An important surgical study

Too often, new surgical techniques do not receive a careful analysis. The VA came through to answer an important question – what is the best approach to hernia repair – Open Mesh Better Than Laparoscopic Mesh Inguinal Herniorrhaphy

Of 2,164 men with inguinal hernias enrolled from one of 14 VA medical centers and randomized to open or laparoscopic repair, 1,983 had surgery, and 1,696 (85.5%) completed two-year follow-up.

There were recurrences in 87 (10.1%) of 862 patients in the laparoscopic repair group and in 41 (4.9%) of 834 patients in the open repair group (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.5 – 3.2). Complications occurred in 39.0% of the laparoscopic repair group and in 33.4% of the open repair group (adjusted OR, 1.3; 95% CI, 1.1 – 1.6).

However, the laparoscopic repair group fared better than the open repair group in terms of pain on a visual analog scale on the day of surgery (difference in mean score, 10.2 mm; 95% CI, 4.8 – 15.6) and at two weeks (6.1 mm; 95% CI, 1.7 – 10.5), and they returned to normal activities one day earlier (adjusted OR, 1.2; 95% CI, 1.1 – 1.3).

Rates of recurrence after repair of recurrent hernias were similar in both groups (10.0% vs. 14.1%). In prespecified analyses, the surgical approach (open or laparoscopic) was associated with the type of hernia (primary or recurrent) (P = .012).

For laparoscopic repair, the recurrence rate was less than 5% for 20 surgeons in the study who reported having done more than 250 of these procedures, but it was consistently above 10% for 58 laparoscopic surgeons who reported less experience with this type of repair. Outcomes of open surgery were far less dependent on the surgeon’s experience.

Study limitations include a nonrepresentative sample of high average age and low health-related quality of life; self-reporting of surgeons’ experience; and exclusion of patients who had previously undergone a hernia repair using mesh.

Surgical studies are always difficult. This study does remind us that we can not randomize surgical skill. Some surgeons obtain better results than others. The wise generalist figures out which surgeons to whom he/she should refer.

If patients need major surgery, they should try to find outcomes if at all possible. At least use a surgeon with significant experience doing that procedure.