Correspondence
Conventional versus Laparoscopic Surgery for Inguinal-Hernia Repair
N Engl J Med 1997; 337:1089-1090October 9, 1997
- Article
To the Editor:
The study by Liem et al. (May 29 issue)1 comparing laparoscopic surgery with conventional surgery for inguinal-hernia repair demonstrated an advantage of laparoscopic repair in terms of recurrences and recovery. However, only 3 percent of the patients in the conventional-surgery group underwent open, tension-free repairs with mesh prostheses. This type of operation has become widely used in recent years by many surgeons and has a more favorable outcome than the classic Bassini open technique or its modifications. For example, of 3480 patients with primary inguinal hernias repaired with an open, tension-free method and with the use of polypropylene mesh, only 5 (0.1 percent) had recurrences during a mean follow-up period of 5.5 years.2 In other large series (involving over 1000 patients), the recurrence rates were 0.6 percent or less during follow-up periods of up to six years.3,4
Furthermore, because large numbers of patients undergo inguinal-hernia repairs each year, the surgical technique should be a simple one. The results of repairs with the use of the tension-free technique have been excellent when the procedure has been performed by general surgeons with no special interest in hernia repairs,5 whereas the laparoscopic procedure involves a longer learning curve; it also requires special and more expensive instrumentation. An additional important issue is that the tension-free, open repair can be done with local anesthesia, with all the advantages that entails.3 We believe that the conclusions of Liem et al. should be evaluated cautiously in view of the well-documented better results of the open, anterior, tension-free operation for inguinal hernias.
5 ReferencesShmuel Avital, M.D.
Nahum Werbin, M.D.
Tel Aviv Sourasky Medical Center, Tel Aviv 64239, Israel1
Liem MSL ,van der Graaf Y ,van Steensel CJ , et al. Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair. N Engl J Med 1997;336:1541-1547
Full Text | Web of Science | Medline2
Amid PK ,Shulman AG ,Lichtenstein IL . Open “tension-free“ repairof inguinal hernias: the Lichtenstein technique. Eur J Surg 1996;162:447-453
Medline3
Kark AE ,Kurzer M ,Waters KJ . Tension-free mesh hernia repair: review of 1098 cases using local anaesthesia in a day unit. Ann R Coll Surg Engl 1995;77:299-304
Web of Science | Medline4
Wantz GE . Experience with the tension-free hernioplasty for primary inguinal hernias in men. J Am Coll Surg 1996;183:351-356
Web of Science | Medline5
Shulman AG ,Amid PK ,Lichtenstein IL . A survey of non-expert surgeons using the open tension-free mesh patch repair for primary inguinal hernias. Int Surg 1995;80:35-36
Web of Science | Medline
To the Editor:
Liem et al. report better results of hernia repairs with the laparoscopic procedure than with open procedures without the use of mesh. Of the 87 surgeons who performed open hernia repairs, 23 also performed laparoscopic repairs. Many of those who did the open repairs were less experienced and needed supervision. This difference in itself may explain the similar operation times in the two groups and the higher rates of recurrence after open repairs.
The authors defined the operation time as the time from the first incision to the placement of the last suture. No account is given of the operating-room revenue lost because of the time necessary to set up for the laparoscopic procedure, or of the time lost because of mechanical failure of the laparoscopic instruments or the switch to another surgical technique, especially in the eight patients who had peritoneal tears during laparoscopic surgery.
An open, tension-free, mesh repair performed with local anesthesia is now the standard operation for patients with inguinal hernia. The results of any other procedure must be compared with this standard. If laparoscopic hernia repair is to earn a secure place, it must be proved that the procedure is at least as easy to perform as an open, tension-free, mesh repair and is less expensive and safer, with faster recovery and lower recurrence rates.
Arthur I. Gilbert, M.D.
Michael F. Graham, M.D.
Hernia Institute of Florida, Miami, FL 33143Author/Editor Response
The authors reply:
To the Editor: The authors of both letters should realize that the most relevant comparison for laparoscopic herniorrhaphy should be not their own experience or their belief about the best treatment but current common practice. To support their assumption that many surgeons perform open, tension-free repairs with mesh prostheses, Avital and Werbin cite an article written by a well-known proponent of this technique.1 This may not represent common practice. We compared laparoscopic repair with current common practice, and we think that in our conventional-surgery group, there was an excellent representation of the various hernia-repair techniques currently used in the Netherlands. In other European countries,2 and perhaps also in the United States, the current practice appears not to be so different. In two recent, small American trials comparing laparoscopic repair with the preferred technique of the surgeon, most surgeons did not use a tension-free technique.3,4 All the evidence cited by Avital and Werbin comes from nonrandomized studies, and some are retrospective. The claim by Avital and Werbin and by Gilbert and Graham that an open, tension-free repair with a mesh prosthesis is the so-called standard operation still lacks the support of data from large, randomized trials, and the available data from national studies certainly do not confirm its alleged widespread use.
Some of the surgeons who did the laparoscopic repairs in our study also needed supervision, and the early recurrences in the laparoscopic-surgery group can hardly be used to argue for greater experience. Recurrences after one year have usually been considered unrelated to the surgeon's experience but related to the type of repair.
Operating-room time, including the set-up time for laparoscopic equipment, differed little between the laparoscopic-surgery group and the conventional-surgery group.5
5 ReferencesMike S.L. Liem, M.D.
Theo J.M.V. van Vroonhoven, M.D.
University Hospital Utrecht, 3508 GA Utrecht, the Netherlands1
Amid PK ,Shulman AG ,Lichtenstein IL . Open “tension-free“ repairof inguinal hernias: the Lichtenstein technique. Eur J Surg 1996;162:447-453
Medline2
Nilsson E ,Anderberg B ,Bragmark M , et al. Hernia surgery in a defined population: improvements possible in outcome and cost effectiveness. Ambulatory Surg 1993;1:150-153
CrossRef3
Barkun JS ,Wexler MJ ,Hinchey EJ ,Thibeault D ,Meakins JL . Laparoscopic versus open inguinal herniorrhaphy: preliminary results of a randomized controlled trial. Surgery 1995;118:703-710
CrossRef | Web of Science | Medline4
Vogt DM ,Curet MJ ,Pitcher DE ,Martin DT ,Zucker KA . Prelim-inary results of a prospective randomized trial of laparoscopic onlay versus conventional inguinal herniorrhaphy. Am J Surg 1995;169:84-90
CrossRef | Web of Science | Medline5
Liem MSL, Halsema SH, van der Graaf Y, Schrijvers AJP, van Vroonhoven TJMV, Coala-Trial Group. Cost-effectiveness of laparoscopic inguinal hernia repair: a randomized comparison with conventional herniorrhaphy. Ann Surg (in press).
