Surgeon utilization of minimally invasive techniques for inguinal hernia repair: a population-based study

Rates of Minimally Invasive Surgery After Introduction of Robotic-Assisted Surgery for Common General Surgery Operations

Importance

Many patients who would benefit from minimally invasive surgery (MIS) have open surgery; robotic-assisted surgery (RAS) addresses some of the limitations of laparoscopic surgery and could increase rates of MIS across different patient populations.

Objective

To determine whether the introduction of RAS increases MIS rates and whether increases are seen across different patient populations undergoing common general surgery procedures.

Design

A retrospective cohort study was performed to compare rates of MIS in the year before and after the index date for hospitals that did and did not introduce RAS. Generalized estimating equation regression models were used to compare rates in MIS over time.

Setting

PINC AI Healthcare Database, an all-payor discharge database of hospitals in the United States.

Participants

Hospitals that performed cholecystectomy, inguinal hernia repair, ventral hernia repair, and colorectal resection from 2016 to 2022.

Exposure

RAS hospitals performing at least 1 common general surgery procedure using RAS.

Main Outcome and Measure

The primary analysis examined rates of MIS, defined as the rate of common general surgeries that were minimally invasive (laparoscopic or RAS) in a hospital. The secondary analysis examined MIS rates for common general surgeries, across age, sex, race, ethnicity, and payor.

Results

Of 408 hospitals included in the study, 153 (38%) introduced RAS for common general surgeries. The relative MIS rate for hospitals that introduced RAS compared with hospitals that did not went from 1.08 (95% confidence interval [CI], 1.02-1.14; P < 0.01) before the index date to 1.15 (95% CI, 1.09-1.22; P < 0.01) after the index date (P interaction < 0.01), indicating a larger increase in MIS rates among hospitals introducing RAS. MIS rates increased significantly more in hospitals that introduced RAS across patient age, sex, ethnicity, race, and payor compared with hospitals that did not introduce RAS.

Conclusions and Relevance

Hospitals that introduced RAS for common general surgery procedures were associated with an increase in MIS rates across different patient populations compared with hospitals that did not introduce RAS.

Impact of 3D Endovision System on Learning Process of Laparoscopic Transabdominal Preperitoneal Repair of Groin Hernia

Background: Laparo-endoscopic hernia surgery is recommended by various international bodies. However, its uptake by general surgeon is low. We aim to assess the impact of Three Dimensional (3D) endovision system in learning laparoscopic transabdominal preperitoneal (TAPP) repair of groin hernia and transferability of skills acquired from 3D to the Two Dimensional (2D) environment. Methodology: Senior resident doctor with no previous experience in laparoscopic hernia surgery did 20 consecutive cases of TAPP repair using 3D endovision system followed by another five cases of TAPP repair using 2D endovision system. Total operating time, operating time during different phases of hernia surgery, faculty take over time, path length of needle holder, and scissors were recorded. Cumulative sum (CUSUM) and split group analysis were done to assess the learning process. Trainee's operating time was compared with that of experts' from previously published study of the same group. Data were compared between last block of five cases done using 3D system and cases done using 2D system for skill transferability. Results: CUSUM method provided inflection points of total operating time, hernia dissection and mesh placement at 9th case, and peritoneal suturing at 11th case in learning TAPP hernia. After 10th case, trainee's operating time was within the middle 50 percentage of experts operating time. Total operating time in last block of cases done under 3D vision and that of 2D endovision comparable, although peritoneal closure was significantly longer in 2D vision (P = .074, .2, .145, .001). Conclusion: Reduction on operating time appears after ninth case of TAPP hernia repair using the 3D endovision system. The skills acquired under 3D endovision system are transferable to perform the procedure under 2D endovision system, albeit incompletely. Use of 3D technology may facilitate adaptation of TAPP hernia repair by young surgeons.

Use of Biologic and Biosynthetic Mesh for Ventral Hernia Repair in Current Practice

Importance

Originally developed for use in contaminated fields, there is growing evidence against the use of biologic and biosynthetic mesh in ventral hernia repair. However, its prevalence and patterns of use in current practice are largely unknown.

Objectives

To describe the prevalence of biologic and biosynthetic mesh use in ventral hernia repair and to identify factors associated with its use.

Design, Setting, and Participants

This retrospective cohort study used a statewide clinical registry in Michigan to identify adults who underwent mesh-based ventral hernia repair between January 1, 2021, and December 31, 2023. Data analysis was performed from February to May 2024.

Exposures

Use of biologic or biosynthetic mesh vs synthetic mesh.

Main Outcomes and Measures

The main outcome was use of biologic or biosynthetic mesh, abstracted directly from the operative report. Multivariable logistic regression was used to identify factors associated with use of biologic or biosynthetic mesh.

Results

A total of 10 838 patients (mean [SD] age, 55.7 [14.0] years; 4619 [42.6%] female) who underwent mesh-based ventral hernia repair were identified, among whom 1174 repairs (10.8%) were performed with biologic or biosynthetic mesh and 9664 (89.2%) were performed with synthetic mesh. Of the 1174 cases using biologic or biosynthetic mesh, 1023 (87.1%) had a clean wound classification and 1039 (88.5%) were performed electively. In multivariable logistic regression, wound contamination was associated with increased odds of biologic or biosynthetic mesh use (clean-contaminated: adjusted odds ratio [aOR], 2.17 [95% CI, 1.62-2.89]; contaminated: aOR, 2.95 [95% CI, 1.63-5.34]; dirty or infected: aOR, 36.22 [95% CI, 12.20-107.56]). Other operative factors associated with increased odds of biologic or biosynthetic mesh use included urgent or emergent surgical priority (aOR, 1.69 [95% CI, 1.33-2.16]), laparoscopic or robotic approach (aOR, 1.31 [95% CI, 1.15-1.50]), larger hernia width (aOR, 1.03 [95% CI, 1.01-1.04] per centimeter), and use of myofascial release (aOR, 2.10 [95% CI, 1.64-2.70]).

Conclusions and Relevance

In this large cohort of patients undergoing ventral hernia repair, 1 in 10 mesh-based repairs was performed with biologic or biosynthetic mesh. Although urgent or emergent repair and wound contamination were associated with increased odds of biologic or biosynthetic mesh use, nearly 90% of biologic and biosynthetic mesh use occurred in elective repairs with clean wound classifications. These results raise questions regarding the appropriateness of its application in current practice.

Trends and predictors of laparoscopic compared with open emergent inguinal hernia repair

BACKGROUND

Laparoscopic emergent inguinal hernia repair remains controversial despite studies suggesting it is safe and feasible. Variables associated with laparoscopic compared with open emergent inguinal hernia repair are currently not well described. This study aims to investigate patient characteristics and risk factors associated with laparoscopic emergent inguinal hernia repair.

METHODS

The American College of Surgeons National Surgical Quality Improvement database was queried for adult patients (age ≥18 years) who had undergone emergent inguinal hernia repair between 2015 and 2021. The relationships between demographic variables and laparoscopic compared with open emergent inguinal hernia repair were evaluated using univariate and multivariate analyses.

RESULTS

A total of 8,215 patients were included in this analysis. Use of laparoscopic emergent inguinal hernia repair increased from 9% in 2015 to 23% in 2021. Female patients (odds ratio, 1.84, P < .001) and patients aged ≤65 years (odds ratio, 1.25, P = .005) were more likely to undergo laparoscopic repair. Black (odds ratio, 0.73, P = .003) and Hispanic (odds ratio, 0.72, P = .006) patients and patients with greater American Society of Anesthesiologists classification (odds ratio, 0.86, P = .037), ascites (odds ratio, 0.39, P = .039), and preoperative dialysis requirement (odds ratio, 0.45, P = .017) were less likely to undergo laparoscopic repair. Aside from a decreased likelihood of readmission in patients who underwent laparoscopic surgery (odds ratio, 0.696, P = .024), there was no difference in other postoperative outcomes, despite a laparoscopic approach being associated with greater rates of concomitant procedures compared with an open approach (24% vs 18%, P < .001).

CONCLUSIONS

Female sex, younger age, and lower American Society of Anesthesiologists class were associated with a greater likelihood of laparoscopic surgery. Black and Hispanic patients and patients with ascites and dialysis requirements were less likely to undergo laparoscopic repair. Laparoscopic inguinal hernia repair can be safely performed in an emergent setting.

Primary abandonment of the sac in the management of scrotal hernias: a dual-institution experience of short-term outcomes

PURPOSE

Management of scrotal hernias presents as a common challenge, with operative interventions to address these hernias associated with higher rates of morbidity compared to those of less-complex pathology. Surgeons have advocated for the use of techniques such as primary abandonment of the distal sac as a potential means to reduce complications for operative intervention, with preliminary findings demonstrating feasibility. We sought to assess outcomes related to primary sac abandonment among patients undergoing minimally invasive (MIS) repair of scrotal hernias.

METHODS

A review of prospectively maintained databases among two academic hernia centers was conducted to identify patients who underwent MIS inguinal hernia repairs with primary sac abandonment. Patient demographics, hernia risk factors, intraoperative factors, and postoperative outcomes were evaluated. Short-term outcomes related to patient-reported experiences and surgical-site occurrences requiring procedural intervention were queried.

RESULTS

Sixty-seven male patients [median age: 51.6 years; interquartile range (IQR): 45-65 years] underwent inguinal hernia repair with primary sac abandonment. Anatomic polypropylene mesh was used in 98.5% cases. Rates of postoperative complications were low and included postoperative urinary retention (6%), clinically identified or patient-reported seromas/hematomas within a 30-day follow-up period (23.9%), deep venous thrombosis (1.5%), and pelvic hematoma (1.5%). No seromas or hematomas necessitated procedural interventions, with resolution of symptoms within three months of their operation date.

CONCLUSION

We report a multi-center experience of patients managed with primary abandonment of the sac technique during repair of inguinoscrotal hernias. Utilization of this technique appears to be safe and reproducible with a low burden of short-term complications.

ENGINE-An EHS Project for Future Guidelines

Clinical guidelines are evidence-based recommendations developed by healthcare organizations or expert panels to assist healthcare providers and patients in making appropriate and reliable decisions regarding specific health conditions, aiming to enhance the quality of healthcare by promoting best practices, reducing variations in care, and at the same time, allowing tailored clinical decision-making. European Hernia Society (EHS) guidelines aim to provide surgeons a reliable set of answers to their pertinent clinical questions and a tool to base their activity as experts in the management of abdominal wall defects. The traditional approach to guideline production is based on gathering key opinion leader in a particular field, to address a number of key questions, appraising papers, presenting evidence and produce final recommendations based on the literature and consensus. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) method offers a transparent and structured process for developing and presenting evidence summaries and for carrying out the steps involved in developing recommendations. Its main strength lies in guiding complex judgments that balance the need for simplicity with the requirement for complete and transparent consideration of all important issues. EHS guidelines are of overall good quality but the application of GRADE method, began with EHS guidelines on open abdomen, and the increasing adherence to the process, has greatly improved the reliability of our guidelines. Currently, the need to application of this methodology and the creation of stable and dedicated group of researchers interested in following GRADE in the production of guidelines has been outlined in the literature. Considering that the production of clinical guidelines is a complex process, this paper aim to highlights the primary features of guideline production, GRADE methodology, the challenges associated with their adoption in the field of hernia surgery and the project of the EHS to establish a stable guidelines committee to provide technical and methodological support in update of previously published guideline or the creation of new ones.

Revisiting femoral hernia diagnosis rates by patient sex in inguinal hernia repairs

INTRODUCTION

Guidelines recommend MIS repairs for females with inguinal hernias, despite limited evidence. We investigated rates of femoral hernias intraoperatively noted during MIS and Lichtenstein repairs in females.

METHODS

ACHQC was queried for adult females undergoing inguinal hernia repair between January 2014-November 2022. Outcomes included identified femoral hernia and size, hernia recurrence, quality of life, and sex-based recurrence.

RESULTS

1357 and 316 females underwent MIS and Lichtenstein inguinal repair respectively. Femoral hernias were identified more frequently in MIS than open repairs (27%vs12%; (p ​< ​0.001). Most femoral hernias in MIS (61%) and Lichtenstein repairs (62%) were <1.5 ​cm(p ​< ​0.001). Identification rates of femoral hernias >3 ​cm were 1% overall(p ​= ​0.09). Surgeon and patient-reported recurrences were similar between approaches at 1-5-years for females(p ​> ​0.05 for all) and similar between sexes(p ​> ​0.05).

CONCLUSION

Most incidental femoral hernias are small and both repair approaches demonstrated similar outcomes. The recommendation for MIS inguinal hernia repairs in females is potentially overstated.

Mesh overlap for ventral hernia repair in current practice

INTRODUCTION

Sufficient overlap of mesh beyond the borders of a ventral hernia helps prevent hernia recurrence. Guidelines from the European Hernia Society and American Hernia Society recommend ≥ 2 cm overlap for open repair of < 1-cm hernias, ≥ 3-cm overlap for open repair of 1-4-cm hernias, ≥ 5-cm overlap for open repair of > 4-cm hernias, and ≥ 5-cm overlap for all laparoscopic ventral hernia repairs. We evaluated whether current practice reflects this guidance.

METHODS

We used the Michigan Surgical Quality Collaborative Hernia Registry to evaluate patients who underwent elective ventral and umbilical hernia repair between 2020 and 2022. Mesh overlap was calculated as [(width of mesh - width of hernia)/2]. The main outcome was "sufficient overlap," defined based on published EHS and AHS guidelines. Explanatory variables included patient, operative, and hernia characteristics. The main analysis was a multivariable logistic regression to evaluate the association between explanatory variables and sufficient mesh overlap.

RESULTS

4178 patients underwent ventral hernia repair with a mean age of 55.2 (13.9) years, 1739 (41.6%) females, mean body mass index (BMI) of 33.1 (7.2) kg/m2, and mean hernia width of 3.7 (3.4) cm. Mean mesh overlap was 3.7 (2.5) cm and ranged from - 5.5 to 21.4 cm. Only 1074 (25.7%) ventral hernia repairs had sufficient mesh overlap according to published guidelines. Operative factors associated with increased odds of sufficient overlap included myofascial release (adjusted odds ratio [aOR] 5.35 [95% CI 4.07-7.03]), minimally invasive approach (aOR 1.86 [95% CI 1.60-2.17]), and onlay mesh location (aOR 1.31 [95% CI 1.07-1.59]). Patient factors associated with increased odds of sufficient overlap included prior hernia repair (aOR 1.59 [95% CI 1.32-1.92]).

CONCLUSION

Although sufficient mesh overlap is recommended to prevent ventral hernia recurrence, only a quarter of ventral hernia repairs in a state-wide cohort of patients had sufficient overlap according to evidence-based guidelines. Factors strongly associated with sufficient overlap included myofascial release, mesh type, and laparoscopic repair.

Nationwide analysis of open groin hernia repairs in Italy from 2015 to 2020

INTRODUCTION

Inguinal hernia repair is one of the most commonly performed operations in general surgery. A total of 130.000 inguinal hernia repairs are performed yearly in Italy, and approximately 20 million inguinal hernias are treated worldwide annually. This report represents the trend analysis in inguinal hernia repair in Italy from a nationwide dataset for the 6-year period from 2015 to 2020.

MATERIALS AND METHODS

Based on regional hospital discharge records, all the inguinal hernia repairs performed in public and private hospitals in Italy between 2015 and 2020 were reviewed based on diagnosis and procedure codes. For the aim of this study, data from the AgeNas (The National Agency for Regional Health Services) data source were analyzed.

RESULTS

Elective inguinal hernia repairs outnumbered urgent operations over the 6-year study period, ranging from 122,737 operations in 2015 to 65,780 in 2020 as absolute numbers, and from 87.96 to 83.3% of total procedures in 2019 and 2020 respectively, with an annual change ranging from - 66.58%, between 2020 and 2019, to - 2.49%, between 2019 and 2018 (mean = - 18.74%; CI =- 46.7%-9.22%; p < 0.0001).

CONCLUSIONS

This large-scale review of groin hernia data from a nationwide Italian dataset provides a unique opportunity to obtain a snapshot of open groin hernia repair activity. More specifically, there is a trend to perform more elective than urgent procedures and there is a steady decrease in the amount of open hernia repairs in favor to laparoscopy.

Comparative Outcomes of Groin Hernia Repair by Sex Among Medicare Beneficiaries

OBJECTIVE

To compare the rates of operative recurrence between male and female patients undergoing groin hernia repair.

BACKGROUND DATA

Groin hernia repair is common but understudied in females. Limited prior work demonstrates worse outcomes among females.

METHODS

Using Medicare claims, we performed a retrospective cohort study of adult patients who underwent elective groin hernia repair between January 1, 2010 and December 31, 2017. We used a Cox proportional hazards model to evaluate the risk of operative recurrence up to 5 years following the index operation. Secondary outcomes included 30-day complications following surgery.

RESULTS

Among 118,119 patients, females comprised the minority of patients (n=16,056, 13.6%). Compared with males, female patients were older (74.8 vs. 71.9 y, P <0.01), more often white (89.5% vs. 86.7%, P <0.01), and had a higher prevalence of nearly all measured comorbidities. In the multivariable Cox proportional hazards model, we found that female patients had a significantly lower risk of operative recurrence at 5-year follow-up compared with males (aHR 0.70, 95% CI 0.60-0.82). The estimated cumulative incidence of recurrence was lower among females at all time points: 1 year [0.68% (0.67-0.68) vs. 0.88% (0.88-0.89)], 3 years [1.91% (1.89-1.92) vs. 2.49% (2.47-2.5)], and 5 years [2.85% (2.82-2.88) vs. 3.7% (3.68-3.75)]. We found no significant difference in the 30-day risk of complications.

CONCLUSIONS

We found that female patients experienced a lower risk of operative hernia recurrence following elective groin hernia repair, which is contrary to what is often reported in the literature. However, the risk of operative recurrence was low overall, indicating excellent surgical outcomes among older adults for this common surgical condition.

Update of the international HerniaSurge guidelines for groin hernia management

BACKGROUND

Groin hernia repair is one of the most common operations performed globally, with more than 20 million procedures per year. The last guidelines on groin hernia management were published in 2018 by the HerniaSurge Group. The aim of this project was to assess new evidence and update the guidelines. The guideline is intended for general and abdominal wall surgeons treating adult patients with groin hernias.

METHOD

A working group of 30 international groin hernia experts and all involved stakeholders was formed and examined all new literature on groin hernia management, available until April 2022. Articles were screened for eligibility and assessed according to GRADE methodologies. New evidence was included, and chapters were rewritten. Statements and recommendations were updated or newly formulated as necessary.

RESULTS

Ten chapters of the original HerniaSurge inguinal hernia guidelines were updated. In total, 39 new statements and 32 recommendations were formulated (16 strong recommendations). A modified Delphi method was used to reach consensus on all statements and recommendations among the groin hernia experts and at the European Hernia Society meeting in Manchester on October 21, 2022.

CONCLUSION

The HerniaSurge Collaboration has updated the international guidelines for groin hernia management. The updated guidelines provide an overview of the best available evidence on groin hernia management and include evidence-based statements and recommendations for daily practice. Future guideline development will change according to emerging guideline methodology.

Trends in Surgical Technique and Outcomes of Ventral Hernia Repair in The United States

OBJECTIVE

To describe national trends in surgical technique and rates of reoperation for recurrence for patients undergoing ventral hernia repair (VHR) in the United States.

BACKGROUND

Surgical options for VHR, including minimally invasive approaches, mesh implantation, and myofascial release, have expanded considerably over the past 2 decades. Their dissemination and impact on population-level outcomes is not well characterized.

METHODS

We conducted a retrospective cohort study of Medicare beneficiaries undergoing elective, inpatient umbilical, ventral, or incisional hernia repair between 2007 and 2015. Cox proportional hazards models were used to estimate the adjusted proportion of patients who remained free from reoperation for hernia recurrence up to 5 years after surgery.

RESULTS

One hundred fort-one thousand two hundred sixty-one patients underwent VHR during the study period. Between 2007 and 2018, the use of minimally invasive surgery increased from 2.1% to 22.2%, mesh use increased from 63.2% to 72.5%, and myofascial release increased from 1.8% to 16.3%. Overall, the 5-year incidence of reoperation for recurrence was 14.1% [95% confidence interval (CI) 14.0%-14.1%]. Over time, patients were more likely to remain free from reoperation for hernia recurrence 5 years after surgery [2007-2009 reoperation-free survival: 84.9% (95% CI 84.8%-84.9%); 2010-2012 reoperation-free survival: 85.7% (95% CI 85.6%-85.7%); 2013-2015 reoperation-free survival: 87.8% (95% CI 87.7%-87.9%)].

CONCLUSIONS

The surgical treatment of ventral and incisional hernias has evolved in recent decades, with more patients undergoing minimally invasive repair, receiving mesh, and undergoing myofascial release. Although our analysis does not address causality, rates of reoperation for hernia recurrence improved slightly contemporaneous with changes in surgical technique.

Racial and Ethnic Differences in Elective Versus Emergency Surgery for Colorectal Cancer

OBJECTIVE

To evaluate differences in presentation and outcomes of surgery for colorectal cancer.

BACKGROUND

Although racial and socioeconomic disparities in colorectal cancer outcomes are well documented, disparities in access affecting disease presentation are less clear.

METHODS

We conducted a statewide retrospective study of patients who underwent resection for colorectal cancer between January 1, 2015, and April 30, 2021. The primary outcome was undergoing emergency surgery. Secondary outcomes included preoperative evaluation and postoperative outcomes. Covariates of interest included race/ethnicity, social deprivation index, and insurance type.

RESULTS

A total of 4869 patients underwent surgery for colorectal cancer, of whom 1122 (23.0%) underwent emergency surgery. Overall, 28.1% of Black non-Hispanic patients and 22.5% of White non-Hispanic patients underwent emergency surgery. On multivariable logistic regression, Black non-Hispanic race was independently associated with a 5.8 (95% CI, 0.3-11.3) percentage point increased risk of emergency surgery compared with White non-Hispanic race. Patients who underwent emergency surgery were significantly less likely to have preoperative carcinoembryonic antigen measurement, staging for rectal cancer, and wound/ostomy consultation. Patients who underwent emergency surgery had a higher incidence of 30-day mortality (5.5% vs 1.0%, P <0.001), positive surgical margins (11.1% vs 4.9%, P <0.001), complications (29.2% vs 16.0%, P <0.001), readmissions (12.5% vs 9.6%, P =0.005), and reoperations (12.2% vs 8.2%, P <0.001).

CONCLUSIONS

Among patients with colorectal cancer, Black non-Hispanic patients were more likely to undergo emergency surgery than White non-Hispanic patients, suggesting they may face barriers to timely screening and evaluation. Undergoing emergency surgery was associated with incomplete oncologic evaluation, increased incidence of postoperative complications including mortality, and increased surgical margin positivity. These results suggest that racial and ethnic differences in the diagnosis and treatment of colorectal cancer impact near-term and long-term outcomes.

The impact of laparoscopic versus open inguinal hernia repair for inguinal hernia treatment: A retrospective cohort study

OBJECTIVES

Although laparoscopic inguinal hernia repair (LIHR) has been widely accepted for treating inguinal hernia, the procedure remains very technical and challenging. The present study aimed to assess the effect of LIHR in relation to operation time, intraoperative hemorrhage and postoperative hospitalization.

METHODS

A total of 503 patients with inguinal hernia admitted at the Wuxi Rehabilitation Hospital between June 2019 and July 2021 were included in this retrospective cohort study. Binary logistic and linear regressions were used for categorical and continuous outcomes, respectively. The learning curve was drawn by cumulative sum analysis.

RESULTS

Multivariate logistic regression analysis identified LIHR as an independent factor associated with prolonging operation time (odd ratio [OR] = 1.750, 95% confidence interval [CI]: 1.215-2.520, p = 0.003) and decreasing intraoperative hemorrhage levels (OR = 0.079, 95 CI: 0.044-0.142, p < 0.001). Multivariate linear regression identified LIHR (Coefficient = -0.702, 95% CI: [-1.050] to [-0.354], p < 0.001) as an independent factor for shortening postoperative hospitalization time. After learning curve, LIHR (OR = 1.409, 95% CI: 0.948 to 2.094, p = 0.090) no longer resulted as a risk factor prolonging operation time.

CONCLUSIONS

LIHR is an important independent predictive factor for decreasing intraoperative hemorrhage levels and shortening postoperative hospitalization time. Additionally, LIHR does not prolong operation time after the learning curve.

Comparing functional outcomes in minimally invasive versus open inguinal hernia repair using the army physical fitness test

PURPOSE

The advantages of minimally invasive inguinal hernia repair (MIHR) over open hernia repair (OHR) continue to be debated. We compared MIHR to OHR by utilizing the Army Physical Fitness Test (APFT) as an outcome measure.

METHODS

The APFT is a three-component test scored on a normalized 300 point scale taken semiannually by active-duty military. We identified 1119 patients who met inclusion criteria: 588 in the OHR group and 531 in the MIHR group. Changes in APFT scores, time on post-operative duty restrictions (military profile), and time interval to first post-operative APFT were compared using regression analysis.

RESULTS

Postoperatively, no APFT score change difference was observed between the OHR or MIHR groups (- 7.3 ± 30 versus - 5.5 ± 27.7, p = 0.2989). Service members undergoing OHR and MIHR underwent their first post-operative APFT at equal mean timeframes (6.6 ± 5 months versus 6.7 ± 5.1, p = 0.74). No difference was observed for time in months spent on an official temporary duty restriction (military profile) for either OHR or MIHR (0.16 ± 0.16 versus 0.15 ± 0.17, p = 0.311). On adjusted regression analysis, higher pre-operative APFT scores and BMI ≥ 30 were independently associated with reduction in post-operative APFT scores. Higher-baseline APFT scores were independently associated with less time on a post-operative profile, whereas higher BMI (≥ 30) and lower rank were independently associated with longer post-operative profile duration. Higher-baseline APFT scores and lower rank were independently associated with shorter time intervals to the first post-operative APFT.

CONCLUSION

Overall, no differences in post-operative APFT scores, military profile time, or time to first post-operative APFT were observed between minimally invasive or open hernioplasty in this military population.

Hospital-level variation in mesh use for ventral and incisional hernia repair

BACKGROUND

Placement of prosthetic mesh during ventral and incisional hernia repair has been shown to reduce the incidence of postoperative hernia recurrence. Consequently, multiple consensus guidelines recommend the use of mesh for ventral hernias of any size. However, the extent to which real-world practice patterns reflect these recommendations is unclear.

METHODS

We performed a retrospective review of the Michigan Surgical Quality Collaborative Hernia Registry (MSQC-HR) to identify patients undergoing clean ventral or incisional hernia repair between January 1, 2020 and December 31, 2021. The primary outcome was mesh use. We used two-step hierarchical logistic regression modeling with empirical Bayes estimates to evaluate the association of hospital-level mesh use with patient, operative, and hernia characteristics.

RESULTS

A total of 5262 patients underwent ventral and incisional hernia repair at 65 hospitals with a mean age of 53.8 (14.5) years, 2292 (43.6%) females, and a mean hernia width of 3.2 (3.4) cm. Mean hospital volume was 81 (49) cases. Mesh was used in 4098 (77.9%) patients. At the patient level, hernia width and surgical approach were significantly associated with mesh use. Specifically, mesh use was 6.2% (95% CI 4.8-7.5%) more likely with each additional centimeter of hernia width and 28.0% (95% CI 26.1-29.8%) more likely for minimally invasive repair compared to open repair. At the hospital level, there was wide variation in mesh use, ranging from 38.0% (95% CI 31.5-44.9%) to 96.4% (95% CI 95.3-97.2%). Hospital-level mesh use was not associated with differences in hernia size (β =  - 0.003, P = 0.978), surgical approach (β =  - 1.109, P = 0.414), or any other patient factors.

CONCLUSIONS

Despite strong evidence supporting the use of mesh in ventral and incisional hernia repair, there is substantial variation in mesh use between hospitals that is not explained by differences in patient characteristics or operative approach. This suggests that opportunities exist to standardize surgical practice to better align with evidence supporting the use of mesh in the management of these hernias.

Five year trends in surgical technique and outcomes of groin hernia repair in the United States

INTRODUCTION

Despite being one of the most commonly performed operations in the US, there is a paucity of data on practice patterns and resultant long-term outcomes of groin hernia repair. In this context, we performed a contemporary assessment of operative approach with 5 year follow-up to inform care for the 800000 persons undergoing groin hernia repair annually.

METHODS

This was a retrospective cohort study of adult patients undergoing elective groin hernia repair in a 20% representative Medicare sample from 2010-17. Surgical approach [minimally invasive (MIS) vs open] was defined using appropriate CPT codes. The primary outcome was operative recurrence at up to 5 years following surgery. We estimated the overall risk of operative recurrence using a multivariable Cox proportional hazards model.

RESULTS

Among 118119 patients, the majority (76.4%) underwent an open repair. Compared to patients who underwent MIS repair, patients in the open surgery cohort were older (mean age 72.7 vs 71.0, p < 0.001), more often female (14.4 vs 10.9%, p < 0.001), less often white (86.9 vs 87.7%, p < 0.001), and had a higher prevalence of nearly all measured comorbidities Patients in the open cohort had a lower incidence of operative recurrence at 1-year (1.0 vs 1.5%, p < 0.001), 3-years, (2.5 vs 3.5%, p < 0.001), and 5-years (3.7 vs 4.7%, p < 0.001). In the Cox proportional hazards model, we found that patients who underwent an open groin hernia repair were significantly less likely to experience operative recurrence (HR 0.86, 95% CI 0.79-0.93).

CONCLUSIONS

In this study, we found that open groin hernia repair was associated with a lower risk of operative recurrence over time. While this may be related to patient comorbidity and age at the index operation, future work should focus on the impact of surgeon volume on outcomes in the modern era.

The transition from open to laparoscopic surgery for bilateral inguinal hernia repair: how we did it

PURPOSE

To describe the transition process from open repair (OR) to laparoscopic repair (LR) of bilateral inguinal hernia in a small basic general hospital METHODS: We describe the technical details and training strategy used to facilitate the transition to systematic LR of bilateral inguinal hernia. We conducted a retrospective analysis of prospectively collected data from all patients undergoing bilateral inguinal hernia repair between January 2017 and December 2020. We analysed the evolution of LR and compared the surgical outcomes: complications, acute pain (24 h), chronic pain (> 3 months), and recurrence (1 year) of the patients operated on by OR and LR.

RESULTS

We performed 132 bilateral inguinal hernia repairs, 55 (41.7%) ORs, and 77 (58.3%) LRs. A significant difference was observed in the choice of LR over time (2017: 9%, 2018: 32%, 2019: 75%, 2020: 91%, p < 0.001). The mean operative time was shorter in the OR group than in the LR group (56 min vs. 108 min, p < 0.001). However, the operative time of the LR decreased over the years. No significant differences were observed in complications or recurrence. LR was associated with lower acute postoperative pain at 24 h (2.2 vs. 3.1 points, p = 0.021) and lower chronic groin pain than OR (1.3% vs. 12.7%, p = 0.009).

CONCLUSION

A structured and systematized training process made the transition from OR to LR of bilateral inguinal hernias feasible and safe in a small basic general hospital. This transition did not increase complications or recurrence. Additionally, LR was associated with a decrease in postoperative pain and chronic groin pain.

Incidence and trends of decision regret following elective hernia repair

BACKGROUND

One approach to evaluate decision-making is using the concept of decision regret, which measures patient remorse after a healthcare decision. This is particularly important for elective, preference-sensitive conditions with multiple treatment options, such as ventral and inguinal hernia repair. In this study, we assessed decision regret among patients who pursued surgical management of ventral and inguinal hernias.

METHODS

We retrospectively reviewed a statewide registry of adult patients who underwent elective ventral and inguinal hernia repair between January 2017 and March 2020 and completed a validated survey measuring decision regret. 30-day outcomes included complications, emergency department (ED) utilization, readmission, and reoperation. Multivariable logistic regression examined the association of regret with age, sex, race, insurance status, ASA, tobacco use, diabetes, admission status, surgical approach (open vs. laparoscopic vs. robotic), year, and outcomes.

RESULTS

8315 patients underwent surgery during the study period with a mean age of 60.5 (14.7) years and 1812 (22%) female patients. Among 2159 patients who underwent ventral hernia repair, 248 (11%) reported regret to undergo surgery, 64 (3%) experienced a complication, 160 (7%) visited an ED, 86 (4%) were readmitted, and 29 (1%) underwent reoperation. Outcomes associated with regret after ventral hernia repair included complications (OR 2.33, 95% CI 1.26-4.29) and readmission (OR 2.67, 95% CI 1.51-4.71). Among 6,156 patients who underwent inguinal hernia repair, 533 (9%) reported regret to undergo surgery, 41 (1%) experienced a complication, 304 (5%) visited an ED, 72 (1%) were readmitted, and 63 (1%) underwent reoperation. Outcomes associated with regret after inguinal hernia repair included ED visits (OR 2.03, 95% CI 1.44-2.87) and readmission (OR 4.23, 95% CI 2.35-7.61).

CONCLUSION

Roughly 1 in 10 patients undergoing hernia repair report regret with their decision to undergo surgery. Developing a better understanding of the factors associated with decision regret after hernia repair may better inform both patients and surgeon decision-making.

Outcomes of Telemedicine-Based Consultation among Rural Patients Referred for Abdominal Wall Reconstruction and Hernia Repair

BACKGROUND

Perioperative telemedicine use has increased as a result of the COVID-19 pandemic and may improve access to surgical care. However, studies assessing outcomes in populations at risk for digital-health disparities are lacking. We sought to characterize the pre- and postoperative outcomes for rural patient populations being assessed for hernia repair and abdominal wall reconstruction with telehealth.

METHODS

Patients undergoing telehealth evaluation from March 2020 through May 2021 were identified. Rurality was identified by zip code of residence. Rural and urban patients were compared based on demographics, diagnosis, treatment plan, and visit characteristics and outcomes. Downstream care use related to supplementary in-person referral, and diagnostic testing was assessed.

RESULTS

Three hundred-seventy-three (196 preoperative, 177 postoperative) telehealth encounters occurred during the study period (rural: 28% of all encounters). Rural patients were more likely to present with recurrent or incisional hernias (90.0 vs 72.7%, p = 0.02) and advanced comorbidities (American Society of Anesthesiologists status score > 2: 73.1 vs 52.1%, p = 0.009). Rural patients derived significant benefits related to time saved commuting, with median distances of 299 and 293 km for pre- and postoperative encounters, respectively. Downstream care use was 6.1% (N = 23) for additional in-person evaluations and 3.4% (N = 13) for further diagnostic testing, with no difference by rurality.

CONCLUSIONS

Perioperative telehealth can safely be implemented for rural populations seeking hernia repair and may be an effective method for reducing disparities. Downstream care use related to additional in-person referral or diagnostic testing was minimally impacted in both the preoperative and postoperative settings. These findings suggest that rurality should not deter surgeons from providing telemedicine-based surgical consultation for hernia repair.

Telemedicine-based new patient consultations for hernia repair and advanced abdominal wall reconstruction

Purpose

Telemedicine has emerged as a viable option to in-person visits for the evaluation and management of surgical patients. Increased integration of telemedicine has allowed for greater access to care for specific patient populations but relative outcomes are unstudied. Given these limitations, we sought to evaluate the efficacy of telemedicine-based new patient preoperative encounters in comparison to in-person encounters.

Methods

We performed a retrospective analysis of adult patients undergoing new patient evaluations from April 2020 to October 2021. Telemedicine visits consist of both video and telephone-based encounters. Visit types, patient demographics, preoperative diagnosis, travel time to the hospital, and prior imaging availability were reviewed.

Results

A total of 276 new patient encounters were conducted (n = 108, 39% telemedicine). Indications for evaluation included inguinal hernia (n = 81, 30%), ventral hernia (n = 149, 54%) and groin or abdominal pain (n = 30, 11%). Patients undergoing telehealth evaluations were more likely to have greater travel distance to the hospital (91 km vs 29 km, p = 0.002) and have CT image-confirmed diagnoses at the initial visit (73 vs 47%, p < 0.001). Patients who were evaluated for a recurrent or incisional hernia were more likely to be seen through a telemedicine encounter (69 vs 45%, p < 0.001).

Conclusions

We report the efficacy of telemedicine-based consultations for new patient preoperative evaluations related to hernia repair and abdominal wall reconstruction. Telemedicine is a useful modality for preoperative evaluation of new patients with hernia and advanced abdominal wall reconstruction needs. Understanding this patient population will allow us to optimize telemedicine encounters for new patients and improve access to care for patients in remote locations.

Surgeon Variation in the Application of Robotic Technique for Abdominal Hernia Repair: A Mixed-Methods Study

INTRODUCTION

Although the utilization of robotic technique for abdominal hernia repair has increased rapidly, there is no consensus as to when it should be applied for optimal outcomes. High variability exists within surgeon practices regarding how they use this technology, and the factors that drive robotic utilization remain largely unknown. This study aims to explore the motivating factors associated with surgeons' decisions to utilize a robotic approach for abdominal hernia repair.

METHODS

An exploratory mixed-methods approach was utilized. Surgeons who performed abdominal hernia repairs were interviewed to identify impactful themes motivating surgical approach. This informed a retrospective analysis of ventral hernia repairs performed in 2020 within the Michigan Surgical Quality Collaborative. Surgeon robotic utilization rates were calculated. Among selective robotic users, multivariable regression evaluated the patient and hernia factors associated with robotic utilization.

RESULTS

Qualitative analysis of 21 interviews revealed three dominant themes in the decision to utilize robotic technology: access and resources, surgeon comfort, and market factors. Among 71 surgeons caring for 1174 hernia patients, robotic utilization rates ranged from 0% to 98% of cases. There were 27 surgeons identified as selective robotic users, who cared for 423 patients. Multivariable regression revealed that hernia location was the only factor associated with robotic technique, with non-midline hernias associated with a 4.47 (95% confidence interval 1.34-14.88) higher odds of robotic repair than epigastric hernias.

CONCLUSIONS

Major drivers of robotic technique for hernia repair were found to be perceived benefits and availability, rather than patient or hernia characteristics. These data will contribute to an understanding of surgeon decision-making and help develop improvements to patient care.

Association of hospital factors and socioeconomic status with the utilization of minimally invasive surgery for colorectal cancer over a decade

BACKGROUND

Surgical resection is a mainstay of treatment for colorectal cancer (CRC). Minimally invasive surgery (MIS) has been shown to have improved outcomes compared to open procedures for colorectal malignancy. While use of MIS has been increasing, there remains large variability in its implementation at the hospital and patient level.

OBJECTIVE

The purpose of this study was to identify disparities in sex, race, location, patient income status, insurance status, hospital region, bed size and teaching status for the use of MIS in the treatment of CRC.

METHODS

This was a retrospective cohort study using the Nationwide Inpatient Sample Database. Between 2008 and 2017, there were 412,292 hospitalizations of adult patients undergoing elective colectomy for CRC. The primary outcome was use of MIS during hospitalization.

RESULTS

Overall, the frequency of open colectomies was higher than MIS (56.56% vs. 43.44%). Black patients were associated with decreased odds of MIS use during hospitalization compared to White patients (OR 0.921, p = 0.0011). As the county population where patients resided decreased, odds of MIS also significantly decreased as compared to central counties of metropolitan areas. As income decreased below the reference of $71,000, odds of MIS also significantly decreased. Medicaid and uninsured patients had decreased odds of MIS use during hospitalization compared to private insurance (OR 0.751, p < 0.0001 and OR 0.629, p < 0.0001 respectively). Rural and urban non-teaching hospitals were associated with decreased odds of MIS as compared to urban teaching hospitals (OR 0.523, p < 0.0001 and OR 0.837, p < 0.0001 respectively). Hospitals with a small bed size were also associated with decreased MIS during hospitalizations (OR 0.888, p < 0.0001).

CONCLUSIONS

Marked hospital level and socioeconomic disparities exist for utilization of MIS for colorectal cancer. Strategies targeted at reducing these gaps have the potential to improve surgical outcomes and cancer survival.

Guideline-discordant care among females undergoing groin hernia repair: the importance of sex as a biologic variable

PURPOSE

Females suffer higher rates of operative recurrence and chronic pain following groin hernia repair. Guidelines recommend minimally invasive (MIS) groin hernia repair as the preferred approach to reduce these adverse outcomes. It is unknown what proportion of females receive MIS hernia repair. Therefore, our goal was to investigate adoption of evidence-based practices in groin hernia repair using sex as a biological variable.

METHODS

Retrospective cohort study of adults undergoing elective groin hernia repair (2014-2019) within a statewide quality improvement collaborative. Primary outcome was surgical approach. Multivariable logistic regression was performed to analyze the likelihood of undergoing MIS hernia repair. Secondary outcomes were 30-day adjusted rates of clinical and patient-reported outcomes (PROs). PROs included regret to undergo surgery among patients who completed post-operative surveys.

RESULTS

Among 23,723 patients, the majority (90.7%) were males. Compared to males, females less often underwent an MIS surgical approach (37.4% vs 45.1%, p < 0.0001). After adjustment for patient and clinical variables, females remained significantly less likely to undergo MIS groin hernia repair (aOR 0.88, 95% CI 0.80-0.97). Adjusted clinical outcomes were not different between males and females. Among 4325 patients who completed post-operative surveys, adjusted rates of regret to undergo surgery were higher among females (12.9% vs 8.5%, p = 0.003).

CONCLUSIONS

Even after adjusting for differences, females were less likely to receive guideline-concordant groin hernia repair and were more likely to regret surgery. Understanding the behaviors of surgeons who treat females with groin hernia may inform quality metrics to promote best practices in this population.

Controversies in Inguinal Hernia

Inguinal hernias represent one of the most common pathologic conditions presenting to the general surgeon. In surgical practice, several controversies persist: when to operate, the utility of a laparoscopic versus open approach, the applicability of robotic surgery, the approach to bilateral hernias, management of athletic-related groin pain ("sports hernia"), and the role of tissue-based repairs in modern hernia surgery. Ideally, surgeons should approach each patient individually and tailor their approach based on patient factors and preferences. The informed consent process is critical, especially given increasing recognition of the risk of long-term chronic pain following hernia repair.

Development and Implementation of Preoperative Optimization for High-Risk Patients With Abdominal Wall Hernia

IMPORTANCE

Real-world surgical practice often lags behind the best scientific evidence. For example, although optimizing comorbidities such as smoking and morbid obesity before ventral and incisional hernia repair improves outcomes, as many as 25% of these patients have a high-risk characteristic at the time of surgery. Implementation strategies may effectively increase use of evidence-based practice.

OBJECTIVE

To describe current trends in preoperative optimization among patients undergoing ventral hernia repair, identify barriers to optimization, develop interventions to address these barriers, and then pilot these interventions.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study used a retrospective medical record review to identify hospital-level trends in preoperative optimization among patients undergoing ventral and incisional hernia repair. Semistructured interviews with 21 practicing surgeons were conducted to elicit barriers to optimizing high-risk patients before surgery. Next, a task force of experts was convened to develop pragmatic interventions to increase surgeon use of preoperative optimization. Finally, these interventions were piloted at 2 sites to assess acceptability and feasibility. This study was performed from January 1, 2014, to December 31, 2019.

MAIN OUTCOMES AND MEASURES

The main outcome was rate of referrals for preoperative patient optimization at the 2 pilot sites.

RESULTS

Among 23 000 patients undergoing ventral hernia repair, the mean (SD) age was 53.9 (14.3) years, and 12 315 (53.5%) were men. Of these, 8786 patients (38.2%) had at least 1 high-risk characteristic at the time of surgery, including 7683 with 1, 1079 with 2, and 24 with 3. At the hospital level, the mean proportion of patients with at least 1 of 3 high-risk characteristics at the time of surgery was 38.2% (95% CI, 38.1%-38.3%). This proportion varied widely from 21.5% (95% CI, 17.6%-25.5%) to 52.8% (95% CI, 43.9%-61.8%) across hospitals. Interviews with surgeons identified 3 major barriers to improving this practice: lost financial opportunity by not offering a patient an operation, lack of surgeon awareness of available resources for optimization, and organizational barriers. A task force therefore developed 3 interventions: a financial incentive to optimize high-risk patients, an educational intervention to make surgeons aware of available optimization resources, and on-site facilitation. These strategies were piloted at 2 sites where preoperative risk optimization referrals increased 860%.

CONCLUSIONS AND RELEVANCE

This study demonstrates a stepwise process of identifying a practice gap, eliciting barriers that contribute to this gap, using expert consensus and local resources to develop strategies to address these barriers, and piloting these strategies. This implementation strategy can be adopted to diverse settings given that it relies on developing and implementing strategies based on local practice patterns.

Development and Implementation of Preoperative Optimization for High-Risk Patients With Abdominal Wall Hernia

IMPORTANCE

Real-world surgical practice often lags behind the best scientific evidence. For example, although optimizing comorbidities such as smoking and morbid obesity before ventral and incisional hernia repair improves outcomes, as many as 25% of these patients have a high-risk characteristic at the time of surgery. Implementation strategies may effectively increase use of evidence-based practice.

OBJECTIVE

To describe current trends in preoperative optimization among patients undergoing ventral hernia repair, identify barriers to optimization, develop interventions to address these barriers, and then pilot these interventions.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study used a retrospective medical record review to identify hospital-level trends in preoperative optimization among patients undergoing ventral and incisional hernia repair. Semistructured interviews with 21 practicing surgeons were conducted to elicit barriers to optimizing high-risk patients before surgery. Next, a task force of experts was convened to develop pragmatic interventions to increase surgeon use of preoperative optimization. Finally, these interventions were piloted at 2 sites to assess acceptability and feasibility. This study was performed from January 1, 2014, to December 31, 2019.

MAIN OUTCOMES AND MEASURES

The main outcome was rate of referrals for preoperative patient optimization at the 2 pilot sites.

RESULTS

Among 23 000 patients undergoing ventral hernia repair, the mean (SD) age was 53.9 (14.3) years, and 12 315 (53.5%) were men. Of these, 8786 patients (38.2%) had at least 1 high-risk characteristic at the time of surgery, including 7683 with 1, 1079 with 2, and 24 with 3. At the hospital level, the mean proportion of patients with at least 1 of 3 high-risk characteristics at the time of surgery was 38.2% (95% CI, 38.1%-38.3%). This proportion varied widely from 21.5% (95% CI, 17.6%-25.5%) to 52.8% (95% CI, 43.9%-61.8%) across hospitals. Interviews with surgeons identified 3 major barriers to improving this practice: lost financial opportunity by not offering a patient an operation, lack of surgeon awareness of available resources for optimization, and organizational barriers. A task force therefore developed 3 interventions: a financial incentive to optimize high-risk patients, an educational intervention to make surgeons aware of available optimization resources, and on-site facilitation. These strategies were piloted at 2 sites where preoperative risk optimization referrals increased 860%.

CONCLUSIONS AND RELEVANCE

This study demonstrates a stepwise process of identifying a practice gap, eliciting barriers that contribute to this gap, using expert consensus and local resources to develop strategies to address these barriers, and piloting these strategies. This implementation strategy can be adopted to diverse settings given that it relies on developing and implementing strategies based on local practice patterns.

Inguinal hernia repair in Spain. A population-based study of 263,283 patients: factors associated with the choice of laparoscopic approach

PURPOSE

The objective of this study is to evaluate the laparoscopic inguinal hernia repair (IHR) rate in Spain and identify the factors associated with the choice of this surgical approach.

METHODS

A retrospective cohort study of 263,283 patients who underwent IHR from January 2016 to December 2018 was conducted. Data were extracted from the Spanish Minimum Basic Data Set (MBDS) of the Health Ministry database. The primary outcome was laparoscopic (LAP) rate utilization. Univariate analysis and multivariable logistic regression analysis were performed to identify factors associated with LAP-IHR.

RESULTS

Only 5.7% (15,059) patients underwent LAP-IHR, whereas the remnant 94.3% (248,224 patients) underwent open repair. High variability in the LAP-IHR rate across the country was observed; ranged between provinces from 0 to 19.7%, for a unilateral hernia, and between 0 to 57.4% in the case of bilateral hernias. On multivariate logistic regression analysis, the patient place of residence was the most remarkable factor associated with the likelihood of receiving LAP-IHR (OR 4.96; p < 0.001). There were also significant differences favoring LAP-IHR for bilateral operation (OR 4.596; p < 0.001), insurance coverage (OR 4.439, p < 0.001) and self-pay patients (OR 2.317; p < 0.001), as well as a recurrent hernia (OR 1.780; p < 0.001), age younger than 65 years (OR 1.555; p < 0.001) and male sex (OR 1.162, p < 0.001).

CONCLUSION

LAP-IHR remains a not frequent choice among surgeons in Spain, even when dealing with recurrent and bilateral hernias. The results suggest that the choice of LAP-IHR could depend on the surgeon's preference rather than on the indication appropriateness.

Initial experience using a handheld fully articulating software-driven laparoscopic needle driver in TAPP inguinal hernia repair

Background

The laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair is a widely performed minimally invasive operation, but can present considerable ergonomic challenges for the surgeon. Our objective was to determine if a novel handheld software-driven laparoscopic articulating needle driver can mitigate these difficulties.

Methods

The video recordings of a consecutive series of TAPP cases by a single surgeon using the articulating device were compared with a series of cases using straight-stick laparoscopy. Two critical steps of the procedure were analyzed for time: mesh fixation and peritoneal suture closure. These steps were then compared before and after 10 initial consecutive cases to analyze whether the surgeon demonstrated improvement. A cost analysis was also performed between the two techniques.

Results

For mesh fixation, the surgeon averaged 227 s using tacker devices, compared with 462.4 s using the novel laparoscopic device (p = 0.06). For the peritoneal closure component of the operation, the surgeon improved the time per suture pass during closure from 60.61 s during the first 10 cases to 38.84 s after the first 10 cases (p = 0.0004), which was comparable to the time per stitch for standard laparoscopy (34.8 s vs 34.84 s, p = 0.997). Left-sided inguinal hernia repairs using the articulating device demonstrated a significantly longer time per stitch during peritoneal closure compared to the right side after first 10 cases (left: 40.62 s; right: 27.91, p = 0.005). Our direct cost analysis demonstrated that suture closure of the peritoneum using the articulating device was more cost-effective than tack fixation.

Conclusions

After only a 10 case initial experience, a laparoscopic hand-held articulating needle driver is comparable to standard laparoscopy to complete suture mesh fixation and peritoneal closure for TAPP inguinal hernia repair. Further, the feasibility of suture mesh fixation minimizes the need for costly tacker devices. This instrument appears to be a promising tool in this largely minimally invasive era of hernia repair.

Simulated training model in a low cost for laparoscopic inguinal hernioplasty

Purpose

Develop a 3D model for the simulation of laparoscopic inguinal hernioplasty transabdominal preperitoneal (TAPP).

Methods

This is an experimental study, 18 participants were selected, divided into three groups, experimental (GE) surgeons in training, control (GC) experienced surgeons and Shaw (GS) nonexperienced surgeons. The simulation in the 3D model was carried out in 6 sessions fulfilling the 5 stages. Opening the peritoneum with the creation of the preperitoneal space; identification of important structures; hernia identification and reduction; placement and fixation of the mesh in Cooper’s ligament and closure of the peritoneum.

Results

In the 1st stage, the GE obtained an average of 1.25 ± 0.42 in the 1st session and 3.25 ± 0.62 in the 6th session (p = 0.05) and in the 5th stage 0.91 ± 0.29 in the first session. 1st session and 1.91 ± 0.29 in the 6th session (p = 0.001), with no significant difference between groups. The learning and skill curve in the SG represented 1.08 ± 0.29 1st and 3.50 ± 0.90 6th session (p = 0.001).

Conclusions

The creation of a systematization of training in simulation applied to the three-dimensional model enabled gain in laparoscopic skills and underpinned its theoretical and practical foundations.

Ten-year trends in minimally invasive hernia repair: a NSQIP database review

BACKGROUND

Utilization of minimally invasive techniques for ventral and inguinal hernia repairs continues to rise. The purpose of this study was to provide updates on national utilization trends and wound complications of minimally invasive versus open ventral and inguinal hernia repairs.

METHODS

Data were accessed from the 2006 to 2017 National Surgical Quality Improvement Program database. All CPT codes that correlated to laparoscopic and open inguinal and ventral hernia repairs were queried. The total number of cases and wound complications, including superficial surgical site infection (SSI), deep SSI, organ space SSI, and wound dehiscence, was collected for each respective CPT code and compared for each year. IBM SPSS Statistics Software and Microsoft Excel were used to collect and analyze the data.

RESULTS

Between 2009 and 2017, the percentage of minimally invasive inguinal hernia repairs increased from 23.1 to 37.8%, whereas the percentage of minimally invasive ventral hernias only increased from 31.5 to 36.6%. Open inguinal hernia repairs had a wound complication rate ranging from 0.60 to 0.74%, which was double the rate of minimally invasive repairs (0.24 to 0.49%) for nearly each respective year. Minimally invasive ventral hernia repairs had total wound complication rates ranging from 0.91 to 1.37%, whereas open ventral hernias had the highest total wound complication rates ranging from 5.07 to 6.26%.

CONCLUSIONS

Over the last ten years, the utilization of minimally invasive inguinal and ventral hernia repair has increased by nearly two-fold. A larger proportion of this increase has been secondary to minimally invasive inguinal compared to ventral hernia repairs. Wound complications across all techniques remained stable or improved, and remained significantly less in the minimally invasive compared to open approaches. This study highlights the continued growth of minimally invasive techniques in hernia repair over the last decade.

Exploration of Factors Associated With Surgeon Deviation From Practice Guidelines for Management of Inguinal Hernias

IMPORTANCE

Despite availability of evidence-based guidelines for surgery, many patients receive guideline-discordant care. Reasons for this are largely unknown. For example, evidence-based guidelines recommend a minimally invasive approach for persons with bilateral or recurrent unilateral inguinal hernias. Benefits are also noted for primary unilateral inguinal hernia. However, findings from previous quantitative research indicate that only 26% of patients receive this treatment and only 42% of surgeons offer a minimally invasive approach, even for recurrent or bilateral hernias.

OBJECTIVE

To explore factors associated with surgeon choice of approach (minimally invasive vs open) in inguinal hernia repair as a tool to gain an understanding of guideline-discordant care.

DESIGN, SETTING, AND PARTICIPANTS

Qualitative study performed as part of a larger explanatory sequential mixed methods design. Purposive sampling was used to recruit 21 practicing surgeons from a large statewide quality collaborative who were diverse with regard to practice type, geographic location, and surgical specialty. Qualitative interviews consisted of a clinical vignette, followed by semi-structured interview questions. Through thematic analysis using qualitive data analysis software, patterns within the data were located, analyzed, and identified. All data were collected between April 24 and July 31, 2018.

EXPOSURE

Clinical vignette as part of the qualitative interviews.

MAIN OUTCOMES AND MEASURES

Capture of surgical approaches and factors motivating decision-making for inguinal hernia repair.

RESULTS

Of the 21 participating surgeons, 17 (81%) were men, 18 (86%) were White, and all were 35 years of age or older. Data revealed 3 dominant themes: surgeon preference and autonomy (eg, favoring one approach over the other), access and resources (eg, availability of robot), and patient characteristics (eg, age, comorbidities).

CONCLUSIONS AND RELEVANCE

Decision-making for the approach to inguinal hernia repair is largely influenced by surgeon preference and access to resources rather than patient factors. Although a one-size-fits-all approach is not recommended, the operative approach should ideally be informed by patient factors, including hernia characteristics. Addressing surgeon preference and available resources with a clinician-facing decision aid may provide an opportunity to optimize care for patients undergoing inguinal hernia repair.

Random forest modeling using socioeconomic distress predicts hernia repair approach

BACKGROUND

Surgical techniques for abdominal wall hernia repair have advanced, yet it is unclear if all patient populations experience these innovations equally. We hypothesized that in patients undergoing abdominal wall herniorrhaphy, there would be socioeconomic variation between robotic, laparoscopic, and open approaches.

METHODS

We performed a retrospective review of patients undergoing abdominal wall herniorrhaphy at a tertiary care center from 2013 through 2019. Patients were stratified by approach: laparoscopic (LH), open (OH), or robotic (RH). Insurance type was categorized as private, Medicare, or Medicaid/uninsured. Using zip code data, we obtained a Distressed Communities Index (DCI), which is comprised of 7 unique socioeconomic variables. We employed random forest (RF) modeling to predict surgical approach and determined each factor's variable importance (VI) for our model.

RESULTS

There were 559 patients; 39.7% (n = 222) LH, 33.3% (n = 186) OH, and 27% (n = 151) RH. The DCI (p < 0.01) and rates of poverty (p = 0.01), adults without diplomas (p < 0.01), and unemployment (p < 0.01) were highest in the OH group while job growth (p = 0.02) and median income ratio (p < .01) were highest in the RH group. The LH group had a greater proportion of privately insured patients than Medicaid/ uninsured patients (43.4% vs 15.9%, p < 0.01). The most important variables identified by our RF model were job growth (for RH), insurance type (for LH), and no high school diploma (for OH).

CONCLUSION

Insurance type, job growth, and educational attainment may influence operative approach and can contribute to the existing disparities in hernia surgery. Surgeons should address these inequalities and commit to parity in the delivery of surgical care.

Variation in colectomy rates for benign polyp and colorectal cancer

BACKGROUND

Removal of pre-cancerous polyps on screening colonoscopy is a mainstay of colorectal cancer (CRC) prevention. Complex polyps may require surgical removal with colectomy, an operation with a 17% morbidity and 1.5% mortality rate. Recently, advanced endoscopic techniques have allowed some patients with complex polyps to avoid the morbidity of colectomy. However, the rate of colectomy for benign polyp in the United States is unclear, and variation in this rate across geographic regions has not been studied. We compared regional variation in colectomy rates for CRC versus benign polyp.

METHODS

We performed a retrospective population-based study of Medicare beneficiaries undergoing colectomy for CRC or benign polyp, using the 100% Medicare Provider Analysis and Review files from 2010 to 2015. We used multivariable linear regression to obtain population-based colectomy rates for CRC and benign polyp at the hospital referral region (HRR) level, adjusted for age, sex, and race.

RESULTS

Of 280,815 patients, 157,802 (65.8%) underwent colectomy for CRC compared to 81,937 (34.2%) for benign polyp. Across HRRs, colectomy rates varied 5.8-fold for cancer (0.32-1.84 per 1000 beneficiaries). However, there was a 69-fold variation for benign polyp (0.01-0.69). While the rate of colectomy for CRC was correlated with the rate of colectomy for benign polyp (slope = 0.61, 95% CI 0.48-0.75), HRRs with the lowest or highest rates of colectomy for CRC did not necessarily have similarly low or high rates for benign polyp.

CONCLUSIONS

The use of colectomy for benign polyp is much more variable compared to CRC, suggesting overuse of colectomy for benign polyp in some regions. This variation may stem from provider-level differences, such as endoscopists' referral practice or skill or surgeons' decision to perform colectomy, or from limited access to advanced endoscopists. Interventions to increase endoscopic resection of benign polyps may spare some patients the morbidity and cost of surgery.

Ten golden rules for a safe MIS inguinal hernia repair using a new anatomical concept as a guide

BACKGROUND

Although laparoscopic inguinal hernia repair was described about 30 years ago and advantages of the technique have been demonstrated, the utilization of this approach has not been what we would expect. Some reasons may be the need for surgeons to understand the posterior anatomy of the groin from a new vantage point, as well as to acquire advanced laparoscopic skills. Recently, however, the introduction of a robotic approach has dramatically increased the adoption of minimally invasive techniques for inguinal hernia repair.

METHODS

Important recent contributions to this evolution have been the establishment of a new concept known as the critical view of the Myopectineal Orifice (MPO) and the description of a new way of understanding the posterior view of the antomy of the groin (inverted Y and the five triangles). In this paper, we describe 10 rules for a safe MIS inguinal hernia repair (TAPP, TEP, ETEP, RTAPP) that combines these two new concepts in a unique way.

CONCLUSIONS

As the critical view of safety has made laparoscopic cholecystectomy safer, we feel that following our ten rules based on understanding the anatomy of the posterior groin as defined by zones and essential triangles and the technical steps to achieve the critical view of the MPO will foster the goal of safe MIS hernia repair, no matter which minimally invasive technique is employed.

Influencing Factors on the Outcome in Female Groin Hernia Repair: A Registry-based Multivariable Analysis of 15,601 Patients

OBJECTIVE

Based on an analysis of data from the Herniamed Registry, this study aims to identify all factors influencing the outcome in female groin hernia repair.

BACKGROUND

In a systematic review and meta-analysis of observational studies, female sex was found to be a significant risk factor for recurrence. In the guidelines, the totally extraperitoneal patch plasty (TEP) and transabdominal preperitoneal patch plasty (TAPP) laparo-endoscopic techniques are recommended for female groin hernia repair. However, even when complying with the guidelines, a less favorable outcome must be expected than in men. To date, there is no study in the literature for analysis of all factors influencing the outcome in female groin hernia repair.

METHODS

In all, 15,601 female patients from the Herniamed Registry who had undergone primary unilateral groin hernia repair with the Lichtenstein, Shouldice, TEP or TAPP technique, and for whom 1-year follow-up was available, were selected between September 1, 2009 and July 1, 2017. Using multivariable analyses, influencing factors on the various outcome parameters were identified.

RESULTS

In the multivariable analysis, a significantly higher risk of postoperative complications, complication-related reoperations, recurrences, and pain on exertion was found only for the Lichtenstein technique. No negative influence on the outcome was identified for the TEP, TAPP, or Shouldice techniques. Relevant risk factors for occurrence of perioperative complications, recurrences, and chronic pain were preoperative pain, existing risk factors, larger defects, a higher body mass index (BMI), higher American Society of Anesthesiologists (ASA) classification and postoperative complications. Higher age had a negative association with postoperative complications and positive association with pain rates.

CONCLUSIONS

Female groin hernia repair should be performed with the TEP or TAPP laparo-endoscopic technique, or, alternatively, with the Shouldice technique, if there is no evidence of a femoral hernia. By contrast, the Lichtenstein technique has disadvantages in terms of postoperative complications, recurrences, and pain on exertion. Important risk factors for an unfavorable outcome are preoperative pain, existing risk factors, higher ASA classification, higher BMI, and postoperative complications. A higher age and larger defects have an unfavorable impact on postoperative complications and a more favorable impact on chronic pain.

Development and evaluation of a novel simulation model for transabdominal preperitoneal (TAPP) inguinal hernia repair

BACKGROUND

Transabdominal preperitoneal (TAPP) inguinal hernia repair requires the surgeon to have good manual skills in laparoscopic surgery, as well as an understanding of the laparoscopic features of the groin anatomy. This is why TAPP is considered a more difficult surgical procedure compared to open techniques. Realistic training model for TAPP inguinal hernia repair would enhance surgeons' skills before they enter in the operation room. Our aim was to create a realistic, inexpensive, and easily reproducible model for laparoscopic TAPP inguinal hernia repair and to assess its effectiveness.

METHODS

The applied TAPP inguinal hernia repair training simulator consists of a laparoscopic box and an inguinal region model placed in it. The model of the groin area is made of the porcine stomach and assembling materials. Uniaxial tensile and T-peel tests were performed to compare the mechanical properties of the porcine stomach and the human cadaver peritoneum. Thirty eight surgeons performed TAPP inguinal hernia repair using this model. Their opinions were scored on a five-point Likert scale.

RESULTS

Close elastic modules of the porcine and human tissues (13.5 ± 4.2 kPa vs. 15.8 ± 6.7 kPa, p = 0.531) gave to trainees a realistic tissue feel and instrument usage. All participants strongly agreed that model was highly useful for TAPP inguinal hernia repair training. They also put the following points: the model as a whole 5 (3-5), simulation of anatomy 5 (3-5), simulation of dissection and mobilization 5 (3-5), and simulation of intracorporeal suture 5 (4-5).

CONCLUSIONS

We successfully created a model for TAPP inguinal hernia repair training. The model is made of inexpensive synthetic and biological materials similar to the human tissue. The model is easy to reproduce and can be used in the training programs of surgical residents.

Laparoscopic inguinal hernia repair in women: Trends, disparities, and postoperative outcomes

INTRODUCTION

This study analyzed trends in laparoscopic inguinal hernia repair over time, rates of laparoscopic repair in women, and subsequent postoperative outcomes.

METHODS

Data for 237,503 patients undergoing repair of an initial, reducible inguinal hernia were analyzed using the National Surgical Quality Improvement Program (NSQIP) database for years 2006-2017. Data were analyzed by univariate and multivariate analysis.

RESULTS

Since 2006, there was an increased proportion of laparoscopic inguinal hernia surgeries, from 20.49% in 2006 to 36.36% in 2017 (p < .001). The percentage of women with bilateral inguinal hernias that underwent laparoscopic repair was less than the percentage of men (31.58% vs. 41.43%, p < .001). Based on multivariate analysis, women were less likely to have laparoscopic hernia repair (OR 0.74, CI 0.71-0.76). Postoperative complications were overall low.

CONCLUSION

A greater proportion of inguinal hernia repairs are performed laparoscopically. Women with bilateral inguinal hernias are more likely than men to undergo open rather than laparoscopic inguinal hernia repair.

Mechanisms of age and race differences in receiving minimally invasive inguinal hernia repair

BACKGROUND

Black patients and older adults are less likely to receive minimally invasive hernia repair. These differences by race and age may be influenced by surgeon-specific utilization rate of minimally invasive repair. In this study, we explored the association between race, age, and surgeon utilization of minimally invasive surgery (MIS) with the likelihood of receiving MIS inguinal hernia repair.

METHODS

A retrospective cohort study was performed in patients undergoing elective primary inguinal hernia repair from 2012 to 2016, using data from the Michigan Surgical Quality Collaborative, a 72-hospital clinical registry. Surgeons were stratified by proportion of MIS performed. Using hierarchical logistic regression models, we investigated the association between receiving MIS repair and race, age, and surgeon MIS utilization rate.

RESULTS

Out of 4667 patients, 1253 (27%) received MIS repair. Out of 190 surgeons, 81 (43%) performed only open repair. Controlling for surgeon MIS utilization, race was not associated with MIS receipt (OR 0.93, p = 0.775), but older patients were less likely to receive MIS repair (OR 0.41, p < 0.001).

CONCLUSIONS

Race differences were explained by surgeon MIS utilization, implicating access to MIS-performing surgeon as a mediator. Conversely, age disparity was independent of MIS utilization, even after adjusting for comorbidities, indicating some degree of provider bias against performing MIS repair in older patients. Interventions to address disparities should include systematic efforts to improve access, as well as provider and patient education for older adults.

Surgeon leadership style and risk-adjusted patient outcomes

BACKGROUND

There are many reasons to believe that surgeon personality traits and related leadership behaviors influence patient outcomes. For example, participation in continuing education, effective self-reflection, and openness to feedback are associated with certain personalities and may also lead to improvement in outcomes. In this context, we sought to determine if an individual surgeon's thinking and behavior traits correlate with patient level outcomes after bariatric surgery.

METHODS

Practicing surgeons from the Michigan Bariatric Surgery Collaborative (MBSC) were administered the Life Styles Inventory (LSI) assessment. The results of this assessment were then collapsed into three major styles that corresponded with particular patterns of an individual's thinking and behavior: constructive (achievement, self-actualizing, humanistic-encouraging, affiliative), passive/defensive (approval, conventional, dependent, avoidance), and aggressive/defensive (perfectionistic, competitive, power, oppositional). We compared patients level outcomes for surgeons in the lowest, middle, and highest quintiles for each style. We then used patient level risk-adjusted rates of complications after bariatric surgery to quantify the impact surgeon style on post-operative outcomes.

RESULTS

We found that patients undergoing bariatric surgery performed by surgeons with high levels of constructive (achievement, self-actualizing, humanistic-encouraging, affiliative) and passive/defensive (approval, conventional, dependent, avoidance) styles had lower rates of adverse events compared with surgeons with low levels of the respective styles [High constructive: 14.7% (13.8-15.6%), low constructive: 17.7% (16.8-18.6%); high passive: 14.8% (13.4-16.1%), low passive: 18.7% (17.3-19.9%)]. Conversely, surgeons identified with high aggressive styles (perfectionistic, competitive, power, oppositional) had similar rates of post-operative adverse events compared with surgeons with low levels [high aggressive: 15.2% (14.3-16.1%), low aggressive: 14.9% (14.2-15.6%)].

CONCLUSION

Our analysis demonstrates that surgeons' leadership styles are correlated with surgical outcomes for individual patients. This finding underscores the need for professional development for surgeons to cultivate strengths in the constructive domains including intentional self-improvement, development of interpersonal skills, and the receptiveness to feedback.