Open hernia repair better than laparoscopic

Journal of Family Practice, August, 2004

Neumayer L, Giobbie-Hurder A, Jonasson O, et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 2004; 350:1819-1827.

* CLINICAL QUESTION

Is an open or laparoscopic approach better for inguinal hernia repair?

** BOTTOM LINE

Although laparoscopic repair is associated with a small reduction in pain and it gets your patient back to work a day sooner, it carries a greater risk of serious complications and recurrence. (LOE=1b)

*** STUDY DESIGN

Randomized controlled trial (nonblinded)

*** SETTING

Inpatient (any location) with outpatient follow-up

* SYNOPSIS

Open surgical repair of inguinal hernias involves use of a prosthetic mesh, the possibility of local anesthesia, and discharge often within a few hours of the procedure. A laparoscopic procedure has been introduced that requires general anesthesia, but claims to reduce postoperative pain and allow earlier return to usual activities. Which is better?

The researchers randomized (allocation concealed) 2164 patients at 14 Veteran's Affairs medical centers to receive either the open or laparoscopic procedure. Of the 2164 initially randomized, 1983 actually underwent surgery. The surgical protocol was standardized for each type of procedure, and surgeons must have performed at least 25 of their chosen procedures to qualify for the study. Patients were followed up for 2 years, and 1696 (86%) completed the follow-up. Crossover from laparoscopic to open repair occurred in 9.8% of patients, compared with only 1.6% crossing over in the other direction. Patients were analyzed by the group to which they were originally assigned, though, which is appropriate.

Patients undergoing laparoscopic repair experienced less pain after surgery and returned to work sooner (4 vs 5 days; 95% confidence interval [CI] for the difference, 1.1-1.3). However, the difference in pain was generally minor: between 6 and 10 on a 100-point visual scale. In general, differences less than 15 points are unlikely to be clinically important.

There were more complications with laparoscopic repair, including more life-threatening complications (0.1% vs 1.1%; odds ratio=11.2; 95% CI, 1.3-95.3). The recurrence rate at 2 years was also lower in the open repair group (4.9% vs 10.1%; absolute risk reduction=5.2%; number needed to treat=20).