Laparoscopic Versus Open Major Hepatectomy: Analysis of Clinical Outcomes and Cost Effectiveness in a High-Volume Center.

BACKGROUND: Considering the increasing evidence on the feasibility of laparoscopic major hepatectomies (LMH), their clinical outcomes and associated costs were herein evaluated compared to open (OMH).

METHODS: Major contributors of perioperative expenses were considered. With respect to the occurrence of conversion, a primary intention-to-treat analysis including conversions in the LMH group (ITT-A) was performed. An additional per-protocol analysis excluding conversions (PP-A) was undertaken, with calculation of additional costs of conversion analysis.

RESULTS: One hundred forty-five LMH and 61 OMH were included (14.5% conversion rate). At the ITT-A, LMH showed lower blood loss (p < 0.001) and morbidity (global p 0.037, moderate p 0.037), shorter hospital stay (p 0.035), and a lower need for intra- and postoperative red blood cells transfusions (p < 0.001), investigations (p 0.004), and antibiotics (p 0.002). The higher intraoperative expenses (+ 32.1%, p < 0.001) were offset by postoperative savings (- 27.2%, p 0.030), resulting in a global cost-neutrality of LMH (- 7.2%, p 0.807). At the PP-A, completed LMH showed also lower severe complications (p 0.042), interventional procedures (p 0.027), and readmission rates (p 0.031), and postoperative savings increased to - 71.3% (p 0.003) resulting in a 29.9% cost advantage of completed LMH (p 0.020). However, the mean additional cost of conversion was significant.

CONCLUSIONS: Completed LMH exhibit a high potential treatment effect compared to OMH and are associated to significant cost savings. Despite some of these benefits may be jeopardized by conversion, a program of LMH can still provide considerable clinical benefits without cost disadvantage and appears worth to be implemented in high-volume centers.