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Computer-Aided Surgical Simulation in Head and Neck Reconstruction: A Cost Comparison among Traditional, In-House, and Commercial Options
Sean S. Li, BA1, Alexander J. Kaminsky, MD, MPH2, Libby R. Copeland-Halperin, MD2, Fahad K. Lodhi, BS1, Jihui Li, PhD2, Reza Miraliakbari, MD3.
1Virginia Commonwealth University, Richmond, VA, USA, 2Inova Fairfax Hospital, Falls Church, VA, USA, 3Private practice, Fairfax, VA, USA.

BACKGROUND: Computer-aided surgical simulation (CASS) has redefined surgery. Initially introduced in neurosurgery, CASS has improved precision and reduced the reliance on intraoperative trial-and-error manipulations. This can lead to improved outcomes and decreased morbidity compared to traditional surgical planning. CASS is provided by third-party services; however hospitals may develop in-house programs that may be more cost-effective. This study provides the first cost analysis and comparison among traditional (no CASS), commercial, and in-house CASS for head and neck reconstruction.
METHODS: The costs of three-dimensional (3D) pre-operative planning for mandibular and maxillary reconstructions were obtained from an in-house CASS program, as well as a commercial provider. Start-up costs were also obtained for our in-house CASS program. The personnel costs are based on ten cases per year for the early development of the program and reflect the learning curve (over-estimation).
Operative times are expressed as averages of the most common types of reconstructions performed by the senior author, with an effort to consider all levels of complexity (i.e. mandibular body reconstruction vs. near total mandibular or maxillary reconstruction).
A cost comparison was then performed among these modalities and extrapolated in-house CASS costs were derived. The calculations are based on CASS use in ten clinical cases annually.
RESULTS: Average sentinel operating room utilization time was estimated at ten hours, with an average of two hours of time saved with the use of CASS. The hourly cost for the use of the operating room at our hospital (including anesthesia and other ancillary costs) is estimated at \/hour.
Annual Costs for In-House CASS
Software (Mimics® Innovation Suite, Unigraphics NX9, and Rhinoceros) maintenance\,000
3D printer (3D Systems' ProJet® 3500) purchase (amortized over 10 years)\,590
Printer maintenance \,000
Personnel costs\,000
Total Annual Cost\,590

Cost Comparison
Expense per case (average)Traditional per caseCommercial per caseIn-house per case10 cases/year annual projection
Preoperative CASS planning\C:\inetpub\wwwroot\WebsiteHosting\NESPS\www.nesps.org\meeting\abstracts\2015\39.cgi\,039\,300
Operating room\,140\,912\,912
Total cost per case\,140\,951\,212
In-house CASS annual maintenance cost-\,590 (expense)
In-house savings comparisonVs. Traditional\,280
Vs. Commercial\,390

CONCLUSIONS: CASS minimizes the trial-and-error manipulations at the initial surgery, resulting in significant time savings in the operating room. Additionally, the precision allowed by CASS results in improved reconstructive outcome, better results, and fewer complications and operative revisions (whose cost savings are not reflected in this abstract). In comparing the in-house option to the traditional one, the program proves financially viable if performing at least ten cases per year (breaks even at \,000). In comparing the in-house option to the commercial option, assuming ten clinical cases per year, there is an added cost to the hospital of \,000. In light of comparable operative time between the in-house and commercial options, the in-house option will in time prove financially beneficial as the number of clinical cases move beyond 15 cases per year and the learning curve is mastered by all involved. In addition, there is the vast benefit of having the immediate availability of an institution's own unit, and not being limited by the commercial option's time restrictions and turnaround times. Our data demonstrate that hospitals performing greater than 10 cases of 3D head and neck reconstructions per year should consider developing an in-house CASS program.

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