Page 104 - International guidelines for groin hernia management

Hernia

Evidence in literature mesh repair. Data for this study were collected in 15
Open tissue IH repair under local anesthetic is the least German hospitals and were used to analyze costs. The
costly technique when materials alone are considered. authors concluded that laparoscopic approaches are not
However, due to longer return-to-work times and higher necessarily associated with higher resource utilization
recurrence rates it may be less cost-effective when com- when compared to open mesh repairs. 85 A recent large
pared to mesh repair. 92–94 English study had a similar finding. 81 This study concluded
Institutional costs were higher for laparoscopic repair that the mean cost of laparoscopic versus open hernia
(TAPP, TEP) when compared with open mesh tech- repair is comparable but laparoscopic repairs appear to
niques. 62, 82, 83, 95–121 In experienced centers with minimal offer higher costs per QALY versus open repairs. 81
disposables use, the cost of laparoscopic repair may be In contradiction to the results seen in studies of direct/
equivalent to, or lower than, the cost of open surgery. hospital costs, nearly all RCTs, systematic reviews and
However, some study data used to arrive at this con- meta-analyses demonstrate that indirect/societal costs for
clusion may be flawed. Operating times in excess of laparoscopic IH repair are lower than open mesh repair.
60 min, 90, 92, 96, 97, 100, 101, 107, 108, 113, 114, 120–122 high This finding is accounted for by more rapid recovery with
recurrence rates for laparoscopic repair (10%) 66, 92, 123 and less pain, 62, 90, 91, 100, 116, 122, 125, 130 shorter sick-leave
high conversion rates (6–10%) 82, 115, 118 may indicate lack time, 83, 84, 96, 101, 102, 106, 108, 109, 113, 120, 124–126, 130–132
of experience. Studies not mentioning instrument and better physio metric test results, 79, 95 and decreased com-
material types are unsuitable for cost calculations. plications and recurrence rates as experience has
Most papers state that higher laparoscopic surgery costs grown. 79, 82, 90, 94, 101, 106, 108, 114, 116, 119, 126, 130–132
mainly reflect the use of expensive disposables and longer If both direct and indirect costs are tabulated, laparo-
operating times. 80, 83, 90, 101, 105–110, 118, 124–126 Multiple scopic hernia repair appears to be more cost-effective than
cost analyses demonstrate that if disposable trocars, gras- open hernia repair. 81, 102, 105, 119, 126, 131, 133–136
pers, preperitoneal balloons and stapling devices (‘‘tack- KQ24.c Which surgeon-specific factors result in improved
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ers’’) are included, direct costs are significantly higher cost-effectiveness?
for laparoscopic over open hernia repair. This was mainly Cost-effectiveness may be enhanced by an increase in
true in the early laparoscopic hernia surgery individual case load (more rapid depreciation of equipment
era. 82, 89, 96, 97, 100, 108, 117, 119, 124, 128 costs, more experience), 137 shortening of the learning curve
Now, institutional costs for laparoscopic hernia repair (resulting in decreased operating times), proper supervision
may be comparable to, or lower than, open hernia repair of residents and junior consultants, surgical technique
costs. 79, 90, 91, 117, 129 One study shows that in large-volume improvements (resulting in lower complication and recur-
laparoscopic surgery centers with minimal use of dispos- rence rates), technique standardization, systematic training
able instruments and no use of preperitoneal balloons and including simulation-based training 46, 83, 87, 97, 100, 132, 138
tackers for mesh fixation, the direct costs of laparoscopic and use of non-disposable trocars and other instru-
repairs are comparable to open repairs. 90 One recent study ments 83, 90, 91, 107, 136, 139, 140 (see Chapter 22 material on
found lower TEP/TAPP costs when compared to open learning curves).

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