In the Annals of Surgery, Glasgow et al published a cost analysis that compared the value of three approaches to inguinal hernia repair (2021;274[4]:572-580). This was a single-center, retrospective study of patients undergoing unilateral inguinal hernia repair with an open, a laparoscopic or a robotic technique. Current Procedural Terminology (CPT) codes were used to identify procedures performed by 14 surgeons, all of whom were experienced in the surgical approach used.

Value was defined as quality divided by cost, in which quality (based on recurrence rate) was assumed to be equivalent for each repair, and cost was calculated as both fixed (basic OR equipment [e.g., surgical instruments, laparoscopic systems and robotic systems use and maintenance]) and variable (“materials,” which included supplies used perioperatively; “providers,” which included surgeon and anesthesiologist time; and “overhead,” which included cost per minute of OR time and factors in support staff labor). Cost data were compared among approaches using linear modeling normalized to the open approach. The study involved 100 consecutive patients undergoing each type of operation.

The authors found that for fixed costs, the laparoscopic inguinal hernia repair was 1.03 times more expensive than an open repair, and the robotic repair was 3.18 times more costly than open. For variable costs, laparoscopic repair was not significantly higher than the open approach (1.02 times; P=0.78), but robotic repair was 2.11 times higher than open (P<0.001) and 2.06 times higher than laparoscopic. Within these costs, material costs for laparoscopic repair were higher (1.5 times; P<0.001) than open repair, but overhead costs were lower (0.81 times; P=0.003) than for an open repair, due to the shorter mean calculated operating time of laparoscopic repair compared with open (82 vs. 107 minutes). All domains of variable costs for robotic repair were higher than for the other approaches.

Taking all costs and considering the revenues associated with each approach, the authors found the laparoscopic inguinal hernia repair had a gross margin 4% higher than the open approach, while the robotic repair’s margin was only 4% of the open repair margin. This led to a final calculation of the value of each minimally invasive repair compared with the open approach as follows: Laparoscopic repairs reduce value by 3%, whereas robotic repairs reduce value by 69%.

The authors conducted a well-done cost analysis of a highly debated topic regarding value, and their findings echo those of cost analyses by Charles et al (Surg Endosc 2018;32[4]:2131-2136) and Abdelmoaty et al (Surg Endosc 2019;33[10]:3436-3443). Based on this study, more expensive technology for unilateral inguinal hernia repair is associated with increased cost. However, limitations in this cost analysis include selection bias and the assumption that quality is equal among all three repairs for all inguinal hernias. Due to the consecutive nature of procedure selection, rather than a randomized controlled trial, the reason for selecting each method is unclear and may introduce bias in the findings. Although the authors assume the quality of repair is equivalent for all three techniques, minimally invasive approaches in certain patient populations (morbidly obese, women, bilateral hernia and recurrent hernia after prior open repair), have been recommended due to their reduced recurrence and complication rate. Additionally, surgical team factors, such as the participation of a trainee and staff experience, can affect the operative case time, and thus the variable costs.

As of 2015, 46% of surgeons provide only an open approach to inguinal hernia repair. Preperitoneal dissection should be part of a surgeon’s armamentarium for inguinal hernia repair and provides value to the patient and the hospital system. It is unclear whether robotic surgery allows for an increased adoption of the preperitoneal repair, but based on current evidence from Kudsi et al (Hernia 2021;25[3]:755-764), the learning curve for robotic repair is much shorter than for the laparoscopic approach. Surgeon experience, patient selection, surgical team factors and operating equipment preferences affect procedure costs, especially given the relatively small cost-related differences between open and laparoscopic approaches. Nevertheless, as robotic surgery continues to expand in use, surgeons should recognize the potential increased costs associated with the technology.

These articles appeared in General Surgery News, Journal Watch column, April 2022. The column editor of Journal Watch is Arielle Perez, MD, MPH, MS, a surgeon at the University of North Carolina School of Medicine, in Chapel Hill.