Cost-effectiveness in health care management is critical. The situation in debt-stricken Greece is further aggravated by the financial crisis and constant National Health System expense cut-downs. In an effort to minimize the cost of laparoscopy, our department introduced reusable laparoscopic instruments in December 2011. The aim of this study was to assess potential cost reduction of laparoscopic operations in the field of general surgery. Hospital records, invoice lists, and operative notes between January 2012 and December 2013, were retrospectively reviewed and data were collected on laparoscopic procedures, instrument failures, and replacement needs. Initial acquisition cost of 5 basic instrument sets was €21,422. Over the following 24 months, they were used in 623 operations, with a total maintenance cost of €11,487. Based on an average retail price of €490 per set, projected cost with disposable instruments would amount to €305,270, creating savings of €272,361 over the two-year period under study. Despite the seemingly high purchase price, each set amortized its acquisition cost after only 9 procedures and instrument cost depreciated to less than €55 per case. Disposable instruments cost 9 times more than reusable ones, and their high price would almost equal the total hospital reimbursement by social security funds for many common laparoscopic procedures.
The wide adoption of the concept of minimally invasive laparoendoscopic surgery and the concomitant progress in technology have reduced the prices of sophisticated laparoscopic instruments; however, cost of laparoscopy remains generally higher than that of open surgery. In most clinical studies, higher operating theatre cost is partly offset by shorter hospital stays, less medication requirements, shorter periods of convalescence, and faster return to work and normal activity [
In an effort to minimize the cost of laparoscopic surgery, without compromising quality of health services, our department introduced RLIs in December 2011, under the pressure of budget limitation. The primary aim of this study was to assess potential cost reduction of laparoscopic procedures performed between January 2012 and December 2013, in the field of general surgery. The secondary aim was to calculate annual maintenance expenses of RLIs and investigate possible ways of further cost limiting.
Hospital records, invoice lists, and operative notes between January 2012 and December 2013 were retrospectively reviewed and data were collected on type and number of laparoscopic operations, instrument failures, and replacement requirements. Maintenance cost was calculated as the sum of resterilization, repackaging, repair, and replacement expenses. For comparison purposes, retail prices of disposable laparoscopic instruments (DLIs) were obtained from the National Price Observatory for Health Supplies. Disposal cost for DLIs, based on weight of waste, was practically negligible.
Cost of insufflation and suction-irrigation tubes, clip appliers, retrieval bags, mesh patches, staplers, and so forth, was not included in the analysis, since there is no choice between reusable and disposable forms.
In December 2011, 5 basic sets of RLIs were purchased (AESCULAP, B-BRAUN, Tuttlingen, Germany), with initial acquisition cost of €21,422. Each set consists of a curved monopolar dissector, two atraumatic grasp monopolar forceps with ratchet, a pair of Metzenbaum monopolar scissors, a suction-irrigation device, a Veress needle, a Hasson cannula, and two 12 mm and two 5 mm bladeless trocars with replaceable rubber valves. Over the following 24 months, they were used in 623 laparoscopic operations (Table
Laparoscopic operations between January 2012 and December 2013.
Operation |
|
---|---|
Cholecystectomy | 454 |
Appendicectomy | 42 |
Hernia repair | 10 |
Nissen fundoplication | 16 |
Colectomy | 33 |
Adjustable gastric band | 16 |
Vertical sleeve gastrectomy | 20 |
Gastric plication | 2 |
Heller’s myotomy | 1 |
Ventral rectopexy | 1 |
Hepatic cyst unroofing | 2 |
Exploratory/staging/biopsy | 26 |
|
|
Total | 623 |
Two-year maintenance cost amounted to €11,487. Resterilization and repackaging of each set were calculated at €5 per procedure, costing €3,115 for the two-year period under study, while replacement and repair costs came to €8,372, with requirements limited to torn trocar valves and a broken grasper forceps (Table
Replacement and repair requirements (incl. VAT 23%).
Part | Number of | Price per | Price (€) |
---|---|---|---|
units | unit (€) | ||
Trocar valve 10–12 mm | 50 | 8.65 | 432.35 |
Trocar valve 10–12 mm | 56 | 76.20 | 4,267.12 |
with 5 mm adaptor | |||
Trocar valve 5 mm | 79 | 12.77 | 1,008.62 |
Adaptor | 36 | 70.11 | 2,523.96 |
Grasper tip repair | 1 | 139.99 | 139.99 |
Scissors sharpening | 1 | Gratis | Gratis |
|
|||
Total | 8,372 Euros |
Based on an average retail price of €490 per set, estimated cost of 623 procedures with DLIs would come to €305,270. The actual total instrument cost was €32,909, creating savings of €272,361 over two years.
Cost-effectiveness in health care management has always been a major issue. The situation in debt-stricken Greece is further aggravated by the financial crisis and constant National Health System expense cut-downs. Hospital administrations are called to drastically reduce their expenditure and use their limited resources wisely.
Our preliminary study of reusable versus disposable laparoscopic instruments, based on a projected number of 200 laparoscopic operations per annum, predicted net yearly savings of around €80,000. Two years later, the results of this analysis clearly confirm our expectations. Despite the seemingly high purchase price, each set amortized its acquisition cost after only 9 laparoscopic operations. Initial cost was 65% of the total two-year expenditure and depreciated to less than €55 per patient. This figure is expected to fall even more, with every future use of the instruments.
As per annual maintenance cost, roughly 30% covered the relatively inflexible expenses of resterilization and repackaging, while 70% pertained to replacements and repairs. Worn-out valves need replacement more often than any other instrument part [
The cost analysis revealed more useful conclusions. Laparoscopic instrument cost would be 9 times higher with disposable compared with reusable instruments. More importantly though disposable instrument cost alone would cover almost half of the total hospital reimbursement by social security funds for many common laparoscopic procedures (Table
Hospital reimbursements by social security funds for common, uncomplicated laparoscopic procedures.
Operation | Hospital reimbursement (€) |
---|---|
Cholecystectomy | 1,085 |
Appendicectomy | 764 |
Hernia repair | 868 |
Nissen fundoplication | 1,649 |
Colon resection | 2,519 |
Rectum resection | 3,506 |
Obesity procedures | 1,506 |
Further reduction in cost will chiefly result from increasing the number of uses, reflecting the decreasing depreciation cost per case. Expanding use of RLIs in the fields of urology and gynecology would add another 50 to 100 procedures annually. On the other hand, maintenance expenses, at €5,750 per year, are already quite acceptable and rather fixed.
Much discussion has occurred in the past regarding the advantages and disadvantages of reusable versus disposable instruments [
Despite speculative arguments, sterilization proved to be adequate, when manufacturer’s instructions are followed, and we could not find any case report in the literature of infectious disease transmission through inadequately processed RLIs [
Modular configuration, adopted by most manufacturers, permits dismantling of the instruments, while maintaining a simple yet robust design. Thus repairs are facilitated, since only the faulty part can be replaced, with minimal cost. Moreover, access is allowed throughout the shaft and the handle, allowing for optimal cleaning and effective sterilization.
Skeptics also voice that ergonomics and efficacy of DLIs are unequaled, since they are “new” every time and this may indeed be true up to a point. Reusable instruments are more prone to technical issues but should be considered an investment for every surgical department and with careful handling and maintenance, the normal wear and tear can be kept to a minimum [
Next to trocar valves that required replacement every 10 procedures, scissors needed sharpening after 60–80 operations, whereas bladeless trocars do not require sharpening at all. Reusable trocars possibly require more force during insertion and this could be associated with more intra-abdominal injuries [
Another cause of collateral damage is electrosurgical injuries due to insulation failure. We routinely check insulation sheaths macroscopically for signs of wear; however, our institution lacks the facility to perform proper electrical conductivity tests on the instruments. Based on the literature, one in five RLIs has some kind of insulation defect, which tends to occur more often at the distal third of the sheath, near the working tip [
Last but not least, increasing environmental concerns are not to be taken lightly [
Cost studies of this type have a certain limitation. Our comparative analysis is based on specific retail prices for DLIs, obtained by the National Price Observatory. Suppliers of instruments may offer favorable pricing packages through individual agreements, when larger quantities are ordered [
The fact remains though that instrumentation cost is only a fraction of total hospital costs per patient [
Reusable laparoscopic instruments substantially reduce the cost of laparoscopic surgery, without compromising safety of patients and medical personnel. Initial acquisition costs are quickly amortized and further depreciated with every use. Although they may be prone to more technical issues compared to disposable instruments, they should be considered an investment for surgical departments and handled with proper care and attention.
The authors declare that there is no conflict of interests regarding the publication of this paper.