic renal surgery: current trends and applications

OBJECTIVE

Hand-assisted laparoscopic surgery has recently been introduced in order to help ease the learning process associated with standard laparoscopic surgery. It has various urological applications in the management of malignant and benign disease of the kidney. The purpose of this study is to review the applications and the success rate associated with hand-assisted laparoscopic surgery.

METHODS

A comprehensive literature review of hand-assisted urological surgery was performed using MEDLINE search.

RESULTS

Hand-assisted laparoscopic nephrectomy has been performed for benign and malignant disease, donor renal transplant, and nephron sparing surgery with good success. Patients who undergo the hand-assisted procedure seem to have less perioperative morbidity than those who undergo an open procedure. This approach minimized the warm-ischemia time in renal transplantation.

CONCLUSION

Hand-assisted nephrectomy is a useful tool facilitating the learning process in laparoscopy.

Surgical outcome and hospital cost analyses of laparoscopic and open tension-free hernia repair

Surgeons who favor the laparoscopic repair of groin hernias must limit the additional costs associated with this technique, which is not universally acknowledged to be superior to other less expensive open tension-free repairs. This retrospective study compared outcome and costs between laparoscopic and open tension-free hernia repair in 320 patients with inguinal hernias. Patients underwent either (a) transabdominal preperitoneal procedure (TAPP; 60 patients, 72 procedures), (b) totally extraperitoneal procedure (TEP; 174 patients, 202 procedures), or (c) open tension-free procedure (86 patients, 105 procedures). Regarding important postoperative complications there were two (3.3%) recurrences in the TAPP group and one (0.6%) in the TEP group, and six (9.9%) transient neuralgias in the TAPP group and one (1.2%) in the tension-free group. There were no deaths, no testicular atrophies, and no wound or mesh infections. The mean hospital postoperative stay was the same in the three groups (1 day). Mean operating time was shorter in the tension-free group concerning the unilateral cases and shorter in the TEP group concerning the bilateral cases. Fewer patients required analgesia during the first 6 h after the operative procedure in the TEP group than in the other two groups. The mean total costs were 483.90 euros in the open tension-free repair, 763.20 euros in the TAPP repair, and 572.50 euros in the TEP repair. The open procedure was the cheaper for the hospital. Laparoscopic hernia repair and tension-free repair as described by Gilbert are comparable in postoperative complications. TEP hernia repair is associated with less postoperative pain and earlier return to normal activities, but it is more expensive and continues to be a difficult procedure. Open tension-free repair is the least expensive method and is easier to learn than the other two procedures.

Early experiences of robotic surgery in children

BACKGROUND

Laparoscopic surgery using a robotic system (Da Vinci) was recently introduced into surgical practice for adult patients. To investigate the feasibility of this system in pediatric surgery, laparoscopic fundoplication (Thal and Nissen), cholecystectomy, and bilateral salpingo-oophorectomy were performed.

METHODS

Eleven children with a mean age of 12 years (range, 7-16 years) underwent either laparoscopic anterior partial fundoplication (Thal, n = 8) or Nissen fundoplication (n = 3) for correction of gastroesophageal reflux disease in the presence of uncontrolled symptoms of regurgitation and pulmonary infection. Two children underwent laparoscopic cholecystectomy due to symptomatic cholecystolithiasis. One child underwent bilateral salpingo-oophorectomy due to a gonadoblastoma.

RESULTS

Mean operating time for fundoplication was 146 min (range, 105-180 min), the operating times for cholecystectomy were 150 and 105 min, and that for salpingo-oophorectomy was 95 min. No complications were registered during either the robotic procedures or the postoperative courses.

CONCLUSIONS

Compared to conventional laparoscopy, the three-dimensional high-quality vision, advanced instrument movement, and improved ergonomic position of the surgeon appear to enhance surgical precision. Robotic surgery in children using the Da Vinci system seems to be feasible and safe. However, the technique is limited due to the fact that instruments adapted to the size of small children are not available. Furthermore, the high costs and prolonged system setup are disadvantages.

Cost comparison for laparoscopic nephrectomy and open nephrectomy: analysis of individual parameters

OBJECTIVES

To identify the cost components of laparoscopic nephrectomy (LN) that could be targeted to reduce the cost of the procedure. LN is typically more costly than open nephrectomy (ON) because of longer operative times and the use of disposable equipment.

METHODS

We compared the overall cost and individual cost centers for uncomplicated LN (n = 11) and ON (n = 8) at a large metropolitan county hospital. A model was created using the DATA program (TreeAge software, version 3.5) to compare the costs of treatment with either ON or LN. We conducted a series of one-way sensitivity analyses to evaluate the effect of varying individual probabilities and costs. Two-way sensitivity analyses were performed to evaluate the costs of ON and LN while varying the hospital length of stay, operative time, and cost of laparoscopic equipment.

RESULTS

LN was less costly overall than ON by $1211 (P = 0.037), despite significant differences favoring ON in overall operating room costs and operating room supply costs. The cost superiority of LN was a consequence of statistically significant differences in the cost of hospitalization, including room and board, that favored the laparoscopic group. One-way sensitivity analyses showed that LN was less costly if (a) the operative time of LN was less than 281 minutes; (b) the length of hospitalization after LN was less than 5.8 days; (c) the operating room costs for LN were less than $3439; (d) the laparoscopic equipment costs were less than $2129; (e) the ON time exceeded 78 minutes; (f) the length of hospitalization for ON was more than 3.6 days; or (g) the operating room costs for ON were greater than $1333.

CONCLUSIONS

The sensitivity analyses enable individual surgeons and institutions to determine the cost impact of ON and LN, given their unique clinical scenarios. At our institution, key cost centers in determining cost effectiveness include length of operating time, hospitalization, and cost of laparoscopic instrumentation for ON and LN. LN is cost effective compared with ON if short operating times and brief length of stays are achieved.

[Clinical and economic evaluation of laparoscopic surgery for inguinal hernia. Return of a difficult clinical choice]

In the year 2000, the ANAES (National Agency for Accreditation and Evaluation of Health Care) published a technological and economic evaluation of the laparascopic approach to the repair of inguinal hernias based principally on the analysis of randomized studies. This analysis was all the more difficult because of the heterogeneity of the studies for which end results had a very weak level of proof. Laparascopic surgical techniques for inguinal hernia repair require the systematic use of mesh prosthesis and also general anesthesia. Published results are insufficient to compare specific laparascopic techniques with each other. The efficacy of laparoscopic repair compared to open repair with regard to hernia recurrence (the principal criteria of efficacy) has not been demonstrated--mainly because longterm results are not yet available. The overall evaluation of complications is too heterogeneous to show a difference between laparascopic and open surgery. There are, however, certain complications specific to laparascopic repair which, though rare, are potentially very serious. Excellent results reported with laparascopic repair may be due more to the systematic placement of mesh than-to to the approach itself--as has been shown in studies of open repairs "with tension" and "tension free." Superiority of the laparoscopic approach for specific types of hernia (primary unilateral, bilateral, recurrent) has not been demonstrated. Open surgery costs less than laparascopic hernia repair. The evaluation to date for laparascopic inguinal hernia repair is insufficient. Controlled studies with rigorous longterm follow-up and analysis of economic impact must be performed in comparable populations of patients.

Laparoscopic versus open gastric bypass

Laparoscopic bypass has become a common approach for the treatment of morbid obesity. This article compares the results of laparoscopic gastric bypass with that of open gastric bypass based on published data from prospective series, comparative studies, and randomized clinical trials.

Cost-effective, reliable laparoscopic hernia repair: a report on 500 consecutive repairs

BACKGROUND

A series of 500 consecutive laparoscopic hernia repairs, performed by one surgeon, was studied to evaluate the procedure for reliability, safety, and cost-effectiveness.

METHODS

Patients with routine, first-time, recurrent or multiply recurrent, inguinal hernias were operated using the technique described.

RESULTS

The recurrence rate was 0.2%. The complication rate was 0.6%. There were no deaths. Ninety-six percent of patients returned to work in 4-10 days.

CONCLUSIONS

Laparoscopic inguinal hernia repair is reliable, safe, and cost-effective.

Subjective and objective comparison of critical care pathways for open donor nephrectomy

PURPOSE

In the era of minimally invasive techniques and cost containment, care pathways after donor nephrectomy are important. While open donor nephrectomy remains the established procedure, questions regarding the surgical approach, postoperative care and patient morbidity/dissatisfaction have surfaced. We compared results of standard and fast-track care pathways after donor nephrectomy.

MATERIALS AND METHODS

Between January 1998 and August 1999, 60 patients underwent open donor nephrectomy. By surgeon preference, patients received either ketorolac only (31), ketorolac plus morphine spinal (17) or patient controlled anesthesia (12). Data related to surgery, hospital course and cost were reviewed. Patients were surveyed regarding return to daily activities and groups were statistically analyzed.

RESULTS

The mean dose per patient was 183 (ketorolac only), 180 (ketorolac plus morphine spinal) and 69 (patient controlled analgesia) mg. Median hospital stay was 2 days for the fast-track pathways (ketorolac only, ketorolac plus morphine spinal) compared to 3 days for the patient controlled analgesia group (p <0.001). Delayed oral intake was seen in 6% of patients on ketorolac only and 3% for those on ketorolac plus morphine spinal compared to 83% of the patient controlled analgesia group (p <0.001). Return to exercise (median weeks, p <0.79) was 2 for the ketorolac only group, 3.5 for ketorolac plus morphine spinal and 3.5 for patient controlled analgesia. Mean global cost was $9,394 for the ketorolac only group, $9,238 for ketorolac plus morphine spinal and $11,601 for patient controlled analgesia (p <0.02).

CONCLUSIONS

Fast-track pathways significantly shortened hospital stay and quickened oral intake. Cost was significantly contained using new pathways. Resumption of daily activities was comparable among the groups. Comparisons of critical care pathways are required to optimize patient care after kidney donation. Prospective trials are needed to verify our results.

A simple, inexpensive method of specimen removal at laparoscopy

After completing operative laparoscopy, it is often necessary to enlarge a 5-mm port to 10 or 12 mm for tissue removal. This may increase the risk of vessel injury and herniation, and has obvious cosmetic drawbacks. A simple, cost-effective technique for tissue removal does not require enlarging the 5-mm port. A long, firm thread is sutured to a sterile plastic bag. When tissue removal is required, the optic telescope is removed and the bag is blindly introduced through the available optical 11- or 12-mm cannula. The telescope is reintroduced, keeping the end of the thread outside the cannula sleeve. The specimen is placed in the bag and the bag is removed by pulling the suture through the optical cannula after removing the telescope. This technique was performed successfully in over 300 patients, with no difficulty or complication either during or after surgery. The device is inexpensive and takes 2 minutes to assemble.

Cost analysis of tubal anastomosis by laparoscopy and by laparotomy

STUDY OBJECTIVE

To compare the costs of tubal anastomosis performed by laparoscopy and by laparotomy.

DESIGN

Cost analysis study using the hospital administrative database (Canadian Task Force classification II-2).

SETTING

University teaching hospital.

PATIENTS

Eighty-nine women. Intervention. Tubal anastomosis by laparoscopy (43) and by laparotomy (46).

MEASUREMENTS AND MAIN RESULTS

Tubal anastomosis took longer when performed by laparoscopy than by laparotomy; however, the total time patients spent in the operating room was similar. Women treated by laparoscopy spent more time in the recovery room. Labor costs for nurses in the operating room and recovery room costs were significantly higher in the laparoscopy group. Costs for operating room supplies were similar. Pharmacy costs and expenses in the ward were lower in the laparoscopy group. The mean total cost for laparoscopic tubal anastomosis was $861 +/- 137 and for laparotomy was $1348 +/- 188 (p <0.001).

CONCLUSION

Laparoscopic tubal anastomosis costs less than tubal anastomosis by laparotomy.

Advantages of laparoscopic resection for ileocecal Crohn's disease

PURPOSE

Elective laparoscopic-assisted resection of terminal ileal Crohn's disease is slowly gaining acceptance as an alternative to conventional surgery, based on the advantages of earlier return of bowel function, reductions in length of stay, and smaller wounds in a population likely to require reoperation. There is limited documentation of the cost-effectiveness of this approach, particularly with the reported longer operating times. The purpose of this study was to compare laparoscopic and open resections for terminal ileal Crohn's disease.

METHODS

We compared contemporaneous cohorts of patients undergoing initial elective laparoscopic or open resection for ileocecal Crohn's disease between June 1, 1999 and October 31, 2000 at a single institution. Operative approach was at the discretion of the surgeon. Data collected included age, gender, body mass index, American Society of Anesthesiologists score, indication for surgery, morbidity, mortality, conversion (laparoscopic-resection group only), operating-room time, length of hospital stay, direct cost per case, 30-day readmission, and return to work. All data are presented as medians and interquartile ranges. Data analysis was performed with the Mann-Whitney U test, Fisher's exact test, and Student's t-test where appropriate. Significance was set at P < 0.05.

RESULTS

There were 45 evaluable patients (laparoscopic-resection group, 21; open-resection group, 24). One procedure was considered a conversion because of the 13-cm incision required to exteriorize the phlegmon (conversion rate, 4.8 percent). The median age (laparoscopic-resection group, 31 years; open-resection group, 39 years) and gender distributions (male/female: laparoscopic-resection group, 129; open-resection group, 915) were significantly different between the two groups. Resumption of oral intake (operating-room day vs. second postoperative day; P < 0.05) and resumption of intestinal function (2 vs. 4 days; P < 0.05) were significantly faster in the laparoscopic-resection patients. The median length of hospital stay was significantly shorter for the laparoscopic-resection patients (3 (2-3) vs. 5 (4-6) days; P < 0.05). The 30-day readmission rate in the laparoscopic-resection group was 9.6 percent (221), whereas none of the open-resection patients required rehospitalization. The overall complication rates were comparable for the laparoscopic-resection and open-resection patients (14.3 vs. 16.7 percent; P not significant), although there was one anastomotic leak and one intra-abdominal abscess in the laparoscopic-resection group, requiring readmission and reintervention (9.6 percent; P not significant). The direct cost per case was significantly lower for the laparoscopic-resection group ($2,547 vs. $2,985; P < 0.05, Student's t-test).

CONCLUSION

The laparoscopic-assisted approach to ileocecal Crohn's disease results in a shortened length of stay and seems economically advantageous to open surgery.

Laparoscopy-assisted live donor nephrectomy: a modified cost-effective approach for developing countries

BACKGROUND AND PURPOSE

Because of the prohibitive cost of laparoscopic disposable instruments such as the PneumoSleeve, Endocatch, and vascular staples, laparoscopic live-donor nephrectomy has not gained wide acceptance in many developing countries. To circumvent this problem, we have developed a cost-saving approach, which is described herein and compared with the open method.

PATIENTS AND METHODS

Forty-nine patients underwent laparoscopic live-donor nephrectomy at our institute, of which two were performed by the hand-assisted technique, five by the technique described by Fabrizio et al and forty-two by our modified cost-saving laparoscopy-assisted technique (LD). The latter patients were compared with 50 patients who had a standard open donor nephrectomy (OD) through a rib-resecting (12th rib) flank incision. Our technique is similar to the procedure described by Fabrizio et al except for a 6- to 8-cm incision placed in the subcostal region to retrieve the kidney after the renal vessels are cut and ligated as in the open procedure. The costs of the various techniques at our institute were compared.

RESULTS

The LD and OD groups were similar in terms of age, weight, side of nephrectomy, and number of renal vessels. The operative time was longer in the LD group than in the OD group (180.7 +/- 18 minutes v 101.5 +/- 10.4 minutes), whereas the mean intraoperative blood loss was less (85.5 +/- 21.35 v 220 +/- 22.5 mL; P < 0.001). Warm ischemia time and recipient outcomes were comparable in the two groups. Patients in the LD group had lower postoperative narcotic (tramadol hydrochloride) requirement (155.3 +/- 53.3 mg v 251.8 +/- 63.1 mg; P < 0.001) and earlier discharge from the hospital (3.14 v 5.7 days; P < 0.001). The mean expense incurred was US$175 v US$160 in the LD and OD groups, respectively. The cost of the hand-assisted and standard laparoscopic techniques was significantly higher than that of our modified technique.

CONCLUSIONS

Our modified technique of laparoscopy-assisted live-donor nephrectomy avoids the use of costly disposables yet offers the advantages of lesser morbidity and small incision of LD. It is cost effective and is an alternative to open nephrectomy in the developing world.

Cost structure of laparoscopic and open sigmoid colectomy for diverticular disease: similarities and differences

PURPOSE

Although laparoscopic colectomy has demonstrated a variety of advantages, it remains unclear whether the reductions in length of stay and faster return of bowel function will offset potential increases in cost caused by operating time and instrumentation. The purpose of this study was to compare the direct cost structure of elective open and laparoscopic resection for sigmoid diverticulitis.

METHODS

We compared consecutive elective open and laparoscopic sigmoid colectomies (n = 71 and n = 61, respectively) performed from March 1, 1999, through December 31, 2000. Data collected included age, gender, body mass index, American Society of Anesthesia score, indication for surgery, morbidity, mortality, conversion (laparoscopic only), operating time, and length of hospital stay. Direct cost data were provided by Stanford's integrated hospital cost management and decision software. Indirect costs and total costs were not addressed. Data were analyzed by Student's t-test and chi-squared test where appropriate. Significance was set at P < 0.05. All data are presented as mean +/- standard error of the mean.

RESULTS

There were 132 elective sigmoid colectomies for diverticular disease (61 laparoscopic and 71 open procedures). There were no significant differences between the groups with respect to age, male/female ratio, or body mass index. Operating time was similar (109 +/- 7 minutes for laparoscopic procedures vs. 101 +/- 7 minutes for open procedures). The laparoscopic group had a significantly shorter length of stay (3.1 +/- 0.2 vs. 6.8 +/- 0.4 days), fewer pulmonary complications (1 (1.6 percent) vs. 4 (5.6 percent)) and fewer wound infections (0 vs. 5 (7 percent)). Conversion to open colectomy was required in 4 (6.6 percent) of 61 patients. Readmission occurred in three laparoscopic colectomy patients (4.9 percent) and four open colectomy patients (5.6 percent). There was one operative death in the laparoscopic group (1.6 percent) and no deaths in the open group. Total direct cost per case was significantly less for laparoscopic procedures ($3,458 +/- 437) than for open colectomies ($4321 +/- 501; P < 0.05, Student's t-test), and operating costs were not significantly different between the groups.

CONCLUSION

The data demonstrate that laparoscopic colectomy is a cost-effective means of electively managing sigmoid diverticular disease. This operative approach may become very important in an era of increasing constraints on hospital occupancy rates and access to nursing services in many regions of the country.

[Current aspects of ambulatory surgery]

In territorial medical association partial redistribution of medical care from hospital to ambulatory was realized. Department of ambulatory laparoscopic surgery and gynecology with day facility and home hospital were organized. Preparation to operation was made ambulatory. After surgery patients were observed in the day hospital during 15-18 hours, then they were transferred to home hospital. In 1998-1999 this policy was applied in 208 patients. 415.5 thousand troubles from the budget were saved.

Economic implications of current surgical management of gastroesophageal reflux disease

BACKGROUND/PURPOSE

Surgical management of gastroesophageal reflux disease in children has evolved with the development of laparoscopy. Because concerns persist regarding increased costs associated with this technique, the authors studied the economic parameters of antireflux surgery at their institution.

METHODS

Seventy-eight patients undergoing either laparoscopic or open fundoplication were studied retrospectively between June 1998 and June 2000 comparing average operating room costs, total inpatient costs, and length of stay. Univariate comparisons were performed using Student's t test, and multivariate analysis was performed using multiple linear regression.

RESULTS

Univariate analysis showed that patients receiving the laparoscopic procedure had significantly shorter inpatient stays (2.4 v. 3.96 days; P =.004) than those receiving open procedures. Average operating room costs were similar (laparoscopic, $2,611; open, $2,162; P =.237), but total costs for the laparoscopic procedure were lower ($4,484 v $5,129; P =.006). Multivariate analysis results suggested that in addition to procedure type, patients who required an intensive care unit admission incurred $6,595 in additional total costs (P <.0001) and 4.8 additional hospital days (P <.0001). After controlling for other variables, the laparoscopic procedure did not significantly reduce total hospital costs ($447; P =.192) but was associated with a significant decrease in length of stay of 1.3 days (P <.0001).

CONCLUSION

These results suggest that laparoscopic procedures are comparable with open operations in terms of operative costs and that other factors are important determinants of the costs associated with antireflux surgery in children.

Laparoscopic appendectomy: An unnecessary and expensive procedure in children?

BACKGROUND/PURPOSE

Laparoscopic Appendectomy (LA) is a safe procedure in adults resulting in shorter hospitalization and sooner return to activity. The relative merits of LA and open appendectomy (OA) are evaluated in this first prospective and randomized study in children.

METHODS

A total of 129 children with appendicitis were included. Forty-three boys and 45 girls, age 1 to 16 years, were enrolled. Randomization was determined by sealed assignment card. OA utilized a 3- to 4-cm right lower quadrant, muscle-splitting incision. Wounds were closed without drains. Antibiotics, when used, consisted of gentamycin, clindamycin, and ampicillin. LA was performed by experienced surgeons utilizing a 3-trocar technique with reusable instruments. Twenty-one children (24%) were perforated. Patients were discharged as soon as they were taking a diet and afebrile. Statistical comparisons were by Fisher's Exact and Wilcoxon rank-sum tests.

RESULTS

There were no differences in postoperative analgesia, resumption of oral intake, length of hospitalization, return to normal activities, or morbidity. Laparoscopic appendectomy was associated with longer operating times and increased cost.

CONCLUSIONS

Laparoscopic appendectomy in children is not associated with the same advantages reported in adults. LA is a more expensive alternative and offers no advantages related to pain relief, length of stay, return to normal activities, or morbidity.

Selective spinal anesthesia versus desflurane anesthesia in short duration outpatient gynecological laparoscopy: a pharmacoeconomic comparison

We compared the cost and effectiveness of selective spinal anesthesia (SSA) with a desflurane-based general anesthetic (DES) for outpatient gynecological laparoscopy. A prospective analysis was undertaken of 10 patients randomized to receive SSA and compared with 10 patients randomized to receive DES. The groups were well matched in their demographic characteristics. The mean cost (in 2000 Canadian dollar values) of anesthesia supplies, drugs, and nursing for the SSA group of $62.31 was less than that for the DES group of $92.31 (P < 0.01). Recovery costs of both groups were similar. Time to administer anesthesia and time spent in the postanesthetic care unit were also similar. Postoperative analgesia was required by 50% of the DES group but in no patient receiving SSA (P < 0.01). SSA is a cost-effective alternative to DES in these patients.

IMPLICATIONS

Small-dose spinal anesthesia is an effective alternative to a desflurane general anesthetic in terms of cost and recovery profiles in ambulatory gynecological laparoscopy.

Hand-assisted laparoscopic surgery (HALS) for live donor nephrectomy is more time- and cost-effective than standard laparoscopic nephrectomy

BACKGROUND

Hand-assisted laparoscopy (HALS) was introduced to increase the safety of living donor nephrectomies. Herein we evaluate the first HALS living donor nephrectomies performed at our center.

METHODS

Traditional laparoscopic nephrectomies (TLS) (n = 11) and HALS nephrectomies (n = 11) were included in the study. One patient from the TLS group was excluded because the operation was converted to open nephrectomy. We compared the operating times (OT) and warm ischemia times (WIT) for the two procedures and calculated the operating costs.

RESULTS

Mean OT was 270 min in the TLS group and 197 min in the HALS group; thus, there was, a significant reduction of 27% with HALS. WIT was 297 sec for the TLS group and 214 sec for the HALS group, for a reduction of 28%. Costs were also lowered for HALS.

CONCLUSION

In addition to shortening both OT and WIT, HALS enhances the safety margin of the procedure, especially during trocar placement. It is further helpful in preventing torsion of the kidney and controlling potential bleedings, as well as during vascular stapling and kidney removal.