Ashley D Willoughby, DO, Robert B Lim, MD, Michael B Lustik. Tripler Army Medical Center
Objectives: Open inguinal hernia repair is felt to be a less expensive operation than a laparoscopic one. However, performing an open repair on patients with an obese body mass index (BMI) results in longer operative times, longer hospital stay, and complications that will potentially impose higher cost to the facility and patient. This study aims to define the ideal BMI at which a laparoscopic inguinal hernia repair will be advantageous over open inguinal hernia repair.
Methods: The NSQIP database was analyzed for (n= 64,501) complications, mortality, and operating time for open and laparoscopic inguinal hernia repairs during the time period from 2005-2012. Bilateral and recurrent hernias were excluded. Chi-square tests and Fisher's exact tests were used to assess associations between type of surgery and categorical variables including demographics, risk factors, and 30-day outcomes. Multivariable regression analyses were performed to determine if odds ratios differed by level of BMI. The HCUP database was used for determining difference in cost and length of stay between open and laparoscopic procedures.
Results: There were 17,919 laparoscopic repairs and 46,582 open repairs in the study period. The overall morbidity across all BMI categories is statistically greater in the open repair group when compared to the laparoscopic group (1.0% v 0.81%, p= 0.03). Post-operative complications (including wound disruption, failure to wean from the ventilator, and UTI) were greater in the open repair group across all BMI categories. Deep incisional surgical site infections (SSI) were more common in the overweight open repair group. The return to the operating room across all BMI categories was statistically significant for the open repair group compared to the laparoscopic repair group (0.58% v 0.39%, p= 0.003). There was no difference in the return to operating room between the BMI categories. The morbidity odds ratio (OR) was found to be statistically significant when comparing the obese category to normal and overweight populations for the open procedure. The HCUP data demonstrated a statistically significant difference in cost between the open and laparoscopic procedures (p<0.001) with median cost of $21,156 and $25,376 respectively. The data also demonstrated statistical significance in length of stay with median length of stay of 1.2 days for laparoscopic and 1.4 days for open repair (p= 0.001).
Conclusion: Unilateral laparoscopic inguinal hernia repairs have less morbidity than open ones regardless of BMI. There does not appear to be an increase in morbidity using the laparoscopic approach in obese patients, as there are in open repairs. In the overweight population, laparoscopic repairs have less deep SSIs than do open ones. Laparoscopic inguinal hernia repairs may be cost effective compared to open ones because of a lower complication rate.