Cost-reductive measures in laparoscopy: Tips and tricks for developing countries

The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, or economic or social condition. (Constitution of the World Health Organization1) With major advances in the early 1980s due to the invention of the television-chip camera that allowed surgeons to operate with both hands, laparoscopic surgery has rapidly established itself and experienced unprecedented growth in well-developed countries. Urologists were ready for this revolution because of the endoscopic skills already acquired with transurethral surgery. Laparoscopic urologic surgery had an impact on minimizing morbidity and decreasing convalescence, which are essential to patient care. However, the spread of laparoscopy in third world countries has been hindered by the difficult management of hospital structures, insufficient medical and paramedical staff training, and, most importantly, limited financial resources. The "cost-effectiveness" of laparoscopy versus open surgery has been investigated in many studies.2,3 However, the evidence is inconclusive on whether or not laparoscopic surgery results in lower costs for the health-care system. Although laparoscopy does reduce hospital stay and periods of sick leave, laparoscopic operations cost more than open surgeries from the hospital's point of view. This is due to the initial investment in instruments and longer duration of operating and anesthesia times. Owing to these direct costs, some urologists in developing countries may encounter resistance from their hospitals regarding these start-up expenses. However, as laparoscopic skills are developed and assisting paramedical staff gain more experience, operating times are significantly reduced. In addition, with a steady increase in the number of cases performed, investment in reusable instrumentation may be an opportunity for cost-saving per case for the hospital. Out of sheer economic necessity, several cost-effective measures have emerged around the developing world aimed at reducing the costs of laparoscopic procedures. Expensive disposable instrument usage is kept to a minimum, and ordinary materials at hand are modified to serve new purposes. By working around the limits and restrictions of the tools available in the operating room, the gifted surgeon can take the least expensive tool and perform a certain task better than others using expensive disposable instruments. This chapter reviews reported tips and tricks that will reduce the costs of consumables, and may help urologists in developing world bring minimally invasive surgery into their everyday practices.