title: Open versus laparoscopic unilateral inguinal hernia repairs: defining the ideal BMI to reduce complications.
abstract: Open inguinal hernia repair is felt to be a less expensive operation than a laparoscopic one. Performing 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.
  
  
  
  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 to 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 whether 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.
  
  
  
  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 (p = 0.03). Postoperative 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 (p = 0.026). The return to the operating room across all BMI categories was statistically significant for the open repair group (n = 269) compared to the laparoscopic repair group (n = 70) with p = 0.003. There was no difference in the return to operating room between the BMI categories. The odds ratio (OR) was found to be statistically significant when comparing the obese category to both normal and overweight populations for the open procedure.
  
  
  
  Open hernia repairs have more complications than do laparoscopic ones; however, there does not appear to be a difference in treating obese patients with hernias using a laparoscopic approach versus an open one. One may consider using a laparoscopic approach in overweight patients (BMI 25-29.9) as there appears to be fewer deep SSI.
authors.affiliation: Department of Surgery/General Surgery, Tripler Army Medical Center, 1 Jarrett White Road, Tripler AMC, HI, 96859, USA. ashley.d.willoughby.mil@mail.mil.
authors.forename: Ashley D
authors.initials: AD
authors.lastname: Willoughby
authors.affiliation: Department of Surgery/General Surgery, Tripler Army Medical Center, 1 Jarrett White Road, Tripler AMC, HI, 96859, USA.
authors.forename: Robert B
authors.initials: RB
authors.lastname: Lim
authors.affiliation: Department of Clinical Investigation/Statistics, Tripler Army Medical Center, 1 Jarrett White Road, Tripler AMC, HI, 96859, USA.
authors.forename: Michael B
authors.initials: MB
authors.lastname: Lustik
mesh_terms: D000293:Adolescent; D000328:Adult; D015992:Body Mass Index; D005260:Female; D006552:Hernia, Inguinal / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009765:Obesity / Q000150:complications*; D011183:Postoperative Complications / Q000517:prevention & control; D012189:Retrospective Studies; D013530:Surgical Wound Infection / Q000209:etiology; D055815:Young Adult
keywords: Body mass index (BMI); Inguinal hernia; Laparoscopic inguinal hernia repair; National Surgical Quality Improvement Program (NSQIP); Open inguinal hernia repair; Surgical site infection (SSI)