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Laparoscopic contralateral groin exploration: is it cost effective?
Journal of Pediatric Surgery (2010) 45, 793–795
www.elsevier.com/locate/jpedsurg
Laparoscopic contralateral groin exploration: is it cost effective? Steven L. Lee ⁎, Roman M. Sydorak, Stanley T. Lau Division of Pediatric Surgery, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA 90027, USA Received 4 May 2009; revised 13 June 2009; accepted 15 June 2009
Key words: Pediatric inguinal hernia; Contralateral groin exploration; Cost analysis; Laparoscopy
Abstract Background: Transinguinal laparoscopy offers a safe and effective method for evaluating the contralateral groin during unilateral inguinal hernia repair (UIHR). The purpose of this study is to determine whether laparoscopic contralateral groin exploration (LCGE) is cost effective. Methods: A retrospective review of all children who underwent UIHR and LCGE from 2006 to 2007 by a single surgeon was performed. Cost analysis comparing the time to perform the LCGE and time to repair the contralateral patent processus vaginalis (CPPV) to the cost saved by preventing future operation for a contralateral inguinal hernia repair was calculated based on Medicare reimbursement. Results: Eighty-one patients underwent UIHR with planned LCGE; 78 (96.3%) had successful LCGE; 8 (10.3%) had a CPPV and underwent contralateral open repair. The total cost for the additional time to perform LCGE and repair of the 8 CPPV was $13 080. The total cost for returning for a second operation to repair the contralateral inguinal hernia was $20 440. Conclusion: Laparoscopic contralateral groin exploration at the time of unilateral inguinal hernia repair was cost effective. © 2010 Elsevier Inc. All rights reserved.
The evaluation and management of the contralateral groin in a child undergoing unilateral inguinal hernia repair (UIHR) has been debated for decades. Recently, transinguinal laparoscopy has been shown to be a safe, accurate, and effective method of evaluating the contralateral side during unilateral herniorraphy [1-3]. However, the cost-effectiveness of this technique has not been demonstrated. The purpose of this study was to determine whether the laparoscopic contralateral groin exploration (LCGE) at the time of UIHR is cost effective. Presented at the 18th Annual Congress of the International Pediatric Endoscopy Group, Phoenix, Ariz. ⁎ Corresponding author. Tel.: +1 323 783 4857; fax: +1 323 783 8747. E-mail address: [email protected] (S.L. Lee). 0022-3468/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2009.06.021
1. Materials and methods Our institutional review board approved this study. A retrospective review of all children who underwent UIHR with and without LCGE from 2006 to 2007 by a single surgeon was performed. Cost analysis was performed by first calculating the additional time required to perform the LCGE. This time, it was calculated by comparing patients who underwent UIHR with LCGE compared to patients who underwent UIHR alone. In addition, the time required to repair the contralateral patent processus vaginalis (CPPV) was also calculated. Cost for this additional time in the operating room was calculated at $20 per minute. Other costs required to perform LCGE and repair of CPPV were also
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calculated. This total cost was then compared to the potential cost saved by preventing a future operation for a contralateral inguinal hernia repair based on Medicare reimbursement. All patients with UIH were offered LCGE. All LCGE were performed with a 3 mm 70° laparoscope. We elected to repair the contralateral side if one or more of these findings were noted: (1) gas seen in the scrotum and a hernia confirmed with LCGE, (2) if the CPPV was large enough such that the laparoscope can easily fit inside, and (3) if the distal end of CPPV was not visualized. Thus, a small diverticulum in which the distal end was easily visualized was not considered a CPPV and was not repaired.
2. Results Eighty-one patients underwent UIHR with planned LCGE (Table 1). Seventy-eight (96.3%) had successful LCGE. The sacs of the other 3 patients were too thin to allow LCGE. Eight patients (10.3%) had a CPPVand underwent contralateral open repair at the time of UIHR. The cost analysis is summarized in Table 2. It took 6 minutes to perform the LCGE. The cost ($20 per minute) for each LCGE was $120. The total cost for 78 patients with LCGE was $9360. The average time to repair the CPPV was 11 minutes and average cost was $220. The total cost for repairing the CPPV in 8 patients was $3720 (including the additional surgeon fee). Thus, the total cost of the LCGE plus CPPV repair was $13 080. Table 2 also summarizes the cost analysis assuming all patients with a CPPV required a second operation for repair. Based on Medicare reimbursement for use of the hospital/ operating room, surgeon fee, and anesthesia fee, the cost for each repair was $2665. Thus, the total cost for 8 patients was $20 440.
3. Discussion Transinguinal laparoscopy at the time of UIHR has been shown to be a safe and effective method of exploring the contralateral groin [1-3]. It is also the preferred method by parents when given the choice [4]. This method is superior to open contralateral inguinal exploration as it minimizes the risk Table 1
b1 y 1-2 y 2-5 y N5 y Female
Patient demographics Offered LCGE (n = 81)
Unsuccessful LCGE (n = 3)
CPPV on LCGE (n = 8)
12 (15%) 9 (11%) 21 (26%) 31 (38%) 26 (32%)
1 1 1 0 0
2 1 2 3 5
LCGE, laparoscopic contralateral groin exploration; CPPV, contralateral patent processus vaginalis.
Table 2 Cost analysis for laparoscopic contralateral groin exploration Cost for LCGE: Time for UIHR + LCGE Time for UIHR alone Time for LCGE Cost for LCGE ($20/min) Total cost for LCGE (78 × $120) Time to repair CPPV Cost to repair CPPV ($20/min) Surgeon fee to repair CPPV Total cost to repair CPPV (8 × $465) Total (9360 + 3720) Cost for return trip to OR for hernia repair: Hospital/OR reimbursement Surgeon fee Anesthesia fee Total: 8 × (1954+491+220)
37 min 31 min 6 min $120 $9360 11 min $220 $245 $3720 $13 080 $1954 $491 $220 $20 440
of damaging the spermatic cord. In addition, the need for a second operation to repair a contralateral inguinal hernia is eliminated. Finally, LCGE also minimizes the risk of presenting with an incarcerated contralateral inguinal hernia and its associated morbidity. The disadvantage of performing a LCGE is that not all CPPV identified will develop into a clinical hernia [5], thus exposing children to unnecessary procedures. At this time, there is no way of predicting which patients with a CPPV will go on to develop a clinically significant hernia. Our initial practice was to offer LCGE to the parents of patients of all ages with UIH for parental convenience [4]. Thus, the age of the patients undergoing LCGE in this study was on the older side; only 15% of patients were less than 1 year of age and 11% were between 1 and 2 years. Not surprisingly, the rate of detecting a CPPV (17%) was highest in patients less than 1 year of age but was still lower than other reports [1,3]. A somewhat unexpected finding was that the rate of CPPV was fairly consistent at 10% for children older than 1 year of age and the oldest child detected to have a CPPV was 16 years. These findings add further support to offering LCGE to all patients undergoing UIHR in addition to parental preference and convenience. Few studies have shown the cost effectiveness of LCGE. Burd et al [6] showed that observation alone was more cost-effective than either open or laparoscopic contralateral groin exploration. However, when the incidence contralateral hernias reached 21%, this study suggested that LCGE became more cost-effective than observation. These results may not accurately reflect clinical practice as this study was based on a review of the existing literature. In contrast, this study showed that LCGE at the time of UIHR was cost effective. This finding was partly owing to the short amount of time (6 minutes) required to perform the LCGE as well as to repair the CPPV (11 minutes). In addition, by using reusable equipment, cost of the LCGE was kept to a minimum.
Laparoscopic contralateral groin exploration One limitation to this study was the low rate of detecting a CPPV (10.3%). Previous studies have shown the CPPV rate to be up to 43% [1]. However, higher rates of CPPV would make LCGE even more cost effective. Another limitation was that we assumed all patients with a CPPV would go on to require a second operation for repair. In this study, LCGE would still be cost effective if 65% of the patients with a CPPV went on to develop a symptomatic hernia. Finally, LCGE may even be more cost effective than shown in this study because potential lost wages for parents owing to a second operation was not taken into account. Transinguinal laparoscopy is a safe and effective method of evaluating the contralateral groin in a child with a unilateral inguinal hernia [1-3]. It is also the preferred technique by parents for managing the contralateral groin based on convenience [4]. Finally, this study showed that LCGE at the time of UIHR is cost effective.
795
References [1] Valusek PA, Spilde TL, Ostlie DJ, et al. Laparoscopic evaluation for contralateral patent processus vaginalis in children with unilateral inguinal hernia. Laparoendosc Adv Surg Tech A 2006;16:650-3. [2] Mollen KP, Kane TD. Inguinal hernia: what we have learned from laparoscopic evaluation of the contralateral side. Curr Opin Pediatr 2007;19:344-8. [3] Bhatia AM, Gow KW, Heiss KF, et al. Is the use of laparoscopy to determine presence of contralateral patent processus vaginalis justified in children greater than 2 years of age? J Pediatr Surg 2004;39:778-81. [4] Holcomb GW, Miller KA, Chiagnaud BF, et al. The parental perspective regarding the contralateral inguinal region in a child with a known unilateral inguinal hernia. J Pediatr Surg 2004;39:480-2. [5] Sozubir S, Ekingen G, Senel U, et al. A continuous debate on contralateral processus vaginalis: evaluation technique and approach to patency. Hernia 2006;10:74-8. [6] Burd RS, Heffington SH, Teague JL. The optimal approach for management of metachronous hernias in children: a decision analysis. J Pediatr Surg 2001;36:1190-5.
www.elsevier.com/locate/jpedsurg
Laparoscopic contralateral groin exploration: is it cost effective? Steven L. Lee ⁎, Roman M. Sydorak, Stanley T. Lau Division of Pediatric Surgery, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA 90027, USA Received 4 May 2009; revised 13 June 2009; accepted 15 June 2009
Key words: Pediatric inguinal hernia; Contralateral groin exploration; Cost analysis; Laparoscopy
Abstract Background: Transinguinal laparoscopy offers a safe and effective method for evaluating the contralateral groin during unilateral inguinal hernia repair (UIHR). The purpose of this study is to determine whether laparoscopic contralateral groin exploration (LCGE) is cost effective. Methods: A retrospective review of all children who underwent UIHR and LCGE from 2006 to 2007 by a single surgeon was performed. Cost analysis comparing the time to perform the LCGE and time to repair the contralateral patent processus vaginalis (CPPV) to the cost saved by preventing future operation for a contralateral inguinal hernia repair was calculated based on Medicare reimbursement. Results: Eighty-one patients underwent UIHR with planned LCGE; 78 (96.3%) had successful LCGE; 8 (10.3%) had a CPPV and underwent contralateral open repair. The total cost for the additional time to perform LCGE and repair of the 8 CPPV was $13 080. The total cost for returning for a second operation to repair the contralateral inguinal hernia was $20 440. Conclusion: Laparoscopic contralateral groin exploration at the time of unilateral inguinal hernia repair was cost effective. © 2010 Elsevier Inc. All rights reserved.
The evaluation and management of the contralateral groin in a child undergoing unilateral inguinal hernia repair (UIHR) has been debated for decades. Recently, transinguinal laparoscopy has been shown to be a safe, accurate, and effective method of evaluating the contralateral side during unilateral herniorraphy [1-3]. However, the cost-effectiveness of this technique has not been demonstrated. The purpose of this study was to determine whether the laparoscopic contralateral groin exploration (LCGE) at the time of UIHR is cost effective. Presented at the 18th Annual Congress of the International Pediatric Endoscopy Group, Phoenix, Ariz. ⁎ Corresponding author. Tel.: +1 323 783 4857; fax: +1 323 783 8747. E-mail address: [email protected] (S.L. Lee). 0022-3468/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2009.06.021
1. Materials and methods Our institutional review board approved this study. A retrospective review of all children who underwent UIHR with and without LCGE from 2006 to 2007 by a single surgeon was performed. Cost analysis was performed by first calculating the additional time required to perform the LCGE. This time, it was calculated by comparing patients who underwent UIHR with LCGE compared to patients who underwent UIHR alone. In addition, the time required to repair the contralateral patent processus vaginalis (CPPV) was also calculated. Cost for this additional time in the operating room was calculated at $20 per minute. Other costs required to perform LCGE and repair of CPPV were also
794
S.L. Lee et al.
calculated. This total cost was then compared to the potential cost saved by preventing a future operation for a contralateral inguinal hernia repair based on Medicare reimbursement. All patients with UIH were offered LCGE. All LCGE were performed with a 3 mm 70° laparoscope. We elected to repair the contralateral side if one or more of these findings were noted: (1) gas seen in the scrotum and a hernia confirmed with LCGE, (2) if the CPPV was large enough such that the laparoscope can easily fit inside, and (3) if the distal end of CPPV was not visualized. Thus, a small diverticulum in which the distal end was easily visualized was not considered a CPPV and was not repaired.
2. Results Eighty-one patients underwent UIHR with planned LCGE (Table 1). Seventy-eight (96.3%) had successful LCGE. The sacs of the other 3 patients were too thin to allow LCGE. Eight patients (10.3%) had a CPPVand underwent contralateral open repair at the time of UIHR. The cost analysis is summarized in Table 2. It took 6 minutes to perform the LCGE. The cost ($20 per minute) for each LCGE was $120. The total cost for 78 patients with LCGE was $9360. The average time to repair the CPPV was 11 minutes and average cost was $220. The total cost for repairing the CPPV in 8 patients was $3720 (including the additional surgeon fee). Thus, the total cost of the LCGE plus CPPV repair was $13 080. Table 2 also summarizes the cost analysis assuming all patients with a CPPV required a second operation for repair. Based on Medicare reimbursement for use of the hospital/ operating room, surgeon fee, and anesthesia fee, the cost for each repair was $2665. Thus, the total cost for 8 patients was $20 440.
3. Discussion Transinguinal laparoscopy at the time of UIHR has been shown to be a safe and effective method of exploring the contralateral groin [1-3]. It is also the preferred method by parents when given the choice [4]. This method is superior to open contralateral inguinal exploration as it minimizes the risk Table 1
b1 y 1-2 y 2-5 y N5 y Female
Patient demographics Offered LCGE (n = 81)
Unsuccessful LCGE (n = 3)
CPPV on LCGE (n = 8)
12 (15%) 9 (11%) 21 (26%) 31 (38%) 26 (32%)
1 1 1 0 0
2 1 2 3 5
LCGE, laparoscopic contralateral groin exploration; CPPV, contralateral patent processus vaginalis.
Table 2 Cost analysis for laparoscopic contralateral groin exploration Cost for LCGE: Time for UIHR + LCGE Time for UIHR alone Time for LCGE Cost for LCGE ($20/min) Total cost for LCGE (78 × $120) Time to repair CPPV Cost to repair CPPV ($20/min) Surgeon fee to repair CPPV Total cost to repair CPPV (8 × $465) Total (9360 + 3720) Cost for return trip to OR for hernia repair: Hospital/OR reimbursement Surgeon fee Anesthesia fee Total: 8 × (1954+491+220)
37 min 31 min 6 min $120 $9360 11 min $220 $245 $3720 $13 080 $1954 $491 $220 $20 440
of damaging the spermatic cord. In addition, the need for a second operation to repair a contralateral inguinal hernia is eliminated. Finally, LCGE also minimizes the risk of presenting with an incarcerated contralateral inguinal hernia and its associated morbidity. The disadvantage of performing a LCGE is that not all CPPV identified will develop into a clinical hernia [5], thus exposing children to unnecessary procedures. At this time, there is no way of predicting which patients with a CPPV will go on to develop a clinically significant hernia. Our initial practice was to offer LCGE to the parents of patients of all ages with UIH for parental convenience [4]. Thus, the age of the patients undergoing LCGE in this study was on the older side; only 15% of patients were less than 1 year of age and 11% were between 1 and 2 years. Not surprisingly, the rate of detecting a CPPV (17%) was highest in patients less than 1 year of age but was still lower than other reports [1,3]. A somewhat unexpected finding was that the rate of CPPV was fairly consistent at 10% for children older than 1 year of age and the oldest child detected to have a CPPV was 16 years. These findings add further support to offering LCGE to all patients undergoing UIHR in addition to parental preference and convenience. Few studies have shown the cost effectiveness of LCGE. Burd et al [6] showed that observation alone was more cost-effective than either open or laparoscopic contralateral groin exploration. However, when the incidence contralateral hernias reached 21%, this study suggested that LCGE became more cost-effective than observation. These results may not accurately reflect clinical practice as this study was based on a review of the existing literature. In contrast, this study showed that LCGE at the time of UIHR was cost effective. This finding was partly owing to the short amount of time (6 minutes) required to perform the LCGE as well as to repair the CPPV (11 minutes). In addition, by using reusable equipment, cost of the LCGE was kept to a minimum.
Laparoscopic contralateral groin exploration One limitation to this study was the low rate of detecting a CPPV (10.3%). Previous studies have shown the CPPV rate to be up to 43% [1]. However, higher rates of CPPV would make LCGE even more cost effective. Another limitation was that we assumed all patients with a CPPV would go on to require a second operation for repair. In this study, LCGE would still be cost effective if 65% of the patients with a CPPV went on to develop a symptomatic hernia. Finally, LCGE may even be more cost effective than shown in this study because potential lost wages for parents owing to a second operation was not taken into account. Transinguinal laparoscopy is a safe and effective method of evaluating the contralateral groin in a child with a unilateral inguinal hernia [1-3]. It is also the preferred technique by parents for managing the contralateral groin based on convenience [4]. Finally, this study showed that LCGE at the time of UIHR is cost effective.
795
References [1] Valusek PA, Spilde TL, Ostlie DJ, et al. Laparoscopic evaluation for contralateral patent processus vaginalis in children with unilateral inguinal hernia. Laparoendosc Adv Surg Tech A 2006;16:650-3. [2] Mollen KP, Kane TD. Inguinal hernia: what we have learned from laparoscopic evaluation of the contralateral side. Curr Opin Pediatr 2007;19:344-8. [3] Bhatia AM, Gow KW, Heiss KF, et al. Is the use of laparoscopy to determine presence of contralateral patent processus vaginalis justified in children greater than 2 years of age? J Pediatr Surg 2004;39:778-81. [4] Holcomb GW, Miller KA, Chiagnaud BF, et al. The parental perspective regarding the contralateral inguinal region in a child with a known unilateral inguinal hernia. J Pediatr Surg 2004;39:480-2. [5] Sozubir S, Ekingen G, Senel U, et al. A continuous debate on contralateral processus vaginalis: evaluation technique and approach to patency. Hernia 2006;10:74-8. [6] Burd RS, Heffington SH, Teague JL. The optimal approach for management of metachronous hernias in children: a decision analysis. J Pediatr Surg 2001;36:1190-5.