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1.
BMJ ; 370: m2457, 2020 07 14.
Artigo em Inglês | MEDLINE | ID: mdl-32665218

RESUMO

OBJECTIVE: To determine whether robotic ventral hernia repair is associated with fewer days in the hospital 90 days after surgery compared with laparoscopic repair. DESIGN: Pragmatic, blinded randomized controlled trial. SETTING: Multidisciplinary hernia clinics in Houston, USA. PARTICIPANTS: 124 patients, deemed appropriate candidates for elective minimally invasive ventral hernia repair, consecutively presenting from April 2018 to February 2019. INTERVENTIONS: Robotic ventral hernia repair (n=65) versus laparoscopic ventral hernia repair (n=59). MAIN OUTCOME MEASURES: The primary outcome was number of days in hospital within 90 days after surgery. Secondary outcomes included emergency department visits, operating room time, wound complications, hernia recurrence, reoperation, abdominal wall quality of life, and costs from the healthcare system perspective. Outcomes were pre-specified before data collection began and analyzed as intention to treat. RESULTS: Patients from both groups were similar at baseline. Ninety day follow-up was completed in 123 (99%) patients. No evidence was seen of a difference in days in hospital between the two groups (median 0 v 0 days; relative rate 0.90, 95% confidence interval 0.37 to 2.19; P=0.82). For secondary outcomes, no differences were noted in emergency department visits, wound complications, hernia recurrence, or reoperation. However, robotic repair had longer operative duration (141 v 77 min; mean difference 62.89, 45.75 to 80.01; P≤0.001) and increased healthcare costs ($15 865 (£12 746; €14 125) v $12 955; cost ratio 1.21, 1.07 to 1.38; adjusted absolute cost difference $2767, $910 to $4626; P=0.004). Among patients with robotic ventral hernia repair, two had an enterotomy compared none with laparoscopic repair. The median one month postoperative improvement in abdominal wall quality of life was 3 with robotic ventral hernia repair compared with 15 following laparoscopic repair. CONCLUSION: This study found no evidence of a difference in 90 day postoperative hospital days between robotic and laparoscopic ventral hernia repair. However, robotic repair increased operative duration and healthcare costs. TRIAL REGISTRATION: Clinicaltrials.gov NCT03490266.


Assuntos
Hérnia Ventral/cirurgia , Herniorrafia/métodos , Laparoscopia , Procedimentos Cirúrgicos Robóticos , Serviço Hospitalar de Emergência , Herniorrafia/efeitos adversos , Herniorrafia/economia , Custos Hospitalares , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/economia , Tempo de Internação , Duração da Cirurgia , Complicações Pós-Operatórias , Qualidade de Vida , Recidiva , Reoperação , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/economia
2.
Am Surg ; 86(6): 715-720, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32683956

RESUMO

BACKGROUND: Surgeons can help reduce health care spending by selecting affordable and efficient instruments. The laparoscopic appendectomy (LA) is commonly performed and can serve as a model for improving health care cost. METHODS: We retrospectively reviewed all adult patients who underwent LA for non-perforated appendicitis from March 2015 to November 2017. Our objective was to determine which combination of disposable instruments afforded the lowest total operative cost without compromising postoperative outcomes. RESULTS: In total, 1857 consecutive patients were reviewed from 2 hospitals. After determining the 8 most commonly utilized combinations of disposable instruments, 846 patients were ultimately analyzed. The combination of a LigaSure, Endoloop, and an EndoBag (LEB) had the shortest median operative time (25 minutes, P < .001) and lowest median total operative cost ($1893, P < .001). CONCLUSIONS: The LEB instrument combination rendered the shortest operative time, lowest total operative cost, and can be used to maximize surgical value during LA.


Assuntos
Apendicectomia/métodos , Apendicite/cirurgia , Equipamentos Descartáveis/economia , Laparoscopia , Instrumentos Cirúrgicos/economia , Adulto , Apendicectomia/economia , Apendicectomia/instrumentação , Apendicite/economia , Análise Custo-Benefício , Feminino , Humanos , Laparoscopia/economia , Laparoscopia/instrumentação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Retrospectivos
3.
Ann Surg ; 272(2): 334-341, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32675547

RESUMO

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.


Assuntos
Colectomia/economia , Colectomia/métodos , Análise Custo-Benefício , Laparoscopia/economia , Procedimentos Cirúrgicos Robóticos/economia , Estudos de Coortes , Técnicas de Apoio para a Decisão , Feminino , Humanos , Laparoscopia/métodos , Laparotomia/economia , Laparotomia/métodos , Masculino , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/métodos , Resultado do Tratamento
4.
Surg Laparosc Endosc Percutan Tech ; 30(5): e28-e29, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32487856

RESUMO

The wide and fast spread of COVID-19 around the world has led to a dramatic increase in the need for protection products both for carers and for populations. Surgical team protection includes a systematic screening of patients, wearing protection devices by all the operating staff, and adequate management of aerosols. The risk of aerosol dispersal is particularly high during laparoscopic and robotic surgeries due to the interaction between circulating CO2 and surgical smoke that may contain small viral particles. To decrease the risk of virus transmission, many recommendations have been implemented including the use of integrated insufflation devices comprising smoke evacuation and filtration mode. Such devices are lacking in many centers around the world and to overcome this urgent unmet need, we designed a cost-effective filtrating suction as a more readily available alternative.


Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Laparoscopia/métodos , Pneumonia Viral/epidemiologia , Procedimentos Cirúrgicos Robóticos/métodos , Fumaça , Aerossóis , Análise Custo-Benefício , Transmissão de Doença Infecciosa , Desenho de Equipamento , Humanos , Hidroxietilrutosídeo , Laparoscopia/economia , Pandemias , Procedimentos Cirúrgicos Robóticos/economia , Sucção/economia , Sucção/métodos
5.
Ann R Coll Surg Engl ; 102(8): 598-600, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32538107

RESUMO

INTRODUCTION: Common bile duct stones are present in 10% of patients with symptomatic gallstones. One-third of UK patients undergoing cholecystectomy will have preoperative ductal imaging, commonly with magnetic resonance cholangiopancreatography. Intraoperative laparoscopic ultrasound is a valid alternative but is not widely used. The primary aim of this study was to assess cost effectiveness of laparoscopic ultrasound compared with magnetic resonance cholangiopancreatography. MATERIALS AND METHODS: A prospective database of all patients undergoing laparoscopic cholecystectomy between 2015 and 2018 at a district general hospital was assessed. Inclusion criteria were all patients, emergency and elective, with symptomatic gallstones and suspicion of common bile duct stones (derangement of liver function tests with or without dilated common bile duct on preoperative ultrasound, or history of pancreatitis). Patients with known common bile duct stones (magnetic resonance cholangiopancreatography or failed endoscopic retrograde cholangiogram) were excluded. Ninety-day morbidity data were also collected. RESULTS: A total of 420 (334 elective and 86 emergency) patients were suspected to have common bile duct stones and were included in the study. The cost of a laparoscopic ultrasound was £183 per use. The cost of using the magnetic resonance cholangiopancreatography unit was £365 per use. Ten postoperative magnetic resonance cholangiopancreatographies were performed for inconclusive intraoperative imaging. The estimated cost saving was £74,650. Some 128 patients had common bile duct stones detected intraoperatively and treated. There was a false positive rate of 4.7%, and the false negative rate at 90 days was 0.7%. laparoscopic ultrasound use saved 129 bed days for emergency patients and 240 magnetic resonance cholangiopancreatography hours of magnetic resonance imaging. CONCLUSION: The use of laparoscopic ultrasound during laparoscopic cholecystectomy for the detection of common bile duct stone is safe, accurate and cost effective. Equipment and maintenance costs are quickly offset and hospital bed days can be saved with its use.


Assuntos
Colecistectomia Laparoscópica , Coledocolitíase , Cuidados Intraoperatórios/economia , Laparoscopia/economia , Ultrassonografia/economia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Colangiopancreatografia por Ressonância Magnética , Colecistectomia Laparoscópica/efeitos adversos , Colecistectomia Laparoscópica/métodos , Colecistectomia Laparoscópica/estatística & dados numéricos , Coledocolitíase/diagnóstico por imagem , Coledocolitíase/cirurgia , Análise Custo-Benefício , Feminino , Cálculos Biliares/diagnóstico por imagem , Cálculos Biliares/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem
6.
J Surg Res ; 253: 232-237, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32387570

RESUMO

BACKGROUND: Evidence suggests that operative delay of up to 24 h is not associated with adverse outcomes among patients undergoing emergent appendectomy. However, the fiscal implication of operative delay is not well described in adults. We sought to examine the effect of delayed appendectomy on clinical outcomes and hospital cost. METHODS: We conducted a retrospective cohort study of patients undergoing nonelective laparoscopic appendectomy from 2014 to 2018 at both a tertiary care center and an affiliated short-stay hospital. Using a unique data set constructed from merged electronic health record and patient-level hospital financial data, patients with delayed surgery, defined as >12 h from emergency department (ED) arrival to operation, were compared with patients who underwent surgery within 12 h. Patient-specific variables were analyzed for their association with resource utilization, and subsequent multivariable linear regression was performed for total hospital cost. RESULTS: 1372 patients underwent laparoscopic appendectomy during the study period. 938 patients (68.3%) underwent surgery within 12 h of ED arrival, and 434 patients (31.6%) underwent delayed surgery. Delayed cases had longer length of stay (44.6 ± 42.5 versus 34.5 ± 36.5 h, P < 0.01) and increased total hospital cost ($9326 ± 4691 versus $8440 ± 3404, P < 0.01). The cost difference persisted on multivariable analysis (P < 0.01). There were no significant differences between delayed cases and nondelayed cases for operative time, intraoperative findings, including rate of perforation, or postoperative complications. CONCLUSIONS: Although safe, delayed appendectomy is associated with an increased length of stay and increased total hospital costs compared with appendectomy within 12 h of reaching the ED.


Assuntos
Apendicectomia/métodos , Apendicite/cirurgia , Custos e Análise de Custo/estatística & dados numéricos , Laparoscopia/métodos , Tempo para o Tratamento/economia , Adulto , Apendicectomia/economia , Apendicectomia/estatística & dados numéricos , Apendicite/economia , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Custos Hospitalares/estatística & dados numéricos , Humanos , Laparoscopia/economia , Laparoscopia/estatística & dados numéricos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Tempo para o Tratamento/estatística & dados numéricos , Resultado do Tratamento , Adulto Jovem
7.
Surg Today ; 50(10): 1255-1261, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32335714

RESUMO

PURPOSE: To compare the short-term outcomes of conventional open colectomy with those of laparoscopic colectomy for colon cancer. METHODS: We retrieved data between January 2014 and March 2016 from the Diagnosis Procedure Combination database. A total of 69,418 patients who underwent colectomy for colon cancer were analyzed from among 15,901,766 cases of colorectal cancer. We applied a multilevel logistic regression model using a 2-level structure of individuals nested from 1065 hospitals. RESULTS: A total of 22,440 open colectomy and 46,978 laparoscopic colectomy procedures were performed. The in-hospital mortality rate was significantly lower in the laparoscopic group than in the open group (0.28% vs. 0.06%, odds ratio [OR] 0.40, p < 0.001). Similarly, the 30-day postoperative mortality rate (0.14% vs. 0.03%, OR 0.47, p = 0.019) and surgical morbidity rate (43.0% vs. 25.3%, OR 0.47, p < 0.001) were significantly lower in the laparoscopic group than in the open group. The postoperative length of stay was significantly longer in the open group (mean difference - 5.6 days, p < 0.001) than in the open group. The admission cost was significantly greater in the open group than in the laparoscopic group (mean difference - 95,080 yen, p < 0.001). CONCLUSIONS: Laparoscopic colectomy is safe and effective in the short term.


Assuntos
Colectomia/métodos , Neoplasias Colorretais/cirurgia , Endoscopia Gastrointestinal/métodos , Laparoscopia/métodos , Idoso , Idoso de 80 Anos ou mais , Colectomia/economia , Colectomia/mortalidade , Neoplasias Colorretais/economia , Neoplasias Colorretais/mortalidade , Custos e Análise de Custo , Bases de Dados Factuais , Endoscopia Gastrointestinal/economia , Endoscopia Gastrointestinal/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Japão , Laparoscopia/economia , Laparoscopia/mortalidade , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Morbidade , Estudos Retrospectivos , Segurança , Resultado do Tratamento
8.
Am Surg ; 86(3): 256-260, 2020 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-32223807

RESUMO

Minimally invasive sigmoid colectomy via the laparoscopic approach (LA) has numerous benefits. We seek to compare outcomes between laparoscopic and robotic sigmoid colectomies. We analyzed the data using the National Inpatient Sample database between 2008 and 2014. Utilization and outcome measures were compared. The seven-year average number of patients who underwent elective sigmoid colectomy in the United States from 2008 to 2014 was estimated to be 197,053. Of these, 95.1 per cent were conducted using the LA. The mean age was 58.33 + 13.6 years and 58.23 + 12.8 years in laparoscopic and robotic approaches, respectively. No significant differences existed in respect to morbidities. Postoperative complications were comparable with respect to other complications. Length of hospital stay was statistically significantly shorter in the robot-assisted approach compared with the LA (mean 4.8 + 4 vs 5.7 + 5 days, respectively, P < 0.001). Patients who underwent robotic surgery had significantly higher total hospital charges than those who underwent laparoscopic surgery (median $45,057 vs $57,871 USD, P < 0.001). The advent of robot-assisted surgery has provided more options for patients and surgeons. Compared with laparoscopy, robot-assisted sigmoid colectomy has no clinical advantages in morbidity and mortality. However, the robotic approach has a significantly higher total charge to the patient.


Assuntos
Colectomia/métodos , Custos Hospitalares , Laparoscopia/métodos , Tempo de Internação/economia , Procedimentos Cirúrgicos Robóticos/economia , Adulto , Idoso , Colectomia/economia , Colo Sigmoide/cirurgia , Análise Custo-Benefício , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Seguimentos , Custos de Cuidados de Saúde , Humanos , Laparoscopia/economia , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Retrospectivos , Medição de Risco , Procedimentos Cirúrgicos Robóticos/métodos , Estados Unidos
10.
J Robot Surg ; 14(6): 903-907, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32253574

RESUMO

Health-care costs are affected by obesity with both the direct and indirect costs of health care increasing as body mass index (BMI) increases. However, one important aspect of obesity that lacks rigorous study is what impact BMI has on direct surgical cost. We performed a retrospective cohort study of women undergoing a laparoscopic hysterectomy at our single academic university center between January 2012 and December 2017. Women were excluded if their surgery was performed by anyone other than those surgeons with subspecialty training in minimally invasive gynecologic surgery (MIGS), if their hysterectomy was performed by a modality other than conventional laparoscopy or with robotic assistance, or if the indication for hysterectomy was related to any gynecologic malignancy. We identified 600 patients who underwent laparoscopic hysterectomy during the study period. Women who underwent robotic hysterectomy, compared to laparoscopic, had a shorter operative time, lower estimated blood loss, and shorter length of stay. Mean direct cost (± standard deviation) for the cohort was $6398.53 ± $2304.67, age was 44.5 ± 7.5 years, and BMI was 32.2 ± 7.6. Direct cost for all laparoscopic hysterectomies was evaluated across the five different BMI quintiles and no significant difference between groups was found. There was no significant difference in direct cost across procedures between obese and non-obese patients (p = 0.62) and this remained true when separated out by surgical modality. However, when evaluating morbidly obese patients, there appears to be a trend toward cost reduction with robotic hysterectomy compared to conventional laparoscopy. It does not appear that BMI has a statistically significant impact on direct cost between robotic-assisted and conventional laparoscopic hysterectomy. However, these findings may be due to surgical proficiency and warrant further investigation among surgeons with lesser volume.


Assuntos
Índice de Massa Corporal , Custos de Cuidados de Saúde , Histerectomia/economia , Laparoscopia/economia , Obesidade/economia , Procedimentos Cirúrgicos Robóticos/economia , Adulto , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Estudos de Coortes , Feminino , Humanos , Histerectomia/métodos , Laparoscopia/métodos , Tempo de Internação/estatística & dados numéricos , Pessoa de Meia-Idade , Duração da Cirurgia , Procedimentos Cirúrgicos Robóticos/métodos
11.
Updates Surg ; 72(3): 701-707, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32152962

RESUMO

The purpose of the study is to evaluate whether laparoscopic pancreatoduodenectomy (LPD) is safe and feasible for elderly patients. From December 2015 to January 2019, 142 LPD surgeries and 93 OPD surgeries were performed by the same surgeon in the third affiliated hospital of Soochow University. After applying the inclusion and exclusion criteria, we retrospectively collected the date of three defined groups: LPD aged < 70 years (group I, 84 patients), LPD aged ≥ 70 years (group II, 56 patients) and OPD aged ≥ 70 years (group III, 28 patients). Baseline characteristics and short-term surgical outcomes of group I and group II, group II and group III were compared. Totally, 168 patients were included in this study; 100 cases were men; 68 cases were women; mean age was 67.9 ± 9.5 years. LPD does not perform as well in elderly as it does in non-elderly patients in terms of intraoperative blood loss (300.0 (200.0-500.0) ml vs. 200.0 (100.0-300.0) ml, p = 0.003), proportion of intraoperative transfusion (17.9% vs. 6.0%, p = 0.026) and time to oral intake (5.0 (4.0-7.0) day vs. 5.0 (3.0-6.0) day, p = 0.036). Operative time, conversion rate, postoperative stay, and proportion of reoperation, Clavien-Dindo classification, 30-day readmission and 90-day mortality were similar in two groups. In elderly patients, when compared with OPD, LPD had the advantage of shorter time to start oral intake (5.0 (4.0-7.0) day vs. 7.0 (5.0-11.3) day, p = 0.005) but the disadvantage of longer operative time (380.0 (306.3-447.5) min vs. 292.5 (255.0-342.5) min, p < 0.001) and higher hospitalization cost (12447.3 (10,189.7-15,340.0) euros vs. 7251.9 (8994.0-11,717.4) euros, p < 0.001). There was no difference between the two groups in terms of postoperative stay, and proportion of reoperation, Clavien-Dindo classification, 30-day readmission and 90-day mortality. LPD is safe and feasible for elderly people, but we need to consider its high cost and long operative time over OPD.


Assuntos
Laparoscopia/métodos , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/métodos , Fatores Etários , Idoso , Custos e Análise de Custo , Ingestão de Alimentos , Estudos de Viabilidade , Feminino , Hospitalização/economia , Humanos , Laparoscopia/economia , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Neoplasias Pancreáticas/economia , Pancreaticoduodenectomia/economia , Estudos Retrospectivos , Segurança , Fatores de Tempo , Resultado do Tratamento
12.
Am J Surg ; 219(5): 776-779, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32172925

RESUMO

BACKGROUND: Currently, no evidence compares outcomes for techniques utilizing surgical specimen extractions bags versus unprotected extraction. METHODS: Evaluation of sleeve gastrectomies performed at two high-volume centers. Cases where an extraction bag was used (+EB) were compared to bag-less extraction (-EB). Outcomes included operative contamination, surgical site infections and extraction-site hernias. RESULTS: 674 patients were evaluated (417 in the +EB group and 257 in the -EB group). Preoperative characteristics were similar between groups. There was a trend toward shorter operative times with the -EB group (-EB = 100 min vs + EB = 106 min, p = 0.07). Gross spillage was documented as a contaminated case in 0.4% of -EB cases compared to 1.2% in +EB cases (p = 0.51). Two superficial infections were appreciated (1.2% = +EB vs 0.7% = -EB, p = 0.7) with one post-operative abscess in the -EB group (p = 0.61). One post-operative hernia was seen in each group (p = 0.62). DISCUSSION: Bag-less extraction is a safe, resource conscious method that may potentially decreased operative time.


Assuntos
Gastrectomia/métodos , Laparoscopia/métodos , Obesidade Mórbida/cirurgia , Manejo de Espécimes/instrumentação , Adulto , Feminino , Gastrectomia/economia , Hérnia/epidemiologia , Humanos , Laparoscopia/economia , Masculino , Duração da Cirurgia , Estudos Retrospectivos , Manejo de Espécimes/economia , Infecção da Ferida Cirúrgica/epidemiologia
13.
World Neurosurg ; 137: e308-e314, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32028009

RESUMO

BACKGROUND: Laparoscopy for ventriculoperitoneal shunt creation might offer smaller incisions and more reliable placement. We assessed the reliability and cost-effectiveness of this technique compared with mini-laparotomy shunt placement. METHODS: All patients undergoing ventriculoperitoneal shunt creation between November 2013 and September 2017 at a single academic institution were evaluated. Individual cases were assessed for the use of laparoscopy for peritoneal shunt placement (laparoscopy) versus mini-laparotomy for peritoneal shunt placement (open). The direct hospital costs for the laparoscopy and open groups were compared for elective shunt placement from the Vizient database. These direct costs were the proportion of the admission cost attributed to surgery. The primary endpoints included costs and revision of the peritoneal catheter within 12 months of the index procedure. RESULTS: A total of 68 patients met the inclusion criteria. Most cases (n = 40; 58.8%) had been performed with laparoscopy, with 28 performed using an open peritoneal approach. Three patients had required ≥1 distal shunt revision: 2 laparoscopy patients (5.0%; 1 had required a second revision) and 1 open patient (3.6%). No statistically significant differences were found for the patients requiring distal shunt revision between the 2 groups (P = 1.000; Fisher's exact test). The direct cost ($9461) of ventriculoperitoneal shunt creation with laparoscopy was greater than that with an open approach ($8247; P = 0.033). CONCLUSIONS: Both laparoscopy and open peritoneal shunt creation are safe procedures, with a 12-month distal revision rate in the present series of ~4%. Laparoscopy provided no relative improvement in safety or complication avoidance but had resulted in a mean increase in costs of >$1200 per patient.


Assuntos
Análise Custo-Benefício , Laparoscopia , Laparotomia , Derivação Ventriculoperitoneal/métodos , Adulto , Idoso , Falha de Equipamento/estatística & dados numéricos , Feminino , Humanos , Hidrocefalia/cirurgia , Laparoscopia/efeitos adversos , Laparoscopia/economia , Laparoscopia/métodos , Laparotomia/efeitos adversos , Laparotomia/economia , Laparotomia/métodos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Reoperação/estatística & dados numéricos
14.
J Laparoendosc Adv Surg Tech A ; 30(3): 292-298, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31934801

RESUMO

Background: Inguinal hernia repair is one of the more common procedures performed in the United States. The optimal surgical approach, however, remains controversial. We aimed to compare the postoperative outcomes and costs between laparoscopic and open inpatient inguinal hernia repairs in a national cohort. Materials and Methods: We performed a retrospective analysis of the National Inpatient Sample during the period 2009-2015. Adult patients (≥18 years old) undergoing laparoscopic and open inguinal hernia repair were included. Multivariable logistic, generalized logistic, and linear regression were used to assess the effect of the laparoscopic approach on postoperative complications, mortality, length of stay, and hospital charges. Results: A total of 41,937 patients undergoing open inguinal hernia repair (N = 36,575) and laparoscopic inguinal hernia repair (N = 5282) were included. Patients undergoing laparoscopic inguinal hernia repair were less likely to have postoperative wound complications (odds ratio [OR]: 0.64, 95% confidence interval [CI]: 0.41-0.98), infection (OR: 0.34, 95% CI: 0.27-0.42), bleeding (OR: 0.72, 95% CI: 0.63-0.82), cardiac failure (OR: 0.72, 95% CI: 0.64-0.82), renal failure (OR: 0.54, 95% CI: 0.47-0.62), respiratory failure (OR: 0.70, 95% CI: 0.58-0.85), and inpatient mortality (OR: 0.27, 95% CI: 0.17-0.40). On average, the laparoscopic approach reduced length of stay by 1.28 days (95% CI: -1.58 to -1.18), and decreased hospital costs by $2400 (95% CI: -$4700 to -$700). Conclusion: Laparoscopic hernia repair is associated with significantly lower rates of postoperative morbidity and mortality, shorter length of hospital stays, and lower hospital costs for inpatient repairs. The laparoscopic approach should be encouraged for the management of appropriate patients with inpatient inguinal hernias.


Assuntos
Hérnia Inguinal/cirurgia , Herniorrafia/métodos , Laparoscopia/métodos , Complicações Pós-Operatórias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Custos de Cuidados de Saúde , Insuficiência Cardíaca/epidemiologia , Herniorrafia/economia , Preços Hospitalares , Mortalidade Hospitalar , Humanos , Laparoscopia/economia , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Hemorragia Pós-Operatória/epidemiologia , Insuficiência Renal/epidemiologia , Insuficiência Respiratória/epidemiologia , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/epidemiologia , Estados Unidos/epidemiologia
15.
J Surg Oncol ; 121(4): 670-675, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31967336

RESUMO

BACKGROUND: Minimally invasive surgery (MIS) is preferred for distal pancreatectomy but is not always attempted due to the risk of conversion to open. We hypothesized that the total cost for MIS converted to open procedures would be comparable to those that started open. METHODS: A prospectively collected institutional registry (2011-2017) was reviewed for demographic, clinical, and perioperative cost data for patients undergoing distal pancreatectomy. RESULTS: There were 80 patients who underwent distal pancreatectomy: 41 open, 39 MIS (11 laparoscopic and 28 robotic). Conversion to open occurred in 14 of 39 (36%, 3 laparoscopic and 11 robotic). Length of stay was shorter for the MIS completed (6 days; range, 3-8), and MIS converted to open (7 days; range, 4-10) groups, compared with open (10 days; range, 5-36; P = .003). Laparoscopic cases were the least expensive (P = .02). Robotic converted to open procedures had the highest operating room cost. However, the total cost for robotic converted to open cohort was similar to the open cohort due to cost savings associated with a shorter length of stay. CONCLUSIONS: Despite the higher intraoperative costs of robotic surgery, there is no significant overall financial penalty for conversion to open. Financial considerations should not play a role in selecting a robotic or open approach.


Assuntos
Pancreatectomia/economia , Pancreatectomia/métodos , Neoplasias Pancreáticas/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Conversão para Cirurgia Aberta/economia , Conversão para Cirurgia Aberta/métodos , Conversão para Cirurgia Aberta/estatística & dados numéricos , Feminino , Custos de Cuidados de Saúde , Humanos , Laparoscopia/economia , Laparoscopia/métodos , Laparoscopia/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/economia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/estatística & dados numéricos , Pancreatectomia/estatística & dados numéricos , Sistema de Registros , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/economia , Procedimentos Cirúrgicos Robóticos/métodos , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Estados Unidos
16.
J Laparoendosc Adv Surg Tech A ; 30(6): 608-611, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31928496

RESUMO

Background: Simulation plays an important role in surgical training. We developed a simulator for laparoscopic ventral hernia repair (LVHR) surgery based on porcine tissue, characterized by low cost and high reality. Methods: Our LVHR model is based on porcine tissue mounted in a human mannequin. The anterior abdominal wall is constructed to allow laparoscopic training. Training sessions are conducted in a simulated operating room environment. Results: During preliminary tests, the LVHR simulator was found to be highly realistic in terms of tissue feedback, instrumentation usage, and performing the key steps of the LVHR procedure. The model was evaluated as a very useful tool for residents' training allowing to gain laparoscopic skills, learn the key steps of LVHR, and practice team work. Conclusions: Our simulator, based on porcine tissue mounted in a mannequin, offers a very realistic and cost-effective model for simulating LVHR surgery.


Assuntos
Cirurgia Geral/educação , Cirurgia Geral/instrumentação , Hérnia Ventral/cirurgia , Herniorrafia/métodos , Laparoscopia/métodos , Animais , Análise Custo-Benefício , Cirurgia Geral/economia , Herniorrafia/economia , Herniorrafia/educação , Humanos , Laparoscopia/economia , Laparoscopia/educação , Salas Cirúrgicas , Treinamento por Simulação , Suínos
17.
J Laparoendosc Adv Surg Tech A ; 30(5): 514-519, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-31928507

RESUMO

Background: Percutaneous aspiration with sclerotherapy (PAS) and laparoscopic marsupialization (LM) are minimally invasive treatment modalities for renal cysts. We aimed to compare the efficacy and cost/effectiveness of LM and PAS for the treatment of simple symptomatic renal cysts. Methods: Data were prospectively collected from three health care institutions in which 80 patients with symptomatic simple renal cysts underwent a single session of PAS with 95% ethanol (PAS group, n = 40) or underwent LM under general anesthesia (LM group, n = 40) between March 2012 and May 2016. We compared the patient profile, duration of procedure, duration of hospital stay, radiological and symptomatic success rates, treatment costs, and incidence of complications between the two groups. Results: At the 6-month follow-up, the radiological success rate in the LM group was significantly greater than that in the PAS group (97.5% versus 60%; P < .001). The symptomatic success rate was comparable in the two groups (95% versus 90%; P = .675). The treatment failure rate did not significantly differ between the two groups (5.0% versus 17.5%, P = .154). The mean total cost in the PAS and LM groups was 1256 USD and 2343 USD, respectively (P = .001). No significant between-group difference was noted regarding the overall complication rate (P = .615). Conclusions: Both LM and PAS are effective and safe procedures for the treatment of symptomatic simple renal cysts. A single session of PAS seems to be a cost-effective method for the management of symptomatic simple renal cysts.


Assuntos
Cistos/terapia , Nefropatias/terapia , Laparoscopia , Escleroterapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Cistos/diagnóstico por imagem , Cistos/cirurgia , Etanol/uso terapêutico , Feminino , Custos de Cuidados de Saúde , Humanos , Nefropatias/diagnóstico por imagem , Nefropatias/cirurgia , Laparoscopia/efeitos adversos , Laparoscopia/economia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Soluções Esclerosantes/uso terapêutico , Escleroterapia/efeitos adversos , Escleroterapia/economia , Sucção/efeitos adversos , Sucção/economia , Resultado do Tratamento
18.
Am J Surg ; 220(1): 191-196, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31582178

RESUMO

BACKGROUND: Splenic flexure mobilization (SFM) increases left colonic reach for a better vascularized and tension-free anastomosis. Open SFM is challenging due to anatomic position. Minimally invasive SFM improves visualization and minimizes splenic traction. METHODS: We retrospectively reviewed all sigmoid and low anterior resections (LAR) by a colorectal surgical group over 10-year period. We analyzed indications, surgical methods and perioperative outcomes of open and MIS SFM cohorts. RESULTS: 793 patients were included; 122 (15.5%) open, 671 (84.5%) MIS (60% laparoscopic-assisted (LA), 40% hand-assisted (HA)). Overall, indications were cancer (56%), diverticulitis (31%), and other benign diseases (13%). Compared to MIS, open cases had more complex disease (45% vs. 18%, p < 0.01), with fewer SFM performed (40% vs. 86%, p < 0.01), required more frequent diversion (30% vs. 21%, p = 0.02) and were complicated by higher leak/abscess (7% vs. 3%, p = 0.06) and reoperation rates (10% vs. 6%, p = 0.11). 1% of SFM required conversion (LA to HA 0.5%, MIS to open 0.5%). There were no open SFM complications. There were 26 (5%) MIS SFM complications; bleeding (18; 12 splenic capsular tears (0 splenectomy/splenorraphy), 6 mesenteric) and organ injury (bowel (3), pancreatic (4), renal (1)). CONCLUSIONS: Our SFM rate was high in the MIS group, with a low overall complication rate. Of note, the anastomotic leak/abscess rate was 3%, and may be related to the high SFM rate. It is the authors' opinion that a major advantage of MIS is to facilitate SFM, hence SFM is more likely to be performed with these methods compared to open procedures.


Assuntos
Fístula Anastomótica/epidemiologia , Colectomia/economia , Colo Sigmoide/cirurgia , Doenças do Colo/cirurgia , Custos de Cuidados de Saúde , Laparoscopia/economia , Baço/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica/métodos , Fístula Anastomótica/prevenção & controle , Colectomia/métodos , Doenças do Colo/economia , Análise Custo-Benefício , Feminino , Humanos , Incidência , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
19.
Trop Doct ; 50(1): 94-99, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31495274

RESUMO

Despite the proven benefits of laparoscopic surgery, it is indeed very costly. The aim of our study was to show an effective way to reduce one of the costs. Between January 2012 and December 2018, we used sterile unpowdered latex-free surgical gloves for specimen retrieval in 243 selected cases of laparoscopic cholecystectomy and appendectomy. The mean retrieval time was 6.7 ± 3.6 min. All procedures were performed safely. Minor wound infection was noted in three patients but there was no case of port site hernia in our series. We conclude that specimen retrieval using sterile, unpowdered, latex-free surgical gloves is safe, effective and cheap. No special additional preparation is required.


Assuntos
Luvas Cirúrgicas , Laparoscopia/economia , Laparoscopia/instrumentação , Manejo de Espécimes/economia , Manejo de Espécimes/instrumentação , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/economia , Procedimentos Cirúrgicos do Sistema Digestório/instrumentação , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Luvas Cirúrgicas/efeitos adversos , Humanos , Laparoscopia/efeitos adversos , Estudos Prospectivos , Manejo de Espécimes/efeitos adversos , Manejo de Espécimes/métodos , Infecção da Ferida Cirúrgica/epidemiologia , Resultado do Tratamento
20.
J Surg Res ; 245: 136-144, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31419638

RESUMO

BACKGROUND: The role of robotic surgery in colorectal cancer remains contentious with most data arising from small, single-institution studies. METHODS: Stage I-III colorectal cancer resections from 2008 to 2014 were identified in New York State. Propensity score-adjusted negative binomial models were used to compare cost and utilization between robotic, laparoscopic, and open resections. RESULTS: A total of 12,218 patients were identified. For colectomy, the robotic-to-open conversion rate was 3%, and the laparoscopic-to-open conversion rate was 13%. For rectal resection, the robotic-to-open conversion rate was 7% and the laparoscopic-to-open conversion rate was 32%. In intention-to-treat analysis, there was no significant difference in cost across the surgical approaches, both in overall and stratified analyses. Both laparoscopic and robotic approaches were associated with decreased 90-d hospital utilization compared with open surgery in intention-to-treat analyses. CONCLUSIONS: Robotic and laparoscopic colorectal cancer resections were not associated with a hospital cost benefit after 90 d compared with open but were associated with decreased hospital utilization. Conversion to open resection was common, and efforts should be made to prevent them. Future research should continue to measure how robotic and laparoscopic approaches can add value to the health care system.


Assuntos
Neoplasias Colorretais/cirurgia , Utilização de Instalações e Serviços/estatística & dados numéricos , Custos Hospitalares/estatística & dados numéricos , Neoplasias Retais/cirurgia , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Idoso , Colectomia/economia , Colectomia/estatística & dados numéricos , Neoplasias Colorretais/economia , Conversão para Cirurgia Aberta/estatística & dados numéricos , Utilização de Instalações e Serviços/economia , Feminino , Humanos , Laparoscopia/economia , Laparoscopia/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , New York , Protectomia/economia , Protectomia/estatística & dados numéricos , Neoplasias Retais/economia , Procedimentos Cirúrgicos Robóticos/economia
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