Surgical Endoscopy

, Volume 27, Issue 4, pp 1326–1333 | Cite as

Comparison of hospital costs and length of stay associated with open-mesh, totally extraperitoneal inguinal hernia repair, and transabdominal preperitoneal inguinal hernia repair: An analysis of observational data using propensity score matching

  • Friedrich Wittenbecher
  • David Scheller-Kreinsen
  • Julia Röttger
  • Reinhard Busse



Laparoscopic inguinal hernia surgery is increasingly seen as the superior technique in hernia repair. Compared to open-mesh hernia repair, laparoscopic approaches are often reported to be more cost-effective but incur higher costs for the provider. The objective of this study was to analyze the effect of transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repair of nonincarcerated inguinal hernias in men on hospital costs and length of stay (LoS).


We used routine administrative, highly standardized, patient-level cost data from 15 German hospitals participating in the national cost data study. We compared TEP, TAPP, and open-mesh repair. We conducted propensity score matching to account for baseline differences between treatment groups and subsequently estimated the treatment effect on costs and LoS.


Total costs for both TEP and TAPP surgery were significantly lower than those for open-mesh repair (p < 0.0001 and p < 0.05, respectively). TEP repair also had a slight but nonsignificant advantage in total costs compared to TAPP repair, while TAPP surgery was associated with a significantly shorter LoS than TEP (p < 0.001).


Results suggest that laparoscopic approaches in hernia repair are not necessarily associated with higher hospital resource consumption than open-mesh repair.


TEP TAPP Inguinal hernia Cost Propensity score matching 



This project was funded through the seventh framework program (FP7) of the European Commission under Grant Agreement No. 223300.


Prof. Dr. Reinhard Busse, David Scheller-Kreinsen, Julia Röttger, and Friedrich Wittenbecher have no conflicts of interest or financial ties to disclose.

Supplementary material

464_2012_2608_MOESM1_ESM.doc (64 kb)
Supplementary Table 1 Procedure per hospital, LoS = Length of stay; d = days; n = frequency; Open-mesh = open-mesh hernia repair; TAPP = transabdominal preperitoneal hernia repair; TEP = totally extraperitoneal hernia repair (DOC 64 kb)
464_2012_2608_MOESM2_ESM.doc (64 kb)
Supplementary Table 2 Standardized differences before and after matching: TEP vs. open-mesh, n = frequency; d = standardized differences; K40.9- = ICD-10GM code for unilateral nonincarcerated inguinal hernia; K40.2- = ICD-10GM code for bilateral nonincarcerated hernia; Open-mesh = open-mesh hernia repair; TEP = totally extraperitoneal hernia repair (DOC 64 kb)
464_2012_2608_MOESM3_ESM.doc (68 kb)
Supplementary Table 3 Standardized differences before and after matching: TAPP vs. open-mesh, n = frequency; d = standardized differences; K40.9- = ICD-10GM code for unilateral nonincarcerated inguinal hernia; K40.2- = ICD-10GM code for bilateral nonincarcerated hernia; Open-mesh = open-mesh hernia repair; TAPP = transabdominal preperitoneal hernia repair (DOC 67 kb)
464_2012_2608_MOESM4_ESM.doc (60 kb)
Supplementary Table 4 Standardized differences before and after matching: TEP vs. TAPP, n = frequency; d = standardized differences; K40.9- = ICD-10GM code for unilateral nonincarcerated inguinal hernia; K40.2- = ICD-10GM code for bilateral non-incarcerated hernia; TAPP = transabdominal preperitoneal hernia repair; TEP = totally extraperitoneal hernia repair (DOC 60 kb)


  1. 1.
    Bittner R, Schwarz J (2012) Inguinal hernia repair: current surgical techniques. Langenbecks Arch Surg 397(2):271–282PubMedCrossRefGoogle Scholar
  2. 2.
    Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J, de Lange D, Fortelny R, Heikkinen T, Kingsnorth A, Kukleta J, Morales-Conde S, Nordin P, Schumpelick V, Smedberg S, Smietanski M, Weber G, Miserez M (2009) European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 13:343–403PubMedCrossRefGoogle Scholar
  3. 3.
    Bittner R, Arregui ME, Bisgaard T, Dudai M, Ferzli GS, Fitzgibbons RJ, Fortelny RH, Klinge U, Kockerling F, Kuhry E, Kukleta J, Lomanto D, Misra MC, Montgomery A, Morales-Conde S, Reinpold W, Rosenberg J, Sauerland S, Schug-Pass C, Singh K, Timoney M, Weyhe D, Chowbey P (2011) Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)]. Surg Endosc 25:2773–2843PubMedCrossRefGoogle Scholar
  4. 4.
    Butler RE, Burke R, Schneider JJ, Brar H, Lucha PA Jr (2007) The economic impact of laparoscopic inguinal hernia repair: results of a double-blinded, prospective, randomized trial. Surg Endosc 21:387–390PubMedCrossRefGoogle Scholar
  5. 5.
    Eklund A, Carlsson P, Rosenblad A, Montgomery A, Bergkvist L, Rudberg C (2010) Long-term cost-minimization analysis comparing laparoscopic with open (Lichtenstein) inguinal hernia repair. Br J Surg 97:765–771PubMedCrossRefGoogle Scholar
  6. 6.
    Jacobs VR, Morrison JE Jr (2008) Comparison of institutional costs for laparoscopic preperitoneal inguinal hernia versus open repair and its reimbursement in an ambulatory surgery center. Surg Laparosc Endosc Percutan Tech 18:70–74PubMedCrossRefGoogle Scholar
  7. 7.
    McCormack K, Wake B, Perez J, Fraser C, Cook J, McIntosh E, Vale L, Grant A (2005) Laparoscopic surgery for inguinal hernia repair: systematic review of effectiveness and economic evaluation. Health Technol Assess 9:1–203, iii–ivGoogle Scholar
  8. 8.
    Papachristou EA, Mitselou MF, Finokaliotis ND (2002) Surgical outcome and hospital cost analyses of laparoscopic and open tension-free hernia repair. Hernia 6:68–72PubMedCrossRefGoogle Scholar
  9. 9.
    Scott NW, McCormack K, Graham P, Go PM, Ross SJ, Grant AM (2002) Open mesh versus non-mesh for repair of femoral and inguinal hernia. Cochrane Database Syst Rev (4):CD002197Google Scholar
  10. 10.
    Langeveld HR, van’t Riet M, Weidema WF, Stassen LP, Steyerberg EW, Lange J, Bonjer HJ, Jeekel J (2010) Total extraperitoneal inguinal hernia repair compared with Lichtenstein (the LEVEL-Trial): a randomized controlled trial. Ann Surg 251:819–824PubMedCrossRefGoogle Scholar
  11. 11.
    Institut für das Entgeltsystem im Krankenhaus (InEK) (Erratum: Official translation for InEK: Institute for the Hospital Remuneration System) (2008) Kalkulationshandbuch. Siegburg: InEKGoogle Scholar
  12. 12.
    Geissler A, Scheller-Kreinsen D, Busse R (2011) Germany: Understanding G-DRGs. In: Busse R, Geissler A, Quentin W, Wiley M (eds) Diagnosis related groups in Europe (European Observatory on Health Systems and Policies). Open University Press, Berkshire, pp 243–272Google Scholar
  13. 13.
    D’Agostino RB Jr (1998) Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group. Stat Med 17:2265–2281PubMedCrossRefGoogle Scholar
  14. 14.
    Rosenbaum PR, Rubin DB (1983) The central role of the propensity score in observational studies for causal effects. Biometrika 70:173–184CrossRefGoogle Scholar
  15. 15.
    Rubin DB (1997) Estimating causal effects from large data sets using propensity scores. Ann Intern Med 127:757–763PubMedGoogle Scholar
  16. 16.
    Austin PC (2011) An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res 46:399–424PubMedCrossRefGoogle Scholar
  17. 17.
    Caliendo M, Kopeining S (2008) Some practical guidance for the implementation of propensity score matching. J Econ Surveys 22:31–72CrossRefGoogle Scholar
  18. 18.
    Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40:373–383PubMedCrossRefGoogle Scholar
  19. 19.
    Quan H, Sundararajan V, Halfon P, Fong A, Burnand B, Luthi JC, Saunders LD, Beck CA, Feasby TE, Ghali WA (2005) Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 43:1130–1139PubMedCrossRefGoogle Scholar
  20. 20.
    Institut für das Entgeltsystem im Krankenhaus (InEK) (Institute for the Calculation of Hospital Reimbursement) (2008) Fallpauschalenkatalog. Siegburg: InEKGoogle Scholar
  21. 21.
    Austin PC (2008) A critical appraisal of propensity-score matching in the medical literature between 1996 and 2003. Stat Med 27:2037–2049PubMedCrossRefGoogle Scholar
  22. 22.
    Austin PC (2011) Comparing paired vs non-paired statistical methods of analyses when making inferences about absolute risk reductions in propensity-score matched samples. Stat Med 30:1292–1301PubMedGoogle Scholar
  23. 23.
    Eklund AS, Montgomery AK, Rasmussen IC, Sandbue RP, Bergkvist LA, Rudberg CR (2009) Low recurrence rate after laparoscopic (TEP) and open (Lichtenstein) inguinal hernia repair: a randomized, multicenter trial with 5-year follow-up. Ann Surg 249:33–38PubMedCrossRefGoogle Scholar
  24. 24.
    McKee M, Britton A, Black N, McPherson K, Sanderson C, Bain C (1999) Methods in health services research. Interpreting the evidence: choosing between randomised and non-randomised studies. BMJ 319:312–315PubMedCrossRefGoogle Scholar
  25. 25.
    Motheral B, Brooks J, Clark MA, Crown WH, Davey P, Hutchins D, Martin BC, Stang P (2003) A checklist for retrospective database studies–report of the ISPOR Task Force on retrospective databases. Value Health 6:90–97PubMedCrossRefGoogle Scholar
  26. 26.
    Concato J, Shah N, Horwitz RI (2000) Randomized, controlled trials, observational studies, and the hierarchy of research designs. N Engl J Med 342:1887–1892PubMedCrossRefGoogle Scholar
  27. 27.
    Eklund A, Rudberg C, Leijonmarck CE, Rasmussen I, Spangen L, Wickbom G, Wingren U, Montgomery A (2007) Recurrent inguinal hernia: randomized multicenter trial comparing laparoscopic and Lichtenstein repair. Surg Endosc 21:634–640PubMedCrossRefGoogle Scholar
  28. 28.
    Eklund A, Rudberg C, Smedberg S, Enander LK, Leijonmarck CE, Osterberg J, Montgomery A (2006) Short-term results of a randomized clinical trial comparing Lichtenstein open repair with totally extraperitoneal laparoscopic inguinal hernia repair. Br J Surg 93:1060–1068PubMedCrossRefGoogle Scholar
  29. 29.
    Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons R Jr, Dunlop D, Gibbs J, Reda D, Henderson W (2004) Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 350:1819–1827PubMedCrossRefGoogle Scholar
  30. 30.
    Krishna A, Misra MC, Bansal VK, Kumar S, Rajeshwari S, Chabra A (2012) Laparoscopic inguinal hernia repair: transabdominal preperitoneal (TAPP) versus totally extraperitoneal (TEP) approach: a prospective randomized controlled trial. Surg Endosc 26(3):639–649PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  • Friedrich Wittenbecher
    • 1
  • David Scheller-Kreinsen
    • 1
  • Julia Röttger
    • 1
  • Reinhard Busse
    • 1
  1. 1.Fachgebiet Management im GesundheitswesenTechnische Universität BerlinBerlinGermany

Personalised recommendations