World Journal of Surgery

, Volume 41, Issue 5, pp 1225–1233 | Cite as

Laparoscopic Versus Open Cholecystectomy: A Cost–Effectiveness Analysis at Rwanda Military Hospital

  • Allison Silverstein
  • Ainhoa Costas-Chavarri
  • Mussa R. Gakwaya
  • Joseph Lule
  • Swagoto Mukhopadhyay
  • John G. Meara
  • Mark G. Shrime
Original Scientific Report



Laparoscopic cholecystectomy is first-line treatment for uncomplicated gallstone disease in high-income countries due to benefits such as shorter hospital stays, reduced morbidity, more rapid return to work, and lower mortality as well-being considered cost-effective. However, there persists a lack of uptake in low- and middle-income countries. Thus, there is a need to evaluate laparoscopic cholecystectomy in comparison with an open approach in these settings.


A cost–effectiveness analysis was performed to evaluate laparoscopic and open cholecystectomies at Rwanda Military Hospital (RMH), a tertiary care referral hospital in Rwanda. Sensitivity and threshold analyses were performed to determine the robustness of the results.


The laparoscopic and open cholecystectomy costs and effectiveness values were $2664.47 with 0.87 quality-adjusted life years (QALYs) and $2058.72 with 0.75 QALYs, respectively. The incremental cost–effectiveness ratio for laparoscopic over open cholecystectomy was $4946.18. Results are sensitive to the initial laparoscopic equipment investment and number of cases performed annually but robust to other parameters. The laparoscopic intervention is more cost-effective with investment costs less than $91,979, greater than 65 cases annually, or at willingness-to-pay (WTP) thresholds greater than $3975/QALY.


At RMH, while laparoscopic cholecystectomy may be a more effective approach, it is also more expensive given the low caseload and high investment costs. At commonly accepted WTP thresholds, it is not cost-effective. However, as investment costs decrease and/or case volume increases, the laparoscopic approach may become favorable. Countries and hospitals should aspire to develop innovative, low-cost options in high volume to combat these barriers and provide laparoscopic surgery.


Gross Domestic Product Laparoscopic Cholecystectomy Laparoscopic Approach Incisional Hernia Investment Cost 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



MGS receives support from the GE Safe Surgery 2020 project and from the Steven and Carmella Kletjian Foundation.

Compliance with ethical standards

Conflict of interest

The authors have no conflicts of interest to declare.


  1. 1.
    Moore D, Feurer I, Holzman M et al (2004) Long-term detrimental effect of bile duct injury on health-related quality of life. Arch Surg 139:476–482CrossRefPubMedGoogle Scholar
  2. 2.
    Tiwari MM, Reynoso JF, High R et al (2011) Safety, efficacy, and cost-effectiveness of common laparoscopic procedures. Surg Endosc 25(4):1127–1135CrossRefPubMedGoogle Scholar
  3. 3.
    Topcu O, Karakayali F, Kuzu MA et al (2002) Comparison of long-term quality of life after laparoscopic and open cholecystectomy. Surg Endosc 17:291–295CrossRefPubMedGoogle Scholar
  4. 4.
    Ray-Offor E, Okoro PE, Gbobo I et al (2014) Pilot study on laparoscopic surgery in Port-Harvourt, Nigeria. Niger J Surg 20(1):23–25PubMedPubMedCentralGoogle Scholar
  5. 5.
    Ali R, Khan MR, Pishori T et al (2010) Laparoscopic appendectomy for acute appendicitis: is this a feasible option for developing countries? Saudi J Gastroenterol 16(1):25–29CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Bailey HH, Dan DV (2005) An economic evaluation of laparoscopic cholecystectomy for public hospitals in Trinidad and Tobago. West Indian Med J 54(2):110CrossRefPubMedGoogle Scholar
  7. 7.
    Bendinelli C, Leal T, Moncade F et al (2002) Endoscopic surgery in Senegal. Benefits, costs and limits. Surg Endosc 16(10):1488–1492CrossRefPubMedGoogle Scholar
  8. 8.
    Chao TE, Mandigo M, Opoku-Anane J et al (2016) Systematic review of laparoscopic surgery in low- and middle-income countries: benefits, challenges, and strategies. Surg Endosc 30(1):1–10CrossRefPubMedGoogle Scholar
  9. 9.
    Tintara H, Leetanaporn R (1995) Cost-benefit analysis of laparoscopic adnexectomy. Int J Gynecol Obstet 50:21–25CrossRefGoogle Scholar
  10. 10.
    Teerawattananon Y, Mugford M (2005) Is it worth offering a routine laparoscopic cholecystectomy in developing countries? A Thailand case study. Cost Eff Resour Alloc 3:10CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Brekalo Z, Innocenti P, Duzel G et al (2007) Ten years of laparoscopic cholecystectomy: a comparison between a developed and a less developed country. Wien Klin Wochenschr 119(23–24):722–728CrossRefPubMedGoogle Scholar
  12. 12.
    Hussain A, Mahmood HK, Dulku K (2008) Laparoscopic cholecystectomy can be safely performed in a resource-limited setting: the first 49 laparoscopic cholecystectomies in Yemen. J Soc Laparoendosc Surg 12:71–76Google Scholar
  13. 13.
    Murphree S, Dakovic S, Mauchaza B et al (1993) Laparoscopic cholecystectomy in Zimbabwe: initial report. Cent Afr J Med 39(5):85–88PubMedGoogle Scholar
  14. 14.
    Price R, Sergelen O, Unursaikhan C (2013) Improving surgical care in Mongolia: a model for sustainable development. World J Surg 37:1492–1499. doi: 10.1007/s00268-012-1763- CrossRefPubMedGoogle Scholar
  15. 15.
    Straub CM, Price RP, Matthews D (2011) Expanding Laparoscopic Cholecystectomy to Rural Mongolia. World J Surg 35:751–759. doi: 10.1007/s00268-011-0965-2 CrossRefPubMedGoogle Scholar
  16. 16.
    Meara JG, Leather AJM, Hagander L et al (2015) Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 386(9993):569–624CrossRefPubMedGoogle Scholar
  17. 17.
    Alkire BC, Raykar NP, Shrime MG et al (2015) Global access to surgical care: a modelling study. Lancet Glob Health 3(6):316–323CrossRefGoogle Scholar
  18. 18.
    Chao TE, Sharma K, Mandigo M et al (2014) Cost-effectiveness of surgery and its policy implications for global health: a systematic review and analysis. Lancet Glob Health 2:e334–e345CrossRefPubMedGoogle Scholar
  19. 19.
    Shrime MG, Dare A, Alkire B et al (2015) Catastrophic expenditure to pay for surgery: a modelling study. Lancet Glob Health 3:38–44CrossRefGoogle Scholar
  20. 20.
    Rwanda Military Hospital; Ministry of Defence. (2015). Accessed 10 Jan 2015
  21. 21.
    Russell LB, Gold M, Siegel JE et al (1996) The role of cost-effectiveness analysis in health and medicine. JAMA 276:1172–1177CrossRefPubMedGoogle Scholar
  22. 22.
    Siegel JE, Weinstein MC, Russell LB et al (1996) Recommendations for reporting cost-effectiveness analyses. JAMA 276(16):1339–1341CrossRefPubMedGoogle Scholar
  23. 23.
    Weinstein MC, Siegel JE, Gold MR et al (1996) Recommendations of the panel on cost-effectiveness in health and medicine. JAMA 276(15):1253–1258CrossRefPubMedGoogle Scholar
  24. 24.
    Shrime MG, Verguet S, Johansson KA et al (2016) Task-sharing or public finance for the expansion of surgical access in rural Ethiopia: an extended cost-effectiveness analysis. Health Policy Plan 31(6):706–716CrossRefPubMedGoogle Scholar
  25. 25.
    Chatterjee A, Krishnan NM, Rosen JM (2014) Complex ventral hernia repair using components separation with or without synthetic mesh: a cost-utility analysis. Plast Reconstr Surg 133:137CrossRefPubMedGoogle Scholar
  26. 26.
    Hussain Talpur KA, Mahmood Malik A, Khan Sangrasi A et al (2011) Comparative study of conventional open versus laparoscopic cholecystectomy for symptomatic cholelithiasis. Pak J Med Sci 27(1):33–37Google Scholar
  27. 27.
    World Bank Purchasing Power Parity (2015) Accessed 17 Sep 2015
  28. 28.
    Choosing interventions that are cost-effective [Internet]. Geneva: World Health Organization (2016). Accessed 30 Jan 2016
  29. 29.
    The World Bank: Rwanda Data (2015) Accessed Oct 9 2015
  30. 30.
    Indiamart: Laparoscopy Equipment from India (2016) Accessed 1 Aug 2016
  31. 31.
    Ersumo T (2006) Gallstone disease in a teaching hospital, Addis Ababa: a 5-year review. Ethiop Med J 44(1):49–59PubMedGoogle Scholar
  32. 32.
    Pikuth D (2000) Radiologic diagnosis of common bile duct stones. Abdom Imaging 25:618–621CrossRefGoogle Scholar
  33. 33.
    Vellacott KD, Powell PH (1979) Exploration of the common bile duct: a comparative study. Br J Surg 66:389–391CrossRefPubMedGoogle Scholar
  34. 34.
    Mohamed MI, Abdalla AA, Alshaikh AA (2014) Laparoscopic cholecystectomy: a 15-years experience at a single centre: Wad Medani, Sudan. East Cent Afr J Surg 19(2):12–16Google Scholar
  35. 35.
    Bass EB, Pitt HA, Lillemoe KD (1993) Cost-effectiveness of laparoscopic cholecystectomy versus open cholecystectomy. Am J Surg 165:466–471CrossRefPubMedGoogle Scholar
  36. 36.
    Moore DE, Feurer ID, Holzman MD et al (2004) Long-term detrimental effect of bile duct injury on health-related quality of life. Arch Surg 139:476–482CrossRefPubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2016

Authors and Affiliations

  • Allison Silverstein
    • 1
    • 2
  • Ainhoa Costas-Chavarri
    • 1
    • 3
  • Mussa R. Gakwaya
    • 3
  • Joseph Lule
    • 3
  • Swagoto Mukhopadhyay
    • 1
    • 4
  • John G. Meara
    • 1
    • 5
  • Mark G. Shrime
    • 1
    • 6
  1. 1.Program in Global Surgery and Social ChangeHarvard Medical SchoolBostonUSA
  2. 2.University of Miami Miller School of MedicineMiamiUSA
  3. 3.Rwanda Military HospitalKigaliRwanda
  4. 4.Department of SurgeryUniversity of ConnecticutFarmingtonUSA
  5. 5.Department of Plastic and Oral SurgeryBoston Children’s HospitalBostonUSA
  6. 6.Department of Otolaryngology and Office of Global SurgeryMassachusetts Eye and Ear InfirmaryBostonUSA

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