Journal Scan: Are rigid endoscopy and laparoscopy worth the investment?

Does investing time and money into endoscopic and laparoscopic surgery add up to a win for small veterinary practices? (Shutterstock.com)Why they did it

Client demand for endoscopic and laparoscopic surgery is on the rise-especially for routine procedures like an ovariectomy (OVE) and a prophylactic gastropexy-thanks to their relative safety and their reduced pain, length of recovery and incidence of surgical site infections.

But there's a catch: The learning curve and costs associated with training and equipping a clinic to provide endoscopic and laparoscopic surgery are steep, which may be why they aren't widely used in practice. We veterinarians need to be convinced it's worth the investment.

This study sought to evaluate the economic and clinical feasibility of using rigid endoscopy and laparoscopy in small animal general practice by comparing investment costs with revenue generated during the first 12 months of use in a single small animal practice.

What they did

Over the course of one year, researchers followed the veterinarians in a two-veterinarian (one practice owner, one associate) small animal practice as they trained in rigid endoscopic and laparoscopic procedures and subsequently performed 78 endoscopic procedures. The researchers collected information about the animals from the owners, and the cost of training and equipment was evaluated in light of revenue, complications and client satisfaction. 

Study definitions:

Revenue: “The gross fees generated from the initial appointment and examination, the procedure (including anesthesia), hospitalization, analgesia, and related medications.”

Major intraoperative complications: “Complications necessitating conversion to an open procedure, blood transfusion, or reoperation.”

Minor intraoperative complications: “Any complications that did not require conversion or notable intervention such as blood transfusion.”

Postoperative complications: “Inflammation, incisional infection, seroma formation, herniation, or documented presence of an ovarian remnant after laparoscopic OVE.”

Neither veterinarian had any previous experience or training in endoscopy or laparoscopy. The practice-owning veterinarian completed two days of one-on-one, in-house training with a board-certified surgeon and was assisted by the surgeon in performing four laparoscopic procedures. The practice's associate veterinarian participated in two days of continuing education training at a separate training site and was assisted by the practice owner during her first five procedures.

All patients that underwent laparoscopic and endoscopic procedures during the year following the two veterinarians' training, including OVE, cryptorchidectomy, gastropexy, visceral biopsy, otoscopy, rhinoscopy, vaginoscopy and preputial exploration, were included in the study. All patient information-including history, signalment, surgery time and complications-were recorded, and intraoperative complications were categorized as major or minor.

What they found

Seventy-eight laparoscopic and endoscopic procedures were performed on 73 animals by the two veterinarians during the study period.

Surgery time: Forty-four laparoscopy OVE procedures were performed with a mean surgery time of 64 minutes (± 20 minutes). Thirty-four of these were performed by the practice owner with a mean time of 59 minutes (± 16.5 minutes). The veterinarians performed five laparoscopic OVE with prophylactic gastropexy procedures with a mean surgery time of 73 minutes (± 34 minutes) and 19 video-otoscopic procedures with a mean surgery time of 42 minutes (± 24 minutes).

Client satisfaction: Client follow-up, which was conducted at the time of the follow-up examination or by telephone, revealed that 49 of the 73 clients were satisfied with their pets' recovery. The other 24 clients were unable to be contacted. 

Costs: Primary equipment costs were just over $10,675 per year and were financed via a five-year lease. Other disposable items cost $995 for the year, and training required another $3,140. Total costs came to $14,810.

Revenue: The total amount of revenue generated from endoscopic and laparoscopic procedures during the year-long study period was $50,424.

Complications: The 54 laparoscopic surgical procedures resulted in 12 minor intraoperative complications. No major or postoperative complications were recorded.

More costs to consider:

Equipment sterilization and reprocessing has the potential to add substantial expense and is an important consideration when weighing the pros and cons of laparoscopy and endoscopy. In this study, single-use items were processed by a nearby hospital free of charge until a sterilizer (ethylene oxide) was purchased after the study for $6,000.

Take-home message

Results suggest that laparoscopic and endoscopic procedures were clinically and economically feasible in this small animal practice. Surgery times and complications were considered acceptable, and client satisfaction was high. Though the surgery times for laparoscopic OVE in this study were two to three times longer than the mean surgery time reported for board-certified surgeons performing the same procedure, this was attributed to the newly trained veterinarians' lack of experience. And although upfront costs and training are required, the procedures generated three times the direct costs associated with equipment and training.

According to this study, economic feasibility is dependent on four things: effective marketing, good client communication, appropriate pricing and frequent equipment use. If equipment is not used regularly, revenue can't be generated and skills can't improve. And because laparoscopic surgeries are more expensive, the researchers stressed the importance of good client communication and marketing to explain why minimally invasive procedures are superior to traditional open surgeries.

If you are considering using rigid endoscopy and laparoscopy in your practice, prudence is warranted. It requires thorough initial and ongoing training, and patient safety is of utmost importance. Complications associated with lack of training, inadequate equipment or inexperience aren't acceptable. When recommending procedures, fully inform clients of the potential risks versus benefits.

Jones K, Case JB, Evans B, et al. Evaluation of the economic and clinical feasibility of introducing rigid endoscopy and laparoscopy to a small animal general practice. J Am Vet Med Assoc 2017;250(7):795-800.

Link to abstract: https://www.ncbi.nlm.nih.gov/pubmed/28306484