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Am Fam Physician. 2005;71(2):378

Recurrence of an inguinal hernia after surgical repair is fairly common. Tension-free repair of hernias using prosthetic mesh has been shown to reduce rates of recurrence compared with traditional tension-producing operative techniques. Laparoscopy is used increasingly for hernia repair and is associated with less postoperative pain and earlier return to normal activities. Laparoscopic repair requires the use of general anesthesia, however, and has higher reported rates of serious complications compared with the local anesthesia technique used for open repair. Neumayer and colleagues report on outcomes from a comparison trial of laparascopic and open mesh repair for inguinal hernias.

Patients with primary or recurrent inguinal hernias were recruited from general surgery clinics at various Veterans Affairs medical centers. Open and laparoscopic repair techniques were standardized across the participating centers and performed by surgeons with at least 25 prior repair experiences. A total of 3,518 patients with hernias initially were screened, and 2,164 consented to randomization. Of the patients randomized to laparoscopic repair, 9.8 percent were converted to open repair. Two-year follow-up data were available for 85.5 percent of the 1,983 patients who successfully underwent surgical repair. The average age of trial participants was 58 years, and more than 20 percent were from minority ethnic groups.

Intraoperative complications (e.g., problems with anesthesia, injuries to spermatic cords or blood vessels) were significantly more common in the group that underwent laparoscopic repair (4.8 versus 1.9 percent in the open mesh group). Life-threatening complications (e.g., myocardial infarction, ischemia, arrhythmia) were uncommon but occurred significantly more often with laparoscopic repair (1.1 versus 0.1 percent). Two deaths occurred within 30 days of surgery in the laparoscopic group, both of which were attributed to the operation. No deaths occurred in the open mesh group within 30 days of surgery. Immediate postoperative complications (e.g., hematoma, pain) were slightly more common with laparoscopic repair. Recurrence of a primary hernia during the two-year follow-up period was more than twice as common with laparoscopic repair than with the open mesh technique (10.1 versus 4.9 percent). Mesh repair of recurrent hernias did not show a significant difference in recurrence rates between laparoscopic and open approaches.

Pain scores in the immediate postoperative period and at the two-week follow-up visit were higher in patients undergoing open repair. The median time for return to normal activities was shorter after laparoscopy than open repair (four versus five days). Post-trial data analysis showed that highly experienced surgeons (i.e., those who had performed more than 250 procedures) had a lower rate of hernia recurrence with laparoscopic repair than less experienced surgeons, but there was no significant difference in recurrence rates after open technique surgeries based on the surgeon’s experience level.

The authors conclude that laparoscopic repair of inguinal hernias is associated with less pain and quicker return to activity than an open technique, but it has a higher rate of operative complications and a significantly higher recurrence rate of primary hernias.

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