Contemporary Matched-Cohort Comparison of Surgical Approach to Inguinal Hernia Repair: Are Minimally Invasive Approaches Associated with Higher Rates of Recurrence?

Abstract

BACKGROUND: Current studies evaluating outcomes for open, laparoscopic, and robotic inguinal hernia repair, in general, include small numbers of robotic cases and are not powered to allow a direct comparison of the 3 approaches to repair. STUDY DESIGN: We queried the Veterans Affairs Surgical Quality Improvement Program Database to identify patients undergoing initial elective inguinal hernia repair between 2013 and 2017. Propensity score matching and multivariable logistic regression were used to make risk-adjusted assessments of association between surgical approach and outcome. RESULTS: A total of 39,358 patients underwent initial elective inguinal hernia repair; 32,881 (84%) underwent an open approach, 6,135 (16%) underwent a laparoscopic approach, and 342 (1%) underwent a robotic-assisted approach. Two hundred sixty-six (1%) patients had a recurrent repair performed during follow-up. On univariate comparison, patients undergoing a robotic-assisted approach had longer operative times for unilateral repair than those undergoing either an open or laparoscopic (73 ± 31 vs 74 ± 29 vs 107 ± 41 minutes; p < 0.001) approach. On multivariable logistic regression, patients with a higher BMI had an increased adjusted risk of a postoperative complication, but there was no association between surgical approach and complication rate. Three hundred forty-two patients undergoing robotic repair were 1:3:3 propensity score matched to 1,026 patients undergoing laparoscopic and 1,026 undergoing open repair. On comparison of matched cohorts, there were no statistical differences between approaches regarding recurrence (0.6% vs 0.8% vs 0.6%, p > 0.05) or complication rate (0.6% vs 1.2% vs 1.2%, p > 0.05). CONCLUSIONS: In patients undergoing initial elective inguinal hernia repair, rates of hernia recurrence are low independent of surgical approach. Both robotic and laparoscopic approaches demonstrate rates of early postoperative morbidity and recurrence similar to those for the open approach. The robotic approach is associated with longer operative time than either laparoscopic or open repair.