Laparoscopic vs Open Right Hepatectomy: A Value-Based Analysis Rachel L Medbery, MD, Tatiana S Chadid, MD, John F Sweeney, MD, FACS, Stuart J Knechtle, MD, FACS, David A Kooby, MD, FACS, Shishir K Maithel, MD, FACS, Edward Lin, DO, FACS, Juan M Sarmiento, MD, FACS BACKGROUND: Current literature lacks sufficient data on outcomes after extensive laparoscopic liver resec- tions. We hypothesized that laparoscopic right hepatectomy (LRH) is associated with better clinical outcomes and less overall hospital costs than open right hepatectomy (ORH), sup- porting the notion that major laparoscopic hepatic resections carry increased value when compared with the open approach. STUDY DESIGN: We reviewed medical records of all patients at our institution who underwent elective LRH (n ¼ 48) or ORH (n ¼ 57) from May 16, 2008 to March 1, 2012. Patient demographics, preoperative comorbidities, operative details, and postoperative outcomes were compared be- tween the 2 groups. Hospital billing data were collected for each case to determine the average hospital costs per case. RESULTS: Average operative duration, estimated blood loss, intravenous fluid resuscitation require- ments, high-grade postoperative complications, the need for postoperative admission to the ICU, and hospital length of stay were significantly less within the LRH cohort. Thirty-day mortality and readmission rates were equivalent between the 2 groups. Despite higher operative costs for LRH ($16,605 vs $10,411, p < 0.001), total postoperative costs were significantly less ($9,075 for LRH vs $16,341 for ORH, p < 0.001), resulting in equivalent overall costs ($25,679 for LRH vs $26,751 for ORH, p ¼ 0.65). CONCLUSIONS: Although overall costs between LRH and ORH are equivalent, clinical outcomes after LRH are comparable to those after ORH, supporting the value of laparoscopy in extensive right hepatic resections. Efforts to reduce operative costs of LRH, while maintaining optimal pa- tient outcomes, should be the focus of surgeons and hospitals moving forward. (J Am Coll Surg 2014;218:929e939. Ó 2014 by the American College of Surgeons) To date, only 2 relatively small case-controlled, non- randomized, comparative studies have evaluated postoper- ative outcomes comparing minimally invasive right hepatectomy vs an open approach. 1,2 The data suggest that the laparoscopic approach in major hepatic resections is associated with less bleeding and fewer transfusion requirements, lower frequency of postsurgical complica- tions, and reduced intensive care and postoperative length of stay. Although such data support the role of laparoscopy as a safe and efficient procedure when performed by highly specialized surgeons in centers with extensive experience, studies with greater numbers of cases are needed to confirm the role of a laparoscopic approach to major liver resection. Furthermore, given the current state of health care reform and emphasis on improving quality while cutting costs (therefore increasing value), it is necessary to analyze whether or not laparoscopic liver surgery is associated with potential cost savings. Two recent studies investigated the cost-effectiveness of laparoscopic liver resection. 3,4 Although the results of these 2 studies are promising, there are currently no data regarding the financial impact of the laparoscopic approach in major liver resections. This study aimed to compare the clinical and economic impact of laparoscopic right hepatectomy (LRH) vs open right hepatectomy (ORH) in both benign and malignant conditions. We chose right hepatectomy because it is the most commonly performed major liver resection, it is well standardized and reproducible (open approach), and it Disclosure Information: Nothing to disclose. Received October 23, 2013; Revised December 30, 2013; Accepted January 7, 2014. From the Divisions of General and Gastrointestinal Surgery (Medbery, Chadid, Sweeney, Lin, Sarmiento), Transplantation (Knechtle), and Surgi- cal Oncology (Kooby, Mathiel), Department of Surgery, Emory University School of Medicine, Atlanta, GA. Correspondence address: Juan M Sarmiento, MD, FACS, Department of Surgery, Emory University School of Medicine, 1365 Clifton Rd, Suite A5039, Atlanta, GA 30322. email: jsarmie@emory.edu 929 ª 2014 by the American College of Surgeons ISSN 1072-7515/14/$36.00 Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jamcollsurg.2014.01.045