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Laparoscopic herniorrhaphy revisited: reply
LETTERS TO THE EDITOR 4. Sharpe A, andJaffe G. Cutting edge: Columbia/HCA plans for more big changes in the health care world. The Wall Street Journal p. A1 May 28, 1997.
419
5. de Chauliac G. What the surgeon ought to be. Preface to On Wounds and Fractures. trans. W. A. Brennan (trans). Birmingham; Gryphon Editions; 1987.
Laparoscopic Herniorrhaphy Revisited C. George Posta, MD, FACS T h e recent Collective Review entitled "Laparoscopic Herniorrhaphy" in the Journal of the American College of Surgeons was an excellent presentation of a state-of-the-art topic (1). It was very disappointing, however, to read the followup ringing i n d i c t m e n t of all laparoscopic hernia repairs from your Editorial Board (2). Those of us successful with the preperitoneal laparoscopic mesh repair (and there are plenty of us) will have a hard time accepting the statement that placing a m e s h with the o p e n tension-free m e t h o d or Stoppa's technique is vastly superior when the exact same m e s h p l a c e m e n t can be accomplished t h r o u g h the use of three small trocar sites. The double mesh preperitoneal technique I a d o p t e d 2½ years ago (3) has served me well in 60 procedures and without a single recurrence. Much larger series with similar excellent results have been reported (4). Besides, p e r f o r m i n g the preperitoneal laparoscopic hernia repair affords a fascinating and beautiful anatomic dissection, and it is hard to imagine how any recurrence could occur if it is p e r f o r m e d properly. In addition, Dr. Nyhus p o i n t e d out that different hernias deserve differ-
ent type of repairs (5), and there is really no n e e d for mesh in small indirect-type inguinal hernias. I continue to p e r f o r m conventional hernia repairs without the use of mesh in the younger age group (and in the Lichtenstein repair if n e e d e d in the older age group), and I strongly believe that the laparoscopic preperitoneal repair does not take second place in any respect to the tension-free o p e n repair. In my view, the simplest indication for the laparoscopic approach is a patient who in the surgeon's o p i n i o n would benefit in the longterm from the p l a c e m e n t of a preperitoneal mesh. References 1. Memon MA, Rice D, and DonohueJH. Laparoscopic herniorrhaphy. J Am Coll Surg 1997;184:325-335. 2. Wantz GE. Laparoscopic herniorrhaphy.J Am Coll Surg 1997; 184:521-522. 3. Posta CG. Laparoscopic inguinal hernia repair with extraperitoneal double mesh technique. J Laparoendosc Adv Surg Tech 1997;7:19-27. 4. Massaad MA, Fiorillo MA, Hallak A, and Ferzli GS. Endoscopic extraperitoneal herniorrhaphy in 316 patients. J Laparoendosc Surg 1996;6:13-16. 5. Nyhus LM. The recurrent groin hernia: therapeutic solutions. World J Surg 1989;13:541-544.
R. Bendavid, MD, ThornhiU, Ontario, Canada T h e editorial presented by Dr. George Wantz (J Am Coil Surg 1997;184:521-522) soundly rej e c t e d laparoscopy as a parallel or alternative m e t h o d for the treatment of i n g u i n a l / f e m o r a l hernias. I must congratulate him for his stand a n d for expressing, unreservedly, an honest assessment of laparoscopic herniorrhaphies. Dr. Wantz is well known for his extensive and valuable contributions to the surgical literature. He c o m m a n d s respect and must be heard. We at the Shouldice Hospital (12 surgeons) share his feelings. O u r institution, which has specialized for 50 years in the field of abdominal wall hernias, looks at every possible new material or p r o c e d u r e with a great deal of interest. We perform 7,000 operations a year, and this year, perhaps thanks to patients who
do n o t wish to have laparoscopic surgery, we are looking at a slate of 7,500 operations. T h r o u g h an attentive survey of the surgical publications along with presence at every major event covering hernia surgery, I have not been convinced that laparoscopic herniorrhaphies represent an advance or an i m p r o v e m e n t in surgical techniques. On the contrary, the n e e d for general anesthesia represents an important drawback because 52% of patients > 50 years old manifest cardiovascular problems such as arrhythmias, congestive heart failure, or a history of myocardial infarction (1). Exclusive of setup Costs, disposable e q u i p m e n t represents an expense that can never compare with $20.00 per patient at Shouldice Hospital. The n e e d for prosthetic material in every
420
J AM COLL SURG OCTOBER1997
VOLUME185:416-421
patient not only represents an expense, but also introduces complications (bowel obstructions, erosion into viscera, fistula formation) that are u n h e a r d of with a classic anterior approach. The magnitude of this problem is becoming more evident with time and was well illustrated at the last hernia symposium of GREPA in Naples (May 1417, 1997) (2, 3). The overwhelming objection to laparoscopic surgery, however, is the nature and severity of its complications. In Ontario in the last 2 years, four patients have died from laceration of a major vessel and large bowel perforation. In October 1996, the Canadian Broadcasting Corporation saw the necessity of investigating the issue and presented its results nationwide with a conclusion to "beware." The unsettling aspect of these complications is that they can happen to surgeons with a respectable experience, and those same surgeons agree that adequate experience means 50-100 cases. In the meantime, it is tantamount to Russian roulette for the first 100 patients of any surgeon who elects to perform laparoscopic herniorrhaphies. We, as surgeons, have succeeded to date in making hernia surgery a safe and reliable intervention, so patients can now consider it a benign procedure with an early return to work. The incidence of
recurrence in trained hands is negligible, not the 15-36% quoted by laparoscopic surgeons to justify their practice (4). Surgeons who cannot perform a simple anterior procedure will not improve their results with laparoscopy. I believe that more than a surgical dilemma, this controversy is an ethical issue. Certainly, laparoscopic herniorrhaphies can be effective, but at a cost in materials and patient complications not in keeping with the nature of the disease. 2, for one, will not delude myself, and I elect to remain classic in my approach to hernia surgery. Insurance companies and courts will not have to impose that choice on me. It may be timely to r e m e m b e r that our "greatest griefs are those we cause ourselves" (Sophocles). References 1. Bendavid R. The merits of the Shouldice repair. In: Problems in General Surgery. 1995:1.05-109. 2. Danielli PG. The complications of plugs: infection and recurrence. Hernia: The J Hernias Abdom Wall Surg 1997; 1 (Suppl) :5-10. 3. Fitzgibbons RJ, et al. Laparoscopic inguinal herniorrhaphy. Results of a multicenter trial. Ann Surg 1995;221:3-13. 4. Hernandez-Richter, et al. Comparison of laparoscopic hernia repair and herniorrhaphy by the Shouldice technique. EurJ Coelio-Surg 1997;19-23.
J o n a t h a n D. Wright, MD, FACS, Toledo, Ohio I am a practicing general surgeon in Toledo, OH, involved primarily in the community practice of general surgery. I have always enjoyed your writings on inguinal hernia, and i consider you to be a refreshingly clear voice of reason in this often m u d d l e d field. I recently read your editorial in the May 1997 issue of the Journal of the American College of Surgeons (J Am Coll Surg 1997;184:521-522) c o m menting on the recent review of laparoscopic herniorrhaphy. I f o u n d this to be delightful, concise, and, in my opinion, the last word on the subject. I almost wrote you a similar letter to thank you for your excellent work in this area after reading your article in the October 1996 issue of this journal (J Am Coll Surg 1996;183:351-6) on tensionfree hernioplasty, but, to my regret, I did not. I
now want to take the opportunity to thank you for your efforts. I consider your voice to be one o f the few that is free of self-serving bias in this area. I share your article on tension-free hernioplasty with the residents whenever I am able to interest them in the subject. I o p e r a t e d on 55 inguinal hernias d u r i n g the past calendar year, the majority of these by the tension-free plug t e c h n i q u e as first described by Gilbert. Your article has b e e n helpful in persuading my partners to consider this technique. I want to thank you again for your efforts and your straightforward, honest work in the field of herniorrhaphy.
Arthur I. Gilbert, MD, and Michael F. Graham, MD, Miami, FL In his May 1997 editorial, George Wantz mentions the high degree of technical expertise required of surgeons who perform laparoscopic hernia repair.
Laparoscopists preach that those technical skills require a substantial "learning curve." We have yet to understand what constitutes, and how to mea-
419
5. de Chauliac G. What the surgeon ought to be. Preface to On Wounds and Fractures. trans. W. A. Brennan (trans). Birmingham; Gryphon Editions; 1987.
Laparoscopic Herniorrhaphy Revisited C. George Posta, MD, FACS T h e recent Collective Review entitled "Laparoscopic Herniorrhaphy" in the Journal of the American College of Surgeons was an excellent presentation of a state-of-the-art topic (1). It was very disappointing, however, to read the followup ringing i n d i c t m e n t of all laparoscopic hernia repairs from your Editorial Board (2). Those of us successful with the preperitoneal laparoscopic mesh repair (and there are plenty of us) will have a hard time accepting the statement that placing a m e s h with the o p e n tension-free m e t h o d or Stoppa's technique is vastly superior when the exact same m e s h p l a c e m e n t can be accomplished t h r o u g h the use of three small trocar sites. The double mesh preperitoneal technique I a d o p t e d 2½ years ago (3) has served me well in 60 procedures and without a single recurrence. Much larger series with similar excellent results have been reported (4). Besides, p e r f o r m i n g the preperitoneal laparoscopic hernia repair affords a fascinating and beautiful anatomic dissection, and it is hard to imagine how any recurrence could occur if it is p e r f o r m e d properly. In addition, Dr. Nyhus p o i n t e d out that different hernias deserve differ-
ent type of repairs (5), and there is really no n e e d for mesh in small indirect-type inguinal hernias. I continue to p e r f o r m conventional hernia repairs without the use of mesh in the younger age group (and in the Lichtenstein repair if n e e d e d in the older age group), and I strongly believe that the laparoscopic preperitoneal repair does not take second place in any respect to the tension-free o p e n repair. In my view, the simplest indication for the laparoscopic approach is a patient who in the surgeon's o p i n i o n would benefit in the longterm from the p l a c e m e n t of a preperitoneal mesh. References 1. Memon MA, Rice D, and DonohueJH. Laparoscopic herniorrhaphy. J Am Coll Surg 1997;184:325-335. 2. Wantz GE. Laparoscopic herniorrhaphy.J Am Coll Surg 1997; 184:521-522. 3. Posta CG. Laparoscopic inguinal hernia repair with extraperitoneal double mesh technique. J Laparoendosc Adv Surg Tech 1997;7:19-27. 4. Massaad MA, Fiorillo MA, Hallak A, and Ferzli GS. Endoscopic extraperitoneal herniorrhaphy in 316 patients. J Laparoendosc Surg 1996;6:13-16. 5. Nyhus LM. The recurrent groin hernia: therapeutic solutions. World J Surg 1989;13:541-544.
R. Bendavid, MD, ThornhiU, Ontario, Canada T h e editorial presented by Dr. George Wantz (J Am Coil Surg 1997;184:521-522) soundly rej e c t e d laparoscopy as a parallel or alternative m e t h o d for the treatment of i n g u i n a l / f e m o r a l hernias. I must congratulate him for his stand a n d for expressing, unreservedly, an honest assessment of laparoscopic herniorrhaphies. Dr. Wantz is well known for his extensive and valuable contributions to the surgical literature. He c o m m a n d s respect and must be heard. We at the Shouldice Hospital (12 surgeons) share his feelings. O u r institution, which has specialized for 50 years in the field of abdominal wall hernias, looks at every possible new material or p r o c e d u r e with a great deal of interest. We perform 7,000 operations a year, and this year, perhaps thanks to patients who
do n o t wish to have laparoscopic surgery, we are looking at a slate of 7,500 operations. T h r o u g h an attentive survey of the surgical publications along with presence at every major event covering hernia surgery, I have not been convinced that laparoscopic herniorrhaphies represent an advance or an i m p r o v e m e n t in surgical techniques. On the contrary, the n e e d for general anesthesia represents an important drawback because 52% of patients > 50 years old manifest cardiovascular problems such as arrhythmias, congestive heart failure, or a history of myocardial infarction (1). Exclusive of setup Costs, disposable e q u i p m e n t represents an expense that can never compare with $20.00 per patient at Shouldice Hospital. The n e e d for prosthetic material in every
420
J AM COLL SURG OCTOBER1997
VOLUME185:416-421
patient not only represents an expense, but also introduces complications (bowel obstructions, erosion into viscera, fistula formation) that are u n h e a r d of with a classic anterior approach. The magnitude of this problem is becoming more evident with time and was well illustrated at the last hernia symposium of GREPA in Naples (May 1417, 1997) (2, 3). The overwhelming objection to laparoscopic surgery, however, is the nature and severity of its complications. In Ontario in the last 2 years, four patients have died from laceration of a major vessel and large bowel perforation. In October 1996, the Canadian Broadcasting Corporation saw the necessity of investigating the issue and presented its results nationwide with a conclusion to "beware." The unsettling aspect of these complications is that they can happen to surgeons with a respectable experience, and those same surgeons agree that adequate experience means 50-100 cases. In the meantime, it is tantamount to Russian roulette for the first 100 patients of any surgeon who elects to perform laparoscopic herniorrhaphies. We, as surgeons, have succeeded to date in making hernia surgery a safe and reliable intervention, so patients can now consider it a benign procedure with an early return to work. The incidence of
recurrence in trained hands is negligible, not the 15-36% quoted by laparoscopic surgeons to justify their practice (4). Surgeons who cannot perform a simple anterior procedure will not improve their results with laparoscopy. I believe that more than a surgical dilemma, this controversy is an ethical issue. Certainly, laparoscopic herniorrhaphies can be effective, but at a cost in materials and patient complications not in keeping with the nature of the disease. 2, for one, will not delude myself, and I elect to remain classic in my approach to hernia surgery. Insurance companies and courts will not have to impose that choice on me. It may be timely to r e m e m b e r that our "greatest griefs are those we cause ourselves" (Sophocles). References 1. Bendavid R. The merits of the Shouldice repair. In: Problems in General Surgery. 1995:1.05-109. 2. Danielli PG. The complications of plugs: infection and recurrence. Hernia: The J Hernias Abdom Wall Surg 1997; 1 (Suppl) :5-10. 3. Fitzgibbons RJ, et al. Laparoscopic inguinal herniorrhaphy. Results of a multicenter trial. Ann Surg 1995;221:3-13. 4. Hernandez-Richter, et al. Comparison of laparoscopic hernia repair and herniorrhaphy by the Shouldice technique. EurJ Coelio-Surg 1997;19-23.
J o n a t h a n D. Wright, MD, FACS, Toledo, Ohio I am a practicing general surgeon in Toledo, OH, involved primarily in the community practice of general surgery. I have always enjoyed your writings on inguinal hernia, and i consider you to be a refreshingly clear voice of reason in this often m u d d l e d field. I recently read your editorial in the May 1997 issue of the Journal of the American College of Surgeons (J Am Coll Surg 1997;184:521-522) c o m menting on the recent review of laparoscopic herniorrhaphy. I f o u n d this to be delightful, concise, and, in my opinion, the last word on the subject. I almost wrote you a similar letter to thank you for your excellent work in this area after reading your article in the October 1996 issue of this journal (J Am Coll Surg 1996;183:351-6) on tensionfree hernioplasty, but, to my regret, I did not. I
now want to take the opportunity to thank you for your efforts. I consider your voice to be one o f the few that is free of self-serving bias in this area. I share your article on tension-free hernioplasty with the residents whenever I am able to interest them in the subject. I o p e r a t e d on 55 inguinal hernias d u r i n g the past calendar year, the majority of these by the tension-free plug t e c h n i q u e as first described by Gilbert. Your article has b e e n helpful in persuading my partners to consider this technique. I want to thank you again for your efforts and your straightforward, honest work in the field of herniorrhaphy.
Arthur I. Gilbert, MD, and Michael F. Graham, MD, Miami, FL In his May 1997 editorial, George Wantz mentions the high degree of technical expertise required of surgeons who perform laparoscopic hernia repair.
Laparoscopists preach that those technical skills require a substantial "learning curve." We have yet to understand what constitutes, and how to mea-