- Email: [email protected]
Variation of laparoscopic hernia repair in Scotland: A postcode lottery?
the surgeon 8 (2010) 140–143
available at www.sciencedirect.com
The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Variation of laparoscopic hernia repair in Scotland: A postcode lottery? A.D. Stevenson*, S.J. Nixon, S. Paterson-Brown Department of Surgery, Royal Infirmary of Edinburgh, UK
article info
abstract
Article history:
Background and Purpose: The laparoscopic approach is now recommended by NICE as the
Received 11 November 2009
preferred technique for repair of bilateral and recurrent inguinal hernia and an accepted
Accepted 11 November 2009
option for unilateral hernia. This study was set up to examine whether patients across Scotland had equal access to this method of treatment.
Keywords:
Methods: Information was collected on laparoscopic hernia repairs in adults at all acute
Inguinal hernia
general NHS hospitals in Scotland between the financial years 1997/8 and 2007/8. Private
Laparoscopic
hospitals were excluded due to lack of data. The data were derived from SMR01 data of
Laparoscopy
inpatient and daycase discharges from non-paediatric general acute NHS hospitals in Scotland as collected by the Information Services Division (ISD) of NHS National Services Scotland. Findings: Of 6821 repairs in 2007/8, only 890 (13.0%) were performed laparoscopically, a small increase from 294 (4.5%) in 1997/8. The highest incidence of laparoscopic hernia repair in 2007/8 was in NHS Lothian, where 435 (41.1%) of all repairs were performed using the laparoscopic technique. Excluding NHS Lothian, the number of laparoscopic hernia repairs in the rest of Scotland showed a much smaller rise, from 184 (3.3%) to 455 (7.9%). NHS Lothian, (which has 20% of the Scottish population) performed 54.5% of laparoscopic repairs in Scotland between 1997/8 and 2007/8. In the most recent year available, 2007/8, 63.1% of bilateral primary, 53.7% of bilateral recurrent and 26.8% of unilateral recurrent hernia operations in Lothian were laparoscopic. This compares to only 9.9%, 7.0% and 7.1%, respectively, for other Scottish hospitals. Conclusions: Despite the fact that laparoscopic hernia repair has several proven advantages over open techniques, particularly in bilateral and recurrent hernias, activity remains at a low level in Scotland with the exception of NHS Lothian. In Scotland, laparoscopic techniques are not being used as recommended by NICE guidelines and there appears to be a ‘‘postcode lottery’’ in the provision of this method of treatment. Possible reasons are discussed and action plans are suggested. ª 2009 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
* Correspondence author. 88/3 Marchmont Crescent, Edinburgh EH9 1HD, UK. Tel.: þ7900927186. E-mail address: [email protected] (A.D. Stevenson). 1479-666X/$ – see front matter ª 2009 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2009.11.001
141
the surgeon 8 (2010) 140–143
Table 1
Introduction
Year The repair of an inguinal hernia is one of the most commonly performed elective operations in the UK, with around 70,000 being undertaken each year in England alone.1,2 The most common method in the UK is the open mesh repair, which involves an incision in the inguinal region and the insertion of a mesh to support the posterior inguinal wall.1 However in recent years, several laparoscopic approaches have been developed and these have gradually increased in prevalence. The two main laparoscopic techniques practiced are the transabdominal pre-peritoneal (TAPP) and the totally extraperitoneal (TEP) repairs.1 Many studies, including several randomised controlled trials, have shown that laparoscopic repair, and in particular the TEP, is associated with fewer postoperative complications, reduced pain and numbness, and earlier return to work compared when compared to the open technique.1,3–5 The National Institute of Clinical Excellence (NICE) now recommends laparoscopic repair as the preferred method of treatment for bilateral and recurrent hernia (which represent around 20% of presenting patients) and accepts it as a suitable technique for unilateral hernia in trained hands.1 We have already reported a substantial increase in the number of laparoscopic mesh repairs for inguinal hernia in SE Scotland between 1993 and 2001,6 and this study was set up to see if a similar trend could be observed in other regions of Scotland.
97/98 98/99 99/00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 TOTAL
No. of Laparoscopic Total no. of % Laparoscopic Repairs repairs 294 350 311 337 263 305 361 507 506 589 890 4,713
6570 6622 6199 6223 6064 5652 6207 6393 6818 6751 6828 70,327
4.5% 5.3% 5.0% 5.4% 4.3% 5.4% 5.8% 7.9% 7.4% 8.7% 13.0% 6.7%
identified as code T21-. This study particularly focussed on the numbers of open and laparoscopic inguinal hernia repairs performed between the financial years 1997/8 and 2007/8 in order to identify any shift in practice from the early days of laparoscopic hernia repair to more recent years. The data were arranged by the type of hernia – unilateral primary, unilateral recurrent, bilateral primary, and bilateral recurrent – for each hospital. These were then analysed to identify trends in the proportion of inguinal hernia repairs performed laparoscopically over this time period.
Results Methods Data were obtained from the Information Services Division (ISD) of NHS National Services Scotland on the incidence of inguinal hernia repair in adults, in acute general hospitals, in Scotland. Private hospitals were excluded due to incomplete data. The number of procedures was derived from SMR01 data of inpatient and daycase discharges. Laparoscopic procedures were identified through the supplementary OPCS4 operation code Y50.8. Bilateral inguinal hernia were identified by the ICD-10 diagnosis codes K40.0, K40.1 and K40.3 and unilateral inguinal hernia were identified by the codes K40.3, K40.4 and K40.9. Primary inguinal hernia repair were identified as the main operation OPCS4 code T20- and recurrent hernia repair
Laparoscopic Repairs (as a % of the total)
Proportion of Inguinal Hernia Repairs Performed Laparoscopically in Scotland, 1997/8 - 2007/8 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 97/98 98/99 99/00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 Year
Fig. 1
Between 1997/8 and 2007/8, a total of 70,327 adult inguinal hernia repairs were carried out in NHS hospitals in Scotland. Of these, 4713 (6.7%) were laparoscopic. In the most recent year available, 2007/8, a total of 6828 adult inguinal hernia repairs were performed, of which 890 (13.0%) were performed laparoscopically Fig. 1. This compares to 294 (4.5%) in 1997/8. The data for all Scottish hospitals are detailed in Table 1. There is wide variation between hospitals, with 3 out of the 49 hospitals performing over 40% of the laparoscopic repairs, compared to 17 hospitals which carried out exclusively open operations. It is clear from these data that hospitals in the Lothian area performed the highest proportion of laparoscopic procedures. These data were therefore extracted and compared to the rest of Scotland over the same time period. Lothian hospitals showed a marked increase in laparoscopic repairs between 1997/8 and 2007/8 compared to the rest of Scotland, where the increase was from 184 (3.3%) in 1997/8 to 455 (7.9%) in 2007/8 (see Fig. 2). Between 1997/8 and 2007/8 the 2568 laparoscopic hernia repairs carried out in Lothian represented 54.5% of all repairs carried out in Scotland Table 2. NICE has stated that repairs on all bilateral hernia and unilateral recurrent hernia should be performed laparoscopically.1 The number of open and laparoscopic repairs preformed in Lothian and the rest of Scotland, between 1997/8 and 2007/8, for each type of inguinal hernia, is represented in Table 3. Again, the proportion of bilateral hernia repaired laparoscopically was found to be much higher in Lothian, as illustrated in Fig. 3.
142
the surgeon 8 (2010) 140–143
A Comparison of NHS Lothian and Other Scottish Hospitals Laparoscopic Inguinal Hernia Repair 1997/8 - 2007/8
Table 2
Lothian 97/98 98/99 99/00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08
110 178 162 172 180 179 216 281 342 313 435
(11.6%) (17.3%) (16.4%) (18.5%) (18.5%) (22.0%) (22.9%) (28.6%) (34.2%) (35.2%) (41.1%)
Rest of Scotland 184 172 143 165 83 126 145 226 164 276 455
(3.3%) (3.1%) (2.7%) (3.1%) (1.6%) (2.6%) (2.8%) (4.2%) (2.8%) (4.7%) (7.9%)
Discussion This study has demonstrated that only 8.9% of inguinal repairs were performed laparoscopically in Scotland in the financial year 2006/7, compared to 13.8% of repairs in NHS hospitals in England during the same year.7 It is also widely believed that the UK lags behind Europe in the adoption of laparoscopic hernia surgery. This is in spite of it now being a well-established technique with significant clinical evidence to support its use, particularly in patients with bilateral and recurrent hernia.1 Although one might also have expected laparoscopic repairs to have risen steadily throughout the last 10 years as more surgeons took up the technique, this clearly has not been the case, with the exception of NHS Lothian, which accounted for over half (54.5%) of all laparoscopic repairs in Scotland during the study period. This trend supports the earlier data from Lothian which found that laparoscopic mesh repair for recurrent hernias increased to 42% by 2001.6 The rate of laparoscopic repairs in the rest of Scotland showed a much smaller rise between 1997/8 and 2007/8, from 3.3% to 7.9%. This disparity remains even if only
NHS Lothian
Laparoscopic Repairs (as a % of the total)
No. of Inguinal Hernia Repairs Performed Laparoscopically (% of area’s total)
Rest of Scotland
45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0%
97/98
98/99
99/00
00/01
01/02
02/03
03/04
04/05
05/06
06/07
07/08
Yea r
Fig. 2
laparoscopic repair for bilateral or recurrent hernia (as suggested by NICE1) are considered (Fig. 2). Clearly not all patients are suitable for a laparoscopic repair and not every surgeon will be capable of performing a laparoscopic repair. However this does not explain the very low overall utilisation of the laparoscopic technique in Scottish Hospitals. Problems with coding may contribute, but this is likely to be
Percentage of Hernia Repairs Performed Laparoscopically 97/98 - 07/08, by Hernia Type NHS Lothian
Rest of Scotland
70.0%
% Laparoscopic
Year
63.1%
60.0%
53.7%
50.0% 40.0% 26.8%
30.0% 20.0% 10.0%
19.2% 2.8%
9.9%
7.1%
7.0%
0.0% Unilateral Primary
Unilateral Recurrent
Bilateral Primary
Bilateral Recurrent
Hernia Type
Fig. 3
Table 3 Area
Hernia Type
No. of Open Repairs
No. of Laparo-scopic Repairs
Total No. of Repairs
% Laparo-scopic
NHS Lothian
Bilateral Recurrent Bilateral Primary Unilateral Recurrent Unilateral Primary
50 391 558 6,885
58 668 204 1,641
108 1,059 762 8,526
53.7% 63.1% 26.8% 19.2%
Rest of Scotland
Bilateral Recurrent Bilateral Primary Unilateral Recurrent Unilateral Primary
211 3,236 3,214 52,421
16 356 246 1,524
227 3,592 3,460 53,945
7.0% 9.9% 7.1% 2.8%
Total
Bilateral Recurrent Bilateral Primary Unilateral Recurrent Unilateral Primary
261 3,627 3,772 59,306
74 1,024 450 3,165
335 4,651 4,222 62,471
22.1% 22.0% 10.7% 5.1%
Footnote: Figures in bold are for procedures where NICE recommends a laparoscopic approach
the surgeon 8 (2010) 140–143
similar across all Scottish regions and therefore comparison of percentages of laparoscopic repairs likely to remain reliable. The single most likely cause is that the majority of general surgeons are comfortable with the open technique and considerable additional training is required for the laparoscopic technique which is technically more complex and difficult to learn.8,9 Other reasons might include a disbelief amongst surgeons as to the benefits of the laparoscopic approach despite extensive trial evidence, a difficulty in obtaining the appropriate training and possibly economic constraints. Furthermore the earlier reports of laparoscopic repair demonstrated disadvantages compared to the open technique which included a longer operating time, increased operating costs (if disposable instrumentation were used), the requirement for a general anaesthetic and an increased rate of recurrence.1,3,7 Although these factors may have deterred many surgeons from taking up this technique in the past, this should no longer be the case, with recent studies now showing that the laparoscopic repair is actually faster9 and has a reduced recurrence rate.5,10 Not surprisingly increasing experience in the laparoscopic technique is associated with reduced rates of complications, conversions and recurrences.8,11,12 Examination of the learning curve in Lothian, demonstrated a recurrence rate of 10% for the first 20 TEP repairs, falling to under 2% after 80 repairs have been undertaken.13 This study included all-comers (primary, unilateral, bilateral and recurrent hernia) and reported an overall 3% recurrence rate following TEP repair over an 11 year period compared to a 10.1% recurrence reported over only 2 years in a large-scale randomised prospective study.14 The introduction of laparoscopic repair in South East Scotland has in fact been associated with a reduction in the ratio of recurrent to primary hernia repairs performed.6 There may also be a reluctance to adopt laparoscopic hernia surgery for economic reasons, although NICE concluded that initial increased hospital costs are offset by benefits from reduced complications and more rapid recovery. Low cost operative techniques have however now been reported.15 If all patients in Scotland (and the rest of the UK) are to be given equal access to appropriate laparoscopic inguinal hernia surgery as recommended by NICE, then the issues of surgical beliefs, operative training and health economics all need to be addressed. This will require much better co-operation between the NHS and professional surgical bodies, such as the Royal Colleges. At present the drive for training and adoption of this technique is very much up to the individual surgeons, supported in many occasions by Industry. There is a wider issue here relating to the ability of the Health Service to react to new techniques in all areas of Medicine and, once evaluated, how they can be introduced on a National scale.
Conclusions Laparoscopic inguinal hernia repair has been shown to have several advantages over open techniques, particularly for bilateral and recurrent hernia. However it still remains at a low level in Scotland with marked regional variation,
143
suggesting that many patients are being denied the most appropriate procedure for their condition simply because of where they live.
Acknowledgments The authors wish to thank Mr Andrew Lee and Ms Ishbel Robertson, Information Analysts at the Information Services Division of NHS Services Scotland for their help in providing the data.
references
1. NICE. Laparoscopic surgery for inguinal hernia repair. Technology Appraisal Guidance 83; September 2004. 2. Parks RW. The abdominal wall and hernia. In: Garden et al, editors. Principles and practices of surgery, 5th edition; 2007. 3. Memon MA, Cooper NJ, Memon B, Memon MI, Abrams KR. Meta-analysis of randomized clinical trials comparing open and laparoscopic inguinal hernia repair. British Journal of Surgery December 2003;90(12):1479–92. 4. McCormack K, Scott NW, Go PM, Ross S, Grant AM. Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev 2003;(1). CD001785. 5. Eklund A, Rudberg C, Smedberg S, Enander LK, Leijonmarck CE, Osterberg J, et al. Short-term results of a randomized clinical trial comparing Lichtenstein open repair with totally extraperitoneal laparoscopic inguinal hernia repair. British Journal of Surgery September 2006;93(9):1060–8. 6. Atkinson HDE, Nicol SG, Purkayastha S, Paterson-Brown S. Surgical management of inguinal hernia: retrospective cohort study in south eastern Scotland, 1985–2001. BMJ Dec 2004;329: 1315–6. 7. NICE. Implementation uptake report: laparoscopic surgery for inguinal hernia repair; February 2008. 8. Edwards CC, Bailey RW. Laparoscopic hernia repair: the learning curve. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques June 2000;10(3):149–53. 9. Duff M, Mofidi R, Nixon SJ. Routine laparoscopic repair of primary unilateral inguinal hernias – a viable alternative in the day surgery unit? The Surgeon 2007;5(4):209–12. 10. Wara P, Bay-Nielsen M, Juul P, Bendix J, Kehlet H. Prospective nationwide analysis of laparoscopic versus Lichtenstein repair of inguinal hernia. British Journal of Surgery October 2005;92(10):1277–81. 11. Lowham AS, Filipi CJ, Fitzgibbons Jr RJ, Stoppa R, Wants GE, Felix EL, et al. Mechanisms of hernia recurrence after preperitoneal mesh repair: traditional and laparoscopic. Ann Surg 1997;225:422–31. 12. Bittner R, Schmedt C-G, Schwarz J, Kraft K, Leibl BJ. Laparoscopic transperitoneal procedure for routine repair of groin hernia. British Journal of Surgery 2002;89(8):1062–6. 13. Lamb ADG, Robson AJ, Nixon SJ. Recurrence after totally extra-peritoneal laparoscopic repair: implications for operative technique and surgical training. Surgeon 2006;4:299–307. 14. Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons Jr R, Dunlop D, Gibbs J, Reda D, Henderson W. Open mesh versus laparoscopic mesh repair of inguinal hernia. New England Journal of Medicine April 29, 2004;350(18):1819–27. 15. Nixon SJ, Kumar S. The totally extraperitoneal approach to inguinal hernia repair. The Surgeon 2005;3(4):281–7.
available at www.sciencedirect.com
The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Variation of laparoscopic hernia repair in Scotland: A postcode lottery? A.D. Stevenson*, S.J. Nixon, S. Paterson-Brown Department of Surgery, Royal Infirmary of Edinburgh, UK
article info
abstract
Article history:
Background and Purpose: The laparoscopic approach is now recommended by NICE as the
Received 11 November 2009
preferred technique for repair of bilateral and recurrent inguinal hernia and an accepted
Accepted 11 November 2009
option for unilateral hernia. This study was set up to examine whether patients across Scotland had equal access to this method of treatment.
Keywords:
Methods: Information was collected on laparoscopic hernia repairs in adults at all acute
Inguinal hernia
general NHS hospitals in Scotland between the financial years 1997/8 and 2007/8. Private
Laparoscopic
hospitals were excluded due to lack of data. The data were derived from SMR01 data of
Laparoscopy
inpatient and daycase discharges from non-paediatric general acute NHS hospitals in Scotland as collected by the Information Services Division (ISD) of NHS National Services Scotland. Findings: Of 6821 repairs in 2007/8, only 890 (13.0%) were performed laparoscopically, a small increase from 294 (4.5%) in 1997/8. The highest incidence of laparoscopic hernia repair in 2007/8 was in NHS Lothian, where 435 (41.1%) of all repairs were performed using the laparoscopic technique. Excluding NHS Lothian, the number of laparoscopic hernia repairs in the rest of Scotland showed a much smaller rise, from 184 (3.3%) to 455 (7.9%). NHS Lothian, (which has 20% of the Scottish population) performed 54.5% of laparoscopic repairs in Scotland between 1997/8 and 2007/8. In the most recent year available, 2007/8, 63.1% of bilateral primary, 53.7% of bilateral recurrent and 26.8% of unilateral recurrent hernia operations in Lothian were laparoscopic. This compares to only 9.9%, 7.0% and 7.1%, respectively, for other Scottish hospitals. Conclusions: Despite the fact that laparoscopic hernia repair has several proven advantages over open techniques, particularly in bilateral and recurrent hernias, activity remains at a low level in Scotland with the exception of NHS Lothian. In Scotland, laparoscopic techniques are not being used as recommended by NICE guidelines and there appears to be a ‘‘postcode lottery’’ in the provision of this method of treatment. Possible reasons are discussed and action plans are suggested. ª 2009 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
* Correspondence author. 88/3 Marchmont Crescent, Edinburgh EH9 1HD, UK. Tel.: þ7900927186. E-mail address: [email protected] (A.D. Stevenson). 1479-666X/$ – see front matter ª 2009 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2009.11.001
141
the surgeon 8 (2010) 140–143
Table 1
Introduction
Year The repair of an inguinal hernia is one of the most commonly performed elective operations in the UK, with around 70,000 being undertaken each year in England alone.1,2 The most common method in the UK is the open mesh repair, which involves an incision in the inguinal region and the insertion of a mesh to support the posterior inguinal wall.1 However in recent years, several laparoscopic approaches have been developed and these have gradually increased in prevalence. The two main laparoscopic techniques practiced are the transabdominal pre-peritoneal (TAPP) and the totally extraperitoneal (TEP) repairs.1 Many studies, including several randomised controlled trials, have shown that laparoscopic repair, and in particular the TEP, is associated with fewer postoperative complications, reduced pain and numbness, and earlier return to work compared when compared to the open technique.1,3–5 The National Institute of Clinical Excellence (NICE) now recommends laparoscopic repair as the preferred method of treatment for bilateral and recurrent hernia (which represent around 20% of presenting patients) and accepts it as a suitable technique for unilateral hernia in trained hands.1 We have already reported a substantial increase in the number of laparoscopic mesh repairs for inguinal hernia in SE Scotland between 1993 and 2001,6 and this study was set up to see if a similar trend could be observed in other regions of Scotland.
97/98 98/99 99/00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 TOTAL
No. of Laparoscopic Total no. of % Laparoscopic Repairs repairs 294 350 311 337 263 305 361 507 506 589 890 4,713
6570 6622 6199 6223 6064 5652 6207 6393 6818 6751 6828 70,327
4.5% 5.3% 5.0% 5.4% 4.3% 5.4% 5.8% 7.9% 7.4% 8.7% 13.0% 6.7%
identified as code T21-. This study particularly focussed on the numbers of open and laparoscopic inguinal hernia repairs performed between the financial years 1997/8 and 2007/8 in order to identify any shift in practice from the early days of laparoscopic hernia repair to more recent years. The data were arranged by the type of hernia – unilateral primary, unilateral recurrent, bilateral primary, and bilateral recurrent – for each hospital. These were then analysed to identify trends in the proportion of inguinal hernia repairs performed laparoscopically over this time period.
Results Methods Data were obtained from the Information Services Division (ISD) of NHS National Services Scotland on the incidence of inguinal hernia repair in adults, in acute general hospitals, in Scotland. Private hospitals were excluded due to incomplete data. The number of procedures was derived from SMR01 data of inpatient and daycase discharges. Laparoscopic procedures were identified through the supplementary OPCS4 operation code Y50.8. Bilateral inguinal hernia were identified by the ICD-10 diagnosis codes K40.0, K40.1 and K40.3 and unilateral inguinal hernia were identified by the codes K40.3, K40.4 and K40.9. Primary inguinal hernia repair were identified as the main operation OPCS4 code T20- and recurrent hernia repair
Laparoscopic Repairs (as a % of the total)
Proportion of Inguinal Hernia Repairs Performed Laparoscopically in Scotland, 1997/8 - 2007/8 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 97/98 98/99 99/00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 Year
Fig. 1
Between 1997/8 and 2007/8, a total of 70,327 adult inguinal hernia repairs were carried out in NHS hospitals in Scotland. Of these, 4713 (6.7%) were laparoscopic. In the most recent year available, 2007/8, a total of 6828 adult inguinal hernia repairs were performed, of which 890 (13.0%) were performed laparoscopically Fig. 1. This compares to 294 (4.5%) in 1997/8. The data for all Scottish hospitals are detailed in Table 1. There is wide variation between hospitals, with 3 out of the 49 hospitals performing over 40% of the laparoscopic repairs, compared to 17 hospitals which carried out exclusively open operations. It is clear from these data that hospitals in the Lothian area performed the highest proportion of laparoscopic procedures. These data were therefore extracted and compared to the rest of Scotland over the same time period. Lothian hospitals showed a marked increase in laparoscopic repairs between 1997/8 and 2007/8 compared to the rest of Scotland, where the increase was from 184 (3.3%) in 1997/8 to 455 (7.9%) in 2007/8 (see Fig. 2). Between 1997/8 and 2007/8 the 2568 laparoscopic hernia repairs carried out in Lothian represented 54.5% of all repairs carried out in Scotland Table 2. NICE has stated that repairs on all bilateral hernia and unilateral recurrent hernia should be performed laparoscopically.1 The number of open and laparoscopic repairs preformed in Lothian and the rest of Scotland, between 1997/8 and 2007/8, for each type of inguinal hernia, is represented in Table 3. Again, the proportion of bilateral hernia repaired laparoscopically was found to be much higher in Lothian, as illustrated in Fig. 3.
142
the surgeon 8 (2010) 140–143
A Comparison of NHS Lothian and Other Scottish Hospitals Laparoscopic Inguinal Hernia Repair 1997/8 - 2007/8
Table 2
Lothian 97/98 98/99 99/00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08
110 178 162 172 180 179 216 281 342 313 435
(11.6%) (17.3%) (16.4%) (18.5%) (18.5%) (22.0%) (22.9%) (28.6%) (34.2%) (35.2%) (41.1%)
Rest of Scotland 184 172 143 165 83 126 145 226 164 276 455
(3.3%) (3.1%) (2.7%) (3.1%) (1.6%) (2.6%) (2.8%) (4.2%) (2.8%) (4.7%) (7.9%)
Discussion This study has demonstrated that only 8.9% of inguinal repairs were performed laparoscopically in Scotland in the financial year 2006/7, compared to 13.8% of repairs in NHS hospitals in England during the same year.7 It is also widely believed that the UK lags behind Europe in the adoption of laparoscopic hernia surgery. This is in spite of it now being a well-established technique with significant clinical evidence to support its use, particularly in patients with bilateral and recurrent hernia.1 Although one might also have expected laparoscopic repairs to have risen steadily throughout the last 10 years as more surgeons took up the technique, this clearly has not been the case, with the exception of NHS Lothian, which accounted for over half (54.5%) of all laparoscopic repairs in Scotland during the study period. This trend supports the earlier data from Lothian which found that laparoscopic mesh repair for recurrent hernias increased to 42% by 2001.6 The rate of laparoscopic repairs in the rest of Scotland showed a much smaller rise between 1997/8 and 2007/8, from 3.3% to 7.9%. This disparity remains even if only
NHS Lothian
Laparoscopic Repairs (as a % of the total)
No. of Inguinal Hernia Repairs Performed Laparoscopically (% of area’s total)
Rest of Scotland
45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0%
97/98
98/99
99/00
00/01
01/02
02/03
03/04
04/05
05/06
06/07
07/08
Yea r
Fig. 2
laparoscopic repair for bilateral or recurrent hernia (as suggested by NICE1) are considered (Fig. 2). Clearly not all patients are suitable for a laparoscopic repair and not every surgeon will be capable of performing a laparoscopic repair. However this does not explain the very low overall utilisation of the laparoscopic technique in Scottish Hospitals. Problems with coding may contribute, but this is likely to be
Percentage of Hernia Repairs Performed Laparoscopically 97/98 - 07/08, by Hernia Type NHS Lothian
Rest of Scotland
70.0%
% Laparoscopic
Year
63.1%
60.0%
53.7%
50.0% 40.0% 26.8%
30.0% 20.0% 10.0%
19.2% 2.8%
9.9%
7.1%
7.0%
0.0% Unilateral Primary
Unilateral Recurrent
Bilateral Primary
Bilateral Recurrent
Hernia Type
Fig. 3
Table 3 Area
Hernia Type
No. of Open Repairs
No. of Laparo-scopic Repairs
Total No. of Repairs
% Laparo-scopic
NHS Lothian
Bilateral Recurrent Bilateral Primary Unilateral Recurrent Unilateral Primary
50 391 558 6,885
58 668 204 1,641
108 1,059 762 8,526
53.7% 63.1% 26.8% 19.2%
Rest of Scotland
Bilateral Recurrent Bilateral Primary Unilateral Recurrent Unilateral Primary
211 3,236 3,214 52,421
16 356 246 1,524
227 3,592 3,460 53,945
7.0% 9.9% 7.1% 2.8%
Total
Bilateral Recurrent Bilateral Primary Unilateral Recurrent Unilateral Primary
261 3,627 3,772 59,306
74 1,024 450 3,165
335 4,651 4,222 62,471
22.1% 22.0% 10.7% 5.1%
Footnote: Figures in bold are for procedures where NICE recommends a laparoscopic approach
the surgeon 8 (2010) 140–143
similar across all Scottish regions and therefore comparison of percentages of laparoscopic repairs likely to remain reliable. The single most likely cause is that the majority of general surgeons are comfortable with the open technique and considerable additional training is required for the laparoscopic technique which is technically more complex and difficult to learn.8,9 Other reasons might include a disbelief amongst surgeons as to the benefits of the laparoscopic approach despite extensive trial evidence, a difficulty in obtaining the appropriate training and possibly economic constraints. Furthermore the earlier reports of laparoscopic repair demonstrated disadvantages compared to the open technique which included a longer operating time, increased operating costs (if disposable instrumentation were used), the requirement for a general anaesthetic and an increased rate of recurrence.1,3,7 Although these factors may have deterred many surgeons from taking up this technique in the past, this should no longer be the case, with recent studies now showing that the laparoscopic repair is actually faster9 and has a reduced recurrence rate.5,10 Not surprisingly increasing experience in the laparoscopic technique is associated with reduced rates of complications, conversions and recurrences.8,11,12 Examination of the learning curve in Lothian, demonstrated a recurrence rate of 10% for the first 20 TEP repairs, falling to under 2% after 80 repairs have been undertaken.13 This study included all-comers (primary, unilateral, bilateral and recurrent hernia) and reported an overall 3% recurrence rate following TEP repair over an 11 year period compared to a 10.1% recurrence reported over only 2 years in a large-scale randomised prospective study.14 The introduction of laparoscopic repair in South East Scotland has in fact been associated with a reduction in the ratio of recurrent to primary hernia repairs performed.6 There may also be a reluctance to adopt laparoscopic hernia surgery for economic reasons, although NICE concluded that initial increased hospital costs are offset by benefits from reduced complications and more rapid recovery. Low cost operative techniques have however now been reported.15 If all patients in Scotland (and the rest of the UK) are to be given equal access to appropriate laparoscopic inguinal hernia surgery as recommended by NICE, then the issues of surgical beliefs, operative training and health economics all need to be addressed. This will require much better co-operation between the NHS and professional surgical bodies, such as the Royal Colleges. At present the drive for training and adoption of this technique is very much up to the individual surgeons, supported in many occasions by Industry. There is a wider issue here relating to the ability of the Health Service to react to new techniques in all areas of Medicine and, once evaluated, how they can be introduced on a National scale.
Conclusions Laparoscopic inguinal hernia repair has been shown to have several advantages over open techniques, particularly for bilateral and recurrent hernia. However it still remains at a low level in Scotland with marked regional variation,
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suggesting that many patients are being denied the most appropriate procedure for their condition simply because of where they live.
Acknowledgments The authors wish to thank Mr Andrew Lee and Ms Ishbel Robertson, Information Analysts at the Information Services Division of NHS Services Scotland for their help in providing the data.
references
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