Skip to main content
Log in

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

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

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).

Methods

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.

Results

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).

Conclusion

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

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Bittner R, Schwarz J (2012) Inguinal hernia repair: current surgical techniques. Langenbecks Arch Surg 397(2):271–282

    Article  PubMed  CAS  Google Scholar 

  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 13:343–403

    Article  PubMed  CAS  Google Scholar 

  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 25:2773–2843

    Article  PubMed  CAS  Google Scholar 

  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 21:387–390

    Article  PubMed  Google Scholar 

  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 97:765–771

    Article  PubMed  CAS  Google Scholar 

  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 18:70–74

    Article  PubMed  Google Scholar 

  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–iv

    Google Scholar 

  8. Papachristou EA, Mitselou MF, Finokaliotis ND (2002) Surgical outcome and hospital cost analyses of laparoscopic and open tension-free hernia repair. Hernia 6:68–72

    Article  PubMed  CAS  Google Scholar 

  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):CD002197

  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 251:819–824

    Article  PubMed  Google Scholar 

  11. Institut für das Entgeltsystem im Krankenhaus (InEK) (Erratum: Official translation for InEK: Institute for the Hospital Remuneration System) (2008) Kalkulationshandbuch. Siegburg: InEK

  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 243–272

    Google Scholar 

  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 17:2265–2281

    Article  PubMed  Google Scholar 

  14. Rosenbaum PR, Rubin DB (1983) The central role of the propensity score in observational studies for causal effects. Biometrika 70:173–184

    Article  Google Scholar 

  15. Rubin DB (1997) Estimating causal effects from large data sets using propensity scores. Ann Intern Med 127:757–763

    PubMed  CAS  Google Scholar 

  16. Austin PC (2011) An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res 46:399–424

    Article  PubMed  Google Scholar 

  17. Caliendo M, Kopeining S (2008) Some practical guidance for the implementation of propensity score matching. J Econ Surveys 22:31–72

    Article  Google Scholar 

  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 40:373–383

    Article  PubMed  CAS  Google Scholar 

  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 43:1130–1139

    Article  PubMed  Google Scholar 

  20. Institut für das Entgeltsystem im Krankenhaus (InEK) (Institute for the Calculation of Hospital Reimbursement) (2008) Fallpauschalenkatalog. Siegburg: InEK

  21. Austin PC (2008) A critical appraisal of propensity-score matching in the medical literature between 1996 and 2003. Stat Med 27:2037–2049

    Article  PubMed  Google Scholar 

  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 30:1292–1301

    PubMed  Google Scholar 

  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 249:33–38

    Article  PubMed  Google Scholar 

  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 319:312–315

    Article  PubMed  CAS  Google Scholar 

  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 6:90–97

    Article  PubMed  Google Scholar 

  26. Concato J, Shah N, Horwitz RI (2000) Randomized, controlled trials, observational studies, and the hierarchy of research designs. N Engl J Med 342:1887–1892

    Article  PubMed  CAS  Google Scholar 

  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 21:634–640

    Article  PubMed  CAS  Google Scholar 

  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 93:1060–1068

    Article  PubMed  CAS  Google Scholar 

  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 350:1819–1827

    Article  PubMed  CAS  Google Scholar 

  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):639–649

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

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

Disclosures

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

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Friedrich Wittenbecher.

Electronic supplementary material

Below is the link to the electronic supplementary material.

464_2012_2608_MOESM1_ESM.doc

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

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

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

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)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Wittenbecher, F., Scheller-Kreinsen, D., Röttger, J. et al. 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. Surg Endosc 27, 1326–1333 (2013). https://doi.org/10.1007/s00464-012-2608-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-012-2608-6

Keywords

Navigation