JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES

Volume 27, Number 12, 2017 2017 IPEG Papers

ª Mary Ann Liebert, Inc.
DOI: 10.1089/lap.2017.0288

In Pursuit of the Most Cost-Effective Pediatric

Laparoscopic Appendectomy:
The Effect of Disposable Instrument Choice
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on Operative Time and Surgeon-Controllable Cost

Emily E. Abbott, DO, MS,1 Jonathan C. Chan, BS,2 Judith Boura, MS,3 and Nathan M. Novotny, MD2,4–6

Abstract

Background: There is a movement toward cost savings in healthcare worldwide. Surgeons can affect two main
cost variables in an operation (controllable cost): disposables and time. Our hypothesis is that increasing
disposable costs do not change outcome or operative time, but simply increases controllable cost.
Methods: We retrospectively reviewed patients younger than the age of 18 years undergoing laparoscopic
appendectomies for nonperforated appendicitis from January 2013 to November 2016. Data obtained included
demographic information in addition to intraoperative details, including disposables used and associated cost,
resident participation, operative time, and final pathology. Patients were excluded if perforation was present as
confirmed by operative findings or pathology (Kansas City definition). Patients were also excluded if concurrent
procedures were performed during the appendectomy.
Results: We reviewed 918 patients and excluded 288 for a total of 690. Disposable cost, operative time, and
complications were compared between cases with a resident present and those without. Residents did not
increase the use of disposables, but did increase operative time and therefore the total controllable cost.
Transumbilical laparoscopic-assisted technique was significantly faster with lower controllable cost when
compared with all other methods. Using disposable trocars with an endostapler was the second fastest and
second lowest controllable cost and retained a significant difference when compared with most other methods.
Endoloop methods did not show overall controllable cost savings versus the vast majority of methods.
Conclusions: To maximize controllable cost savings, we recommend a transumbilical laparoscopic-assisted
appendectomy or a standard three-port laparoscopic appendectomy, with disposable trocars and the endostapler.

Keywords: appendectomy, cost, disposables

Introduction health insurance coverage may postpone medically necessary

treatment, which has been associated with both increased in-
cidence of perioperative complications and increased costs.3 In
I n the United States, national spending on healthcare
expenditures is projected to grow 5.8% each year through
2020, making up an increasing share of the nation’s gross
this context, it is urgent that we continue to develop a com-
prehensive understanding of the surgical costs to better man-
domestic product (GDP).1 In particular, the percentage of age our national healthcare expenditures as well as the
spending on surgical care in the United States continues to rise, accessibility of surgical care for individuals in our society.
despite the government and institutional efforts to limit this Surgeons are uniquely positioned to both understand and
trend.2 Healthcare spending on surgical services and care is impact the costs associated with surgical procedures.2,4 A
expected to cost $912 billion by 2025, making up 7.3% of the study on surgeons’ choice of instrument use during an ap-
national GDP.2 In addition, individuals who lack adequate pendectomy showed that the increased cost of disposable
1
Department of Surgery, Beaumont Health, Royal Oak, Michigan.
2
Oakland University William Beaumont School of Medicine, Rochester, Michigan.
Departments of 3Biostatistics and 4Pediatric Surgery, Beaumont Health, Royal Oak, Michigan.
5
Department of Pediatric Surgery, King Abdullah University Hospital, Irbid, Jordan.
6
Jordan University of Science and Technology, Irbid, Jordan.
Oral presentation at IPEG 2017, London, England.

1
 2 ABBOTT ET AL.

instruments could influence the overall procedure cost and
often surpassed the reimbursement for that procedure.4
Appendectomies are one of the most common surgical
procedures for both the pediatric and general population.5–7
The laparoscopic approach to the appendectomy has been
established as an accepted approach that optimizes patient
safety, quality, and cost.8,9 Therefore, analyzing the cost of
the laparoscopic appendectomy can offer additional insight
into overall surgical healthcare spending.10
At our institution, laparoscopic techniques for pediatric
appendicitis include transumbilical laparoscopic-assisted
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pendix was perforated, if they had an interval appendectomy or
a concurrent procedure during their operation, or if they were
not within the eight methods analyzed. The median age was 12
(range 3–17). The mean body mass index (BMI) – standard
deviation (SD) was 21.0 – 5 (Table 1). There were 208 females
and 271 males. The patient population was 78% Caucasian,
3% Asian, 5% African American, and 14% other, which is
similar to our hospital population (Table 1). Patient co-
morbidities were identified from the chart such as history of
cancer, diabetes, asthma, heart disease, irritable bowel, gastro-
esophageal reflux disease (GERD), or Celiac disease, but were

approaches, traditional three-incision procedures, and nearly not considered impactful on the outcome or speed of the case.
every option in between. In addition, surgeons utilize any The median operative time was 37 minutes (12–89 min-
combination of various staplers, endoloops, disposable, or re- utes). Median length of stay was 1.44 (0.28–13.1) days
usable trocars with or without energy devices—all without the (Table 1). The maximum length of stay of 13.1 days was a
explicit direction of administration. The aim of this study was patient with a new diagnosis of acute lymphoblastic leukemia
to further analyze the effects of the use of disposable instru- that developed acute appendicitis during his hospitaliza-
ments on operative time, complications, and overall control- tion. There were 17 different attending surgeons found to
lable cost. Controllable cost is defined as disposable instrument have performed the surgery, but three pediatric surgeons
cost combined with operative cost, which was operative time performed the vast majority of cases (68%).
multiplied by the cost per minute. We hypothesized that in- Most cases had resident involvement, 342 (71%) versus
creasing disposable instrument costs does not change outcome 137 (29%) that did not. The majority of cases had minimal
or operative time, but simply increases controllable cost. blood loss recorded [p9 mL, 474 (99%)]. The maximum
blood loss was 20 mL, and those documented with greater than
Methods minimal blood loss were only 5 patients and not considered
significant (Table 1). Complications were also evaluated. We
Patient charts were retrospectively reviewed through elec-
tronic medical records, including surgeon operative reports,
hospital charge codes, and progress notes, at an American
tertiary children’s hospital and its community-based sister Table 1. Patient Demographics
hospital from January 2013 to November 2016. All patients
were younger than 18 years of age and were undergoing lap- Typical
value Range n Percent
aroscopic appendectomies for nonperforated appendicitis.
Data obtained included demographic information in addition Age 12 3–17 479
to intraoperative details, including disposables used— BMI 21 –5 418
endostaplers, endoloops, LigaSure (Covidien, Zelienpole, OR time 37 minutes 12–89 minutes 479
PA), Harmonic (Ethicon, Cincinnati, OH), clips, hook cau- Length of stay 1.44 days 0.28–13.1 days 479
tery, disposable or reusable trocars, and Endobag (Covidien) Estimated blood Minimal Minimal— 479
or Endo Catch (Covidien), their associated costs, resident loss 20 mL
participation, operative time, and final pathology. Race
Due to the numerous methods (49 in total) used by multiple, Caucasian 328 78
African 23 5
different surgeons, the eight most common approaches were American
analyzed and compared. Perioperative complications within Asian 11 3
30 days of their operation were also analyzed. Patients were Other 61 14
excluded if they were older than the age of 18 years, if they had Gender
concurrent procedures performed at the time of the appen- Male 271 57
dectomy, or if it was an interval appendectomy or perforated. Female 208 43
We defined perforation using the Kansas City definition Complications
(perforated by operative or pathology report), a visible hole in None 440 92
the appendix or a fecalith found within the abdomen. Intra-abdominal 12 2.5
The data were analyzed by our Biostatistics Department using abscess
SSI 6 1.3
SAS for Windows, 9.3 Cary, NC software. Complications were Ileus 9 1.9
analyzed with Pearson’s Chi-square test wherever possible (ex- Respiratory 2 0.4
pected frequency >5), otherwise, Fischer’s exact tests were used. Bladder injury 1 0.2
Continuous variables were analyzed with either Wilcoxon rank Other 16 3.3
sum tests or Kruskal-Wallis tests. The Dwass-Steel-Critchlow-
Fligner Method for pairwise two-sided multiple comparisons was Median age in years reported along with range. Mean BMI is
reported with the standard deviation (BMI could not be calculated
used, and P-values<.05 were considered statistically significant. for 61 patients due to incomplete records).
Outcomes for operative time, length of stay, and estimated blood
Results loss (EBL) are listed below. Operative time was defined as incision
to closure. Length of stay was preoperative admission to discharge.
There were 918 patient charts reviewed with 439 excluded BMI, body mass index; OR, operating room; SSI, surgical site
for a total of 479 patients. Patients were excluded if the ap- infection.
 CONTROLLABLE COST IN LAPAROSCOPIC APPENDECTOMY 3

Table 2. Groups A–H of Method of Appendix Removal and Instruments Used

Entry method Hemostasis Appendix control
Bag used

Reusable Disposable LigaSure / Endo Catch/
Group trocar trocar Harmonic Hook Endostapler Endoloop Endobag n
A X 45
B X X X 52
C X X X X 106
D X X 69
E X X X 69
F X X X 47
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G X X X X 57
H X X X X 34
Total n 479
Each group is described by entry method used, hemostasis method, how the base of the appendix was controlled, and whether or not a
removal bag was used and the type.

found 12 patients with intra-abdominal abscess formation lable cost. Groups B, D, and F were not statistically signifi-
(2.5%), 6 with surgical-site infection (1.3%), 9 developed an cantly different from each other. Both Groups D and F had
ileus (1.9%), 2 patients developed pneumonia (0.4%), one higher instrument costs, but faster OR time and Groups B and
patient with a bladder injury (0.2%), and 16 patients developed F both used endoloops. There were not enough complications
other complications (3.3%). However, there were not enough within these methods to compare the methods on complica-
occurrences from which to draw meaningful conclusions about tion rates (Table 3).
associated complications (Table 1). Transumbilical laparoscopic-assisted approach (Group A:
There were many different appendectomy methods utilized reusable trocars only) was faster and had significantly lower
with too few observations to discuss with significant meaning, controllable cost when compared with all other methods
consequently, only the eight most frequent methods were ex- (P < .0001). Using disposable trocars and the endostapler
amined, which constituted 69% or 479 of the total cases. These (Group D) was the second fastest and second lowest con-
were then labeled as Group A through H based on their total trollable cost and retained a significant difference when
disposable cost ordered, least costly to most expensive. compared with most other methods. While the median cost
Group A consisted of reusable trocars only, which was difference between Groups C and D (endoloop and staplers,
considered the transumbilical laparoscopic-assisted approach, respectively) was only $36, endoloop methods did not show
described as an open cutdown Hassan approach (5 or 10 mm), overall controllable cost savings versus the vast majority of
placing the camera through that reusable trocar and then in- methods when the entire dataset was taken into consideration.
serting an instrument through the fascia next to the camera Disposable instrument cost, operative time, and compli-
port, grasping the tip of the appendix, incising the fascial cations were compared between cases with a resident and
bridge between the instrument and camera port, and suture those without. Residents did not increase the use of dispos-
ligating it extracorporially (45 patients); Group B, disposable ables, but did increase median operative time (39 versus 34
trocars, hook cautery, and endoloops (52 patients); Group C, minutes) and therefore the total controllable cost (P < .0001).
disposable trocars, hook cautery, endoloops, and Endo Catch There were not enough complications to make any mean-
(106 patients); Group D, disposable trocars and endostapler ingful statements about residents and complications.
(69 patients); Group E, disposable trocars, endostapler, and
Endo Catch (69 patients); Group F, reusable trocars, Har-
monic or LigaSure, and endoloops (47 patients); Group G, Table 3. Controllable Costs
reusable trocars, Harmonic or LigaSure, endoloops, and En- Instrument OR Time Controllable Complications
dobag (57 patients); and Group H, reusable trocars, Harmonic Groups cost ($) (minutes) cost ($) n (%)
or LigaSure, endostaplers, and Endo Catch (34 patients)
(Tables 2 and 3). A Baseline 28 1,410 2 (4.4)
All groups had a baseline cost of a basic laparoscopic tray B +257 40 2,267 5 (9.6)
and since Group A used no disposables, this was considered C +322 45 2,572 5 (4.7)
the baseline instrument cost (Fig. 1). Group B and C, with D +521 32 2,231 2 (2.9)
disposable trocars and endoloops, had lower instrument costs E +586 36 2,451 8 (11.6)
than group D, which used endostaplers and disposable tro- F +590 33 2,250 7 (14.9)
G +607 38 2,497 9 (15.8)
cars. Operative time was considered time from incision to H +785 36 2,615 1 (2.9)
closure and as mentioned previously, Group A had the
shortest operative time. Operative cost was calculated by the Each group had a baseline cost, the basic laparoscopic tray plus the
time per minute in the operating room (OR) and the cost of cost for any additional instruments, such as an endostapler or endoloop,
each minute. Controllable cost was the sum of instrument and so on. Operative cost was calculated by the cost per minute of use.
Controllable cost was calculated by combining instrument cost with
costs and operative costs. Group A had the lowest control- operative cost. Group A used extracorporeal cautery for hemostasis and
lable cost followed by Group D. Groups B and C, while suture to ligate the base of the appendix, and these costs were
having lower instrument costs, did not have lower control- considered trivial and not included in the analysis.
 4 ABBOTT ET AL.
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FIG. 1. Distribution of controllable costs by group.

Table 4 was included to assist surgeons in weighing the cost Discussion

of a disposable instrument as a relative value when compared With the cost of healthcare in the United States rising, it
to time. The total cost of the instrument was divided by the becomes increasingly important to find savings without
operative time cost. This table ignores any possible com- compromising patient care. Eliminating the use of expensive
plications associated with or prevented by the instruments disposable instruments or increasing the speed of the opera-
and also the time to application, if applicable. The Endobag tion while doing so safely could be a way to decrease
essentially costs 0.3 minutes of OR time, whereas the en- healthcare costs. In this study, we found that a transumbilical
dostapler, depending on the type of stapler, size, and how laparoscopic-assisted approach (Group A: reusable trocars
many loads were used, could cost up to 15 minutes of OR only) with using a reusable trocar via the umbilicus and
time. Each endoloop costs much less OR time (0.2 minutes), bringing the appendix up through that incision was the least
although when application time was taken into account, the expensive in terms of disposable instrument use, but also the
endoloop groups did not provide a statistically cheaper method quickest operation, making it the most cost-effective appen-
when compared with the vast majority of other groups. dectomy operation (P < .0001).
Confounding factors must be considered, including that
operative time may be influenced by patient size, mobility of
Table 4. Relative Value of Disposable Instruments the appendix, and the severity of the appendicitis. We at-
as a Function of Operating Room Time tempted to control this bias by excluding perforated cases, but
Value of instrument it is possible that larger patients who were not selected to
Disposable instrument in OR time, minutes undergo the transumbilical laparoscopic-assisted approach
may have been more difficult, take longer, and therefore cost
Three disposable trocars 4.8 more. Wound infections have shown to be a concern in the
Harmonic 11.6 transumbilical laparoscopic-assisted method and could
LigaSure 9.2 therefore increase cost.11 However, we had zero wound in-
EndoCatch 1.3 fections in this technique. The disposable trocars and en-
Endobag 0.3
Endoloops 0.2 dostapler appeared to have sped up the operation by allowing
Endo GIA Stapler Handle and 5.5 faster control of the appendiceal mesentery enough to com-
45 mm reload pensate for the cost of the trocars and stapler. This is bene-
Endo GIA Stapler 45 mm reload 3.5 ficial for larger patients and when single incision is not
JustRightStapler 15 possible. Surprisingly, despite endoloops being much
cheaper than the endostapler, the time of cauterization of the
The value is obtained by dividing the cost of the instrument by the mesentery and application of the endoloops outweighed the
OR time cost. When weighing the utility of a disposable instrument,
this table helps surgeons understand how much time needs to be cost savings.
saved to justify the use of specific disposable instruments (from a One limitation of our study is its relatively small number of
pure cost standpoint). patients. Since the majority of the cases were done by three
 CONTROLLABLE COST IN LAPAROSCOPIC APPENDECTOMY
surgeons, surgeon skill could influence operative time and
therefore surgeon controllable cost by technique. In addi-
tion, there was variance in technique even by surgeon (i.e.,
many surgeons performed multiple methods of removal). In
addition, given the retrospective nature of this review, there
may have been some selection bias in the transumbilical
laparoscopic technique by surgeon preference and patient
characteristics.
We did find that residents increased the operative time
enough to significantly increase the overall cost of the op-
eration. However, we feel strongly that surgeon training is
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vitally important and a slight increase in costs despite being
statistically significant (P < .0001), far outweighs this draw-
back and should not be eliminated.
We are moving toward standardization to the lower cost
methods at our institution. However, this is for the routine
easy pediatric appendectomy, and the authors would like to
emphasize that when there is concern for safety or increasing
OR time, more costly disposable methods may be justified.
Applying the most cost-effective method to all is potentially
dangerous, given nuances of each patient and surgery. We do
contend that education on costs could help decrease spending
in surgical healthcare. Since the conclusion of the study,
some surgeons have been performing the single incision more
often, whenever it is safe to do so, in an effort to reduce cost,
and we are encouraging others to follow suit.
In summary, we determined that disposable instruments
can influence cost and operative time. We advocate for the
use of the transumbilical laparoscopic-assisted technique or
traditional three-port appendectomy with disposable trocars
and endostapler whenever clinically appropriate. Further
studies could be done with a randomized prospective, multi-
institutional trial to gain enough power to better evaluate
complications to compare the different disposables and to
study each surgeon individually.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Nathan M. Novotny, MD
Department of Pediatric Surgery
Beaumont Health
3535 West 13 Mile Road
Suite 307
Royal Oak, MI 48073
E-mail: nathan.novotny@beaumont.edu