ORIGINAL ARTICLE

The economic burden of incisional ventral hernia repair:a multicentric cost analysis

J-F Gillion1 • D. Sanders2 • M. Miserez3 • F. Muysoms4

Received: 27 September 2015 / Accepted: 17 February 2016 / Published online: 1 March 2016

� Springer-Verlag France 2016

Abstract

Purpose A systematic review of literature led us to take

note that little was known about the costs of incisional

ventral hernia repair (IVHR).

Methods Therefore we wanted to assess the actual costs

of IVHR. The total costs are the sum of direct (hospital

costs) and indirect (sick leave) costs. The direct costs were

retrieved from a multi-centric cost analysis done among a

large panel of 51 French public hospitals, involving 3239

IVHR. One hundred and thirty-two unitary expenditure

items were thoroughly evaluated by the accountants of a

specialized public agency (ATIH) dedicated to investigate

the costs of the French Health Care system. The indirect

costs (costs of the post-operative inability to work and loss

of profit due to the disruption in the ongoing work) were

estimated from the data the Hernia Club registry, involving

790 patients, and over a large panel of different Collective

Agreements.

Results The mean total cost for an IVHR in France in

2011 was estimated to be 6451€, ranging from 4731€ for

unemployed patients to 10,107€ for employed patients

whose indirect costs (5376€) were slightly higher than the

direct costs.

Conclusion Reducing the incidence of incisional hernia

after abdominal surgery with 5 % for instance by imple-

mentation of the European Hernia Society Guidelines on

closure of abdominal wall incisions, or maybe even by use

of prophylactic mesh augmentation in high risk patients

could result in a national cost savings of 4 million Euros.

Keywords Incisional hernia � Prevention � Cost analysis �Health economics � Mesh augmentation

Introduction

Incisional hernias are a frequent complication of abdominal

surgery and some patient variables including obesity,

postoperative surgical site infections and the presence of

abdominal aortic aneurysm have been identified as risk

factors [1–3]. The surgical technique and material to close

abdominal wall incisions are also of utmost importance to

avoid a high frequency of incisional hernias [4, 5]. The

European Hernia Society has recently developed and

published guidelines on the closure of abdominal wall

incisions [6]. As part of this initiative, the Guidelines

Development Group ‘‘The Bonham Group’’ has tried to

determine the economic burden related to the treatment of

an incisional hernia according to previously published

recommendations [7]. Apart from the known negative

impact of an incisional hernia on the patients’ quality of

life and body image, patients with an incisional hernia are

at risk of potential serious complications [8]. The repair of

incisional hernia has direct costs and indirect costs. Esti-

mation of the costs related to the treatment of incisional

hernias can reflect the socio-economic gain to be made by

The data of the present study were presented by J-F Gillion during the

36th Annual Congress of the European Hernia Society in Edinburgh

on 31 May 2014.

& J-F Gillion

jfgillion@wanadoo.fr

1 Unite de Chirurgie Viscerale et Digestive, Hopital Prive

d’Antony, Antony, France

2 Department of Surgery, Derriford Hospital, Plymouth, UK

3 Department of Abdominal Surgery, University Hospitals,

KU Leuven, Leuven, Belgium

4 Department of Abdominal Surgery, AZ Maria Middelares,

Ghent, Belgium

123

Hernia (2016) 20:819–830

DOI 10.1007/s10029-016-1480-z

optimizing abdominal wall closure technique and reduction

of the incidence of incisional ventral hernia.

The magnitude on a national level of the costs related to

incisional hernias has been reported for Sweden, where

about 2000 incisional hernias are repaired annually with a

direct cost approximately 170 million Swedish Krona

(SEK) (±18 million Euro). The direct and indirect costs for

an incisional hernia have been calculated to be 86,257 SEK

(±9112€) [9]. In a nationwide study for the United State

(US) an estimated 348,000 ventral hernia repairs were

performed in 2006 with a direct cost for inpatient proce-

dures of 15,899 US dollar (±13,000€) and for outpatient

procedures 3873 US dollar (±3168€) [10]. This amounts to

a total cost of ventral hernia repair for the US in 2006 of

3.2 billion US dollar (±2.6 billion Euro).

The objective of this study was to perform a review of

the literature on the costs related to incisional hernia repair

and to make an estimate of the direct and indirect costs for

incisional hernia repair in France using nationwide data.

Materials and methods

A systematic review of the literature was performed on 25

February 2014 in Pubmed, Medline and EmBase, limited to

Human data with the search terms: ‘‘Incisional hernia OR

ventral hernia AND health planning/economics/cost and

cost analysis/vital statistics/demography/population char-

acteristics/quality adjusted life years/health burden’’. The

Prisma flow diagram of the records found is shown in

Fig. 1. The results [9–16] are displayed in Table 1.

The cost of an incisional hernia repair is the sum of

direct costs and indirect costs [10]. The direct costs com-

prise all consumption of resources resulting from the

treatment. The indirect costs are those related to the out-

patient care during the sick leave, but mainly related to the

inability to work, such as the costs of a substitute, the loss

of productivity, and the costs of the daily allowance.

Direct costs

Analysis of the ATIH data

In our study the direct costs were estimated from a cost

analysis [17] performed in 2011 among 51 public French

hospitals by the Agence Technique de l’ Information sur l’

Hospitalisation (ATIH). The ATIH (www.atih.sante.fr) is a

public agency dedicated to investigate the costs of the

French Health Care system, especially the intra-hospital

costs of various diseases, classified in more than 3000

GHM (Groupes Homogenes de Malades = Homogeneous

groups of patients), the French version of the DRG (Di-

agnosis-Related Groups). The actual costs, observed in

such cost analysis serve as a basis to determine the amount

of money to be reimbursed to the hospitals for each GHM.

The reimbursement of every GHM is not calculated for

every patient, it is a package, annually updated. It has to be

noted that the reimbursed prices may be different from the

actual costs, especially if the National Health Policy targets

to promote certain healthcare priorities and therefore

adjusts the tariff to make the procedure more attractive to

healthcare providers.

The ATIH data are actual observed costs, written in the

general ledger. Among these ATIH data, we extracted

those concerning Incisional Ventral Hernia Repair in

adults, gathered in five GHM (Table 2). One of them is

dedicated to day-care surgery (06C24J), the four others

concern the inpatients, classified into four levels of severity

(06C241, 06C242, 06C243, 06C244).

Patients are grouped into four levels to determine the

complexity of their care and hence the costs involved.

Levels 1–4 are calculated using a National Health Care

System (National Security Fund) software named ‘group-

eur’, taking into account the severity of the co-morbidities,

the associated intra-hospital events (such as pulmonary

embolism, cardiac failure), the length of stay out of the

target. Not many surgical items are taken into account,

such as: complications related to a previous mesh, bowel

necrosis, or a bacteriologically proven deep infection. For

instance, this financial classification does not take into

account whether the procedure is done laparoscopically or

through an open approach, even though it probably carries

some financial implications. The list of the relevant items is

annually updated. Clinical conditions, which do not have

any impact on finance, are removed from the list at the

annual review.

In the ATIH multi-centric study, every observed unitary

piece of expenditure was detailed by specialized accoun-

tants, classified into 132 sub-groups of expenditure, and 6

chapters (medical expenses, technical-medical expenses,

management, direct charges, structural expenses) registered

and averaged for each GHM (Table 3).

Calculations based on the ATIH data

We wanted to calculate the average direct cost regardless

of the level of severity:

The average cost for each GHM was then weighted

according to the prevalence of the corresponding GHM

(Table 3) resulting in a ‘‘weighted average of the direct

cost for an average incisional hernia repair’’.

Indirect costs

The sick leave and the inability to work (including the

hospital stay) were estimated using data extracted from the

820 Hernia (2016) 20:819–830

123

prospective registry on abdominal wall hernias from the

‘‘Club Hernie’’. This is a collaborative registry of nearly 50

French surgeons with a specific interest in abdominal wall

surgery. Each participant accepts and signs the charter of

quality stating that ‘‘all input must be registered consecu-

tive, unselected, exhaustive and in real time’’. The partic-

ipants allow peer review control of the original medical

chart of randomly selected patients. Follow-up is obtained

by a clinical research assistant, independent from the

individual participants and blinded for the surgical proce-

dure. Consecutive patients with an IVH operated between

September 30th, 2011 and August 31st, 2014, were used

for the estimation of the indirect cost. Data on hospital stay

and postoperative absence from work were extracted from

the database to determine the estimated average duration of

inability to work (Table 4).

The average cost of inability to work and loss of pro-

ductivity, were estimated, firstly from the mean wages in

France in 2011 (Table 5), published by the National

Institute of Statistics (INSEE), and secondly using a

table taking into account the most frequent Collective

Agreement among the myriad of the different French social

public and private contracts (Table 6).

Results

Systematic review

The results of our systematic review are shown in the

Prisma flow diagram in Fig. 1. Initially 402 records were

identified, after removal of duplicates and non-relevant

Fig. 1 Prisma flow diagram

Hernia (2016) 20:819–830 821

123

Table

1Summaryoffindingstable

Summaryofevidence

table

for‘‘thecost

ofincisional

hernia

repair’’

Reference

citation

Studytype

Level

of

evidence

GRADE

Number

of

patients

Patientcharacteristics

Intervention

Comparison

Length

of

follow-up

Outcomemeasure

(currency)

Sourceof

funding

[9]

Economic

evaluation

from

RCT

Moderate

691

Matched

Smallstitch

closure

(n=

321)

Largestitch

closure

(n=

370)

5years

Costdirectandindirect

(SEK

=Swedish

Krona)

University

Grant

Effectsize

1.Costreductionwithsm

allstitches

1339SEK

per

patient

2.Directcostsofincisional

hernia

repair59909SEK

andindirectcosts26348SEK

[11]

Economic

evaluation

Low

44

Consecutivepatients

Meshrepair

Suture

repair

[1year

Costdirectandindirect

(SEK

=Swedish

Krona)

Notstated

Effectsize

Costsavingof6034SEK

withmeshrepair

[10]

Economic

evaluation

Verylow

N/A

Patientsfrom

healthcare

cost

and

utilizationproject

Inpatientventral

hernia

repair

None

5years

1.Totalnumber

of

repairs

Notstated

2.Meancosts(U

S$=

USDollar)

Effectsize

1.154,278ventral

hernia

repairs

inUSin

2006

2.Costper

operationUS$15,899

3.TotalcostUS$3.2billion

4.US$32milliondollar

reductionin

costforevery1%

decreasein

incisional

hernias

[12]

Economic

evaluation

Moderate

861

Consecutivepatients1988-1992having

midlinelaparotomy

Suture

length

towoundlength

ratioC4

Suture

length

towoundlength

ratio\4

1year

1.Incisional

hernia

rate

None

2.Costs

(SEK

=Swedish

Krona)

Effectsize

1.Relativerisk

reduction0.016withS:W

C4

2.CostreductionSEK

686

3.Savingper

patientofSEK116

4.Estim

ated

nationwidesavingofSEK2,107,140(2000)per

year

[13]

Economic

evaluation

Low

884

Consecutivepatients

undergoing

incisional

hernia

repairs

Laparoscopic

incisional

hernia

repair

Open

incisional

hernia

repair

30days

1.Operativetime

Notstated

2.Cost(U

S$=

US

Dollar)

3.Length

ofstay

4.30dayspostoperative

hospital

encounters

Effectsize

1.Shorter

stay

withlap

2.Longer

optimewithlap

3.Higher

supply

costswithlap(U

S$6396vsUS$664)

4.Higher

30dayshospital

encounters

withlap(15vs13%)

[14]

Economic

evaluation

Low

N/A

Theoreticalpatientswithincisional

hernia.Placedinto

decisionanalysis

model

Open

meshrepair

Open

suture

repair

N/A

1.Costs(U

S$=

US

Dollar)

Educational

Grant

Olympus

2.Costeffectiveness

822 Hernia (2016) 20:819–830

123

records, eight records remained for qualitative evaluation.

The Summary of Findings of the systematic review is

shown in Table 1. Significant heterogeneity in time periods

and the different currencies of the studies make it impos-

sible to perform quantitative evaluation.

Direct cost of IVHR in our study

In this multi-centric study the direct costs were studied

among 3239 patients treated in 51 French public hospitals.

The average direct costs for incisional hernia repair are

shown in Table 3. They were, respectively, 3497€, 4652€,8402€, 16,367€ for the level 1, level 2, level 3 and level 4

GHM and 2041€ for day-case incisional hernia repair. Eachof these five average costs was then weighted according to

the prevalence of the related GHM resulting in the

weighted average direct cost of a mean incisional hernia

repair, which is 4731€.

Indirect cost of incisional hernia repair in our study

From 30 September 2011 till 31 August 2014, 10,529

patients were registered in the Hernia Club Registries,

including 7851 patients operated on for groin hernias and

2678 patients for ventral hernias, including 991 patients

operated on for incisional ventral hernias. Sick leave,

hospital stay and nature of employment were properly

recorded in 790 of these 991 patients (Table 4). One-third

of our patients were employed. The hospital stay was

2.6 days for employed and 3.7 days when including

unemployed patients. The mean sick leave duration for

employed patients, including the hospital stay was 29.6

(range 0–90) days.

The mean monthly wages for employees in France in

2011, retrieved from the National Institute of Statistics are

reported Table 5. The average monthly wages were as

follows: Net wages: 2130€, Gross wages: 2830, Total

wages 4671€, corresponding to weekly Net wages of 492€,Gross wages of 654€ and Total wages of 1078€. The dif-

ferences between these different wages are explained in

Table 5.

The estimation of the value of one-week sick leave

among the most frequent French collective agreements for

this mean wages is reported in Table 6. The value of a

weekly sick leave for employed widely ranged across these

collective agreements from 359 to 1977€.The weighted mean value of a weekly sick leave for

employed was estimated at 1271€ (Table 6).

Therefore the average sick leave cost for our employed

patients was 5376€ (1271€ per week/7 9 29.6) while the

values ranged from 1518€ (359/7 9 29.6) to 8360€ (1977/

7 9 29.6) [Tables 4, 6].Table

1continued

Summaryofevidence

table

for‘‘thecostofincisional

hernia

repair’’

Reference

citation

Studytype

Level

of

evidence

GRADE

Number

of

patients

Patientcharacteristics

Intervention

Comparison

Length

of

follow-up

Outcomemeasure

(currency)

Sourceof

funding

Effectsize

1.Totalcostofsuture

repairUS$16,355

2.TotalcostofmeshrepairUS$16,947

3.Increm

entalcoststo

preventonerecurrence

withmeshUS$1878

[15]

Economic

evaluation

Moderate

1008

Allsurgical

patientsundergoingan

operation

N/A

N/A

Mean

1year

Costs(U

S$=

US

Dollar)

Notstated

Effectsize

1.Medianhospital

costsifnocomplication:US$4487

2.Medianhospital

costsifminorcomplicationsoccurred:US$14,094

3.Medianhospital

costifmajorcomplicationsoccurred:US$28,536

[16]

Review

Verylow

N/A

Incisional

hernias

N/A

N/A

N/A

N/A

None

Effectsize

Meshincisional

hernia

ismore

costeffectivethan

suture

repair

Hernia (2016) 20:819–830 823

123

Total cost of incisional hernia repair in our study

(Table 7)

For employed persons the global average cost (di-

rect ? indirect costs) in 2011 of an incisional hernia repair

in France was estimated at 10,107€. For these employed

patients, the indirect costs were higher than the direct costs.

Some of our patients, mainly unemployed and/or

elderly, probably spent their recovery in convalescent

home, but we could not evaluate these costs due to the lack

of indication concerning the rate, the duration, and the

prices.

For unemployed we took into account the direct costs,

because of the difficulty to evaluate in Euros the impact of

surgery on their daily life.

Finally the average total costs of IHR, regardless to the

employment was 4731 9 68 ? 10,107 9 32 % = 6451€.In other words: ‘‘the average total cost for an average

incisional hernia repair in an average patient’’ in France in

2011 was estimated to be 6451€.

Table 2 The five IVHR-GHM (Homogeneous groups of patients for Incisional Ventral Hernia repairs)

GHM Description Relevant comorbidities

or risk factors

Relevant associated

intra-hospital events

Hospital stay\ or[to the target

06C241 IVHR[ 17 years, level 1 0 0 0

06C242 IVHR[ 17 years, level 2 Level calculated using the French National Health Care computerized device ‘groupeur’ taking into

account severity and combinations of items annually updated according to their financial relevance06C243 IVHR[ 17 years, level 3

06C244 IVHR[ 17 years, level 4

06C24J IVHR[ 17 years, D case Low risk 0 0

Levels are calculated using the National Health Care computerized device (‘groupeur’) taking into account severity and combinations of the co-

morbidities, the associated intra-hospital events (such as pulmonary embolism, cardiac failure), the length of stay out of the target; Not many

surgical items are taken into account such as complications related to a previous mesh, bowel necrosis, or a bacteriologically proven deep

infection. For instance, this classification does not take into account whether the procedure is done laparoscopically or through an open approach

These items are annually updated. If one of these items does not have any financial relevance, it is withdrawn from the list

IVH incisional ventral hernia repair, y year, D case day case surgery

Table 3 Prevalence and observed direct costs of the five IVHR-GHM in the ATIH multicentric study, and calculation of the weighted average

direct cost of an average IVHR

GHM Description Prevalence Costsa Weightingb Weighted average

Cases % € € 9 %

06C241 IVHR[ 17 years, level 1 1.285 39.7 3497 1388

06C242 IVHR[ 17 years, level 2 1.516 46.8 4652 2177

06C243 IVHR[ 17 years, level 3 221 6.8 8402 571

06C244 IVHR[ 17 years, level 4 105 3.2 16,367 524

06C24J IVHR[ 17 years, D case 112 3.5 2041 71

3.239 100 4731€ Weighted average of the direct

cost of an average IVHR

a Observed costs per caseb Each cost was weighted according to the prevalence of the corresponding GHM

Table 4 Average sick leave duration, in IVHR registered in the Hernia Club registry

Occupation (item available for 790 patients) Average hospital stay (days, range) Average sick leave including

the hospital stay (days, range)

Employed Unemployed Employed Total Employed

251 539 2.6 3.7 29.6

32 % 68 % (0–11) (0–29) (0–90)

824 Hernia (2016) 20:819–830

123

Table 5 Wages in France in

2011 (INSEE)Net wagesa (€) Gross wagesb (€) Total wagesc Total wagesd

Monthly (€) Weekly (€)

Senior manager 3988 5385

Intermediate professions 2182 2910

Employees 1554 2049

Workers 1635 2137

Average 2130 2830 4671 1078€e

INSEE National Institute of Statistics and Economic Studies (www.insee.fr/)a Net wages: take home wages after payment of the compulsory social contributions (employer and

employee’s parts) and before payment of the direct taxesb Gross wages (Net 9 1.329): wages paid to the employee minus the compulsory employer’s part of social

contributionsc Total wages (Net 9 2.195 or Gross 9 1.65): net wages ? employee’s and employer’s compulsory social

contributions = the real employee’s wages = the actual cost of the employee for his employerd Weekly wages = Monthly wages/4.33e An average monthly gross wages of 2830€ is equivalent to weekly net wages of 492€, gross wages of654€, total wages of 1,078€

Table 6 Estimation of the value of 1 week sick leave among the most frequent French Collective Agreements for the average gross wages of

2830€

Collective

agreement (CA)

Sickness, benefita,

(SB) %

of wages

Waiting

periodb,

before SB

Income,

supplementc,

up to 100 %

Substituted Profit

loss (%)eValuef,

(€)Prevalence

(%)gWeighted,

valueh (€)

Private sector 80

Income supplement, not

included in CA

50 % 3 days No No 15 359 8 29

50 % 3 days No Yes 20 1196 8 96

Income supplement,

included in CA

50 % 3 days Yes No 15 947 16 152

50 % 3 days Yes Yes 20 1896 16 303

50 % Assumed, by

employer

Yes No 15 1028 16 164

50 % Assumed, by

employer

Yes Yes 20 1977 16 316

Public sector 20

100 % 0 day – No 15 505 10 51

100 % 0 day – Yes 20 1603 10 160

Weighted average value

of a weekly, sick leavei1271

Note it is almost the double of the gross wage and 2 times and a half more than the net wage

CA collective agreementa The Sickness Benefit, or Daily Allowance, is directly paid to the employee by the National Social Security Insurance (Securite Sociale),

usually after a waiting period of 3 days, except in Public sector, or if it is assumed by the employerb During their sickness, the public employers are given 100 % of their wages, the private employees are given 50 % of their wagesc Some private employees are given income supplement up to 100 % wages depending on their contractsd The cost of a substitute is comparable with the total wage of the substituted (1078€)e Due to the work disruption a profit loss of 15–20 % is generally estimatedf Value of a one-week sick leave taking into account the former itemsg Estimated prevalence of each collective agreementh Weighted value (value 9 prevalence)i Weighted average value of a weekly sick leave (1271€) for a weekly gross wage of 654€

Hernia (2016) 20:819–830 825

123

Key results

The mean total cost for an incisional hernia repair in France

in 2011 was estimated to be 6451€, ranging from 4731€ for

unemployed patients to 10,107€ for employed patients

whose indirect costs were slightly higher than the direct

costs. The average direct cost was 4731€, but direct costswidely ranged from 3497€ for level 1 to 16,367€ for level 4of severity (Tables 2, 3). The mean cost of a day-case IVHR

was 2041. The average indirect cost for employed patients

was 5376€ (Table 7), but the indirect costs spread across a

wide range of 1518€–8360€ (Tables 4, 6).

Discussion

Systematic review

The summary of findings of the systematic review is shown

in Table 1. Three records were from the Sundsvall Hospital

in Sweden [9, 11, 12]. In their most recent publication the

overall mean cost for an incisional hernia repair was

86,257 SEK (±9060€), with a direct cost of 59,909 SEK

(±6294€) and an indirect cost of 26,348 SEK (±2768€)[9]. They estimated that by adopting the technique of small

bites during closure of a midline laparotomy, the antici-

pated reduction of incisional hernias results in a cost

reduction for each patient of 1339 SEK (±141€).Four other studies reported data from the United States

and one record is a recent review on the topic [10, 13–16].

Dimick et al. showed that the incidence of postoperative

complications in surgical procedures, including hernia

surgery, increases the costs related to the procedure sig-

nificantly [15]: after adjusting for differences in patient

characteristics, major complications were associated with

an increase of $11,626 (95 % CI $9419 to $13,832;

p\ 0.001).

Bower et al. concluded that mesh repair of incisional

hernias is more cost effective than suture repair, because of

the significant higher need for subsequent repair of recur-

rent incisional hernia [16]. In the most recent study by

Poulouse et al. reporting on the cost of ventral hernia repair

(including both primary ventral and incisional hernias), the

direct cost for inpatient procedures was 15,899 US dollar

(±13,000€) and for outpatient procedures 3873 US dollar

(±3168€) [10]. Overall we can conclude that most authors

see an important cost saving in the prevention of incisional

hernias.

Significant heterogeneity in time periods and the dif-

ferent currencies of the studies, made it is not possible to

perform quantitative evaluation. Therefore we wanted to

assess the actual costs of IVHR.

Financial study

In this multi-centric cost analysis, the mean total cost for an

incisional hernia repair in France in 2011 was estimated to

be 6451€, ranging from 4731€ for unemployed patients

(68 % of patients) to 10,107€ for employed patients (32 %

of patients) whose indirect costs were slightly higher than

the direct costs. The average direct cost was 4731€, butdirect costs widely ranged from 3497€ for level 1 to

16,367€ for level 4 of severity (Tables 2, 3). The mean cost

of a day-case IVHR was 2041. The average indirect cost

for employed patients was 5376€ (Table 7) but the indirect

costs spread across a wide range of 1518€ to 8360€(Tables 4, 6).

Around 13.000 incisional hernia repairs are performed

in France each year. The global yearly cost for incisional

hernia repair in France can be estimated to be almost 84

million Euros, with a direct cost of 62 million Euros. In this

study the costs were calculated for public hospitals. In

France, 50–55 % of surgery is performed in private hos-

pitals. From data of the ATIH we know that the direct costs

are 25–50 % lower in private hospitals [17] even after

reintegration of the medical fees, not included in the pri-

vate hospital costs. Therefore the direct overall cost in

France (private and public) are probably closer to 45 mil-

lion Euros.

Nevertheless, reducing the incidence of incisional hernia

repair after abdominal surgery by 5 % (13.000 9 5 % =

650) would result in a yearly national cost savings (direct

Table 7 Total (direct and indirect) costs of IVHR for employed and unemployed patients

Employment % Average direct,

costs (€)Average indirect, costs (€) Average,

total cost

Average sick leave

Cost per week Cost Per day Duration (days) Total cost

Unemployed 68 4731 – – 4731€

Employed 32 4731 1271 182 29.6 5376a 10,107€

Irrespective,

of employment

(0.68 9 4731) ?

(0.32 9 10,107) =

6451€

a (1271/7) 9 29.6

826 Hernia (2016) 20:819–830

123

and indirect cost) of approximately 4 million Euros

(6451 9 650 = 4193,150€).Implementation of the recently published European

Hernia Society guidelines on the closure of abdominal wall

incisions [6], thus hold a good potential not only to avoid

postoperative morbidity related to incisional hernias, but

also to a significant cost saving from avoiding subsequent

incisional hernia repair operations. Prevention of incisional

hernias in patients at high risk for this complication with a

primary mesh augmentation is currently being studied in

several studies and the evidence on the efficacy and the

safety of this approach is increasing rapidly [6, 18, 19]. The

resulting decrease in incisional hernias will undoubtedly

compensate for the additional cost for a primary mesh

augmentation in mesh material and operative time in high-

risk patients.

Strengths of this study

This study is the first published multi-centric cost analysis

of both direct and indirect costs of IVHR. It was done

among a large panel of 51 French public hospitals,

including 3239 patients for the direct costs evaluation and

790 patients for the indirect costs evaluation. The hospital

costs were retrieved from a thorough analysis of 132 uni-

tary expenditure items done by the accountants of a spe-

cialized public agency (ATIH) dedicated to investigate the

costs of the French Health Care system. Moreover, the

ATIH data consist in observed costs (written in the general

ledger) and not reimbursed prices, which may differ from

actual costs especially if the national health policy targets

to promote some priorities and changes in the sanitary

behaviours.

The pathology studied (IVHR) is homogeneous and did

not include primary ventral hernias, which are very dif-

ferent in terms of pathology, hospital stay, postoperative

complications, recurrence rate [20] and finally in terms of

costs.

Furthermore this study estimates the costs of the post-

operative inability to work and loss of profit due to the

disruption in the on-going work over a large panel of dif-

ferent Collective Agreements.

Limitations

The ATIH cost analysis dates back from 2011. Such a wide

cost analysis is not organized each year. Fortunately, due to

a very low inflation rate over this period these costs are still

valid today.

The ATIH analysis does not address the indirect costs,

which were evaluated from the patients registered in the

Hernia Club Registry. These two populations may slightly

differ. For instance more laparoscopic repairs could have

been performed in the CH cohort, and more level 4 cases

could be treated in the ATIH cohort. The difference, if it

exists, may have a slight impact because the relative

financial weight of the level 4 is not prominent (Table 3).

The indirect costs, mainly for unemployed patients, are

probably slightly underestimated:

Unemployed and elderly patients may have spent some

of their recovery in convalescent homes, for which costs

could not be evaluated. Furthermore the Quality of Life is

not a financial variable, so we could not evaluate in

unemployed patients the cost of the daily life impairment

during the sick leave. The costs of a redo surgery in case of

recurrent IVHR, the costs of further medical care and work

gaps in case of complications such as chronic pain were

also not taken into account.

It would have been helpful to split the cost analysis

between open and laparoscopic repairs. Unfortunately due

to the lack of specific GHM (DRG) in this financial and not

medical ATIH study we could not assess the specific costs

of the laparoscopic repairs. This becomes more relevant as

laparoscopic techniques continue to improve and more

complex cases are being done in this fashion. This will

have a direct effect on the direct cost of the procedure as

laparoscopic consumables are more costly and the length of

the procedure may be longer. This may be offset by the fact

that laparoscopic procedures generally have a shorter

length of stay and a quicker return to work.

Moreover it is really difficult to briefly explain what the

four levels of hernia repair are and how they differ. Levels

are calculated using the National Health Care computerized

device (groupeur) taking into account severity and com-

binations of the co-morbidities, the associated intra-hos-

pital events (such as pulmonary embolism, cardiac failure),

the length of stay out of the target; Not many surgical items

are taken into account such as complications related to a

previous mesh, bowel necrosis, or a bacteriologically pro-

ven deep infection. These items are annually updated and

move: If one of these items has not got any financial rel-

evance, it is withdrawn from the list. Therefore it is really

difficult to briefly explain what these four levels are.

We have used the best available data at our disposal to

estimate the different components of the direct and indirect

costs. Although we think the samples are representative

they might not reflect the overall population of French

patients undergoing incisional hernia repair, such as inde-

pendent professionals, farmers, artisans, liberal professions

whose social systems are different from those of

employees.

The economic evaluations are, a priori, difficult to

extrapolate to other countries, because of variations in

healthcare systems and financing, the changes in currencies

and the inflation over time. Nevertheless the costs identi-

fied in the current study are very similar to those found in

Hernia (2016) 20:819–830 827

123

Sweden (9, 11–12). Therefore these costs seem represen-

tative for the cost of IVHR in Europe. In the United States

direct costs (16), are significantly higher than those

reported in this study.

Conclusion

Our study shows that next to a considerable direct cost, also

the indirect costs of incisional hernia repair have to be

accounted for when calculating the potential benefit of

preventive measures to decrease the rate of incisional

hernias after abdominal wall incisions. Upcoming evidence

on the efficacy and safety of mesh augmentation during

closure of abdominal wall incisions in the prevention of

incisional hernias shows an important potential to decrease

the costs related to subsequent incisional hernia repair.

Acknowledgments The authors would like to acknowledge the

Bonham Group and Hernia Club members (see appendix) and Guy

Gravet (GG), a specialized accountant, for helping them in the esti-

mation of the indirect costs.

Compliance with ethical standards

Conflict of interests None for this work: As President of the Her-

nia-Club and Organiser of the Mesh Congress, JFG has financial

partnerships with a number of companies. However, he received no

personal funding for this study.

The Hernia-Club is an independent scientific institution whose

objective is to assess the use of different procedures and prostheses

for hernia repair. It therefore has relationships with a number of

companies with an interest in independent evaluation of their

products.

Appendix A: Members of the Bonham Group

* F.E. Muysoms

Head of the Department of Abdominal Surgery, AZ

Maria Middelares, Ghent, Belgium

* J-F. Gillion

Unite de Chirurgie Viscerale et Digestive, Hopital Prive

d’Antony, France

* D.L. Sanders

Department of Surgery, Derriford Hospital, Plymouth,

United Kingdom

* M. Miserez

Department of Abdominal Surgery, University Hospi-

tals, KU Leuven, Belgium

* S.A. Antoniou 1,2

1Center for Minimally Invasive Surgery, Neuwerk

Hospital, Monchengladbach, Germany2Department of General Surgery, University Hospital of

Heraklion, University of Crete, Greece

* K. Bury

Department of Cardiac and Vascular Surgery, Medical

University of Gdansk, Poland

* G. Campanelli

University of Insubria, General and day surgery, Center

of research and high specialization for abdominal wall

pathology and hernia repair, Istituto Clinico Sant’

Ambrogio, Milano, Italy

* J. Conze

UM Herniacentre, Munich and Department of General,

Visceral and Transplantation Surgery, University Hospital

of the RWTH Aachen, Aachen, Germany

* D. Cuccurullo

Department of General and Laparoscopic Surgery,

Monaldi Hospital, Azienda Ospedaliera dei Colli, Naples,

Italy

*A.C. de Beaux

Department of General Surgery, The Royal Infirmary of

Edinburgh, Edinburgh, United Kingdom

* E.B. Deerenberg

Department of Sugery, Erasmus MC University Medical

Center Rotterdam, Rotterdam, the Netherlands

* B. East

Department of Surgery, Second Faculty of Medicine,

Charles University in Prague, Czech Republic

* R.H. Fortelny

Chief of the Hernia Center, Department of General,

Visceral and Oncological Surgery, Wilhelminenspital,

Vienna, Austria

* N.A. Henriksen

Digestive Disease Center, Bispebjerg Hospital and

Department of Gastroenterology, Hvidovre Hospital,

Copenhagen, Denmark

* L. Israelsson

Department of Surgery and Perioperative science, Umea

University, Umea, Sweden

* A. Jairam

Department of Sugery, Erasmus MC University Medical

Center Rotterdam, Rotterdam, the Netherlands

* A. Janes

Head of Upper GI and Trauma Surgery, Department of

Surgery, Sundsvall Hospital, Sundsvall, Sweden

* J. Jeekel

Department of Neurosciences, Erasmus MC University

Medical Center Rotterdam, Rotterdam, the Netherlands

* M. Lopez-Cano

Abdominal Wall Surgery Unit, Hospital Universitario

Vall d’Hebron. Universidad Autonoma de Barcelona,

Barcelona, Spain

* S. Morales-Conde

Chief of the Unit of Innovation in Minimally Invasive

Surgery, University Hospital Virgen del Rocıo,

Seville, Spain

* M.P. Simons

828 Hernia (2016) 20:819–830

123

Department of Surgery, Onze Lieve Vrouw Gasthuis,

Amsterdam, The Netherlands

* M. Smietanski

Department of General and Vascular Surgery, Ceynowa

Hospital in Wejherowo, Poland

* L. Venclauskas

Lithuanian University of Health Sciences, Department

of Surgery, Kaunas, Lithuania

* F. Berrevoet

Department of General and Hepatobiliary Surgery and

Liver Transplantation Service, University Hospital Ghent,

Belgium

Appendix B: Members of the Hernia Club

Ain J-F: Polyclinique Val de Saone, Macon, France

Beck M: Clinique Ambroise Pare, Thionville, France

Barrat C: Hopital Universitaire Jean Verdier, Bondy,

France

Berney C: Bankstown-Lidcombe Hospital, Sydney,

Australia

Berrot J-L: Groupe Hospitalier Paris St Joseph, Paris,

France

Binot D: MCO Cote d’Opale, Boulogne sur Mer, France

Blazquez D: Clinique Jeanne d’Arc, Paris, France

Bonan A: Hopital Prive d’Antony, Antony, France

Cas O: Centre Medico Chirurgical–Fondation WAL-

LERSTEIN, Ares, France

Dabrowski A: Clinique de Saint Omer, Saint Omer,

France

Champault-Fezais A: Groupe Hospitalier Paris St

Joseph, Paris, France

Chastan P: Bordeaux, France

Cardin J-L: Polyclinique du Maine, Laval, France

Chollet J-M: Hopital Prive d’Antony, Antony, France

Cossa J-P: CMC Bizet, Paris, France

Durou J: Clinique de Villeneuve d’Ascq, Villeneuve

d’Ascq, France

Dugue T: Clinique de Saint Omer, Saint Omer, France

Faure J-P: CHRU Poitiers, Poitiers, France

Framery D: CMC de la Baie de Morlaix, Morlaix,

France

Fromont G: Clinique de Bois Bernard, Bois Bernard,

France

Gainant A: CHRU Limoges, Limoges, France

Gauduchon L: CHRU Amiens, France

Gillion J-F: Hopital Prive d’Antony, Antony, France

Jacquin C: CH du Prado, Marseille, France

Jurczak F: Clinique Mutualiste, Saint Nazaire, France

Khalil H: CHRU Rouen, Rouen, France

Lacroix A: CH de Auch, Auch, France

Ledaguenel P: Clinique Tivoli, Bordeaux, France

Lepere M: Clinique Saint Charles, La Roche-sur-Yon,

France

Letoux N: Clinique Jeanne d’Arc, Paris, France

Loriau J: Groupe Hospitalier Paris St Joseph, Paris

Magne E: Clinique Tivoli, Bordeaux, France

Ngo P: Hopital Americain, Neuilly, France

Paterne D: Clinique Tivoli, Bordeaux, France

Pavis d’Escurac X: Strasbourg, France

Renard Y: CHRU Reims, Reims, France

Soler M: Polyclinique Saint Jean, Cagnes-sur-Mer,

France

Rignier P: Polyclinique des Bleuets. Reims

Roos S: Clinique Claude Bernard, Albi, France

Thillois J-M: Hopital Prive d’Antony, Antony, France

Tiry P: Clinique de Saint Omer, Saint Omer, France

Zaranis C: Clinique de la Rochelle, La Rochelle, France

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