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EDITORIALS: Andrew Kingsnorth Treating inguinal hernias BMJ 2004; 328: 59-60 [Full text]

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Poor solutions for poor surgery.

Richard G Fiddian-Green   (11 January 2004)

Misleading account

Paul M Peyser   (14 January 2004)

Not the whole truth.

Emilie Oeberg, Jacob Rosenberg   (19 January 2004)

Treating Inguinal Hernias

Peter A Jones, Sue E Jones   (21 January 2004)

Hernia repairs must be able to be performed economically Worldwide. Cost counts.

Nick J Barwell   (21 January 2004)

Misleading title - 'Lichtenstein opearation is preferred over Laparoscopy'

Amir Nisar   (22 January 2004)

Is Laparoscopic Hernia repair very expansive?

Amir Nisar   (22 January 2004)

Inguinal Hernias

James Wellwood   (23 January 2004)

Convincing Picture of Preperitoneal hernia repair

Amir Nisar   (25 January 2004)

The Elusive Inguinal Hernia Repair

Abd H Mat Sain   (15 August 2005)

Poor solutions for poor surgery. 11 January 2004
Richard G Fiddian-Green, None None Send response to journal: Re: Poor solutions for poor surgery.	In a prospective study the risk-adjusted mortality rates following major elective non-cardiac surgery, measured with the Portsmouth POSSUM score, performed in a cohort of 1539 UK patients was four times higher than that in a cohort of 1056 US patients (1). The inference is that the risk-adjusted mortality rates in Kingsnorth's district hospital in Portsmouth is four times higher than that in the US. In which case the lower rates of recurrence reported following the Lichtenstein repair relative to the more traditional repairs may be largely a reflection of the poor standard of surgery in Portsmouth rather than of the benefits of the Lichtenstein repair. If so the choice of a simpler operation is a poor solution to the poor standard of surgery. This is an important issue for the unacceptably high operative mortality rates in the UK reported in a series of prospective studies provides the evidence-base for GPs and physicians to deny patients such as those with chronic pancreatitis the relief of their pain by definitive surgery, and those with cancers of the oesophagus, biliary tract, liver and rectum with the opportunity of more effective palliation and even cure by definitive surgery. The swing of the pendulum towards conservatism deprives many other patients of the opportunity of more effective symptomatic treatment including those with oesophageal reflux and inflammatory bowel diseases. In a recent survey of Canadian surgical practice 23% of patients with inguinal hernias had a Bassini, 20% a mesh plug, 16% a Lichtenstein, 15% a laparoscopic, 11% a Shouldice and 11% a McVay repair (2). In a region of the US adjacent the Canadian border in which I worked in tertiary referral center in which I did most of my surgery some years earlier the McVay seems to have been the most commmonly performed operation. I never heard of a mesh being used for an inguinal hernia, but this is a more recent "advance". That we did not have a waiting list for inguinal hernias and that I rarely saw an inguinal hernia let alone a chronically infected or recurrent one speaks well of the standard of hernia repairs being performed in the community by surgeons who had a financial incentive to repair it promptly and well. In the VA in which I once worked, which like the NHS is a state institution with salaried staff, there was a massive waiting list and I suspect from the very poor outcomes from major surgery reported in all VA hospitals that the recurrence rate must also have been unacceptably high. Why the difference? In the VA the chief resident made up the lists and decided who was to do the operation. He/she was more interested in doing as many "big cases" as he/she could during their brief tenure. A few hernias were added to keep the administrators quiet but more importantly to keep the juniors happy because it was the attendings whom the administrators blamed for the waiting list. The net effect is that, unless an attending had a special interest in doing hernias or in teaching a junior the hernias ended up being repaired by the most junior of the trainees. I suspect that is a large part of the problem in the NHS. Inserting an open mesh in a patient is akin to inserting a limpet mine. It may never be hit by a ship but if it is it could sink it. The risk is of infection developing in the mash latter years during the course of another illness, such as an AP resection which requires the formation of an adjacent colostomy or admission to an ICU for organ dysfunction. In the latter instance the mesh could become an occult nidus of infection that kills the patient. How many cases with infected mesh has Kingsnorth seen? Whilst the risk might be very small young patients could be exposed to that risk for many decades. It would be a tragedy to lose a person in their prime for an avoidable reason. Until the magnitiude of this risk is known the evidence-base for the Lictenstein hernia repair is incomplete. I for one would be happy to accept a higher rate of recurrence and would choose to have my hernia repaired by someone who did the Shouldice well. I would, however, be happy to consider having a mesh if in my dotage I were to develop a recurrence. The real issue is how best to tackle the problem of poor surgery in the UK and indeed the VA and create an environment in which clinical excellence of the level seen in a Mayo clinic can thrive throughout the country. I cannot imagine that ever happening without giving patients private insurance or vouchers and the choice of where to go and whom to do their operation. 1. Bennett-Guerrero E, Hyam JA, Shaefi S, Prytherch DR, Sutton GL, Weaver PC, Mythen MG, Grocott MP, Parides MK. Comparison of P-POSSUM risk- adjusted mortality rates after surgery between patients in the USA and the UK. Br J Surg. 2003 Dec;90(12):1593-8. 2. DesCoteaux JG, Sutherland F. Inguinal hernia repair: a survey of Canadian practice patterns. Can J Surg. 1999 Apr;42(2):127-32. Competing interests: None declared
Misleading account 14 January 2004
Paul M Peyser, Consultant Gastrointestinal and Laparoscopic Surgeon Royal Cornwall Hospital TR1 Send response to journal: Re: Misleading account	Andrew Kingsnorth has misrepresented the role of the laparoscopic hernia repair in his article. A clinician reading this who has no experience of surgical options for inguinal hernia repair may come away with the impression that laparoscopic repair has largely been dismissed by the surgical community and NICE (National Institute of Clinical Excellence). He reports that the incidence of chronic groin pain post hernia repair has now overtaken that of hernia recurrence without making it clear that amongst the various advantages of laparoscopic hernia repair (less post op pain and earlier return to normal activity) chronic groin pain almost never occurs. The rare but serious complications that he quotes from the European Union's Hernia Trialists collaboration (1) were for TAPP (Trans Abdominal PrePeritoneal) hernia repairs (as opposed to TEP Totally ExtraPeritoneal)which are not currently recommended by NICE. The article also failed to highlight the fact that laparoscopic repair is recommended by NICE for bilateral and reccurrent hernia repair. It would appear the main objections to laparoscopic repair for primary hernias are financial and not clinical(2). Interestingly the illustration of mesh in the preperitoneal space is the mesh placement for laparoscopic not open repairs, although this is not stated in the text. This may further mislead the reader who is not aware of these differences, into believing this represents mesh replacement for open hernia repair. Finally, Professor Kingsnorth does oversee a Hernia Unit at Plymouth which deals exclusively with open hernia repairs, which may be regarded as a competing interest. 1 EU Hernia Trialists Collaboration. Laparoscopic compared with open methods of groin hernia repair: systematic review of randomised controlled trials Br J Surg 2000;87:860-7 2 National Institute for Clinical Excellence. Guidance on the use of Laparoscpic surgery foringuinal hernias: London: NICE, 2001. (Technology appraisal guidance No.18) Competing interests: I perform both open and Laparoscopic TEP hernia repairs
Not the whole truth. 19 January 2004
Emilie Oeberg, Research fellow Gentofte Hospital, University of Gentofte, Jacob Rosenberg Send response to journal: Re: Not the whole truth.	Letter to the editor. In an editorial (January 10th, 2004), Kingsnorth (1) argued that open inguinal hernia repair a.m. Lichtenstein is superior to the laparoscopic approach due to fewer serious complications, shorter learning period for the surgeon and lower cost. We find, however, that this is not the whole truth. In a recent Cochrane Review (2) based on 41 randomised trials including 7161 patients, 6 visceral injuries (in 2498 patients) were reported in the laparoscopic group and 1 (in 2758 patients) in the open group. Vascular injuries occurred in 7 patients in the laparoscopic group and in 5 patients in the open group. These differences did not reach statistical significance. There was no difference in hospital-stay, but in the laparoscopic group convalescence was significantly shorter than in patients after open surgery (7 days shorter, p<0.001). Furthermore, and probably the most important finding, the review found a significant reduction in the rate of chronic groin pain (290/2101 vs. 459/2399, p<0.001) and persisting numbness (102/1419 vs. 217/1624, p<0.001) after laparoscopic compared with open repair with no difference in recurrences rate after the two procedures. The laparoscopic operation lasted 15 minutes longer than the open procedure. It is true that the direct cost (during operation) of the laparoscopic technique is higher than the open Lichtenstein procedure. But this difference in cost is eliminated by recommending a convalescence of one week only (3). The majority of the cost associated with hernia repair is dependent on the period of convalescence (4). By recommending an even shorter period of convalescence than one week, a possible further saving may be found in the laparoscopic group, although this has not yet been thoroughly studied. The concern of professor Kingsnorth regarding the complex nature of the laparoscopic procedure is legitimate but as the learning curve is 30- 50 operations (5), this problem can be solved by establishing dedicated laparoscopic hernia-centres as indeed is commonly done in many countries when the Lichtenstein procedure is the preferred method. This would also add to minimising of cost. The development in conventional hernia repair in most places is also towards specialization where junior surgeons are not any more allowed to perform Lichtenstein repairs without formal training. This situation is therefore not at all different from laparoscopic repair. What the editorial fails to recognize and acknowledge, and which is very important – probably the most important outcome measure after inguinal hernia repair now that recurrence is not a big problem anymore, is the compelling evidence that laparoscopic approach is followed by significantly lower rates of postoperative pain - both acute and chronic. Although there may be room for further improvement especially after open repair with better pain control and therefore hopefully also with a better outcome in the long run, why not just do the best operation right now? The available pain data are indisputable (2). In conclusion, laparoscopic hernia repair is not a dangerous procedure, the learning curve can be facilitated by the establishing laparoscopic hernia centres and the cost can effectively be reduced and equalised with the open procedure. And most importantly, the hernia repair will be followed by significantly less pain for the patient when done laparoscopically and this must be one of the top priorities of a responsible surgeon. Emilie Øberg, MS, Research fellow Jacob Rosenberg, MD, DSc, Professor, Chief Surgeon Department of Surgical Gastroenterology Gentofte Hospital, University of Copenhagen DK-2900 Hellerup, Denmark. Competing interests: None declared. Literature 1. Kingsnorth A. Treating inguinal hernias. Open mesh Lichtenstein operation is preferred over laparoscopy. BMJ 2004;328:59-60 2. McCormack K, Scott NW, Go PMNYH et al. on behalf of the EU Hernia Trialists Collaboration. Laparoscopic techniques versus open techniques for inguinal hernia repair (Cochrane review).In: The Cochrane Library, Issue 3, 2003. Oxford: Update Software. 3. Swanstrom LL. Laparoscopic hernia repairs: the importance of cost as an outcome measurement at the century’s end. Surg Clin N Am 2000;80:1341-51. 4. Bay-Nielsen M, Knudsen MS, Christensen JK et al. Analyse af omkostninger ved lyskebrokkirurgi i Danmark. Ugeskr Læger 1999;161:5317- 21. 5. DeTurris SV, Cacchione RN, Mungara A et al. Laparoscopic herniorrhaphy: beyond the learning curve. J Am Coll Surg 2002;194:65-73. Competing interests: None declared
Treating Inguinal Hernias 21 January 2004
Peter A Jones, Consultant Surgeon Maidstone Hospital ME16 9QQ, Sue E Jones Send response to journal: Re: Treating Inguinal Hernias	Andrew Kingsnorth’s editorial on treating inguinal hernias (1) is particularly notable for its absence of any mention of the Shouldice repair, long regarded as the “gold standard”. In his recent seminar in the Lancet (2) Kingsnorth acknowledges the “excellent” outcomes achievable when the Shouldice repair is performed properly, with a less than 1% recurrence rates consistently reported (3) That an operation may be technically more demanding seems to suggest the need for better teaching rather than a change to a more expensive, and in our view, more painful operation. We abandoned a randomised trial comparing the Lichtenstein with the Shouldice because of the severe persistent pain experienced in a significant proportion of the mesh group. Miedeme et al in their study concluded that the Shouldice inguinal hernia repair has a role in decreasing the risk of chronic groin pain ( 4). Whilst many studies have focused on the similarity of short term outcomes the instance of chronic pain has been largely ignored. Time spent on proper training of the shouldice procedure would certainly produce a significant economic benefit. With 100,000 hernia repairs performed in the UK each year the most conservative estimate would indicate an annual saving of 5 million pounds using a sutured technique. Yours faithfully, Peter Jones, Consultant Surgeon Sue Jones, Associate Specialist, Department of Surgery, Maidstone Hospital, Hermitage Lane, Barming, Maidstone, Kent. ME 16 9QQ E-mail – peter.jones3@nhs.net References: 1. Kingsnorth, A Treating Inguinal Hernias, BMJ 2004; 328: 59-60 2. Kingsnorth, A., Le Blanc, K. Hernias: Inguinal and incisional, Lancet 2003; 362: 1561-1571 3. Deysine, M., Grimson, R.C., Soroff, H.S. Inguinal herniorrhaphy reduces morbidity by service standardisation. Arch Surg 1991; 126: 628-30 4. Miedema, B.W., Ibrahim, S.M., Davis, B.D., and D.G., Koivunen. A prospective trial Of primary inguinal hernia repair by surgical trainees. Hernia: The World Journal of Hernia and Abdominal Wall Surgery. 2003 10.1007/s10029-003-0151-z Competing interests: None declared
Hernia repairs must be able to be performed economically Worldwide. Cost counts. 21 January 2004
Nick J Barwell, Retired Consultant Surgeon Royal Cornwall Hospital, Truro, TR1 3LJ Send response to journal: Re: Hernia repairs must be able to be performed economically Worldwide. Cost counts.	The Shouldice clinic repairs 7,500 Hernias each year. Why? Because they specialise and have superb results so that Patients choose to go there from personal recommendation. It seems unlikely that 260,000 patients can all be wrong. They use local with sutured ovelap of stretched tissue. They use occasional mesh in multi-recurrent cases and have been resposible for the general improvement in hernia care and results over the last 20 years as others strive to emulate them. Of course Lichtenstein and other mesh repairs produce good results when carefully performed, but we still see failures and these, as with all recurrences are the fault of a Surgeon's technical error. Expert laparoscopists also achieve wonderfull results but this can hardly be translated to the impoverished 3rd World or even the cash- strapped NHS. Surely cost and patient satisfaction are of concern. In recent semi- retirement we have repaired over 300 groin hernias as day cases under local anaesthetic in a GP surgery. Simplified Shouldice repair needs just Surgeon, scrub nurse and a sympathetic 'runner'! We could certainly do this anywhere -- it is very popular and we even have happy customers from 'Kingsnorth country' next door! We should surely train the Surgeons of the future to keep it simple! Why not use the Primary care sector for common simple operations and even Professors could enjoy a day away from the Ivory towers. It is a splendid environment for teaching and even Medical students like to come and join in. Competing interests: A 30 year experience of Shouldice repairs
Misleading title - 'Lichtenstein opearation is preferred over Laparoscopy' 22 January 2004
Amir Nisar, Associate Specialist, Royal Surrey County Hospital, Guildford GU2 7XX Send response to journal: Re: Misleading title - 'Lichtenstein opearation is preferred over Laparoscopy'	EDITOR- I was surprised to read this article. The title was not only misleading but lacked any evidence in the article to support such a claim. There are numerous studies to show the advantage and benefits of Laparoscopic hernia surgery over Lichtenstein reapir. These benefits are not only in early recovery, less post operative pain, early return to activity and work but also reduced incidence of chronic neuralgia. I must also point out here that the reference to the 'NICE' recommendation has not been quoted accurately in the article. The so called serious complications mentioned in the article are extremely rare now. Laparoscopic hernia surgery is becomming increasingly popular and an increasing number of surgeons with good laparoscopic skills are now performing this opeartion in routine.This is also evident from the courses run at varios centres which are mostly fully booked. I have worked at MATTU (Minimal Access Therapy Training Unit), Guildford for many years and performed several hundred operations myself. I have been involved with proctoship and perceptorship at various centres in the country. I can say with confidence that this is a technique which has come leaps and bounds in the last three or four years and now we have lots of competent well trained Laparoscopic surgeons performing this operation in almost every region of the country. Laparoscopic technique is probabaly the 'best way' to deal with the recurrent hernias. However this is the 'only way' to deal with bilateral 'day case' hernia operation and complex hernias like 'prevascular hernias'. We believe that the surgeons who are serious about hernia surgery should expose themselves to this technique. Competing interests: None declared
Is Laparoscopic Hernia repair very expansive? 22 January 2004
Amir Nisar, Associate Specialist, Royal Surrey County Hospital, Guildford GU2 7XX Send response to journal: Re: Is Laparoscopic Hernia repair very expansive?	EDITOR- Professor Kingsnorth has mentioned in his article about the laparoscopic hernia operation being costly and sometimes this argument goes against this technique which undoubtedly serves a patient the best because of its well known advantages over the conventional technques. I would like to point out that once a surgeon is familiar with the technique then the operation can be performed very cheaply with no extra cost than that of the mesh. One can argue about the expansive laparoscopic equipment but now every hospital in the country has the equipment and this does not incur any additional cost if one starts doing Laparoscopic hernias in addition to the routine Laparoscopic Cholecystectomies! Valuable theatre time is saved by performing bilateral hernias laparoscopically in much less time than that required to perform the same operation with the open technique. Valauable inpatient bed space is utilised for other patients in the hospital rather than providing B&B facilities to the patients having their bilateral hernias done with the open technique. In the end I would like to stress that due to early return to work many days are saved for the individuals having the surgery done keyhole way. This will add up to hundreds and thousands of days if one would consider that 100,000 hernias are repaired annually in the United Kingdom. This makes even a more stronger case for Laparoscopic repair than the conventional surgey. Competing interests: I perform open and Laparoscopic hernias
Inguinal Hernias 23 January 2004
James Wellwood, Consultant General Surgeon 134 Harley Street London W1G 7JY Send response to journal: Re: Inguinal Hernias	Dear Sir, Not every surgeon who treats inguinal hernias frequently would agree with Professor Kingsnorth’s views expressed in your editorial (ref 1). Professor Kingsnorth refers to the increased cost of the laparoscopic repair of groin hernias but most studies only compare the direct cost to the hospital of laparoscopic and open mesh repair. Laparoscopic repair is more expensive for the hospitals. However, patients who have had laparoscopic mesh repair of their hernias return to work or normal activities sooner, thereby reducing societal costs. Professor Kingsnorth refers to inguinal hernia as a minor abnormality. Few of the patients with chronic groin pain following open mesh repair would regard their procedure as having been minor. Professor Kingsnorth does not mention the fact that chronic groin pain is found more frequently after open mesh repair than after laparoscopic mesh repair. Whilst I would agree that laparoscopic hernia repair can be a difficult technical procedure, I do not agree that British surgeons, once trained, would be unable to perform the procedure safely. Laparoscopic hernia repair in my hands is a shorter operation than open mesh repair. I know the same to be true for some of my colleagues. The length of the operative procedure is at least in part determined by the number of such operations the surgeon has performed. As laparoscopic hernia surgery is a relatively recent innovation, most surgeons have performed more open hernia repairs than laparoscopic hernia repairs. Professor Kingsnorth mentions the rare but serious complications associated with laparoscopic surgery. Most new procedures result in higher complication rates than existing procedures until the clinician has successfully passed through the learning curve. The National Institute for Clinical Excellence recommended that the surgical procedure of choice for a primary unilateral inguinal hernia was the Lichtenstein repair. However, the report acknowledged that laparoscopic repair may be superior for bilateral and recurrent inguinal hernias. Since this report, the increased incidence of chronic groin pain in patients undergoing open mesh repair compared to those undergoing laparoscopic mesh repair has become more widely recognised. Furthermore the shorter time to return to work and the reduced pain of laparoscopic repair is attractive to many patients given that the recurrence rate for both types of mesh repair are similar once the surgeon has become competent in the techniques. Yours sincerely, James McK Wellwood MChir FRCS Ref 1. Treating Inguinal Hernias A. Kingsnorth 2004 Brit Med J 328,59 Competing interests: None declared
Convincing Picture of Preperitoneal hernia repair 25 January 2004
Amir Nisar, Associate Specialist, Royal Surrey County Hospital, Guildford GU2 7XX Send response to journal: Re: Convincing Picture of Preperitoneal hernia repair	EDITOR- I was very pleased to see the picture of a mesh placed preperitoneal space to repair a hernia. The clarity and of the picture, the wide area of dissection and clear identification and display of all the important structures suggested that this was the art work of a laparoscopic surgeon. There is no doubt that the coverage of the myopectineal orifice is most effective this way(preperitoneally) whatever the type, cause or size of an inguinal hernia. In order to achieve this, the best way to create this space and place the mesh is a minimal invasive approach rather than a big 'laparotomy'type/size cut. The minimal invasive approach is commonly referrred to as a 'laparoscopic hernia repair'. Then why are we against this and still like to talk about 'Open Pre Peritoneal approach'? Competing interests: I perform open and laparoscopic hernias
The Elusive Inguinal Hernia Repair 15 August 2005
Abd H Mat Sain, Consultant Surgeon ColumbiaAsia Medical Centre,292 Jln Haruan 2,Oakland Commercial Ctr,70300 S'ban,N.Sembilan,Malaysia Send response to journal: Re: The Elusive Inguinal Hernia Repair	Dear Sir, It seems that the debates on the best treatment techniques for the management of inguinal hernia is becoming a chronic insoluble problem. The method of repair of inguinal hernia,like any surgical therapy originated from a different era and paradigm of thoughts. The simplistic understanding of anatomical defect of the posterior inguinal wall led to the blooming of repairs of that area as an important part of hernia therapy.There was no Randomized Controlled Trial demanded after Bassini advocated such repair.The techniques evolved because of the insatisfactory outcome especially with such a high rate of recurrence. The high tension of tissues in the simplistic anatomical repair has given rised to the belief or assumption that the high tension engendered in the tissue after the anatomical repair techniques was the main cause of the unacceptably high recurrence rate.This premise has given rise to the tension-free mesh repair which dramatically reduce the recurrence rate. This technique has dominated the scene of hernia repair since then till the onslought of laparoscopic repair. Like any other laparoscopic surgery, laparoscopic hernioplasty/herniorraphy does not start from a very strong clinical foundation in terms of need to progress hernia repair.It seems to be another traditional open surgery being attempted by the laparoscopic enthusiasts.No wonder among the initial laparoscopic hernia repair was the abandoned IPOM(IntraPeritoneal Onlay Mesh) which was frought with many intraperitoneal complications.TAPP and TEP were the results of persistent pursuant by the laparoscopic enthusiasts. The current knowledge era has influenced the way clinician embrace new knowledge and skills.The quantitative knowledge through Randomized Controlled Trials(RCT) and the likes form the supreme guiding method in accepting new knowledge to be applied in clinical practice. The laparoscopic enthusiasts have joined the bandwagon of clinical trials in order to scientifically legitimize the new methods of hernia repair. Unfortunately, the reductionistic hypothesis-driven method of scientific analysis applied to surgery is ridden with too many confounding factors,both quantitative and qualitative in nature.The inguinal hernia is not a homogenous condition in terms of degree of anatomical derangment.Individual surgeons differ in the tacit techniques of their operations and hence outcomes. Thus far,inguinal hernia surgery should benefit from laparoscopy perhaps only if the hernia are bilateral and recurrent, performed by appropriately trained surgeons.Further analysis of data from various cohorts of performance should not be neglected in evaluating the usefulness of laparoscopic hernioplasty. Competing interests: None declared