Laparoscopic surgery of the abdominal wall: Why has it not been implemented like other laparoscopic procedures?

CIRUGÍA ESPAÑOLA has recently published an article by the Endoscopic Surgery Group of the Spanish Association of Surgeons (AEC), which has analyzed the 25 years since the introduction of laparoscopic surgery in Spain. One of the main conclusions of the article is that, despite the advantages of laparoscopy, its implementation and consolidation in this country has not been homogeneous, especially in advanced laparoscopic techniques. Laparoscopic abdominal wall surgery is a clear example. In recent years, laparoscopic techniques have demonstrated potential advantages in the treatment of inguinal hernias, and several studies have demonstrated them to be ideal in bilateral and recurrent hernia subgroups. Therefore, several medical associations and clinical guidelines recommend laparoscopy as the initial option for surgical treatment. Moreno-Sanz et al.,however, report that 64% of Spanish surgeons never use endoscopic surgery for inguinal hernia repair, 30% do so occasionally, and only 6% do so frequently. These percentages contrast notably with published reports from the United States and Europe, where French and German registries show that laparoscopic hernioplasty is used in 25%–28% of cases, while rates in Denmark, Netherlands, United Kingdom and Italy are 15%–18%. Moreover, some of these countries report the use of laparoscopic hernioplasty in more than 40% of bilateral and recurrent hernia procedures. In the case of incisional hernias, the same study shows that the results in Spain are also not very promising: the use of laparoscopy is routine in 10%, selective in 49%, and never even contemplated in 41%. These results are very similar to those reported by the same group in another survey from 2003, which confirms that this technique has not been widely accepted in our setting. Similar rates have been compiled in the National Registry of Incisional Hernias (Spanish acronym, EVEREG) sponsored by the AEC: with nearly 3000 registered cases, only 12.8% of the repairs were laparoscopic. Meanwhile, if we analyze what happens in other countries, 2 studies have reported that laparoscopic repair is done in the U.S. in 26%–28%. The Danish registry reported a laparoscopic repair rate of 54% and a recurrence rate that was lower than in open surgical repairs; they concluded that the laparoscopic approach provides patient benefits while also being costeffective. Why are there differences between the recommendations made in clinical guidelines and everyday clinical practice? There are several reasons that contribute in one way or another to this anomalous situation: our unwillingness to learn a new procedure with a demanding learning curve; the lack of training of most surgeons in the open pre-peritoneal approach for inguinal hernias; higher costs, especially if single-use products are utilized; and, basically, the peculiarities of our healthcare system, which treats hernias as an unimportant pathology in our surgical programs and favors the quantity of procedures over quality. What has been done in the US and other European countries to motivate the implementation of laparoscopic abdominal wall surgery? Basically, it comes down to training. In most of these countries, training in laparoscopic abdominal wall surgery has been included in resident training programs. Particular emphasis is given to acquiring necessary laparoscopic technical skills as well as adequate understanding of the wall anatomy when using this approach, which is different to what residents are familiar with in open surgery. To this end, simulators have been shown to be very useful in improving laparoscopic skills, especially among the latest c i r e s p . 2 0 1 5 ; 9 3 ( 2 ) : 6 5 – 6 7