Is an open or laparoscopic approach better for inguinal hernia repair?
Open surgical repair of inguinal hernias involves use of a prosthetic mesh and the possibility of local anaesthesia, and the patient is often discharged within a few hours of the procedure. A laparoscopic procedure has been introduced that requires general anaesthesia but claims to reduce postoperative pain and allow earlier return to usual activities. Which is better? The authors randomised (allocation concealed) 2164 patients at 14 Veteran's Affairs medical centres to receive either the open or laparoscopic procedure. Of the 2164 initially randomised, 1983 actually had surgery. The surgical protocol was standardised for each type of procedure, and surgeons must have performed at least 25 of their chosen procedure to qualify for the study. Patients were followed up for two years, and 1696 (86%) completed the follow up. Crossover from laparoscopic to open repair occurred in 9.8% of patients, compared with only 1.6% crossing over in the other direction. Patients were analysed by the group to which they were originally assigned, which is appropriate. Patients who had laparoscopic repair experienced less pain after surgery and returned to work sooner (4 v 5 days; 95% confidence interval for difference 1.1 to 1.3). However, the difference in pain was generally minor, between 6 and 10 on a 100 point visual scale (in general, differences less than 15 points are unlikely to be clinically important). There were more complications with laparoscopic repair, including more life threatening complications (0.1% v 1.1%; odds ratio 11.2, 1.3 to 95.3). The recurrence rate at two years was also lower in the open repair group (4.9% v 10.1%; absolute risk reduction 5.2%; number needed to treat = 20).
Conclusion Although laparoscopic repair is associated with a small reduction in pain and gets your patient back to work a day sooner, it carries a greater risk of serious complications and recurrence.

Neumayer L, Giobbie-Hurder A, Jonasson O, et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med.