Open surgery better than laparoscopic for repair of inguinal hernia
http://www.100md.com
《英国医生杂志》
New York
The open surgical repair of primary inguinal hernias is better than the laparoscopic technique for mesh repair, a new study has shown ( New England Journal of Medicine 2004;350: 1819-27).
Laparoscopic primary repair of hernias had been previously reported to result in low recurrence rates and to be associated with substantially less pain in the immediate postoperative period and earlier return to normal activities compared to open repair ( New England Journal of Medicine 1997;336; 1541-7). But the laparoscopic technique requires general anaesthesia (because the abdominal cavity has to be inflated with air) and it is more often associated with serious intraoperative complications than is open repair, although such complications are infrequent ( Lancet 1999;354: 185-90).
In the current study, researchers led by Dr Leigh Neumayer of the Department of Surgery at the University of Utah in Salt Lake City randomly assigned men with inguinal hernias at 14 Veterans Affairs medical centres to either open mesh or laparoscopic mesh repair. The primary outcome was recurrence of hernias at two years; the secondary outcomes included complications and outcomes, such as reported pain and time off before returning to work.
The researchers randomly assigned 2164 patients aged 18 years or older to one of the two procedures. A total of 1983 patients had an operation, and two year follow up was completed in 1696 of the patients (86%).
Recurrences were more common in the group having laparoscopic surgery (87 of 862 patients (10.1%)) than in the group having open surgery (41/834 (4.9%) (odds ratio 2.2; 95% confidence interval 1.5 to 3.2). The rate of complications, including injury to spermatic cord, injury to a vessel, orchitis, and wound infection, among other complications, was also higher in the laparoscopic repair group than in the open repair group (39.0% v 33.4%; adjusted odds ratio, 1.3; 1.1 to 1.6).
Open repair of inguinal hernias, as for the indirect hernia pictured above, leads to fewer recurrences than laparoscopic repair, a new study says
Credit: BIOPHOTO ASSOCIATES/SPL
The laparoscopic repair group had less pain on the day of surgery (difference in mean score on a visual analogue scale, 10.2 mm; 95% confidence interval 4.8 to 15.6) and at two weeks (6.1 mm; 1.7 to 10.5) and returned to normal activities one day earlier (adjusted hazard ratio for a shorter time to return to normal activities 1.2; 1.1 to 1.3).
Although recurrence was significantly more common after laparoscopic repair than after open repair of primary hernias, rates of recurrence after repair of recurrent hernias were similar in the two groups (10.0% and 14.1% respectively). The presence of bilateral hernias did not alter the rate of recurrence after either procedure.
In an accompanying editorial (pp 1895-7), Dr Danny Jacobs of Duke University Medical Center in Durham, North Carolina, said that the findings showed that "most general surgeons can achieve excellent outcomes in hernia repair by using the tension-free open technique with local anesthesia."(Scott Gottlieb)
The open surgical repair of primary inguinal hernias is better than the laparoscopic technique for mesh repair, a new study has shown ( New England Journal of Medicine 2004;350: 1819-27).
Laparoscopic primary repair of hernias had been previously reported to result in low recurrence rates and to be associated with substantially less pain in the immediate postoperative period and earlier return to normal activities compared to open repair ( New England Journal of Medicine 1997;336; 1541-7). But the laparoscopic technique requires general anaesthesia (because the abdominal cavity has to be inflated with air) and it is more often associated with serious intraoperative complications than is open repair, although such complications are infrequent ( Lancet 1999;354: 185-90).
In the current study, researchers led by Dr Leigh Neumayer of the Department of Surgery at the University of Utah in Salt Lake City randomly assigned men with inguinal hernias at 14 Veterans Affairs medical centres to either open mesh or laparoscopic mesh repair. The primary outcome was recurrence of hernias at two years; the secondary outcomes included complications and outcomes, such as reported pain and time off before returning to work.
The researchers randomly assigned 2164 patients aged 18 years or older to one of the two procedures. A total of 1983 patients had an operation, and two year follow up was completed in 1696 of the patients (86%).
Recurrences were more common in the group having laparoscopic surgery (87 of 862 patients (10.1%)) than in the group having open surgery (41/834 (4.9%) (odds ratio 2.2; 95% confidence interval 1.5 to 3.2). The rate of complications, including injury to spermatic cord, injury to a vessel, orchitis, and wound infection, among other complications, was also higher in the laparoscopic repair group than in the open repair group (39.0% v 33.4%; adjusted odds ratio, 1.3; 1.1 to 1.6).
Open repair of inguinal hernias, as for the indirect hernia pictured above, leads to fewer recurrences than laparoscopic repair, a new study says
Credit: BIOPHOTO ASSOCIATES/SPL
The laparoscopic repair group had less pain on the day of surgery (difference in mean score on a visual analogue scale, 10.2 mm; 95% confidence interval 4.8 to 15.6) and at two weeks (6.1 mm; 1.7 to 10.5) and returned to normal activities one day earlier (adjusted hazard ratio for a shorter time to return to normal activities 1.2; 1.1 to 1.3).
Although recurrence was significantly more common after laparoscopic repair than after open repair of primary hernias, rates of recurrence after repair of recurrent hernias were similar in the two groups (10.0% and 14.1% respectively). The presence of bilateral hernias did not alter the rate of recurrence after either procedure.
In an accompanying editorial (pp 1895-7), Dr Danny Jacobs of Duke University Medical Center in Durham, North Carolina, said that the findings showed that "most general surgeons can achieve excellent outcomes in hernia repair by using the tension-free open technique with local anesthesia."(Scott Gottlieb)