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Examining variation in cost based on surgeon choices for elective laparoscopic cholecystectomy



Laparoscopic cholecystectomy (LC) is the standard of care for treatment of benign biliary disease. Declining reimbursements and increasing medical costs require physicians to examine closely their choices for equipment to decrease overall costs, particularly looking at key steps of cholecystectomy. The objective of this study was to examine variations between surgeons in equipment and operating room costs for elective LC.


Elective LC performed at IUH West Hospital in 2013 was analyzed. Patient demographics, preoperative diagnosis, operative time, surgical equipment, and resident participation were tracked. Exclusion criteria included acute cholecystitis and cases with additional procedures. Electronic medical records for clinical data and administrative records for reimbursement data were reviewed. Total supply costs and disposable costs for key portions of the LC were analyzed. Reimbursements were obtained from all payers for LC.


All LC were examined (n = 362) and 272 met inclusion criteria. Demographics and pathology were similar between surgeons. Operative time varied significantly (range 53–98 min) with the lowest cost surgeon taking the longest overall time. Times were significantly affected by resident participation. The total morbidity was 4 %, with no mortalities. Total supply costs by surgeon ranged from $412–$924. The most costeffective technique included the use of plastic locking clips and hook electrocautery. Hospital and surgeon reimbursements were $336–$11,554 and $669–$1500 respectively.


This study highlights effects of surgeon choice as it relates to variable costs for surgical technique during elective LC without compromising safety. With healthcare reform emphasizing reduced healthcare expenditures, it is vital for surgeons to identify areas of unnecessary cost. Operating room time also contributes to cost, thus surgeons should implement techniques to complete procedures in a safe yet efficient fashion. Transparency by surgeons can lead to data that may support standardization of technique across a healthcare system to lower total supply costs.

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Fig. 1



Affordable Care Act


Center for Medicare and Medicaid Services


Indiana University Health


Laparoscopic cholecystectomy


  1. Emanuel E, Tanden J, Altman S, Armstrong S, Berwick D, De Brantes F, Calsyn M, Chernew M, Colmers J, Cutler D, Daschle T, Egerman P, Kocher B, Milstein A, Oshima Lee E, Podesta J, Reinhardt U, Rosental M, Sharfstein J, Shortell S, Stern A, Orszag PR, Spiro T (2012) A systemic approach to containing health care spending. N Engl J Med 367(10):949–954

    CAS  Article  PubMed  Google Scholar 

  2. Kaiser Family Foundation (2015) Medicare spending. JAMA. 313(1):19.

  3. Center of Medicare and Medicaid Services. National Health Expenditure Data. Available at

  4. Congressional Budget Office (2012) The 2012 long-term budget outlook.

  5. Traverso LW (1996) The laparoscopic surgical value package and how surgeons can influence costs. Surg Clin N Am 76:631–639

    CAS  Article  PubMed  Google Scholar 

  6. Cosimi AB (2011) Modern day bloodletting. Arch Surg 146(5):527

    Article  PubMed  Google Scholar 

  7. Mason SE, Nicolay CR, Darzi A (2015) The use of lean and six sigma methodologies in surgery: a systematic review. Surgeon 13(2):91–100

    CAS  Article  PubMed  Google Scholar 

  8. Cima RR, Brown MJ, Hebl JR, Moore R, Rogers JC, Kollengode A, Amstutz GJ, Weisbrod CA, Narr BJ, Deschamps C (2011) Use of lean and six sigma methodology to improve operating room efficiency in high volume tertiary care academic medical center. J Am Surg 213(1):83–92

    Article  Google Scholar 

  9. Macario A (2010) What does one minute of operating room time cost? J Clin Anesth 22:233–236

    Article  PubMed  Google Scholar 

  10. Frazee RC, Elliott VG, Larsen W, Lerner S, Minnis KW, Huber C, Nolan J, Papaconstantinou H, Smythe WR (2014) Can laparoscopic cholecystectomy be performed with a positive margin at medicaid reimbursement rates? J Am Coll Surg 218(4):546–551

    Article  PubMed  Google Scholar 

  11. General Surgery Medicare Reimbursement Coding Guide.

  12. Consumer Reports Health (2012) What’s fair? Fair Healthcare pricing from Healthcare Blue Book. Laparoscopic cholecystectomy.

  13. Virk P, Paranjape C (2014) Variation in national DRG payments for laparoscopic cholecystectomy: Hospital level analysis. In: Poster presentation, SAGES Surgical Spring Week 2014. Salt Lake City, UT

  14. Vanek VW, Bourguet CC (1995) The cost of laparoscopic versus open cholecystectomy in a community hospital. Surg Endosc 9(3):314–323

    CAS  Article  PubMed  Google Scholar 

  15. Ure BM, Lefering R, Troidl H (1995) Costs of laparoscopic cholecystectomy, analysis of potential savings. Surg Endosc 9(4):401–406

    CAS  Article  PubMed  Google Scholar 

  16. Troidl H, Spangenberger W, Langen R, Al-Jaziri A, Eypasch E, Neugebauer E, Dietrich J (1992) Laparoscopic cholecystectomy: technical performance, safety and patient’s benefit. Endoscopy 24:252–261

    CAS  Article  PubMed  Google Scholar 

  17. Lawson EH, Hall BL, Louis R, Ettner SL, Zingmond DS, Han L, Rapp M, Ko CY (2013) Association between occurrence of postoperative complication and readmission. Ann Surg 258(1):10–18

    Article  PubMed  Google Scholar 

  18. Boltz MM, Hollenbeak CS, Julian KG, Ortenzi G, Dillon PW (2011) Hospital costs associated with surgical site infections in general and vascular surgery patients. Surgery 150(5):934–942

    Article  PubMed  Google Scholar 

  19. Strasberg SM, Brunt LM (2010) Rationale and use of the critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg 211(1):132–138

    Article  PubMed  Google Scholar 

  20. Hunter JG (1991) Avoidance of bile duct injuries during laparoscopic cholecystectomy. Am J Surg 162(1):71–76

    CAS  Article  PubMed  Google Scholar 

  21. Strasberg SM (2002) Avoidance of biliary injury during laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg 9(5):543–547

    Article  PubMed  Google Scholar 

  22. Chu T, Chandhoke RA, Smith PC, Schwaitzberg SD (2011) The impact of surgeon choice on cost of performing laparoscopic appendectomy. Surg Endosc 25(4):1187–1191

    Article  PubMed  Google Scholar 

  23. Association of American Medical Colleges. Preserve Medicare Support for Physician Training. AAMC Government Relations (202) 828-0526.

  24. Wilensky G (2014) The challenges of reforming graduate medial education. JAMA 312(23):2479–2480

    Article  PubMed  Google Scholar 

  25. Wilensky GR, Berwick DM (2014) Reforming the financing and governance of GME. N Engl J Med 371(9):792–793

    CAS  Article  PubMed  Google Scholar 

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Correspondence to Eugene P. Ceppa.

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Heather H. Adkins, Thomas J. Hardacker, and Eugene P. Ceppa have no conflicts of interest or financial ties to disclose.

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Adkins, H.H., Hardacker, T.J. & Ceppa, E.P. Examining variation in cost based on surgeon choices for elective laparoscopic cholecystectomy. Surg Endosc 30, 2679–2684 (2016).

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  • Laparoscopic cholecystectomy
  • Reimbursements
  • Supply costs
  • Medicare