Closing the gap between the laparoscopic and open approaches to abdominal wall hernia repair: an outcomes-based analysis of the ACS-NSQIP database

Samantha L Savitch, Paresh C Shah, MD, FACS. NYU Langone Medical Center

Objective: To build upon previous studies since the creation of procedure codes for laparoscopic abdominal wall hernia repairs, and compare the short term outcomes and utilization of laparoscopic and open abdominal wall hernia repair.

Methods: Using the ACS-NSQIP database between 2009 and 2012, patients were identified as having an ICD-9 diagnosis of an umbilical, ventral, or incisional hernia as well as a Current Procedural Terminology (CPT) code for a laparoscopic or open abdominal wall hernia repair. Qualifying patients were placed into two distinct groups within an aggregate cohort depending on surgical approach. Baseline risk factors were determined for the two surgical approaches. A Coarsened Exact Matching (CEM) procedure was utilized to create a matched cohort in order to remove patient selection bias. 30-day outcomes analysis was done for the aggregate and matched cohorts. Subcategory analysis was performed for inpatient/outpatient status, strangulated/incarcerated hernias, initial/recurrent repairs, and hernia type (umbilical, ventral, incisional). χ2 analysis was performed to determine the statistical significance of each comparison.

Results: 112,074 patients underwent an abdominal wall hernia repair during the study period, 86566 (77.24%) by an open approach and 25508 (22.76%) laparoscopically. Patients undergoing laparoscopic repair were more likely to have comorbidities, but less likely to experience any post-operative morbidity (11.74% vs. 7.25%, P<0.0001), serious morbidity (4.55% vs. 3.02%, P<0.0001), or mortality (4.55% vs. 3.02%, P=0.0030). When assessed by hernia type (incisional, ventral, or umbilical), rates of overall morbidity, mortality, and serious morbidity were significantly lower in the laparoscopic group as compared to the open. Creation of the matched cohort produced 17394 patients in both the laparoscopic and open groups, and resulted in a loss of advantage for the laparoscopic approach in terms of mortality (P=0.0030 vs. P=0.6169), post-operative pneumonia (P=0.0430 vs. P=0.8465), morbidity in the case of umbilical hernia repairs (P=0.0082 vs. P=0.3172), and serious morbidity for outpatient cases (P=0.0008 vs. P=0.9706). Patients undergoing a laparoscopic repair were still less likely to experience any post-operative morbidity (9.57% vs. 4.92%, P<0.0001) or serious morbidity (3.37% vs. 1.70%, P<0.0001). The laparoscopic approach gained an advantage over the open approach for rates of unplanned intubation (P=0.0765 vs. P=0.0187), as well as overall morbidity associated with outpatient procedures (P=0.0647 vs. P=0.0141). Hospital length of stay in the matched cohort overwhelmingly supported initial primary repairs done by an open approach.

Conclusion: Laparoscopic approach is used in a minority of abdominal wall hernia repairs. However, utilization of the laparoscopic approach has increased by 40% from 16.77% to 22.76% between 2009-2012. While still a controversial subject, the laparoscopic approach continues to be safer on many fronts, but not all, and is arguably not better for umbilical or primary hernia repairs on the basis of overall morbidity and length of stay.

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