For most patients hernias provoke minimal symptoms

EDITOR—In Wellwood et al's trial of laparoscopic hernia repair versus open mesh repair only patients fit for general anaesthesia were preselected.1 We do not know if the rejected patients were suitable for local anaesthesia, which is usually ideal for frail and elderly patients and those with high American Society of Anesthesiologists grades.

The type of anaesthesia used greatly affects morbidity associated with elective hernia repair.2 As the authors report, after laparoscopic repair with general anaesthesia, patients may have postoperative nausea, vomiting, and retention of urine. Disorientation and cognitive dysfunction may occur with elderly patients after general anaesthesia but are rare after local anaesthesia.

In Wellwood et al's trial postoperative discomfort after laparoscopic repair was reduced slightly, but does it matter? Assessment of postoperative pain is difficult, but elderly patients commonly experience less pain and require less analgesia than young adults after open hernia repair. This might be attributed to the loss of neurones with ageing3 combined with the decrease in muscle bulk. Although laparoscopic repair is more expensive, many people have suggested that there are economic benefits of early return to work. In reality this is not so: patients over 60are unlikely to be engaged in the labour market, so there is minimal benefit. For elderly patients, who represent half of most series, whether laparoscopic repair offers any benefits at all remains to be proved. Even with rapid recovery most employees expect a traditional amount of time off, whereas self employed patients tend to return to work as soon as possible despite any slight discomfort. The ability and desire to return to work are subjective and greatly influenced by personal circumstances.

Laparoscopic repair is a more complex invasive procedure, and catastrophic complications may occur4; these are unheard of with open repair. In a statistical sense …