title: Laparoscopic versus open liver segmentectomy: prospective, case-matched, intention-to-treat analysis of clinical outcomes and cost effectiveness.
abstract: BACKGROUND
  Reduction in hospital stay, blood loss, postoperative pain and complications are common findings after laparoscopic liver resection, suggesting that the laparoscopic approach may be a suitable alternative to open surgery. Some concerns have been raised regarding cost effectiveness of this procedure and potential implications of its large-scale application. Our aim has been to determine cost effectiveness of laparoscopic liver surgery by a case-matched, case-control, intention-to-treat analysis of its costs and short-term clinical outcomes compared with open surgery.
  
  
  METHODS
  Laparoscopic liver segmentectomies and bisegmentectomies performed at Ninewells Hospital and Medical School between 2005 and 2007 were considered. Resections involving more than two Couinaud segments, or involving any synchronous procedure, were excluded. An operation-magnitude-matched control group was identified amongst open liver resections performed between 2004 and 2007. Hospital costs were obtained from the Scottish Health Service Costs Book (ISD Scotland) and average national costs were calculated. Cost of theatre time, disposable surgical devices, hospital stay, and high-dependency unit (HDU) and intensive care unit (ICU) usage were the main endpoints for comparison. Secondary endpoints were morbidity and mortality. Statistical analysis was performed with Student's t-test, chi(2) and Fisher exact test as most appropriate.
  
  
  RESULTS
  Twenty-five laparoscopic liver resections were considered, including atypical resection, segmentectomy and bisegmentectomy, and they were compared to 25 matching open resections. The two groups were homogeneous by age, sex, coexistent morbidity, magnitude of resection, prevalence of liver cirrhosis and indications. Operative time (p < 0.03), blood loss (p < 0.0001), Pringle manoeuvre (p < 0.03), hospital stay (p < 0.003) and postoperative complications (p < 0.002) were significantly reduced in the laparoscopic group. Overall hospital cost was significantly lower in the laparoscopic group by an average of 2,571 pounds sterling (p < 0.04).
  
  
  CONCLUSIONS
  Laparoscopic liver segmentectomy and bisegmentectomy are feasible, safe and cost effective compared to similar open resections. Large-scale application of laparoscopic liver surgery could translate into significant savings to hospitals and health care programmes.
authors.affiliation: Unit of HPB and Advanced Laparoscopic Surgery, Department of Surgery and Molecular Oncology, Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, UK. f.polignano@nhs.net
authors.forename: Francesco M
authors.initials: FM
authors.lastname: Polignano
authors.forename: Aaron J
authors.initials: AJ
authors.lastname: Quyn
authors.forename: Rodrigo S M
authors.initials: RS
authors.lastname: de Figueiredo
authors.forename: Nikola A
authors.initials: NA
authors.lastname: Henderson
authors.forename: Christoph
authors.initials: C
authors.lastname: Kulli
authors.forename: Iain S
authors.initials: IS
authors.lastname: Tait
mesh_terms: D000368:Aged; D016063:Blood Loss, Surgical / Q000517:prevention & control / Q000706:statistics & numerical data; D016022:Case-Control Studies; D003362:Cost-Benefit Analysis; D005260:Female; D006498:Hepatectomy / Q000191:economics / Q000379:methods* / Q000706:statistics & numerical data; D017721:Hospital Costs / Q000706:statistics & numerical data; D006801:Humans; D007432:Intraoperative Period / Q000706:statistics & numerical data; D010535:Laparoscopy / Q000191:economics / Q000379:methods* / Q000706:statistics & numerical data; D007813:Laparotomy / Q000191:economics / Q000706:statistics & numerical data; D007902:Length of Stay / Q000191:economics / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010149:Postoperative Pain / Q000453:epidemiology / Q000517:prevention & control; D011446:Prospective Studies; D012606:Scotland; D016896:Treatment Outcome