A Cochrane review [Abstract] 1 included 41 studies with a total of 7161 subjects (with individual patient data available for 4165). Operation times for laparoscopic repair were longer (WMD 14.81 minutes; 95% CI 13.98 to 15.64; p<0.0001) and there was a higher risk of rare serious complications. Return to usual activities was faster in the laparoscopic groups (HR 0.56, 95% CI 0.51 to 0.61; p<0.0001). This is equivalent to an absolute difference of about 7 days. There were fewer cases of persisting pain at one year after the operation in the laparoscopic groups (overall 290/2101 versus 459/2399; Peto OR 0.54, 95% CI 0.46 to 0.64; p< 0.0001). A total of 86/3138 recurrences were reported after laparoscopic repair and 109/3504 after open repair (Peto OR 0.81, 95% CI 0.61 to 1.08; p = 0.16). Hernia recurrence was less common than after open non-mesh repair but not different to open mesh methods.
A technology assessment report 2 on laparoscopic surgery for inguinal hernia repair including 37 studies was abstracted in the Health Technology Assessment Database. For unilateral hernias, open flat mesh is the least costly option but provides less quality adjusted life years (QALYs) than laparoscopic totally extraperitoneal (TEP) or laparoscopic transabdominal preperitoneal (TAPP) repair. TEP is likely to dominate TAPP (on average TEP is estimated to be less costly and more effective). For the management of symptomatic bilateral hernias, laparoscopic repair would be more cost-effective. The increased adoption of laparoscopic techniques may allow patients to return to usual activities faster. Increased use of laparoscopic repair would lead to an increased requirement for training and the risk of serious complications may be higher.
Another systematic review 3 including 119 studies was abstracted in DARE. Of these, 44 were RCTs, and 26 were other studies with a prospective design. Laparoscopic repair was superior to open procedures in terms of less post-operative pain and faster return to normal activities. Open mesh repairs may cause less post-operative pain and lead to a faster return to normal activities compared to Shouldice, which is the best method of open repair. Of laparoscopic methods, there was some evidence that the totally extraperitoneal approach (TEP) may be associated with a lower recurrence and complication rate.
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