Cost analysis of four surgical techniques for pediatric inguinal hernia repair in a Dutch hospital

• PIRS was associated with the lowest OR cost compared to the other three techniques. • Robot-assisted IHR incurred the highest costs, which is most likely due to due to prolonged anesthesia time, caused by the docking of the robotic system. • Non-OR costs were significantly influenced by patient characteristics, such as gestational age, incarceration, and recurrence. Pediatric inguinal hernia repair (IHR) can be performed using open repair, laparoscopic approaches such as percutaneous internal ring suture (PIRS) or conventional laparoscopic IHR (LIHR) with N-/Z-suture, and robot-assisted IHR (RIHR). While extensive literature on clinical outcomes exists, cost data remain scarce. This study aims to determine the real costs of these four techniques. A retrospective cohort of consecutive patients with pediatric IHR in the past five years (2019–2023) was analyzed. Patients were grouped by technique. Individual one-year costs were collected, including pre-operative, per-operative, postoperative and complication costs. Kruskal-Wallis test was performed to compare costs between techniques. Multivariable-adjusted linear regression analyses were performed to identify factors associated with (non-OR) costs. 184 patients were included in four groups: PIRS (n= 56), LIHR (n=56), Open (n=50), RIHR (n=22). Total OR cost for PIRS were significantly lower than for the other laparoscopic techniques (€1915 vs. €2414 for LIHR; p=0.001 and €3340 RIHR; p=0.000), but not for the open technique (€1915 vs. €1971; p=1.000). They were the highest for RIHR, probably due to prolonged anesthesia time, which is explained by docking of the robotic system. Other costs of the treatment journey (excluding OR costs) were significantly associated with gestational age (4.2% increase per week the patient was born earlier; p=0.001), age at surgery (7% increase per year the patient was younger; p=0.001), reducible incarceration (40.7% increase; p=0.037) and recurrence (124.5% increase; p=0.001). Hospitalization costs were significantly higher for the open technique (38.8% increase; p=0.030). This retrospective analysis shows that the PIRS technique is related to lower OR costs. Other (non-OR) costs are highly dependent on patient characteristics and clinical outcomes. Prospective randomized studies are needed to confirm these findings and guide optimal decision making concerning surgical technique with an adequate cost-effectiveness study.