Page 48 - World Journal of Laparoscopic Surgery

Snehal Fegade

anticoagulants, smoking, heavy lifting, malignancy and anemia. lower minor-complication rates and higher percentage of pain-
Laparoscopic inguinal hernia repair offers excellent results in free recoveries.
experienced hands.
DISCUSSION
BILATERAL ASSESSMENT AND TREATMENT
The Shouldice technique is the ‘gold standard’ of open non-
Up to 30% of patients with a unilateral hernia will subsequently mesh hernia repair. The 5-year recurrence rate is acceptable,
develop a further hernia on the contralateral side. Also, when with no difference between TAPP and Shouldice repair. Poor
examined at operation, 10-25% is found to have an occult hernia operative performance resulted in a higher recurrence rate. The
on the contralateral side. Both laparoscopic approaches allow TAPP operation represents an excellent alternative for primary
assessment and treatment of the contralateral side at the same inguinal hernia repair. Laparoscopic repair compared favorably
operation without the need for further surgical incisions, very with Lichtenstein repair for primary indirect and direct hernias,
little further dissection and minimal additional postoperative and unilateral and bilateral recurrent hernias, but was inferior
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pain. In open surgery a further large incision is required in the for primary bilateral hernias. General anesthesia and higher costs
opposite groin. This considerably impairs postoperative mobility are reasonable compromises for a shorter period of discomfort
and increases the likelihood of admission to hospital. Some in patients with a low ASA index and busy job/sport activity. 18
surgeons advocate routine repair of the contralateral side during With open Lichtenstein hernia repair in terms of
laparoscopic repair. intraoperative and postoperative complications and short-term
recurrence. In fact with extra care, complications can be nearly
COST EFFECTIVENESS avoided. The laparoscopic operations caused significantly less
pain in the early postoperative period, leading to earlier
It is suggested that laparoscopic hernia repair is more expensive mobilization and earlier return to work than open mesh repair.
to perform than open hernia repair. The primary reason for this This was clearly seen in the manual workers undergoing
relates to the cost of extra equipment used for the laparoscopic laparoscopic operation. Furthermore, laparoscopic TEP repair
repair with secondary costs attributed to perceived increases is associated with greater patient satisfaction and better
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in operating time for the laparoscopic procedure. From the cosmetic results than its open counterpart. On the basis of
Indian perspective, various factors come into play when these early experiences, laparoscopic extraperitoneal hernia
analyzing the cost implications of laparoscopic repair of inguinal repair seems to be as good as, if not superior to, the existing
hernia. In most hospitals, except the larger corporate ones, the open Lichtenstein repair in terms of postoperative pain, hospital
theater time is charged on a per-case basis rather than by the stay, return to work, and cosmesis provided the long-term
hour. Thus, increase in the operating time, particularly during recurrence rates also are comparable. It is possible to achieve
the learning curve, does not necessarily mean additional expense high standards even during the learning phase of the surgeon
for the patient. If the surgeon were to adopt cost-containment if there is strict adherence to the protocols. The TEP technique
strategies such as use of reusable laparoscopic instruments took no longer to perform, and was associated with less
(which is more or less the norm in India) as against disposable postoperative pain, a shorter period of sick leave and a faster
ones, use of indigenous balloons devices rather than recovery, compared with open Lichtenstein hernia repair. 19
commercially available ones, sparing use of fixation devices TAPP and TEP repairs were compared and found to give
and reliance on sutures for fixation of the mesh, the cost of the equally good results. TAPP is an easier procedure to learn and
laparoscopic hernia repair should be comparable to the open is less expensive than TEP repair done with balloon dissectors
repair. It is likely that many surgeons are already practicing and their ports; however, the reverse is true if no balloon
these strategies and passing on the benefits of laparoscopic dissectors and staples are used during TEP repair. TEP repair
repair to their patients. 17
has a longer learning curve. 1
Laparoscopic hernia repair may not be more expensive than
LEARNING CURVE
open repair in terms of direct hospital costs or where a difference
This period represents the developmental and learning curve exists, this is relatively small. Societal costs due quicker recovery
for the consultant and the senior registrars. There have been and return to employment show clear advantages for the
some modifications of the technique as difficulties have been laparoscopic repair and although not currently evaluated in
recognized. There is steep learning curve for laparoscopic repair. detail, the reduction in chronic groin pain after laparoscopic
Initially everyone used to fix mesh with staples, but nowadays repair is likely to lead to savings in both direct hospital costs
many surgeons are using sutures for it. As experience increases, and societal costs.
our ability to recognize finer structures and to keep within the At present, the laparoscopic repair of hernias finds its clinical
correct tissue planes, improves. This has been associated with niche in patients with bilateral or recurrent hernias or in patients

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