trial laparoscopic vs Lichtenstain repair - Forum

[Dottore]

For those interested there was a new trial on exactly this in the BMJ last week by Wellwood et al.

Key messages

In the 4 hours after surgery laparoscopic hernia repair with general
anaesthesia causes more pain than open repair with local anaesthesia
(mainly because of the anaesthesia used) and necessitates longer stay in
hospital. Laparoscopic hernia repair, however, causes less pain than
open hernia repair during the first 2 weeks after discharge

Laparoscopic hernia repair results in fewer episodes of wound infection,
persistent local pain, genital swelling, numbness, and constipation than
open repair. Urinary disturbances are more common after laparoscopic
than after open repair

Patients' perception of health 1 month after the operation (assessed
with the SF-36) and satisfaction with treatment is superior for
laparoscopic patients who also have a shorter period of convalescence
after surgery

The health service cost of day case laparoscopic repair is $335 more
than the cost of open mesh hernioplasty performed on a day case basis

[Surgeon]

Still, an infection rate of 11% in a very clean operation (particularly that
it involves placing a foreign body, viz. the mesh) is too high. This is not
to criticize the surgeons in the study. The question is whether these
morbidity numbers are so universal that they could be accepted as a
reference, based on which a conclusion of the superiority of Lap hernia
repair could be drawn. I hope this is not the case. If so, then we all
probably should get back to how we perform hemostasis in the OR. Thanks for
the comments.

[Billroth]

I would criticize the surgeons with an infection rate of 11% in a clean
operation. That seems to me like something is drastically wrong. Either
that or I am not measuring wound infection correctly. If I had an infection
rate of anything over 1% in a clean proceedure i'd be compulsively looking
over my methods.

In the last two yrs i've even quit using prophylactic antibiotics in hernia
surgery, something that came as a result of listening and reading this
group. I haven't noticed any change in my infection rate (0 is still 0). I
do about 75-125 lichtenstein repairs/yr. I have no way of doing a
comparison with laprascopic repair as I refuse to do that proceedure. The
most i've seen is a vicryl knot spit out the end of the incision rarely,
and I don't consider that an infection although maybe some do.

As for hematomas that is a different story. I've found that meticulous
hemostatis to the point of being totally neurotic about it, combined with
treating tissues very gently along with identifying the epigastic vessels
and avoiding them seems to help.

Routinely dividing the ilial inguinal nerve has reduced the "entrapped
nerve" syndrome.

One problem i have run into requiring reop in two patients: Using 0 prolene
sutures to sew in the mesh. The medial knots at the tubercle have caused
severe pain requiring re-exploration, removal of the knots and resolution
of the symptoms.

[Grandpa Phil]

This is a good question. I have significantly more groin wound hematomas than
hematomas anywhere else I operate. Is there some trick to reducing groin
hematomas?

[Billroth]

This IS to criticize the surgeons in the study This is a classic Type III
statistical error as described by Bob Condon in an editorial some years
back--a faulty conclusion deriving from a faulty result in a control group
NOBODY should be getting an 11% infection rate in a clean operation--this
invalidates the entire rest of the results, and thus the paper

[Noro]

I still preserve the ilio-inguinal nerve, and didn't see a reason to change
that so far.


>One problem i have run into requiring reop in two patients: Using 0 prolene
>sutures to sew in the mesh. The medial knots at the tubercle have caused
>severe pain requiring re-exploration, removal of the knots and resolution
>of the symptoms.

That good stitch into the periosteum of the pubic tubercle? It hurts
sometimes. I use a basically a sutureless technique. The only suture that I
place routinely is the one holding the ends of the fish-tail end of the
mesh, lateral to the cord. I bet removing those knots did not weaken your
repair. How soon after the surgery did you have to remove the prolenes?