Cost Comparison Between Hand-Assisted Laparoscopic Colectomy and Open Colectomy

Abstract

Purpose:

Our aim was to compare the costs associated with hand-assisted laparoscopic colectomy (HALC) and open colectomy (OC).

Methods:

The data of patients who underwent either HALC or OC between March 2009 and August 2010 were retrospectively reviewed. The assessed short-term outcomes included operative time, blood lost, retrieved lymph nodes, conversion rates, and complications. Direct costs of operating room, nursing, intensive care, anesthesia, laboratory, pharmacy, radiology, and other costs related to initial hospitalization were compared.

Results:

Forty-two patients underwent HALC, whereas 45 underwent OC. Demographics in both groups were similar. The HALC patients had significantly shorter hospital stays and incision lengths, faster recovery of bowel function, and less blood loss (P<.001). There were no significant differences in operative time (169 minutes for HALC versus 171 minutes for OC), complication rates, or the number of retrieved lymph nodes. Although operative costs were higher for HALC (US $2260 versus $1992; P<.001), total costs were not significantly different between both methods (US $5593 vs. $5638; P=.29).

Conclusion:

Total costs of HALC are not significantly higher compared with OC. HALC is safe and leads to better short-term outcomes than OC.

Introduction

Although laparoscopic-assisted colectomy (LAC) was introduced 20 years ago, the number of these operations still remains quite low.¹ This is despite the fact that LAC exhibits multiple short-term patient benefits including faster postoperative recovery, fewer perioperative complications, and shorter hospital stay.² The reasons why LAC has not been accepted by the majority of surgeons include procedural complexity, long operative times, steep learning curve, and lack of tactile feedback.³ These limitations stimulated developing of hand-assisted laparoscopic colectomy (HALC). HALC enables the use of a hand for organ retraction, dissection, and prompt hemostasis.⁴ Furthermore, HALC has a lower rate of conversion to open surgery and facilitates completion of complex procedures.^5,6 Therefore, HALC may be a useful bridging technique for surgeons still acquiring complex skill sets required for standard laparoscopic surgery.

To date, only a few published reports exist regarding the costs of HALC.^7,8 A recent systematic review showed that cost-effectiveness of HALC for colon cancer is not consistent.⁹ Until now, no previous study has directly compared the costs of HALC with those of open colectomy (OC).^10,11 The aim of our study was to determine the costs associated with HALC and OC.

Patients and Methods

Details of the technique

We retrospectively reviewed cases of HALC and OC performed by the same colorectal surgeon in our hospital from March 2009 to August 2010. A senior resident or fellow assisted in all operations. Forty-two patients underwent HALC, whereas another 45 patients underwent OC. Cancer was the sole indication for operation in all patients in the present study, and none of the patients in this evaluation had stage IV disease. The selection of patients for HALC or OC was determined by the surgeon's experience, patient characteristics, disease status, and operative factors. Patients with acute intestinal obstruction, preoperative radiological evidence of locally advanced disease, and/or contraindications to pneumoperitoneum were excluded from this study. Informed consent was obtained from each patient.

The oncological principles for both types of surgery included adequate mucosal resection margins, wide en bloc mesenteric and vascular resection, and minimal intraoperative manipulation of the tumor. All anastomoses were performed extra- or intracorporeally by staples. The OC was performed according to standard procedures.¹² The technique and equipment for HALC were as reported in the literature.¹³ The incision for the hand-assist device was placed in the midline and tailored to the surgeon's hand. This incision subsequently served as the extraction site. We used the LAP DISC hand access device (Ethicon Endo-Surgery Inc., Cincinnati, OH). In addition, two or three ports for camera and other instruments were inserted.

Conversion was defined as extension of surgical incision beyond what was normally required to complete the operation by HALC.

Postoperatively, epidurals or patient-controlled analgesia was administered according to the requirements for each patient. A clear-liquid diet was started when bowel sounds were heard or after bowel movements. Patients were discharged when a normal diet was tolerated and the stool frequency was acceptable.

Data collected included age, sex, body mass index, American Society of Anesthesiologists score, history of past abdominal surgeries, tumor stage, and tumor location. Furthermore, operative procedures, operative time, intraoperative complications, blood loss, number of lymph nodes harvested, positive resection margin, conversion to open surgery, and surgical outcomes were also recorded.

Costs for each patient were expressed as department-specific and other costs and total costs. The department-specific costs included the costs for operative room, nursing, laboratory, anesthesia, pharmacy, intensive care, and radiology. Other costs included consumables, room charges, counseling, and other procedural costs. The calculation of total costs was based on all costs for surgery. The database was maintained by a trained clinical research nurse who was supervised by the Principal Investigators.

Statistical analysis

All numerical values are expressed as mean (range). The differences in categorical or numerical variables between study groups were analyzed using Fisher's exact test, chi-squared test, or Mann–Whitney U test, where appropriate. Statistical analysis was performed with SPSS statistical software (version 13.0; SPSS Inc., Chicago, IL); differences were considered significant at P<.05.

Results

Characteristics of study patients

Eighty-seven eligible patients with colon cancer were enrolled in the study, of which 42 underwent HALC and 45 had OC. There were no significant differences between the groups in terms of age, sex distribution, body mass index, American Society of Anesthesiologists grade, previous abdominal surgeries, TNM stage, or comorbidities (Table 1).

Table 1.

Demographic Characteristics of Study Patients

	HALC (n=42)	OC (n=45)	P
Age [mean (range)] (years)	62 (35–78)	63 (40–80)	NS
Male/female ratio	25/17	23/22	NS
BMI [mean (range)] (kg/m²)	21.7 (18.5–28.2)	22.1 (18.0–29.5)	NS
Previous abdominal surgery [n (%)]	2 (4.8)	3 (6.7)	NS
Mean ASA grade	2	2	NS
TNM stage [n (%)]			NS
I	4 (9.5)	3 (6.7)
II	20 (47.6)	22 (48.9)
III	18 (42.9)	20 (44.4)
Comorbidities [n (%)]			NS
Hypertension	6 (14.3)	8 (17.8)
Diabetes mellitus	2 (4.8)	1 (2.2)
Ischemic heart disease	5 (11.9)	4 (8.9)

ASA, American Society of Anesthesiologists; BMI, body mass index; HALC, hand-assisted laparoscopic colectomy; NS, not significant; OC, open colectomy.

Short-term perioperative outcomes

The operative time tended to be somewhat shorter in the HALC group compared with the OC group, although the difference did not reach statistical significance (169 versus 171 minutes, respectively) (Table 2). Blood loss was significantly lower in the HALC group compared with the OC group (107 versus 141 mL, respectively; P<.001) (Table 2). Furthermore, the length of surgical incision was significantly shorter in the HALC group (7.1 versus 15.3 cm, respectively; P<.001) (Table 2). One patient (2.4%) who underwent HALC required conversion to OC.

Table 2.

Operative Results

	HALC (n=42)	OC (n=45)	P
Operating time [mean (range)] (minutes)	169 (125–225)	171 (112–230)	NS
Blood loss [mean (range)] (mL)	107 (50–265)	141 (65–450)	<.001
Number of retrieved lymph nodes [mean (range)]	14 (6–30)	14 (8–30)	NS
Positive resection margins [n (%)]	0 (0)	0 (0)	NS
Conversion to open surgery [n (%)]	1 (2.4)	0 (0)	NS
Intraoperative complications [n (%)]	0 (0)	0 (0)	NS
Operative procedure [n (%)]			NS
Right hemicolectomies	23 (54.8)	25 (55.6)
Left hemicolectomies	19 (45.2)	20 (44.4)
Incision length [mean (range)] (cm)	7.1 (6.8–7.6)	15.3 (13. 5–18.5)	<.001

In the postoperative period, patients in the HALC group experienced flatus and bowel movement earlier (Table 3). Furthermore, patients who underwent HALC had a shorter hospital stay compared with patients in OC group (8 versus 11 days, respectively; P<.001) (Table 3). Finally, there were no differences between the two groups in complication rates, such as wound infection, bowel obstruction, urinary tract infection, or anastomotic leakage (P>.05) (Table 3).

Table 3.

Surgical Outcomes

	HALC (n=42)	OC (n=45)	P
Time (days) to flatus [mean (range)]	2 (1–6)	3 (1–7)	.01
Time (days) to bowel opening [mean (range)]	3 (2–6)	4 (3–7)	<.001
Postoperative hospital stay [mean (range)] (days)	8 (5–15)	11 (7–25)	<.001
Wound infection [n (%)]	1 (2.4)	1 (2.2)	NS
Bowel obstruction [n (%)]	1 (2.4)	2 (4.4)	NS
Urinary tract infection [n (%)]	2 (4.8)	3 (6.6)	NS
Anastomotic leakage [n (%)]	0 (0)	0 (0)	NS
Deaths [n (%)]	0 (0)	0 (0)	NS

Costs

Operative costs were higher in the HALC group (US $2260 versus $1992 in the OC group; P<.001) (Table 4). By contrast, nursing, pharmacy, and other costs were higher in the OC group (P<.001) (Table 4). Costs for radiology, laboratory, anesthesia, or intensive care did not differ significantly between the HALC and OC groups (P>0.05) (Table 4). Finally, total costs were not significantly different between both groups (P>.05) (Table 4).

Table 4.

Comparison of Costs Between Hand-Assisted Laparoscopic Colectomy and Open Colectomy

	HALC (n=42)	OC (n=45)	P
Operating room	$2260 ($2065–$2616)	$1992 ($1815–$2387)	<.001
Nursing	$354 ($256–$485)	$475 ($380–$615)	<.001
Pharmacy	$528 (225–768)	$627 ($482–$714)	<.001
Radiology	$47 ($0–$150)	$50 ($0–$75)	NS
Laboratory	$211 ($157–365)	$221 ($165–$370)	NS
Anesthesia	$1265 ($1090–$1456)	$1276 ($1105–$1452)	NS
Intensive care	$22 ($0–$915)	$0 ($0–$0)	NS
Other costs^a	$648 ($580–$815)	$734 ($558–$826)	<.001
Total direct costs	$5593 ($5136–$7292)	$5,638 ($4975–$6402)	NS

Costs are presented as mean (range) in US$.

Other costs include consumables, room charges, counseling, and other procedural costs.

Discussion

With the introduction of hand-assisted laparoscopic surgery in the early 1990s, an attempt was made to facilitate the transition from open techniques to minimally invasive procedures.¹⁴ This procedure can simplify the otherwise technically complex operations and can be used to initiate non-skilled surgeons to perform more advanced laparoscopic surgery.^15–17

Similar short-term outcomes for HALC and OC have been demonstrated in previous studies.^18–20 There are several published reports comparing the costs of HALC and LAC; however, their results are inconsistent. Technically, HALC is less expensive than a standard laparoscopic approach because it reduces the number of laparoscopic ports and instruments required. Two recent studies demonstrated similar total costs between HALC and LAC.^10,11 Only one previous study compared the costs between hand-assisted and open approaches, and only operative and consumables costs were analyzed.²¹ There have been no published detailed cost analyses comparing these two techniques. Therefore, to our knowledge, this is the first study to compare costs of HALC and OC from a short-term outcome perspective. Our study did not reveal any significant differences in total costs for HALC and OC, despite the fact that operative costs were higher for HALC.

Compared with the OC group, patients in the HALC group demonstrated substantial short-term benefits including early recovery of bowel functions, shorter hospital stays, and smaller incision lengths. Similar to our study, Kang et al.¹² reported that HALC patients had a significantly shorter hospital stay, shorter incision lengths, faster recovery of gastrointestinal function, less use of analgesics, lower blood loss, and lower pain scores on postoperative days 1, 3, and 14. In addition, Wolf et al.²² reported that laparoscopic donor nephrectomy is associated with a faster, less complicated, and more complete convalescence than the open surgical approach. Furthermore, our study revealed a trend toward a lower complication rate in HALC compared with OC, and there were no severe complications.

The reported conversion rate of HALC varies from 0% to 22%.^23–28 The most common reason for conversion is a difficulty in maintaining a satisfactory pneumoperitoneum. In our study, conversion to OC was required in only one patient. The reason for conversion was a difficulty in the presence of a bulky tumor.

The literature provides conflicting evidence whether operative time is shorter in hand-assisted versus open surgery.^12,29 In our study, operative times were comparable between HALC and OC. This finding may have been caused by more extensive surgical experience and better instruments in our study.

The hand-assist device and a greater use of disposable ports were the main reasons for higher consumable costs. However, with the exception of the hand-assist device, many consumables were not essential to conducting HALC and could potentially be skipped in order to cut costs.¹⁰ Furthermore, our study demonstrates that differences in costs of nursing, pharmacy, and other costs (consumables, room charges, counseling, and other procedural costs) were sufficient to offset the increased operative costs of HALC.

Conclusion

Total costs are not significantly higher in HALC compared with OC. Patients who underwent HALC had significantly shorter hospital stays and incision lengths, faster recovery of bowel function, and lower blood loss. To more accurately address the role of HALC in the curative management of colorectal cancer, longer-term studies are needed.

Footnotes

Disclosure Statement

No competing financial interests exist.

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