Trends in Inguinal Hernia Repair Approach: An Augmented Evidence Review

Minimally invasive surgery has transformed inguinal hernia management; however, its utilization compared to open approaches remains poorly quantified, particularly in the recurrent setting. This study aims to assess the utilization trends for open and minimally invasive surgery (MIS) in inguinal hernia repair (IHR) with 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 inguinal hernia repair changed over the last ten years, and has this affected how we approach the repair of recurrent inguinal hernias specifically?" The AER framework integrates three complementary evidence streams: (1) empiric, (2) social media, and (3) artificial intelligence. The empiric evidence was drawn from the Abdominal Core Health Quality Collaborative registry and included patients that underwent IHR via either open, laparoscopic, or robotic approach from 2016-2023. Social media evidence was collected through the International Hernia Collaboration, a private Facebook group with more than 15,000 professional members. Artificial intelligence evidence was obtained from the platform OpenEvidence, 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 ACHQC 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 repairs being the primary driver. Laparoscopy utilization declined. Temporal trend analysis confirmed a significant correlation between MIS repair and chronological year (initial IHR |rho| = 0.89; p=0.012; recurrent IHR |rho| = 0.96; p=0.002). The IHC poll had 474 responses with 72.4% of respondents reporting a transition towards MIS. The most common transitions were open to laparoscopic (31.0%) and laparoscopic to robotic (29.3%), with 41.4% of respondents reporting robotic adoption. OpenEvidence corroborated these findings with numerous published guidelines and studies. Areas of divergence included the degree of robotic versus laparoscopic platform preference 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 "Augmented Evidence Review (AER)." All three evidence streams converged on a major shift towards MIS, particularly robot-assisted techniques, for both initial and recurrent repairs. While postoperative outcomes did not differ significantly across approach type, approach selection should nevertheless be tailored based on 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.