Recently, minimally invasive, or keyhole, surgery (laparoscopy see

A few pioneering surgeons have tacked the groin from the inside andbehind using keyhole techniques and mesh, but the technique hasn't caught on for hernias as it has for the gall bladder operation, which tends to be a more straightforward case of removal. Keyhole is experimental and may never establish itself for hernia operations. It has also proved to be expensive and difficult three times as long as the conventional operation even in experienced hands.

The procedure requires lengthy, general anesthesia and exposes patients to unnecessary risks. A number of complications occur, including respiratory problems, major hemorrhage, perforation of the bowel and bladder, and intestinal obstruction (The Lancet, 7 May 1994).

One Australian Test cricketer recently developed a strangulated hernia in Britain as the result of a complication after a keyhole hernia operation he'd had just before he left home. He had to have another operation and missed the test match.

The mesh patch the Australian surgeons had placed inside had provoked adhesions, the cricketer's gut became stuck to the mesh inside his belly and twisted.

Through PR and massive advertising campaigns, corporate America is

attempting to convince surgeons and the public of the necessity to perform hernia repairs via laparoscopy. Single-day training courses and week-long conferences are claiming to turn surgeons into experts virtually overnight (Arch Surg: vol 127, Nov 1992). But there is also evidence, as with the darn technique, that surgeons are not always qualified to perform the operations and that laparoscopic hernia repair has entered surgical practice without proper evaluation (The Lancet, 21 May 1994).

One also has to question the financial motivation behind laparoscopic

hernia repair. Surgeons who have performed gall bladder operations using keyhole techniques are now stuck with expensive equipment, the investment for which has to be justified. In the US, it is also thought the determined attitude held by surgeons, hospitals and, especially, the surgical product suppliers to use laparoscopic equipment for hernia repair is largely motivated by financial considerations (Surg Cl of N Amer, 73 (3); June 1993).