Why does NICE not recommend laparoscopic herniorraphy?

Editor—Motson disagrees with the recommendation that laparoscopic herniorraphy has a limited role.1-1 But he managed to write the whole of his article without mentioning the fact that the Lichtenstein open mesh repair needs only a local anaesthetic.1-2 Instead, he makes the odd comment that “if the patient was unfit for general surgery then they would be limited to open operation under general anaesthetic.” Once you remove the need for a general anaesthetic open repair is far more cost effective. Even more alarmingly, however, he does not include the use of local anaesthetic in his section on telling patients the options. Since local anaesthesia has many advantages this omission is surprising. His final statement, unsupported by any evidence other than a personal communication from another enthusiast for laparoscopy, implies that well informed patients will request laparoscopic repair. I could equally well state that well informed patients wish to avoid the expense and morbidity of general anaesthesia. Both statements reflect only vested interest and prejudice.