Treating inguinal hernias

Editor—Oberg and Rosenberg are keen protagonists of the laparoscopic operation for treating inguinal hernias and propose the establishment of dedicated laparoscopic hernia centres. To train surgeons in one operation in specialised units is clearly impracticable and is not cost effective. It will take a long time to train a cohort of surgeons proficient in laparoscopic herniorrhaphy on the basis of the data of Bittner et al, who reported over 8000 laparoscopic repairs in eight years, during which they were able to train only eight junior surgeons.1 The average general surgeon will repair only 30-40 inguinal hernias yearly. Enthusiastic laparoscopic surgeons, however, are strident in their demands for other surgeons to be converted to this operation with its long learning curve. DeTurris et al, in analysing 38 randomised trials, concluded that their analysis failed to make a convincing case for the superiority of either open or laparoscopic herniorrhaphy, which includes operative time, postoperative pain, return to work, complications, and recurrences.2 Peyser's letter is riddled with misleading and inaccurate information. Laparoscopic herniorrhaphy has been largely dismissed by the surgical community: 96% of UK surgeons, 86% of US surgeons, and virtually all Japanese surgeons use open repair.3-5 There are no hard data for European countries, but in France laparoscopic repair is rapidly declining following guidance from the French equivalent of the National Institute for Clinical Excellence. Regarding chronic groin pain, the EU Hernia Trials Collaboration has pointed out the large confidence intervals in its analysis and has indicated that a large randomised controlled trial is needed, with specific end points to arrive at definitive conclusions. Figure 1 Placement of mesh into the periperitoneal space with wide overlap to prevent recurrence The illustration in my editorial and here is for an open mesh placed by the preperitoneal route, as described by Stoppa (figure). The Plymouth Hernia Service not only supports my practice of open inguinal herniorrhaphy but also that of three of my colleagues who undertake laparoscopic repair for bilateral and recurrent inguinal hernias and incisional hernias.