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Page 2 of 7 Oyola et al. Mini-invasive Surg 2023;7:26 https://dx.doi.org/10.20517/2574-1225.2023.26

INTRODUCTION
Inguinal hernias are the most common types of hernias occurring worldwide, with an annual incidence of
[1]
223 million, of which approximately 20 million get repaired . Options to date include laparoscopic vs. open
approaches. Traditional primary tissue repairs such as the Bassini, McVay, and Shouldice techniques have
[2]
been employed . The Bassini repair entails suturing the conjoined tendon to the inguinal ligament from the
pubic tubercle medially to the area of the internal ring laterally, whereas the McVay repair is the only
primary tissue repair technique that may be used for inguinal or femoral hernias and involves suturing the
conjoined tendon to Cooper’s ligament with the last stitch capturing the inguinal ligament and includes a
relaxing incision in the rectus sheath due to the high tension of the repair. The Shouldice repair is a four-
layer bi-directional closure, with the first two layers reapproximating the conjoined tendon with the
transversalis fascia and the transversalis fascia with the inguinal ligament in opposing runs of continuous
suture starting from medial to lateral, and the second two layers reapproximating the internal oblique with
the inguinal ligament, followed by reapproximation of the external aponeurosis and reconstruction of the
[3]
external inguinal ring again in opposing runs of continuous suture from lateral to medial . The recurrence
rate for the Bassini and McVay techniques ranges from 10%-30%, while the Shouldice repair has a much
lower rate of 4.8% . These techniques were improved by the Lichtenstein technique, which performed an
[4]
open repair in a tension-free fashion by incorporating mesh and significantly reduced recurrence rates.
However, the criticism associated with the use of mesh in inguinal hernia repair is chronic pain, which
[5]
occurs in 11% of cases . Mesh is also inherent to laparoscopic hernia repair, but the incidence of chronic
groin pain is less with this approach. The re-operative recurrence rates between tension-free Lichtenstein
repair (2.4%) and laparoscopic repair (3.3%) are comparable .
[4]
The HerniaSurge Group, an international collaboration of surgeons, established guidelines for inguinal
hernia repair based on a systematic literature search with the goal of reducing recurrence and chronic
pain . Nationally, the Abdominal Core Health Quality Collaborative (ACHQC) was established as a non-
[6]
profit comprised of 440 institutional and individual surgeon members who voluntarily report patient data
that are then aggregated, de-identified, and shared within a national database, with a focus on quality
improvement . Members are those who are engaged in abdominal core and hernia surgical repair, while the
[7]
patients they plan to operate on are prospectively registered, and data collection continues throughout the
peri-operative and post-operative timeline. The pertinent operations for this database include inguinal and
ventral hernias. In addition to patient demographics, surgical data, and any complications, the collected
information also includes but is not limited to long-term follow and patient-reported data. Data entry is not
compulsory but rather encouraged, and active member status is predicated on continued data entry.
Therefore, we accessed this database to evaluate the degree of ACHQC surgeon compliance with the hernia
guidelines and identify potential areas for improvement. Recognizing and addressing the areas of
improvement will be central in working toward a standardized surgical approach to inguinal hernia repair
and thus facilitating future research on minimizing hernia recurrences, chronic pain, and associated costs.

METHODS
Data obtained from the ACHQC between the years 2013 - 2021 were retrospectively reviewed. The
population consisted of 18,641 male and female eligible subjects with inguinal and femoral hernias
undergoing elective and emergent hernia repair with 30-day follow-up. Data points were displayed as
numerical values and percentages and were selected and correlated with key questions addressed in the
International Guidelines for Groin Hernia Management published by the HerniaSurge Group in 2018. While
28 questions were posed within the publication, 23 focused on management, of which 19 were able to be
assessed for compliance based on ACHQC available data, including use of prophylactic antibiotics, same-
day surgery, open vs. laparoscopic repair, total extraperitoneal (TEP) vs. transabdominal pre-peritoneal