Running head: LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 1

Transcription

1 Running head: LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 1 Laparoscopic Versus Open Inguinal Hernia Repair Jacob D. Schoeff Advanced Research and Internship Fall, 2010

2 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 2 Table of Contents Page Number Abstract 4 Chapter 1: Introductory Paragraphs. 5 Statement of the Problem...5 Purpose..5 Significance of the Problem..6 Research Question & Hypothesis.7 Chapter 2: Background.. 8 Literature Review.8 Definition of Terms..14 Chapter 3: Methodology Null & Alternative Hypotheses.15 Population and sampling...16 Instrumentation Procedure and time frame.. 16 Analysis plan Validity and reliability. 18 Assumptions. 18 Scope and limitations... 18

3 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 3 Chapter 4: Page Number Description of Sample..19 Time to Full Recovery..19 Complications..19 Short-Term Recurrences..20 Total Costs 20 Analysis 20 Chapter 5: Conclusion 23 Discussion 24 Recommendation.24 References...26

4 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 4 Abstract In this study, the goal is to discover which method, Laparoscopic or Open, of inguinal hernia repair is most efficient considering the recovery time, recurrence rate, amount of complications, and the total cost involved. Establishing which method is more effective could provide surgeons with the proper information to decide what technique of inguinal hernia repair is more suitable for individual patients. While conducting the research, a total of 80 patient files from 2009 at Summit Surgical Specialist, PC were recorded. 40 of the patient files were patients that underwent Laparoscopic inguinal hernia repair, while the other 40 of the patient files were patients that underwent Open mesh inguinal hernia repair. When the patient files were collected and all the data was analyzed, the more efficient technique would be the Open mesh inguinal hernia repair method. I concluded, from the data, that both techniques of inguinal hernia repair had similar recovery times, Laparoscopic repair had a greater complication rate and a greater total cost of $250 to $500 more than the Open procedure, and that both techniques of inguinal hernia repair had the same recurrence rate of 0%. Therefore, this study shows that for the repair of an inguinal hernia, the Open mesh repair technique is more efficient than the Laparoscopic repair technique.

5 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 5 Laparoscopic Versus Open Inguinal Hernia Repair Inguinal hernia repair is one of the most common procedures in general surgery. According to the Society of American Gastrointestinal and Endoscopic Surgeons in 2004, there were approximately 600,000 hernia repair procedures performed in the United States. An inguinal hernia occurs when a fatty intra-body substance, or the small intestines, protrudes through a weakened section of muscle creating a sizable bulge which can grow if left untreated. Inguinal hernias cause discomfort or a sharp pain, a feeling of weakness or pressure in the groin, or a burning, aching feeling at the bulge, ( Inguinal Hernia, 2008). There are several methods of acquiring an inguinal hernia or worsening a current hernia, which are sudden twists, pulls, or muscle strains, lifting heavy objects, straining on the toilet because of constipation, weight gain, or chronic coughing, ( Inguinal Hernia, 2008). The procedure involved in repairing an inguinal hernia is quite safe and complications are uncommon, but understanding about the possible risks helps patients report postoperative symptoms. Information by Hendren, and Black, (1986) describe possible complications including cellulitis, chronic pain due to nerve damage, recurrence, or damage to the testicles or other male organs. The methods concerning the surgical repair of inguinal hernias are evaluated regarding time to full recovery, recurrence rate, and complications. It is hypothesized that the laparoscopic inguinal hernia repair technique results in both shorter time to full recovery and shorter time to return to work, at the price of substantially increased costs, (Johansson, M.D. et al., 1999). Statement of the Problem The most efficient technique of inguinal hernia repair is still an intense argument amongst surgeons around the World. This controversial argument has been under question ever since the Laparoscope technique was implemented. Establishing the most efficient technique for

6 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 6 inguinal hernia repairs can help to reduce complications, recurrences rate, recovery time, and the total cost involved for the patient. Purpose The goal is to discover which method, Laparoscopic or Open, of inguinal hernia repair is most efficient considering the recovery time, recurrence rate, amount of complications, and the total cost involved. Significance of the Problem One of the most commonly performed procedures for general surgery is the repair of inguinal hernias. Hernias can cause discomfort or pain, and may even lead to death if the hernia is strangulated. There are currently two commonly practiced methods of inguinal hernia repair: Laparoscopic and Open. Laparoscopic inguinal hernia repair is the newest technique, during which four smaller incisions are made and a small lighted-camera called the laparoscope is positioned inside the body to illuminate the surgery site for the surgeon. Only one larger incision is made during an Open inguinal hernia repair and the hernia is repaired by hand. A synthetic mesh-like material is used for both methods, and the goal of this research is to establish which method is more effective. The recovery time, recurrence rate, amount of complication, and the total expenditure involved for each method will be compared to distinguish which technique is more effective. Researching the most efficient technique of inguinal hernia repair could help patients recover faster with fewer complications. Establishing which method is more effective could provide surgeons with the proper information to decide what technique of inguinal hernia repair is more suitable for individual patients.

7 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 7 Research Question What is the most efficient technique for inguinal hernia repairs concerning recovery time, recurrence rate, amount of complications, and the total cost involved for the patient? Hypotheses Sub-problem I: Which hernia repair technique that has the quickest recovery time? Hypothesis A: Laparoscopic method results in the quickest recovery time compared to the recovery time of the Open method. Null Hypothesis A: There is no significant difference in recovery time between Laparoscopic and Open inguinal hernia repair. Alternative Hypothesis A: There is a significant difference in recovery time between Laparoscopic and Open inguinal hernia repair. Sub-problem II: Which hernia repair technique has the highest recurrence rate? Hypothesis B: Laparoscopic method results in the highest recurrence rate compared to the recurrence rate of the Open method. Null Hypothesis B: There is no significant difference in recurrence rate between Laparoscopic and Open inguinal hernia repair. Alternative Hypothesis B: There is a significant difference in recurrence rate between Laparoscopic and Open inguinal hernia repair. Sub-problem III: Which hernia repair technique that has the most complications? Hypothesis C: Laparoscopic method results in the most complications compared to the amount of complications of the Open method. Null Hypothesis C: There is no significant difference in the amount of complications between Laparoscopic and Open inguinal hernia repair.

8 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 8 Alternative Hypothesis C: There is a significant difference in the amount of complications between Laparoscopic and Open inguinal hernia repair. Sub-problem IV: Which hernia repair technique that has the highest total cost? Hypothesis D: Laparoscopic method results in the highest total cost compared to the total cost of the Open method. Null Hypothesis D: There is no significant difference in the total cost between Laparoscopic and Open inguinal hernia repair. Alternative Hypothesis D: There is a significant difference in the total cost between Laparoscopic and Open inguinal hernia repair. Chapter II Literature Review Laparoscopic tension-free inguinal hernia repair is a technique that was presented in 1980 by Patrick Steptoe. Four incisions are made directly under the navel, and the abdomen is inflated with air so the surgeon can see the abdominal organs, (Rhodes, 2009). A laparoscope is inserted through one of the incisions, and other surgical paraphernalia, like trocars and forceps, are inserted through the additional three incisions. The laparoscope broadcasts an enlarged picture from within the lower abdomen to a television screen, supplying the general surgeon with a convenient examination of the inguinal hernia and adjacent sinew. Synthetic mesh is then used to cover the inguinal hernia, which helps strengthen the abdominal wall. An informational article from WebMD states that recovery time involved in laparoscopic hernia repair is about one to two weeks and that people usually have less pain after laparoscopic repair compared to the conventional method of open inguinal hernia repair, (Rhodes, 2009). Herniorrhaphy is the original method when dealing with inguinal hernias. This method involved only one incision in the groin and no mesh was used. This creates tension because the surgeon has to stretch the

9 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 9 muscle wall back together and reinforce it with stitches. The current approach involves placing a synthetic mesh material over the weakened area of muscle to add supplementary support. The synthetic mesh is now used for all inguinal hernia repairs, laparoscopic or open, because of the decrease in tension the mesh provides. Laparoscopic Versus Open Inguinal Hernia Repair Inguinal hernia repair is one of the most common procedures in general surgery. According to the Society of American Gastrointestinal and Endoscopic Surgeons in 2004, there were approximately 600,000 hernia repair procedures performed in the United States. An inguinal hernia occurs when a fatty intra-body substance, or the small intestines, protrudes through a weakened section of muscle creating a sizable bulge which can grow if left untreated. Inguinal hernias cause discomfort or a sharp pain, a feeling of weakness or pressure in the groin, or a burning, aching feeling at the bulge, ( Inguinal Hernia, 2008). There are several methods of acquiring an inguinal hernia or worsening a current hernia, which are sudden twists, pulls, or muscle strains, lifting heavy objects, straining on the toilet because of constipation, weight gain, or chronic coughing, ( Inguinal Hernia, 2008). The procedure involved in repairing an inguinal hernia is quite safe and complications are uncommon, but understanding about the possible risks helps patients report postoperative symptoms. Information by Hendren, and Black, (1986) describe possible complications including cellulitis, chronic pain due to nerve damage, recurrence, or damage to the testicles or other male organs. The methods concerning the surgical repair of inguinal hernias are evaluated regarding time to full recovery, recurrence rate, and complications. It is hypothesized that the laparoscopic inguinal hernia repair technique results in both shorter time to full recovery and shorter time to return to work, at the price of substantially increased costs, (Johansson, M.D. et al., 1999).

10 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 10 Complication Rate & Average Cost Lawrence et al. (1995), conducted a study which there were 125 men randomized to either open or laparoscopic repair of their inguinal hernias. Two specific questions concerning the study; what percentage difference is there between the complication rates of laparoscopic and open hernia repair and what is the average cost difference between the laparoscopic technique and the open technique? The results stated that there were greater complications in the laparoscopic technique, one vascular complication in the open technique group and seven complications in the laparoscopic technique group (difference of 10% in complication rate). The amount of pain and quality of life after the procedure in short term analysis showed that there was a considerable advantage to the group who underwent laparoscopic hernia repair. The average costs were higher, however, in the laparoscopic group ($965 to $1673) compared to average cost of the open hernia repair group ($380 to $453). Because of the substantial difference in complication rates and average cost, the laparoscopic technique s outcome effectiveness should be taken into account before proceeding with this method of inguinal hernia repair. Operative time & Recovery Time A comparison study by Tanphiphat, Tanprayoon, Sangsubhan, & Chatamra (1997) contrasted the open hernia repair technique to laparoscopic hernia repair technique and whether or not switching to the laparoscopic method was a justifiable option. Tanphiphat et al. conducted a randomized organized experiment during which 120 qualified patrons were selected for an inguinal hernia repair at a local university hospital. The patients were indiscriminately placed in one of the two groups, 60 experienced the laparoscopic repair while the other 60 experienced the open technique. During the procedure there was an increased operative time for laparoscopic

11 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 11 hernia repair, (95 minutes compared to the 67 minutes). Accomplishing gentle tasks for the patients of laparoscopic repair without tenderness or soreness was considerably earlier, average of 8 (5 14) days versus 14 (8 19) days for patients who underwent open technique. Recommencing strenuous tasks for patients was also earlier following laparoscopic repair, average of 28 (17 60) days versus 35 (20 56) days. There was only one average day difference between laparoscopic hernia repair and open hernia repair, so the recommencement of work was not considerably contrasting, average of 14 (8 25) days following laparoscopic hernia repair versus 15 (11 21) days following open hernia repair. There was only one patient who provoked a recurrent hernia after only three months following laparoscopic hernia repair. Laparoscopic inguinal hernia repair was associated with less early postoperative pain and disability and earlier return to full activities than open repair laparoscopic repair was also more costly than open repair by approximately $400, (Tanphiphat et al., 1997). Overall Comparison of Open and Laparoscopic In a British comparison article by Wellwood et al. (1998), they evaluated tension-free open mesh inguinal hernia repair and tension-free laparoscopic hernia repair to compare time until discharge, postoperative pain and complications, duration of convalescence, patients satisfaction with surgery, and health service costs, (Wellwood et al., 1998). There were a total of 403 patients that were involved with this study and it was completely randomized and controlled. There were fewer patients discharged in the laparoscopic tension-free hernia repair group (89 percent) than the open tension-free hernia repair group (96 percent). Both tension-free hernia repair groups had very few serious operative complications (two cases of testicular atrophy and four cases of wound infection) and no recurrent hernias were found after the three month follow-up. The day after the procedure the open tension-free hernia repair group had

12 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 12 considerably more pain than the laparoscopic tension-free hernia repair group. The reduction in pain for the laparoscopic group is most likely due to the smaller incisions. Costs are always a lot higher in the laparoscopic group than the open group ($335 more expensive than open tensionfree). This study verifies that laparoscopic hernia repair has considerable short term clinical advantages after discharge compared to open mesh hernioplasty, although it was more expensive, (Wellwood et al., 1998). In a Swedish comprehensive study by Johansson et al. (1999), they evaluated the time to full recovery and return to work, complications, recurrence rate, and the economic aspects of the influences of the laparoscopic technique in inguinal hernia repair. The study considered that laparoscopic hernia repair may result in shorter time to full recovery and earlier return to work, at the price of substantially increased cost, (as cited in Cook, M.D., FACS, n.d.). During the randomized, multicenter (10 hospitals) study, there were 613 male patients from the ages 40 to 75 who were placed in one of three hernia repair groups (open mesh technique, laparoscopic mesh group, or the non-mesh conventional technique). There were three planned follow-up dates for each patient (one week, eight weeks, and one year). There was a considerably reduced recovery time for the laparoscopic mesh technique (18.4 days) considering the recovery time for the open mesh technique (24.2 days). The amount of time it took for the patients to return to work did not have as much of a steep difference in the laparoscopic mesh technique (14.7 days) compared to the open mesh technique (17.7 days). The laparoscopic mesh technique was more expensive, mainly as a result of longer surgical time and equipment costs, even after compensation for earlier time to work, (Johansson, M.D. et al., 1999). There were a deviating paradigm of complications and recurrences with no considerable distinction between the three groups. This comparison validates the findings of several other studies in the literature showing

13 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 13 a faster return to normal activity as well as faster return to work in patients undergoing laparoscopic inguinal hernia repairs, (as cited in Cook, M.D., FACS, n.d.). The study also authenticates that repairing an inguinal hernia using the laparoscopic mesh technique has a more exorbitant price ($1,800 compared to $1,300). A New England study has shown that open technique is superior to the laparoscopic technique for mesh repair of primary hernias, (Neumayer, M.D. et al., 2004). There were 2164 patients who were desultorily appointed to one of the two techniques. The study explains that the recurrences rates and complications were more common for the laparoscopic technique, even though the laparoscopic-surgery group had less pain initially than the open-surgery group, (Neumayer, M.D. et al., 2004). Even though the recurrence rate (10.1 percent) and amount of complications (39 percent) involved in laparoscopic inguinal hernia repair is higher than the recurrence rate (4.9 percent) and amount of complications (33.4 percent) involved with the hernioplasty, the recovery time the amount of time it took to get back to work is still shorter when it comes to the laparoscopic technique. Patients who experienced the laparoscopic tensionfree technique were able to return to their customary day by day enterprise only one day earlier than those who experienced the open tension-free technique. The open tension-free group of patients endured considerably superior stages of discomfort than those in the laparoscopic tension-free group, both directly after the procedure and two weeks post-operation. There was no considerable distinction, however, two weeks after the procedure. Conclusion Inguinal hernia repair using either the laparoscope technique or the open technique is still a controversial concept in the general surgery field of medicine. We can assume by these research articles that using the laparoscope for an inguinal hernia repair can result in a quicker

14 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 14 recovery time with less postoperative discomfort at the cost of a higher expenditure and risk of more complications and recurrent hernias. Definition of Terms Bilateral: Two hernias, one on each side of the inguinal area. Cellulitis: Inflammation or Infection of cellular tissue. Fascia: A sheet of connective tissue separating and connecting layers of muscle throughout the body. Forceps: An instrument, as pincers or tongs, for seizing and holding objects. Hematoma: A collection of blood underneath the tissue. Another name for Ecchymosis. Hernioplasty: An operation for the repair of a hernia where a synthetic mesh is used so as to create no tension. Herniorrhaphy: Surgical correction of a hernia by stitching the muscle together using no mesh. Inguinal Hernia: A common type of hernia in which a loop of the intestine protrudes directly through a weak area of the abdominal wall in the groin region. Laparoscope: A flexible fiber-optic instrument, passed through a small incision in the abdominal wall with which to examine the abdominal cavity or perform minor surgery. Open mesh hernia repair: another name for a Hernioplasty. Seroma: A collection of uninfected fluid underneath the tissue. Can produce a tumor-like mass. Trocars: A sharp-pointed surgical instrument used to puncture a body cavity. Unilateral: When a hernia is only on one side of the groin region. Chapter III - Methodology What is the most efficient technique of inguinal hernia repairs concerning recovery time, recurrence rate, amount of complications, and the total cost involved for the patient? The most

15 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 15 efficient technique of inguinal hernia repair is still a heated argument amongst surgeons around the World. The Goal is to discover which method of inguinal hernia repair is most efficient considering the recovery time, recurrence rate, amount of complications, and the total cost involved. This problem has been under question every since the Laparoscope technique has been invented. Inguinal hernia repairs are one of the top most surgeries in General Surgery today with at least one per week for my mentor. Finding the most efficient technique for inguinal hernia repairs can help to reduce complications, recurrences, recovery time, and the total cost involved for the patient. Null & Alternative Hypotheses Sub-problem I: Which hernia repair technique that has the quickest recovery time? Null Hypothesis A: There is no significant difference in recovery time between Laparoscopic and Open inguinal hernia repair. Alternative Hypothesis A: There is a significant difference in recovery time between Laparoscopic and Open inguinal hernia repair. Sub-problem II: Which hernia repair technique that has the highest recurrence rate? Null Hypothesis B: There is no significant difference in recurrence rate between Laparoscopic and Open inguinal hernia repair. Alternative Hypothesis B: There is a significant difference in recurrence rate between Laparoscopic and Open inguinal hernia repair. Sub-problem III: Which hernia repair technique that has the most complications? Null Hypothesis C: There is no significant difference in the amount of complications between Laparoscopic and Open inguinal hernia repair.

16 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 16 Alternative Hypothesis C: There is a significant difference in the amount of complications between Laparoscopic and Open inguinal hernia repair. Sub-problem IV: Which hernia repair technique that has the highest total cost? Null Hypothesis D: There is no significant difference in the total cost between Laparoscopic and Open inguinal hernia repair. Alternative Hypothesis D: There is a significant difference in the total cost between Laparoscopic and Open inguinal hernia repair. Population and Sampling The sampling involved with the research involves hard-copies of the patient files at Summit Surgical Specialist, PC. This involves reviewing approximately 80 patient files (40 patient files that underwent Open inguinal hernia repair and 40 patient files that underwent Laparoscopic inguinal hernia repair). The population involved with the research includes all the patients that underwent inguinal hernia repairs associated at Summit Surgical Specialist, PC from the year Instrumentation In this research, the patient files at Summit Surgical Specialist, PC from the year 2009 will be used. Procedure and Time Frame Commencement of the research will begin on August 31, 2010 and completing the research will be done by November 19, The patient files that are being collected from Open inguinal hernia repair were patients that either had Dr. Holcomb, MD, FACS or Dr. Anderson, MD, FACS as a surgeon. The patient files that are being collecting from Laparoscopic

17 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 17 inguinal hernia repair were patients that either had Dr. Hathaway, MD, FACS or Dr. Schwab, MD, FACS as a surgeon. Analysis plan While looking through patients files from 2009, the age, sex, date of procedure, type of procedure (Right Inguinal Hernia or Left Inguinal Hernia), and follow-up dates with a description of the patient s recovery will be recorded. The collection of the data from bilateral hernia repairs and unilateral hernia repair in the laparoscopic group only will be used. The collection of the patient files is all randomized. Once collected, all 80 patient files, separation of the data into groups based on age and technique of surgery will begin. After that, data related to any problems post-operation, like complications or recurrences will be recorded. Data evaluating each individual s recovery time from the procedure, will also be recorded. Table 1: Recovery Time 7-days days days 26 days Laparoscopic (patients) Open (patients) Laparoscopic (patients) Table 2: Laparoscopic Complications Cellulitis Hematoma Injury to Internal Organs Total

18 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 18 Open (patients) Table 3: Open Complications Cellulitis Wound Infection Nerve Damage Total Table 4: Total Cost Laparoscopic Open Unilateral Bilateral Validity and Reliability The validity of the information in the patient files at Summit Surgical Specialist, PC from the year 2009 is reliable. They were all reviewed by the nurse practitioners, and dictations were taken place by the surgeons directly after the surgeries. Assumptions This study assures the surgeons recorded all information in the patient files correctly (i.e. dates of procedures, dates of follow-ups, complications involved if any, age of patient, type of surgery and the technique involved, and any other information used with looking through the files). This study assures the surgeries in the same hernia repair technique carry out the same way each time. This study assures the surgeons all performed the surgeries the same way as the other surgeons. Scope and limitations The limitations involved are time and lack of excessive information from other institutions. The research has a deadline, so time is a precious luxury. Also, being only able to collect patient

19 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 19 files from Summit Surgical Specialist, PC from the year 2009 is a limitation. No authority is given towards the study to review patient files from other companies or even the hospital, so the resources are not very plentiful. These limitations degrade the research by making the study little time to gather as much information as possible can from both groups. They also degrade my research by not allowing the study to have an abundant amount of information. Chapter IV Data and Results Description of Sample While conducting my research I recorded a total of 80 patient files from 2009 at Summit Surgical Specialist, PC. 40 of the patient files were patients that underwent Laparoscopic inguinal hernia repair, while the other 40 of the patient files were patients that underwent Open mesh inguinal hernia repair. The range of the age was 18 to 87 in both methods. Time to Full Recovery Table 1: Recovery Time 9-days days days 26 days Laparoscopic (patients) 20 (50%) 9 (22.5%) 4 (10%) 7 (17.5%) Open (patients) 21 (52.5%) 11 (27.5%) 5 (12.5%) 3 (7.5%) Complications Table 2: Laparoscopic Complications Cellulitis Hematoma Injury to Internal Organs Total Laparoscopic (patients) 1 (2.5%) 5 (12.5%) 2 (5%) 8 (20%)

20 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 20 Table 3: Open Complications Cellulitis Wound Infection Nerve Damage Total Open (patients) 2 (5%) 2 (5%) 1 (2.5%) 5 (12.5%) Short-Term Recurrences Table 4: Recurrences # of Recurrences Recurrence Rate Laparoscopic (patients) 0 0% Open (patients) 0 0% Total Costs Table 5: Total Cost Laparoscopic Open Unilateral $1, $1, Bilateral $3, $3, Analysis For sub-problem I, Which hernia repair technique has the quickest recovery time? the number of patients who recovered in the 1-week follow up and following follow-ups was recorded in the set groups ( 9-days, days, days, and 26 days). The objective of the study was to reject the null hypothesis, There is no significant difference in recovery time between Laparoscopic and Open inguinal hernia repair. and confirm the alternative hypothesis, There is a significant difference in recovery time between Laparoscopic and Open inguinal hernia repair. Results from the study are shown in Table 1: Recovery Time.

21 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR (50%) of the 40 patients who underwent Laparoscopic inguinal hernia repair recovered in 9 days. 21 (52.5%) of the 40 patients who underwent Open inguinal hernia repair also recovered in 9 days. Nine (22.5%) of the 40 patients who underwent Laparoscopic inguinal hernia repair recovered in 10 to 16 days. 11 (27.5%) of the 40 patients who underwent Open inguinal hernia repair also recovered in 10 to 16 days. Four (10%) of the 40 patients who underwent Laparoscopic inguinal hernia repair recovered in 17 to 25 days. Five (12.5%) of the 40 patients who underwent Open inguinal hernia repair also recovered in 17 to 25 days. Seven (17.5%) of the 40 patients who underwent Laparoscopic inguinal hernia repair recovered in 26 days. 3 (7.5%) of the 40 patients who underwent Open inguinal hernia repair also recovered in 26 days. The average time it took for the patients to recover was considerably less for the Open group (12.7 days), contrasted against the Laparoscopic group (17.2 days). For sub-problem II, Which hernia repair technique has the highest recurrence rate? all recurrences were counted up in each group and recorded in each set method (Laparoscopic or Open). The objective of the study was to reject the null hypothesis, There is no significant difference in recurrence rate between Laparoscopic and Open inguinal hernia repair. and confirm the alternative hypothesis, There is a significant difference in recurrence rate between Laparoscopic and Open inguinal hernia repair. Results from the study are shown in Table 4: Recurrences. There were no short-term recurrences in either group. For sub-problem III, Which hernia repair technique that has the most complications? the number of patients who encountered complications during their recoveries in the 1-week follow up and following follow-ups was recorded in the set groups. The complications for Laparoscopic inguinal hernia repair were: cellulitis, hematoma, injury to internal organs, and the total amount of complications. The complications for Open inguinal hernia repair were:

22 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 22 cellulitis, wound infection, nerve damage, and the total amount of complications. The objective of the study was to reject the null hypothesis, There is no significant difference in the amount of complications between Laparoscopic and Open inguinal hernia repair. and confirm the alternative hypothesis, There is a significant difference in the amount of complications between Laparoscopic and Open inguinal hernia repair. Results from the study are shown in Table 2: Laparoscopic Complications and Table 3: Open Complications. Postoperative complications were recorded at each 7-day follow-up and every other follow-up date the patient visited. There were a total of five complications in the Open group (two wound infections, two cases of Cellulitis, and one case of nerve damage) and a total of eight complications in the Laparoscopic group (five cases of hematomas, one case of Cellulitis, and two cases of injuries to internal organs, which consisted of a small tear of the bladder and the swelling of a Vas Deferens). The total complication rate of the Open group was 12.5% compared to the 20% of the Laparoscopic group. For sub-problem IV, Which hernia repair technique that has the highest total cost? the cost of each general procedure was recorded in each set group. There were two types of surgeries in each method of surgery. Both Laparoscopic and Open inguinal hernia repair had patients with both bilateral hernias and unilateral hernias repairs. The objective of the study was to reject the null hypothesis, There is no significant difference in the total cost between Laparoscopic and Open inguinal hernia repair. and confirm the alternative hypothesis, There is a significant difference in the total cost between Laparoscopic and Open inguinal hernia repair. Results from the study are shown in Table 5: Total Cost. The research question was What is the most efficient technique for inguinal hernia repairs concerning recovery time, recurrence rate, amount of complications, and the total cost

23 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 23 involved for the patient? The objective of the study was to reject the null hypothesis, There is no difference in the efficiency of the techniques, Laparoscopic and Open inguinal hernia repair. and confirm the alternative hypothesis, There is a significant difference in the efficiency of the techniques, Laparoscopic and Open inguinal hernia repair. Chapter V- Conclusion and Recommendations Conclusion The purpose of this study was discover which method, Laparoscopic or Open, of inguinal hernia repair is most efficient considering the recovery time, recurrence rate, amount of complications, and the total cost involved. 80 patient files were collected randomly from a list of patients who underwent Laparoscopic or Open inguinal hernia repair (40 patients per hernia repair group). I recorded the patient s recovery time, any complications they experienced, whether or not they had a recurrence of their hernia, and what the total cost of the procedure was. I concluded, from the data, that both techniques of inguinal hernia repair had similar recovery times, even if the patient was 87-years-old or 18-years-old. I concluded, from the data, that Laparoscopic repair has a greater complication rate than Open repair. I concluded, from the data, that for recurrences to occur, it takes a couple years, not a couple weeks. Lastly I concluded, from the data, that the total cost of the Laparoscopic procedure costs $250 to $500 more than the Open procedure. This data rejects my hypotheses of Laparoscopic repair having shorter recovery time and a higher recurrence rate. This data supports my hypotheses of Laparoscopic repair having a greater number of complications and a higher total cost. This data supports my null hypothesis concerning recurrence rate due to both techniques not producing any recurrences throughout the study.

24 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 24 Discussion From all the patient files collected and all the data analyzed, the more efficient technique, based on the research, would be the Open mesh inguinal hernia repair method. Laparoscopic repair is advertised as having a quicker recovery time, but looking at the data I can conclude that the recovery times are very close to each other. The three to four incisions involved in Laparoscopic repair may be smaller, but the surgeon is still cutting through all those layers of skin, muscle, and fascia, while during an Open inguinal hernia repair there is only one medium sized incision. The complication rate involved in the Open inguinal hernia repair group is significantly lower than the complication rate involved in the Laparoscopic inguinal hernia repair group. The complication rate of the Open group is 20%, while the complication rate of the Laparoscopic group is 12.5%. That is a whole 7.5% complication rate. Laparoscopic patients are more likely to obtain complications due to the fact that the surgeons have to work around internal organs, like the bladder, while repairing the inguinal hernia. Both techniques did not acquire any recurrences amongst the patients. It is unlikely that the hernias will come back only a couple of weeks later. A recurrent hernia usually takes five to ten years to appear if it recurs at all. The total cost of Open inguinal hernia repair is also $250 to $500 cheaper than the Laparoscopic inguinal hernia repair technique. Open repair is cheaper because it is a quicker procedure with less expensive equipment. Based on this data collected, the more efficient inguinal hernia repair technique is Open mesh repair. Recommendation If a similar study is conducted again, a greater number of patients are recommended. Because only a total of 80 patient files were collected, there is a serious lack of representation of the population as a whole. If more patient files are available, I recommend at least doubling,

25 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 25 maybe tripling the number of patient files collected. The collection of greater numbers of patient files would reveal more information about the complications rates and recovery times. If more time is available, adding the third method of inguinal hernia repair, a Herniorrhaphy, and having a 1-year follow-up as well as just a 1-week follow-up is strongly recommended. Adding the Herniorrhaphy to the study would give greater results as to why adding mesh to the hernia is now a regular procedure. Having a 1-year follow-up would reveal greater information about hernia recurrences.

26 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 26 References Bittner, R., Schmedt, C.G., Schwarz, J., Kraft, K., & Leibl, B.J. (2002). Laparoscopic transperitoneal procedure for routine repair of groin hernia. British Journal of Surgery, 89(8), Retrieved from doi: /j x Cook, M.D., FACS, C.H. (n.d.). Open versus laparoscopic inguinal hernia repair. The Journal of Family Practice, Retrieved from Hendren, W.H., & Black, P.R. (1986). Inguinal hernia repair in children [Vol. 3, ed. 3]. Inguinal hernia. (2008, December). Retrieved from ddiseases/pubs/inguinalhernia/ Johansson, B. et al. (1999). Laparoscopic mesh versus open preperitoneal mesh versus conventional technique for inguinal hernia repair. Annals of Surgery, 230(225), Retrieved from Lawrence, K. et al. (1995). Randomised controlled trial of laparoscopic versus open repair of inguinal hernia: Early results. BMJ, 311(981), Retrieved from 311/7011/981.full Malangoni, M.A., & Rosen, M.J. (2008). Sabiston textbook of surgery: The biological basis of modern surgical practice [Vol. 2, ed. 18]. Neumayer, M.D., L. et al. (2004). Open mesh versus laparoscopic mesh repair of inguinal hernia [pp ]. Retrieved from Moa040093#t=articleTop

27 LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR 27 Rhodes, M. (2009, april 29). Open inguinal hernia repair (herniorrhaphy, hernioplasty). WebMD, Retrieved from Rhodes, M. (2009). Laparoscopic Inguinal Hernia Repair. WebMD, Retrieved from Society of American Gastrointestinal and Endoscopic Surgeons, Initials. (2004, March). Patient information for laparoscopic inguinal hernia repairc. Retrieved from publication/id/pi06/ Tanphiphat, C., Tanprayoon, T,, Sangsubhan, C., & Chatamra, K. (1997). Laparoscopic vs open inguinal hernia repair a randomized, controlled trial [Vol. 12, ed. 6, pp ]. (Adobe Digital Editions), Retrieved from doi: /s Wellwood, J. et al. (1998). Randomised controlled trial of laparoscopic versus open mesh repair for inguinal hernia: Outcome and cost. BMJ, 317(103), Retrieved from /content/317/7151/103.full?view=full&pmid=