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Surgeon practice variation drives disposable supply cost in inguinal hernia repair: a real-world health system
Ramsey M Dallal1,2,3, Sami Tannouri4,5,6, Sultan S Abdelhamid4,5,6
1Department of Surgery, Jefferson Health, 5501 Old York Rd, Suite 510, Philadelphia, PA, 19141, USA. ramsey.dallal@jefferson.edu.
Background:
As robotic platform adoption expands, differences in procedural cost for inguinal hernia repair are frequently attributed to surgical technology. However, the relative contribution of surgical approach versus surgeon-specific practice patterns to cost variation remains incompletely defined.
Methods:
We conducted a retrospective cohort study of adults undergoing inguinal hernia repair within a multi-hospital healthcare system from 2017 to 2025. Mixed-effects regression models evaluated direct disposable supply cost and operating room time, adjusting for patient characteristics, case complexity, surgeon experience, calendar year, and clustering at both surgeon and hospital levels.
Results:
The cohort included 14,313 repairs performed by 137 surgeons across 29 hospitals (open 43.8%, robotic 46.7%, laparoscopic 9.5%). Robotic utilization increased from 8.7 to 66.0% by 2024, largely replacing laparoscopy; 62% of surgeons performed only one approach. After adjustment, mean direct disposable supply cost was $567 for open, $1,527 for robotic, and $1,741 for laparoscopic repair (robot vs. laparoscopic: - $213, 95% CI - $274 to - $153, p < 0.001). Adjusted mean operating room time was 119 min for open, 142 for robotic, and 120 for laparoscopic repair (robotic vs. open: + 23.1 min, p < 0.001). Robotic repair was associated with lower odds of overnight admission (OR 0.73, 95% CI 0.55-0.96, p = 0.022). Within each platform, surgeon-level cost deviations ranged up to $777 (open) and $196 (robotic) above the platform mean, often exceeding between-platform differences. Standardized per 1,000 cases, combined potentially avoidable cost (supplies plus operating room time at $75/min) was $638,000 for robotic repairs.
Conclusions:
Surgeon-level practice variation is a major contributor to procedural cost variation in inguinal hernia repair and may provide an important target for value-improvement efforts. Because most surgeons in this cohort performed only one approach, such efforts are likely to have the greatest practical impact when directed at preference-card standardization and peer benchmarking within the platforms where surgeons already practice.