Impact of randomized trials on the application of endoscopic techniques for inguinal hernia repair in the Netherlands

Background: One year after publication of a Dutch prospective trial randomizing patients with inguinal hernias to either endoscopic or open repair, a questionnaire was sent to all Dutch surgeons to evaluate the impact of this trial on the application of endoscopic inguinal hernia repair in the Netherlands. Methods: All 780 registered Dutch surgeons were surveyed. The performance of endoscopic inguinal hernia repair, the technique and the indications, the involvement of surgical residents, the motives for use of conventional techniques, and the type of open repair were documented. Results: The response rate was 100%. Endoscopic inguinal hernia repair was performed by 16% of Dutch surgeons. For 81% of the surgeons, the total extraperitoneal approach was the preferred endoscopic technique. Primary inguinal hernias were approached endoscopically by only 54% of these surgeons, and recurrent hernias by 92%. The technique of choice for open repair of primary hernias was the Shouldice repair. The predominant repair for recurrent inguinal hernias was the Lichtenstein technique. Conclusions: Although randomized clinical trials have provided evidence that the endoscopic approach to inguinal hernias is preferable, only 1 of 6 Dutch surgeons has adopted endoscopic inguinal hernia repair. Improvement in training of both surgical residents and surgeons and increasing awareness among medical doctors and patients about the benefits of endoscopic inguinal hernia repair are necessary to enhance the acceptance of this valuable technique for inguinal hernia repair.