Abstract
Background
Surgical decision-making for preference-sensitive operations among older adults is understudied. Ventral hernia repair (VHR) is one operation where granular data are limited to guide preoperative decision-making. We aimed to determine risk for VHR in older adults given clinically nuanced data including surgical and hernia characteristics.
Methods
We performed a retrospective analysis of the Michigan Surgical Quality Collaborative Core Optimization Hernia Registry from January 2020 to March 2023. The primary outcome was postoperative complication across age groups: 18–64, 65–74, and ≥ 75 years, with secondary outcome of surgical approach. Mixed-effects logistic regression evaluated association between minimally invasive surgery (MIS) and 30-day complications, controlling for patient and hernia characteristics.
Results
Among 8,659 patients, only 7% were 75 or older. MIS rates varied across hospitals [Median = 31.4%, IQR: (14.8–51.6%)]. The overall complication rate was 2.2%. Complication risk for undergoing open versus MIS approach did not vary between age groups; however, patients over age 75 undergoing laparoscopic repair had increased risk (aOR = 4.58, 95% CI 1.13–18.67). Other factors associated with risk included female sex (aOR = 2.10, 95% CI 1.51–2.93), higher BMI (aOR = 1.18, 95% CI 1.03–1.34), hernia width ≥ 6 cm (aOR = 3.15, 95% CI 1.96–5.04), previous repair (aOR = 1.44, 95% CI 1.02–2.05), and component separation (aOR = 1.98, 95% CI 1.28–3.05). Patients most likely to undergo MIS were female (aOR = 1.21, 95% CI 1.09–1.34), black (aOR = 1.30, 95% CI 1.12–1.52), with larger hernias: 2–5.9 cm (aOR = 1.76, 95% CI 1.57–1.97), or intraoperative mesh placement (aOR = 14.4, 95% CI 11.68–17.79). There was no difference in likelihood to receive MIS across ages when accounting for hospital (SD of baseline likelihood = 1.53, 95% CI 1.14–2.05) and surgeon (SD of baseline likelihood = 2.77, 95% CI 2.46–3.11) variation.
Conclusions
Our findings demonstrate that hernia, intraoperative, and patient characteristics other than age increase probability for complication following VHR. These findings can empower surgeons and older patients considering preoperative risk for VHR.
Keywords: Ventral hernia repair, Surgical decision-making, Preference-sensitive surgical conditions, Hernia
Surgical decision-making for older adults undergoing preference-sensitive elective operations is not well understood, despite an increasingly aging patient population worldwide [1]. This is especially relevant for ventral hernia repair (VHR), where nearly 20% of the more than 600,000 operations are performed on persons older than 70 [2, 3]. Furthermore, older adults may be at greater risk of postoperative complications due to increased risk for factors associated with older age including frailty, polypharmacy, functional dependence, and malnutrition [3]. Yet, there is a paucity of evidence which uses patient- and hernia-specific characteristics to determine whether older adults are actually at increased risk of developing postoperative complications compared to younger patients [4]. This evidence is necessary to guide shared decision-making and develop recommendations where risk or benefit is influenced by factors other than age such as patient or hernia characteristics.
Most studies among older adults undergoing elective hernia repair have been limited. The majority utilize administrative claims datasets, which lack the ability to make clinically nuanced conclusions or have been conducted as single-institution studies, limiting patient number and diversity [5, 6]. Even among these studies, findings are inconclusive. Some show VHR to be safe in older adults and that laparoscopic approaches improve quality of life [7, 8]; others report poor prognosis and higher mortality with increasing age [2]. However, these studies do not account for patient, hernia, and intraoperative-specific characteristics, including hernia size, mesh use, use of component separation, and open versus minimally invasive approach. In the absence of population level data in which provider decision-making for older adults can be assessed, individual providers and their patients have limited evidence to guide shared decision-making, leaving discretion for surgical eligibility primarily to the surgeon [9, 10].
In this context, we leveraged a state-wide population-level hernia registry with clinically nuanced data, to assess risk for undergoing VHR in older adults, with specific considerations for surgical, patient, and hernia-level factors. Such findings assess risk in a more nuanced way to better inform shared decision-making among surgeons and older candidates for VHR. The purpose of this study was to determine what factors surgeons may consider when evaluating perceived risk for postoperative complication rates in older adults including how age, hernia size, and comorbidities compared with the general population.
Methods
Data source and patient population
This study utilized data from the Michigan Surgical Quality Collaborative Core Optimization Hernia Registry (MSQC-COHR). The registry is a representative, random sample of adult patients from more than 70 hospitals across the state of Michigan, encompassing surgeries performed between Jan 1, 2020 and March 31, 2023. These data include hernia surgeries with patient characteristics, perioperative clinical details, interoperative care processes, hernia characteristics, and patient-reported outcomes including 30 and 90-day outcomes [11–13]. For this study, patients were adults (aged ≥ 18) undergoing ventral hernia repair from January 2020 to March 2023. Our analytic sample included patients with a mix of different payers (Medicare, Medicaid, Private, Uninsured), races, and geographic locations throughout the state of Michigan. Individual surgeon and hospital sites were differentiated by unique identifiers assigned through the MSQC data validation process. Operations included open, laparoscopic, and robotic ventral and incisional hernia repairs.
Covariates
Covariates of interest included patient and hernia characteristics as well as surgeon and hospital site identifiers. Patient characteristics available through MSQC-COHR and included in this analysis were age, race, body mass index (BMI), smoking status, and comorbidities including a history of diabetes, hypertension, chronic obstructive pulmonary disease (COPD), use of chronic steroids, deep vein thrombosis (DVT), sleep apnea, and cancer. We stratified patients into three categories based on their age: 18–64, 65–74, and ≥ 75. These age groups were considered appropriate based on analytic approaches used in previously published hernia studies among older adults and considerations of US-based insurance groupings, with Medicare eligibility beginning at age 65 [14, 15]. The registry does not capture patients under age 18, and those older than 92 were censored to be 92 consistent with registry practices to avoid accidental deductive disclosure. Hernia-specific characteristics included hernia size, location, and if the hernia was recurrent. Surgeons and hospital sites undertaking hernia repair were assigned a specific identifier which was used to determine differences in surgical approach across individual and facility levels. Our analytic sample excluded patients who underwent urgent or emergent hernia repair (n = 1672), as our focus was on factors affecting preoperative decision-making and risk assessment. Similarly, operations that began with a minimally invasive laparoscopic or robotic approach and converted to open were excluded from analysis, given the focus of this study on planned surgical approach decision-making (n = 3067). Patients who were missing key hernia-specific or surgical approach characteristics such as hernia location or whether mesh was used intraoperatively were also excluded (n = 5421), as these clinically nuanced data were a major factor motivating our study question and therefore considered necessary for analysis.
Outcomes
The primary outcome of this study was the probability of any 30-day postoperative complication stratified by age. Postoperative complications were defined as reoperation, readmission, surgical site infection, emergency department visit, and mortality. Secondary outcomes included the rate of varied surgical approach across age groups, including technique which was defined as open vs. minimally invasive (laparoscopic or robotic), whether mesh was used, and use of component separation.
Statistical analysis
We conducted complete case analyses of patients aged 18 and above who underwent elective hernia repairs. Descriptive statistics were used to describe cohort characteristics including patient and hernia factors, surgical approach frequencies, and complication rates. We performed three different analyses. The first was linear regression which was used to determine the association of comorbidities on age as a proxy for general health of the sample according to age groups. The second was a multivariable logistic regression to assess the risk of postoperative complications with factors of surgical approach, age group, sex, race, ethnicity, smoking status, BMI, hernia location, hernia size, previous hernia repair, mesh use, use of component separation, and comorbidities of hypertension, diabetes, sleep apnea, chronic steroid use, and COPD as categorical variables. In this model, surgical approach was interacted with age to ascertain differences in both axes. Third, a logistic mixed-effects model was used to determine the likelihood of undergoing a minimally invasive surgical approach for hernia repair including the aforementioned categorical variables, while accounting for surgeon and hospital-level clustering. A predictive margins plot was created from the second regression to visualize predicted probability of complication between age groups according to specific hernia size. An alpha (α) value of 0.05 was used in all statistical tests.
All analyses were performed in StataSE version18.0 (StataCorp, Inc., College Station, TX). The requirement for written informed consent was waived due to a lack of identifiable information. This study was exempt from regulation by The University of Michigan Institutional Review Board (HUM00091060) and adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines [16].
Results
Patient characteristics
Our study included 8,659 patients, who were majority male (57.4%) and white (82.7%), with an average age of 54 years. Three-fourths of patients were less than 65 years old (n = 6488, 74.9%), 17.9% were 65–74 years old (n = 1548), and the remaining 7% were 75 and older (n = 623). Patients were mostly overweight (28.2%) or obese (59%), with higher BMI among female patients (mean female = 32.5, mean male = 32.1; P = 0.015). Nearly one-fifth of patients were smokers. Hypertension, obstructive sleep apnea (OSA), hypertension, and diabetes were the most common comorbidities. (Table 1). The linear regression of comorbidities with age demonstrated significant associations between older age and comorbidities, including hypertension (aOR = 9.70, P < 0.001), obstructive sleep apnea (OSA) (aOR = 3.35, P < 0.001), COPD (aOR = 5.49, P < 0.001), deep vein thrombosis (DVT) (aOR = 5.16, P < 0.001), and cancer (aOR = 8.95, P < 0.001). Diabetes was the only comorbidity that was inversely correlated with age (aOR = 0.63, P < 0.001) (Online Appendix 1).
Table 1.
Patient and hernia characteristics across age groups
| Overall N = 8659 (%) |
Aged 18–64 N = 6488 (74.9) |
Aged 65–74 N = 1548 (17.9) |
Aged ≥ 75 N = 623 (7.2) |
P-value | |
|---|---|---|---|---|---|
|
| |||||
| Mean age (SD) | 54.0 (0.15) | 48.0 (0.14) | 68.9 (0.07) | 79.5 (0.16) | |
| Sex | |||||
| Female | 3691 (42.6) | 2814 (43.4) | 581 (37.5) | 296 (47.5) | < 0.001 |
| Male | 4968 (57.4) | 3674 (56.6) | 967 (62.5) | 327 (52.5) | |
| BMI | |||||
| < 18.5 | 40 (0.5) | 28 (4.3) | 7 (0.5) | 5 (0.8) | < 0.001 |
| 18.5–24.9 | 1064 (12.3) | 796 (12.3) | 168 (10.9) | 100 (16.1) | |
| 25–29.9 | 2438 (28.2) | 1,697 (26.2) | 493 (31.8) | 248 (39.8) | |
| 30–34.9 | 2529 (29.2) | 1,833 (28.3) | 531 (34.3) | 165 (26.5) | |
| 35–39.9 | 1476 (17.1) | 1,182 (18.2) | 223 (14.4) | 71 (11.4) | |
| ≥ 40 | 1112 (12.8) | 952 (14.7) | 126 (8.1) | 34 (5.5) | |
| Race | |||||
| White | 7160 (82.7) | 5,225 (80.5) | 1,364 (88.1) | 571 (91.7) | < 0.001 |
| Black | 1018 (11.8) | 874 (13.5) | 117 (7.6) | 27 (4.3) | |
| Other | 481 (5.6) | 389 (6.0) | 67 (4.3) | 25 (4.0) | |
| Ethnicity | |||||
| Hispanic | 288 (3.3) | 249 (3.8) | 31 (2.0) | 8 (1.3) | < 0.001 |
| Not Hispanic | 7983 (92.2) | 5,935 (91.5) | 1,456 (94.1) | 592 (95.0) | |
| Unknown | 388 (4.5) | 304 (4.7) | 61 (3.9) | 23 (3.7) | |
| Smoker | 1633 (18.9) | 1,426 (22.0) | 168 (10.9) | 39 (6.3) | < 0.001 |
| Comorbidities | |||||
| Hypertension | 3960 (45.7) | 2,446 (37.7) | 1,038 (67.1) | 476 (76.4) | < 0.001 |
| OSA | 3369 (39.0) | 2,256 (34.8) | 735 (47.5) | 323 (51.8) | < 0.001 |
| Diabetes | 1310 (15.1) | 832 (12.8) | 354 (22.9) | 124 (19.9) | < 0.001 |
| COPD | 533 (6.2) | 302 (4.7) | 168 (10.9) | 63 (10.1) | < 0.001 |
| Deep vein thrombosis | 306 (3.5) | 174 (2.7) | 83 (5.4) | 49 (7.9) | < 0.001 |
| Chronic steroid use | 272 (3.1) | 177 (2.7) | 73 (4.7) | 22 (3.5) | < 0.001 |
| Cancer | 165 (1.9) | 68 (1.1) | 71 (4.6) | 26 (4.2) | < 0.001 |
| Hernia location | |||||
| Umbilical | 5793 (66.9) | 4509 (69.5) | 932 (60.2) | 352 (56.5) | < 0.001 |
| Epigastric | 1838 (21.2) | 1300 (20.0) | 393 (25.4) | 145 (23.3) | |
| Infraumbilical | 521 (6.0) | 352 (5.4) | 103 (6.7) | 66 (10.6) | |
| No midline component | 398 (4.6) | 246 (3.8) | 101 (6.5) | 51 (8.2) | |
| Suprapubic | 109 (1.3) | 81 (1.3) | 19 (1.2) | 9 (1.4) | |
| Previous hernia repair | 1212 (14.0) | 872 (13.4) | 235 (15.2) | 105 (16.9) | 0.021 |
| Hernia width (cm) | |||||
| < 2 | 3317 (38.3) | 2676 (41.3) | 480 (31.0) | 161 (25.8) | < 0.001 |
| 2–5.9 | 4352 (50.3) | 3177 (49.0) | 809 (52.3) | 366 (58.7) | |
| > 6 | 990 (11.4) | 635 (9.8) | 259 (16.7) | 96 (15.4) | |
Surgical approach
Ventral hernia repairs were performed with open (61.5%) and minimally invasive approaches (38.5%) (Table 2). Rates of minimally invasive surgery varied across hospital sites [Median = 31.4%, IQR: (14.8–51.6%)]. Using univariate statistics, the proportion of MIS vs. open surgical approach was not significant across age groups (P = 0.495). Mesh was used in more than three-fourths of cases (77.0%, n = 6665), while component separation techniques were used in 5.01% (n = 434) with differences across age groups (P < 0.001).
Table 2.
Operative characteristics across age groups
| Overall N = 8659 (%) |
Aged 18–64 N = 6488 (74.9) |
Aged 65–74 N = 1548 (17.9) |
Aged ≥ 75 N = 623 (7.2) |
P-value | |
|---|---|---|---|---|---|
|
| |||||
| Surgical approach | |||||
| Open | 5326 (61.5) | 3965 (61.1) | 966 (62.4) | 395 (63.4) | 0.495 |
| Laparoscopic | 1073 (12.4) | 821 (12.7) | 187 (12.1) | 65 (10.4) | |
| Robotic | 2260 (26.1) | 1702 (26.2) | 395 (25.5) | 163 (26.2) | |
| Mesh used | |||||
| Yes | 6665 (77.0) | 4877 (75.2) | 1,282 (82.8) | 506 (81.2) | < 0.001 |
| No | 1994 (23.0) | 1611 (24.8) | 266 (17.2) | 117 (18.8) | |
| Component separation | |||||
| Yes | 434 (5.0) | 285 (4.4) | 103 (6.7) | 46 (7.4) | < 0.001 |
| No | 8225 (95.0) | 6203 (95.6) | 1445 (93.3) | 577 (92.6) | |
Using a simple logistic regression model, adults 65–74 were less likely to undergo MIS approaches (aOR = 0.85, 95% CI 0.75–0.97). When accounting for hospital and surgeon variation through the mixed-effects logistic regression, older patients had a similar likelihood of undergoing minimally invasive approach (laparoscopic or robotic) compared with younger patients, including those 65–74 years old (aOR = 0.003, P = 0.978) and 75 and older (aOR = − 0.182, P = 0.239). Factors which significantly influenced the likelihood of receiving an MIS repair included female sex (aOR = 0.305, P < 0.001), BMI (aOR = 0.150, P < 0.001), hernia size 2–5.9 cm (aOR = 0.683, P < 0.001), hernia location (aOR = 0.150, P = 0.001), having a history of previous hernia repair (aOR = 0.327, P = 0.003), and use of mesh (aOR = 3.89, P < 0.001). Only component separation negatively predicted an MIS approach (aOR = − 2.31, P < 0.001). Random-effects parameters from the mixed-effects logistic regression demonstrated variability in surgical approach at the surgeon (SD of baseline likelihood across surgeons = 2.77, 95% CI 2.46–3.11) and hospital level (SD of baseline likelihood across hospital site = 1.53, 95% CI 1.14–2.05).
Complications
The total unadjusted complication rate for our sample was 2.2%, with surgical site infection and emergency department visit within 30 days of operation as the most common complications (Table 3). Patients who underwent MIS repair were significantly less likely to experience postoperative complications than those who underwent open repair (aOR = 0.41, 95% CI 0.27–0.0.63, P < 0.001). When analyzed by type of MIS, those undergoing robotic approach were less likely to experience complications (aOR = 0.37, 95% CI 0.22–0.62), while patients undergoing laparoscopic repair approached but did not reach significance for reduced risk of complication (aOR = 0.53, 95% CI 0.28–1.01). When age group and surgical approach as MIS vs. open were directly interacted to assess complication by each grouped pairing for age and surgical approach, there was no difference in complication rate between patients 65–74 years old (aOR = 1.20, 95% CI 0.59–2.80) or older than 75 (aOR = 1.92, 95% CI 1.51–2.93) compared with patients 18–64. However, when analyzed by type of MIS, patients 75 and older undergoing laparoscopic repair had a significantly higher likelihood of complications (aOR = 4.58, 95% CI 1.13–18.67) (Fig. 1). Additional factors which increased the likelihood of complication were female sex (aOR = 2.10, 95% CI 1.51–2.93), higher BMI (aOR = 1.18, 95% CI 1.03–1.34), hernia width ≥ 6 cm (aOR = 3.15, 95% CI 1.96–5.04) compared with hernias < 2 cm, history of previous hernia repair (aOR = 1.44, 95% CI 1.02–2.05), history of DVT (aOR = 2.18, 95% CI 1.32–3.6), COPD (aOR = 1.65, 95% CI 1.02–2.65), or hypertension (aOR = 1.44, 95% CI 1.02–2.04) or use of component separation technique (aOR = 1.98, 95% CI 1.28–3.05). Complication rate increased with hernia size, a trend that persisted across all sized hernias for each age group (Fig. 2).
Table 3.
Complication rates across age groups following elective ventral hernia repair
| Overall N = 8659 (%) |
Aged 18–64 N = 6488 (74.9) |
Aged 65–74 N = 1548 (17.9) |
Aged ≥ 75 N = 623 (7.2) |
P-value | |
|---|---|---|---|---|---|
|
| |||||
| Any complication | 188 (2.2) | 122 (1.9) | 49 (3.2) | 17 (2.7) | 0.005 |
| Emergency department visit within 30 days | 51 (0.6) | 35 (0.5) | 13 (0.8) | 3 (0.5) | 0.327 |
| Readmission | 23 (0.3) | 11 (0.2) | 8 (0.5) | 4 (0.6) | 0.034 |
| Surgical site infection | |||||
| Superficial | 60 (0.7) | 47 (0.7) | 10 (0.6) | 3 (0.5) | 0.760 |
| Deep | 29 (0.3) | 25 (0.4) | 3 (0.2) | 1 (0.2) | 0.371 |
| Organ space | 19 (0.2) | 14 (0.2) | 4 (0.3) | 1 (0.2) | 0.900 |
| Blood transfusion within the first 72 h | 25 (0.3) | 15 (0.2) | 7 (0.5) | 3 (0.5) | 0.225 |
| Sepsis | 24 (0.3) | 18 (0.3) | 3 (0.2) | 3 (0.5) | 0.514 |
| Urinary tract infection | 23 (0.3) | 6 (0.1) | 14 (0.9) | 3 (0.5) | < 0.001 |
| Pneumonia | 17 (0.2) | 6 (0.1) | 6 (0.4) | 5 (0.8) | < 0.001 |
| Deep vein thrombosis | 6 (0.1) | 3 (0.1) | 3 (0.2) | 0 (0) | 0.111 |
| Pulmonary embolism | 5 (0.1) | 1 (0) | 4 (0.3) | 0 (0) | 0.001 |
| Death | 6 (0.1) | 2 (0) | 1 (0.1) | 2 (0.3) | < 0.001 |
Fig. 1.
Forest plot demonstrating factors influencing probability of patients experiencing a postoperative complication with lines representing the range of 95% Confidence Interval
Fig. 2.
Predicted probability of patients experiencing a complication following ventral hernia repair according to age (18–64, 65–75, or ≥75) across hernias 0.1 to 10 cm in size. Solid lines represent the median likelihood of receiving MIS and branching lines represent the 95% confidence interval for each age group. Summed complications included reoperation, readmission, surgical site infection, emergency department visit, and mortality
Discussion
Our findings from a state-wide hernia registry with clinically nuanced data demonstrate that, when adjusted for clinically nuanced hernia and patient-specific factors, younger and older patients undergoing VHR face similar risks for complication. This finding persisted across all hernia sizes controlling for patient-, surgeon-, hospital site-, intraoperative-, and other hernia-specific variables. Certain variables were found to increase risk for VHR postoperative complication, including female sex, higher BMI, larger hernia size, history of previous repair, use of component separation, and comorbidities including DVT, hypertension, and COPD. Interestingly, there was no increased risk for postoperative complication when comparing smoking and nonsmoking patients. These findings have significant implications for surgical shared decision-making among older adults and their surgeons considering VHR. Particularly, we found that age alone does not impact postoperative complication risk. While frailty and certain comorbidities common with age can increase the likelihood of postoperative complications, surgeons and their patients could benefit from these findings by accounting for specific patient, hernia, and intraoperative characteristics to assess risk better than using age alone as a proxy [17, 18]. Instead, using validated methods including risk calculators and frailty scores to guide preoperative decision-making can empower surgeons and patients to make more informed decisions related to their surgical options.
We also found that adults older than 65 were less likely to undergo MIS approaches for VHR when not accounting for surgeon or hospital-level variation. However, we observed variability in the likelihood of receiving MIS at both site and surgeon levels in our mixed-effects model, suggesting that the likelihood of older patients receiving MIS depends on which surgeon and hospital they present to for their operation. MIS approaches to VHR are shown to be safe and effective for older adults and can offer numerous benefits including reduced recovery time, length of stay, postoperative pain, and risk of surgical site infection and bleeding [19, 20]. One study of adults over 65 undergoing VHR demonstrated that robotic approach led to significantly shorter hospital length of stay, similar postoperative complications, and better quality of life compared with open repair [21]. While some variation in MIS is expected given resource and training differences across sites, more work should be done to determine if older adults are more likely to present to surgeons or hospital sites with increased likelihood to receive MIS, or if there are other factors which affect decision-making which vary between surgeon and site.
Multiple patient characteristic and hernia factors such as sex, race, surgical technique, and hernia size were significant predictors of MIS approach, independent of age. Although historical and intraoperative factors such as mesh use, component separation, and previous hernia repair can dictate the use of MIS techniques, it is unexpected for patient characteristics of sex and race to influence approach. These differences could be explained by characteristics of our registry, where hospitals which are more likely to operate on black patients are also most likely to offer MIS, particularly robotics. We also observed females were at increased risk for complications. Since we found that gender differences were correlated with BMI and higher BMI among female patients, it is possible that these terms have an influence of confounding. However, increased risk of complication among female patients does reflect findings from other hernia registries and the growing importance of understanding sex as a biological variable for conceptualizing hernia repair complexity [22, 23].
Other findings in our sample were notable. Importantly, only 7% of the sample was older than 75, suggesting a potential bias for whether to operate on older patients at all. With increasing understanding of the negative quality of life that can result from denying patients a preference-sensitive operation, taking steps to appropriately select older operative candidates for VHR will be critical [24]. We found that comorbidities increased with age, indicating that surgeons are not necessarily only selecting the healthiest older adult patients to operate on. This result suggests that the difference in predicted complication between age groups is unlikely to be due to preoperative risk from comorbidities. In fact, it is surprising that postoperative complication rates were relatively equal despite increased comorbidities in older patients.
Limitations
This study had several limitations. First, our sample derived from a single-state registry with a relatively homogeneous population geographically, racially, and ethnically. The registry also does not record patient residence or zip code, so we were limited in our analyses by geographic distribution and socioeconomic status. These could limit generalizability, though the MSQC data collection process does sample from over 70 hospitals, including urban and rural, throughout the state of Michigan. Similarly, MSQC COHR is deidentified with respect to patient and hospital zip code, which limits our ability to determine if there was a correlation between resources available to patients at hospitals where surgery was being done laparoscopy versus robotically at different rates. Future work should prioritize determining associations between hospital resources, likelihood of MIS approach by type, and complication risk. Second, we did not calculate a frailty score and opted instead to analyze comorbidities to estimate general health according to age. However, surgeons often do not calculate frailty during preoperative sessions when counseling their patients. Therefore, our findings on age alone most closely reflect the reality of how many surgeons are making decisions around if and how to operate on their older adult patients. Finally, our study only examined 30-day outcomes, which limited our ability to detect longer term complications including recurrence.
Conclusion
Our findings provide novel insights into surgical decision-making among older adult patients, particularly for common elective hernia procedures, and suggest that surgeons performing VHR should be using specific patient and hernia characteristics beyond age to assess preoperative complication risk, including sex, hernia width, and history of previous repair. While this study can prove helpful for surgeons and patients making decisions around VHR, our approach demonstrates one method to address an important research gap: preoperative decision-making around quality of life and preference-sensitive surgical conditions in older patients. We encourage future studies to further extrapolate surgeon and site-level variation of operative approach among older patients undergoing VHR and to understand the perspectives of surgeons caring for these patients.
Supplementary Material
Funding
No financial support was provided for this study and ensured the authors independence in designing the study, interpreting the data, writing, and publishing the report.
Footnotes
Declarations
Disclosures Dana A. Telem and Michael Rubyan are investigators on an NIH R01 NIDDK. Christopher W. Reynolds, Alexander Hallway, Joshau K. Sinamo, Serena Bidwell, Tyler Bauer, and Anne P. Ehlers have no conflict of interest or financial ties to disclose.
Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s00464-024-11136-8.
Data availability
Datasets and analytic methods involved in this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Datasets and analytic methods involved in this study are available from the corresponding author upon reasonable request.