Laparoscopic hernia surgery

Abstract

The MRC Laparoscopic Groin Hernia Trial Group1The MRC Laparoscopic Groin Hernia Trial Group.Laparoscopic versus open repair of groin hernia: a randomised comparison.Lancet. 1999; 354: 185-190Summary Full Text Full Text PDF PubMed Scopus (334) Google Scholar suggests that laparoscopic repair of groin hernias should come under the domain of the specialist surgeon. However, the trial results might not be generally applicable to laparoscopic hernia repair. The poorer than expected results in the laparoscopic group of the trial may well indicate a learning curve, rather than poor technique. Other works have shown that 50 repairs are required to ascend the learning curve.2Voitk AJ The learning curve in laparoscopic inguinal hernia repair for the community general surgeon.Can J Surg. 1998; 41: 446-450PubMed Google Scholar Since some surgeons had only done ten hernia repairs before starting the trial they were likely to be at the very early phase of the learning curve, and therefore have a higher rate of complications and recurrences.2Voitk AJ The learning curve in laparoscopic inguinal hernia repair for the community general surgeon.Can J Surg. 1998; 41: 446-450PubMed Google Scholar, 3Hussein MK Khoury GS Taha AM Laparoscopic inguinal hernia repair.Int Surg. 1998; 83: 253-256PubMed Google Scholar, 4Leibl BJ Schmedt CG Schwarz J et al.A single institution's experience with transperitoneal laparoscopic hernia repair.Am J Surg. 1998; 175: 446-451Summary Full Text Full Text PDF PubMed Scopus (43) Google ScholarAlthough recommendations were made about mesh size, what was the mesh size actually used? The use of too small a mesh results in a higher rate of recurrence. Lack of fixation of the mesh may also cause a rise in recurrence rates.Serious complications such as the vascular injury and small bowel obstruction are of concern, and are recognised as being rare but important complications that can arise in laparoscopic operations. Testicular complications are usually lower in laparoscopic series, and the high rate seen in the trial may again be a result of operators in the steep early part of their learning curve.An advantage of laparoscopic hernia surgery is that contralateral hernias not diagnosed preoperatively can be repaired with little extra effort and expense under the same anaesthetic. Series of TAPP repairs identify between 10% and 25% incidental contralateral hernias. This fact was not mentioned in the current trial; was this an omission or were they not recognised?The investigators do not define hernia recurrence, and there were some unexplained deviations from allocated method of operation. Of the patients invited to take part in the trial only 60% did so and we are not told enough about the non-participants to enable us to determine the external validity of the trial.A systematic review of published work showed no significant difference in recurrence rates between laparoscopic and open techniques.5Cheek CM Black NA Devlin HA Kingsnorth AN Taylor RS Watkin DFL Groin hernia surgery: a systematic review.Ann R Coll Surg Engl. 1998; 80: 1-80PubMed Google Scholar Further trials with surgeons more experienced in the technique are needed before we can conclude that laparoscopic hernia repair should be confined to specialist operators only. The MRC Laparoscopic Groin Hernia Trial Group1The MRC Laparoscopic Groin Hernia Trial Group.Laparoscopic versus open repair of groin hernia: a randomised comparison.Lancet. 1999; 354: 185-190Summary Full Text Full Text PDF PubMed Scopus (334) Google Scholar suggests that laparoscopic repair of groin hernias should come under the domain of the specialist surgeon. However, the trial results might not be generally applicable to laparoscopic hernia repair. The poorer than expected results in the laparoscopic group of the trial may well indicate a learning curve, rather than poor technique. Other works have shown that 50 repairs are required to ascend the learning curve.2Voitk AJ The learning curve in laparoscopic inguinal hernia repair for the community general surgeon.Can J Surg. 1998; 41: 446-450PubMed Google Scholar Since some surgeons had only done ten hernia repairs before starting the trial they were likely to be at the very early phase of the learning curve, and therefore have a higher rate of complications and recurrences.2Voitk AJ The learning curve in laparoscopic inguinal hernia repair for the community general surgeon.Can J Surg. 1998; 41: 446-450PubMed Google Scholar, 3Hussein MK Khoury GS Taha AM Laparoscopic inguinal hernia repair.Int Surg. 1998; 83: 253-256PubMed Google Scholar, 4Leibl BJ Schmedt CG Schwarz J et al.A single institution's experience with transperitoneal laparoscopic hernia repair.Am J Surg. 1998; 175: 446-451Summary Full Text Full Text PDF PubMed Scopus (43) Google Scholar Although recommendations were made about mesh size, what was the mesh size actually used? The use of too small a mesh results in a higher rate of recurrence. Lack of fixation of the mesh may also cause a rise in recurrence rates. Serious complications such as the vascular injury and small bowel obstruction are of concern, and are recognised as being rare but important complications that can arise in laparoscopic operations. Testicular complications are usually lower in laparoscopic series, and the high rate seen in the trial may again be a result of operators in the steep early part of their learning curve. An advantage of laparoscopic hernia surgery is that contralateral hernias not diagnosed preoperatively can be repaired with little extra effort and expense under the same anaesthetic. Series of TAPP repairs identify between 10% and 25% incidental contralateral hernias. This fact was not mentioned in the current trial; was this an omission or were they not recognised? The investigators do not define hernia recurrence, and there were some unexplained deviations from allocated method of operation. Of the patients invited to take part in the trial only 60% did so and we are not told enough about the non-participants to enable us to determine the external validity of the trial. A systematic review of published work showed no significant difference in recurrence rates between laparoscopic and open techniques.5Cheek CM Black NA Devlin HA Kingsnorth AN Taylor RS Watkin DFL Groin hernia surgery: a systematic review.Ann R Coll Surg Engl. 1998; 80: 1-80PubMed Google Scholar Further trials with surgeons more experienced in the technique are needed before we can conclude that laparoscopic hernia repair should be confined to specialist operators only.