Introduction and meaning of Laparoscopy
Laparoscopy is a type of surgery in which small incisions are made in the abdominal wall through which a laparoscope and other instruments can be placed to permit structures within the abdomen and pelvis to be seen. Through these small incisions in the skin a variety of probes or other instruments can also be pushed. In this way without the need for surgical incision, a number of surgical procedures can be performed
Laparoscopy is a standard procedure offered for many years by most medical centers providing surgical services. The number and range of laparoscopic procedures is steadily increasing. For some time, laparoscopic procedures have been successfully applied in the treatment of acute cases, such as acute cholecystitis and acute appendicitis, and applied minimally invasive techniques, such as exploratory laparoscopy, are progressively used in diagnostics. Videoscopy development also allows for the treatment of neoplastic diseases. The clinical condition of the patient and concomitant disturbances, including their past surgical history is considered by the surgical team in choosing between the open or laparoscopic procedures, the cost of therapy is now also playing a more important role.
A laparoscopic procedure results in least interference in the condition and functioning of the patient, and the wound is properly dressed as in an open procedure. A smaller post-operative wound reduces post-operative pain, which in turn contributes to a lower risk of bacterial infection and post-operative hernia complications. Shorter hospitalization time and post-operative recovery might also reduce treatment costs.
The aim of the study is to represent the real total costs of open and laparoscopic cholecystectomy, appendectomy and sigmoidectomy.
What is Laparoscopic Surgery?
Laparoscopic or “minimally invasive” surgery is a specialized technique used for performing surgery. In the past, this technique was used for gynecologic surgery and for gall bladder surgery. Over the previous 10 years the use of this technique has extended into intestinal surgery. In conventional “open” surgery a single incision is used by the surgeon to enter into the abdomen. Laparoscopic surgery uses several 0.5-1cm incisions called as port. At each port a tubular instrument is inserted which is known as a trochar. During the procedure, specialized instruments and a special camera known as a laparoscope are passed through the trochars. At the beginning of the procedure, using carbon dioxide gas the abdomen is inflated to provide a working and viewing space for the surgeon. The laparoscope transmits images from the abdominal cavity to high-resolution video monitors placed in the operating room. During the operation the surgeon observes detailed images of the abdomen on the monitor. This system allows the surgeon to perform the same operations as conventional surgery but with smaller incisions.
In some situations a surgeon may choose to use a special type of port that is large enough to insert a hand. The surgical technique of using a hand port is called the “hand assisted” laparoscopy. The incision required for the hand port is larger than the other laparoscopic incisions, but is usually smaller than the incision required for conventional surgery.
Why is laparoscopy performed?
Laparoscopy is often used to identify and diagnose the source of pelvic or abdominal pain. It’s usually performed when noninvasive methods are unable to help with diagnosis.
In many cases, abdominal problems can also be diagnosed with imaging techniques such as:
- ultrasound, which uses high-frequency sound waves to create images of the body
- CT scan, which is a series of special X-rays that take cross-sectional images of the body
- MRI scan, which uses magnets and radio waves to produce images of the body
Laparoscopy is performed when these tests don’t provide enough information or insight for a diagnosis. The procedure may also be used to take a biopsy, or sample of tissue, from a particular organ in the abdomen.
Your doctor may recommend laparoscopy to examine the following organs:
- small intestine and large intestine (colon)
- pelvic or reproductive organs
By observing these areas with a laparoscope, your doctor can detect:
- an abdominal mass or tumor
- fluid in the abdominal cavity
- liver disease
- the effectiveness of certain treatments
- the degree to which a particular cancer has progressed
As well, your doctor may be able to perform an intervention to treat your condition immediately after diagnosis.
What are the advantages of laparoscopic surgery?
Compared to conventional open surgery, patients may often experience less pain, a shorter recovery period, and less scarring with laparoscopic surgery.
Working this way has several advantages compared with traditional surgery. Because it involves less cutting:
- You have smaller scars.
- You get out of the hospital quicker.
- You’ll feel less pain while the scars heal, and they heal quicker.
- You get back to your normal activities sooner.
- You may have less internal scarring.
Here’s an example. With traditional methods, you might spend a week or more in the hospital for intestinal surgery, and your total recovery might take 4 to 8 weeks. If you have laparoscopic surgery, you might stay only 2 nights in the hospital and recover in 2 or 3 weeks. And a shorter hospital stay generally costs less.
Different kinds of operations that can be performed using laparoscopic surgery
Intestinal surgeries mostly can be performed using the laparoscopic technique. These may include surgery for Crohn’s disease, ulcerative colitis, diverticulitis, cancer, rectal prolapse and severe constipation.
Concerns had been raised in the past about the safety of laparoscopic surgery for cancer operations. Lately, several studies which is involving hundreds of patients, have shown that laparoscopic surgery is safe for certain colorectal cancers.
Laparoscopic surgery-is it safe?
Laparoscopic surgery is as safe as conventional open surgery. At the inception of a laparoscopic operation the laparoscope instrument is inserted through a small incision near the belly button also known as umbilicus. The surgeon who initially inspects the abdomen to determine whether laparoscopic surgery can be safely performed. If the amount of inflammation is large or if the surgeon has encountered other factors that is preventing a clear view of the structures, a larger incision may need to be taken by the surgeon in order to complete the operation safely.
Certain risks are associated with any intestinal surgery such as complications related to anesthesia and bleeding or infectious complications. The risk of any operation or surgery is determined in part by the nature of the specific operation or surgery. General heath of an individual and other medical conditions are also factors that can affect the risk of any operation. The individual should discuss with their surgeon regarding the individual risk for any operation.
Material and methods
Between May 2010 and March 2014 in the Department of Thoracic Surgery, General and Oncological Surgery, Medical University of Lodz, and the Department of General Surgery of the Saint John of God Hospital, Lodz, 1404 cholecystectomies, around 400 appendectomies and 88 sigmoidectomies were performed. In total, 97% of the cholecystectomy procedures were laparoscopic operations and 3% were open operations. Likewise, 18% of appendectomies were laparoscopic and 82% were open, and 9% of sigmoidectomies were laparoscopic and 91% were open. In patients who underwent cholecystectomy, a procedure of laparoscopic was standard. In more than ten cases, doctors performed open surgery due to prior surgical history, confirmed complicated acute cholecystitis or suspected gallbladder cancer. Although an open procedure was commonly used for appendectomy until 2011, since then some surgeons have been taking a laparoscopic approach. Similarly, laparoscopic sigmoidectomy is a relatively new procedure in Poland, with operations of this type only being performed since 2013, but only in selected cases.
Due to the need for single-use equipment in laparoscopic procedures, the cost of the procedures has an addition. After adding up all other costs along with the differences between the costs of laparoscopic and open procedures, a range of differences for each type of procedure: for appendectomy, the open procedure is 7.8% less expensive than laparoscopy, but for cholecystectomy, the open procedure is 28.6% more expensive than laparoscopy. While the cost of laparoscopic and open sigmoidectomies appears to be comparable, the latter is around 9% cheaper.
Analysis of costs
Financial problems are faced by most public health care centers. The financial outcome of a center is not often related to its personnel or work organization but from underestimating the cost of surgical procedures which results in potential financial problems. The direct costs related to the hospital treatment were calculated. For each patient the most important cost items such as operation room times, bed-day costs, and costs of reoperation and readmission were calculated. The fixed costs were calculated as the mean per patient, fixed costs which may include the laparoscopic equipment.
For items of laparoscopic hardware and reusable instruments, an estimation of their life span is obtained as well as an approximate was made of the number of times it is used. An annual equivalent cost was estimated and divided by the annual use to obtain a cost per patient. Valuation is also carried out. The annual use of equipment obtained from a hospital database in which all procedures are recorded. The same standard set of reusable instruments used in other laparoscopic procedures performed. An estimation of the amortization of reusable instruments. The monitor, camera, and light source were used in laparoscopies, thoracoscopies, and arthroscopies per year.The annual use of carbon dioxide is evaluated to estimate a cost per patient.
During the LAs and OAs, the operating room which is staffed by 1 surgeon, 1 anesthesiologist and 3 nurses. Fixed basic salary paid for operation room staff during the regular working hours, whilst employees are to be paid additional compensation for assigned on-call duty. A surgeon and anesthesiologist and the nurses in the hospital receive the same on-call compensation for each hour of work irrespective of whether there was any active work.
Other costs for operating room consumables, overhead property, and administration, salaries of ancillary staff, anesthetic equipment, equipment maintenance, and sterilization of the instruments, antibiotics, nonopioid analgesics, and anesthetics are considered to be the same between LA and OA.
There are essentially 4 aspects to the cost. First is time in Operating Room. Second is the surgeon’s charge, and then the third is charges of anesthesia. And finally the charges associated with the length of stay. All of this is then dependent on the insurance, pre-negotiated coverage and co-payment. The question arises is that why is the person having surgery. Is it for appendix? Gallbladder? Lap banding? The cost generally of a laparoscopic gallbladder might be around $30,000. But this has no logical prediction to this bill actually received. This assumes a couple of hours on surgery, a couple in recovery room and plausible 3 day stay.
The Laparoscopic surgery cost could generally depend upon four areas, which are mentioned below:
Firstly, it may depend on which hospital one is choosing for laparoscopic surgery, whether it’s a private one or government one.
Secondly, the equipment quality which is to be used during laparoscopic surgery.
Thirdly, it depends upon how much the surgeon is experienced, if the surgeon is a novice or beginner he may charge less, but if the surgeon is a professional then it is dependent upon him.
Fourth, the length of stay in the hospital after the laparoscopic surgery is conducted.
Laparoscopic surgery packages
For most surgical procedures the Packages are in fashion today in various corporate hospitals and this has also included laparoscopic procedures too. A package system helps in enabling the hospitals to get cost arrangement done more easily. And also, it is more convenient for the patients who are aware in advance of the charges. The primary disadvantages seems to be for the surgeon, who may face disapproval of the patient, hospital or insurance agencies apart from forfeiting his personal charges depending upon if (a) he is a novice in laparoscopic surgery and takes more time to complete a surgery, (b) unpredictable problems occur during the surgery, or (c) new pathologies are discovered on exploration.
Various packages are designed by a majority of the private and corporate hospitals for the laparoscopic surgeries which are performed in the hospital. The package will include all the charges pertaining to a particular treatment/procedure including the registration charges, admission and accommodation charges, injection/transfusion charges, bandage charges, operation charges, anesthetic charges, operation theater charges, procedural charges/surgeon fee, doctor or consultant’s visit charges, ICU/ICCU charges, monitoring charges, cost of the disposable surgical charges and cost of all items used during hospitalization related routine investigation, and physiotherapy charges, etc. from the time of the admission of the patient to the time of discharge of patient. The only charges that are excluded from the package may include the telephone charges and toiletries charges. The insurance companies and government organizations referring the patients for laparoscopic surgery to such private or corporate hospitals insist on strict commitment to the packages and may routinely block any charges if they are exceeding the scheduled package, irrespective of any valid or invalid reason offered by the hospital or due to any unpredicted complication.
Open cholecystectomy is expensive when compared to Laparoscopic cholecystectomy, considered the standard surgical procedure in treating gallbladder diseases. Laparoscopic appendectomy and sigmoidectomy are methods which are safe of minimally invasive surgery which are only slightly more expensive than open operations.
The laparoscopic surgery although carries well-defined benefits and usually does not cross the package charges, but in cases of unexpected developments the competent authority should be liberal, especially in minimally invasive surgery. The package system should be such that untoward/unforeseen/unpredictable complications or prolonged antibiotics or hospitalization, if it is needed, are taken care of without issuing a penalty to the patient, surgeon, or the hospital. An adequate training can be provided to the surgical staff and processing staff so that hospitals can maximize their returns on minimally invasive surgery, and by standardizing equipment and wisely choosing when to use the equipment used in for minimally inversive surgery (MIS). In the even more challenging medical environment, the concept of increasing value by increasing quality without an attempt to decrease costs is a very important principle that the health care system should learn.