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Education And Debate

Why does NICE not recommend laparoscopic herniorraphy?

BMJ 2002; 324 doi: (Published 04 May 2002) Cite this as: BMJ 2002;324:1092
  1. Roger W Motson, professor of surgery (
  1. Colchester General Hospital, Colchester, Essex CO4 5JL

    NICE's reluctance to recommend laparoscopic repair of hernias is based mainly on economic considerations, some of which are inaccurate, according to Roger Motson

    More than 100 000 inguinal herniorraphies are carried out each year in the United Kingdom, making it one of the commonest operations. Newer techniques have superseded the simple suture technique popularised by Bassini more than 100 years ago: firstly the tension-free darn with monofilament nylon and then the Lichtenstein repair with a polypropylene mesh patch. 1 2 Although there was no initial randomised trial of the Lichtenstein technique, it rapidly gained popularity during the past decade. Laparoscopic repair, which places a considerably larger polypropylene mesh patch against the inner surface of the abdominal wall than that used in the Lichtenstein technique, was first performed about 10 years ago. 3 4 This larger patch reinforces the entire groin, covering the sites of both indirect and direct inguinal hernias and also of femoral hernias. The position of the mesh is the same as that used in the open Stoppa repair,5 but the laparoscopic approach has the great advantage of avoiding the large incision required for this technique.

    Summary points

    Inguinal herniorraphy is one of the commonest operations in the United Kingdom

    Laparoscopic herniorraphy is less painful postoperatively than traditional open repair and allows the patient to return to work more quickly

    The true costs of laparoscopic repair are lower than those of open repair, particularly when it allows detection and simultaneous repair of an undiagnosed contralateral hernia

    Surgeons are under-represented on NICE's appraisal panel

    Laparoscopic repair has been subject to a number of randomised trials, recently summarised by the European Hernia Trials Group, who found that the incidences of recurrence in laparoscopic and Lichtenstein repairs were similar (2.3% and 2.9%, respectively).6 The only differences in clinical outcomes were a …

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