Lichtenstein technique should be used

BMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7026.310 (Published 03 February 1996) Cite this as: BMJ 1996;312:310
  1. David Pelta,
  2. Philip Lafferty
  1. Senior partner Surgeon in primary health care Queensway Surgery, Southend on Sea, Essex SS1 2AB

    EDITOR,—Since the early 1960s a technique of inguinal hernia repair, the Lichtenstein repair, has been available that precludes the use and inherent risks of general anaesthesia. The true Lichtenstein technique is tailor made to suit most patients regardless of their anaesthetic risk, is cost effective, and gives immediate postoperative mobility and reduced postoperative morbidity and pain; patients return to work or normal function after on average 2 to 10 days. In addition, the Lichtenstein repair shows long term recurrence rates of 0.13% at five years.1 Given these factors, it is alarming that in Kate Lawrence and colleagues' study of only 125 men, in all of whom general anaesthesia was used, the Maloney darn was taken as the current standard surgical technique,2 with, we presume, standard recurrence rates of 10-15% at three years.3

    The statement that open herniorrhaphy rarely causes severe pain or morbidity is at variance with popular belief and the authors' results, which show that 40-50% of patients who had open repair had not returned to normal function by four weeks. Indeed, when standard techniques are used it is common for patients to return to normal function only after six weeks.4

    The absence of local data surely reflects auditing techniques and is not an excuse to assume a short term complication rate of 0.5%. It is disconcerting that 1% of patients crossed from laparoscopic to open repair. Moreover, 12% of patients who had laparoscopic repair suffered important early complications, with 5% requiring admission.

    Despite these findings the authors propose to undertake longer term, larger studies of laparoscopic techniques, hoping that complication rates decrease as part of a learning curve. They conclude that sample sizes of thousands are needed to detect differences in recurrence rates. Such sample sizes have already been studied: the short and long term benefits of the Lichtenstein technique of hernia repair to patients are conclusive.5

    As first wave fundholders, we offer Lichtenstein repairs to patients in a primary health care setting. A clinical audit and an audit of patients' perceptions are being undertaken, and we have had a 100% response rate to our anonymised questionnaires. Results for one year will be available in June. In our opinion, further assessment of laparoscopic herniorrhaphy is unnecessary and the use of archaic standard repairs inappropriate when modern, safer, and more effective techniques are readily available—now in a primary health care setting.


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