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Traditional Hernia Surgery Tops Laparoscopic Technique

Researchers report fewer recurrences and fewer complications

SUNDAY, April 25, 2004 (HealthDayNews) -- Traditional open mesh surgery is superior to laparoscopic surgery for most hernias, a new study reports.

The traditional surgery resulted in fewer recurrences and fewer complications, claims the study, which is to be presented April 25 at the spring meeting of the American College of Surgeons in Boston. The findings will also appear in the April 29 issue of the New England Journal of Medicine.

"The study establishes open hernia repair for a first-time hernia as a good choice for most patients. It is a very good procedure. It definitely should not be supplanted by laparoscopic surgery," said study chairman Dr. Leigh Neumayer, a staff surgeon at Salt Lake City Veterans Affairs Medical Center in Utah.

"There are particular patients for whom laparoscopic surgery might be as good or better," Neumayer added. These patients might include people who have already had hernia repair surgery or who have hernias on two sides.

Inguinal hernias occur when a portion of the intestine protrudes through the abdominal wall and into the groin area. The condition is extremely common and, according to an editorial in the same issue of the journal, more than 800,000 hernia operations were performed in the United States in 2003, most of them on an outpatient basis.

While there are different techniques to repair this type of problem, experts have struggled to determine which is best. Laparoscopic surgery involves making a tiny incision so as to insert tiny tools and cameras. This type requires general anesthesia and therefore more risk.

Open surgery requires a larger incision -- about 3 inches long -- and involves a slower recovery time but it can be done with local anesthesia.

In either case, surgeons use a plastic mesh to repair the wall of the abdomen and prevent the abdomen from bulging through. Previously, surgeons used to stitch the area up.

For this study, the researchers randomly assigned 1,696 men at 14 different VA medical centers to have either open mesh surgery or laparoscopic mesh surgery.

At the end of two years, men in the laparoscopic group had about double the recurrence rate as men in the open group: 10.1 percent vs. 4.9 percent. And the laparoscopic group had a 39 percent complication rate, compared with 33.4 percent for the open surgery group.

On the other hand, those in the laparoscopic group had less pain on the day of surgery and returned to normal activities one day earlier. These differences had resolved themselves by the end of three months.

Dr. Danny O. Jacobs, author of the editorial and chairman of the Department of Surgery at Duke University School of Medicine, wasn't surprised by the differences, only by the size of the differences.

"In surgery, we had been talking about these issues for years but we knew that laparoscopic surgery was technically challenging compared to removing a gall bladder," he said. "That it turned out as pronounced as it did appears a little surprising."

The anatomy in that region of the body does make laparoscopic surgery more complicated. "There are a number of other structures in the area that are potentially more likely to be injured than some other laparoscopic procedures," Jacobs said.

In a post-study analysis, the researchers also found differences in outcomes depending on how experienced the surgeon was. For the 58 surgeons who reported having performed 250 or fewer laparoscopic procedures of any type, the recurrence rate was 10 percent. For surgeons who had done more than 250 procedures, the recurrence rate was less than 5 percent.

"It looked like surgeons' experience had an impact. Whether it's truly that or something else, we can't say," Neumayer said. "That information has to be interpreted cautiously."

Still, for that reason and others, laparoscopic surgery is likely to take a back seat to open mesh surgery for repairing groin hernias.

"When you consider the issues about the level of experience required to get to that level of competence and the relatively good recurrence rates for open procedures, surgeons in many areas of country will never get to that type of number," Jacobs said. "We won't have many laparoscopic surgeries performed in this country."

More information

For more on hernias, visit the American Urological Association or the British Hernia Centre.

SOURCES: Leigh Neumayer, M.D., staff surgeon, Salt Lake City Veterans Affairs Medical Center, and associate professor, surgery, University of Utah School of Medicine; Danny O. Jacobs, M.D., professor and chairman, Department of Surgery, Duke University School of Medicine, Durham, N.C.; April 29, 2004, New England Journal of Medicine
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