Laparoscopic Hernia Repair Benefits

People whose groin (inguinal) hernias are repaired using a laparoscopic method recover more rapidly and have fewer repeat hernias than others treated with standard open surgery, a study shows.

The laparoscope-treated patients had less pain, resumed work and normal activities sooner, and expressed greater satisfaction with the procedure, according to a report in The New England Journal of Medicine.

Laparoscopes are long flexible tubes with a light source, and can be used to view the interior of the abdomen through a small incision. Using instruments inserted through other incisions, surgeons can perform some surgeries or take tissue samples.

Inguinal hernias have been a painful problem for humankind since prehistory, and records of surgical attempts at repairing them occur through the centuries. In these hernias, some of the abdominal contents – most often a part of the intestine – bulges through the inguinal canal, the passage through which the testes descended into the scrotum early in life. Untreated, the sometimes painful bulge may become stuck, leading to a potentially dangerous condition called hernia strangulation.

Today, many hernias are repaired by day surgery, on an outpatient basis via an open operation in which the hernia is pushed back into place and the weakened muscle tissue is strengthened by stitching it to a mesh material.

Now, according to researchers in Holland led by Dr. Mike S.L. Liem of the University Hospital Utrecht, it appears that inguinal hernia repair can be accomplished with equal success by a laparoscopic method.

The method calls for several small incisions in the abdomen to allow insertion of the laparoscope and small surgical instruments. It is usually performed while patients are under general anesthesia.

In the new study, the researchers compared inguinal hernia outcomes in 487 patients treated with the new method with those of another 507 people treated using the conventional surgical procedure.

“Six patients in the open-surgery group but none in the laparoscopic-surgery group had wound abscesses (infections)” after the operation, report the researchers.

They note that the time to return to work after laparoscopy was 14 days, versus 21 days after open surgery. Resumption of normal daily activity was also more rapid for laparoscopic patients – 6 versus 10 days, as was the return time to athletic activities – 24 versus 36 days.

During a follow-up period (of about two years), 6% (31 patients) in the open-surgery group had hernia recurrences compared with 3% (17 patients) in the laparoscopy group.

Liem and his colleagues note that nearly all the laparoscopic operations were performed under general anesthesia, compared with the patient being awake under spinal anesthesia in 60% of the open surgeries.

“The use of general anesthesia might be considered a disadvantage of laparoscopic repair,” they write. “Nevertheless, the patients in the laparoscopic-surgery group were discharged from the hospital sooner and had less early and late postoperative pain than the patients in the open-surgery group.”

Commenting on the findings, Drs. Jonathan L. Meakins and Jeffrey S. Barkun of McGill University, Montreal, Canada, say the researchers “have made an important contribution” to the knowledge of hernia repair.

“The economic impact of hernia repairs on health care is substantial; almost 700,000 repairs are performed annually in the United States,” they note, adding that in Canada, direct costs for laparoscopic repair run 40% higher than that for open surgery.

“Such an evaluation, however, does not take into account the indirect costs, paid from a variety of pockets, of a longer period of recovery from open repair,” they point out.

But Meakins and Barkun also point out that the hernia repair methods used in the conventional surgical procedures were not always the same, thereby possibly limiting the validity of the comparison results.

SOURCE: The New England Journal of Medicine (1997;336:1541-1547, 1596-159)

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