Why does NICE not recommend laparoscopic herniorraphy?

In the education and debate article "Why does NICE not recommend
laparoscopic hernia repair", in respons to the NICE guideline, Motson
correctly cites the evidence that is available up to now. This evidence
tells us that endoscopic hernia repair is as good as the best conventional
repair when recurrence rates are considered. It also tells us that
recovery is quicker and pain is less. Furthermore it tells us that overall
costs (in hospital and thereafter) are the same or even less.
So what then is the problem? There is no evidence that for fit patients
the required general anaesthesia is a drawback. There is also no evidence
that the use of a mesh is harmful (which probably accounts for the
increasing worldwide use of mesh repair in conventional hernia surgery).
The problems are cost and training. The in-hospital costs are higher, but
the community profits from a faster return to work. This should be solved
by reallocation of funds. The other problem, the technique that is still
considered difficult, is more a matter of training than of the technique
itself. If all trainers would start teaching their residents the
endoscopic technique as early as they do with the conventional repair, the
residents will become equally familiar with either techniques.
We should not deny our patients a good opereation, nor should we deny our
residents the training in it.