Page 45 - World Journal of Laparoscopic Surgery

Spencer EE Efem

postoperative period as a result of persistent effect of local comparison of laparoscopic versus open repair sponsored by
7,8
anesthetic. For every activity considered the median time until EU Biomed, program included 45 relative comparisons in 41
return to normal was significantly shorter in the laparoscopic eligible trials involving over 700 patients. Individual patients
group. The mean cost per patient was 335 pounds costlier in data was available in 4165 patients. Meta analysis revealed that
the laparoscopic. They concluded that laparoscopic repair has laparoscopic repair was associated with reduced recurrence
considerable short-term clinical advantage after discharge rate when compared with open nonmesh repair but was not
compared with open mesh hernioplasty, although it was more different to open mesh repair. This analysis also revealed six
expensive. visceral injuries four bladder injuries, one bowel injury and three
4
In another MRC study carried out by Lawrence et al data vascular injuries.
was collected on 104 patients undergoing laparoscopic and All studies unanimously agreed that cost of laparoscopic
open hernia repair on a day care basis in the context of a repair is very much higher that the cost of open mesh repair. 2-5
4
randomized control trial. They found out that the mean total The MRC studies by Lawrence et al. specifically stated that
health service cost of laparoscopic repair was $1074 vs $489 for the cost per patient for laparoscopic repair was $1074 as against
open repair (mean difference in total health service cost $583; $489 for open repair. This is outrageous considering that most
95% confidence interval C I $265-$904). They explained that the open repair are now carried out as day cases. The reason for
difference was largely accounted for the difference in theater this escalated cost is the cost of equipment and theater
cost. They concluded that laparoscopic hernia appears an modification to accommodate the equipment and the after care
expensive option in most plausible situation furthermore; many of the equipment after use.
uncertainties still exist about long-term outcome after the The conclusions arrived at by the various studies are as
procedure and about the condition necessary to maximize cast follows the MRC studies does not recommended laparoscopic
effectiveness. approach as the method of choice for hernia repair. Neumayer
In a long-term follow-up of laparoscopic transabdominal et al concluded that open mesh repair is superior to laparoscopic
preperitoneal (TAPP) mesh repair under general anesthesia repair for primary hernias. Wellwood and his colleague
compared with open mesh repair under local anesthesia. Douek concluded in their studies that laparoscopic hernia repair has
5
et al. reported that long-term complication occurred less considerable advantages over open mesh repair even through
frequently in TAPP patients compared with Lichtenstein group, more expensive. Douek et al believed that laparoscopic approach
and 4% of TAPP group experienced groin pain and numbness is the favored method (Table 1).
compared with 33% of Lichtenstein group. The symptoms were The main drawback in laparoscopic hernia are high cost
clinically important in 12 patients in the open surgery group and the serious complications like puncture of the bladder
and not in the TAPP group. Recurrence in TAPP and open intestine and major blood vessels. These can be offset by
repair were 2% and 3% respectively. thorough and intensive training of residents and the use of
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Paganini et al. All in their study concluded that TAPP was reusable instruments in order to bring down cost. Only then
associated with less postoperative pain but the increase cost can the advantages such as short hospital stay, improved
was uncompensated by early return to work. cosmesis, early return to work and patients satisfaction be
meaningfully achieved.
DISCUSSION
In this review only studies that used mesh in the open repair CONCLUSION
were included in order to eliminate bias. All studies agreed that From the review of laparoscopic versus open mesh repair of
early postoperative pain was less in the Lichtenstein open mesh inguinal hernia there was no clear consensus on the preference
repair than with laparoscopic mesh repair but chronic pain and of one method to the other. In advanced countries where people
paraesthesia were more the Lichtenstein group. This was enjoy health insurance and are well to do and also have enough
explained on the basis that the local anesthesia used in the well-trained man power, laparoscopic surgery repair of inguinal
open mesh group kept the patients pain free the first post- hernia could be considered the favored approach. In surgically
operative day but as the effect wore off pain returned. poor third would countries where people are poor and have no
Large single and multi-institutional studies stated that health insurance scheme open mesh repair will continue to be
complication rate after laparoscopy hernioplasty vary from the method of choice.
1-13% but the complication recorded by each study differ
widely and only 1-1.3% in expert specialist centers. Where as ACKNOWLEDGMENT
many studies reported more long-term complication in the open
mesh then in laparoscopic. They also reported life-threatening I wish to thank Professor RK Mishra, Director of laparoscopy
complications such as bladder perforation, bowel injuries, and Hospital, New Delhi, India for his useful hints on how to conduct
vascular injuries in the laparoscopic method. In a number of the literature search. I wish to thanks Mr Anil Aryan and
meta-analyses and systematic reviews on randomized Mr Anand Sinha for their secretarial assistance.

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