Thursday, April 29, 2004

Both Medpundit and Medrants have recently posted on this study published in this weeks New England Journal of Medicine. From the Medscape synopsis:

Of 2,164 men with inguinal hernias enrolled from one of 14 VA medical centers and randomized to open or laparoscopic repair, 1,983 had surgery, and 1,696 (85.5%) completed two-year follow-up.

There were recurrences in 87 (10.1%) of 862 patients in the laparoscopic repair group and in 41 (4.9%) of 834 patients in the open repair group (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.5 - 3.2). Complications occurred in 39.0% of the laparoscopic repair group and in 33.4% of the open repair group (adjusted OR, 1.3; 95% CI, 1.1 - 1.6).

However, the laparoscopic repair group fared better than the open repair group in terms of pain on a visual analog scale on the day of surgery (difference in mean score, 10.2 mm; 95% CI, 4.8 - 15.6) and at two weeks (6.1 mm; 95% CI, 1.7 - 10.5), and they returned to normal activities one day earlier (adjusted OR, 1.2; 95% CI, 1.1 - 1.3).

My thoughts:
I reserve laparoscopic inguinal hernia repair for two types of patients: bilateral hernias and recurrences. The rationale for bilateral hernias is that the discomfort can be severe after a bilateral open repair. Re-do hernias benefit from laparoscopy due to the posterior approach used, avoiding the scarring from the previous operation, hopefully minimizing the potential for nerve or vas deferens injury. An open preperitoneal technique has also been described. The only time I have done a primary laparoscopic inguinal hernia was on a patient that also had a ventral hernia that was repaired laparoscopically. It recurred.

The widespread use of mesh has become a great equalizer in the repair of hernias. Used to be if you wanted a very low recurrence rate you had to go to a place like the Shouldice hospital where all they did were herniorraphies. Now using the plug-and-patch method described by Rutkow and Robbins, I have a known recurrence rate of less than 1 percent. I call it a "known recurrence" rate because in private practice, unlike in a study, a patient may go find another surgeon if they do recur.

I tend to hold laparoscopic inguinal hernia repair in the same regard as laparoscopic appendectomy, a procedure that is very good and possibly better than the open technique under certain circumstances. Outside of those circumstances, however, laparoscopy brings on additional expense and potential complications with minimal improvement over the open procedure.
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