|Year : 2021 | Volume
| Issue : 4 | Page : 181-187
Ambulatory laparoscopic inguinal hernioplasty: Feasibility and cost minimization analysis
Natalia J Sanchez, Fernando Cetolini, Rodolfo Scaravonati, Sebastian Roche, Claudio Brandi, Santiago Bertone
Abdominal Wall and Microsurgery Section, Hospital Italiano de Buenos Aires, Capital Federal, Argentina
|Date of Submission||21-May-2021|
|Date of Decision||05-Aug-2021|
|Date of Acceptance||10-Aug-2021|
|Date of Web Publication||31-Dec-2021|
Mr. Natalia J Sanchez
Abdominal Wall and Microsurgery Section, Hospital Italiano de Buenos Aires, Capital Federal.
Source of Support: None, Conflict of Interest: None
BACKGROUND: In recent years, laparoscopic inguinal hernia repair has become one of the elective techniques, attributing the advantages of minimally invasive procedures to it. However, the high costs related to the need for hospitalization and materials make them a limitation at the time of its indication. OBJECTIVE: Evaluate the feasibility of performing this procedure in an outpatient surgery center and the cost analysis of an outpatient procedure regarding the same in the setting of hospitalization. Retrospective cohort study of feasibility and minimization cost. METHODS: A retrospective analysis was carried out on a prospective database in which all patients were included in those who underwent laparoscopic inguinal hernioplasty on an outpatient basis between August 2015 and June 2018. Feasibility is expressed as the percentage of patients who were referred from the outpatient surgery unit. A cost minimization study was conducted taking the average cost of performing an ambulatory procedure versus the same procedure requiring a day of hospitalization. This work has been reported in line with the CHEERS criteria. RESULTS: 116 patients were operated as outpatients, of which 109 were men (93.96%). The median age was 56.5 years (RIQ 19). 102 patients (87.93%) were operated on due to bilateral inguinal hernia, and 14 of them (12.07%) due to recurrent unilateral hernia, adding a total of 218 inguinal hernioplasties. The mean operative time in bilateral interventions was 112 minutes (DS 24) and in the unilateral recurrences it was 79 minutes (DS 13). 114 patients were discharged from the outpatient unit with 98.3% feasibility. The average postoperative stay was 2.53 h (DS 1). The average cost of ambulatory inguinal hernioplasty was $17725.1 vs $27297.3 in hospitalization. The same implies a cost reduction of 35%. CONCLUSIONS: Laparoscopic inguinal hernioplasty is a feasible and safe technique to perform on an outpatient basis. It provides a significant reduction in the costs of the procedure.
Keywords: Abdominal wall, cost, inguinal hernioplasty, laparoscopic
|How to cite this article:|
Sanchez NJ, Cetolini F, Scaravonati R, Roche S, Brandi C, Bertone S. Ambulatory laparoscopic inguinal hernioplasty: Feasibility and cost minimization analysis. Int J Abdom Wall Hernia Surg 2021;4:181-7
|How to cite this URL:|
Sanchez NJ, Cetolini F, Scaravonati R, Roche S, Brandi C, Bertone S. Ambulatory laparoscopic inguinal hernioplasty: Feasibility and cost minimization analysis. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2022 Jan 20];4:181-7. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/4/181/334559
| Introduction|| |
Inguinal hernioplasty is one of the most frequently performed surgical procedures. Since its inception in the 1990s, laparoscopic repair of inguinal hernia has become one of the methods of choice, attributing the advantages of minimally invasive procedures, among which we can mention minor postoperative pain, rapid recovery, and early labor reincorporation.
However, despite the multiple advantages listed, its implementation does not exceed 20%. This is probably due to the need for general anesthesia, the high costs related to the material, and the need for hospitalization of the patient. Payne et al. in 1994 were the first to compare the economic cost and demonstrate that laparoscopic hernioplasty represents a greater cost for the health system.
Ambulatory surgery units allowed reducing the costs of the procedures by dispensing with hospitalization costs, as well as reducing the surgical waiting time. For many years, conventional inguinal hernioplasty has been carried out systematically in these units.
In the literature, there are articles, regarding the performance of laparoscopic hernioplasties in the form of “day cases” or in “short stay units.” These include cases of patients admitted to the hospital regime, using the resources of hospitalization and discharged without staying overnight in the institution, or of patients who remain under observation for less than 24 h, staying overnight in the institution.
That is why the primary objective of this work is to evaluate the feasibility of performing this procedure in an autonomous ambulatory surgery center. Secondarily, we evaluate the costs of an outpatient procedure with respect to the same in the setting of hospitalization.
| Materials and Methods|| |
A retrospective analysis was performed on a prospective database in which all patients older than 18 years were included, in which a laparoscopic inguinal hernioplasty was performed in the period between August 2015 and June 2018 in the unit of ambulatory surgery of our hospital. The same corresponds to an autonomous unit controlled by a health facility with hospitalization, as established by the Organization Guide and Procedures in Ambulatory Surgery.
Laparoscopic repair using a transabdominal preperitoneal technique (TAPP) was proposed for patients with a clinical diagnosis of bilateral inguinal hernia or a recurrent unilateral hernia operated primarily through the anterior approach following the indications for laparoscopic surgery proposed by the European Hernia Society.,
The demographic data of the patients considered for this study were age, gender, body mass index (BMI), anesthetic risk according to the ASA (American Society of Anesthesiologists) score, comorbidities, bilateral primary or unilateral recurrent hernia, history of previous abdominal surgeries, and associated midline hernias.
Those patients who were older than 85 years, high anesthetic risk (decompensated ASA III and ASA IV), morbid obesity (higher BMI 40), sleep apnea with indication of use of continuous positive airway pressure (CPAP), medicated psychiatric disease, drug-dependent patient, and patients with an inadequate social environment were excluded from the ambulatory surgery program.
The details of the surgical procedure and the ambulatory surgery regimen, as well as possible postoperative complications, were explained to all patients in the preoperative consultation and an informed consent was signed. This work has been reported in line with the CHEERS criteria.
The anesthetic technique was the same for everyone. The patients were operated under general anesthesia. Anesthetic induction was performed with propofol 2 mg/kg EV and fentanyl 2 µg/kg EV. Rocuronium 0.6 mg/kg EV was used to facilitate laryngeal mask placement. The anesthetic level was maintained with air, oxygen, sevoflurane at 1.5% expired, and with remifentanil (0.25 at 0.5 µg/kg/min) based on the demand of the patient’s plan. It was ventilated mechanically in a controlled mode. As intraoperative analgesia, ketorolac 1 mg/ kg according to renal function or diclofenac 1 mg/kg was used in patients with a history of bronchospasm. This was associated with 8 mg of dexamethasone.
Antibiotic prophylaxis during anesthetic induction was performed with cefazolin 2 g/kg EV.
In 100% of the cases, the surgical technique used was TAPP. The patient was asked to urinate prior to the transfer to the operating room to avoid the placement of a urinary catheter.
With the patient in the supine position, pneumoperitoneum was performed by umbilical scar with closed Veress needle technique. The abdomen was insufflated with a pressure of 12 mmHg. A 10-mm trocar was placed at the umbilical level and two 5-mm trocars were placed on both flanks outside the rectus sheath. In the event that the patient presents with an associated midline hernia, optic trocar was inserted due to hernia defect. It was approached first on one side and then on the contralateral side. After the opening of the peritoneum, dissection of the preperitoneal space, and reduction of the hernial content, a polypropylene mesh (Prolene®, Ethicon Johnson & Johnson) of 15 cm × 12 cm was placed covering the myopectineal orifice from the symphysis pubis medially, until the anterosuperior iliac spine laterally. In patients with bilateral hernia, two meshes were placed, one on each side, respectively, surpassing the midline. The mesh was fixed with tuckers made of resorbable material (Securetrap®) or unabsorbable material (Protack®), according to the preference of the surgeon in charge of the procedure. The peritoneum was closed with continuous suture of slow absorbable material (Vycril®) or slow reabsorbed barb suture (Stratafix®). Local infiltration of all wounds was performed with ropivacaine at a dose of 3 mg/kg.
Surgical time was recorded as intraoperative variables, which was defined as minutes from the preparation of the surgical site to the closure of the skin, the type of hernia according to Nyhus classification, and the presence of intraoperative complications.
At the end of the procedure, the patients were transferred to the recovery room. During the postoperative recovery, an analgesic scheme was stipulated according to need. The rescues were made according to the evaluation of the nurse and the treating anesthetist and consisted of the following levels:
- - First level: ketorolac 30 mg EV or diclofenac 75 mg EV. In patients with decreased glomerular filtration, paracetamol 1,000 mg EV was used.
- - Second level: morphine 1–3 mg EV.
When the requirements of the ambulatory surgery guide listed in [Table 1] were fulfilled, the patient was discharged from the hospital. The same was in charge of the responsible surgeon, who delivered the postoperative indications verbally and in writing, confirming the understanding by the patient and the companion.
The length of stay in the unit was recorded, as well as the need to administer analgesics during the same and pain according to the visual analog scale (EVA) at discharge.
Feasibility is expressed as the percentage of patients who were referred from the outpatient surgery unit.
The data about postoperative complications were collected prospectively through ambulatory controls previously stipulated at 7, 30, 180, and 360 days. They are classified into early (up to 30 days of the procedure) and late. The first included seroma, surgical site infection, and hematoma, and the late included trocar hernias, recurrence, and postoperative pain. Chronic postoperative pain is one that persists beyond the 3rd month after the procedure.
In the first ambulatory control consultation at 7 days, patients were asked to rate their level of satisfaction with the procedure by choosing one of the four categories: not satisfied, not very satisfied, satisfied, and very satisfied.
For the study of costs in addition to outpatients, those patients who underwent laparoscopic inguinal hernia in the inpatient setting during the period analyzed were included in the analysis. In this way, two branches of study were drawn up, one corresponding to patients operated on an outpatient basis and the other to patients operated through a hospital regime.
Being a surgical procedure performed under a different hospital regime, a cost minimization study was carried out taking the average cost of performing an ambulatory procedure versus the same requiring admission.
When considering the economic situation of the República Argentina in the time under study (devaluation of the peso Argentine weight of 100% and inflation of approximately 30% per year), continuous patients operated between December 2016 and April 2017 were taken, which represents the average of the period under study, as representative samples of each branch. For each patient, the surgical time, the persistence time in the ambulatory anesthetic recovery room or the hospitalization room, and the time of postoperative hospitalization were recorded in a database.
The materials used during surgery and anesthesia were previously standardized so that all the patients who underwent this procedure used the same resources.
The cost department of our hospital was responsible for collecting the costs of each of these patients. They were divided into fixed costs per procedure, per hour/operating room, per hour in the ambulatory surgery recovery room, per hour in the recovery room of the central operating room, and per day of hospitalization.
The costs were calculated in Argentine peso (AP) and converted into US dollars (USD) taking into account the exchange rate in January 2017: 1 USD = 16.30 PA.
The categorical data were described as percentages and the quantitative data as mean and standard deviation or median and interquartile range according to the observed distribution. To compare means of quantitative variables, Student’s t-test or Mann–Whitney U-test was used according to the observed distribution. χ2 or Fisher’s test was used for the rest of the variables. A P <0.05 was considered significant.
Regression models were constructed to adjust for confounding potentials.
| Results|| |
During the period between August 2015 and June 2018, a total of 223 patients underwent laparoscopic inguinal hernioplasty. One hundred and sixteen were operated on as outpatients (representing 52% of total laparoscopic hernioplasties), of which 109 were men (93.96%). The median age was 56.5 years (RIQ 19). About 67.24% of the patients presented an anesthetic risk ASA II. The mean BMI of the patients was 26.09 (SD 2.75). One hundred and two patients (87.93%) were operated on due to bilateral inguinal hernia, and 14 (12.07%) due to a recurrent unilateral hernia, adding a total of 218 inguinal hernioplasties. There was no need for conversion of the technique to any patient. Seventeen of the 116 patients underwent inguinal hernioplasty to repair an associated midline hernia. Forty patients presented a history of previous abdominal surgery, with appendectomy being the most frequent (50%) [Table 2].
[Table 3] shows the intraoperative and postoperative variables recorded. There were two intraoperative complications, a colonic lesion noticed and repaired through a suture of the affected sigmoid colon segment, and a vascular lesion of the epigastric artery also repaired during the same surgical procedure. Two patients required hospitalization after the intervention: one of them was the patient with colonic injury noted above and another referred in the immediate postoperative pain 10/10 (according to EVA) that required a relaparoscopy that resulted in no findings. Both patients remained hospitalized for 24 h in the general admission ward before discharge.
One hundred and fourteen patients were discharged from the ambulatory surgery unit, with a 98.3% feasibility. In these patients, the mean postoperative stay was 2.53 h (SD 1).
About 67.25% of the patients presented between 0 and 3 of pain according to EVA 1 h postprocedure, being 97.35% at the time of discharge. The mean pain at discharge was 0.48 (SD: 1.09). Thirty-three patients required a rescue analgesic during the postoperative stay, with only four patients requiring second-level analgesia.
At a mean follow-up of 19 months (DS 7), 87.07% did not present postoperative complications. Two patients presented hernia recurrence, which corresponds to a recurrence of 0.91% and no patient reported pain beyond the 3rd postoperative month.
The degree of patient satisfaction in relation to the procedure is expressed in [Graph 1].
In the selected period, 22 patients were treated on an outpatient basis and 21 patients under the hospitalization regime. [Table 4] shows the demographic data and intraoperative time and recovery variables of the aforementioned patients. The significant difference in terms of age and ASA corresponds to the initial selection of patients to comply with ambulatory surgery standards.
A summary of the general costs is described in [Table 5]. Patients who underwent surgery in hospital had higher overall average costs when compared with the ambulatory group (27,297.3 PA vs. 17,725.1 PA, P < 0.001).
A multivariable analysis was performed for total cost that included age, gender, ASA, and the performance of outpatient procedure. [Table 6] shows that performing an outpatient procedure reduces costs by 9572 PA adjusted to the aforementioned variables.
| Discussion|| |
Performing procedures in the outpatient centers without the need to use hospital facilities (operating rooms and hospital beds) has direct advantages in health resources as it increases the availability of beds for other procedures as well as decreases waiting times for operating rooms and the costs.
Our study demonstrates the feasibility of performing a laparoscopic inguinal hernioplasty under an outpatient regimen with a 98.3% success rate. Over the years, other authors have published their experience in performing these procedures on an outpatient basis[4.6],,,,; however, in these publications, many patients spent the night at the hospital and others were not admitted to an outpatient surgery center.
Our experience is the first published series in which this type of procedure is performed in an autonomous ambulatory unit controlled by a health facility with hospitalization. This is an autonomous area in terms of its structure, personnel, and its own external circuits where only ambulatory procedures can be performed, within a hospital institution.
Proper selection of patients is crucial to avoid the failure of ambulatory repair. Age over 85 years, high anesthetic risk (ASA III decompensated and ASA IV), morbid obesity (BMI greater than 40), sleep apnea with indication of use of CPAP, psychiatric disease, patient with drug dependence, and patients with an inadequate social environment represent our criteria of contraindication to perform procedures through this regime.
In addition to adequate patient selection, the definition of precise discharge criteria [Table 1] is important since admission/readmission may decrease after outpatient surgery.
In our experience, bilateral hernias, recurrent hernias, or previous surgeries were not contraindicated, as they were in other published series. Given our indications for laparoscopic surgery, bilateral hernia corresponds to 87.9% of the cases operated on. This study is the one with the highest percentage of patients with operated bilateral hernia compared with the other series that do not exceed 50%.,,, Thirty-five percent of our selected patients had previous abdominal surgeries, the most frequent being appendectomy. Five patients had a history of prostatic resection. No patient required conversion to conventional surgery. Therefore, at present, the previous abdominal surgeries are not a limitation when it comes to indicating outpatient surgery.
Two patients required postoperative hospitalization. In the case of the patient who required repair of the segment of the sigmoid colon with a raffia, this had two clinical episodes of acute diverticulitis as a clinical antecedent, which conditioned the presence of adhesions between this segment of the intestine and the peritoneum. The patient who required a relaparoscopy experienced an acute abdominal pain of 10/10, 40 min after the procedure, the reoperation did not reveal any findings. In the first case, admission was indicated given that the procedure lasted 3.5 h and in the second case it was due to the fact that the patient underwent two general anesthesias. Both patients remained in control for 24 h, and they were discharged during this period.
Age has been stipulated as a limitation to perform outpatient practices. In the studies published by McCloud and Evans and O’Riordain et al., we observed a hospitalization of 13% in patients older than 70 years and 34% in those older than 60 years, respectively. In our series, 21.5% of the patients had an age greater than 70 years, requiring no further hospitalization in any case. This is probably due to an advance in both surgical and anesthesiological techniques.
Postoperative pain, urinary retention, and vomiting are factors associated with the need for postoperative hospitalization.,,, In our series, 97.3% of the patients presented pain less than 3 in the VAS at discharge. In addition to general anesthetics, the use of adjunctive local anesthetics at the end of the surgical procedure is crucial to reduce the postoperative pain sensation. The avoidance of placing a urinary catheter also helps to avoid urinary retention.
Despite not having used a validated satisfaction score, which is a weak point in our work, greater than 90% of the patients expressed a high degree of satisfaction regarding the procedure and the non-hospital surgery regimen.
At present, there are no studies in the literature that demonstrate the reduction of costs when performing a laparoscopic inguinal hernioplasty on an outpatient basis with respect to the setting of hospitalization. In our study, it was possible to demonstrate that performing this type of procedure on an outpatient basis reduces costs significantly compared with hospitalization (27,297.3 AP vs. 17,725.1 AP; P < 0.001). The same represents a global cost reduction of 35%.
The economic situation of our environment, with devaluation of the currency and high inflation, did not allow us to carry out a study including all the patients intervened in the period of 3 years. This is another weakness that the current work presents. However, we consider that the selected population is a representative sample of our study population.
| Conclusion|| |
Laparoscopic inguinal hernioplasty is a feasible and safe technique to perform on an outpatient basis. It provides a significant reduction in the costs of the procedure. Furthermore, at present, 95% of the laparoscopic hernioplasty are performed in an outpatient basis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
CEPI (Comite Etica de Protocolos de Investigación) Hospital Ethics Committee ID: 5614.
| References|| |
Jenkins JT, O’Dwyer PJ. Inguinal hernias. Br Med J 2008;336:269-72.
Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons R Jr, Dunlop D, Gibbs J, et al
; Veterans Affairs Cooperative Studies Program 456 Investigators. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 2004;350:1819-27.
Smink DS, Paquette IM, Finlayson SR. Utilization of laparoscopic and open inguinal hernia repair: A population-based analysis. J Laparoendosc Adv Surg Tech A 2009;19:745-8.
Kallianpur AA, Parshad R, Dehran M, Hazrah P. Ambulatory total extraperitoneal inguinal hernia repair: Feasibility and impact on quality of life. JSLS 2007;11:229-34.
Payne JH Jr, Grininger LM, Izawa MT, Podoll EF, Lindahl PJ, Balfour J. Laparoscopic or open inguinal herniorrhaphy? A randomized prospective trial. Arch Surg 1994;129:973-9; discussion 979-81.
Torralba Martínez JA, Egea AM, Ruiz RL, Perelló JM, Alarte Garví JM, Martín Lorenzo JG, et al
. ¿Es adecuado incluir el tratamiento convencional y laparoscópico de la hernia inguinal bilateral en un programa de cirugía mayor ambulatoria sin ingreso? Circ Esp 2003; 73:342-6.
Lau H. Outpatient endoscopic totally extraperitoneal inguinal hernioplasty. J Laparoendosc Adv Surg Tech A 2004;14:93-6.
Procedimientos GDE. Título: Guía de Organización y procedimientos en Cirugía: 1–31. Available from: http://www.aac.org.ar/imagenes/guias/guia_ambulatoria.pdf. [Last accessed on 2013].
Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J, et al
. European Hernia Society Guidelines on the treatment of inguinal hernia in adult patients. Hernia 2009;13:343-403.
Miserez M, Peeters E, Aufenacker T, Bouillot JL, Campanelli G, Conze J, et al
. Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia2014;18:151-63.
Nyhus LM. Individualization of hernia repair: A new era. Surgery 1993;114:1-2.
O’Riordain DS, Kelly P, Horgan PG, Keane FB, Tanner WA. Laparoscopic extraperitoneal inguinal hernia repair in the day-care setting. Surg Endosc 1999;13:914-7.
Singhal T, Balakrishnan S, Grandy-Smith S, El-Hasani S. Consolidated five-year experience with laparoscopic inguinal hernia repair. Surgeon 2007;5:137-40, 142.
McCloud JM, Evans DS. Day-case laparoscopic hernia repair in a single unit. Surg Endosc 2003;17:491-3.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]