Cost Efficiency of Laparoscopic Versus Open Colon Surgery in a Tertiary Care Centre

Nawar A Alkhamesi, MD PhD FRCSGenSurg FRCS FRCSEd, Christopher M Schlachta, BSc MD CM FRCSC FACS. CSTAR (Canadian Surgical Technologies and Advanced Robotics), London Health Science Centre, London, Ontario, Canada

Objective
A real world cost analysis of elective laparoscopic versus open colon resection in a tertiary Canadian teaching health centre was performed to evaluate the financial impact of minimal invasive surgery with the appointment of a focused laparoscopic surgeon in a single payer system.

Method
A retrospective review of all elective laparoscopic and open segmental colectomies between January 2005 and April 2010 for both benign and malignant disease was performed to coincide with the recruitment of a focused laparoscopic surgeon to our institution. Combined cases and procedures carried out on inpatients were excluded to minimize cost variables. The hospital case costing system was used to calculate hourly cost of operating room time, including reusable instruments, and daily hospital ward stay. The cost of disposable equipment was calculated manually. This system considers the cost applicable to the hospital alone and not physician payments.

Result
A total of 470 right hemicolectomies, RHC, (325 open and 145 laparoscopic) and 135 left or sigmoid colectomies, LHC (105 open and 30 laparoscopic) were found to match the inclusion criteria. The average operating room time for laparoscopic procedures was longer than open cases 3.39 v 2.89 hours (p=0.8) for RHC and 4.79 v 3.81 hours (p=0.7) LHC resulting in greater OR time cost of $4094 v $3312 for RHC and $5785 v $4582 for LHC. Incremental disposable costs for laparoscopic surgery were $948 for RHC and $1500 for LHC. Comparing laparoscopic to open, the median length of stay during the index admission was shorter after RHC, 5 v 8 days (p=0.01) and LHC 4 v 7 days (p=0.06) resulting in lower ward cost of $4556 v $6633 for right colon and $3297 v $5949 for left resection. The mean calculated cost of care per index admission following laparoscopic versus open surgery was $9598 vs. $9945 for RHC and $10,582 vs. $10,532 for LHC. The cost of 30 day readmission was not considered, but readmission was significantly higher following open compared to laparoscopic colectomy; 19.6% v 8.9%, p=0.04 for RHC and 24.7% v 13%, P=0.05 for LHC. Over the five year period we noted a steady rise in the proportion of laparoscopic colectomies with the greatest increase in the number of RHC (23%, 23%, 33%, 33%, and 40% by year). The use of laparoscopic surgery has actually saved our hospital $48,815 on index admission alone over a five year period, which translates to a possible saving of $32,100 per year if all eligible cases will be performed laparoscopically.
Conclusion
The reason for observed differences in operating room time and length of hospital stay were uncontrolled and may be multifactorial; however, these results demonstrate that adopting a minimal invasive approach to elective colon surgery in this institution has realized a modest but progressive financial saving.

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