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Oyola et al. Mini-invasive Surg 2023;7:26 https://dx.doi.org/10.20517/2574-1225.2023.26 Page 5 of 7

DISCUSSION
Inguinal hernia repair is a common procedure that, in the elective setting, has ample potential for a
[8]
standardized approach. The development of the European Hernia Society guidelines in 2009 and the
recent 2018 update offers an evidence-based platform for this goal. Previous literature indicated that most
[6]
[9]
surgeons participating in the ACHQC adhere to recent guidelines for ventral and epigastric hernia repair .
To date, this same analysis regarding inguinal hernia repair has not been examined. In this retrospective
study, we found that despite a variety of factors that determine clinical decision-making in inguinal hernia
repair, most surgeons that participate in the ACHQC also adhere to most guidelines for inguinal hernia
repair.

Of the guidelines not met by the threshold set in this study, more than 50% of surgeons still followed the
published recommendations in all the categories except using local anesthesia for open repair of reducible
inguinal hernias and avoiding prophylactic antibiotics in laparoscopic hernia repair. The former
recommendation is based on the knowledge and confidence of surgeons in performing field blocks, which
could understandably account for the underutilization of this technique during open inguinal hernia repair
and failure to meet this guideline.

The recommendation to avoid antibiotics in elective laparoscopic inguinal hernia repair is specific to an
“average risk” population, grossly defined within the guidelines as any individual with a “primary hernia
and minimal medical or operative risk factors” . The obvious challenge for any surgeon is appropriately
[10]
categorizing the patient as an “average risk” without more specific criteria. Moreover, the current SCIP
guidelines recommend prophylactic antibiotic administration one hour prior to surgical incision.
Disseminated by the Centers for Medicare and Medicaid, these guidelines are widely known by surgeons
nationally and followed as the current standard of care. The Surgical Care Improvement Project (SCIP)
guidelines do not, however, specifically delineate the recommendations for prophylactic antibiotics within
laparoscopic surgery, and it was not until the meta-analysis conducted in the publication of the 2018
Inguinal Hernia Guidelines that the difference in surgical site infection was found to be negligible
specifically in low to average risk patients undergoing elective laparoscopic inguinal hernia repair.

This study highlights the utility of the ACHQC in examining quality metrics in hernia surgery. Areas for
future research include identifying and combating healthcare disparities with regard to hernia care. It has
been well documented that there are healthcare disparities among minority and rural patients with regard to
cancer care and surgeon compliance with guideline-based therapy [11,12] .

The retrospective nature of this study presents several inherent limitations, including reporting bias. To gain
access to ACHQC data, surgeons must contribute patient outcomes to the database . Due to the effort and
[7]
resources required to input this data, it would seem likely that most surgeons in the ACHQC practice in an
academic or teaching setting and are more likely to follow the latest guidelines due to a heightened
awareness of existing practice patterns. With the volume of inguinal hernia repairs performed annually, it is
imperative that community general surgeons also be made aware of and adhere to current guidelines.

In addition, our data examined patients as early as 2013, and practice patterns are known to change over
time. With many of the recommendations favoring a laparoscopic approach, ongoing research should be
performed as laparoscopy continues to become a standard component of resident training and physician
practice. As surgeons become more comfortable with laparoscopy and robotic surgery, it should be re-
examined whether adherence to laparoscopy-specific guidelines improves.