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Lap hernia repair results in more recurrence than open
Look at long-term outcome to pick best procedure
Less pain. Quicker recovery. These are the two reasons minimally invasive surgery has been touted as an improvement over traditional surgery. However, minimally invasive surgery is not always the best choice for a positive long-term outcome in hernia repair, according to a study published in the New England Journal of Medicine.1
"We initiated the study of open mesh versus laparoscopic repair of inguinal hernia because we saw an opportunity to put real science behind the emerging technology of laparoscopic hernia repair," says Leigh Neumayer, MD, MS, a staff surgeon at the VA Medical Center in Salt Lake City and lead researcher for the study. The study found that a recurrence of the hernia within two years occurred in 10.1% of the group of patients undergoing laparoscopic hernia repair, compared to a recurrence rate of 4.9% of patients undergoing open repair, she says. The rate of complications for the laparoscopic procedure (39%) was also higher than the rate of complications for open repair (33.4%), she points out.
"There were three fatal complications for patients undergoing the laparoscopic procedure," says Robert J. Fitzgibbons, MD, professor in the department of surgery at Creighton University in Omaha, NE, and another researcher for the study. "Two of these complications related to the anesthesia, and one was the result of a bowel injury," he explains.
For a unilateral hernia, both open and laparoscopic hernia repair can be performed in the same amount of operating room time, says Fitzgibbons. However, laparoscopic repair is a higher-risk procedure because general anesthesia is always used and because the surgeon can accidentally injure another organ due to the limited vision of the operating field as compared to the open procedure, he points out. Many surgeons use local anesthesia with sedation for open repairs, but more effort is required on the part of the anesthesiologist and the surgeon to control the effectiveness of the anesthesia, he says. For this reason, open repairs most often are performed with general anesthesia, he adds.
Pain levels differ at first
There were some differences between the procedures with regard to postoperative pain and time to return to normal activity, Neumayer notes. Patients undergoing open repair reported significantly more pain in the first two weeks following surgery than patients undergoing laparoscopic repair, but the difference in reported pain disappeared by the three-month follow-up visit, she says.
Patients undergoing laparoscopic repair resumed normal activities in four days, as compared to five days for patients undergoing open repair, says Fitzgibbons. Although more of the laparoscopic patients were able to perform some activities at the two-week point, such as climbing stairs, shoveling, or weightlifting, all patients were at the same level of activity at the three-month assessment, he adds.
Researchers did find that while recurrence rates for study participants who underwent repair of primary hernias were higher for the laparoscopic procedure, the recurrence rate for procedures performed to repair recurrent hernias was not significantly different for the laparoscopic procedure, and was even slightly better than for open repair, says Fitzgibbons. For primary hernias, the recurrence rate was 10.1% for laparoscopic repair, compared to 4% for the open procedure. Repair of recurrent hernias resulted in a recurrence rate of 10% for laparoscopic repair and 14.1% for open repair, he points out.
Laparoscopic repair as good as open repair
"We can’t make any definitive recommendations on recurrent hernia repairs because our numbers [of study participants with recurrent hernias] were too small, but it appears that at a minimum, laparoscopic repair of hernias is as good as, and possibly better than, open repair, especially in the hands of an experienced surgeon," says Neumayer.
Although the researchers did not plan to look for an association between the level of surgeon experience and recurrence rates and complications, they did evaluate the association between these rates and the surgeons’ self-reported experience in terms of number of procedures previously performed with each technique. "We found that surgeons who had performed the laparoscopic procedure in more than 250 cases had the lowest recurrence and complication rates," says Fitzgibbons.
For this reason, Fitzgibbons suggests that "surgeons who have patients with primary hernias who insist on a laparoscopic procedure refer those patients to a specialist with a higher level of experience if they do not have the experience themselves."
1. Neumayer L, Giobbie-Hurder A, Jonasson O, et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 2004; 350:1,819-1,827.
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