腹腔镜与开放腹膜前疝修补手术治疗成人腹股沟疝的成本效益分析

目的从成本-效益角度对比分析腹腔镜与开放腹膜前疝修补手术在成人腹股沟疝中的应用情况。 方法纳入2019年1-12月在眉山市人民医院诊治的单侧腹股沟疝患者132例，患者自主选择手术方式，开放手术组52例，腹腔镜手术组80例。成本费用计算包括住院费用、手术费用、其他费用；使用《欧洲五维健康量表（EQ-5D）中文版》在术后1 d、7 d、15 d分别对患者进行获益评价，并据此计算质量调整生命年（QALYs），进而计算和分析成本效益比（C/E）及增量成本效益比（ICER）。 结果开放手术组的平均总费用为7742.72元，腹腔镜手术组的平均总费用为12 866.56元。开放手术组和腹腔镜组的QALYs在第1天分别为0.501±0.178/0.692±0.106，第7天为0.673±0.123/0.814±0.042，差异均有统计学意义；第15天时QALYs分别为0.809±0.046/ 0.821±0.040，差异无统计学意义。腹腔镜组在第1天的ICER为3138.76（元/QALYs）；第7天时的ICER为4301.8（元/QALYs）；敏感性分析得出腹腔镜组在第1天和第7天C/E变化影响最大的费用是材料费；临界值分析显示如果材料费下降到5082.32元或3752.68元时腹腔镜组和开放组分别在第1天和第7天的C/E相当。 结论腹腔镜腹股沟疝手术后第1天和第7天时患者生活质量要高于开放手术患者，在第15天时二者没有差异。腹腔镜手术治疗腹股沟疝虽然费用较高，但是对于提高生活质量来说是相对值得的。     

单孔腹腔镜疝高位结扎术在小儿隐匿疝治疗中的意义

【摘要】 目的〓评价单孔腹腔镜在小儿隐匿疝诊断及治疗中的价值。方法〓收集我院2008~2012收治的小儿腹股沟斜疝高位结扎术病例1864例,隐匿疝病例534例(28.6%),隐匿疝病例中采用单孔腹腔镜手术436例(腔镜组),传统开放手术98例(传统组)。通过隐匿疝的发现率,治疗总费用、住院天数及手术并发症统计和分析,评估腹腔镜诊治小儿隐匿疝的优势。结果〓单孔腹腔镜手术组与传统开放手术组在小儿隐匿疝发现率、治疗总费用、住院天数和手术并发症等方面的比较有显著性差异(P<0.05)。结论〓单孔腹腔镜行小儿疝高位结扎术不但能同时发现术前漏诊的对侧隐匿疝,并可同时手术治疗,避免了患儿再次手术的痛苦,减少了经济负担,具有传统开放手术不可比拟的优点。     

腹腔镜下疝囊高位结扎术与传统疝囊高位结扎术治疗小儿腹股沟疝的疗效

目的探究腹腔镜下疝囊高位结扎术与传统疝囊高位结扎术治疗小儿腹股沟疝的疗效。 方法选取2016年6月至2018年6月,亳州市人民医院106例腹股沟疝患儿的临床资料,随机分为腹腔镜组（53例）和传统手术组（53例）。传统手术组采用传统疝囊高位结扎术进行,而腹腔镜组采用腹腔镜下疝囊高位结扎术。比较2组患儿的手术情况、住院情况、并发症、隐匿性疝、对侧疝突出、复发情况。 结果腹腔镜组的手术时间、术中出血量、切口长度、术后下床活动时间及术后疼痛时间均低于传统手术组,差异有统计学意义（t=8.574、19.072、58.681、14.511、4.981,P均<0.001）。腹腔镜组住院费用（4 152.85±541.59）元高于传统手术组（3 860.71±459.72）元,差异有统计学意义（t=2.994,P=0.003）;腹腔镜组住院时间（2.07±1.12）d与传统手术组（2.14±1.49）d比较,差异无统计学意义（t=0.273,P=0.785）。腹腔镜组的并发症发生率为7.5%,低于传统手术组30.2%,差异有统计学意义（χ²=8.874,P=0.003）。术后腹腔镜组对侧疝突出的发生率低于传统手术组,差异有统计学意义（0比9.4%,P=0.003）;隐匿性疝发生率显著高于传统手术组,差异有统计学意义（17.0%比0,χ²=5.248,P=0.022）;2组间复发率比较,差异无统计学意义（0比3.8%,χ²=2.038,P=0.153）。 结论腹腔镜下疝囊高位结扎术治疗小儿腹股沟疝,手术效果较好,可有效缓解患儿术后疼痛,减少并发症的发生,帮助患儿迅速康复,降低医疗成本。     

小儿腹股沟疝腹腔镜疝囊高位结扎术与传统开放疝囊高位结扎术的临床疗效对比

目的：比较小儿腹股沟疝腹腔镜疝囊高位结扎术与传统开放疝囊高位结扎术治疗的临床疗效。方法回顾性分析我院2010年1月-2013年12月收治的200例小儿腹股沟疝病例的临床资料,其中100例（腹腔镜手术组）运用腹腔镜疝囊高位结扎术治疗,另100例（传统开放手术组）使用传统开放疝囊高位结扎术治疗,比较二者切口长度、手术时间、住院时间、住院费用、术后并发症、复发率等情况。结果腹腔镜手术组较传统开放手术组切口长度、手术时间、住院时间及并发症均明显减少,但住院费用高于传统开放手术组,差异有统计学意义（P均＜0.05）。结论腹腔镜疝囊高位结扎术的切口小,微创,手术时间短,术后恢复快,术后并发症少,较传统开放疝囊高位结扎术优势明显。     

单孔腹腔镜下大圆针体外二次缝合法治疗小儿腹股沟斜疝的疗效分析

目的探讨应用单孔腹腔镜下大圆针体外二次缝合法治疗小儿腹股沟斜疝的疗效。 方法2016年8月至2017年6月,南方医科大学附属何贤纪念医院收治且由同一手术团队治疗的小儿腹股沟斜疝患者共400例,均采用腹腔镜手术,分为观察组和对照组,其中观察组应用大圆针体外二次缝合法治疗小儿腹股沟斜疝208例,对照组应用大圆针及Endoclose腹壁缝合器治疗小儿腹股沟斜疝192例。回顾分析2组不同方法在手术时间、住院时间、住院费用、是否需要增加辅助钳、术中血管损伤、术后并发症及复发情况等。 结果2组患儿均顺利完成腹腔镜下疝囊高位结扎术,观察组和对照组在住院费用[单侧：（6.29±0.32）千元比（7.40±0.53）千元,双侧（8.85±0.65）千元比（9.60±0.38）千元]、是否需要增加辅助钳（106/208比48/192）方面比较,差异均有统计学意义（P均<0.05）;而手术时间、住院时间、术中血管损伤、术后并发症及复发情况差异无统计学意义（P均>0.05）。 结论单孔腹腔镜下大圆针体外二次缝合法行疝囊高位结扎术,操作简单、方便;无需"疝针"或腹壁缝合器即能完成手术,费用更低;而且该技术微创、安全,具有一定的临床推广价值。     

微型腹腔镜治疗小儿斜疝的探讨

目的探讨腹腔镜疝囊高位结扎术治疗小儿斜疝的应用价值。方法回顾分析腹腔镜手术及传统腹壁手术治疗的临床资料。结果腹腔镜手术组从手术时间、术中出血量、切口长度、住院时间、术后复发等方面明显优于传统手术组,差异有统计学意义(P<0.05)。结论腹腔镜手术具有创伤小、恢复快、住院时间短、术后不易复发、美容效果好等优点,是治疗小儿斜疝较理想的手术方式。     

微型腹腔镜在小儿腹股沟斜疝的临床应用(附139例报告)

目的介绍微型腹腔镜在治疗小儿腹股沟斜疝中的应用。方法使用微型腹腔镜配合改进的针形器械,缝扎疝囊内环口周边腹膜治疗小儿腹股沟斜疝139例。结果所有患儿术后经过顺利,术后无切口感染及血肿形成,无腹胀及排尿困难,术后1～2天可出院,平均住院时间3天,术后随访3个月至3年,未见复发及肠粘连发生。结论本手术方法较传统的开放手术具有切口和创伤小,操作简单,恢复快,术后无复发等优点,值得推广。     

腹腔镜手术治疗小儿腹股沟斜疝的价值

探讨腹腔镜手术治疗小儿腹股沟斜疝的手术方法及临床效果。选取2013年11月—2016年5月手术治疗的600例腹股沟斜疝患儿进行回顾性分析,其中300例采取腹腔镜手术治疗(腹腔镜组)、300例采取传统手术治疗(传统组),对比两组患儿的围手术期指标、手术效果。腹腔镜组的手术时间、手术出血量、术后下床活动时间、术后住院时间均显著低于传统组,差异有统计学意义(P<0.05);腹腔镜组的手术费用高于传统组,差异有统计学意义(P<0.05);两组患儿术前的各项肝功能指标、CRP水平差异均无统计学意义(P>0.05);术后24 h的ALT、AST、TP差异无统计学意义(P>0.05),腹腔镜组TBIL高于传统组(P<0.05),DBIL和CRP水平低于传统组(P<0.05)。腹腔镜手术治疗小儿腹股沟斜疝具有手术创伤小、恢复快、效果可靠的优点,但是手术费用较高,CO2气腹可能导致患儿血清TBIL、DBIL发生短暂性改变。     

腹腔镜完全腹膜外腹股沟疝修补术治疗原发性单侧腹股沟斜疝的临床研究

目的探讨腹腔镜完全腹膜外腹股沟疝修补术治疗原发性单侧腹股沟斜疝的临床的效果。 方法回顾分析2014年1月至2017年1月120例原发性单侧腹股沟斜疝患者资料,根据术式不同分为微创手术组和开放手术组,各60例。开放手术组患者使用传统的经正中线切口腹膜前腹股沟疝修补术进行治疗,微创手术组患者使用腹腔镜完全腹膜外腹股沟疝修补术进行治疗。采用SPSS18.0软件处理数据,两组患者各手术指标、疼痛评分等计量资料采用( ±s)表示,行独立t检验;并发症发生率等采用χ²检验;P<0.05差异有统计学意义。 结果微创手术组中患者并发症发生率少于开放手术组患者(P<0.05);两组患者手术时间无差异(P>0.05),微创手术组患者下床活动时间与住院时间均短与开放手术组患者(P<0.05),VAS评分优于开放手术组患者(P<0.05)。 结论应用腹腔镜完全腹膜外腹股沟疝修补术进行治疗效果显著,在临床上应该进一步推广应用。     

腹腔镜完全腹膜外疝修补术补片免固定方法的研究

目的:探讨腹腔镜完全腹膜外疝修补术(totally extraperitoneal,TEP)中补片免固定的临床应用价值及疗效。方法:回顾分析2009年1月至2013年3月采用补片免固定法腹腔镜TEP治疗86例腹股沟疝患者的临床资料(研究组),观察其手术方法、术式特点、补片免固定的疗效与价值及补片位置,并与同期开放疝环充填式(mesh-plug)疝修补术的92例患者(对照组)进行对比分析。结果:两组患者手术时间、阴囊血肿或积液例数、术后复发率差异无统计学意义(P>0.05),住院时间、一次性耗材费用、切口疼痛例数差异有统计学意义(P<0.05)。结论:补片免固定法腹腔镜TEP不仅适宜腹壁缺损小的疝,也可用于腹壁缺损≥4 cm的直疝、斜疝,其手术指征同疝环充填式疝修补术;多项临床指标优于疝环充填式疝修补术,是疼痛轻微、耗材费用低廉、复发率极低的理想术式。     

自制穿刺带线针辅助单孔腹腔镜疝囊高位结扎术治疗小儿腹股沟疝

目的:探讨自制穿刺带线针辅助单孔腹腔镜下疝囊高位结扎术中治疗小儿腹股沟疝的可行性与疗效。方法:回顾性分析2012年1月—2014年11月期间收治的47例小儿腹股沟疝患者资料,其中23例行自制穿刺带线针辅助单孔腹腔镜下疝囊高位结扎术(腹腔镜组),采用全身麻醉;24例行传统开放性疝囊高位结扎术(开放组),采用连续硬膜外麻醉。比较两组患者的相关临床指标。结果:腹腔镜手术均获成功,无中转开腹。与开放组比较,腹腔镜组手术时间缩短(8.26 min vs.36.54 min),术中出血量降低(0.63 m L vs.4.15 m L)、术后住院时间减少(1.39 d vs.3.75 d),但住院费用增加(6 682.18元vs.4 385.93元),差异均有统计学意义(均P0.05);腹腔镜组无术后并发症,开放组术后发生并发症5例,其中阴囊血肿3例,皮下血肿2例,两组总并发症发生率差异有统计学意义(0 vs.20.8%,P0.05)。两组随访期间均无复发病例。结论:自制穿刺带线针辅助下单孔腹腔镜治疗小儿腹股沟疝安全有效、具有微创、无明显瘢痕、并发症少等优点。     

Cost effectiveness of laparoscopic versus open mesh hernia operation: results of a Department of Veterans Affairs randomized clinical trial

BACKGROUND: Evidence comparing laparoscopic versus open hernia repair has varied with time and with changes in techniques used. Cost effectiveness is an important consideration when evidence for predominance of one surgical technique is lacking. Current cost estimates of hernia repair are not available. STUDY DESIGN: This study is a cost effectiveness analysis within a randomized controlled trial comparing open (OPEN) versus laparoscopic (LAP) hernia repair using mesh at 14 Department of Veterans Affairs medical centers, with 2-year followup for each patient. Between January 1999 and November 2001, 2,164 men with inguinal hernia were randomized and 1,983 had an operation; 1,395 patients (708 OPEN and 687 LAP) with outpatient hernia operations were included in the cost effectiveness analysis. Outcomes included surgical and postoperative costs, quality adjusted life years (QALY), and incremental cost per QALY gained or the incremental cost effectiveness ratio (ICER). RESULTS: Over 2 years, LAP cost an average of $638 more than OPEN. QALYs at 2 years were similar, resulting in $45,899 per QALY gained (95% CI: -$669,045, $722,457). The probability that LAP is cost effective at the $50,000 per QALY level (slightly more costly but more effective), was 51%. For unilateral primary and unilateral recurrent hernia repair, the probabilities that LAP is cost effective at the $50,000 per QALY level were 64% and 81%, respectively. For bilateral hernia repair, OPEN was less costly and more effective. CONCLUSIONS: Overall, laparoscopic hernia repair is not cost effective compared with open repair. For patients with unilateral (primary or recurrent) hernia, laparoscopic repair is a cost effective treatment option.     

Laparoscopic versus open retroperitoneal lymph node dissection: a cost analysis

PURPOSE: Laparoscopic retroperitoneal lymph node dissection is significantly less morbid than open retroperitoneal lymph node dissection but it is generally more costly due to longer operative time and disposable equipment. In response to budgetary pressure at our large county hospital we identified the cost components of laparoscopic retroperitoneal lymph node dissection that could be targeted to decrease procedure costs before expanding our laparoscopic retroperitoneal lymph node dissection program. MATERIALS AND METHODS: A comprehensive literature review of open and laparoscopic retroperitoneal lymph node dissection was performed and certain parameters were abstracted, including operative time and equipment, hospital stay, perioperative complications and surgical success rates. Using these data the projected overall cost and individual cost centers at our institution were compared for open and laparoscopic retroperitoneal lymph node dissection. Decision tree analysis models were devised to estimate the cost of each treatment using commercially available software. We performed 1 and 2-way sensitivity analysis to evaluate the effect of individual treatment variables on overall cost. Base case analysis involved a young man with clinical stage I nonseminomatous testicular cancer who was a candidate for retroperitoneal lymph node dissection. RESULTS: Based on a review of the costs at our institution open retroperitoneal lymph node dissection was a less costly procedure at $7,162 versus $7,804 for the laparoscopic approach. The slight cost superiority of the open approach was due to significantly lower costs associated with operating room time and equipment. On the other hand, the laparoscopic procedure showed a cost advantage for hospital stay. On 1-way sensitivity analysis laparoscopic dissection was less costly when operative time was less than 3.6 hours, hospitalization was less than 2.2 days or laparoscopic equipment costs were less than $768. On 2-way sensitivity analysis the laparoscopic approach was cost advantageous when performed in less than 5 hours or when the patient was discharged home within 2 days postoperatively. CONCLUSIONS: The primary cost variables for surgical treatment for testicular cancer include operative time, hospital stay and equipment cost. According to published data and decision tree analysis open retroperitoneal lymph node dissection is slightly less costly (less than $650) than laparoscopic retroperitoneal lymph node dissection for the surgical treatment of clinical stage I nonseminomatous testicular cancer at our institution. Our model identifies several measures that can be applied at any institution to render laparoscopic retroperitoneal lymph node dissection economically superior to the open approach.     

成人腹股沟疝合并隐睾治疗效果的多中心回顾性研究(附61例报告)

目的:分析成人腹股沟疝合并隐睾的治疗方案及效果。方法:回顾分析2013年1月至2017年12月三家医院手术治疗的61例腹股沟疝合并隐睾患者的临床资料及1年随访资料。结果:61例患者中,17例(27.9%)行腹腔镜手术(腹腔镜组),44例(72.1%)行开放手术(开放组),两组患者隐睾分型、术中出血量、术后住院时间、住院费用、切口疼痛、阴囊血肿、睾丸疼痛、睾丸萎缩、血清肿发生率差异无统计学意义,腹腔镜组手术时间长于开放组(P=0.031),睾丸切除率高于开放组(P=0.022),差异有统计学意义。结论:腹腔镜手术与开放手术治疗成人腹股沟疝合并隐睾可取得较好效果,各具优势,应在术前明确诊断的前提下,选择最佳手术方案。     

单孔腹腔镜全腹膜外操作与开放式腹股沟疝无张力修补术的对比研究

目的比较单孔腹腔镜全腹膜外操作与开放式腹股沟疝无张力修补术的临床治疗效果。方法回顾性分析我院2015年1月~2015年6月收治的50例男性单侧腹股沟疝患者的临床资料,年龄18~63岁,中位年龄37岁,所有患者均签署知情同意书,符合医学伦理学规定。患者术前均经超声及临床体格检查,确诊为腹股沟疝。21例行单孔腹腔镜全腹膜外腹股沟疝无张力修补术,29例行开放无张力疝修补术治疗,比较两种术式的手术时间、术中出血量、术后住院时间、术后并发症、术后24小时及慢性疼痛(1月以上)、总住院费用等临床疗效。结果单孔腹腔镜组手术时间、术中出血量、术后平均住院时间及术后24小时疼痛率显著低于开放组,差异有显著性(P0.05);而在总住院费用方面,开放式腹股沟疝无张力修补术组显著低于SILS-TEP组,差异有显著性,有统计学意义(P0.05);而二者在慢性疼痛(1月以上)和术后并发症方面没有显著性差异(P0.05)。结论采用单孔腹腔镜全腹膜外腹股沟疝无张力修补术的患者术后恢复较好,临床效果明显优于开放性无张力修补术。     

单孔腹腔镜疝囊高位结扎术在小儿腹股沟疝治疗中的应用

目的探讨单孔腹腔镜疝囊高位结扎术在小儿腹股沟疝治疗中的疗效及安全性。 方法选取2017年12月至2018年12月首都医科大学附属友谊医院平谷医院收治的小儿腹股沟疝患者94例,根据所行手术方式不同分为试验组及对照组,每组47例。试验组行切口腹腔镜疝囊高位结扎术,对照组行开放疝囊高位手术。比较2组临床疗效,统计2组手术时间、住院时间、下床活动时间、术中出血量及术后并发症发生率。 结果治疗后试验组总有效率为95.74%,显著高于对照组的80.85%,差异有统计学意义（P<0.05）;试验组患儿手术、住院及下床活动时间与对照组相比明显缩短,术中出血量与对照组相比明显降低（P<0.05）;术后试验组阴囊水肿及继发鞘膜积液等并发症发生率显著低于对照组（P<0.05）。 结论单孔腹腔镜疝囊高位结扎术治疗小儿疝可显著缓解患儿临床症状,改善患者手术指标的同时有效控制术后并发症,值得临床推广。     

经脐单部位腹腔镜治疗罕见儿童疝体会

目的探索经脐单部位腹腔镜手术在罕见儿童疝的临床应用。 方法回顾性分析2014年10月至2017年10月山西省儿童医院11例罕见疝患儿行腹腔镜手术的临床资料。其中男性患儿7例，女性患儿4例，年龄1～12岁。其中腹股沟滑疝5例，腹股沟直疝5例及股疝1例。 结果本组患儿均经脐单部位完成，手术时间20～39 min，无中转开放手术，均术后第2天出院。术后无切口感染、阴囊血肿发生。 结论经脐单部位腹腔镜手术治疗罕见小儿疝安全、微创、恢复快，值得推广应用。     

Comparison of institutional costs for laparoscopic preperitoneal inguinal hernia versus open repair and its reimbursement in an ambulatory surgery center

OBJECTIVE: To compare institutional costs for open versus laparoscopic inguinal hernia repair and its relationship to reimbursement in an ambulatory surgery center in the United States. METHOD: Analysis of institutional costs in US$ of 2006 for all nonreusables used in a laparoscopic total extraperitoneal (TEP) hernia repair using a polyester mesh compared with open hernia repair using polypropylene mesh. A comparison of the institution's disposable costs related to reimbursement at an ambulatory surgery center in Southeastern United States was performed to identify the most cost-effective procedure for the outpatient facility. RESULTS: As fixed and indirect costs of the ambulatory surgery center are similar for both procedures, a cost difference can only be found in direct disposable costs with that being US$ 235.57 for the procedure-specific disposables in the laparoscopic hernia repair as compared with US$ 117.15 for the open hernia repair. Cost for identical disposables used in both procedures amounted to US$ 32.57. Laparoscopic TEP hernia repair has a higher cost for procedure related disposables versus the open hernia repair at +US$ 118.42 mainly being due to the more costly polyester mesh. A flat rate reimbursement of US$ 1800 for a laparoscopic procedure compared with only US$ 950 for the open procedure minus all disposable cost results in a higher institutional income of +US&$ 731.58 (US$ 1531.86 vs. US$ 800.28), from which other institutional costs can be paid. CONCLUSIONS: Despite marginally higher procedure-related disposable costs for laparoscopic TEP hernia repair, the institutional income is remarkably higher owing to a better reimbursement for this procedure in ambulatory surgery centers. From the institution's point of view, laparoscopic hernia repair is by far the more cost-effective procedure when compared with an open hernia procedure at the present time.