Fewer recurrences and complications overall with open surgery than with laparoscopic surgery

A Veterans Affairs study of nearly 1,700 hernia-repair operations found fewer recurrences and complications overall with open surgery than with laparoscopic surgery. The study is being presented April 25 at the spring meeting of the American College of Surgeons in Boston. The findings also appear in the April 29 issue of the New England Journal of Medicine.

The researchers analyzed 834 open and 862 laparoscopic surgeries performed at 14 VA medical centers between 1999 and 2001 to repair inguinal, or groin, hernias, the most common type.

In two years of follow-up, the laparoscopic group had a 10-percent recurrence rate and 39-percent complication rate, compared to about 5 percent and 33 percent for the open-surgery group. The laparoscopic patients were more active and had less pain in the two weeks after the operation, but these factors leveled off for the two groups within three months.

“Based on these findings, we’d recommend that men with a hernia that has never been repaired before should undergo an open repair,” said study leader Leigh Neumayer, MD, of the Salt Lake City VA Medical Center and University of Utah. She noted that for recurrent hernias—which account for about 10 percent of groin hernias—the numbers in the study were too small to make recommendations.

Laparoscopic surgery uses pencil-thin tubes fitted with cutting tools and miniature cameras that enable the surgeon to see inside the abdomen or pelvis. The procedure uses a few tiny cuts; open surgery requires a single incision about three inches long. Laparoscopy is a more intricate procedure but is associated with less pain and faster recovery for patients.

Today it is widely used for gallbladder repair and some other operations. But it has not become the overwhelming procedure of choice for hernias. “This may be because open hernia repair is a common procedure with excellent results that is already done on an outpatient basis without many complications,” said Neumayer.

In the study, surgeons’ experience mattered most when it came to laparoscopy.
For the 20 surgeons in the study who reported having done more than 250 laparoscopic repairs, the recurrence rate was below 5 percent—similar to the rate for open repairs. However, the figure was consistently above 10 percent for the 58 laparoscopic surgeons who reported less experience with the procedure. Open surgery was far less experience-dependent.

Based on this finding, Neumayer said patients seeking laparoscopic repair might be well advised to visit a specialized hernia center staffed by surgeons highly experienced in the technique.

About 700,000 Americans each year undergo repair of an inguinal hernia, making it one of the most common surgeries. In the VA health system, the nation’s largest, about 10,000 hernia repairs are performed each year.

Inguinal hernias occur when a loop of intestine pushes through the abdominal wall and down into the inguinal canal in the groin, either due to an inborn weakness or excessive strain. The result is a bulge that is usually painless in its early stages, but that could cause pain and complications later on. Men are tenfold more likely than women to have the condition.

With either open or laparoscopic surgery, doctors nowadays use a plastic “tension-free” mesh instead of sutures to patch the abdominal wall. One plus of laparoscopy is that it allows the surgeon to place the mesh on the inside of the abdominal wall, where it can be held in place by the natural outward pressure of the abdomen.

Laparascopy also enables the surgeon to check for hernias elsewhere in the abdomen. But the procedure, unlike open surgery, requires general anesthesia—and therefore carries a greater risk of serious complications during surgery. With either method, most patients go home after a few hours.

Neumayer’s study was supported by VA’s Cooperative Studies Program. Her collaborators included Anita Giobbie-Hurder, MS, of the Hines (Ill.) VA; Olga Jonasson, MD, of the University of Illinois; Robert Fitzgibbons Jr., MD, Creighton University; Dorothy Dunlop, PhD, and James Gibbs, PhD, Northwestern University; Domenic Reda, PhD; Hines VA; and William Henderson, PhD, formerly with VA and now with the University of Colorado.