April 26, 2004 -- Hernia "keyhole" surgery may be less painful for men initially, but a new study shows that the standard, open-surgery technique is superior in terms of long-term effectiveness and safety.
In a large study published in the April 29 issue of TheNew England Journal of Medicine, researchers found men who had laparoscopic, or what's known as "keyhole" hernia surgery were more than twice as likely to suffer another hernia compared with those who had conventional hernia surgery.
The study shows that although men who undergo laparoscopic hernia surgery may experience less pain immediately after surgery and return to normal activities slightly earlier, their overall risk of complications is significantly greater.
Hernia surgery repair in men is very common, but the most effective surgical technique is not known. The researchers compared the two types of surgeries for repair of an inguinal hernia, a common type of hernia where tissue bulges out because of a weak spot of the abdominal wall. It can occur on one or both side of the groin and is often the result of heavy lifting or the normal wear and tear associated with aging.
Laparoscopic vs. Conventional Hernia Surgery
Researchers say more than 800,000 hernia operations were performed in the U.S. in 2000, and most of them were performed in men and on an outpatient basis. During conventional, open hernia surgery, the hernia is repaired through an incision made in the groin under local anesthesia. Typically, the patient is numbed from the waist down but is not asleep.
In recent years, a laparoscopic technique of hernia repair has been developed, in which the surgeon inserts a thin, lighted scope through an incision in the abdomen and repairs the hernia through another incision in the abdomen. The procedure requires general anesthesia.
In the study, researchers randomly assigned about 2,000 men to either laparoscopic or conventional hernia surgery using mesh prostheses and followed them for two years. The procedures were performed at 14 Veterans Affairs (VA) medical centers throughout the U.S.
Overall, 36% of the men who underwent a hernia repair had at least one complication, but complication rates were significantly higher among those who had laparoscopic surgery (39%) compared with those who had open surgery (33%).
Researchers found complications during and immediately after surgery as well as potentially life-threatening complications occurred significantly more frequently in the laparoscopic group than in the open group. But rates of long-term complications were similar between the two groups.
Men who had open surgery reported more pain in the two weeks following surgery than those in the laparoscopic group, but by three months after surgery reported pain levels were similar in both groups.
Other findings of the study include:
Men who had laparoscopic hernia surgery returned to normal activities one day earlier than those who had open surgery.
- Time to return to sexual activity was similar in the two groups.
- More men in the laparoscopic group were able to perform specific activities, such as climbing stairs, shoveling, or weight lifting, at two weeks after the procedure, but differences in activity level function between the groups disappeared after three months of follow-up.
- Both groups had improved function at three months after surgery compared to before the procedure, and there were no differences in improvement scores after two years.
Based on the results of their study, the researchers conclude that for first-time hernias, the standard, open technique of surgical repair "is superior to the laparoscopic technique, both in terms of recurrence rates and in terms of safety."
More Not Necessarily Better
In an editorial that accompanies the study, Danny O. Jacobs, MD, MPH, of Duke University Medical Center, says these findings show that most general surgeons can achieve excellent results using conventional hernia surgery techniques under local anesthesia.
"They also remind us that substantive short-term and long-term complications may occur, even after 'simple' hernia surgery," writes Jacobs.
But he says the study also raises many important questions about how the surgeon's and other hospital employees' experience with hernia surgery affects how well the patient does.
"The relationship between the volume of procedures performed and the outcomes is not straightforward," writes Jacobs. "It is apparent that some hospitals that do few hernia surgeries have good outcomes and some hospitals that do many hernia surgeries have relatively poor outcomes," he explains.