Laparoscopic versus Open Inguinal Hernia Repair in the Obese: An American College of Surgeons NSQIP Clinical Outcomes Analysis

Dvir Froylich, MD, Ivy Haskins, MD, Ali Aminian, MD, Zhamak Khorgami, MD, Mena Boules, MD, Stacy Brethauer, MD, Phillip Schauer, MD, Michael Rosen, MD. Cleveland Clinic

Introduction: The laparoscopic approach to inguinal hernia repair (IHR) has proven beneficial in reducing postoperative pain and facilitating earlier return to normal activity for all patients. Except for indications such as recurrent or bilateral inguinal hernias, there remains a paucity of data that specifically identities patient populations which would benefit most from the laparoscopic approach to IHR. Nevertheless, previous experience has shown that obese patients have increased morbidity following open surgical procedures. The aim of this study, therefore, is to investigate the effect of a laparoscopic versus open approach to IHR on early postoperative morbidity in the obese population using the National Surgical Quality Improvement Database (NSQIP).

Methods: All inguinal hernia repairs were identified within the NSQIP database from 2005-2013. Obesity was defined as a body mass index (BMI) ≥ 30kg/m2. Association of obesity with postoperative outcomes in both the open and laparoscopic IHR groups were investigated using the Pearson’s chi-square test, Fisher’s exact test, student t-test, and multivariate logistic regression.

Results: A total of 7,326 patients with a BMI ≥30kg/m2 underwent IHR from the years 2005-2013; 5,448 patients underwent laparoscopic IHR while 1,878 patients underwent open IHR. A significantly higher rate of superficial surgical site infection (p=0.01), deep surgical site infection (p=0.01), wound dehiscence (p<0.01), and return to the operating room (p=0.03) occurred in the open IHR group. There was no statistically significant difference in occurrences of sepsis (p=0.38), septic shock (p=0.06), myocardial infarction (p=1.0), cardiac arrest (p=0.25), deep venous thrombosis (p=0.70), pneumonia (p=0.22) and pulmonary emboli (p=0.33) between the laparoscopic and open groups. As a preoperative risk factor, increased BMI was associated with an increased risk of postoperative morbidity for all patients (p<0.01, 95%CI: 0.01 (0.0004-0.01)).

Conclusions: Increased BMI significantly increases the risk for postoperative morbidity in open IHR. We propose that the ideal approach to IHR for the obese population is laparoscopically. Further studies are needed to investigate the long-term effects of the open and laparoscopic approaches to IHR in the obese population.