Standardization of operative technique in laparoscopic right hepatectomy: improving cost-value relationship through value stream mapping

Abstract

Background: With the current emphasis on improving quality and cost reduction in medicine, it is imperative to critically evaluate cost-value relationships for surgical procedures. Previously our group had demonstrated comparable clinical outcomes, reduced length of stay (LOS) and reduced operative time for Laparoscopic Right Hepatectomy (LRH) compared to open right hepatectomy (ORH). Though the two groups had similar overall costs, intraoperative cost in the LRH group was higher. Methods: We decoded LRH into its component critical steps using value stream mapping (VSM), and analyzed the associated costs. We prospectively modified our surgical technique to target those steps that had high intraoperative costs (parenchymal transection, hemostasis) and measured the changes in outcomes. We reviewed medical records at our institution for patients who underwent elective LRH before (pre-LRH n = 22) and after (post-LRH n = 22) the intervention and those who had ORH (n = 65), between January 1, 2008 and November 30, 2016. Results: Average overall cost for the procedure was significantly lower for the post- standardization LRH group (post-LRH $21,768, pre-LRH $28,066, ORH $33,020; p < 0.0001). Average intraoperative blood loss was significantly reduced with LRH (post-LRH 167 mL, pre-LRH 292 mL, ORH 509 mL; p < 0.001). Operative times were significantly shorter for LRH (post-LRH 147 mins, pre- LRH 190 mins, ORH 229 mins; p < 0.001). LOS was significantly reduced for LRH (post-LRH 3 days, pre- LRH 4 days, ORH 7 days; p < 0.002). Conclusion: Using a common quality improvement tool (VSM), we have established a model for cost effective clinical care in hepatobiliary surgery. These tools allow surgeons to overcome personal and traditional biases such as stapler choices, but most importantly eliminate nonvalue added interventions for patients.