Excess use of surgical supplies in minimally invasive benign gynecology surgery: an observational study.

BACKGROUND: Single-use materials and equipment are regularly opened by the surgical team during procedures but left unused, potentially resulting in superfluous costs and excess environmental waste. OBJECTIVE: This study aimed to estimate the excess use of surgical supplies in minimally invasive benign gynecologic surgeries. STUDY DESIGN: This is a prospective observational study conducted at a university-affiliated single tertiary medical center. Designated study personnel were assigned to observe surgical procedures performed during July to September 2022. Surgical teams were observed while performing surgeries for benign indications. The teams were not informed of the purpose of the observation to avoid potential bias. Disposable materials and equipment opened during the procedure were documented. Excess supplies were defined as those opened but left unused before being discarded. Costs per item of the excess supplies were estimated on the basis of material and equipment costs provided by the hospital. RESULTS: A total of 99 surgeries were observed, including laparoscopic (32%), robotic (39%), hysteroscopic (14%), vaginal (11%), and laparotomy procedures (3%). Excess use of surgical supplies was documented in all but one procedure. The total cost across all surgeries reached $6357. The contained tissue extraction bag was the most expensive item not used (Applied Medical, Rancho Santa Margarita, CA; $390 per unit) in 4 procedures, contributing 25.54% to the total cost. Raytec was the most common surgical waste, with a total of n=583 opened but unused (average n=5.95 per surgery). A significant difference was found in the rate of excess supplies across the surgical approaches, with robotic surgery contributing 52.19% of the total cost (P=.01). CONCLUSION: Excess use of disposable materials and equipment is common in minimally invasive benign gynecologic surgeries and contributes to superfluous costs and excess environmental waste. It is predominantly attributed to the opening of inexpensive materials that are left unused during the procedure. Increased awareness of costs and generated waste may reduce excess use of surgical supplies and should be further explored in future research.

Economic Analysis of AbClo, a Novel Abdominal Fascia Closure Device, for Patients With an Open Abdomen Following Trauma or Acute Abdominal Surgery.

BACKGROUND: Open Abdomen (OA) cases represent a significant surgical and resource challenge. AbClo is a novel non-invasive abdominal fascial closure device that engages lateral components of the abdominal wall muscles to support gradual approximation of the fascia and reduce the fascial gap. The study objective was to assess the economic implications of AbClo compared to negative pressure wound therapy (NPWT) alone on OA management. METHODS: We conducted a cost-minimization analysis using a decision tree comparing the use of the AbClo device to NPWT alone among patients with midline laparotomy for trauma or acute abdominal surgery who were ineligible for primary fascial closure. The time horizon was limited to the length of the inpatient hospital stay, and costs were considered from the perspective of the US Medicare payer. Clinical effectiveness data for AbClo was obtained from a randomized clinical trial. Cost data was obtained from the published literature. Probabilistic and deterministic sensitivity analyses were performed. The primary outcome was incremental cost. RESULTS: The mean cumulative costs per patient were $76 582 for those treated with NPWT alone and $70,582 for those in the group treated with the AbClo device. Compared to NPWT alone, AbClo was associated with lower incremental costs of -$6012 (95% CI -$19 449 to +$1996). The probability that AbClo was cost-savings compared to NPWT alone was 94%. CONCLUSIONS: The use of AbClo is an economically attractive strategy for management of OA in in patients with midline laparotomy for trauma or acute abdominal surgery who were ineligible for primary fascial closure.

A prospective comparison of costs between robotics, laparoscopy, and laparotomy in endometrial cancer among women with Class III obesity or higher.

BACKGROUND AND OBJECTIVES: To compare the immediate operating room (OR), inpatient, and overall costs between three surgical modalities among women with endometrial cancer (EC) and Class III obesity or higher. METHODS: A multicentre prospective observational study examined outcomes of women, with early stage EC, treated surgically. Resource use was collected for OR costs including OR time, equipment, and inpatient costs. Median OR, inpatient, and overall costs across surgical modalities were analyzed using an Independent-Samples Kruskal-Wallis Test among patients with BMI ≥ 40. RESULTS: Out of 520 women, 103 had a BMI ≥ 40. Among women with BMI ≥ 40: median OR costs were $4197.02 for laparotomy, $5524.63 for non-robotic assisted laparoscopy, and $7225.16 for robotic-assisted laparoscopy (p < 0.001) and median inpatient costs were $5584.28 for laparotomy, $3042.07 for non-robotic assisted laparoscopy, and $1794.51 for robotic-assisted laparoscopy (p < 0.001). There were no statistically significant differences in the median overall costs: $10 291.50 for laparotomy, $8412.63 for non-robotic assisted laparoscopy, and $9002.48 for robotic-assisted laparoscopy (p = 0.185). CONCLUSION: There was no difference in overall costs between the three surgical modalities in patient with BMI ≥ 40. Given the similar costs, any form of minimally invasive surgery should be promoted in this population.

Cost-effectiveness Evaluation of Laparoscopic Versus Robotic Minimally Invasive Colectomy.

OBJECTIVE: Evaluate the cost-effectiveness of open, laparoscopic, and robotic colectomy. BACKGROUND: The use of robotic-assisted colon surgery is increasing. Robotic technology is more expensive and whether a robotically assisted approach is cost-effective remains to be determined. METHODS: A decision-analytic model was constructed to evaluate the 1-year costs and quality-adjusted time between robotic, laparoscopic, and open colectomy. Model inputs were derived from available literature for costs, quality of life (QOL), and outcomes. Results are presented as incremental cost-effectiveness ratios (ICERs), defined as incremental costs per quality-adjusted life year (QALY) gained. One-way and probabilistic sensitivity analyses were performed to test the effect of clinically reasonable variations in the inputs on our results. RESULTS: Open colectomy cost more and achieved lower QOL than robotic and laparoscopic approaches. From the societal perspective, robotic colectomy costs $745 more per case than laparoscopy, resulting in an ICER of $2,322,715/QALY because of minimal differences in QOL. From the healthcare sector perspective, robotics cost $1339 more per case with an ICER of $4,174,849/QALY. In both models, laparoscopic colectomy was more frequently cost-effective across a wide range of willingness-to-pay thresholds. Sensitivity analyses suggest robotic colectomy becomes cost-effective at $100,000/QALY if robotic disposable instrument costs decrease below $1341 per case, robotic operating room time falls below 172 minutes, or robotic hernia rate is less than 5%. CONCLUSIONS: Laparoscopic and robotic colectomy are more cost-effective than open resection. Robotics can surpass laparoscopy in cost-effectiveness by achieving certain thresholds in QOL, instrument costs, and postoperative outcomes. With increased use of robotic technology in colorectal surgery, there is a burden to demonstrate these benefits.

Cost-Effectiveness of Exploratory Laparotomy in a Regional Referral Hospital in Eastern Uganda.

BACKGROUND: Surgical disease increasingly contributes to global mortality and morbidity. The Lancet Commission on Global Surgery found that global cost-effectiveness data are lacking for a wide range of essential surgical procedures. This study helps to address this gap by defining the cost-effectiveness of exploratory laparotomies in a regional referral hospital in Uganda. MATERIALS AND METHODS: A time-and-motion analysis was utilized to calculate operating theater personnel costs per case. Ward personnel, administrative, medication, and supply costs were recorded and calculated using a microcosting approach. The cost in 2018 US Dollars (USD, $) per disability-adjusted life year (DALY) averted was calculated based on age-specific life expectancies for otherwise fatal cases. RESULTS: Data for 103 surgical patients requiring exploratory laparotomy at the Soroti Regional Referral Hospital were collected over 8 mo. The most common cause for laparotomy was small bowel obstruction (32% of total cases). The average cost per patient was $75.50. The postoperative mortality was 11.7%, and 7.8% of patients had complications. The average number of DALYs averted per patient was 18.51. The cost in USD per DALY averted was $4.08. CONCLUSIONS: This investigation provides evidence that exploratory laparotomy is cost-effective compared with other public health interventions. Relative cost-effectiveness includes a comparison with bed nets for malaria prevention ($6.48-22.04/DALY averted), tuberculosis, tetanus, measles, and polio vaccines ($12.96-25.93/DALY averted), and HIV treatment with multidrug antiretroviral therapy ($453.74-648.20/DALY averted). Given that the total burden of surgically treatable conditions in DALYs is more than that of malaria, tuberculosis, and HIV combined, our findings strengthen the argument for greater investment in primary surgical capacity in low- and middle-income countries.

The (cost) effectiveness of procedural sedation and analgesia versus general anaesthesia for hysteroscopic myomectomy, a multicentre randomised controlled trial: PROSECCO trial, a study protocol.

BACKGROUND: In women with abnormal uterine bleeding, fibroids are a frequent finding. In case of heavy menstrual bleeding and presence of submucosal type 0-1 fibroids, hysteroscopic resection is the treatment of first choice, as removal of these fibroids is highly effective. Hysteroscopic myomectomy is currently usually performed in the operating theatre. A considerable reduction in costs and a higher patient satisfaction are expected when procedural sedation and analgesia with propofol (PSA) in an outpatient setting is applied. However, both safety and effectiveness - including the necessity for re-intervention due to incomplete resection - have not yet been evaluated. METHODS: This study is a multicentre randomised controlled trial with a non-inferiority design and will be performed in the Netherlands. Women > 18 years with a maximum of 3 symptomatic type 0 or 1 submucosal fibroids with a maximum diameter of 3.5 cm are eligible to participate in the trial. After informed consent, 205 women will be randomised to either hysteroscopic myomectomy using procedural sedation and analgesia with propofol in an outpatient setting or hysteroscopic myomectomy using general anaesthesia in a clinical setting in the operating theatre. Primary outcome will be the percentage of complete resections, based on transvaginal ultrasonography 6 weeks postoperatively. Secondary outcomes are cost effectiveness, menstrual blood loss (Pictorial blood assessment chart), quality of life, pain, return to daily activities/work, hospitalization, (post) operative complications and re-interventions. Women will be followed up to one year after hysteroscopic myomectomy. DISCUSSION: This study may demonstrate comparable effectiveness of hysteroscopic myomectomy under procedural sedation and analgesia versus general anaesthesia in a safe and patient friendly environment, whilst achieving a significant cost reduction. TRIAL REGISTRATION: Dutch trial register, number NTR5357 . Registered 11th of August 2015.

Diagnostic staging laparoscopy in gastric cancer treatment: A cost-effectiveness analysis.

BACKGROUND AND OBJECTIVES: Accurate preoperative staging helps avert morbidity, mortality, and cost associated with non-therapeutic laparotomy in gastric cancer (GC) patients. Diagnostic staging laparoscopy (DSL) can detect metastases with high sensitivity, but its cost-effectiveness has not been previously studied. We developed a decision analysis model to assess the cost-effectiveness of preoperative DSL in GC workup. METHODS: Analysis was based on a hypothetical cohort of GC patients in the U.S. for whom initial imaging shows no metastases. The cost-effectiveness of DSL was measured as cost per quality-adjusted life-year (QALY) gained. Drivers of cost-effectiveness were assessed in sensitivity analysis. RESULTS: Preoperative DSL required an investment of $107 012 per QALY. In sensitivity analysis, DSL became cost-effective at a threshold of $100 000/QALY when the probability of occult metastases exceeded 31.5% or when test sensitivity for metastases exceeded 86.3%. The likelihood of cost-effectiveness increased from 46% to 93% when both parameters were set at maximum reported values. CONCLUSIONS: The cost-effectiveness of DSL for GC patients is highly dependent on patient and test characteristics, and is more likely when DSL is used selectively where procedure yield is high, such as for locally advanced disease or in detecting peritoneal and superficial versus deep liver lesions.

Effect of Time to Operation on Value of Care in Acute Care Surgery.

BACKGROUND: As reimbursement models evolve, there is increasing emphasis on maximizing value-based care for inpatient conditions. We hypothesized that longer intervals between admission and surgery would be associated with worse outcomes and increased costs for acute care surgery patients, and that these associations would be strongest among patients with high-risk conditions. METHODS: We performed a 5-year retrospective analysis of three risk cohorts: appendectomy (low-risk for morbidity and mortality, n = 618), urgent hernia repair (intermediate-risk, n = 80), and laparotomy for intra-abdominal sepsis with temporary abdominal closure (sTAC; high-risk, n = 102). Associations between the interval from admission to surgery and outcomes including infectious complications, mortality, length of stay, and hospital charges were assessed by regression modeling. RESULTS: Median intervals between admission and surgery for appendectomy, hernia repair, and sTAC were 9.3, 13.5, and 8.1 h, respectively, and did not significantly impact infectious complications or mortality. For appendectomy, each 1 h increase from admission to surgery was associated with increased hospital LOS by 1.1 h (p = 0.002) and increased intensive care unit (ICU) LOS by 0.3 h (p = 0.011). For hernia repair, each 1 h increase from admission to surgery was associated with increased antibiotic duration by 1.6 h (p = 0.007), increased hospital LOS by 3.3 h (p = 0.002), increased ICU LOS by 1.5 h (p = 0.001), and increased hospital charges by $1918 (p < 0.001). For sTAC, each 1 h increase from admission to surgery was associated with increased antibiotic duration by 5.0 h (p = 0.006), increased hospital LOS by 3.9 h (p = 0.046), increased ICU LOS by 3.5 h (p = 0.040), and increased hospital charges by $3919 (p = 0.002). CONCLUSIONS: Longer intervals from admission to surgery were associated with prolonged antibiotic administration, longer hospital and ICU length of stay, and increased hospital charges, with strongest effects among high-risk patients. To improve value of care for acute care surgery patients, operations should proceed as soon as resuscitation is complete.

An evaluation of mini-laparotomy cholecystectomy in the laparoscopic era: a rural experience.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the gold standard for the management of symptomatic cholelithiasis and complications of gallstone disease. Mini laparotomy cholecystectomy (MOC) may be a more appropriate option in the resource constrained rural setting due to its widespread applicability and comparable outcome with LC. The study aimed to provide an epidemiological analysis of gallstone disease in the rural population and to evaluate the outcome of MOC in a rural hospital. METHOD: A retrospective chart analysis of 248 patients undergoing cholecystectomy in a rural regional referral hospital in KwaZulu-Natal from January 2009 to December 2013 was undertaken. RESULTS: Of the 248 patients, the majority were females (n = 211, [85%]). The most frequent indications for cholecystectomy included: biliary colic (n = 115, [46.3%]); acute cholecystitis (n = 80, [32.3%]); gallstone pancreatitis (n = 27, [10.8%]). Forty cases (16.1%) were converted to open cholecystectomy (OC). The median operative time was 40 minutes (range18-57). Twenty-three morbidities (9.3%) occurred including: bile leaks (n = 6, [2.4%]); bleeding from drain site (n = 1, [0.4%]), incisional hernia (n = 8 [3.2%]) and wound sepsis (n = 8 [3.2%]). The median length of hospital stay in patients who underwent MOC was 48 hours (range: 24-72 hours) and the median time to return to work was 10 days (range: 4-14 days). There was one mortality in the entire cohort. CONCLUSION: MOC is a safe and feasible operation for symptomatic cholelithiasis when cholecystectomy is indicated. The low operative morbidity and mortality in the context of a high risk patient profile and complicated gallstone disease makes this procedure an alternative to LC where LC is inaccessible.

Considering Value in Rectal Cancer Surgery: An Analysis of Costs and Outcomes Based on the Open, Laparoscopic, and Robotic Approach for Proctectomy.

OBJECTIVE: The aim of the study was to compare value (outcomes/costs) of proctectomy in patients with rectal cancer by 3 approaches: open, laparoscopic, and robotic. BACKGROUND: The role of minimally invasive proctectomy in rectal cancer is controversial. In the era of value-based medicine, costs must be considered along with outcomes. METHODS: Primary rectal cancer patients undergoing curative intent proctectomy at our institution between 2010 and 2014 were included. Patients were grouped by approach [open surgery, laparoscopic surgery, and robotic surgery (RS)] on an intent-to-treat basis. Groups were compared by direct costs of hospitalization for the primary resection, 30-day readmissions, and ileostomy closure and for short-term outcomes. RESULTS: A total of 488 patients were evaluated; 327 were men (67%), median age was 59 (27-93) years, and restorative procedures were performed in 333 (68.2%). Groups were similar in demographics, tumor characteristics, and treatment details. Significant outcome differences between groups were found in operative and anesthesia times (longer in the RS group), and in estimated blood loss, intraoperative transfusion, length of stay, and postoperative complications (all higher in the open surgery group). No significant differences were found in short-term oncologic outcomes. Direct cost of the hospitalization for primary resection and total direct cost (including readmission/ileostomy closure hospitalizations) were significantly greater in the RS group. CONCLUSIONS: The laparoscopic and open approaches to proctectomy in patients with rectal cancer provide similar value. If robotic proctectomy is to be widely applied in the future, the costs of the procedure must be reduced.

Impact of body mass index and operative approach on surgical morbidity and costs in women with endometrial carcinoma and hyperplasia.

OBJECTIVE: To assess the impact of body mass index (BMI) and operative approach on surgical morbidity and costs in patients with endometrial carcinoma (EC) and hyperplasia (EH). METHODS: All women with BMI data who underwent surgery for EC or EH from 2008 to 2014 were identified from MarketScan, a healthcare claims database. Differences in 30-day complications and costs were compared between BMI groups and stratified by surgical modality. RESULTS: Of 1112 patients, 35%, 36%, and 29% had a BMI of ≤29, 30-39, and ≥40kg/m2, respectively. Compared to patients with a BMI of 30-39 and ≤29, women with a BMI ≥40 had higher rates of venous thromboembolism (3% vs 0.2% vs 0.3%, p<0.01) and wound infection (7% vs 3% vs 3%, p=0.02). This increase was driven by the subset of patients who had laparotomy and was not seen in those undergoing minimally invasive surgery (MIS). Median total costs for women with a BMI ≥40, 30-39, and ≤29 were U.S. $17.3k, $16.8k, and $16.6k respectively (p=0.53). Costs were higher for patients who had laparotomy than those who had MIS across all BMI groups, with the cost difference being highest in morbidly obese women (≥40: $21.6k vs $14.9k, p<0.01; 30-39: $18.9k vs $16.1k, p=0.01; ≤29: $19.3k vs $15k, p<0.01). Patients who had complications had higher costs compared to those who did not, with a higher cost difference in the laparotomy group ($27.7k vs $16.4k, p<0.01) compared to the MIS group ($19.9k vs $15k, p<0.01). CONCLUSIONS: MIS may increase the value of care by minimizing complications and decreasing costs. This may be most pronounced in morbidly obese women.

Costs and quality of life of small-incision open cholecystectomy and laparoscopic cholecystectomy - an expertise-based randomised controlled trial.

BACKGROUND: Health care providers need solid evidence based data on cost differences between alternative surgical procedures for common surgical disorders. We aimed to compare small-incision open cholecystectomy (SIOC) and laparoscopic cholecystectomy (LC) concerning costs and health-related quality of life using data from an expertise-based randomised controlled trial. METHODS: Patients scheduled for cholecystectomy were assigned to undergo LC or SIOC performed by surgeons in two different expert groups. Total costs were calculated in USD. Reusable instruments were assumed for the cost analysis. Quality of life was measured using the EuroQol 5-D 3-L (EQ 5-D-3L), at five postoperative time points and calculated to Area Under Curve (AUC) for 1 year postoperatively. Two hospitals participated in the trial, which included both emergency and elective surgery. RESULTS: Of 477 patients that underwent a cholecystectomy during the study period, 355 (74.9%) were randomised and 323 analysed, 172 LC and 151 SIOC patients. Both direct and total costs were less for SIOC than for LC patients. The total costs were 5429 (4293-6932) USD for LC and 4636 (3905-5746) USD for SIOC, P = 0.001. The quality of life index did not differ between the LC and SIOC groups at any time. Median values (25th and 75th percentiles (p25-p75)) for AUC at 1 year were as follows: 349 (337-351) for LC and 349 (338-350) for SIOC. CONCLUSIONS: In this expertise-based randomised controlled trial LC was a more costly procedure and quality of life did not differ after SIOC and LC. (ClinicalTrials.gov Identifier: NCT00370344, August 30, 2006).

The comparative costs of laparoscopic and open liver resection: a report for the 2nd International Consensus Conference on Laparoscopic Liver Resection.

BACKGROUND: The techniques of laparoscopic liver resection (LLR) have developed rapidly in selected centers, while global adoption of this approach has been cautious. The costs of LLR compared to open resection (OLR) are considered an important metric in evaluating this approach and may be a barrier to adoption in some centers. METHODS: To formulate a consensus statement using the Zurich-Danish consensus model to the question of "What are the comparative outcomes of cost for LLR and OLR, minor and major?" a systematic search of the literature was conducted. Results were presented to the jury in September 2014 and updated in August 30, 2015. Adjustments for currency conversions and inflation were not performed due to limitations in available data. RESULTS: Thirty-four studies were reviewed, and 11 relevant papers were selected for inclusion. No randomized control studies were found. Five studies were case-matched comparisons, while the remaining studies were retrospective reviews. The number of patients in each study ranged from 28 to 74, and the cumulative number of patients was 643 comparing 350 OLR to 293 LLR. Overall median hospital stay was lower for LLR at 4.6 versus 7.4 days. This remained valid when only the case-matched studies were analyzed, 4.6 (n = 178) versus 6.6 days (n = 266). The median overall total costs were 16.3 % lower (range 0 to -22 %) for LLR compared to OLR. This remained valid in the subgroup analysis of the case-matched studies, with a median 17.4 % lower costs for the LLR. Median OR costs were 3 % higher for LLR (range -9 to 40 %) but 32.9 % lower for hospital ward costs (range 0 to -60 %) when compared to OLR. CONCLUSIONS: Currently, the published literature indicates that overall hospital costs are less for LLR when compared to OLR (Level of evidence 3a and 3b). This evidence is strongest for minor hepatic resections. The decreased cost is based on savings in hospital ward costs and likely related to a significantly shorter hospital stay for LLR.

A national evaluation of clinical and economic outcomes in open versus laparoscopic colorectal surgery.

BACKGROUND: Surgical value is based on optimizing clinical and financial outcomes. The clinical benefits of laparoscopic surgery are well established; however, many patients are still not offered a laparoscopic procedure. Our objective was to compare the modern clinical and financial outcomes of laparoscopic and open colorectal surgery. METHODS: The Premier Perspective database identified patients undergoing elective colorectal resections from January 1, 2013 to December 31, 2013. Cases were stratified by operative approach into laparoscopic and open cohorts. Groups were controlled on all demographics, diagnosis, procedural, hospital characteristics, surgeon volume, and surgeon specialty and then compared for clinical and financial outcomes. The main outcome measures were length of stay (LOS), complications, readmission rates, and cost by surgical approach. RESULTS: A total of 6343 patients were matched and analyzed in each cohort. The most common diagnosis was diverticulitis (p = 0.0835) and the most common procedure a sigmoidectomy (p = 0.0962). The LOS was significantly shorter in laparoscopic compared to open (mean 5.78 vs. 7.80 days, p < 0.0001). The laparoscopic group had significantly lower readmission (5.82 vs. 7.68 %, p < 0.0001), complication (32.60 vs. 42.28 %, p < 0.0001), and mortality rates (0.52 vs. 1.28 %, p < 0.0001). The total cost was significantly lower in laparoscopic than in open (mean $17,269 vs. $20,552, p < 0.0001). By category, laparoscopy was significantly more cost-effective for pharmacy (p < 0.0001), room and board (p < 0.0001), recovery room (p = 0.0058), ICU (p < 0.0001), and laboratory and imaging services (both p < 0.0001). Surgical supplies (p < 0.0001), surgery (p < 0.0001), and anesthesia (p = 0.0053) were higher for the laparoscopic group. CONCLUSIONS: Laparoscopy is more cost-effective and produces better patient outcomes than open colorectal surgery. Minimally invasive colorectal surgery is now the standard that should be offered to patients, providing value to both patient and provider.

Comparison of open, laparoscopic, and robotic approaches for total abdominal colectomy.

BACKGROUND: The utilization of minimally invasive surgery is increasing in colorectal surgery. We sought to compare the outcomes of patients who underwent elective open, laparoscopic, and robotic total abdominal colectomy. METHODS: The NIS database was used to examine the clinical data of patients who underwent an elective total colectomy procedure during 2009-2012. Multivariate regression analysis was performed to compare the three surgical approaches. RESULTS: We sampled a total of 26,721 patients who underwent elective total colectomy. Of these, 16,780 (62.8 %) had an open operation, while 9934 (37.2 %) had a minimally invasive approach (9614 laparoscopic surgery, and 326 robotic surgery). The most common indication for an operation was ulcerative colitis (31 %). Patients who underwent open surgery had significantly higher mortality and morbidity compared to laparoscopic (AOR 2.48, 1.30, P < 0.01) and robotic approaches (AOR 1.04, 1.30, P < 0.01 and P = 0.04, respectively). There was no significant difference in mortality and morbidity between the laparoscopic and robotic approaches (AOR 0.96, 1.03, P = 0.10, P = 0.78). However, conversion rate of laparoscopic surgery to open was significantly higher than that of robotic approach (13.3 vs. 1.5 %, P < 0.01). Patients who underwent laparoscopic surgery had significantly lower total hospital charges compared to patients who underwent open surgery (mean difference = $21,489, P < 0.01). Also, total hospital charges for a robotic approach were significantly higher than for a laparoscopic approach (mean difference = $15,595, P < 0.01). CONCLUSION: Minimally invasive approaches to total colectomy are safe, with the advantage of lower mortality and morbidity compared to an open approach. Although there was no significant difference in the morbidity between minimally invasive approaches, robotic surgery had a significantly lower conversion rate compared to laparoscopic approach. Total hospital charges are significantly higher in robotic surgery compared to laparoscopic approach.

Epidural Local Anesthetics Versus Opioid-Based Analgesic Regimens for Postoperative Gastrointestinal Paralysis, Vomiting, and Pain After Abdominal Surgery: A Cochrane Review.

BACKGROUND: The aim of this review was to compare the effects of postoperative epidural analgesia with local anesthetics to postoperative systemic or epidural opioids in terms of return of gastrointestinal transit, postoperative pain control, postoperative vomiting, incidence of gastrointestinal anastomotic leak, hospital length of stay, and cost after abdominal surgery. METHODS: Trials were identified by computerized searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 12), Medical Literature Analysis and Retrieval System Online (MEDLINE) (from 1950 to December, 2014) and Excerpta Medica dataBASE (EMBASE) (from 1974 to December 2014) and by checking the reference lists of trials retained. We included parallel randomized controlled trials comparing the effects of postoperative epidural local anesthetic with regimens based on systemic or epidural opioids. The quality of the studies was rated according to the Cochrane tool. Two authors independently extracted data. We judged the quality of evidence according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) working group scale. RESULTS: Based on 22 trials including 1138 participants, an epidural containing a local anesthetic will decrease the time required for return of gastrointestinal transit as measured by time required to observe the first flatus after an abdominal surgery standardized mean difference (SMD) -1.28 (95% confidence interval [CI], -1.71 to -0.86; high quality of evidence; equivalent to 17.5 hours). The effect is proportional to the concentration of local anesthetic used. Based on 28 trials including 1559 participants, we also found a decrease in time to first feces (stool): SMD -0.67 (95% CI, -0.86 to -0.47; low quality of evidence; equivalent to 22 hours). Based on 35 trials including 2731 participants, pain on movement at 24 hours after surgery is also reduced: SMD -0.89 (95% CI, -1.08 to -0.70; moderate quality of evidence; equivalent to 2.5 on a scale from 0 to 10). Based on 22 trials including 1154 participants, we did not find a difference in the incidence of vomiting within 24 hours: risk ratio 0.84 (95% CI, 0.57-1.23); low quality of evidence. Based on 17 trials including 848 participants we did not find a difference in the incidence of gastrointestinal anastomotic leak: risk ratio 0.74 (95% CI, 0.41-1.32; low quality of evidence). Based on 30 trials including 2598 participants, epidural analgesia reduces length of hospital stay for an open surgery: SMD -0.20 (95% CI, -0.35 to -0.04; very low quality of evidence; equivalent to 1 day). Data on cost were very limited. CONCLUSIONS: An epidural containing a local anesthetic, with or without the addition of an opioid, accelerates the return of the gastrointestinal transit (high quality of evidence). An epidural containing a local anesthetic with an opioid decreases pain after an abdominal surgery (moderate quality of evidence). An epidural containing a local anesthetic does not affect the incidence of vomiting or anastomotic leak (low quality of evidence). For an open surgery, an epidural containing a local anesthetic would reduce the length of hospital stay (very low quality of evidence).

Estimated costs before, during and after the introduction of the emergency laparotomy pathway quality improvement care (ELPQuIC) bundle.

Implementation of a quality improvement bundle for peri-operative management of emergency laparotomy (ELPQuIC) improved mortality in a previous study. We used data from one site that participated in that study to examine whether it was associated with the cost of care. We collected data from 396 patients: 144 before, 144 during and 108 after implementation of the bundle. We estimated costs incurred using previously published methodology based on the time the patient spent in hospital, in the operating theatre and in critical care. Duration of stay in hospital and critical care did not differ between time periods, p = 0.14 and p = 0.28, respectively. The costs per patient and per survivor did not differ between the time periods, p = 0.87 and p = 0.17, respectively. Costs were similar for patients aged < 80 years vs. ≥ 80 years. Implementation of a quality improvement bundle for emergency laparotomy has the capacity to save lives without increasing hospital costs.

Increasing Minimally Invasive Hysterectomy: A Canadian Academic Health Centre Experience.

OBJECTIVE: An institution wide strategic plan was established to improve minimally invasive surgery (MIS) across all surgical divisions at The Ottawa Hospital (TOH). The primary objective of this study is to determine the change in MIS hysterectomy rate between 2005 and 2012 at this centre. Secondary objectives include determining the impact on overall length of stay (LOS) in hospital, complications, return to hospital, operating room time, and cost. METHODS: We performed a retrospective analysis of all hysterectomies for benign disease performed at TOH between 2005 and 2012. Cases were excluded if they were related to pregnancy or classified as "partial hysterectomy." The outcomes and cost of the approaches were compared. RESULTS: A total of 4337 hysterectomy cases were reviewed. The MIS hysterectomy rate increased from 40.1% in 2005 to 74.2% in 2012. There was a decrease in mean LOS from 2.5 to 1.6 days. This translated to a saving of 1898 inpatient bed days. Compared with laparotomy, laparoscopic hysterectomy was associated with a reduced risk of transfusion and a reduced risk of ileus, and vaginal hysterectomy was associated with an increased risk of postoperative abscess. There was no difference in rates of returning to hospital or other complications between women undergoing abdominal hysterectomy and women undergoing MIS hysterectomy (which included both laparoscopic and vaginal approaches). The mean (SD) cost per approach was $7241 ($1985), $4532 ($1718), and $5637 ($1579) for abdominal hysterectomy, vaginal hysterectomy, and laparoscopic hysterectomy, respectively. CONCLUSION: The initiatives implemented at TOH in 2007 resulted in a significant increase in the MIS hysterectomy rate, a decrease in mean LOS, and substantial theoretical cost savings for the hospital.

Less cost by using hanging maneuver and Pringle maneuver in left lateral hepatectomy through small laparotomy wound--experience of Southern Taiwan.

BACKGROUND: Laparoscopic segmentectomy for liver tumor located in the left lateral segment (LLS) is thought to be a standard protocol nowadays with several advantages, such as small wound, few blood loss, and short hospital stay. However, there are still many disadvantages during executing laparoscopic LLS segmentectomy. This manuscript aims to present the technique to execute LLS segmentectomy with small incision, hanging maneuver without Pringle maneuver in patients with tumor at LLS of the liver. MATERIAL AND METHODS: Between November 2010 and July 2011, hepatectomies through small incision for nine patients with benign and malignant tumors were performed at Kaohsiung Chang Gung Memorial Hospital, Taiwan. Perioperative and postoperative results, such as operation time, blood loss, incisional width, and postoperative stay were used to determine consequents for this technique. RESULT: Results demonstrated that modified LLS segmentectomy by the author's team was performed successfully in patient with liver tumor with fewer blood loss, smaller incisional width, and lower hospital cost than traditional open surgery. In addition, the instrument cost and blood loss in our series were less than that in laparoscopic LLS segmentectomy in published literature. CONCLUSION: Authors concluded that minimally incisional segmentectomy, with less cost and technical demanding, could be an alternative choice in patient with liver tumor at LLS.

The trend towards minimally invasive surgery (MIS) for endometrial cancer: an ACS-NSQIP evaluation of surgical outcomes.

OBJECTIVE: Our objective was to evaluate the surgical trend towards increased MIS in the management of endometrial cancer in regard to improvements in patient outcomes. METHODS: Using the American College of Surgeons-National Surgical Quality Improvement Project's database, patients who underwent hysterectomy for endometrial cancer from 2006-2010 were identified and categorized into exploratory laparotomy (XLAP) or MIS. Comparative analyses were performed and stratified by year of surgery to evaluate demographics, surgical outcomes, and 30-day surgical morbidity. RESULTS: A total of 2076 patients (1269 XLAP and 807 MIS) underwent hysterectomy for endometrial cancer between 2006 and 2010. Longer operative times were seen in MIS compared to XLAP (192 vs. 148 min; p<0.001) as well as significant increase in mean hospital stay in the XLAP group of 3.8 days compared to 1.6 days in MIS (p<0.0001). When controlling for preoperative comorbidities, significant increases in postoperative complications were observed in XLAP compared to MIS group (total 396 vs. 91; p<0.0001). MIS increased from 16% in 2006 to 48% in 2010, which correlated to decreases in complications and hospital stays. Each 10% increase in MIS would save $2.8 million and 41 postoperative complications. If used exclusively, MIS would save 6434 hospital days and 416 complications. CONCLUSIONS: Despite increases in operative times, MIS for the treatment of endometrial cancer significantly reduces perioperative complications and hospital stay. Considering the improvements in patient outcomes and the potential savings to the health care system, MIS should be the preferred route for the surgical treatment of this disease when feasible.