Hernia Repair: Is Laparoscopic Always Best?
By Michael Lasalandra
Beth Israel Deaconess Medical Center correspondent
Laparoscopic or minimally invasive surgery means smaller incisions, less pain and a quicker recovery for patients undergoing abdominal operations.
But while surgeons tend to agree that certain operations are best done laparoscopically, there is disagreement over whether minimally invasive or traditional open surgery is best for other types of abdominal surgery.
“It is clear that for some areas of surgery, like gall bladder, for example, laparoscopic is better,” says Dr. Michael J. Cahalane, Director of Undergraduate Education for the Department of Surgery at Beth Israel Deaconess Medical Center. But, he adds that the best choice for hernia repair is not clear.
Dr. Daniel Jones, Chief of Minimally Invasive Surgery and Director of the Weight Loss Surgery Center at BIDMC, says there are definite advantages to the newer approach.
“If you qualify for a laparoscopic procedure, it is better to do it,” he says. “There is less pain with a few small cuts rather than one big one. In my practice, well over 90 percent of hernia patients benefit from the laparoscopic approach. Patients heal better, hurt less and look better. And if you want to get back to golf, you’ll do that more quickly too.”
Dr. Jones points to a 2003 New England Journal of Medicine study that demonstrated the laparoscopic approach resulted in more rapid recovery, fewer recurrences (5 percent vs. 10 percent) and less chronic pain than open repairs, but took longer to perform.
Another study published in the same journal one year later concluded open repair to be superior, with overall higher rates of complications and recurrences with laparoscopy. But that study also found that in the hands of surgeons who specialize in minimally invasive surgery, the recurrence rate was the same for open and laparoscopic repairs, and better for recurrent hernia done laparoscopically.
"If you put a violin in the hands of a piano player, it won't sound as good," Dr. Jones says.
Laparoscopic surgery is a technique in which operations in the abdomen are performed through tiny incisions rather than one large cut. The incisions allow surgeons to insert tiny surgical instruments that are guided by a tiny telescope attached to a camera, called a laparoscope.
A hernia is a tear or weakening of the abdominal wall that left untreated can cause serious intestinal complications. Dr. Jones notes that not all hernias should be repaired laparoscopically. He says very large ones may do better with the traditional open approach.
And Dr. Cahalane concedes that certain types of hernias are better repaired laparoscopically. These include bilateral hernias that occur on both the right and left sides and hernias that have recurred after prior repair, he says.
"With bilateral hernias, you can attack both sides at once," he says. "And with those who have recurring hernias, you can use a route that has not been used before."
With both open and laparoscopic surgeries, the tear is repaired by sewing in a mesh patch to plug the hole. In open surgery, the patch is placed over the hole. In laparoscopy, it is put in from behind the abdominal wall.
"What could be more direct than to open it up and patch it from the front?" Dr. Cahalane says, noting that the procedure does not usually require general anesthesia.
Laparoscopy is more complicated, he says.
"They have to put the person to sleep and go into the abdominal cavity and come back from the inside to fix it," Dr. Cahalane says. "I don't believe in it. I don't do it."
Dr. Jones puts it another way: "If you had a hole in a tire, would you want the patch on top, like in the open operation, or underneath, like we do with the laparoscopic approach?"
He also adds, "Most of my patients prefer to be asleep during the operation."
Jay Dobek, a video producer from Natick, had a traditional repair done by Dr. Cahalane a few years ago. He says he was referred to the surgeon by a relative and didn't really investigate the two approaches.
"I trusted the doctor's opinion and everything went fine," he says, noting he was out of work for about two days following the operation and on pain medication for a few days.
"It wasn't a big deal," he says.
Donald Huber, 30, of Brookline, chose the laparoscopic route after doing research and determining recovery time would be quicker.
He was referred to Dr. Jones by his primary care doctor and had the procedure done under general anesthesia. He says he was out of the hospital the same day and the very next day went for a walk of several hours duration. He took pain medications for just two days.
Huber, who works in an office, was back on the job three days later. A week after the operation, he says he was pretty much back to normal.
"I'm pretty happy with the way things went," he says.
Above content provided by Beth Israel Deaconess Medical Center. For advice about your medical care, consult your doctor.
Posted March 2013