Surgical Endoscopy

, Volume 25, Issue 4, pp 1187–1191 | Cite as

The impact of surgeon choice on the cost of performing laparoscopic appendectomy

  • Thomas Chu
  • Ryan A. Chandhoke
  • Paul C. Smith
  • Steven D. Schwaitzberg



While laparoscopic appendectomy (LA) can be performed using a myriad of techniques, the cost of each method varies. The purpose of this study is to analyze the effects of surgeon choice of technique on the cost of key steps in LA.


Surgeon operative notes, hospital invoice lists, and surgeon instrumentation preference sheets were obtained for all LA cases in 2008 at Cambridge Health Alliance (CHA). Only cases (N = 89) performed by fulltime staff general surgeons (N = 8) were analyzed. Disposable costs were calculated for the following components of LA: port access, mesoappendix division, and management of the appendiceal stump. The actual cost of each disposable was determined based on the hospital’s materials management database. Actual hospital reimbursements for LA in 2008 were obtained for all payers and compared with the disposable cost per case.


Disposable cost per case for the three portions analyzed for 126 theoretical models were calculated and found to range from US $81 to US $873. The surgeon with the most cost-effective preferred method (US $299) utilized one multi-use endoscopic clip applier for mesoappendix division, two commercially available pretied loops for management of the appendiceal stump, and three 5-mm trocars as their preferred technique. The surgeon with the least cost-effective preferred method (US $552) utilized two staple firings for mesoappendix division, one staple firing for management of the appendiceal stump, and 12/5/10-mm trocars for access. The two main payers for LA patients were Medicaid and Health Safety Net, whose total hospital reimbursements ranged from US $264 to US $504 and from US $0 to US $545 per case, respectively, for patients discharged on day 1.


Disposable costs frequently exceeded hospital reimbursements. Currently, there is no scientific literature that clearly illustrates a superior surgical method for performing these portions of LA in routine cases. This study suggests that surgeons should review the cost implications of their practice and to find ways to provide the most cost-effective care without jeopardizing clinical outcome.


Laparoscopic appendectomy Cost Surgery Disposable costs 



Authors Steven Schwaitzberg has served on the Merck Speakers’ Bureau and as a consultant to Starion during the past 3 years. He has ongoing consultant activities with Olympus, Stryker, Surgiquest, Neatstitch, Cambridge Endo, and Endocore. Authors Thomas Chu and Ryan Chandhoke have no conflicts of interest or financial ties to disclose.


  1. 1.
    Addiss DG, Shaffer N, Fowler BS, Tauxe RV (1990) The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 132(5):910–925PubMedGoogle Scholar
  2. 2.
    Attwood SE, Hill AD, Murphy PG, Thornton J, Stephens RB (1992) A prospective randomized trial of laparoscopic versus open appendectomy. Surgery 112(3):497–501PubMedGoogle Scholar
  3. 3.
    Frazee RC, Roberts JW, Symmonds RE, Snyder SK, Hendricks JC, Smith RW, Custer MD 3rd, Harrison JB (1994) A prospective randomized trial comparing open versus laparoscopic appendectomy. Ann Surg 219(6):725–731PubMedCrossRefGoogle Scholar
  4. 4.
    Minne L, Varner D, Burnell A, Ratzer E, Clark J, Huan W (1997) Laparoscopic vs open appendectomy. Prospective randomized study of outcomes. Arch Surg 132(7):708–711PubMedGoogle Scholar
  5. 5.
    Yau KK, Siu WT, Tang CN, Yang GP, Li MK (2007) Laparoscopic versus open appendectomy for complicated appendicitis. J Am Coll Surg 205(1):60–65PubMedCrossRefGoogle Scholar
  6. 6.
    Sauerland S, Lefering R, Neugebauer EAM (2004) Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 4:CD001546. doi:10.1002/14651858.CD001546.pub2
  7. 7.
    Daniel JF, Gurley LD, Kurtz BR, Chambers JF (1991) The use of an automatic stapling device for laparoscopic appendectomy. Obstet Gynecol 78(4):721–723Google Scholar
  8. 8.
    Kazemier G, In’t Hof KH, Saad S, Bonjer HJ, Sauerland S (2006) Securing the appendiceal stump in laparoscopic appendectomy: evidence for routine stapling? Surg Endosc 20(9):1473–1476. doi:10.1007/s00464-005-0525-7 PubMedCrossRefGoogle Scholar
  9. 9.
    Klaiber C, Wagner M, Metzger A (1994) Various stapling techniques in laparoscopic appendectomy: 40 consecutive cases. Surg Laparosc Endosc 4(3):205–209PubMedGoogle Scholar
  10. 10.
    Wagner M, Aronsky D, Tschudi J, Metzger A, Klaiber C (1996) Laparoscopic appendectomy. A prospective study of 267 consecutive cases. Surg Endosc 10(9):895–899PubMedCrossRefGoogle Scholar
  11. 11.
    Cristalli BG, Izard V, Jacob D, Levardon M (2007) Laparoscopic appendectomy using a clip applier. Surg Endosc 5(4):176–178CrossRefGoogle Scholar
  12. 12.
    Aslan A, Karaveli C, Elpek O (2008) Laparoscopic appendectomy without clip or ligature. An experimental study. Surg Endosc 22(9):2084–2087PubMedCrossRefGoogle Scholar
  13. 13.
    Elemen L, Yazir Y, Tugay M, Akay A, Aydin S, Yanar K, Ceylan S (2010) LigaSure compared with ligatures and endoclips in experimental appendectomy: how safe is it? Pediatric Surg Int. doi:10.1007/s00383-010-2557-x
  14. 14.
    Sajid MS, Rimple J, Cheek E, Baig MK (2009) Use of endo-GIA versus endo-loop for securing the appendicular stump in laparoscopic appendicectomy: a systematic review. Surg Laparosc Endosc Percutan Tech 19(1):11–15PubMedCrossRefGoogle Scholar
  15. 15.
    Sauerland S, Kazemier G (2007) Appendix stump closure during laparoscopic appendectomy (Protocol). Cochrane Database Syst Rev 2:CD006437. doi:10.1002/14651858.CD006437
  16. 16.
    Fritts LL, Orlando R III (1993) Laparoscopic appendectomy: a safety and cost analysis. Arch Surg 128(5):521–525PubMedGoogle Scholar
  17. 17.
    Martin LC, Puente I, Sosa JL, Bassin A, Breslaw R, McKenney MG, Ginzburg E, Sleeman D (1995) Open versus laparoscopic appendectomy. A prospective randomized comparison. Ann Surg 222(3):256–262PubMedCrossRefGoogle Scholar
  18. 18.
    McCahill LE, Pellegrini CA, Wiggins T, Helton WS (1996) A clinical outcome and cost analysis of laparoscopic versus open appendectomy. Am J Surg 171(5):533–537. doi:10.1016/S0002-9610(96)00022-0 PubMedCrossRefGoogle Scholar
  19. 19.
    Beldi G, Muggli K, Helbling C, Schlumpf R (2004) Laparoscopic appendectomy using endoloops: a prospective, randomized clinical trial. Surg Endosc 18(5):749–750. doi:10.1007/s00464-003-9156-z Google Scholar
  20. 20.
    Houben F, Willmen HR (1998) Simplified appendectomy without stump embedding. Experiences of 20 years conventional and 5 years laparoscopic application. Chirurg 69(1):66–71PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Thomas Chu
    • 1
    • 2
  • Ryan A. Chandhoke
    • 1
    • 2
  • Paul C. Smith
    • 3
  • Steven D. Schwaitzberg
    • 3
    • 4
    • 5
  1. 1.Tufts University School of MedicineBostonUSA
  2. 2.Heller School for Social Policy and ManagementWalthamUSA
  3. 3.Cambridge Health AllianceCambridgeUSA
  4. 4.Harvard Medical SchoolBostonUSA
  5. 5.Department of SurgeryCambridge Health AllianceCambridgeUSA

Personalised recommendations