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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. [ABSTRACT FROM AUTHOR]

Aim: A study was conducted to explore the characteristics of the videos on pediatric inguinal hernia repair on YouTube and compare the most popular videos (MPV) with the least popular ones in terms of educative value vis-a-vis their popularity. Materials and Methods: The term "Pediatric inguinal hernia repair" was searched for on YouTube on August 15, 2021, with the filter set to "view rate." Pertinent data were collected from the 50 MPV and the 50 least popular videos (LPV) and then compared. The h-index and affiliation of the surgeon were obtained from the Scopus database, and their affiliation was further categorized as academic or nonacademic. Results: One hundred and seventy-five videos were found with median views of MPV: LPV being 9270 (interquartile range [IQR] – 12099):127 (IQR – 194), respectively (P < 0.0001). Most of the videos in the MPV and LPV groups were uploaded from the United States of America (USA) (MPV – 17 and LPV – 13) and India (MPV – 15 and LPV – 15). The MPV were on YouTube for a median duration of 3.1 (IQR – 5.5) years as compared to 1.2 (IQR – 2.3) years for the LPV (P < 0.0001). Ninety-two surgeons were identified. The median h-index of the surgeons of MPV was 3 (IQR – 12) in comparison to 1 (IQR – 10) of LPV (P = 0.13). The ratio of academic versus nonacademic affiliation among MPV and LPV was almost equal in both the groups. Conclusions: On either end of the spectrum of popularity, the majority of the pediatric inguinal hernia videos on YouTube were surgical videos uploaded from the USA and India. The educative value of these videos was found to be low and widely dispersed. Surgeons from both academic and nonacademic affiliations had contributed similarly. [ABSTRACT FROM AUTHOR]

Purpose: The most common techniques used to repair umbilical hernias are open and laparoscopic. As the obesity epidemic in the United States is growing, it is essential to understand how this morbidity affects umbilical hernia repairs. This study compares laparoscopic versus open umbilical hernia repairs in obese patients.Methods: All patients with body mass index (BMI) ≥ 30 kg/m2 who underwent elective, open or laparoscopic repair of a primary umbilical hernia with mesh were identified from the Americas Hernia Society Quality Collaborative (AHSQC). A retrospective review of the prospectively collected data was conducted. Outcomes of interest included surgical site infections (SSI), surgical site occurrences requiring procedural intervention (SSOPI), hernia-related quality-of-life survey (HerQles), and long-term recurrence. A logistic regression model was used to generate propensity scores.Results: Of 1507 patients who met the inclusion criteria, 322 were laparoscopic, and 1185 were open cases. The laparoscopic group had higher mean BMI (37 ± 6 vs. 35 ± 5 kg/m2 , P < 0.001 ) and mean hernia width (3 cm ± 1 vs. 2 cm ± 2, P < 0.001). Using a propensity score model, we controlled for several clinically relevant covariates. Propensity score adjustment showed no differences in the 30-day HerQles score (OR 0.93, 95% CI 0.58-1.49), SSI (OR 1.57, 95% CI 0.52-4.77), SSOPI (OR 2.85, 95% CI 0.84-9.62) or hernia recurrence (hazard ratio 0.86, 95% CI 0.50-1.49).Conclusion: In obese patients with primary umbilical hernias, there is likely no benefit to laparoscopy over open umbilical hernia repair with mesh with regard to wound morbidity. Although, the long-term recurrence also showed no difference between these two approaches, overall follow up was lacking. [ABSTRACT FROM AUTHOR]

Introduction: Socioeconomic factors predispose certain populations to an increased exposure to emergent operative procedures. The aim of this study is to evaluate the role socioeconomic factors play in emergent repairs of inguinal, ventral and umbilical hernias.Methods: The SPARCS database was used to identify all patients undergoing emergent ventral hernia repair (EVR), emergent inguinal hernia repair (EIR), and emergent umbilical hernia repair (EUR) between 2008 and 2015. Chi-square test with exact p values from Monte Carlo simulation determined marginal associations between repairs (elective vs. emergent), and patient characteristics and comorbidities. Multivariable logistic regression models were further utilized to examine socioeconomic disparity.Results: 107,887 ventral hernias, 66,947 inguinal hernias, and 63,515 umbilical hernias (total 238,349) were noted. African Americans were most likely to undergo an EVR compared to Caucasians (OR 1.55, 95% CI: 1.48-1.61), Asians (OR 1.31, 95% CI: 1.15-1.5), and Hispanics (OR 1.3, 95% CI: 1.23-1.37). African Americans were most likely to undergo EIR compared to Caucasians (OR 2.2, 95% CI: 2.06-2.36), Asians (OR 1.74, 95% CI: 1.49-2.02), and Hispanics (OR 1.22, 95% CI: 1.12-1.34). African Americans were most likely to undergo EUR compared to whites (OR 1.29, 95% CI: 1.22-1.36), Asians (26.62%, OR 1.21, 95% CI: 1.01-1.46) and Hispanic (28.03%, OR 1.08, 95% CI: 1.01-1.16). Medicaid patients were also more likely to undergo EVR (OR 1.31, OR 1.73), EIR (OR 2.92, OR 4.55) and EUR (OR 1.63, OR 2.31) compared to Medicare and commercial insurance.Conclusion: Race is a contributing factor in who undergoes an emergent hernia repair in New York State. A significantly larger proportion of the African American population is undergoing hernia repair in the emergent setting. Socioeconomic status, as indicated by the significant number of Medicaid patients undergoing emergent hernia repairs, also plays a role. [ABSTRACT FROM AUTHOR]

Local anesthesia (LA) for open inguinal hernia repair (OIHR) is not widely used in the United States. An LA program for OIHR was initiated at the Dallas Veteran Affairs Medical Center in 2015. We hypothesize that outcomes under LA for OIHR are similar to general anesthesia with adequate patient satisfaction. A total of 1422 groin hernias were performed by a single surgeon using a standardized technique at the Dallas Veteran Affairs Medical Center (2015-2019). Only unilateral, primary, elective, OIHRs were included (n = 1092). LA was used in 26.0% (n = 285) and compared with patients undergoing general anesthesia. Univariate analysis was performed by the Student t -test for continuous variables and χ2 test (or the Fisher exact test) for categorical variables. OIHR performed with LA increased from 15.5% in 2015 to 76.6% in 2019. Patients undergoing LA were older and had significantly more comorbidities. Holding time to operating room (OR), OR to start of the operation, skin-to-skin time, and end of the operation to out of the OR were all reduced with LA (all P values <0.05). Inguinodynia, recurrence, and overall complications were similar. Patients undergoing LA indicated that they were comfortable (93.0%), rated their worst pain as 2.03 ± 2.2 (of 10), and would undergo LA if they had to do it again (94.0%). LA was associated with decreased OR times and had good patient satisfaction. Overall complication rates were similar despite a higher burden of comorbid conditions in patients undergoing LA. [ABSTRACT FROM AUTHOR]

Background: Recent data on opioid consumption indicate that patients typically require far less than is prescribed. Prisma Health Upstate Hernia Center adopted standardized postoperative prescribing after hernia repair and began tracking patient-reported opioid utilization. The aim of this study is to evaluate patient opioid use after hernia repair in order to guide future prescribing.Methods: All patients who underwent primary ventral (umbilical and epigastric), incisional, and inguinal hernia repair between February and May 2019 were reviewed. Patients reported the number of opioid pills taken at their first postoperative visit and documented either in the progress note or in the Americas Hernia Society Quality Collaborative (AHSQC) patient-reported outcomes (PRO) questionnaire. All demographic, operative, and outcomes data were captured prospectively in the AHSQC. Opioid use reported as milligram morphine equivalents (MME).Results: A total of 162 surgeries were performed during the study period, and 107 had patient-reported opioid use for analysis. Inguinal hernia repair was performed in 36 patients, 10 primary ventral hernia repairs, and 61 incisional hernia repairs. No opioid use was reported in 63.9% of inguinal hernias, 60% of primary ventral hernias, and 20% of incisional hernias. Inguinal hernia patients consumed a mean of 10.5 MME, primary ventral patients 11 MME, and incisional hernia patients 78.5 MME.Conclusion: Patients require little to no opioid after primary ventral or inguinal hernia repair and opioid-free surgery is feasible. Incisional hernia is more heterogenous, but the majority of patients still required less opioid than previously thought. [ABSTRACT FROM AUTHOR]

It is expected that graduating general surgery residents be confident in performing common abdominal wall hernia repairs. The objective of our study was to assess the confidence of senior surgical residents in these procedures and to identify factors that correlate with confidence. We performed a cross-sectional survey of PGY-4 and PGY-5 general surgery residents at ACGME-accredited programs in the United States in the spring of 2019. Respondents rated their confidence level in 12 hernia procedures on a Likert scale from 1 (not confident) to 5 (extremely confident). Respondents were classified as "Not Confident" (Not Confident, Minimally Confident, Neutral responses) or "Confident" (Confident, Extremely Confident responses). Resident characteristics, program characteristics, and operative experience were collected, and we calculated the area under the curve to screen which factors discriminated between those confident versus not. Multivariable Poisson regression was used to estimate prevalence ratios (PR) and 95% confidence intervals (CI) to identify which factors were most predictive. A total of 93 surveys were completed. Respondents reported low confidence rates (25%-60%) in the following hernia repairs: minimally invasive (MIS) inguinal, femoral, tissue (nonmesh) inguinal, pediatric inguinal, and abdominal wall reconstruction. High confidence rates (>80%) were reported for open umbilical, open ventral, and MIS ventral hernia repairs. For MIS inguinal hernia repair, PGY-5 level was associated with a twofold increase in confidence (PR = 2.01; 95% CI = 1.34-3.30), and dedicated research years were associated with low confidence (PR = 0.67; 95% CI = 0.43-1.04). In general, higher operative volumes of a specific repair were associated with increased confidence in that procedure. Senior surgical residents reported low confidence in performing a variety of essential hernia repairs (particularly MIS inguinal, femoral, and tissue inguinal). Addressing factors associated with low confidence may help increase resident confidence. [ABSTRACT FROM AUTHOR]

Background: Inguinal hernia repair is one of the more common procedures performed in the United States. The optimal surgical approach, however, remains controversial. We aimed to compare the postoperative outcomes and costs between laparoscopic and open inpatient inguinal hernia repairs in a national cohort. Materials and Methods: We performed a retrospective analysis of the National Inpatient Sample during the period 2009-2015. Adult patients (≥18 years old) undergoing laparoscopic and open inguinal hernia repair were included. Multivariable logistic, generalized logistic, and linear regression were used to assess the effect of the laparoscopic approach on postoperative complications, mortality, length of stay, and hospital charges. Results: A total of 41,937 patients undergoing open inguinal hernia repair (N = 36,575) and laparoscopic inguinal hernia repair (N = 5282) were included. Patients undergoing laparoscopic inguinal hernia repair were less likely to have postoperative wound complications (odds ratio [OR]: 0.64, 95% confidence interval [CI]: 0.41-0.98), infection (OR: 0.34, 95% CI: 0.27-0.42), bleeding (OR: 0.72, 95% CI: 0.63-0.82), cardiac failure (OR: 0.72, 95% CI: 0.64-0.82), renal failure (OR: 0.54, 95% CI: 0.47-0.62), respiratory failure (OR: 0.70, 95% CI: 0.58-0.85), and inpatient mortality (OR: 0.27, 95% CI: 0.17-0.40). On average, the laparoscopic approach reduced length of stay by 1.28 days (95% CI: -1.58 to -1.18), and decreased hospital costs by $2400 (95% CI: -$4700 to -$700). Conclusion: Laparoscopic hernia repair is associated with significantly lower rates of postoperative morbidity and mortality, shorter length of hospital stays, and lower hospital costs for inpatient repairs. The laparoscopic approach should be encouraged for the management of appropriate patients with inpatient inguinal hernias. [ABSTRACT FROM AUTHOR]

Purpose: Relying solely on in-person encounters to assess long-term outcomes of hernia repair leads to substantial loss of information and patients lost-to-follow-up, hindering research and quality improvement initiatives. We aimed to determine if inguinal hernia recurrences could be assessed using the Ventral Hernia Recurrence Inventory (VHRI), a previously existing patient-reported outcome (PRO) tool that can be administered through the telephone and has already been validated for diagnosing ventral hernia recurrence.Methods: A prospective, multicentric comparative study was conducted. Adult patients from two centers (United States and Brazil) at least 1 year after open or minimally invasive inguinal hernia repair were asked to answer the questions of the VHRI in relation to their prior repair. A physical exam was then performed by a blinded surgeon. Testing characteristics and diagnostic performance of the PRO were calculated. Patients with suspected recurrences were preferentially recruited.Results: 128 patients were enrolled after 175 repairs. All patients answered the VHRI and were further examined, where a recurrence was present in 32% of the repairs. Self-reported bulge and patient perception of a recurrence were highly sensitive (84-94%) and specific (93-94%) for the diagnosis of an inguinal hernia recurrence. Test performance was similar in the American and Brazilian populations despite several baseline differences in demographic and clinical characteristics.Conclusion: The VHRI can be used to assess long-term inguinal hernia recurrence and should be reestablished as the Hernia Recurrence Inventory (HRI). Its implementation in registries, quality improvement efforts, and research could contribute to improving long-term follow-up rates in hernia patients. [ABSTRACT FROM AUTHOR]

Background: The recurrence rate after groin hernia repair (GHR) has been estimated to be between 1-10% in adult patients. Neither national rates nor trends in recurrence over time have been reliably established for Medicare patients in the USA.Materials: We evaluated patients undergoing GHR (inguinal = IHR; femoral = FHR) from 2011 to 2014 from the Medicare Provider Analysis and Review database. Patients were identified using ICD-9 diagnosis and ICD-9 and CPT procedure codes, stratified both by primary vs. recurrent hernia repair and by sex. One-tailed Cochran-Armitage tests evaluated trends over time and a generalized estimating equation model estimated factors associated with recurrent IHR or FHR.Results: We identified 407,717 patients (87.0%, ≥ 65 years) who underwent an IHR and 11,578 (91.0%, ≥ 65 years) who underwent a FHR. The proportion of IHRs for recurrence decreased statistically from 14.3% in 2011 to 13.9% in 2014 (p < 0.01) in males and was increased, but not statistically so (7.0-7.4%) in females (p = 0.08). The proportion of FHRs for recurrence was decreased, but not statistically so (16.3-14.8%, p = 0.29) in males and increased in females (5.3-6.3%, p = 0.02). On multivariable analysis, males were more than twice as likely as females to undergo recurrent repair (IHR or FHR, both p < 0.01).Conclusions: Within the Medicare population, recurrence rates after groin hernia repairs were found to be higher than previously reported but have remained clinically stable over time. Establishing and reducing this rate is important for patient outcomes and expectations. [ABSTRACT FROM AUTHOR]

Purpose: As the ultimate procedure which each surgeon decides to perform for a unilateral uncomplicated inguinal hernia remains controversial, we queried the Americas Hernia Society Quality Collaborative (AHSQC) database to report the collective experience of surgeons in the United States whom contribute to AHSQC to provide a view of the surgical approaches performed.Methods: The AHSQC data registry was queried for all adult patients who underwent a primary, unilateral, elective, inguinal hernia repair. A retrospective review was conducted to analyze patient demographics, hernia characteristics, operative details, and post-operative outcomes. Our main outcomes of interest were 30-day surgical site infections (SSI), surgical site occurrences (SSO), 30-day patient-reported outcomes, and 1-year recurrence rates.Results: 4613 patients met inclusion criteria. 1925 were repaired using an open technique (42%), 1841 were repaired using a laparoscopic technique (40%), and 847 were repaired using a robotic technique (18%). The Shouldice technique remains the most common tissue-based repair performed in the AHSQC. The Lichtenstein repair is the most common open mesh-based repair. Minimally invasive approaches to unilateral inguinal hernia repairs remained very common in our series. The robotic approach accounted for nearly one-third of the minimally invasive inguinal hernia repairs.Conclusion: In general, all of the repair techniques reported similar and low rates of 30-day complications. The AHSQC continues on-going efforts to improve long-term follow-up and looks forward to addressing long-term outcomes such as recurrence and chronic pain with increasing data acquisition. [ABSTRACT FROM AUTHOR]

Introduction: Healthcare systems and surgeons are under increasing pressure to provide high-quality care for the lowest possible cost . This study utilizes national data to examine the outcomes and costs of common laparoscopic procedures based on hospital type and location.Methods: The National Inpatient Sample was queried from 2008 to 2011 for five laparoscopic procedures: colectomy (LC), inguinal hernia repair, ventral hernia repair (LVHR), Nissen fundoplication (NF), and cholecystectomy (LCh). Outcomes, including complication rate and inpatient mortality, were stratified by region and hospital type. Both univariate and multivariate regression analyses were performed using regression-based survey methods; risk-adjusted mean costs for hospital were calculated after adjusting for patient characteristics.Results: In univariate analysis, the rates of minor complications varied significantly between geographic regions for LCh, LC, NF, and LVHR (p < 0.05). Though LCh and LVHR had statistical variation between regions for rates of major complications (p < 0.05), all regions were equivalent in rates of inpatient mortality for the procedures (p > 0.05). Rural and urban centers had similar rates of complications (p > 0.05), except for higher rates of major complications following IHR and LC in rural centers (p < 0.02) and following Nissen fundoplication in urban facilities(p < 0.0003). Though urban centers were more expensive for all procedures (p < 0.0001), mortality was similar between groups (p > 0.05). For hospital ownership, private investor-owned facilities were substantially more expensive (p < 0.0001), but had no significant differences in complications compared to other hospital types (p > 0.05). In multivariate analysis, while patient factors helped explain differences between outcome differences in different hospital types and locations, in general, the difference in cost remained statistically significant between hospitals.Conclusion: Though patient demographics and characteristics accounted for some differences in postoperative outcomes after common laparoscopic procedures, higher cost of care was not associated with better outcomes or more complex patients. [ABSTRACT FROM AUTHOR]

Background: Postoperative urinary retention (POUR) is a common entity following surgery, particularly after laparoscopic inguinal hernia repair. Here the intent is to investigate the incidence of POUR in all comers at a single institution following laparoscopic inguinal hernia repair.Methods: A retrospective chart review of all patients who underwent laparoscopic hernia repair at our institution from January 2010 through December 2013 was performed. POUR was defined as the inability to spontaneously urinate following surgery, requiring straight catheterization or placement of a Foley catheter. Perioperative data including narcotic use, operative time, type of mesh, and intraoperative fluid use were also recorded for each patient.Results: A total of 346 patients underwent laparoscopic inguinal hernia repair in the specified time period, 340 patients were included in this study. The incidence of POUR after laparoscopic inguinal hernia repair at our institution was 8.2 % (n = 28) with the most common presentation of POUR being failure to void (n = 23). Postoperative narcotic use of 6.5 mg or greater of morphine or morphine equivalent was associated with higher risk of POUR via ROC analysis (OR 2.5, 95 % CI 1.2-5.6, p = 0.025). In univariate analysis, age greater than 50 years was also a risk factor for developing POUR (OR 2.8, 95 % CI 1.2-6.4, p = 0.02). Factors not found to be significant included intraoperative IV fluids, history of BPH, unilateral versus bilateral repair, and preoperative void time in relation to surgery start.Conclusions: Minimizing postoperative narcotic medications may reduce the risk of developing POUR after laparoscopic inguinal hernia repairs. If possible surgeons should consider non-steroidal anti-inflammatory drugs, acetaminophen, or regional anesthetic blocks to minimize postoperative narcotic requirements. [ABSTRACT FROM AUTHOR]