Hernia Repair Approaches Vary: A Case for Including Private Surgeons in Residency Training

Hernia repair is the most common general surgical operation, and new surgical techniques continue to advance the field. Surgical residency would benefit from exposing residents to various surgical techniques and practice patterns in hernia repair during their training..

To compare inguinal (IHR) and ventral (VHR) hernia repair practice patterns among surgeons with academic (AA), private-with-academic (PWA), and private (PA) affiliations, to plan residency rotations that maximize breadth of training in hernia care.

A retrospective cohort analysis of 108,137 hernia repairs was performed, as captured by the Abdominal Core Health Quality Collaborative (ACHQC) from 2013 to 2023 (ACHQC). Outcomes included operative approach (open, laparoscopic, robotic), mesh placement (VHR), defect size (VHR), ASA class, and urgency (elective vs non-elective). Group comparisons used χ² tests with Cramér's V for categorical variables and 1-way ANOVA with η² for continuous variables; α = 0.01. Time trends display the annual share of robotic approach by setting; to avoid unstable estimates, year-setting points with total n < 50 were excluded from the figures.

Significant differences were observed among AA, PWA, and PA surgeons. PA were most likely to use a robotic approach for both IHR and VHR (39.9% and 37.3%, respectively; p < 0.01) and to perform tissue-based (non-mesh) IHR (7.5%; p < 0.01). IHR urgency differed by setting (elective: AA 64.9%, PWA 82.6%, PA 83.8%; p < 0.001; Cramér's V = 0.210, small), and IHR defects were larger at AA than at PWA/PA (length 4.41 ± 6.10 vs 2.87 ± 4.45-3.75 ± 5.31 cm; width 3.16 ± 3.91 vs 2.21 ± 2.67-2.75 ± 3.18 cm; η² ≈ 0.011, small). AA managed sicker patients and performed more complex VHR with larger defects (mean width 7.05 cm; p < 0.01). For VHR, AA most frequently placed retrorectus mesh (43.2%), whereas private practice surgeons more commonly used intraperitoneal mesh (p < 0.01). Robotic utilization increased across all settings: for IHR, absolute gains from 2017 to 2023 were 31.2% (AA), 27.6% (PWA), and 18.6% (PA); for VHR, the 2023 robotic share was 32.5% (AA), 58.5% (PWA), and 49.2% (PA). Overall, PA adopted robotic technique the earliest, and PWA had the highest VHR share in the most recent year.

Practice setting is strongly associated with hernia care patterns. This is an important fact that can help residency programs as they prioritize training goals in hernia care for the residents. By including private practice surgeons in residency training, residents can be exposed to a wider breadth of hernia repair techniques, including open tissue-based IHR and various robotic repair techniques for both IHR and VHR. As hernia repairs are the most common operation in surgical practice, including private practice surgeons, can augment resident training and experience.