Underutilization of laparoscopic oophorectomy

[Evaluation of cost of laparoscopic surgery in gynecology]

The objective of this work was to evaluate hospital and postoperative costs associated with gynecologic laparoscopic surgery for benign pathologies. Hospital costs were broken down into several categories: operating room, postoperative hospitalization, pharmacy, surgical instruments, sterilization of reused equipment, food and laundry, indirect costs. The mean total costs for the hospitalization time were 8547,2 francs. Medical charges in recovery time were calculated with the help of the Social Security. These charges represented less than 5% of the total cost associated with the procedure.

Surgeon predictions on growth of minimal invasive therapy: the difficulty of estimating technologic diffusion

OBJECTIVE

To compare five-year predictions made in 1992 by academic surgeon leaders in UK, US and Canada, with actual experiences in 1997, of increased rates of minimal invasive therapy (MIT) for surgical operations.

METHOD

We compared 1992 predictions of percent of operations done by minimal invasive therapy and length of stay in the US with actual 1997 percents found by literature searches.

RESULTS

We found sufficient data on 12 operations done by MIT in 1997 of the original 34 operations predicted in 1992 by surgeon experts to be to be amenable to this technique. These 12 operations were among the top 20 most commonly performed procedures in 1992 and 1997. Of these 12 operations, ten had 40-60% lower 1997 percentages than predicted, one had about 10% lower rate, and two had 18% and 100% higher rates of MIT than predicted. Overall mean length of stay (LOS) for all 34 study operations fell from 6.8 days in 1992 to 5.2 days in 1997. Mean LOS in 1997 was 2.5 days by MIT and 6.7 days by open technique (OT).

CONCLUSION

Most of the predictions made in 1992 by surgical leaders in Canada, US and UK were incorrect when examined 5 years later. The rate of MIT diffusion and its effect on length of stay were overestimated for most operations, while for two procedures the predictions underestimated extent of diffusion. Also, much of the declines of LOS for surgical care paralleled declines in length of stay for all care, supplemented by the individual contributions of MIT specifically. Relying on expert opinion alone to predict the acceptability, rapidity, scope and extent of technological change is fraught with uncertainty. Unexpected consequences occur when one or a few parts of complex systems are changed. This is a particular problem when predictions are a main basis for informed decision making in the absence of any supporting data from appropriately designed empirical or controlled study.

The place of laparoscopic surgery in surgical gynaecology

This review was undertaken to ascertain whether the low usage of laparoscopic surgery in gynaecology resulted from unacceptable complication rates and long operating times. The safety and efficacy of laparoscopic surgery has been compared to that of laparotomy. Reports of controlled or comparative trials of laparoscopic gynaecological surgery for adhesions, infertility, ectopic pregnancy, oophorectomy, myomectomy and laparoscopically-assisted vaginal hysterectomy (LAVH) have been reviewed between 1984 and 1997. Although further multicentre controlled trials may improve the assessment of complication rates for both laparotomy and laparoscopy procedures, laparoscopy appears to be as safe as laparotomy and generally has the advantage of shorter hospital stay and earlier return to normal activities. Except for LAVH, operating times of laparoscopic surgery are similar to that of laparotomy.

Presidential address

Gynecologic endoscopic surgeons have achieved remarkable results in the past decade. We have frequently improved results compared with traditional open techniques. This has resulted in billions of dollars saved for the work force by converting inpatient to outpatient procedures and as a result decreasing the amount of time patients must be out of work. The growth of several industries including ambulatory surgicenters, managed care, and medical device manufacturers has been encouraged. Incomes for endoscopic surgeons have, however, decreased. Possible solutions include decreasing overhead, increasing income by participating in facility fees and performing a greater percentage of office procedures, and educating ourselves in billing processes and attempting to improve reimbursements for gender-specific procedures.