1. Important questions As good or better ? Cost effective ? Overall, safer? Is it safe as a cancer operation? Can all surgeons do it? Compare to open surgery or alternative treatments Need evidenced based studies

2. Important questions Compare to open surgery or alternative treatments Appendectomy Hernia repair Colon operations GORD Bariatric operations Evidence based studies

3. Appendectomy-Laparoscopic versus Open Summary of 4 Meta-analyses Earlier recovery 4 Less pain 3 Less wound infection 4 advantages disadvantages More intra-abdominal infection 4 Longer operation & higher cost 3

4. Appendectomy Prospective randomised trail openlaparoscopic (113) operation time (min) time to solids (h) analgesics hospital stay (days) complications activity score 60 38 2(1-5) 3 21 80 27 2(1-4) 2(2-4) 23 Katkhouda et al: 2005 (134) equal P< 0.000

5. appendectomyPlace for laparoscopic Young women where the diagnosis - is in question Obese patients cosmetic considerations? Conclusion

6. Inguinal hernia mesh repair Prospective randomized trail laparoscopicopen (862) (834) Complications intra-operative post-operative recurrence at 2 yrs post op pain return to work 4.8% 24.6% 10% < 2wks < 1 day 1.9% 19.4% 5% - Neumayer et al : NEJM 2004 0R 2.6 1.4 2.2

7. Inguinal hernia repair AES & NICE ( National Institute for Clinical Excellence ) Recommendations Primary repair - open mesh Recurrent and bilateral hernias - consider laparoscopic repair Laparoscopic technique – TEP Adequate training

8. Colon Surgery - laparoscopic versus open Current opinion - Level I evidence No difference hospital stay recurrence and disease free survival long-term survival morbidity and mortality Laparoscopic operation time is longer More costly

9. Laparoscopic Colon Surgery Possible role Right and sigmoid colectomy Reversal of Hartmann’s colostomy Raising of colostomy Repair of rectal prolapse

10. Laparoscopic versus Open (3 randomised trails) Compared to open Operation time (longer) 2 Less pain 2 Shorter hospital stay 2 Significant Fundoplication Early experience

11. Gastroesophageal reflux disease L Lundell et al – American College of Surgeons 2001 Medical therapy versus antireflux surgery

12. Scandanavian *Myrvold et al USA Di Re et al Netherlands Van den Boom et al Finland Viljakka et al Cost analysis *Randomised trial Gastro - esophageal reflux disease Period (yrs) Medical Fundoplication 5 years 1 year 4 years 15 months = advantage 5 1 4 1.3

13. Medical or Surgical Therapy for Erosive Reflux Esophagitis Cost-Utility Analysis Using A Markov Model Medical Surgical Romagnuolo et al Ann Surg 2002 5% surgical recurrence

14. Patients 83 of 142 response Mean follow-up 20 months Complete satisfaction 57% New GI symptoms 67% Continue antacids 27% Repeat surgery 7% Laparoscopic fundoplication outcome in community practice USA - Milwaukee N Vakil (abstract)

15. Missed fundic perforation

16. Medical therapy mostly predictable Surgical results are variable - complications - recurrence rate Hidden costs - eg. loss of work “Eye of the beholder” - medical / surgical bias - insurers GORD - medical vs surgical therapies Problems with cost analysis