Thirty-day outcomes of spinal versus general anesthesia for high-risk patients undergoing open inguinal hernia repair

General anesthesia (GA) is the predominant choice for open inguinal hernia repair but may be associated with a higher risk of postoperative complications, particularly in patients with multiple comorbidities. Spinal anesthesia (SA) is therefore considered as an alternative for high-risk patients. However, its potential benefits in reducing postoperative complications remain unclear. This study aimed to compare 30-day outcomes between SA and GA in high-risk patients undergoing initial open inguinal hernia repair.

Patients who underwent initial open inguinal hernia repair were identified in the ACS-NSQIP database from 2005 to 2024. High-risk status was defined as a Modified Frailty Index (mFI) ≥3 and American Society of Anesthesiology (ASA) score ≥3. Exclusion criteria included emergency surgery, ventilator dependency, procedures not performed by general surgeons, cases with concomitant bowel resection, and cases where the primary anesthesia type was neither SA nor GA. A 1:1 propensity-score matching was performed to balance demographics and comorbidities between patients who received SA versus GA, and thirty-day outcomes were then compared. Additionally, a multivariable logistic regression analysis that included all high-risk patients was conducted to evaluate thirty-day outcomes while adjusting for all preoperative variables.

A total of 118 high-risk patients underwent open inguinal hernia repair under SA, of whom 106 were successfully propensity-score matched to 106 of the 1,365 patients who received GA. After matching, 30-day mortality rates were comparable between SA and GA (0.94% vs. 0%, p = 1.00), as were rates of organ system complications, including cardiac (0.94% vs. 1.89%, p = 1.00), pulmonary (2.83% vs. 0.94%, p = 0.62), and renal complications (1.89% vs. 0%, p = 0.50). Operative time (63.44 ± 30.61 vs. 65.05 ± 30.74 min, p = 0.70), as well as length of stay for outpatient cases (0.28 ± 0.63 vs. 0.32 ± 0.95 days, p = 0.79) were comparable between SA and GA. All other 30-day outcomes were likewise comparable. Multivariable analysis confirmed that the 30-day outcomes of SA and GA were comparable for all high-risk patients.

In high-risk patients undergoing open inguinal hernia repair, this study showed no evidence of a difference in 30-day outcomes between SA and GA; however, given the limited statistical power, these findings should not be interpreted as evidence of equivalence. The choice between SA and GA should therefore be guided by patient-specific factors, surgical complexity, and surgeon and center expertise. Further prospective studies are needed to validate these findings.