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Is Laparoscopic Always Best? When It Comes To Hernia Repair, Depends Who You Ask
By Michael Lasalandra
Beth Israel Deaconess Medical Center Correspondent
Laparoscopic or minimally invasive surgery means smaller incisions, less pain and a quicker recovery for patients undergoing abdominal operations.
But while surgeons tend to agree that certain operations, such as gall bladder removal, are best done laparoscopically, there is disagreement over whether minimally invasive or traditional open surgery is best for some other abdominal operations, including hernia repair.
At Beth Israel Deaconess Medical Center, where both types of hernia surgery are offered, surgeons agree that laparoscopy is superior for gall bladder surgery, for example.
“It is clear that for some areas of surgery, for example, gall bladder surgery, it is better,” says Dr. Michael J. Cahalane, Director of Undergraduate Education for the Department of Surgery at Beth Israel Deaconess Medical Center.
But Dr. Cahalane says the choice is not so cut and dried for hernia repair. “Which one is better is not clear,” he says.
Dr. Daniel Jones, Chief of the section of minimally invasive surgery at Beth Israel Deaconess, says there are clear advantages to the newer approach.
“If you qualify for a laparoscopic procedure, it is better to do it,” he says. “There is less pain with a few small cuts rather than one big one. In my practice, well over 90 percent of hernia patients benefit from the laparoscopic approach. Patients heal better, hurt less and look better. And if you want to get back to golf, you’ll do that more quickly too.”
Dr. Jones points to a 2003 New England Journal of Medicine study that demonstrated the laparoscopic approach resulted in more rapid recovery, fewer recurrences (5% vs. 10%) and less chronic pain than open repairs, but took longer to perform. Another study published in the same journal a year later (2004) concluded open repair to be superior, with overall higher rates of complications and recurrences with laparoscopy. But that study also found that in the hands of surgeons who specialize in minimally invasive surgery, the recurrence rate was the same for open and laparoscopic repairs, and better for recurrent hernia done laparoscopically.
“If you put a violin in the hands of a piano player, it won’t sound as good,” Dr. Jones says.
Laparoscopic surgery is a technique in which operations in the abdomen are performed through tiny incisions rather than one large cut. The incisions allow surgeons to insert tiny surgical instruments that are guided by a tiny telescope attached to a camera, called a laparoscope, inserted through one of the incisions.
A hernia is a tear or weakening of the abdominal wall that left untreated can cause serious intestinal complications. Dr. Jones notes that not all hernias should be repaired laparoscopically. He says very large ones may do better with the traditional open approach.
And Dr. Cahalane concedes that certain types of hernias are better repaired laparoscopically. These include bilateral hernias that occur on both the right and left sides and hernias that have recurred after prior repair, he says.
“With bilateral hernias, you can attack both sides at once,” he says. “And with those who have recurring hernias, you can use a route that has not been used before.”
With either the open or laparoscopic, the tear is repaired by sewing in a mesh patch to plug the hole. In open surgery, the patch is placed over the hole. In laparoscopy, it is put in from behind the abdominal wall.
“What could be more direct than to open it up and patch it from the front?” Dr. Cahalane says, noting that the procedure does not usually require general anesthesia.
Laparoscopy is more complicated, he says. “They have to put the person to sleep and go into the abdominal cavity and come back from the inside to fix it,” he says. “I don’t believe in it. I don’t do it.”
But Jones puts it another way: “If you had a hole in a tire, would you want the patch on top, like in the open operation, or underneath, like we do with the laparoscopic approach?”
He also adds: “Most of my patients prefer to be asleep during the operation.”
Jay Dobek, 31, a video producer from Natick, had a traditional repair done by Dr. Cahalane a few years ago. He says he was referred to the surgeon by a relative and didn’t really investigate the two approaches.
“I trusted the doctor’s opinion and everything went fine,” he says, noting he was out of work about two days following the operation and on pain meds for a few days.
“It wasn’t a big deal,” he says.
Dr. James Hurst, Acting Chief of the Roberta and Stephen R. Weiner Department of Surgery at Beth Israel Deaconess Medical Center, does 80 percent of his hernia procedures open—reserving the laparoscopic technique for those who have multiple recurrences. He also has personal experience with both procedures -- as a patient.
“I can tell you, recovery time was no different in my case but the laparoscopic procedure is more costly,” says Dr. Hurst. But he adds that the New England Journal study did indicate laparoscopic outcomes are better when surgeons are experienced, having at done at least 250 such procedures.
Because there is some debate over which procedure is better, he adds patients should feel free to ask plenty of questions. “I encourage patients to talk openly with their surgeon about which technique will be best for their situation,” he says.
Donald, 30, of Brookline, chose the laparoscopic route after doing research and determining recovery time would be quicker.
He was referred to Dr. Jones by his primary care doctor and had the procedure done under general anesthesia in October of this year. He says he was out of the hospital the same day and the very next day went for a walk of several hours duration. He took pain medications for just two days.
Donald, who works in an office, was back on the job three days later. A week after the operation, he says he was pretty much back to normal.
“I’m pretty happy with the way things went,” he says.
Above content provided by Beth Israel Deaconess Medical Center. For advice about your medical care, consult your doctor.
Posted October 2008
Beth Israel Deaconess Medical Center Correspondent
Laparoscopic or minimally invasive surgery means smaller incisions, less pain and a quicker recovery for patients undergoing abdominal operations.
But while surgeons tend to agree that certain operations, such as gall bladder removal, are best done laparoscopically, there is disagreement over whether minimally invasive or traditional open surgery is best for some other abdominal operations, including hernia repair.
At Beth Israel Deaconess Medical Center, where both types of hernia surgery are offered, surgeons agree that laparoscopy is superior for gall bladder surgery, for example.
“It is clear that for some areas of surgery, for example, gall bladder surgery, it is better,” says Dr. Michael J. Cahalane, Director of Undergraduate Education for the Department of Surgery at Beth Israel Deaconess Medical Center.
But Dr. Cahalane says the choice is not so cut and dried for hernia repair. “Which one is better is not clear,” he says.
Dr. Daniel Jones, Chief of the section of minimally invasive surgery at Beth Israel Deaconess, says there are clear advantages to the newer approach.
“If you qualify for a laparoscopic procedure, it is better to do it,” he says. “There is less pain with a few small cuts rather than one big one. In my practice, well over 90 percent of hernia patients benefit from the laparoscopic approach. Patients heal better, hurt less and look better. And if you want to get back to golf, you’ll do that more quickly too.”
Dr. Jones points to a 2003 New England Journal of Medicine study that demonstrated the laparoscopic approach resulted in more rapid recovery, fewer recurrences (5% vs. 10%) and less chronic pain than open repairs, but took longer to perform. Another study published in the same journal a year later (2004) concluded open repair to be superior, with overall higher rates of complications and recurrences with laparoscopy. But that study also found that in the hands of surgeons who specialize in minimally invasive surgery, the recurrence rate was the same for open and laparoscopic repairs, and better for recurrent hernia done laparoscopically.
“If you put a violin in the hands of a piano player, it won’t sound as good,” Dr. Jones says.
Laparoscopic surgery is a technique in which operations in the abdomen are performed through tiny incisions rather than one large cut. The incisions allow surgeons to insert tiny surgical instruments that are guided by a tiny telescope attached to a camera, called a laparoscope, inserted through one of the incisions.
A hernia is a tear or weakening of the abdominal wall that left untreated can cause serious intestinal complications. Dr. Jones notes that not all hernias should be repaired laparoscopically. He says very large ones may do better with the traditional open approach.
And Dr. Cahalane concedes that certain types of hernias are better repaired laparoscopically. These include bilateral hernias that occur on both the right and left sides and hernias that have recurred after prior repair, he says.
“With bilateral hernias, you can attack both sides at once,” he says. “And with those who have recurring hernias, you can use a route that has not been used before.”
With either the open or laparoscopic, the tear is repaired by sewing in a mesh patch to plug the hole. In open surgery, the patch is placed over the hole. In laparoscopy, it is put in from behind the abdominal wall.
“What could be more direct than to open it up and patch it from the front?” Dr. Cahalane says, noting that the procedure does not usually require general anesthesia.
Laparoscopy is more complicated, he says. “They have to put the person to sleep and go into the abdominal cavity and come back from the inside to fix it,” he says. “I don’t believe in it. I don’t do it.”
But Jones puts it another way: “If you had a hole in a tire, would you want the patch on top, like in the open operation, or underneath, like we do with the laparoscopic approach?”
He also adds: “Most of my patients prefer to be asleep during the operation.”
Jay Dobek, 31, a video producer from Natick, had a traditional repair done by Dr. Cahalane a few years ago. He says he was referred to the surgeon by a relative and didn’t really investigate the two approaches.
“I trusted the doctor’s opinion and everything went fine,” he says, noting he was out of work about two days following the operation and on pain meds for a few days.
“It wasn’t a big deal,” he says.
Dr. James Hurst, Acting Chief of the Roberta and Stephen R. Weiner Department of Surgery at Beth Israel Deaconess Medical Center, does 80 percent of his hernia procedures open—reserving the laparoscopic technique for those who have multiple recurrences. He also has personal experience with both procedures -- as a patient.
“I can tell you, recovery time was no different in my case but the laparoscopic procedure is more costly,” says Dr. Hurst. But he adds that the New England Journal study did indicate laparoscopic outcomes are better when surgeons are experienced, having at done at least 250 such procedures.
Because there is some debate over which procedure is better, he adds patients should feel free to ask plenty of questions. “I encourage patients to talk openly with their surgeon about which technique will be best for their situation,” he says.
Donald, 30, of Brookline, chose the laparoscopic route after doing research and determining recovery time would be quicker.
He was referred to Dr. Jones by his primary care doctor and had the procedure done under general anesthesia in October of this year. He says he was out of the hospital the same day and the very next day went for a walk of several hours duration. He took pain medications for just two days.
Donald, who works in an office, was back on the job three days later. A week after the operation, he says he was pretty much back to normal.
“I’m pretty happy with the way things went,” he says.
Above content provided by Beth Israel Deaconess Medical Center. For advice about your medical care, consult your doctor.
Posted October 2008
