World J. Surg. 23, 415–421, 1999WORLDJournal of

SURGERY© 1999 by the Societe

Internationale de Chirurgie

Cost-effective Minimally Invasive Surgery: What Procedures Make Sense?

Richard M. Newman, M.D., L. William Traverso, M.D.

Department of Surgery, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, Washington 98111, USA

Abstract. Because laparoscopic surgery has emerged during a time ofmedical cost-consciousness, emphasis has been placed on the economicimplications of this emerging field. The cost of these procedures, however,is just one component in determining their overall value to most of thestakeholders in the health care system. The value of a treatment isproportional to its appropriateness and quality per unit cost. Severalconfounding factors affect the variables in this equation and contribute tothe difficulty in this type of assessment of an emerging technology. Byunderstanding the mechanics of value assessment and certain caveats forspecific procedures, the surgeon will be better able to determine whatprocedures makes sense (or are of value) in their practice and for theirpatients.

As demonstrated herein, as well as in the recent general surgicalliterature, attention is being focused on procedures that can beperformed laparoscopically and how these minimally invasivetechniques compare to their open surgical equivalents. Becausethese techniques have emerged in a health care climate ofeconomic contraction, emphasis has been placed on the economicimplications of this emerging field [1]. The cost of minimallyinvasive surgery is just one component the practicing surgeonmust evaluate when determining whether a procedure makessense. The assessment of any procedure’s value to all of theparticipants (including managed care organizations, hospitals,surgeons, and patients) determines what “makes sense” andtherefore which procedure is incorporated into everyday practice.

Performing value assessment on this emerging technology isfraught with the hazard of inaccuracy due to multiple confoundingfactors. By presenting the complexities involved in the determi-nation of value we hope to leave the reader with a framework bywhich to better interpret an ever-growing body of literaturerelating to the value of laparoscopic procedures. Armed with theknowledge of the potential pitfalls of value assessment, we believethe surgeon will be better able to assess reported conclusions incontext and eventually to decide what procedures are of value (ormake sense) for their practice and their patients.

Deciding What Procedures Make Sense: Value Assessment

The value of a particular procedure has not changed sincelaparoscopy entered our everyday general surgical lives during thelate 1980s. The biology of the diseases we treat with minimallyinvasive technology has also not changed. Clinical judgement isstill paramount when providing surgical procedures of value. Thevalue package of a surgical procedure can be defined by examin-ing the relations of appropriate utilization, quality, and cost [1].Appropriateness and quality of a procedure, no matter what typeof surgery is employed, remains the numerator in value assess-ment, with cost being the denominator. The value equation can beexpressed as:

Value 5 appropriateness 3quality

cost

Each of the variables in the value equation has multiple subvari-ables, examples of which are discussed below. The accuracy bywhich each of these components are assessed adds or detractsfrom the usefulness of the value equation. Understanding thecomplexity of these variables allows critical assessment of theliterature on this subject (i.e., the prospective value determinationof procedures as they emerge and mature) [2].

Appropriateness of Laparoscopic Procedures

Appropriate utilization of surgical procedures underscores anydiscussion of whether a procedure makes sense. The judgment ofthe physicians treating the patients should not be changed byminimal access technology, but in fact indications for proceduresmay have been broadened during the maturation of laparoscopicalternatives. Since the widespread use of laparoscopic cholecys-tectomy the overall number of cholecystectomies has increased by25% to 35% in the United States [3–5] as well as internationally[6, 7]. Some authors have gone on to project that an increase invalue by laparoscopic cholecystectomy [8–10] will be offset by theincreased total health care spending through increased utilization[7, 11]. Other procedures have been shown to exhibit similarincreases in utilization since the inception of a laparoscopicalternative. Changing operative indications at the same time as atechnique is developing must be held suspect [12]. Hopefully, ashas been postulated, the increased numbers of certain proceduresmay partially reflect a prior patient and referring physician

Correspondence to: R.M. Newman, M.D., Department of Surgery, NewYork University School of Medicine, Bellevue Hospital Center (15thFloor), 27th Street and First Avenue, New York, NY 10016, USA

reluctance to accept standard surgery in the setting of a trueindication [13]. As a surgical community in a managed careenvironment, we have begun to audit in order to prevent loweringappropriateness of any procedure because of its integral part invalue assessment.

A caveat exists when acquiring outcome data from patientsundergoing a procedure with subjective or ill-defined indications.Obviously, outcomes from patients with asymptomatic gallstonesor mild reflux disease simply cannot be compared to that inpatients with more severe disease. The early experience with anew technology has traditionally been vulnerable to selection bias.The antidote may be the use of various scoring systems of clinicalor disease severity to make indications more objective [12, 14].

Quality: Assessed by Short- and Long-term Outcomes

As surgeons we can further define the numerator of the valueequation by controlling quality. Quality assessment is equivalentto outcome assessment [1, 2]. Surgeons have historically docu-mented and reported objective quality assessment measures, suchas morbidity, mortality, and length of stay in hospital. It seemednatural to evaluate laparoscopic techniques by comparing theseoutcome measures with those of the open surgical procedure. Theproblem with assessing outcomes in this manner has been twofold.First, outcomes of minimally invasive procedures improve withrepeated utilization and familiarity. Operative time, hospital stay,and perioperative complications cannot be accurately comparedwhile a procedure is in development. The second confoundingfactor is the trend to “minimalize” any operation’s postoperativecare. Increasingly there are reports of same-day surgery for opencholecystectomy [15] and open-colectomy patients being fed at 24hours and discharged as early as 2 days after surgery [16]. Thisforce has been somewhat economically driven but to a large extentit has been a by-product of the rapid recovery and discharge seenin laparoscopic patients. This has led to patients being dischargedsooner after open procedures. The beneficial cost implications ofthese changes in the postoperative course of all surgical patientshas not been characterized. The baselines for some qualityassessment parameters are a “moving target,” which must be keptin mind when evaluating the value assessment literature oflaparoscopic procedures.

The establishment of acceptable outcome standards for lapa-roscopic procedures is needed to place reports on value in contextwith your practice. The surgical community should preemptivelybe concerned with coordinating this activity before it is mandatedby others who do not understand the intricacies involved intreating patients. A multicenter study reporting average short-term outcomes of laparoscopic cholecystectomy has been pub-lished [17]. The mean operative time for laparoscopic cholecys-tectomy with routine cholangiogram was 73 minutes regardless ofpatient characteristics. This type of information, though difficultto obtain, will eventually be available for all commonly performedprocedures. These data can be used to modify and improvetechnique so it becomes more in line with accepted standards [2,17]. Standards for laparoscopic techniques must also be calibratedas an accepted range of outcomes rather than the outcome of adedicated laparoscopic center. Many years and many thousands oflaparoscopic cholecystectomies were required before the stan-dardization of the procedure was possible. Accordingly, standardsfor other “less perfected” procedures are not available and will

probably be years in coming. This further attests to the fact thatmost laparoscopic procedures are still in evolution and are not yetamenable to accurate value assessment.

In addition to short-term results, long-term follow-up is aningredient in the assessment of quality. Length of this follow-updiffers depending on the particular disease for which the laparo-scopic approach is implemented. Even the measure of long-termfollow-up after laparoscopic procedures is not as simple asfollowing established norms for the disease processes establishedhistorically. Minor modifications in the laparoscopic approach,such as placing many metallic clips on the cystic duct remnant,may have long-term sequelae that are yet to be appreciated.Major procedural modifications, such as seen with laparoscopichernia repair for example, have an unknown required length offollow-up [18, 19]. Further complicating the issue of long-termfollow-up is that the laparoscopic approach itself may causechanges in the biology of the disease independent of the surgicalprocedure. perhaps the most disturbing example of this has beenthe development of port-site metastasis after laparoscopic inter-vention in the setting of gallbladder or colon cancer [20, 21]. It isbecoming clear that long-term follow-up for laparoscopic tech-niques must wait for just that: long-term follow-up.

Costs: Complex, Inaccurate, Estimated, and Elusive

Money is the denominator of the value equation. The goal is thebest results at a reasonable cost. Sweeping changes in the wayhealth care is financed unfortunately coincided almost exactlywith the explosive use of laparoscopic technology in everydaygeneral surgical practice. This dynamic change placed significant,perhaps premature pressure on the cost ramifications of this newlydeveloping technology. A basic understanding of the terminologyand concepts involved is necessary when attempting to interpretcost data. This information allows one to be critical of the way inwhich charges and costs are determined and the conclusionsderived from their application [1].

In the past, payment for medical care was in the form of feescharged for services rendered. In this setting, charges were animportant variable when determining the value of a given treat-ment. In the present health care environment of managed care,there has been a shift toward a lump sum annual payment for eachbeneficiary in exchange for a defined range of services. The costsof individual procedures, such as a new laparoscopic procedure,are shifted to the providers of the services (i.e., managed careorganizations, doctors, and hospitals) [22]. Increased costs due toa higher volume of cases, questionable preliminary results, andthe added need for expensive supplies have led to intense scrutinyof the costs of these new techniques. It is for these reasons thatcosts rather than charges for procedures are important in thecurrent health care climate.

Analysis of how costs are determined provides a basis on whichto assess the validity of conclusions based on cost analysis. Costcan be divided into two categories: direct patient care costs andindirect, or overhead, costs, which are not increased by increasingpatient volume. Indirect costs, such as mortgage, electricity,administrator’s salary and employee benefits, do not changeregardless of how many procedures are performed, so they areinherently uncontrollable [1]. Indirect costs are also different fromone health care system to another based on wide variations of thecomponents of these costs. Direct costs are those that arise

416 World J. Surg. Vol. 23, No. 4, April 1999

directly from the number of patients treated. The most importantexamples of direct costs to us, as surgeons, are nurses’ salaries andoperating room equipment [2]. Direct costs are potentially con-trollable by utilization and because hospitals (doctors and admin-istrators) have the ability to regulate how much is spent on eachprocedure with efficient use of staff and materials [1].

Complicating the interpretation and discussion of cost analysisreports is the fact that most of these costs are estimated, notactual [1]. This point is particularly true with regard to determi-nation of the cost of time in the operating room. A micro costanalysis of laparoscopic cholecystectomy indicates that 60% of thecost of that procedure is incurred in the operating room (OR) andthat one-half of these costs were attributed to services by person-nel and the other half to the equipment [2]. Similar cost break-downs have been reported for other commonly performed lapa-roscopic procedures (Table 1). Because a significant portion oftotal costs for laparoscopic procedures were incurred in the ORand most of these costs are estimated, the practicing surgeon isleft with a potentially confusing picture of what is economicallyrelevant. The cost estimations for services in terms of OR timeshould not be overinterpreted to mean that shaving minutes off acase can directly correlate to less cost [1]. The economic conceptof demand elasticity must also be considered [1, 22]. According to

this concept, saving time during one procedure is of benefit onlyif there is a demand for another procedure to be performed; thatis, an additional case with the same OR team can be done duringthe time saved. Stated another way, efficiency cannot be realizedunless there is a demand.

The costs, complications, and operating times should decreaseas time increases after introduction of the new procedure. Voyleshas shown that hospital charges and operating times for laparo-scopic cholecystectomy decreased significantly with the number ofcases performed per year [38]. Technology is also evolving. Thereis a strong tendency toward newer, reusable instruments ortrocars. As these reusable tools are purchased, their cost will beamortized with use for other types of procedure, thereby loweringthe cost of many minimally invasive procedures [2, 38, 39]. Notethat here again is another reason the early experience with newprocedures may not be accurate when assessing value.

Procedural Variation of Value Assessment

As can be seen, determination of the value of a surgical procedureis much more complex than just determining how much a partic-ular procedure costs. The above discussion of the components ofvalue assessment can be broadly applied to all types of emerging

Table 1. Literature on the value of minimally invasive procedures.

Study Location

Compared to surgery

ConclusionsQuality Cost

Laparoscopic cholecystectomyGraves [8] USA 11 — Surgeons should learn techniqueGrace [9] UK 11 — Procedure of choiceStoker [10] USA 11 11 Shorter stay but more expensiveBarkun [7] Canada 11 — Overall superiority of LCMcMahon [23] UK 6 11 More expensive

Laparoscopic appendectomyNeal [24] USA 6 11 Easily learned, similar outcomeMcCahill [25] USA 6 11 Expensive, no improved outcomeZaninotto [26] Italy 6 11 Useful for diagnosis in women, but too expensive

for general useRichards [27] USA 11 6 Quicker recovery, comparable costWilliams [28] USA 11 11 Earlier discharge, less pain, much more expensive

Laparoscopic herniorrhaphyLawrence [29] UK 6 11 Expensive option with uncertain outcomesSchurz [18] USA 6 11 Premature for outcome conclusions; costs are

technique-dependent and can be loweredMillikan [30] USA 11 11 Fewer short-term complications, double the costGoodwin [19] USA — 11 Increased cost and potential for complications

Laparoscopic GE junctionsurgery (reflux surgery)

Richards [31] USA 11 — Less morbidity, lower total hospital costsLaycock [32] USA 11 — Less expensive due to shorter hospital stayIncarbone [33] USA 6 6 Almost equivalent

Laparoscopic colon surgeryFalk [34] USA 11 6 Shorter stay, no significant cost differencesBruce [35] USA 11 11 Faster recovery but difficult to justify

economically, cost may decrease with changesin OR supply usage

Liberman [36] USA 11 — More rapid recovery, though increased OR costs,total cost, and charges are lower

Bergamaschi [37] France 6 11 No difference in outcomes, greater cost

11: increased or improved; —: decreased; 6: similar; LC: laparoscopic cholecystectomy; GE: gastroesophageal; OR: operating room.

Newman and Traverso: Cost-effective Minimally Invasive Surgery 417

minimally invasive procedures. Additional complexities areadded, however, when considering value assessment issues foreach particular procedure. To touch on some of the moreimportant issues we have reviewed a recent sample of the costsand outcomes literature as it pertained to five of the morecommonly performed laparoscopic procedures: cholecystectomy,appendectomy, herniorrhaphy, antireflux surgery, and colon re-section. These procedures are similar in that they have relativelyspecific and frequently encountered indications, and they havelimited alternative treatments. Other procedures such as thelaparoscopic management of common bile duct stones and mini-mally invasive vascular surgery rely heavily on institutional exper-tise and are subject to significant local biases in this regard. Thiscomplicates value assessment by increasing the variability ofappropriateness and quality from one center to another. Othertechniques presented in this “state of the art” article are no lessimportant to the discussed procedures but, rather, are limited intheir application by relying on local expertise to treat less com-monly encountered clinical entities. It is premature to discuss thevalue of these procedures, and they should be considered to be inthe evolutionary phase of their development. After establishingsafety and feasibility, the determination of appropriate utilizationand initial outcomes are the next priority for these emergingprocedures.

Assuming appropriateness was controlled, Table 1 outlinessome of the recent reports on value. Even after simplifying thegeneral reporting of overall quality and costs and their finalconclusions about value, it is still evident that there is littleconsensus in this field of value assessment. This disparity is due inpart to the complexities of value assessment as discussed above.Procedural variations also add to this complexity, and we discusssome of them in the next sections.

Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy (LC) was truly a unique and revo-lutionary procedure that swept the world of general surgery in1989 and 1990. Fueled almost solely by patient and referringphysician demand, one of the most common general surgicalprocedures was radically changed without regard to science orvalue. Virtually overnight, surgeons were rushing to courses andbuying expensive equipment to meet this demand. Even thosewaiting for prospective, randomized trials soon realized that nonewas ongoing and jumped on the laparoscopic bandwagon, how-ever reluctantly.

Retrospectively discussing the value of LC, though often done,seems almost rhetorical at this point. This procedure was rapidlyadopted even in the face of reports of increased procedure risks,initial cost increases, and contemporaneous improvements in theless expensive open approach to cholecystectomy [8, 15]. Afteralmost a decade of practice and improvement, this procedure isaccepted as a “standard of care.” Although a randomized trialbetween LC and open cholecystectomy is not practical, an elab-orate computer model prospectively projected long-term costsavings of LC over open cholecystectomy [40]. In addition, twoprospective randomized trials comparing LC to a modification ofthe open technique through a small incision (minicholecystec-tomy) have been performed [7, 23]. The conclusions from thesetrials indicate a shorter stay but increased cost of disposableequipment in the laparoscopy group. Differences in the way that

overall hospital costs were estimated made the laparoscopicprocedure more expensive than open cholecystectomy in one trial[23] or similar in cost in another study [7].

The laparoscopic approach to cholecystectomy “makes sense”because it appeals to most of the stakeholders involved withhealth care (i.e., patient, referring providers, hospitals, and indus-try). It is interesting to note that the surgeon-provider wasambivalent at best, at least at the outset. LC is the first of suchprocedures to be at a level of maturity to begin a true analysis ofindividual experiences to fine-tune the procedure with the goal ofcontinuing to improve its value to our patients and the health caresystem.

Laparoscopic Appendectomy

The introduction of laparoscopic appendectomy has been lessrapidly incorporated into clinical practice. The emergent nature ofthe disease necessitates operations at times when equipment andtrained operating room personnel may be limited. In addition,patient demand does not drive the laparoscopic approach to thediseased appendix to the degree it has for cholecystectomy.Laparoscopic appendectomy has been less popularized in themedia, and patients are usually acutely ill when introduced to theconcept of needing an operation. From a value standpoint, theliterature seems to report similar [24–26] to slightly improved [27,28] outcomes with the laparoscopic approach. These results areobtained at a generally reported increased cost [24–26, 28].Increased operating room time and disposable laparoscopic sup-plies account for the increased cost. These costs are direct and canpotentially be controlled by the surgeon. The use of multifireendoscopic staplers increases the cost of the operation substan-tially over the use of pretied endoscopic ligatures. The perceptionis that expensive staplers make control of the mesoappendix andappendiceal stump less difficult and therefore less time-consumingthan use of the less expensive endoscopic ligatures. This does notseem to be the case, however, as the operating time did not differbetween the two techniques in a report where both were used [41].A mean operating time of 60 to 65 minutes was reported in thisstudy, which did not differ with the ligation technique employedand was consistent with other reports using one or the othertechnique [41]. The outcome for both of the techniques alsoappear comparable. This an example of how surgeons can changethe cost of laparoscopic surgery as their expertise with the varioustechniques improve and reliance on expensive facilitative devicesis lessened (controlling direct costs).

One area where the laparoscopic approach to appendectomymay offer advantages over the open method is in young womenwhere the diagnosis is in question [26]. The improved intraab-dominal visualization afforded by the laparoscopic approach mayincrease diagnostic accuracy in this group, which has a historicallyhigh negative appendectomy rate. In the healthy young womanwith right lower quadrant pain, the laparoscopic approach maysave the time and cost of expensive diagnostic imaging tests as wellas days of in-hospital observation. Removal of a normal appendixin a patient with recurrent hospital admissions for right adnexalpain and pathology may save the patient and community expen-ditures.

Because of the practical factors dissuading surgeons fromattempting late night laparoscopic forays, the minimal perceivedclinical benefit for their effort, and the lack of patient demand, the

418 World J. Surg. Vol. 23, No. 4, April 1999

routine use of laparoscopic appendectomy make sense to somebut not to others.

Laparoscopic Herniorrhaphy

The initial excitement for the minimally invasive approach forhernia repair has been tempered. The results of multiple studiesdemonstrate uncertain to worse outcomes at an increased cost[18, 19, 29, 30]. Surgeons do not prefer the procedure because itconverts a simple, quick procedure done under local or regionalanesthesia to a complex, time-consuming operation that requiresgeneral anesthesia [42]. The potential benefits of the repair are itssavings to society by causing less postoperative morbidity, whichmanifests as less time off from work [43]. This has been a difficultcost reduction to quantify as there is subjectivity in the patient’sability and desire to return to work more quickly. Overall, it isdifficult to justify the routine use of laparoscopic hernia repair inits present state [19].

Laparoscopic Antireflux Surgery

Laparoscopic antireflux surgery is unique among the proceduresbeing discussed because there are two main questions to considerwhen determining its value. The first consideration is whethersurgical treatment for gastroesophageal reflux disease is betterthan medical treatment. Second, is the laparoscopic approachbetter than the open approach?

Even though reports have demonstrated surgical treatment tobe superior to medical therapy in terms of effectiveness and cost[44], there is still much institutional variation in referral foroperative therapy [45, 46]. Overall, there has been increasedinterest in and utilization of this type of surgery ever since thelaparoscopic approach emerged as a treatment option. We mustbe critical about whether indications for surgical treatment arebeing broadened (with its appropriateness reduced) or whetherpatient and referring physician acceptance are increasing becauseof reported improvement in the procedure’s quality. Objectivemeasures of reflux disease are required. Examples are clinicalscoring systems [14] and manometric criteria in both pre- andpostoperative patients [46, 47].

The cost-analysis literature generally reports an improvedshort-term outcome (decreased length of stay and time to normalactivity), leading to decreased total hospital costs for the laparo-scopic antireflux procedure over the open variety [31, 32]. Thistrend may be changing, however, as the rapid recovery seeninitially in laparoscopic groups has been expected also in the opensurgery patients. There seems to be a normalization in both thecosts and outcomes of both access techniques. A contemporane-ous comparison of open and laparoscopic fundoplication showedno difference in hospital costs or charges between the groups, ascost shifting rendered hospital day savings in the laparoscopicgroup to be canceled out by increased operating room costs [33].

From a quality standpoint, gas bloat and dysphagia, the maincomplications of antireflux surgery, have been reported to besimilar for the laparoscopic and open groups [46, 47]. This is to beexpected because the component of the surgery that is associatedwith these complications, the fundic wrap, is theoretically unaf-fected by the access technique. Variations in reflux operationsthat facilitate the laparoscopic approach, such as wrap modifica-tion and short gastric vessel preservation, may have significant

outcome ramifications. When analyzing the value or quality ofthese procedures the reader must be critical about identifyingtechnical modifications to determine if the conclusions are valid.As is true for all of these procedures, historical open controls areonly guidelines for comparison and then only if the laparoscopicvariation is unchanged technically.

Laparoscopic Colon Surgery

Laparoscopic colon resection for benign disease has been shownby many to be safe and feasible [34, 35, 48]. The literature differs,however, on whether the short-term outcomes are improvedenough to justify the increased operative costs [36, 37, 49]. Theissues that surround the value assessment of laparoscopic colonresection provide an excellent example of how the costs andquality variables change along with the evolution of a procedure.This phenomenon makes an accurate determination of value foremerging technologies premature and inherently less useful.

Laparoscopic colectomy was introduced to reap the benefits ofa minimally invasive technique: shorter hospital stay and lesspostoperative morbidity. This was the justification for the mark-edly increased costs of operating room supplies and time involvedwith providing this type of treatment. When compared to histor-ical controls, the length of stay and time to oral intake withlaparoscopic colectomy were significantly less. However, probablyas a by-product of surgeons’ laparoscopic experience, open colec-tomy patients are enjoying earlier resumption of diet and dis-charge. Recent reports of enteral feeding 24 hours postopera-tively, leading to significantly earlier discharge (a mean of 4 daysafter elective open colectomy) have demonstrated this trend [16,50]. At the same time, shorter operative times, new hemostatictechnologies, and reusable instruments and trocars lower theoperating room costs involved with laparoscopic colectomy.Where these two opposing forces leave the value of laparoscopiccolon surgery for benign disease is currently being debated [37].

One area that has been a cause for concern is utilization oflaparoscopic techniques for colon cancer resection [51]. Port-siterecurrence and short follow-up intervals render minimally inva-sive oncologic surgery of unknown value at present, becauseoutcome (and thus quality) is unable to be determined at this time[21, 52]. Surgeons should be commended that the experimentalprocedure—laparoscopic colectomy for malignancy—is now beingperformed within the setting of a prospective, randomized trial toassess the quality of this approach by carefully examining out-comes as they pertain to oncologic standards [51]. Only afteroncologic equivalence is established is a further look into valuewarranted.

Establishing a Framework for Assessing What ProceduresMake Sense

Hopefully this review has demonstrated that more goes into thedetermination of value for a procedure than just looking at whatit costs. By elucidating some of these intricacies we hope to leavethe reader with a framework by which to prospectively assessvalue, whether it be in the literature or locally at the individualinstitutional level. Careful consideration of the value equation’svariables help make the determination of value more objectiveand focused. The appropriateness of procedures should be con-

Newman and Traverso: Cost-effective Minimally Invasive Surgery 419

trolled using objective measures of disease severity or clinicalscoring systems. Quality, or outcome analysis, should be appro-priate for the procedure and the biology of the disease beingtreated. Reasons for increases in the number of procedures beingperformed should be scrutinized as to the cause. Accepted rangesof outcomes derived from current, laparoscopically treated seriesare important for establishing a range of acceptable standards forthese evolving procedures. One of the greatest contributions oflaparoscopic surgery has been the impetus to look at our openprocedures and improve them. Therefore comparisons to histor-ical open surgery controls are problematic, as outcomes of opensurgery have been improved by the influence of laparoscopy.Knowledge of the types of costs and the complexities surroundingtheir determination helps make sense of the often confusingcost-analysis literature. Determining which costs are relevant andpotentially controllable by us as surgeons is the first step in puttingcost conclusions into perspective. The latter has been anothercontribution by laparoscopic surgery to our overall surgical prac-tice.

By understanding the components of the surgical value pack-age, the surgeon is prepared to examine how these variables arecontrolled at the institutional level. This knowledge providessurgeons the opportunity to have a central role in the control ofvalue, possibly allowing us to decide what procedures “makesense.”

Resume

Parce que la chirurgie laparoscopique a emerge a un temps ou lescouts sont devenus si importants dans l’esprit de tout le monde, onsouligne les implications economiques de cette nouvelle technolo-gie. Pour la plupart des partenaires dans le monde socio-economique de la sante, cependant, le cout de ces procedes n’estqu’un seul des composantes. La valeur d’un traitement est pro-portionnelle a sa place dans la panoplie des techniques dis-ponibles et a sa qualite par rapport a son cout. Il faut prendre encompte aussi d’autres variables dans cette equation qui contri-buent a la difficulte de ce type d’evaluation dans le domaine d’unetechnologie emergeante. Par la comprehension de la mecaniquede l’evaluation et de certaines indications pour des procedesspecifiques, le chirurgien saura mieux determiner quel procede estlogique (ou, est valable) pour sa pratique et pour ses patients.

Resumen

Puesto que la cirugıa laparoscopica ha surgido en la era de lacontencion de costos, se ha hecho enfasis en las implicacioneseconomicas de este campo emergente. Sin embargo, el costo deestos procedimientos es apenas uno de los factores determinantesde su valor global para la mayorıa de los estamentos del sistemade atencion de la salud. El valor de un tratamiento determinadoes proporcional a su adecuacion y calidad por unidad de costo.Diversos factores inciden sobre las variables en tal ecuacion ycontribuyen a la dificultad en la evaluacion de una tecnologıa endesarrollo. Mediante la comprension de la mecanica de la val-oracion y de ciertos aspectos pertinentes a los procedimientosespecıficos, el cirujano queda mejor capacitado para determinarcual procedimiento tiene sentido (o es de valor) en su practica encuanto al mayor beneficio para sus pacientes.

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