The Benefits of a Dedicated Minimally Invasive
`Surgery Program to Academic General
`Surgery Practice
`
`Robert E. Glasgow, M.D., Kathy A. Adamson, Sean J. Mulvihill, M.D.
`
`In 2001, a dedicated minimally invasive surgery (MIS) program was established at a large university
`hospital. Changes included improvement and standardization of equipment and instruments, patient care
`protocols, standardized orders, and staff education. The aim of this study was to evaluate the impact of
`this program on an academic surgery practice. From January 1999 through October 2003, hospital and
`departmental databases were reviewed for all records pertaining to general surgery cases. Data trends
`were analyzed by regression analysis and are expressed as mean ⫾ SEM. In 1999, 15.0 ⫾ 0.1% of all
`general surgery cases were MIS cases compared with 30.2 ⫾ 0.1% in 2003 (P ⬍ 0.0001). During this
`period, the number of patients requiring conversion from a laparoscopic to an open approach decreased
`from 14.4% to 4.0% (P ⫽ 0.0007). In 1999, 30% of appendectomies were laparoscopic, compared with
`92% in 2003 (P ⬍ 0.0001). This increase in the rate of laparoscopic appendectomy resulted in a decrease
`in average length of hospital stay for all patients with acute appendicitis, from 5.5 ⫾ 1.0 days in 1999
`to 2.7 ⫾ 0.2 days in 2003 (P ⬍ 0.0001), and a decrease in total hospital cost per case, from $6569 ⫾ 400
`in 1999 to $4819 ⫾ 175 in 2002 (P ⬍ 0.001). Total operating room time per case for cholecystectomy
`decreased from 131 ⫾ 3.7 to 108 ⫾ 3.2 minutes (P ⬍ 0.0001), and actual surgery time decreased from
`95 ⫾ 4.1 to 74 ⫾ 4.0 minutes (P ⫽ 0.0006). Implementation of a dedicated MIS program resulted in a
`significant increase in the number of MIS cases and percentage of general surgery cases performed by
`MIS. This increase in the utilization of MIS resulted in reduced length of stay and cost and has
`been accompanied by improvements in operating room efficiency. Changes in practice associated with
`development of an MIS program have had measurable institutional benefits. (J GASTROINTEST SURG
`2004;8:869–873) 쑖 2004 The Society for Surgery of the Alimentary Tract
`
`KEY WORDS: Laparoscopy, program development, cost, volume
`
`The introduction of minimally invasive surgical
`(MIS) techniques to general surgical practice has rev-
`olutionized patient care. Although widely accepted
`as the standard of care in the management of many
`gastrointestinal disorders, such as gallstone and reflux
`disease, laparoscopic surgery is often viewed as inef-
`ficient and costly compared with open surgery. This
`perception is based on the acquisition cost of mini-
`mally invasive equipment, longer duration of surgery,
`and increased operating room expenditures. In addi-
`tion, the introduction of MIS to a hospital requires
`training of hospital staff and personnel. In an era of
`limited resources and cost containment, these issues
`
`dampen hospital enthusiasm for introducing new
`laparoscopic technology and procedures.
`Some evidence suggests that a dedicated MIS pro-
`gram provides improved operating room efficiency
`and surgical volumes compared with MIS performed
`outside the context of a dedicated program. For exam-
`ple, when comparing laparoscopic cholecystectomy
`performed by a dedicated MIS team compared with
`that performed without a trained team, decreased
`operative time, an improvement in patient care,
`and decreased costs to the patient have been ob-
`served.1,2 In the academic environment, the introduc-
`tion of a full-time director of MIS resulted in a 100%
`
`Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004
`(oral presentation).
`From the Department of Surgery, University of Utah, Salt Lake City, Utah.
`Reprint requests: Robert E. Glasgow, M.D., Department of Surgery, University of Utah, 30 North, 1900 East, Salt Lake City, UT 84132-
`2806. e-mail: robert.glasgow@hsc.utah.edu
`
`쑖 2004 The Society for Surgery of the Alimentary Tract
`Published by Elsevier Inc.
`
`1091-255X/04/$—see front matter
`doi:10.1016/j.gassur.2004.08.002 869
`
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`870 Glasgow et al.
`
`Journal of
`Gastrointestinal Surgery
`
`increase in laparoscopic surgery volume and an in-
`crease in MIS research and training.3
`Recognizing the importance of the current and
`future role of MIA in academic general surgical practice
`and resident training and the potential benefit to an
`academic institution in the form of improvements
`in patient care, a dedicated MIS program was estab-
`lished at a large university hospital in 2001. The aim
`of this study was to evaluate the impact of this
`program on an academic surgery practice, including
`surgical volumes and approaches, operating room ef-
`ficiency, and cost.
`
`MATERIAL AND METHODS
`Under the direction of a fellowship trained faculty
`member, changes were implemented to standardize
`and improve the MIS practice of a busy academic
`general surgery practice at a university hospital.
`Changes included improvement and standardization
`of equipment and instruments, patient care protocols,
`postoperative orders, and staff education. Instrument
`standardization included acquisition of new, reusable
`instruments and elimination of disposable instru-
`ments. In addition, imaging equipment was updated
`and made more available by increasing the number
`of towers. Changes in the surgical management of
`patients with acute appendicitis and symptomatic
`gallstones were studied to ascertain the impact of a
`dedicated MIS program on the practice of common
`general surgical operations. In addition, trends in the
`number of advanced laparoscopic gastrointestinal
`procedures were studied to ascertain the impact of
`this program on the referral practice within the insti-
`tution. These index procedures included laparoscopic
`small bowel, colon, esophageal, stomach, hepatic,
`pancreatic, adrenal, and spleen surgery. Hospital and
`departmental databases were reviewed for all records
`pertaining to general surgery cases performed from
`January 1999 through October 2003. Data trends
`were analyzed by regression analysis.
`
`RESULTS
`After the introduction of a dedicated MIS program
`in 2001, a dramatic increase in the number of mini-
`mally invasive operations was observed. The average
`monthly number of minimally invasive general sur-
`gery cases increased from 25 in 1999 and 2000 to 61
`
`Fig. 1. (A) Average number of minimally invasive surgery
`(MIS) cases per month by year. (B) Percentage of all general
`surgery cases done via a minimally invasive approach. Data
`are given as monthly mean ⫾ SEM; P ⬍ 0.0001 by regres-
`sion analysis.
`
`in 2003 (Fig. 1, A). In addition, the percentage of
`all general surgery cases performed via a minimally
`invasive approach increased from 15% in 1999 and
`2000 to nearly 30% in 2003 (Fig. 1, B). These trends
`were statistically significant
`(P ⬍ 0.001 by re-
`gression analysis).
`The impact of the dedicated MIS program on
`choice of operative approach and conversion rates
`were analyzed. In the case of appendectomy, a sig-
`nificant increase in the use of the laparoscopic ap-
`proach was seen after introduction of the program.
`Thirty-one percent of appendectomies were laparos-
`copic in 1999. By 2003, 92% were laparoscopic (Fig.
`2). This trend was highly significant (P ⬍ 0.0001). A
`significant increase in the number of index cases was
`also observed. In 1999, 37 advanced minimally inva-
`sive cases were performed. By 2003, the yearly
`number of the index cases had significantly increased
`to 145 per year (Table 1). This increase in the number
`of advanced laparoscopic cases included increases in
`the number of commonly performed operations and
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`Vol. 8, No. 7
`2004
`
`Benefits of Academic MIS Program Development
`
`871
`
`Fig. 2. Number of open (open) and laparoscopic (shaded)
`appendectomies by year. P ⬍ 0.0001 by regression analysis.
`
`Fig. 3. Ratio of conversion of laparoscopic to open cholecys-
`tectomy by year. P ⫽ 0.007 by regression analysis.
`
`the introduction of operations previously not per-
`formed at the institution. For example, the number of
`laparoscopic antireflux procedures increased more
`than two-fold from 34 in 1999 to 74 in 2003.
`Before 2001, all colectomies were open. With the
`introduction of the MIS program, the number of
`laparoscopic colectomies increased from 10 in 2002
`to 20 in 2003. Similarly, 31 laparoscopic esophageal,
`hepatic, gastric, and pancreatic operations were per-
`formed between fall of 2001 to fall of 2003. During
`this same period, a significant reduction was observed
`in the rate of conversion of laparoscopic to open
`cholecystectomies, from 14.4% in 1999 to 4.0%
`in 2003 (Fig. 3).
`Laparoscopic appendectomy was associated with a
`shorter length of hospital stay in any given year of
`the study (Fig. 4). Yearly average length of hospital
`stay ranged from 1.4 to 2.0 days for laparoscopic
`appendectomy and 3.2 to 5.5 days for open appen-
`dectomy. As the percentage of appendectomies per-
`formed by a laparoscopic approach increased between
`1999 and 2002, the average length of hospital stay
`for all patients with acute appendicitis decreased from
`5.5 days to 2.7 days (P ⬍ 0.0001). Similarly, a signifi-
`cant reduction in average total hospital costs for pa-
`tients with acute appendicitis was observed. The
`
`Table 1. Advanced minimally invasive cases per year
`
`Year
`
`1999
`2000
`2001
`2002
`2003
`
`No. of cases
`
`37
`37
`60
`96
`145
`
`Advanced minimally invasive surgical cases include esophageal, gastric,
`colon, small bowel, liver, pancreas, spleen, adrenal.
`
`average total cost was $6569 in 1999 compared with
`$4819 in 2002 (Table 2). Cost data were not available
`for the calendar year 2003.
`Changes implemented with the MIS surgery pro-
`gram included standardization and improvement of
`instruments and imaging equipment and training of a
`dedicated nursing and operating room staff. For
`laparoscopic cholecystectomy, average disposable in-
`strument costs decreased from $526 to $119 per case.
`These changes also resulted in significant
`im-
`provements in operating room efficiency. A signifi-
`cant reduction in overall operating room time and
`surgery times was observed. The mean ⫾ SEM op-
`erating room times for patients undergoing laparos-
`copic cholecystectomy decreased from 131 ⫾ 3.7
`minutes in 1999 to 108 ⫾ 3.2 minutes in 2003 (Fig.
`4). The mean ⫾ SEM surgical times decreased from
`95 ⫾ 4.1 minutes in 1999 to 74 ⫾ 4.0 minutes in
`
`Fig. 4. Average length of hospital stay by year for patients
`undergoing appendectomy by approach: all patients undergo-
`ing appendectomy (diamond line), patients undergoing lapar-
`oscopic appendectomy (square line), and patients undergoing
`open appendectomy (triangle line). Data are given as yearly
`mean ⫾ SEM; P ⬍ 0.001 by regression analysis for all patients.
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`872 Glasgow et al.
`
`Journal of
`Gastrointestinal Surgery
`
`Table 2. Appendectomy costs by approach
`
`Mean total hospital costs ($)
`Laparoscopic
`All patients*
`
`1999
`2000
`2001
`2002
`
`6569
`5662
`4646
`4819
`
`Not Available
`3318
`4086
`4224
`
`Data are yearly mean cost in U.S. dollars.
`*P ⬍ 0.001.
`
`Open
`
`6569
`5846
`4982
`6432
`
`2003. These trends were highly significant (P ⬍
`0.0001 and P ⫽ 0.006, respectively) (Fig. 5).
`
`DISCUSSION
`In the fall of 2001, a dedicated MIS program was
`established at a large academic, referral center.
`Changes instituted under the direction of a fellow-
`ship-trained program director included improvement
`and standardization of equipment and instruments,
`patient care protocols, standardized postoperative
`orders, staff education and establishment of a dedi-
`cated MIS operating room team, and limited market-
`ing on the part of the hospital and health plan. The
`implementation of this program has resulted in sig-
`nificant changes to the general surgery practice.
`Increases in the number of MIS cases and the per-
`centage of general surgery cases performed via a mini-
`mally invasive approach were observed. This was
`accompanied by an increase in the number of ad-
`vanced laparoscopic surgery cases not previously per-
`formed at the institution. These increases in case
`volume have previously been reported elsewhere.3 In
`addition, a significant change in the operative ap-
`proach to common diseases was observed. At the cur-
`rent time, more than 90% of appendectomies are
`
`Fig. 5. Mean ⫾ SEM operating room time (filled bar) and
`surgery time (open bar) for laparoscopic cholecystectomy by
`year. Both trends are significantly shorter, P ⬍ 0.001 by regres-
`sion analysis.
`
`performed via a laparoscopic approach, whereas less
`than one third were performed laparoscopically
`before development of the program. This represents
`an evolution in surgeon preference, likely in response
`to improvement in feasibility of laparoscopic appen-
`dectomy stemming from improvements in imaging,
`equipment, and staff training.4
`The increase in the use of a laparoscopic approach
`to common diseases such as appendicitis and more
`complicated advanced minimally invasive operations
`has also resulted in significant reductions in length
`of hospital stay and hospital cost. In this study,
`length of hospital stay was significantly shorter for
`patients with acute appendicitis treated laparoscopi-
`cally compared with those treated with an open ap-
`proach. As the use of laparoscopic appendectomy
`increased, the overall length of hospital stay for pa-
`tients with acute appendicitis decreased by 2.8 days,
`from 5.5 days in 1999, when the majority of appen-
`dectomies were open, to 2.7 days in 2003, when most
`appendectomies were laparoscopic. At our current
`volume of 140 appendectomies per year, this is a
`reduction of 392 patient-days per year, creating an
`opportunity for additional hospital admissions for
`other conditions. Similarly, a dramatic reduction in
`the total hospital costs associated with treating pa-
`tients with acute appendicitis has occurred. Average
`cost associated with the laparoscopic approach was
`significantly lower than cost for the open approach.
`As the percentage of patients treated via a laparos-
`copic approach increased, overall
`total hospital
`costs associated with the treatment of all patients with
`acute appendicitis decreased an average of $1750 per
`patient. This translates into a savings of $245,000
`per year for the institution. Further savings were gen-
`erated through the use of reusable instruments, the
`standardization of surgeon preference cards, and
`the use of patient care protocols.5,6
`In addition to savings resulting from decreased
`length of hospital stay and standardization of instru-
`ments, improvements in operating room efficiency
`and surgery times were observed. Others have re-
`ported similar improvements in operating room effi-
`ciency.1,7 At our institution, a 23-minute reduction
`in overall operating room time was observed be-
`tween 1999 and 2003. Most of this time savings
`resulted from a 21-minute reduction in average sur-
`gery times. At a current volume of approximately 350
`cholecystectomies per year and an operating room
`cost of $17 per minute, this translates into a poten-
`tial savings of $136,850 per year. As seen in other
`studies, we observed an added benefit of a dedicated
`minimally invasive team in a lower rate of open
`conversion.7,8
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`Vol. 8, No. 7
`2004
`
`Benefits of Academic MIS Program Development
`
`873
`
`These data may be criticized based on the retro-
`spective and unmatched nature of data collection and
`comparisons between open and laparoscopic ap-
`proaches. The purpose of this study was not to com-
`pare surgical approaches but rather to provide an
`analysis of the impact of program development on the
`overall practice of general surgery at our institution.
`The increased use of a laparoscopic approach to
`common diseases like appendicitis and gallstones has
`resulted in significant reductions in hospital stay and
`cost to the institution. Similar dramatic savings have
`been previously reported.6,7 In addition, improve-
`ments in patient outcomes with lower conversion
`rates and increased exposure of the surgical trainees
`to advanced laparoscopic procedures have occurred.
`At our institution, a dedicated MIS program is an
`asset and worthwhile investment for the academic
`surgery department and hospital.
`
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`
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