Barriers to the Implementation of Local Anesthesia for Older Adults Undergoing Inguinal Hernia Repair

Use of local anesthesia for inguinal hernia repair in older adults is recommended by society guidelines because of reduced postoperative cognitive dysfunction and improved functional recovery after surgery compared to general anesthesia. However, in practice, few inguinal hernia repairs in older adults are actually done under local anesthesia.

Key stakeholders involved in inguinal hernia repair at Veterans' Affairs hospital systems including patients, surgeons, anesthesiologists, and hospital leaders.

We conducted semi-structured interviews and focus groups to identify barriers and facilitators to use of local anesthesia for inguinal hernia repair in older adults. Qualitative data were analyzed using Direct Content Analysis guided by the Capability, Opportunity, and Motivation (COM-B) framework.

We interviewed 40 Veterans aged ≥ 65 years who had undergone inguinal hernia repair at 3 hospitals, and we convened focus groups and interviews with 10 surgeons, 9 anesthesiologists, and 7 hospital leaders. We found patients were not consistently offered the opportunity to have shared decision-making conversations about the advantages and disadvantages of local versus general anesthesia because standard pre-operative care workflows did not allow for conversations incorporating perspectives of all stakeholders, especially anesthesiologists. Also, it was difficult to disentangle choice of anesthesia modality from choice of surgical approach. There were entrenched opinions among many surgeons about perceived advantages of minimally invasive surgery, which requires general anesthesia, without regard for the cognitive and recovery benefits of open surgery using local anesthesia. Finally, providers and hospital leaders highlighted how improved protocols for local anesthesia administration, increased buy-in from hospital leadership, and more high-quality evidence in support of local anesthesia were all necessary to increase its use.

The findings serve as a roadmap for a multi-component plan to increase use of local anesthesia for inguinal hernia repair in older adults, with clear advantages for post-operative cognitive and functional recovery.