Surgeon utilization of minimally invasive techniques for inguinal hernia repair: a population-based study

Surg Endosc. 2019 Feb;33(2):486-493. doi: 10.1007/s00464-018-6322-x. Epub 2018 Jul 9.


Background: MIS utilization for inguinal hernia repair is low compared to in other procedures. The impact of low adoption in surgeons is unclear, but may affect regional access to minimally invasive surgery (MIS). We explored the impact of surgeon MIS utilization in inguinal hernia repair across a statewide population.

Methods: We analyzed 6723 patients undergoing elective inguinal hernia repair from 2012 to 2016 in the Michigan Surgical Quality Collaborative. The primary outcome was surgeon MIS utilization. The geographic distribution of high MIS-utilizing surgeons was compared across Hospital Referral Regions using Pearson's Chi-squared test. Hierarchical logistic regression was used to identify patient and hospital factors associated with MIS utilization.

Results: Surgeon MIS utilization varied, with 58% of 540 surgeons performing no MIS repair. For the remaining surgeons, MIS utilization was bimodally distributed. High-utilization surgeons were unevenly distributed across region, with corresponding differences in regional MIS rate ranging from 10 to 48% (p < 0.001). MIS was used in 41% of bilateral and 38% of recurrent hernia. MIS repair was more likely with higher hospital volume and less likely for patients aged 65+ (OR 0.68, p = 0.003), black patients (OR 0.75, p = 0.045), patients with COPD (OR 0.57, p < 0.001), and patients in ASA class > 3 (OR 0.79 p < 0.001).

Conclusions: MIS utilization varies between surgeons, likely driving differences in regional MIS rates and leading to guideline-discordant care for patients with bilateral or recurrent hernia. Interventions to reduce this practice gap could include training programs in MIS repair, or regionalization of care to improve MIS access.

Keywords: Inguinal hernia repair; Laparoscopy; Minimally invasive surgery; Robotic inguinal hernia repair; Surgical disparity; Surgical technology.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Aged
  • Elective Surgical Procedures / methods
  • Female
  • Hernia, Inguinal / surgery*
  • Herniorrhaphy / methods*
  • Hospital Bed Capacity
  • Hospitals, High-Volume
  • Humans
  • Laparoscopy / methods
  • Logistic Models
  • Male
  • Michigan
  • Middle Aged
  • Minimally Invasive Surgical Procedures / statistics & numerical data*
  • Procedures and Techniques Utilization / statistics & numerical data
  • Robotic Surgical Procedures / statistics & numerical data
  • Surgeons