inguinal herniorrhaphy is one of the most common elective procedures performed worldwide . in the united states , an estimated 800,000 inguinal hernia repairs are performed each year , accounting for 10% to 15% of all surgical procedures . however , there continues to remain controversy surrounding the optimal surgical management of this condition . several studies have validated the clinical utility of laparoscopic inguinal herniorrhaphy and have demonstrated comparable short - term safety and long - term efficacy relative to the open approach . given increasing fiscal constraints , procedural cost - effectiveness has become an important metric in evaluating surgical procedures . although several studies have demonstrated higher costs associated with laparoscopic inguinal herniorrhaphy , others have successfully reported cost - containment strategies in laparoscopic surgery . given that elective inguinal hernia repairs are most often ambulatory procedures , the direct operating room ( or ) expense predominates as the driving factor in the total cost of care . therefore , the objective of this study was to compare the or and total hospital costs associated with laparoscopic versus open inguinal herniorrhaphy performed at a publicly funded , tertiary academic institution . using a prospectively maintained database , all patients undergoing elective open or laparoscopic inguinal hernia repair between april 2009 and march 2011 at the toronto western hospital , university health network , were identified . open inguinal herniorrhaphy was performed using a standardized lichtenstein repair with either a polypropylene or a polyester mesh . a retrospective review of electronic patient records was performed , along with a standardized case - costing analysis using data from the ontario case costing initiative . laparoscopic mesh repair varied by surgeon preference between a standardized transabdominal preperitoneal ( tapp ) and a total extraperitoneal ( tep ) approach . as part of a local cost - awareness strategy , permanent trocars are preferentially used . monetary values are shown in canadian dollars and were converted to 2012 values using consumer price index inflationary adjustments . secondary outcomes included perioperative complications , 30-day hospital readmission , and 30-day emergency department visits . short - term perioperative complications included early recurrence , surgical site infection , seroma and hematoma formation , and urinary retention . statistical analysis was conducted using spss version 21 ( spss , inc , chicago , illinois ) . continuous variables are expressed as means or medians and were compared using t tests , analysis of variance , or mann - whitney u tests as appropriate . categorical variables are expressed as proportions and were compared using either  or fisher exact tests . the university health network case costing department ( ccd ) is responsible for capturing costs ascribed to each patient 's hospital visit . the university health network subsequently reports this information at regular intervals to ensure fiscal responsibility and fiduciary control . the total cost of care is recorded under the patient 's unique medical record number and a specific hospital visit number . the total cost per patient visit ( from preadmission to discharge ) is an aggregate of individual departmental costs ; for the purposes of this study , departmental costing centers were grouped as appropriate and termed  hospital departments . specific visit numbers relating to patients undergoing elective inguinal herniorrhaphy were used to retrieve costing information from the ccd . , total direct cost is calculated on the basis of the consumption of resources , including supplies , medications , investigations , food , and lodging expense . each or has a computerized dispensing cabinet that itemizes supplies used during each case and allocates cost to a specific patient procedure ( pyxis procedurestation system ; cardinal health , dublin , ohio ) . all pharmaceuticals throughout the hospital are dispensed by a similar system ( pyxis medstation system ; cardinal health ) . personnel cost data were based on budgetary statements provided by individual hospital departments to the ccd . personnel cost includes the wages ( compensation and benefits ) of the nursing , paramedical , and administrative staffs . approach by dividing total costs by the number of patients admitted on any given day . these costs are subsequently reported in the ccd figures as the  indirect costs  associated with specific hospital visits . additional overhead expenses , such as heating costs , are derived by dividing total costs by ward square footage and the number of admitted patients . equipment ( including maintenance ) , facilities , and other global expenses ( including information technology infrastructure ) were included in departmental budgets . physician fees are separately reimbursed by the ontario ministry of health and were not recorded in this study . furthermore , postdischarge care , follow - up , readmission , and potential loss of income were not included in this analysis . all costs were adjusted for inflation to 2012 canadian dollars according to the bank of canada 's inflation calculator . the university health network case costing department ( ccd ) is responsible for capturing costs ascribed to each patient 's hospital visit . the university health network subsequently reports this information at regular intervals to ensure fiscal responsibility and fiduciary control . the total cost of care is recorded under the patient 's unique medical record number and a specific hospital visit number . the total cost per patient visit ( from preadmission to discharge ) is an aggregate of individual departmental costs ; for the purposes of this study , departmental costing centers were grouped as appropriate and termed  hospital departments . specific visit numbers relating to patients undergoing elective inguinal herniorrhaphy were used to retrieve costing information from the ccd . , total direct cost is calculated on the basis of the consumption of resources , including supplies , medications , investigations , food , and lodging expense . each or has a computerized dispensing cabinet that itemizes supplies used during each case and allocates cost to a specific patient procedure ( pyxis procedurestation system ; cardinal health , dublin , ohio ) . all pharmaceuticals throughout the hospital are dispensed by a similar system ( pyxis medstation system ; cardinal health ) . personnel cost data were based on budgetary statements provided by individual hospital departments to the ccd . personnel cost includes the wages ( compensation and benefits ) of the nursing , paramedical , and administrative staffs . approach by dividing total costs by the number of patients admitted on any given day . these costs are subsequently reported in the ccd figures as the  indirect costs  associated with specific hospital visits . additional overhead expenses , such as heating costs , are derived by dividing total costs by ward square footage and the number of admitted patients . equipment ( including maintenance ) , facilities , and other global expenses ( including information technology infrastructure ) were included in departmental budgets . physician fees are separately reimbursed by the ontario ministry of health and were not recorded in this study . furthermore , postdischarge care , follow - up , readmission , and potential loss of income were not included in this analysis . all costs were adjusted for inflation to 2012 canadian dollars according to the bank of canada 's inflation calculator . one hundred twenty - six patients ( 51.6% ) underwent open inguinal herniorrhaphy , while 118 ( 48.4% ) underwent laparoscopic repair . among the laparoscopic cases , 94 patients ( 79.7% ) underwent tapp repair , while 24 ( 20.3% ) were treated using the tep technique . patients undergoing laparoscopic hernia repair were younger ( mean age , 55 vs 66 years ; p < .001 ) and had lower american society of anesthesiologists classes ( p < .001 ) . a significantly higher proportion of patients undergoing open surgical repair had histories of abdominal surgery ( 67.5% vs 46.6% , p < .001 ) . bilateral inguinal hernia repair was preferentially performed using a laparoscopic approach ( 72.7% vs 27.3% , p = .002 ) , and all hernias diagnosed as bilateral had both sides operated during the same procedure . all laparoscopic inguinal herniorrhaphies were performed under general anesthesia , compared with 42.9% of open cases . twenty - three patients undergoing open inguinal herniorrhaphy required postoperative admission , compared with 2 patients in the laparoscopic cohort ( p = .025 ) . one case was converted from laparoscopic ( tapp technique ) to open repair because of significant small bowel adhesions . during the study period patients in the laparoscopic group had a longer median or time of 101 minutes compared with 84 minutes for open repairs ( p < .001 ) . total hospital costs ( from preadmission to discharge ) for open unilateral inguinal herniorrhaphy were significantly lower than for the laparoscopic approach ( median total cost , $ 3207.15 and $ 3723.66 , respectively ; p < .001 ) . this difference in total costs was driven primarily by the or costs associated with the laparoscopic approach ( median or cost , $ 2399.49 and $ 3092.03 , respectively ; p < total hospital costs for repair of elective bilateral inguinal hernias were similar between the open and laparoscopic approaches ( median total hospital cost , $ 4574.02 vs $ 4662.89 ; p = .827 ) ( table 4 ) . cost for unilateral inguinal herniorrhaphy iqr , interquartile range ; or , operating room ; pacu , postanesthesia care unit . cost for bilateral inguinal herniorrhaphy iqr , interquartile range ; or , operating room ; pacu , postanesthesia care unit . when comparing unilateral and bilateral hernia repair within the laparoscopic cohort , there was no statistical difference in the cost ( either or or total episode of care ) between the tapp and tep techniques . further to the operative approach , the use of general anesthesia was associated with an increased cost compared with other types of anesthesia ( local or regional ) ( p < .0001 ) . in this study , we systematically reviewed the or and total hospital costs involved with the treatment of inguinal hernias and , specifically , compared the costs associated with an open versus a laparoscopic approach . our results demonstrate that or and total hospital costs for open unilateral inguinal hernia repair were significantly lower than for the laparoscopic approach . however , or and total hospital costs for repair of bilateral inguinal hernias were similar between the 2 groups . the results of this analysis are comparable with those from other centers in the united states . khajanchee et al showed a $ 795 incremental cost associated with the tep approach relative to an open lichtenstein repair . similarly , schneider et al found the total cost of laparoscopic herniorrhaphy to be higher than for the open approach ( $ 2,861 vs $ 2,009 ) . combined with the current analysis , these studies suggest that the total cost of each procedure may be independent of local economic factors and may be directly attributable to surgical technique . however , the perioperative benefits of laparoscopy are significant . several studies have demonstrated enhanced recovery after surgery , shorter lengths of stay , and fewer perioperative complications associated with a minimally invasive approach . as such , the incremental value associated with laparoscopic repairs of unilateral hernias may justify the increased relative cost ( $ 453.51 ) . further studies using hernia - specific outcomes are necessary to understand the economic utility and cost - effectiveness of each approach . in addition , the calculation of total hospital cost does not address the out - of - hospital expenses incurred by the patients . furthermore , the indirect and societal costs associated with patient suffering , loss of productivity , and caregiver expense are difficult to quantify . further studies are needed to evaluate the total societal cost associated with inguinal hernia repairs to determine the cost - effectiveness of each strategy . a methodological limitation in the cost analysis is related to the institutional segmentation of expenses . or costs are clustered as an aggregate of all expenses incurred in the or . as such , with the current accounting system , it is difficult to distill the material contribution of operative time , general anesthesia , or equipment costs to the total expense . a refined case - costing system may provide additional insight into each component of patient care and highlight opportunities for efficiency . in the setting of a canadian tertiary academic hospital , the or and total hospital costs of open inguinal herniorrhaphy were significantly lower than for the laparoscopic approach . however , there was no statistical difference between or and total hospital costs when comparing open surgical and laparoscopic techniques for repair of bilateral inguinal hernias . given the perioperative benefits of laparoscopic surgery , further studies incorporating hernia - specific outcomes are necessary to determine the cost - effectiveness of each approach and to define the optimal treatment strategy .