Laparoscopic Inguinal Hernia Repair can be Judiciously used in the Acute Setting

Prior research on laparoscopic versus inguinal hernia repair has traditionally produced mixed conclusions as to whether laparoscopic versus open technique confers any specific advantages. The recently published article by Perez et al, Nationwide Analysis of Inpatient Laparoscopic Versus Open Inguinal Hernia Repair, attempts to address this important question by performing a retrospective review of data acquired from the National Inpatient Sample of adult patients who had underwent inguinal hernia repair from 2009-2015 using a laparoscopic and open technique [1]. The study included both elective and non-elective inguinal hernia repairs, and its outcomes included post-operative complication rate, post-operative mortality rate, length of stay, and cost of hospitalization. The primary conclusion of the article is that laparoscopic repair confers a marginal but statistically significant improvement in post-operative complications, length of stay, and cost of hospitalization. This article provides further insight into the feasibility of laparoscopic inguinal hernia repair in the inpatient setting. 

The primary strengths of this article are the large sample size (~42,000 patients) and inclusion of a wide array of patients (including bilateral hernias, women, and patients with multiple comorbidities). Furthermore, the study’s authors were able to perform some differentiation in the sample of elective versus non-elective repair. In both the elective and non-elective setting, there was no statistically significant difference in the proportion of patients undergoing a laparoscopic versus open repair. Consequently, the article concludes that the laparoscopic technique should be considered when caring for the appropriate patient and with a properly skilled surgeon and may be utilized in emergent or non-elective hernia repairs. 

This conclusion is supported by smaller studies showing laparoscopic inguinal hernia repair in the acute setting appears to trend towards shorter length of stays and lower complication rates when compared to the open method [2,3]. Both of these studies have fairly small sample sizes, but they have the advantage of being single-center trials where the performing surgeons are constant, hopefully leading to less variation in technical comfort. In the work by Perez et al, there is a disproportionate number of open repairs (36,575 open versus 5,282 laparoscopic), which may be due to surgeon comfort trending towards open repair. Furthermore, the greater frequency of open repair may also reflect other unaccounted for patient factors making an open repair preferential. The article does not address operative time, whereas the two other articles note a longer operative time for the laparoscopic repair which is not ideal for an unstable patient. 

At this time, there appears to be a preference for repair of the acutely incarcerated or strangulated inguinal hernia with an open approach. However, in the appropriately chosen patient, a laparoscopic approach may be superior in regard to reduced post-operative complications, shorter lengths of stay, and lowered hospital costs. It is essential that individual patient factors and surgeon comfort be taken into account prior to making a decision on surgical technique. It is hypothesized that with increased exposure to laparoscopy during surgical training, more surgeons will become familiar with laparoscopic inguinal hernia repair and judiciously utilizes this technique for the acutely incarcerated or strangulated inguinal hernia.