Why do I offer open hernia repair?

Laparoscopic surgery has actually been around for a while, pioneered by adventurous gynaecologists. Widespread adoption occurred in the 1990s when video cameras became small enough to allow the images to be seen by the entire team on tv screens. An explosion of general surgical operations followed starting with laparoscopic cholecystectomy (removal of the gallbladder) but now many operations can be performed safely, including complex cancer procedures. Further advances have included robotic surgery, another step advance in some areas.

 

The game-changing advantage of laparoscopic surgery comes from making smaller incisions resulting in less pain, fewer wound complications, and faster recovery. When compared to large or painful incisions, this is true. Laparoscopic cholecystectomy is a great example. Where this argument becomes marginal is with relatively small incisions that aren’t particularly painful — and a lot of hernia surgery is in this category. 

 

Soon after laparoscopic hernia surgery was introduced, some enthusiasts predicted it would rapidly become the only way to deal with these problems. Interestingly, that has not happened. In fact, about two thirds of hernia operations are still performed in the open, traditional manner. So what has changed?

 

First, learning laparoscopic hernia is difficult. There is a “learning curve” of around 200 operations before expertise is obtained. While current training in General Surgery includes these procedures, much of it is under supervision, and the numbers are usually not of the magnitude to guarantee mastery.
Always ask your surgeon how many procedures they have personally performed.

 

Second, the cost of laparoscopic procedures is significantly higher than open surgery. You may argue that someone else pays (such as an insurer) but ultimately this cost has to be passed on, usually by way of higher premiums for yourself and others. In the public health system, cost is a very real issue. Spending more in one area means less in another. When the medium- to long-term outcomes are no better, the extra money should be challenged.

 

Third, the advantageous early return to normal activities has been overstated in laparoscopic surgery — or, more correctly, patients undergoing open surgery are getting back to normal much faster. Surgeons have recognised we probably put over-cautious proscriptions on activities.
My own advice is take it easy for a couple of days; expect to be doing normal day-to-day things comfortably by one week; and avoid rugby practice for two weeks. Beyond that: use common sense! 

 

Finally: there is a theoretical risk that future laparoscopic or robotic prostate surgery may be technically more difficult, or even not possible. While skills are improving, this at least needs to be considered.

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It all comes down to considering both the benefits AND THE RISKS for any operation.

 

Does this mean there’s NO role for laparoscopic hernia surgery?

 

There are some groups of patients who may benefit from laparoscopic surgery. 

 

1. Those with recurrence after previous open hernia repair. The scarring and altered anatomy after these operations mean the laparoscopic approach, through fresh tissues, is wise.

2. Young healthy people with hernias on both sides.

3. Professional athletes/heavy manual labourers. You may get back to paid activities slightly faster.

 

I am very happy to recommend and refer to selected, highly-experienced colleagues in these situations.