Open Mesh versus Laparoscopic Mesh Hernia Repair
http://www.100md.com
《新英格兰医药杂志》
To the Editor: Life-threatening complications and a high rate of recurrence of hernias (10.1 percent) cast doubt on the safety and clinical effectiveness of laparoscopic hernia repairs in the trial reported by Neumayer et al. (April 29 issue).1 Laparoscopic total extraperitoneal repair is generally considered superior to transabdominal preperitoneal repair. Transabdominal preperitoneal repair is associated with serious, though uncommon, complications such as visceral injury. In a Medical Research Council trial, all serious complications and port-site hernias developed in the 94 patients who had undergone transabdominal preperitoneal repair.2 The National Institute for Clinical Excellence, in the United Kingdom, favors total extraperitoneal repair. Its current appraisal document on laparoscopic surgery for repair of inguinal hernias notes that transabdominal preperitoneal repair carries a higher risk of visceral complications (0.76 percent) than total extraperitoneal repair (0.16 percent).3 In my experience, involving more than 430 laparoscopic total extraperitoneal repairs performed between April 1995 and March 2004, there have been no serious complications and no in-hospital deaths within 30 days after the procedure. Could the authors state how each of these two laparoscopic techniques compares with open mesh repair?
Sudhir Kumar, F.R.C.S.
Western General Hospital
Edinburgh EH4 2XU, United Kingdom
sudhir@sudhir.freeserve.co.uk
References
Neumayer L, Giobbie-Hurder A, Jonasson O, et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 2004;350:1819-1827.
The MRC Laparoscopic Groin Hernia Trial Group. Laparoscopic versus open repair of groin hernia: a randomised comparison. Lancet 1999;354:185-190.
National Institute for Clinical Excellence home page. (Accessed August 31, 2004, at http://www.nice.org.uk.)
To the Editor: Neumayer et al. report that the rate of recurrence of hernias was higher after laparoscopic repair than after repair by the Lichtenstein procedure (10.1 percent vs. 4.9 percent) at two years of follow-up. The rate of recurrence in the laparoscopic group is astonishingly high, as compared with the rate in another multicenter trial (0.4 percent among 6875 patients, at 3 years of follow-up)1 and in a single-center trial (1.5 percent for total extraperitoneal repair and 2.3 percent for transabdominal preperitoneal repair among 528 patients at 5.7 years of follow-up).2 One explanation could be the size of the mesh. There is enough evidence that, irrespective of the size of the hernia, the mesh should be at least 10 by 15 cm; Heikkinen et al. reported recurrences only in patients with mesh implants that were 6 by 10 cm.3 Neumayer et al. should state what size mesh they used in the laparoscopic group and whether the size had any effect on recurrences. Maybe the increased incidence of recurrences in their study is related not to the technique (laparoscopy) but rather to the size of the mesh. If so, the conclusions, which basically eliminate primary laparoscopic hernia repair as an option, must be revised.
Tim Strate, M.D.
Oliver Mann, M.D.
Jakob R. Izbicki, M.D.
University Hospital Hamburg
20246 Hamburg, Germany
strate@uke.uni-hamburg.de
References
Felix E, Scott S, Crafton B, et al. Causes of recurrence after laparoscopic hernioplasty: a multicenter study. Surg Endosc 1998;12:226-231.
Czechowski A, Schafmayer A. TAPP versus TEP: a retrospective analysis 5 years after laparoscopic transperitoneal and total endoscopic extraperitoneal repair in inguinal and femoral hernia. Chirurg 2003;74:1143-1148.
Heikkinen T, Bringman S, Ohtonen P, Kunelius P, Haukipuro K, Hulkko A. Five-year outcome of laparoscopic and Lichtenstein hernioplasties. Surg Endosc 2004;18:518-522.
To the Editor: In the study by Neumayer et al., the increased overall rate of recurrence after laparoscopic repair as compared with open repair may be explained by the presence of more advanced disease in the laparoscopy group. Could the authors provide data on the size of the defects? Alternatively, seromas and hematomas, which are more frequent after laparoscopic repairs than after open repair, can be difficult to differentiate from hernias by ultrasonography or physical examination. Acceptance of diagnoses of asymptomatic recurrences as definitive, without further investigation, could have contributed to the apparent increase in the rate of recurrence after laparoscopic repair. Were there differences between the groups in the rate of infections necessitating mesh removal or repeated operation?
Carlos Alvarez, M.D.
Highland Park Surgical Associates
Highland Park, NJ 08904
c.alvarez23@verizon.net
The authors reply: Dr. Kumar raises questions about the approaches to surgery in our study. Only 10 percent of the laparoscopic repairs were repaired by the transabdominal approach.1 The rate of complications (including life-threatening, intraoperative, short-term, and long-term complications) in the subgroup that underwent total extraperitoneal repair were similar to those in the subgroup that underwent transabdominal preperitoneal repair. The one bowel injury in our study, which resulted in death, occurred in a patient who underwent a total extraperitoneal repair. The rate of complications did not correlate with the experience of the attending surgeons in either the laparoscopic-repair or the open-repair groups.
As noted by Dr. Strate and colleagues, the rates of recurrence in our study were higher than those in other reports, but we believe that our rates are concordant with those in practice outside of specialized centers. In addition, we report two-year follow-up data. In a review conducted by the European Union Hernia Trialists Collaboration, only a third of the studies followed patients for two or more years; no indication of the percentage of patients available for follow-up was given.2 In the Medical Research Council trial, patients were followed for only one year, and 27 surgeons in 26 hospitals took part, suggesting that only the most experienced surgeons participated.3
Dr. Strate and colleagues also suggest that the size of the mesh used in laparoscopic repair might be linked to the risk of recurrence. We agree. In our laparoscopy group, the mean vertical dimension of the mesh among patients whose hernias recurred was smaller than that among patients whose hernias did not recur (8.1±0.6 cm vs. 8.5±1.3 cm, P<0.001), although the surgeon's level of experience may confound this observation.
Dr. Alvarez raises the possibility that other factors may have affected the observed recurrence rates. We did not measure the size of the defects. In the laparoscopy group, recurrences were distributed fairly evenly among types of hernia (according to Nyhus's classification4) recorded at the time of surgery. Sixteen percent of the reported recurrences were confirmed either at the time of repeated operation or by ultrasonography, and 84 percent were confirmed by another surgeon. There were no mesh infections that necessitated repeated operation or removal of the mesh.
Leigh Neumayer, M.D.
Veterans Affairs Medical Center
Salt Lake City, UT 84148
leigh.neumayer@hsc.utah.edu
Anita Giobbie-Hurder, M.S.
Veterans Affairs Cooperative Studies Program
Coordinating Center
Hines, IL 60141
Olga Jonasson, M.D.
University of Illinois
Chicago, IL 60612
References
Neumayer L, Jonasson O, Fitzgibbons R, et al. Tension-free inguinal hernia repair: the design of a trial to compare open and laparoscopic surgical techniques. J Am Coll Surg 2003;196:743-752.
EU Hernia Trialist Collaboration. Laparoscopic compared with open methods of groin hernia repair: systematic review of randomized controlled trials. Br J Surg 2000;87:860-867.
The MRC Laparoscopic Groin Hernia Trial Group. Laparoscopic versus open repair of groin hernia: a randomised comparison. Lancet 1999;354:185-190.
Nyhus LM. Individualization of hernia repair: a new era. Surgery 1993;114:1-2.
Sudhir Kumar, F.R.C.S.
Western General Hospital
Edinburgh EH4 2XU, United Kingdom
sudhir@sudhir.freeserve.co.uk
References
Neumayer L, Giobbie-Hurder A, Jonasson O, et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 2004;350:1819-1827.
The MRC Laparoscopic Groin Hernia Trial Group. Laparoscopic versus open repair of groin hernia: a randomised comparison. Lancet 1999;354:185-190.
National Institute for Clinical Excellence home page. (Accessed August 31, 2004, at http://www.nice.org.uk.)
To the Editor: Neumayer et al. report that the rate of recurrence of hernias was higher after laparoscopic repair than after repair by the Lichtenstein procedure (10.1 percent vs. 4.9 percent) at two years of follow-up. The rate of recurrence in the laparoscopic group is astonishingly high, as compared with the rate in another multicenter trial (0.4 percent among 6875 patients, at 3 years of follow-up)1 and in a single-center trial (1.5 percent for total extraperitoneal repair and 2.3 percent for transabdominal preperitoneal repair among 528 patients at 5.7 years of follow-up).2 One explanation could be the size of the mesh. There is enough evidence that, irrespective of the size of the hernia, the mesh should be at least 10 by 15 cm; Heikkinen et al. reported recurrences only in patients with mesh implants that were 6 by 10 cm.3 Neumayer et al. should state what size mesh they used in the laparoscopic group and whether the size had any effect on recurrences. Maybe the increased incidence of recurrences in their study is related not to the technique (laparoscopy) but rather to the size of the mesh. If so, the conclusions, which basically eliminate primary laparoscopic hernia repair as an option, must be revised.
Tim Strate, M.D.
Oliver Mann, M.D.
Jakob R. Izbicki, M.D.
University Hospital Hamburg
20246 Hamburg, Germany
strate@uke.uni-hamburg.de
References
Felix E, Scott S, Crafton B, et al. Causes of recurrence after laparoscopic hernioplasty: a multicenter study. Surg Endosc 1998;12:226-231.
Czechowski A, Schafmayer A. TAPP versus TEP: a retrospective analysis 5 years after laparoscopic transperitoneal and total endoscopic extraperitoneal repair in inguinal and femoral hernia. Chirurg 2003;74:1143-1148.
Heikkinen T, Bringman S, Ohtonen P, Kunelius P, Haukipuro K, Hulkko A. Five-year outcome of laparoscopic and Lichtenstein hernioplasties. Surg Endosc 2004;18:518-522.
To the Editor: In the study by Neumayer et al., the increased overall rate of recurrence after laparoscopic repair as compared with open repair may be explained by the presence of more advanced disease in the laparoscopy group. Could the authors provide data on the size of the defects? Alternatively, seromas and hematomas, which are more frequent after laparoscopic repairs than after open repair, can be difficult to differentiate from hernias by ultrasonography or physical examination. Acceptance of diagnoses of asymptomatic recurrences as definitive, without further investigation, could have contributed to the apparent increase in the rate of recurrence after laparoscopic repair. Were there differences between the groups in the rate of infections necessitating mesh removal or repeated operation?
Carlos Alvarez, M.D.
Highland Park Surgical Associates
Highland Park, NJ 08904
c.alvarez23@verizon.net
The authors reply: Dr. Kumar raises questions about the approaches to surgery in our study. Only 10 percent of the laparoscopic repairs were repaired by the transabdominal approach.1 The rate of complications (including life-threatening, intraoperative, short-term, and long-term complications) in the subgroup that underwent total extraperitoneal repair were similar to those in the subgroup that underwent transabdominal preperitoneal repair. The one bowel injury in our study, which resulted in death, occurred in a patient who underwent a total extraperitoneal repair. The rate of complications did not correlate with the experience of the attending surgeons in either the laparoscopic-repair or the open-repair groups.
As noted by Dr. Strate and colleagues, the rates of recurrence in our study were higher than those in other reports, but we believe that our rates are concordant with those in practice outside of specialized centers. In addition, we report two-year follow-up data. In a review conducted by the European Union Hernia Trialists Collaboration, only a third of the studies followed patients for two or more years; no indication of the percentage of patients available for follow-up was given.2 In the Medical Research Council trial, patients were followed for only one year, and 27 surgeons in 26 hospitals took part, suggesting that only the most experienced surgeons participated.3
Dr. Strate and colleagues also suggest that the size of the mesh used in laparoscopic repair might be linked to the risk of recurrence. We agree. In our laparoscopy group, the mean vertical dimension of the mesh among patients whose hernias recurred was smaller than that among patients whose hernias did not recur (8.1±0.6 cm vs. 8.5±1.3 cm, P<0.001), although the surgeon's level of experience may confound this observation.
Dr. Alvarez raises the possibility that other factors may have affected the observed recurrence rates. We did not measure the size of the defects. In the laparoscopy group, recurrences were distributed fairly evenly among types of hernia (according to Nyhus's classification4) recorded at the time of surgery. Sixteen percent of the reported recurrences were confirmed either at the time of repeated operation or by ultrasonography, and 84 percent were confirmed by another surgeon. There were no mesh infections that necessitated repeated operation or removal of the mesh.
Leigh Neumayer, M.D.
Veterans Affairs Medical Center
Salt Lake City, UT 84148
leigh.neumayer@hsc.utah.edu
Anita Giobbie-Hurder, M.S.
Veterans Affairs Cooperative Studies Program
Coordinating Center
Hines, IL 60141
Olga Jonasson, M.D.
University of Illinois
Chicago, IL 60612
References
Neumayer L, Jonasson O, Fitzgibbons R, et al. Tension-free inguinal hernia repair: the design of a trial to compare open and laparoscopic surgical techniques. J Am Coll Surg 2003;196:743-752.
EU Hernia Trialist Collaboration. Laparoscopic compared with open methods of groin hernia repair: systematic review of randomized controlled trials. Br J Surg 2000;87:860-867.
The MRC Laparoscopic Groin Hernia Trial Group. Laparoscopic versus open repair of groin hernia: a randomised comparison. Lancet 1999;354:185-190.
Nyhus LM. Individualization of hernia repair: a new era. Surgery 1993;114:1-2.