Outcomes from Early Experience with Laparoscopic Inguinal Hernia Repair Versus Open Technique: Navigating the learning curve.

Objectives: This study aimed to evaluate the outcomes of laparoscopic inguinal hernia repair (LIHR) regarding postoperative pain, recurrence rates, duration of hospital stay and other postoperative outcomes within the context of a tertiary care teaching hospital in South India, and the initial experience of laparoscopic repairs. The current consensus in the literature often suggests LIHR as superior to open inguinal hernia repair (OIHR). Methods: This single-centre, retrospective, observational study was conducted at the Jawaharlal Institute of Postgraduate Education and Research, Puducherry, India, from January 2011 to September 2020. All patients who underwent elective OIHR and LIHR were included. Data on the patients demographics, comorbidities, hernia type, mesh characteristics, surgery duration, hospital stay and immediate postoperative complications were collected and analysed. Results: A total of 2,690 OIHR and 158 LIHR cases were identified. The demographic profiles, hospital stay and complication rates were similar in both groups. However, surgical site infection was present exclusively in the OIHR group (3.55% versus 0.0%; P <0.05). The timeline for returning to normal activities was statistically shorter for the LIHR group (6 versus 8 days; P <0.05). The most frequent immediate complication in the LIHR group was subcutaneous emphysema (6.54% versus 0.0%; P <0.05). Recurrence (9.23% versus 3.61%; P = 0.09) and chronic pain (41.53% versus 13.55%; P <0.05) were higher in the LIHR group. Conclusion: Lower recurrence and chronic pain rates were observed with OIHR in the initial experience with LIHR in the hospital. However, LIHR had significant advantages concerning faster patient recovery and lower rates of surgical site infections. While the results contribute an interesting deviation from the standard narrative, they should be interpreted within the context of a learning curve associated with the early experience of the research team with LIHR.

Access to and quality of elective care: a prospective cohort study using hernia surgery as a tracer condition in 83 countries.

BACKGROUND: Timely and safe elective health care facilitates return to normal activities for patients and prevents emergency admissions. Surgery is a cornerstone of elective care and relies on complex pathways. This study aimed to take a whole-system approach to evaluating access to and quality of elective health care globally, using inguinal hernia as a tracer condition. METHODS: This was a prospective, international, cohort study conducted between Jan 30 and May 21, 2023, in which any hospital performing inguinal hernia repairs was eligible to take part. Consecutive patients of any age undergoing primary inguinal hernia repair were included. A measurement set mapped to the attributes of WHO's Health System Building Blocks was defined to evaluate access (emergency surgery rates, bowel resection rates, and waiting times) and quality (mesh use, day-case rates, and postoperative complications). These were compared across World Bank income groups (high-income, upper-middle-income, lower-middle-income, and low-income countries), adjusted for hospital and country. Factors associated with postoperative complications were explored with a three-level multilevel logistic regression model. FINDINGS: 18 058 patients from 640 hospitals in 83 countries were included, of whom 1287 (7·1%) underwent emergency surgery. Emergency surgery rates increased from high-income to low-income countries (6·8%, 9·7%, 11·4%, 14·2%), accompanied by an increase in bowel resection rates (1·2%, 1·4%, 2·3%, 4·2%). Overall waiting times for elective surgery were similar around the world (median 8·0 months from symptoms to surgery), largely because of delays between symptom onset and diagnosis rather than waiting for treatment. In 14 768 elective operations in adults, mesh use decreased from high-income to low-income countries (97·6%, 94·3%, 80·6%, 61·0%). In patients eligible for day-case surgery (n=12 658), day-case rates were low and variable (50·0%, 38·0%, 42·1%, 44·5%). Complications occurred in 2415 (13·4%) of 18 018 patients and were more common after emergency surgery (adjusted odds ratio 2·06, 95% CI 1·72-2·46) and bowel resection (1·85, 1·31-2·63), and less common after day-case surgery (0·39, 0·34-0·44). INTERPRETATION: This study demonstrates that elective health care is essential to preventing over-reliance on emergency systems. We identified actionable targets for system strengthening: clear referral pathways and increasing mesh repair in lower-income settings, and boosting day-case surgery in all income settings. These measures might strengthen non-surgical pathways too, reducing the burden on society and health services. FUNDING: NIHR Global Health Research Unit on Global Surgery and Portuguese Hernia and Abdominal Wall Society (Sociedade Portuguesa de Hernia e Parede Abdominal).

Outpatient Surgery and Unplanned Overnight Admission in Bilateral Inguinal Hernia Repair: A Population-based Study.

PURPOSE: The use of outpatient surgery in inguinal hernia is heterogeneous despite clinical recommendations. This study aimed to analyze the utilization trend of outpatient surgery for bilateral inguinal hernia repair (BHIR) in Spain and identify the factors associated with outpatient surgery choice and unplanned overnight admission. METHODS: A retrospective observational study of patients undergoing BIHR from 2016 to 2021 was conducted. The clinical-administrative database of the Spanish Ministry of Health RAE-CMBD was used. Patient characteristics undergoing outpatient and inpatient surgery were compared. A multivariable logistic regression analysis was performed to identify factors associated with outpatient surgery choice and unplanned overnight admission. RESULTS: A total of 30,940 RHIBs were performed; 63% were inpatient surgery, and 37% were outpatient surgery. The rate of outpatient surgery increased from 30% in 2016 to 41% in 2021 (p < 0.001). Higher rates of outpatient surgery were observed across hospitals with a higher number of cases per year (p < 0.001). Factors associated with outpatient surgery choice were: age under 65 years (OR: 2.01, 95% CI: 1.92-2.11), hospital volume (OR: 1.59, 95% CI: 1.47-1.72), primary hernia (OR: 1.89, 95% CI: 1.71-2.08), and laparoscopic surgery (OR: 1.47, 95% CI: 1.39-1.56). Comorbidities were negatively associated with outpatient surgery. Open surgery was associated (OR: 1.26, 95% CI: 1.09-1.47) with unplanned overnight admission. CONCLUSIONS: Outpatient surgery for BHIR has increased in recent years but is still low. Older age and comorbidities were associated with lower rates of outpatient surgery. However, the laparoscopic repair was associated with increased outpatient surgery and lower unplanned overnight admission.

Trends in minimally invasive and open inguinal hernia repair: an analysis of ACGME general surgery case logs.

BACKGROUND: Groin hernia repair is one of the most commonly performed surgical procedures and is often performed by surgical interns and junior residents. While traditionally performed open, minimally invasive (MIS) groin hernia repair has become an increasingly popular approach. The purpose of this study was to determine the trends in MIS and open inguinal and femoral hernia repair in general surgery residency training over the past two decades. METHODS: Accreditation Council for Graduate Medical Education (ACGME) national case log data of general surgery residents from 1999 through 2022 were reviewed. We collected means and standard deviations of open and MIS inguinal and femoral hernia repairs. Linear regression and ANOVA were used to identify trends in the average annual number of open and MIS hernia repairs logged by residents. Cases were distinguished between level of resident trainees: surgeon-chief (SC) and surgeon-junior (SJ). RESULTS: From July 1999 to June 2022, the average annual MIS inguinal and femoral hernia repairs logged by general surgery residents significantly increased, from 7.6 to 47.9 cases (p < 0.001), and the average annual open inguinal and femoral hernia repairs logged by general surgery residents significantly decreased, from 51.9 to 39.7 cases (p < 0.001). SJ resident results were consistent with this overall trend. For SC residents, the volume of both MIS and open hernia repairs significantly increased (p < 0.001). CONCLUSIONS: ACGME case log data indicates a trend of general surgery residents logging overall fewer numbers of open inguinal and femoral hernia repairs, and a larger proportion of open repairs by chief residents. This trend warrants attention and further study as it may represent a skill or knowledge gap with significant impact of surgical training.

Advancing geriatric surgical outcomes in elective ventral and incisional hernia repair surgeries: An American college of surgeons national surgical quality improvement program study.

INTRODUCTION: Increasing age is known to be associated with increased risk for postoperative morbidity and mortality, however, the goal of this study was to determine if an increase in age correlates to differences in surgical outcomes for elective ventral hernia repair. METHODS: Retrospective cohort study using American College of Surgeons NSQIP database from 2016 to 2020. Included diagnosis codes were laparoscopic or open incisional or ventral hernia repairs, categorized into three age groups: 18-64y, 65-74y, and ≥75y. Thirty-day perioperative outcomes analyzed using bivariate χ2 test and multivariate logistic regression. RESULTS: We identified 116,643 people who had elective ventral or incisional hernia repair. Compared to 18-64y and 65-74y age groups, patients ≥75y were significantly more likely to develop any post-operative complication, be re-admitted post-operatively for any reason, have an extended hospital stay, and require a reoperation. CONCLUSIONS: Patients ≥75y have significantly higher rates of perioperative complications after elective hernia repair compared to younger patients.

Effect of Early vs Late Inguinal Hernia Repair on Serious Adverse Event Rates in Preterm Infants: A Randomized Clinical Trial.

Importance: Inguinal hernia repair in preterm infants is common and is associated with considerable morbidity. Whether the inguinal hernia should be repaired prior to or after discharge from the neonatal intensive care unit is controversial. Objective: To evaluate the safety of early vs late surgical repair for preterm infants with an inguinal hernia. Design, Setting, and Participants: A multicenter randomized clinical trial including preterm infants with inguinal hernia diagnosed during initial hospitalization was conducted between September 2013 and April 2021 at 39 US hospitals. Follow-up was completed on January 3, 2023. Interventions: In the early repair strategy, infants underwent inguinal hernia repair before neonatal intensive care unit discharge. In the late repair strategy, hernia repair was planned after discharge from the neonatal intensive care unit and when the infants were older than 55 weeks' postmenstrual age. Main Outcomes and Measures: The primary outcome was occurrence of any prespecified serious adverse event during the 10-month observation period (determined by a blinded adjudication committee). The secondary outcomes included the total number of days in the hospital during the 10-month observation period. Results: Among the 338 randomized infants (172 in the early repair group and 166 in the late repair group), 320 underwent operative repair (86% were male; 2% were Asian, 30% were Black, 16% were Hispanic, 59% were White, and race and ethnicity were unknown in 9% and 4%, respectively; the mean gestational age at birth was 26.6 weeks [SD, 2.8 weeks]; the mean postnatal age at enrollment was 12 weeks [SD, 5 weeks]). Among 308 infants (91%) with complete data (159 in the early repair group and 149 in the late repair group), 44 (28%) in the early repair group vs 27 (18%) in the late repair group had at least 1 serious adverse event (risk difference, -7.9% [95% credible interval, -16.9% to 0%]; 97% bayesian posterior probability of benefit with late repair). The median number of days in the hospital during the 10-month observation period was 19.0 days (IQR, 9.8 to 35.0 days) in the early repair group vs 16.0 days (IQR, 7.0 to 38.0 days) in the late repair group (82% posterior probability of benefit with late repair). In the prespecified subgroup analyses, the probability that late repair reduced the number of infants with at least 1 serious adverse event was higher in infants with a gestational age younger than 28 weeks and in those with bronchopulmonary dysplasia (99% probability of benefit in each subgroup). Conclusions and Relevance: Among preterm infants with inguinal hernia, the late repair strategy resulted in fewer infants having at least 1 serious adverse event. These findings support delaying inguinal hernia repair until after initial discharge from the neonatal intensive care unit. Trial Registration: ClinicalTrials.gov Identifier: NCT01678638.

The evolution of incisional hernia repair in Spain. A comparative analysis of results from the EVEREG registry.

BACKGROUND: The aim of this study was to assess the utility of the EVEREG registry in evaluating the evolution of surgical treatment for incisional hernia and its outcomes in Spain by comparing data from 2 study periods. METHODS: A retrospective comparative analysis of hernia surgeries performed between 2011 and 2015 (first period) and between 2017 and 2022 (second period) was conducted using data collected from the EVEREG registry. RESULTS: Statistically significant differences were observed in the second cohort, including: a decrease in minimally invasive procedures (11.7% vs 8.2%; P < .001), an increase in emergency surgeries for males (31.7% vs 41.2%; P = .017), an increase in trocar hernia repairs (16% vs 26.2%; P < .0001), a reduction in suture repairs (2.8% vs 1.5%; P < .0001), and an increase in retromuscular techniques (36.4% vs 52.4%; P < .001) in open surgery with mesh. In elective surgery, there was a decrease in the average length of stay (4.9 vs 3.8 days; P < .0001), the percentage of complications (27.9% vs 24.0%; P < .0001), reoperations (3.5% vs 1.4%; P < .0001), and mortality (0.6% vs 0.2%; P = .002). Long-term outcomes included a decrease in recurrences after 12 months (20.7% vs 14.5%; P < .0001) and in chronic pain (13.7% vs 2.5%; P < .0001) and chronic infections (9.1% vs 14.5%; P < .0001) after 6 months. CONCLUSION: In recent years, there has been a significant improvement in the outcomes of incisional hernia treatment. The registry serves as a fundamental tool for assessing the evolution of hernia treatment and enables the identification of key areas for improvement and the evaluation of treatment outcomes.

Bariatric surgery is as safe as other common operations: an analysis of the ACS-NSQIP.

BACKGROUND: Metabolic and Bariatric Surgery (MBS) is the most effective management for patients with obesity and weight-related medical conditions. Nonetheless, some primary care physicians (PCPs) and surgeons from other specialties are reluctant to refer patients for MBS due to safety concerns. OBJECTIVES: To compare the outcomes of patients who underwent MBS with those who underwent other common operations. SETTING: American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP). METHODS: Patients who underwent laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB), classified as MBS, were compared to nine frequently performed procedures including hip arthroplasty and laparoscopic cholecystectomy, appendectomy, colectomy, hysterectomy, and hernia repairs, among others. A multivariable logistic regression was constructed to compare outcomes including readmission, reoperation, extended length of stay (ELOS) (>75th percentile or ≥3 days) and mortality. RESULTS: A total of 1.6 million patients were included, with 11.1% undergoing MBS. The odds of readmission were marginally lower in the cholecystectomy (adjusted odds ratio [aOR] = .88, 95% confidence interval (CI) [.85, .90]) and appendectomy (aOR = .88, 95% CI [.85, .90]) cohorts. Similarly, odds of ELOS were among the lowest, surpassed only by same-day procedures such as cholecystectomies and appendectomies. The MBS group had significantly low odds of mortality, comparable to safe anatomical procedures such as hernia repairs. Infectious and thrombotic complications were exceedingly rare and amongst the lowest after MBS. CONCLUSIONS: MBS demonstrates a remarkably promising safety profile and compares favorably to other common procedures in the short-term. PCPs and surgeons from other specialties can confidently refer patients for these low-risk, lifesaving operations.

Impact of race and ethnicity on rates of emergent ventral hernia repair (VHR): has anything changed?

BACKGROUND: Non-white patients have been shown to have higher rates of emergent VHR, though no study to date has characterized these disparities over time. METHODS: National Surgical Quality Improvement Program (NSQIP) database was queried for VHR patients between 2008 and 2019. White, black, and hispanic patients were included for analysis. Older (2008-2011) versus New (2016-2019) time-periods were compared. The primary outcome was emergent VHR proportion. Multivariable analysis identified predictors of emergent VHR, then patients in each time-period were propensity matched (PSM) to control for confounders. RESULTS: The 665,809 VHRs between 2008 and 2019 consisted of 69.2% white, 9.7% black, and 8.1% hispanic patients. Emergent VHR rates were higher (all p < 0.001) for black (6.8%) and hispanic (5.6%) patients compared to White (4.1%). Emergent VHR rates between white vs black and white vs hispanic for both old (4.6% vs 7.4% and 4.6% vs 7.4%) and new (3.6% vs 5.8% and 3.6% vs 5.1%) groups demonstrated lower rates in White patients (all p < 0.001). Ratios of emergent VHR rates over time (old to new) remained similar (black:white 1.61-1.61; hispanic:white 1.43-1.42). Multivariable analysis showed older age, higher BMI, smoking, female sex, and increasing ASA class increased odds for emergent VHR. Comparison of PSM-groups (white-PSM vs black-PSM and white-PSM vs hispanic-PSM) for both old (5.0% vs 7.0% and 3.6% vs 6.3%) and new (3.2% vs 4.8% and 3.8% vs 5.5%) time-periods showed lower emergent VHR rates in white patients (all p < 0.001). Ratios of emergent VHR rates over time increased for black patients and decreased for Hispanic patients (black:white:1.4 to 1.5, and hispanic:white:1.75 to 1.45). CONCLUSION: Black and Hispanic patients have higher rates of emergent VHR compared to White patients, and this has not improved over time. After PSM to control for confounding variables, disparities in emergent VHR rates have increased for Black patients and decreased for Hispanic patients.

Manual Closed Reduction of Incarcerated Hernia: Is It Safe in the Emergency Department?

BACKGROUND: Emergency surgical repair is the standard approach to the management of an incarcerated abdominal wall hernia (IAWH). In cases of very high-risk patients, manual closed reduction (MCR) of IAWH may prevent the need for emergency surgery. OBJECTIVES: To evaluate the safety, success rate, and complications of MCR in the management of IAWH conducted in an emergency department. METHODS: The data of all patients who underwent MCR between 2012 and 2018 were retrospectively collected. Patient demographics, presenting symptoms, clinical parameters, and management during the hospitalization were retrieved from the medical charts. RESULTS: Overall, 548 patients underwent MCR during the study period. The success rate was 25.4% (139 patients). One patient had a complication that required a laparotomy 2 days after his discharge. A recurrent incarceration occurred in 23%, 60% of them underwent successful repeated MCR and the others underwent emergency surgery. Six patients (1.4%) had a bowel perforation after a failed MCR. CONCLUSIONS: MCR can be performed safely in the emergency department and should be consider as an option to treat IAWH, especially in high operative risk patients.

Feasibility of Umbilical Hernia Repair Under Local Anesthesia and Monitored Anesthesia Care at a Veteran Affairs Hospital.

BACKGROUND: Local anesthesia (LA) for open umbilical hernia tissue repair (OUHTR) is not widely utilized in academic centers in the United States. We hypothesize that LA for OUHTR is feasible in a veteran patient population. METHODS: From 2015 to 2019, 449 umbilical hernias were repaired at our institution utilizing a standardized technique in veteran patients. OUHTR was included in this analysis (n = 283). Since 2017, 18.7% (n = 53) UH were repaired under LA. We compared outcomes and operative times between general anesthesia and LA in patients undergoing OUHTR. Univariable and multivariable analyses were performed to determine significance. RESULTS: The entire cohort was composed of older (56.3 ± 12.1 years), White (75.5%), obese (body mass index [BMI] = 32.3 ± 4.6 kg/m2) men (98.0%). The average hernia size for the entire cohort was 2.42 ± 1.2 cm. The groups were similar in age and BMI. Patients with higher American Society of Anesthesiologists (ASA) (Odds ratio [OR] 3.1; 95% CI 1.5-6.8) and cardiovascular disease (OR 2.7; 95% CI 1.0-7.2) were more likely to receive LA. Recurrence (0.0% vs 6.0%; P = .9) and 30-day complications (6.0% vs 13%; P = .9) were similar between LA and GA after correcting for hernia size. Operating room times were reduced in the LA group (17.7 minutes; P < .05). None of the patients with LA required postanesthesia care unit for recovery. The patients who received LA reported being comfortable (78.9% of patients), with the worst reported pain being 2.4 ± 2.4 (out of a scale of 10), and 94.7% would elect to receive LA if they had another hernia repair. CONCLUSION: Patients who received LA had more cardiac disease and a higher ASA. Complications were similar between both groups. LA reduced operating room times. Patients were satisfied with LA.

Nationwide Readmissions Analysis of Minimally Invasive Versus Open Ventral Hernia Repair: A Retrospective Population-Based Study.

INTRODUCTION: Minimally invasive ventral hernia repair (MISVHR) has been performed for almost 30 years; recently, there has been an accelerated adoption of the robotic platform leading to renewed comparisons to open ventral hernia repair (OVHR). The present study evaluates patterns and outcomes of readmissions for MISVHR and OVHR patients. METHODS: The Nationwide Readmissions Database (NRD) was queried for patients undergoing OVHR and MISVHR from 2016 to 2018. Demographic characteristics, complications, and 90-day readmissions were determined. A subgroup analysis was performed to compare robotic ventral hernia repair (RVHR) vs laparoscopic hernia repair (LVHR). Standard statistical methods and logistic regression were used. RESULTS: Over the 3-year period, there were 25 795 MISVHR and 180 635 OVHR admissions. Minimally invasive ventral hernia repair was associated with a lower rate of 90-day readmission (11.3% vs 17.3%, P < .01), length of stay (LOS) (4.0 vs 7.9 days, P < .01), and hospital charges ($68,240 ± 75 680 vs $87,701 ± 73 165, P < .01), which remained true when elective and non-elective repairs were evaluated independently. Postoperative infection was the most common reason for readmission but was less common in the MISVHR group (8.4% vs 16.8%, P < .01). Robotic ventral hernia repair increased over the 3-year period and was associated with decreased LOS (3.7 vs 4.1 days, P < .01) and comparable readmissions (11.3% vs 11.2%, P = .74) to LVHR, but was nearly $20,000 more expensive. In logistic regression, OVHR, non-elective operation, urban-teaching hospital, increased LOS, comorbidities, and payer type were predictive of readmission. CONCLUSIONS: Open ventral hernia repair was associated with increased LOS and increased readmissions compared to MISVHR. Robotic ventral hernia repair had comparable readmissions and decreased LOS to LVHR, but it was more expensive.

Management of blunt traumatic abdominal wall hernias: A Western Trauma Association multicenter study.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWH) occur in approximately 15,000 patients per year. Limited data are available to guide the timing of surgical intervention or the feasibility of nonoperative management. METHODS: A retrospective study of patients presenting with blunt TAWH from January 2012 through December 2018 was conducted. Patient demographic, surgical, and outcomes data were collected from 20 institutions through the Western Trauma Association Multicenter Trials Committee. RESULTS: Two hundred and eighty-one patients with TAWH were identified. One hundred and seventy-six (62.6%) patients underwent operative hernia repair, and 105 (37.4%) patients underwent nonoperative management. Of those undergoing surgical intervention, 157 (89.3%) were repaired during the index hospitalization, and 19 (10.7%) underwent delayed repair. Bowel injury was identified in 95 (33.8%) patients with the majority occurring with rectus and flank hernias (82.1%) as compared with lumbar hernias (15.8%). Overall hernia recurrence rate was 12.0% (n = 21). Nonoperative patients had a higher Injury Severity Score (24.4 vs. 19.4, p = 0.010), head Abbreviated Injury Scale score (1.1 vs. 0.6, p = 0.006), and mortality rate (11.4% vs. 4.0%, p = 0.031). Patients who underwent late repair had lower rates of primary fascial repair (46.4% vs. 77.1%, p = 0.012) and higher rates of mesh use (78.9% vs. 32.5%, p < 0.001). Recurrence rate was not statistically different between the late and early repair groups (15.8% vs. 11.5%, p = 0.869). CONCLUSION: This report is the largest series and first multicenter study to investigate TAWHs. Bowel injury was identified in over 30% of TAWH cases indicating a significant need for immediate laparotomy. In other cases, operative management may be deferred in specific patients with other life-threatening injuries, or in stable patients with concern for bowel injury. Hernia recurrence was not different between the late and early repair groups. LEVEL OF EVIDENCE: Therapeutic/care management, Level IV.

Single-centre experience of emergency hernia surgery during COVID-19 pandemic: a comparative study of the operative activity and outcomes before and after the outbreak.

Aim The outbreak of COVID-19 pandemic in January 2020 affected largely the elective operating for non-urgent surgical pathologies, such as hernias, due to periodical cancellations of the operating lists on a worldwide scale. To the best of our knowledge, the long-term impact of the COVID-19 pandemic in relation to the emergency hernia surgery operative workload and postoperative outcomes remains largely unknown. Methods Retrospective research of admission, operation and inpatient records of all patients who underwent emergency surgery over a 2-year period (2019-2020) was done. Results An 18% increase in terms of emergency hernia surgery operating volume, with a 23% increase of visceral resections due to unsalvageable herniated content strangulation was found. Overall morbidity did not increase during the pandemic period and there was no postoperative mortality or occurrence of COVID-19 related complications. Conclusion Emergency operative management of acutely symptomatic hernias can be safely performed even during the COVID-19 infection peak waves; hernia taxis should be reserved only for patients unfit or unwilling to undergo upfront surgery.

Racial and Ethnic Disparities in Access to Local Anesthesia for Inguinal Hernia Repair.

BACKGROUND: Many studies have identified racial disparities in healthcare, but few have described disparities in the use of anesthesia modalities. We examined racial disparities in the use of local versus general anesthesia for inguinal hernia repair. We hypothesized that African American and Hispanic patients would be less likely than Caucasians to receive local anesthesia for inguinal hernia repair. MATERIALS AND METHODS: We included 78,766 patients aged ≥ 18 years in the Veterans Affairs Surgical Quality Improvement Program database who underwent elective, unilateral, open inguinal hernia repair under general or local anesthesia from 1998-2018. We used multiple logistic regression to compare use of local versus general anesthesia and 30-day postoperative complications by race/ethnicity. RESULTS: In total, 17,892 (23%) patients received local anesthesia. Caucasian patients more frequently received local anesthesia (15,009; 24%), compared to African Americans (2353; 17%) and Hispanics (530; 19%), P < 0.05. After adjusting for covariates, we found that African Americans (OR 0.82, 95% CI 0.77-0.86) and Hispanics (OR 0.77, 95% CI 0.69-0.87) were significantly less likely to have hernia surgery under local anesthesia compared to Caucasians. Additionally, local anesthesia was associated with fewer postoperative complications for African American patients (OR 0.46, 95% CI 0.27-0.77). CONCLUSIONS: Although local anesthesia was associated with enhanced recovery for African American patients, they were less likely to have inguinal hernias repaired under local than Caucasians. Addressing this disparity requires a better understanding of how surgeons, anesthesiologists, and patient-related factors may affect the choice of anesthesia modality for hernia repair.

Leveraging a statewide quality collaborative to understand population-level hernia care.

BACKGROUND: Although ventral hernia repair (VHR) is extremely common, there is profound variation in operative technique and outcomes. This study describes the results of a statewide registry capturing hernia-specific variables to understand population-level practice patterns. METHODS: Retrospective analysis of adult patients in a new statewide hernia registry undergoing VHR in 2020. RESULTS: 919 patients underwent VHR across 57 hospitals and 279 surgeons. Hernia width was <2 cm in 233 (25%) patients, 2-5 cm in 420 (46%) patients, 5-10 cm in 171 (19%) patients, and >10 cm in 95 (10%) patients. Mesh was used in 79% of cases and varied in use from 53% of hernias <2 cm to 95% of hernias >10 cm. The most common mesh type was synthetic non-absorbable (46%), followed by synthetic absorbable mesh (37%). The incidence of complications was significantly associated with hernia width. CONCLUSIONS: A population-level, hernia-specific database captured operative details for 919 patients in 1 year. There was significant variation in mesh use and outcomes based on hernia size. These nuanced data may inform higher quality clinical practice.

Surgeon Volume and Risk of Reoperation after Laparoscopic Primary Ventral Hernia Repair: A Nationwide Register-Based Study.

BACKGROUND: Repairs of primary ventral hernias are common procedures but are associated with high recurrence rates. Therefore, it is important to investigate risk factors for recurrence to optimize current treatments. The aim of this study was to assess the impact of annual surgeon volume on the risk of reoperation for recurrence after primary ventral hernia repair. STUDY DESIGN: We conducted a nationwide register-based study with data from the Danish Ventral Hernia Database and the Danish Patient Safety Authority's Online Register linked via surgeons' authorization identification. We included patients 18 years and older, undergoing umbilical or epigastric hernia repair between 2011 and 2020. Annual surgeon volume was categorized into ≤ 9, 10 to 19, 20 to 29, and ≥ 30 cases. Patients were followed until reoperation, death, emigration, or end of the study period. RESULTS: We included 7,868 patients who underwent laparoscopic (n = 1,529 [19%]), open mesh (n = 4,138 [53%]), or open nonmesh (n = 2,201 [28%]) repair. There was an increased risk of reoperation after laparoscopic umbilical or epigastric hernia repair for surgeons with ≤ 9 (hazard ratio 6.57; p = 0.008), 10 to 19 (hazard ratio 6.58; p = 0.011), and 20 to 29 (hazard ratio 13.59; p = 0.001) compared with ≥ 30 cases/y. There were no differences in risk of reoperation after open mesh and open nonmesh repair in relation to annual surgeon volume. CONCLUSIONS: There was a significantly higher risk of reoperation after laparoscopic primary ventral hernia repair performed by lower-volume surgeons compared with high-volume surgeons. Additional research investigating how sufficient surgical training and supervision are ensured is indicated to reduce risk of reoperation after primary ventral hernia repair.

Outcomes of primary and recurrent inguinal hernia repair with prosthetic mesh in a single region over 15 years.

BACKGROUND: Sutured inguinal hernia repairs are now uncommon, with evidence suggesting that those augmented with mesh are associated with a lower recurrence rate. We aimed to explore the suggestion that the established use of mesh does indeed lower the rate of operation for recurrence in a single National Health Service region. METHOD: We collected retrospective Office of Population Censuses and Surveys coded data across one region of all primary and recurrent inguinal hernia repairs over 15 years (2004-2019). Electronic records of recurrent repairs were scrutinised to identify year and type of previous primary repair. RESULTS: In total, 7,234 repairs were performed during this time, of which 289 (4%) were for symptomatic recurrence. Operations for primary repair increased year on year (111 in 2004 to 402 in 2019). Frequency of operation for recurrent herniation declined with increasing use of mesh (8.8% in 2004 to 3.5% in 2019). The majority of repairs (73%) for recurrence were by an open approach. As opposed to an open mesh repair, a primary laparoscopic repair was associated with an earlier recurrence. CONCLUSIONS: Inguinal hernia repairs are increasing in frequency but operations for later symptomatic recurrence following an open primary prosthetic mesh repair are not.

[Inguinal hernia in children: easily incarcerated]. / Liesbreuk bij kinderen: snel beklemd.

Inguinal hernia in children is caused by an incomplete obliteration of the vaginal process during the embryological development. The vaginal process can thus become a hernia sac that often contains bowel and in girls, an ovary. The diagnosis of inguinal hernia is made by history and physical examination. According to current guidelines surgical repair should be performed without delay to avoid incarceration, which gives a high risk of complications, including testicular atrophy and ischemia of vital organs. However, patients are regularly not referred adequately. We present three cases of children who developed complications of a non-repaired inguinal hernia. Additionally, the data of all children with a congenital inguinal hernia, surgically treated from January 2018 until August 2019 show that out of 243 children 13.6% presented acutely with an incarcerated inguinal hernia. Another 6% received a wrong advice from their primary care doctor and was not referred to a (pediatric) surgeon.