Laparoscopic totally extraperitoneal versus open preperitoneal mesh repair for inguinal hernia recurrence: a decision analysis based on net health benefits.
BACKGROUND
The aim of this study is to evaluate the most cost-effective treatment strategy using preperitoneal mesh for patients with recurrent inguinal hernia. Currently, the issue of cost-effectiveness is entirely unresolved.


METHODS
A decision analysis was carried out based on the results of a systematic literature review of articles concerning recurrent inguinal hernia repair that were published between 1979 and 2011. A virtual cohort was programmed to undergo three different treatment procedures: (1) laparoscopic totally extraperitoneal hernia repair (TEP), (2) open preperitoneal mesh repair according to Stoppa, and (3) open preperitoneal mesh repair according to Nyhus. We carried out a base-case analysis and varied all variables over a broad range of reasonable hypotheses in multiple one-way and two-way sensitivity analyses.


RESULTS
The average cost-effectiveness ratio of Nyhus, Stoppa, and TEP per quality-adjusted life year was US $ ($)1,942, $1,948, and $2,011, respectively. In terms of the incremental cost-effectiveness ratio (ICER), Stoppa was dominated. The choice between TEP or Nyhus procedure depends on the combination of a specific center's rates of recurrence and morbidity as disclosed by three-way sensitivity analysis.


CONCLUSIONS
Nyhus and TEP repairs are possible optimal choices depending primarily on the institution's rates of recurrence and morbidity. Based on our net benefit-related decision analysis, a hypothetical "fixed budget trade-off" suggests potential annual incremental health system cost savings of $200,000 attained by shifting care for 1,000 patients from TEP to Nyhus repair (depending on clinical end-points, which is a decisive factor).
2nd Surgical Department and Surgical Oncology Unit of "Korgialenio-Benakio", Red Cross Hospital, 11 Mantzarou St, Neo Psychiko, 15451 Athens, Greece. ggsgourakis@yahoo.gr
George
G
Sgourakis
Georgia
G
Dedemadi
Ines
I
Gockel
Irene
I
Schmidtmann
Sophocles
S
Lanitis
Paraskevi
P
Zaphiriadou
Athanasios
A
Papatheodorou
Constantine
C
Karaliotas
D003362:Cost-Benefit Analysis; D003663:Decision Trees; D006552:Hernia, Inguinal / Q000191:economics* / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy / Q000191:economics* / Q000379:methods*; D019057:Quality-Adjusted Life Years; D012008:Recurrence; D013526:Surgical Mesh