Trends in inguinal hernia repair approach: an augmented evidence review

Minimally invasive surgery (MIS) has transformed inguinal hernia management; however, its utilization compared with open approaches remains poorly quantified, particularly in the recurrent setting. This study aims to assess trends in the utilization of open and MIS in inguinal hernia repair (IHR) using an innovative review methodology.

This study employs a novel framework, the "Augmented Evidence Review (AER)," to address the following unified research question: "How has the surgical approach for IHR changed over the last 10 years, and has this affected how we approach the repair of recurrent inguinal hernias specifically?" The AER framework integrates 3 complementary evidence streams: (i) empiric, (ii) social media, and (iii) artificial intelligence. The empiric evidence was drawn from the Abdominal Core Health Quality Collaborative registry and included patients who underwent IHR via open, laparoscopic, or robotic approaches from 2016 to 2023. Social media evidence was collected through the International Hernia Collaboration, a private Facebook (Meta Inc., Menlo Park, CA) group with more than 15,000 professional members. Artificial intelligence evidence was obtained from the platform OpenEvidence (OpenEvidence, Inc., Miami, FL), which was used to synthesize peer-reviewed literature. Each evidence stream was analyzed independently before being evaluated within the AER framework. Findings were then synthesized to identify areas of convergence, divergence, and potential directions for future study.

The Abdominal Core Health Quality Collaborative analysis included 2766 patients undergoing initial IHR (1777 open vs 989 MIS) and 294 patients undergoing recurrent IHR (142 open vs 152 MIS). MIS utilization increased by 20.2% and 18.0% in the initial and recurrent settings, respectively, with robot-assisted repair being the primary driver. Laparoscopic utilization declined. Temporal trend analysis confirmed a significant correlation between MIS repair and chronological year (initial IHR |rho| = 0.89; P =.012; recurrent IHR |rho| = 0.96; P =.002). The International Hernia Collaboration poll had 474 responses, with 72.4% of respondents reporting a transition toward MIS. The most common transitions were from open to laparoscopic (31.0%) and from laparoscopic to robotic (29.3%), with 41.4% of respondents reporting adoption of robotic repair. OpenEvidence corroborated these findings with numerous published guidelines and studies. Areas of divergence included the degree of preference for the robotic vs laparoscopic platforms and adherence to the "Alternate-Plane Principle" in the recurrent setting, both of which represent priorities for future study.

This is the first evaluation of recent IHR trends using a novel methodology: the AER. All 3 evidence streams converged on a major shift toward MIS, particularly robot-assisted techniques, for both initial and recurrent repairs. Although postoperative outcomes did not differ significantly across approach types, approach selection should nevertheless be tailored to patient factors, provider experience, and resource availability. This study demonstrates that the AER framework can capture both measured outcomes and real-world practice patterns and may serve as a model for future research.