Over/under: examining the cost difference in vaginal vs. laparoscopic cuff closure following a laparoscopic hysterectomy

Abstract

Vaginal cuff closure following a total laparoscopic hysterectomy (TLH) can be approached laparoscopically or transvaginally. Route of closure is primarily determined by surgeon preference and may also be influenced by clinical/patient characteristics. The objective of this study is to compare the proportion of laparoscopic (LSC) closure to the proportion of transvaginal (TV) closure of the vaginal cuff following a TLH. We also aim to compare the cost utility of both cuff closure approaches. This is a retrospective cross-sectional study of all TLH cases performed at our institution between June 2018 – May 2019. We collected patient demographics, surgery parameters (vaginal cuff closure method, necessity for X-ray), and time measurements between case milestones (case start-to-end, X-ray completed, patient out of room). Of note, our institution carries a unique protocol that may not be the standard across other institutions, which mandates an abdominal X-ray (AXR) to evaluate for retained foreign bodies in patients with a BMI ≥35 when a laparoscopic case includes a TV cuff closure. This protocol does not apply in LSC cuff closure following TLH. Exclusion criteria included conversion to open procedure and involvement of concomitant procedures. Based on review of existing literature, operating room (OR) costs have been estimated to range between $30 - $81 per minute and post-operative radiologic images cost about $168 per procedure. Data were analyzed with Chi-square test and two-tailed t-test (α = 0.05). During the study period, 120 qualifying TLH cases were performed. Eighty-seven patients (73%) underwent LSC closure and thirty-three patients (27%) underwent TV closure. Mean age and BMI did not significantly differ between LSC and TV closure groups. Fifteen patients in the LSC closure group and nineteen patients in the TV closure group had BMI > 35. Service type differs between the two groups (p<.001). For the LSC closure group, the mean case time was shorter by a mean difference of 66 minutes (133 minutes for LSC versus 199 minutes for TV; 95% CI = -84.1, -47.8). If all TV closures were done laparoscopically, this translates to a potential cost saving of $1,980 - $5,346 per case. The mean time difference between case end time and out of OR time was shorter by 15.75 minutes in cases that did not require AXR. Nineteen patients who had a TV closure after TLH also required AXR for BMI>35. Thus, 19 AXR would be potentially avoided if TV closures were replaced by LSC closures. With added OR time and cost of AXR, there is a potential saving of $12,169 - $27,431 per year if LSC closures were chosen. Compared to TV cuff closure, LSC vaginal cuff closure following a TLH may afford a cost benefit due to decreased operating room time. Given our institutional policy, further cost savings can be seen by avoiding additional AXR.