inguinal herniorrhaphy is one of the most common elective procedures performed worldwide . in the united states
, an estimated 800,000 inguinal hernia repairs are performed each year , accounting for 10% to 15% of all surgical procedures .
however , there continues to remain controversy surrounding the optimal surgical management of this condition .
several studies have validated the clinical utility of laparoscopic inguinal herniorrhaphy and have demonstrated comparable short - term safety and long - term efficacy relative to the open approach .
given increasing fiscal constraints , procedural cost - effectiveness has become an important metric in evaluating surgical procedures .
although several studies have demonstrated higher costs associated with laparoscopic inguinal herniorrhaphy , others have successfully reported cost - containment strategies in laparoscopic surgery .
given that elective inguinal hernia repairs are most often ambulatory procedures , the direct operating room ( or ) expense predominates as the driving factor in the total cost of care .
therefore , the objective of this study was to compare the or and total hospital costs associated with laparoscopic versus open inguinal herniorrhaphy performed at a publicly funded , tertiary academic institution .
using a prospectively maintained database , all patients undergoing elective open or laparoscopic inguinal hernia repair between april 2009 and march 2011 at the toronto western hospital , university health network , were identified .
open inguinal herniorrhaphy was performed using a standardized lichtenstein repair with either a polypropylene or a polyester mesh .
a retrospective review of electronic patient records was performed , along with a standardized case - costing analysis using data from the ontario case costing initiative .
laparoscopic mesh repair varied by surgeon preference between a standardized transabdominal preperitoneal ( tapp ) and a total extraperitoneal ( tep ) approach . as part of a local cost - awareness strategy , permanent trocars are preferentially used .
monetary values are shown in canadian dollars and were converted to 2012 values using consumer price index inflationary adjustments .
secondary outcomes included perioperative complications , 30-day hospital readmission , and 30-day emergency department visits .
short - term perioperative complications included early recurrence , surgical site infection , seroma and hematoma formation , and urinary retention .
statistical analysis was conducted using spss version 21 ( spss , inc , chicago , illinois ) .
continuous variables are expressed as means or medians and were compared using t tests , analysis of variance , or mann - whitney u tests as appropriate .
categorical variables are expressed as proportions and were compared using either  or fisher exact tests .
the university health network case costing department ( ccd ) is responsible for capturing costs ascribed to each patient 's hospital visit .
the university health network subsequently reports this information at regular intervals to ensure fiscal responsibility and fiduciary control
. the total cost of care is recorded under the patient 's unique medical record number and a specific hospital visit number .
the total cost per patient visit ( from preadmission to discharge ) is an aggregate of individual departmental costs ; for the purposes of this study , departmental costing centers were grouped as appropriate and termed  hospital departments .
 specific visit numbers relating to patients undergoing elective inguinal herniorrhaphy were used to retrieve costing information from the ccd .
, total direct cost is calculated on the basis of the consumption of resources , including supplies , medications , investigations , food , and lodging expense .
each or has a computerized dispensing cabinet that itemizes supplies used during each case and allocates cost to a specific patient procedure ( pyxis procedurestation system ; cardinal health , dublin , ohio ) .
all pharmaceuticals throughout the hospital are dispensed by a similar system ( pyxis medstation system ; cardinal health ) .
 personnel cost data were based on budgetary statements provided by individual hospital departments to the ccd .
personnel cost includes the wages ( compensation and benefits ) of the nursing , paramedical , and administrative staffs .
approach by dividing total costs by the number of patients admitted on any given day .
these costs are subsequently reported in the ccd figures as the  indirect costs  associated with specific hospital visits .
additional overhead expenses , such as heating costs , are derived by dividing total costs by ward square footage and the number of admitted patients .
equipment ( including maintenance ) , facilities , and other global expenses ( including information technology infrastructure ) were included in departmental budgets .
physician fees are separately reimbursed by the ontario ministry of health and were not recorded in this study .
furthermore , postdischarge care , follow - up , readmission , and potential loss of income were not included in this analysis .
all costs were adjusted for inflation to 2012 canadian dollars according to the bank of canada 's inflation calculator .
the university health network case costing department ( ccd ) is responsible for capturing costs ascribed to each patient 's hospital visit .
the university health network subsequently reports this information at regular intervals to ensure fiscal responsibility and fiduciary control .
the total cost of care is recorded under the patient 's unique medical record number and a specific hospital visit number .
the total cost per patient visit ( from preadmission to discharge ) is an aggregate of individual departmental costs ; for the purposes of this study , departmental costing centers were grouped as appropriate and termed  hospital departments .
 specific visit numbers relating to patients undergoing elective inguinal herniorrhaphy were used to retrieve costing information from the ccd .
, total direct cost is calculated on the basis of the consumption of resources , including supplies , medications , investigations , food , and lodging expense .
each or has a computerized dispensing cabinet that itemizes supplies used during each case and allocates cost to a specific patient procedure ( pyxis procedurestation system ; cardinal health , dublin , ohio ) .
all pharmaceuticals throughout the hospital are dispensed by a similar system ( pyxis medstation system ; cardinal health ) .
 personnel cost data were based on budgetary statements provided by individual hospital departments to the ccd .
personnel cost includes the wages ( compensation and benefits ) of the nursing , paramedical , and administrative staffs .
approach by dividing total costs by the number of patients admitted on any given day .
these costs are subsequently reported in the ccd figures as the  indirect costs  associated with specific hospital visits .
additional overhead expenses , such as heating costs , are derived by dividing total costs by ward square footage and the number of admitted patients .
equipment ( including maintenance ) , facilities , and other global expenses ( including information technology infrastructure ) were included in departmental budgets .
physician fees are separately reimbursed by the ontario ministry of health and were not recorded in this study .
furthermore , postdischarge care , follow - up , readmission , and potential loss of income were not included in this analysis .
all costs were adjusted for inflation to 2012 canadian dollars according to the bank of canada 's inflation calculator .
one hundred twenty - six patients ( 51.6% ) underwent open inguinal herniorrhaphy , while 118 ( 48.4% ) underwent laparoscopic repair . among the laparoscopic cases , 94 patients ( 79.7% ) underwent tapp repair , while 24 ( 20.3% ) were treated using the tep technique .
patients undergoing laparoscopic hernia repair were younger ( mean age , 55 vs 66 years ; p < .001 ) and had lower american society of anesthesiologists classes ( p < .001 ) . a significantly higher proportion of patients undergoing open surgical repair had histories of abdominal surgery ( 67.5% vs 46.6% , p < .001 ) .
bilateral inguinal hernia repair was preferentially performed using a laparoscopic approach ( 72.7% vs 27.3% , p = .002 ) , and all hernias diagnosed as bilateral had both sides operated during the same procedure .
all laparoscopic inguinal herniorrhaphies were performed under general anesthesia , compared with 42.9% of open cases .
twenty - three patients undergoing open inguinal herniorrhaphy required postoperative admission , compared with 2 patients in the laparoscopic cohort ( p = .025 ) .
one case was converted from laparoscopic ( tapp technique ) to open repair because of significant small bowel adhesions . during the study period
patients in the laparoscopic group had a longer median or time of 101 minutes compared with 84 minutes for open repairs ( p < .001 ) .
total hospital costs ( from preadmission to discharge ) for open unilateral inguinal herniorrhaphy were significantly lower than for the laparoscopic approach ( median total cost , $ 3207.15 and $ 3723.66 , respectively ; p < .001 ) .
this difference in total costs was driven primarily by the or costs associated with the laparoscopic approach ( median or cost , $ 2399.49 and $ 3092.03 , respectively ; p <
total hospital costs for repair of elective bilateral inguinal hernias were similar between the open and laparoscopic approaches ( median total hospital cost , $ 4574.02 vs $ 4662.89 ; p = .827 ) ( table 4 ) .
cost for unilateral inguinal herniorrhaphy iqr , interquartile range ; or , operating room ; pacu , postanesthesia care unit .
cost for bilateral inguinal herniorrhaphy iqr , interquartile range ; or , operating room ; pacu , postanesthesia care unit .
when comparing unilateral and bilateral hernia repair within the laparoscopic cohort , there was no statistical difference in the cost ( either or or total episode of care ) between the tapp and tep techniques .
further to the operative approach , the use of general anesthesia was associated with an increased cost compared with other types of anesthesia ( local or regional ) ( p < .0001 ) .
in this study , we systematically reviewed the or and total hospital costs involved with the treatment of inguinal hernias and , specifically , compared the costs associated with an open versus a laparoscopic approach .
our results demonstrate that or and total hospital costs for open unilateral inguinal hernia repair were significantly lower than for the laparoscopic approach . however , or and
total hospital costs for repair of bilateral inguinal hernias were similar between the 2 groups .
the results of this analysis are comparable with those from other centers in the united states .
khajanchee et al showed a $ 795 incremental cost associated with the tep approach relative to an open lichtenstein repair .
similarly , schneider et al found the total cost of laparoscopic herniorrhaphy to be higher than for the open approach ( $ 2,861 vs $ 2,009 ) . combined with the current analysis
, these studies suggest that the total cost of each procedure may be independent of local economic factors and may be directly attributable to surgical technique . however , the perioperative benefits of laparoscopy are significant .
several studies have demonstrated enhanced recovery after surgery , shorter lengths of stay , and fewer perioperative complications associated with a minimally invasive approach . as such
, the incremental value associated with laparoscopic repairs of unilateral hernias may justify the increased relative cost ( $ 453.51 ) .
further studies using hernia - specific outcomes are necessary to understand the economic utility and cost - effectiveness of each approach .
in addition , the calculation of total hospital cost does not address the out - of - hospital expenses incurred by the patients .
furthermore , the indirect and societal costs associated with patient suffering , loss of productivity , and caregiver expense are difficult to quantify .
further studies are needed to evaluate the total societal cost associated with inguinal hernia repairs to determine the cost - effectiveness of each strategy .
a methodological limitation in the cost analysis is related to the institutional segmentation of expenses . or costs are clustered as an aggregate of all expenses incurred in the or . as such , with the current accounting system
, it is difficult to distill the material contribution of operative time , general anesthesia , or equipment costs to the total expense
. a refined case - costing system may provide additional insight into each component of patient care and highlight opportunities for efficiency .
in the setting of a canadian tertiary academic hospital , the or and total hospital costs of open inguinal herniorrhaphy were significantly lower than for the laparoscopic approach . however , there was no statistical difference between or and total hospital costs when comparing open surgical and laparoscopic techniques for repair of bilateral inguinal hernias .
given the perioperative benefits of laparoscopic surgery , further studies incorporating hernia - specific outcomes are necessary to determine the cost - effectiveness of each approach and to define the optimal treatment strategy .
 purpose : the purpose of this study was to compare the total hospital costs associated with elective laparoscopic and open inguinal herniorrhaphy.methods:a prospectively maintained database was used to identify patients who underwent elective inguinal herniorrhaphy from april 2009 to march 2011 . 
 a retrospective review of electronic patient records was performed along with a standardized case - costing analysis using data from the ontario case costing initiative . 
 the main outcomes were operating room ( or ) and total hospital costs.results:two hundred eleven patients underwent elective unilateral inguinal herniorrhaphy ( 117 open and 94 laparoscopic ) , and 33 patients underwent elective bilateral inguinal herniorrhaphy ( 9 open and 24 laparoscopic ) . or and total hospital costs for open unilateral inguinal hernia repair were significantly lower than for the laparoscopic approach ( median total cost , $ 3207.15 vs $ 3723.66 ; p < .001 ) . or and total hospital costs for repair of elective bilateral inguinal hernias were similar between the open and laparoscopic approaches ( median total cost , $ 4574.02 vs $ 4662.89 ; p = .827).conclusions : in the setting of a canadian academic hospital , when considering the repair of an elective unilateral inguinal hernia , the or and total hospital costs of open surgery were significantly lower than for the laparoscopic techniques . 
 there was no statistical difference between or and total hospital costs when comparing open surgery and laparoscopic techniques for the repair of bilateral inguinal hernias . 
 given the perioperative benefits of laparoscopy , further studies incorporating hernia - specific outcomes are necessary to determine the cost - effectiveness of each approach and to define the optimal treatment strategy . 
INTRODUCTION
MATERIALS AND METHODS
Costing Analysis
RESULTS
DISCUSSION
CONCLUSIONS