After the introduction of Bassini’s procedure in the late 19^th century, methods of repairing hernias changed little until the 1990s, when synthetic mesh and laparoscopic methods arrived. In contrast to the open mesh technique, laparoscopic surgery remains uncommon. In January 2001, the National Institute for Clinical Excellence (NICE) issued guidance that stated, ‘For repair of primary inguinal hernia, open [mesh] should be the preferred surgical procedure’. A recent BMJ article described patterns of surgical repair of inguinal hernias and assessed the impact of NICE’s guidance.

They found 217,000 cases with a primary procedure code for primary surgery for an inguinal hernia from the hospital episode statistics database for England from April 1998 to December 2001. Of these, secondary procedure codes for minimal access surgery identified 8960 (4.1%) cases in which surgery was laparoscopic.

Publication of the NICE guidance did not reduce the proportion of repairs done laparoscopically. Before the NICE guidance, the rate of laparoscopic as a proportion of all repairs was increasing slowly and non-significantly by 0.08% per year. After issue of the guidance the rate increased slightly to 0.14% per year.

The pattern was similar in the effects of NICE guidance on the overall use of laparoscopic repair of hernias. Before publication of the guidance, the annual increase in the number of laparoscopic repairs was 3.4 procedures, and afterwards the annual rate of increase rose slightly to 4.4 procedures. Rates before and after did not differ significantly (P=0.6).

Guidance from NICE on laparoscopic repair of hernias had no impact on practice during the first year after publication. Despite the clarity of the advice given on laparoscopic hernia repair, on this occasion, NICE guidance did not achieve the desired change in clinical practice. Resistance to the guidance is illustrated by an appeal lodged to NICE and other articles; however, it is in areas of uncertainty and controversy that NICE should provide guidance.

Laparoscopic repair of hernias is a small part of NHS practice, but if the findings are applicable to other areas on which NICE has published guidance, NICE needs more active dissemination and implementation procedures. Guidance from NICE could be incorporated more directly into systems of clinical governance in the NHS.

The analysis shows that routinely collected data can be used in clinical governance. Chief executives and medical directors of trust hospitals have access to hospital episode statistics and could use these data to monitor implementation of guidance as part of clinical governance. To improve evidence based practice in the NHS, guidance must be implemented more efficiently and clinical practical practice should be reviewed and monitored using well-validated data.

Ref: web

Like cars and computers - even doctors - Cochrane has its own charming idiosyncracies. To get the best out of it, you need to take a 'belt and braces' approach to searching, remembering that not all the records are listed in the same way. Most records are indexed using MeSH (Medical Subject Headings), as per Medline, but NOT the newer Reviews, nor records from sources other than Medline. This means that you are best advised to search using both MeSH headings AND Keywords.

1.Use Textwords - Words that describe the subject you're interested in!
2. Use MeSH Headings - Medical Subject Headings, as standardized by the National Library of Medicine across the 'pond'.
3. Combine your results. OR broadens your search, finding records which contain either of the terms (so that OR gives you more)

Alternatively, you might prefer to use the record of your searches, by clicking on 'History', to combine the search results.

There's a tendency to talk about 'The Cochrane' as if it were just one database. Not so! It includes 8 databases, of which these are the most important to everyday users:

The Cochrane Database of Systematic Reviews is perhaps the most famous of the canon. These lengthy Systematic Reviews are produced by the Cochrane Collaboration. Having slaved to retrieve not just published literature, but also the results of unpublished studies, the collection is then culled in line with explicit quality criteria. The subsequent data is subjected to meta-analysis .

Most of the SRs include Odds-ratio diagrams. You might want to download MetaView software to be able to see these. You can also view them in the ‘Tables & Graphs’ section. With the latest version, you can now choose which graphs to print out.

The output of the various Collaborative Review Groups appears first. Don't be fooled by the term 'Protocols' - these are merely the protocols agreed for reviews that have yet to be completed.

The next 'volume' in the library is the DARE database. It comprises abstracts that summarise and assess other systematic reviews published somewhere or other, plus 'source records', ie. individual articles (often comparative trials) that review the effectiveness of specific interventions. The Cochrane Controlled Trials Register is a massive listing of references to RCTs tracked down by searching through printed journals as well as using databases.

The Health Technology Assessment database takes some of us years to spot this small database of systematic reviews and primary research tucked away at the foot of the page. Health Technology has been defined as including “all the methods that are used to promote health, prevent and treat disease, and improve rehabilitation or long-term care."

NHS Economic Evaluation Database
Tucked away at the very foot of the search page is a register of published economic evaluations of health care interventions. Each record in NHS EED includes both a summary and a qualitative assessment, plus comments on any practical implications for the NHS.