If you're not doing laparoscopic hernia repair, it's easy to see why.

• The learning curve for surgeons is steep.
• A study found that laparoscopic repair was inferior to open mesh procedures (see "Grading on a Steep Curve" on page 12).
• And reimbursement rates for these procedures are sparse when they're performed in freestanding surgery centers.

If you eschew laparoscopic inguinal hernia repair for these reasons, you may want to rethink your position, if for no other reason than most of the proposed Medicare reimbursement rates for 2008 are much higher (see table on page 11).

Preparing for pre-op
When Bruce J. Ramshaw, MD, trains fellows, laparoscopic hernia repair is the last of the procedures they become comfortable with, he says. "It's not an operation that's learned quickly and it's a very difficult technique to master," says the chief of the division of surgery at University of Missouri Healthcare in Columbia, Mo.

It isn't only the surgeon who faces a steep learning curve when it comes to mastering laparoscopy, according to Guy Voeller, MD, FACS, professor of surgery at University of Tennessee Health Science Center in Memphis and president of the American Hernia Association. He says that everyone involved needs thorough training in the new technology. "The equipment is somewhat demanding, so you need to have a very knowledgeable staff," he says. "They have to know what each thing is and how to use it."

Since there is a lot to learn and few training programs, says Dr. Ramshaw, it may be best to do the education in-house. "Probably the best way to train everyone is for the individual surgeon to get the facility's staff together and train them."

To teach his staff, Dr. Ramshaw developed what he calls "OR cards." These have pictures of the necessary equipment along with information about how it's used and list what the steps are for the procedure. After a few flashes for reference, the staffers usually know what they have to do and with what device.

Smoothing out the mesh
The actual techniques behind laparoscopy have not changed dramatically over the past decade through practice, but some experts have found techniques to make it more efficient. For example, Adrian E. Park, MD, chief of general surgery at University of Maryland Medical Center in Baltimore, revealed some of his preferences during a surgical webcast available through his facility's Web site (http://www.umm.edu/webcasts/), including the following:

• marking a "North Star" spot on the mesh to be sure it is properly aligned,
• using a mesh that overextends the hernia by four to five millimeters on all sides, and
• using polytetrafluoroethylene (Gore-Tex) sutures as well as surgical stapling to secure the mesh in place.

Every surgeon will develop his own surgical style over time with individualized techniques, but deciding what kind of mesh to use may take some thinking. These days, the heavy, hydrophobic polypropylene patches that were commonly used are associated with contracture, stiff tissues and chronic pain, and are falling out of favor. The newer meshes are available in heavy or light weights, can be made from hydrophilic materials, and are generally more comfortable and easier to use.

"There are many new meshes coming on board," says Dr. Voeller. "The industry has been very good with coming up with newer meshes that have less shrinkage, less contracture and less stiffening of native tissues over the past few years. They also stay soft and supple so patients can't feel them."

There are still more meshes in the pipeline, says Dr. Ramshaw. "We're kind of just scratching the surface of mesh materials and learning how the commonly used meshes of past decades are not best for the human body," he says.

One interesting prospect in development is biologic meshes, which are made from reprocessed and sterilized tissues taken from animals or cadavers. The supposed advantage, says Dr. Voeller, is that the patient's body can incorporate these into part of the scar tissue.

"We really don't know if these work well yet," says Dr. Voeller. "They have the FDA's 510(k) approval, and in the early studies some patients had very good results while others were not so good. We're still learning what the indications are, and we still don't know if it's as good as permanent synthetic meshes in the long term."

The flurry of activity in this area may lead to another kind of problem, says Dr. Voeller, in which facilities will have representatives from eight or nine different mesh manufacturers competing for their business. "Since most facilities won't want a huge inventory, they'll probably only buy a couple of them and these may not meet the surgeon's preferences. We're not there yet, but that's where we're headed," says Dr. Voeller.

When it comes to making a choice for now, Dr. Ramshaw suggests using a mesh with a good memory. This way, it will spring open when it is placed and hold its position. "Some of the polyester meshes have good memory," he says.

Minimizing post-op problems
Just as it's important to train staffers about what to do before surgery, Dr. Voeller says it's important to train them what to tell patients to expect when they're in the PACU. He says it's important that the facility's personnel understand that this is a very different procedure than the traditional hernia repair.

"Some staffs are still back in the old days, and they may tell patients, ?no activity and don't lift anything,'" says Dr. Voeller. "That's not the case anymore. The patients can usually do what they like three or four days later. It's important to have a staff that understands that."

Patient education is also important, says Dr. Ramshaw. He says it's important that they know what to expect, such as some difficulty when urinating, some bruising and how to use ice and pain medications. "In the short term, there is a quicker recovery and less pain," he says. "Most of the studies show the recovery is anywhere from a couple of days shorter to half the time of open mesh repair, and more importantly it appears to lead to less chronic pain in the long term."

The low ASC reimbursement rates for this procedure have discouraged many freestanding facilities from investing in the necessary equipment. "That's a shame for patients, because when done by the right surgeon the procedure is very beneficial," says Dr. Voeller. "But in the end it's just a numbers game, and it comes down to if you can make the numbers balance at the end of the month."

The new reimbursement rates from Medicare are closer to covering the costs, but Dr. Voeller says taking a minimally invasive approach still requires such an investment in technology that it is often less profitable than the more traditional methods. "When I cut you open, I don't have to use new technology. I can rely on tools that have been used since the '50s," he says.