NICE guidance on laparoscopic surgery for inguinal hernias

Editor—We have two comments on the paper by Bloor et al on the impact of NICE guidance on laparoscopic surgery for inguinal hernias.¹

Figure 1.

Laparoscopic inguinal hernia repairs as percentage of all repairs before and after NICE guidance (15 March, p 578)

Firstly, the authors say that guidance from the National Institute for Clinical Excellence (NICE) on laparoscopic hernia repair had no impact on practice and that the rate of laparoscopic repair has not changed much. Although the rate of laparoscopic repair has not changed, NICE guidance has an impact on practice as it stopped the normal progression in laparoscopic hernia repair. Without the guidance the number of laparoscopic repairs would be much larger now.

Secondly, surgeons who were already doing laparoscopic repairs have not stopped doing so, and morbidity has not increased, which means that the NICE guidance was not correct. The European Hernia Trials Group found that the incidence of recurrence in laparoscopic and Lichtenstein repairs was similar (2.3% and 2.9%).² A recent study from Germany, including 8050 patients, showed that recurrence rate for transabdominal preperitoneal hernia repair is only 0.4%.³ Although the difference is minimal, the true cost of laparoscopic hernia repair is lower.⁴,⁵

In January 2001 NICE said that open mesh repair should be the preferred procedure for primary inguinal hernias, and the laparoscopic repair should be considered only for recurrent or bilateral hernias.

Preferred and considered by whom? The 23 members of the NICE appraisal panel include pharmacologists, healthcare economists, patient representatives, and one surgeon. Apart from written submission, by the Association of Endoscopic Surgeons of Great Britain and Ireland, oral evidence was taken from just one surgeon.⁵ NICE has made it clear that the reasons have more to do with control of NHS cost than with clinical excellence.⁵