The Gap Between Evidence‐Based Guidelines and Daily Practice

Abstract

I read with interest both the paper of Bernhardt et al. [1] and the invited commentary of Holzheimer [2] on the gap between evidence-based guidelines and the daily practice of inguinal hernia surgery. In 2006, the French Society of Digestive Surgery published evidence-based guidelines recommending the use (by nonexpert laparoscopic surgeons) of the conventional approach instead of laparoscopy for primary inguinal hernia repair [3]. These recommendations have been very much criticized by expert surgeons [4] and the French laparoscopic societies [5]. It was stated in the latter guidelines that ‘‘the Societies state no negative recommendation regarding laparoscopic hernia repair’’ [5]. One can be surprised by the publication of two conflicting guidelines on the same topic in the same country, but this is perhaps the so-called ‘‘French touch’’!! Nevertheless, a quick look at the actual practice after the published guidelines in France (administrative data) showed that in 2007 and 2008, 31% of repairs were done laparoscopically each year (among almost 140,000 procedures), which is not significantly different from the rates observed 5 years earlier (28 and 29% in 2002 and 2003, respectively). French data are in contrast with those from the UK where most surgeons followed the NICE guidance [6]. Hence, the situation in Continental Europe contrasts with that in Anglo-Saxon countries. The reasons advocated by Holzheimer [2] are probably true in some instances. Beside evidence-based medicine, one can advocate for example confidence-based medicine or even brain-trustbased medicine. Some experts would argue that laparoscopic surgery was born in Continental Europe; they consider themselves the main defenders of this approach and cannot imagine abandoning it (in hernia repair) in favor of an ‘‘old technique.’’ However, I do think that it takes wisdom to know the respective benefits and limitations of laparoscopy and applying the evidence is something we owe our patients [7]. The actual cost effectiveness of laparoscopic repairs in the era of ambulatory surgery [8] remains to be addressed. In France, most laparoscopic hernia repairs (72% according to the aforementioned administrative data) are done in private trusts. Because they are rarely performed in university hospitals (mainly for recurrent or bilateral hernias) they are not routinely learned by young surgeons. Because of this, I am afraid that in the future (when experts in laparoscopic repair will retire), laparoscopic repair will perhaps no longer be performed by the next generation of surgeons.