Subxiphoid hernias: does surgical approach matter? An analysis of the ACHQC database

Subxiphoid incisional hernias (SIH) are challenging to repair with recurrence rates ranging from 10 to 43%. There is a paucity of data regarding the optimal repair method and a small amount of early data on robotic SIH repair. The purpose of this study was to compare how surgical approach-open, laparoscopic, and robotic-affects clinical outcomes.

A retrospective analysis of the Abdominal Core Health Quality Collaborative was performed from 2014 to 2024. Patients undergoing incisional hernia repair involving only midline 1 (M1) or midline 1 and 2 (M1-2) defects were included. Demographic data, operative details, and clinical outcomes were collected and compared by surgical approach. Multivariable logistic regression was completed to evaluate risk variables for recurrence. The primary outcome was 1-year recurrence.

Eight hundred fifty-eight patients met study criteria including 499 open, 104 laparoscopic, and 255 robotic repairs. The groups were similar in age, race, BMI, ASA Class, and hernia width. Mesh was placed in 95.6% of cases with location varying by surgical approach (p < 0.001). Fascial closure rates were 94.2, 55.8, and 92.5% for open, laparoscopic, and robotic repairs respectively (p < 0.001). The 1-year recurrence rate was 9.0% in open repairs, 26.3% in laparoscopic repairs, and 4.3% in robotic repairs (p = 0.01). On multivariable analysis, only CDC Wound Class 4 conveyed an increased risk of recurrence (p = 0.004).

In this study, laparoscopic SIH repair had the highest 1-year recurrence rate followed by open and robotic repairs. The contributing factors for this remain elusive, and more studies need to be completed in this regard.