Lawrence K, McWhinnie D, Goodwin A, Gray A, Gordon J, Storie J, Britton J, Collin J
Department of Public Health and Primary Care, Oxford University.
J Public Health Med. 1996 Mar;18(1):41-8. doi: 10.1093/oxfordjournals.pubmed.a024460.
The rapid and widespread introduction of minimal access surgery has major implications for the National Health Service. It cannot be assumed that replacing an open procedure with a minimal access alternative will be cost-effective. Laparoscopic inguinal hernia repair is a procedure for which the potential economic benefits are particularly unclear. It is currently being adopted in many centres, although limited evidence on its clinical and cost-effectiveness exists.
This economic comparison of laparoscopic versus open hernia repair was undertaken on data collected on 104 patients undergoing surgery on a day case basis, in the context of a randomized controlled trial.
The mean total health service cost of laparoscopic repair was 1074 pounds versus 489 pounds for open repair [mean difference in total health service costs 583 pounds; 95 percent confidence interval (CI) 265 pounds-904 pounds]. This difference was largely accounted for by the difference in theatre costs. Laparoscopic repair remained significantly more expensive for most but not all of the scenarios explored in the sensitivity analysis. The direction of the cost-effectiveness ratio was not sensitive to assumptions about long-term recurrence. Neither was it sensitive to halving the operating time in the laparoscopic arm of the trial. When both operating time and the costs of consumables were reduced, laparoscopic repair remained more expensive, but results for this scenario did not achieve statistical significance on this sample size.
Laparoscopic hernia repair appears an expensive option in most plausible situations. Furthermore, many uncertainties still exist about long-term outcome after the procedure and about the conditions necessary to maximize cost-effectiveness. Large-scale randomized studies to evaluate laparoscopic hernia repair are currently under way to address these issues. We suggest that further evidence is awaited before this technology is further diffused.
微创外科手术的迅速广泛应用对国民医疗服务体系具有重大影响。不能认为用微创替代开放手术就具有成本效益。腹腔镜腹股沟疝修补术的潜在经济效益尤其不明确。目前许多中心都在采用该手术，尽管关于其临床和成本效益的证据有限。
在一项随机对照试验背景下，对104例日间手术患者的数据进行了腹腔镜与开放疝修补术的经济学比较。
腹腔镜修补术的平均总医疗服务成本为1074英镑，而开放修补术为489英镑[总医疗服务成本的平均差异为583英镑；95%置信区间（CI）265英镑 - 904英镑]。这种差异主要是由手术室成本的差异造成的。在敏感性分析所探讨的大多数但并非所有情况下，腹腔镜修补术仍然明显更昂贵。成本效益比的方向对长期复发的假设不敏感。对试验腹腔镜组手术时间减半的假设也不敏感。当手术时间和耗材成本都降低时，腹腔镜修补术仍然更昂贵，但在该样本量下此情况的结果未达到统计学显著性。
在大多数合理情况下，腹腔镜疝修补术似乎是一种昂贵的选择。此外，该手术后的长期结果以及实现成本效益最大化所需的条件仍存在许多不确定性。目前正在进行大规模随机研究以评估腹腔镜疝修补术来解决这些问题。我们建议在该技术进一步推广之前等待更多证据。
