Presidential address. Endoscopic surgery, cost effectiveness, and the quality of life.

One measure of mitigating escalating costs of health care is to create an economic market-based system that connects value to cost. Cost-effectiveness analysis compares treatments that produce different benefits and require different costs, and ranks them by the amount of net treatment benefit divided by cost. Evaluation of the impact of illness and treatment on the medical condition, quality of life, and productivity of individual patients is essential for capturing all dimensions of treatment outcome. When performed by efficient teams, laparoscopic surgery compared with conventional open surgery, adds value through reduced operative morbidity, earlier returns to work, and improved quality of life. These advantages have to be confirmed by cost-effectiveness analysis, however. Endoscopic surgery will be consistently more cost effective than conventional surgery only when performed by a dedicated team of surgeons, nurses, and technicians. The need for a specialized team arises from the fact that endoscopic surgery requires different skills, including the ability to develop a two-dimensional concept for tissue manipulation, perform major surgery through small incisions using a different type of hand-eye coordination, and operate and maintain highly sophisticated and sensitive equipment and instrumentation. Reusable instruments will contribute to lower costs.