The verdict is out on laparoscopic hernia repair
Lack of cost benefit means fewer select method
Laparoscopic procedures are usually hailed as a way to reduce length of stay, cut costs for patients and managed care companies, and return the patient to work sooner than open surgical procedures. While laparoscopic inguinal hernia repair does result in less pain and a quicker return to work,1,2 experts have been less enthusiastic about its value to completely replace open repairs.
"About 15% to 20% of inguinal hernias are repaired laparoscopically," says Lee L. Swanstrom, MD, medical director of the department of minimally invasive surgery at Legacy Health Systems in Portland, OR. "Laparoscopic repairs are generally performed by surgeons who have a special interest and experience in laparoscopy," he adds.
There are several reasons many surgeons have not switched to laparoscopic repair of inguinal hernias, says Swanstrom. "Inguinal hernia repair is a minor surgery anyway and is usually performed on an outpatient basis, so the laparoscopic procedure doesn’t make an inpatient procedure into an outpatient procedure," he explains.
For many surgery programs, the open procedure has lower costs associated with it because it has been performed for many years and has been evaluated in terms of cost containment for the past decade, he adds.
"We are just now beginning to negotiate package pricing for the laparoscopic procedure and address cost issues that will make the financial picture for both procedures more equal," says Swanstrom.
Recovery time following the laparoscopic procedure can be longer than recovery time for the open procedure because of the anesthesia requirements for each, says Robert J. Fitzgibbons, MD, professor in the department of surgery at Creighton University in Omaha, NE, and immediate past president of the American Hernia Society in Orlando, FL. The open procedure requires only local anesthesia, but the laparoscopic procedure requires general anesthesia since the abdominal cavity is distended with gas during surgery, he explains.
Same-day surgery managers and medical directors also have to be aware that laparoscopic hernia repair is a more difficult procedure to teach and to learn, says Swanstrom. The surgeon is working in the preperitoneal space for inguinal hernias rather than intra-abdominal space as in other procedures such as cholecystectomy, so there is less room to maneuver, he explains. For this reason, Swanstrom suggests that laparoscopic hernia repair have different credentialing criteria than other laparoscopic procedures. While each same-day surgery program needs to establish their criteria based upon the needs of its own patients and experience of its surgeons, the credentialing criteria should look for good training programs, a strong background in other laparoscopic procedures, and enough procedures to allow for the longer learning curve, he suggests. There is no magic number of procedures that Swanstrom can recommend for credentialing purposes because he says, "The number needs to be determined by the individual program and the experience of its surgeons."
The benefits of laparoscopic herniorrhaphy are less pain during recovery and an earlier return to normal activity for the patient,1,2 says George S. Ferzli, MD, professor of surgery at the State University of New York’s Health and Science Center in Brooklyn. Patients undergoing conventional hernia repair take four to six weeks to return to normal activity, while most patients undergoing the laparoscopic repair return to full activity in two weeks, says Ferzli. While same-day surgery managers cannot take reduced pain and increased productivity of the patient into account when justifying the costs of laparoscopic surgery, Ferzli points out, "As surgeons become more skilled, operating time decreases and costs decrease."
Another way to decrease costs of the procedure is to use no or fewer staples, says Swanstrom. Eliminating the use of staples is preferred by most surgeons because staples not only add cost but can cause bleeding, infection, or trapped nerves that result in postoperative pain, he says.
Although the laparoscopic procedure is a higher medical risk and open repair might be appropriate for most patients or surgeons, there are times that the laparoscopic is the far better choice, says Fitzgibbons. "With a bilateral hernia, we can repair both at the same time with no additional incisions," he explains. This is far less painful and much easier for the patient than the open procedures, he adds.
Patients with recurrent hernias are also good candidates for the laparoscopic repair because the procedure results in a stronger repair, says Fitzgibbons. "In the laparoscopic repair, we are placing the patch on the inside of the abdominal wall rather than the outside of the wall as we do in the open procedure."
When explaining the procedure to patients, Fitzgibbons always asks, "If you are repairing a tire, do you want the patch on the inside of the tire or the outside?"
References
1. Liem MSL, van der Graff Y, van Steensel CJ, et al. Comparison of conventional anterior surgery and laparoscopic surgery for inguinal hernia repair. N Engl J. Med 1997; 336: 1,541-1,547.
2. Juul P, Christensen K. Randomized clinical trial of laparoscopic versus open inguinal hernia repair. Br J Surg 1999; 86:316-319.
Sources
For more information about laparoscopic hernia repair, contact:
• Robert J. Fitzgibbons, MD, Professor, Department of Surgery, Creighton University, 601 N. 30th St., Suite 3740, Omaha, NE 68131. Telephone: (402) 280-4503. E-mail: [email protected].
• Lee L. Swanstrom, MD, Medical Director, Department of Minimally Invasive Surgery, Legacy Health Systems, 501 N. Graham St., Suite 120, Portland, OR 97227. Telephone: (503) 288-6167. E-mail: [email protected].
• George S. Ferzli, MD, Professor of Surgery, State University of New York, Health and Science Center at Brooklyn, 78 Cromwell Ave., Staten Island, NY 10304. Telephone: (718) 667-8100. E-mail: [email protected].
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