In Pursuit of the Most Cost-Effective Pediatric Laparoscopic Appendectomy: The Effect of Disposable Instrument Choice on Operative Time and Surgeon-Controllable Cost.

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.