Which Type of Hernia Repair is Best?

Journal Watch. 2004;3(5) 

Most comparative studies of laparoscopic and open repair of inguinal hernia have had limitations, such as small sample sizes, inadequate follow-up, and differences between groups in the use of surgical mesh. In this randomized trial conducted at 14 U.S. veterans' hospitals, 1983 men (mean age, 58) with inguinal hernia underwent either open mesh repair (by the Lichtenstein method) or laparoscopic mesh repair. All laparoscopic-repair patients received general anesthesia, whereas 39% of open-repair patients received regional or local anesthesia.

Compared with the open-repair group, the laparoscopic group had somewhat less severe postoperative pain and a slightly quicker return to usual activities (median, 5 vs. 4 days). However, laparoscopic-repair patients were significantly more likely than open-repair patients to have postoperative complications (39% vs. 33%) and life-threatening complications within 30 days (11 vs. 1 event). In addition, the 2-year hernia recurrence rate was significantly higher in the laparoscopic group (10% vs. 5%). Among surgeons who reported performing more than 250 laparoscopic hernia repairs, hernia recurrence rates after laparoscopic repair were similar to rates after open repair. In contrast, among surgeons who reported less laparoscopic experience, hernia recurrence rates were substantially higher after laparoscopic repair than after open repair.

This might be the best comparative trial of hernia repair so far. Although somewhat less postoperative pain was reported after laparoscopic repair, severe complications and recurrent hernia were more likely to occur in the laparoscopic group. The association between physicians' self-reported surgical experience and patients' hernia recurrence was a post-hoc finding that certainly deserves scrutiny in future studies.

— Allan S. Brett, MD

Neumayer L et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 2004 Apr 29; 350:1819-27.

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