Abstract
Background:
Compared to elective surgery, emergent hernia repairs carry higher morbidity. Additionally, frailty is independently associated with worse postoperative outcomes. This study aimed to assess if the surgical approach, minimally invasive surgery versus open, confers improved outcomes for frail patients who underwent emergent hernia repairs.
Methods:
The National Surgical Quality Improvement Program database (2018–2020) was queried for patients who underwent emergency hernia repair by Current Procedural Terminology (CPT) codes (49505–49659). A modified frailty index-5 score was calculated; only frail patients with a score of ≥2 were included. The impact of surgical approach on length of stay, discharge destination, and mortality was determined by multivariate analysis.
Results:
A total of 1,893 patients met the inclusion criteria. Most patients (56.5%) were female, and 61.4% of patients were age ≥65. Most patients (83.62%) underwent open repair. After adjusting for covariates, patients who underwent minimally invasive surgery had a shorter length of stay compared to open surgery (hazard ratio = 1.22; 95% confidence interval [1.06,1.41]; P = .006). Surgical approach was not associated with a difference in 30-day mortality (P =.28) or discharge destination (P = .97).
Conclusion:
Minimally invasive emergent hernia repairs in frail patients in the National Surgical Quality Improvement Program database cohort are associated with a shorter length of stay compared to open surgery, without increased 30-day mortality or change in discharge destination. Prospective studies are needed to validate best-practices in treating frail surgical patients.
Keywords: Emergency, Frail, Hernia, Minimally invasive surgery, Outcomes
INTRODUCTION
Abdominal wall hernias are ubiquitous, frequently morbid, and can be lethal when incarcerated. Approximately 10% of abdominal hernias require repair in an emergency setting due to incarceration or strangulation.1 Emergently repaired femoral hernias are associated with a 10-fold increase in mortality when compared to their elective counterparts.2
There are various approaches to surgical repair, including open repair and minimally invasive surgery (MIS) approaches (conventional laparoscopy and robotic-assisted laparoscopy). Historically, open repair has been favored in high-risk populations, especially in emergency settings, for concerns of intolerance to pneumoperitoneum or general anesthesia.3,4 Frail patients comprise a particularly vulnerable population to undergo emergency hernia repair. Frailty is defined by the decrease of reserves in several organ systems, due to various causes such as acute or chronic stress, reduced nutritional intake, lack of activity, and other signs of aging.5 These factors can all lead to impaired ability to maintain physiologic homeostasis.6 Frailty is not always associated with age, and only 3%–3% of people aged 65–75 are frail.7 The accumulating deficits model of frailty has been vastly studied, showing that as patients accumulate deficits, they become increasingly frail.8–10 This model is the framework for several validated indexes that identify and measure frailty in patients. Postoperative frail patients are often at a disadvantage to nonfrail patients, with stepwise increases in mortality and morbidity rates for each unit increase in frailty index.8 Adverse postoperative outcomes in frail patients can be attributed to an inability to maintain physiologic homeostasis and a decrease in reserves across several organ systems.5,6
After controlling for patient-, operative approach-, and hernia-specific characteristics, frailty is associated with worse postoperative outcomes for patients undergoing either ventral or femoral hernia repair.11,12 Emergency surgery further complicates these procedures, and frail patients who undergo emergency abdominal surgery have mortality rates of 24.7%, compared to 15.7% for nonfrail patients.13,14
There is still no single gold-standard scale for measuring frailty in clinical settings.15,16 The Modified 5-Item Frailty Index (mFI-5) is comprised of 5 variables that are routinely recorded in the National Surgical Quality Improvement Program (NSQIP) database including diabetes (either insulin or noninsulin dependent), hypertension requiring medication, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and partial or complete dependent functional status.17 Patients with an mFI-5 score ≥2 are considered frail. Frailty scales, like the mFI-5, are often better than age alone at predicting adverse outcomes, as they capture several conditions that may lead to worse postoperative outcomes.18–20 Emergency surgery further complicates hernia repair among frail patients, leading to statistically significant increased odds of overall postoperative morbidity.11
While it is known that MIS typically incites a lesser inflammatory response than open surgery and has demonstrated faster recovery with fewer postoperative complications, it is unknown whether the physiologic alterations during laparoscopic surgery are well tolerated by frail patients in emergent settings.21,22 By understanding which surgical approach for managing emergency hernia repair leads to improved outcomes for frail patients, surgeons may be able to choose interventions which provide greater benefit for this at-risk population. The objective of this study was to assess if the surgical approach, MIS versus open, conferred improved outcomes for frail patients who underwent emergent hernia repairs. We hypothesized that MIS would lead to improved postoperative outcomes for frail patients, since this has been proven for other vulnerable populations. The primary outcome was 30-day mortality, and the secondary outcomes were discharge location, either home or outpatient facility, and hospital LOS.
MATERIALS AND METHODS
Data Extraction, Inclusion and Exclusion Criteria
The American College of Surgeons NSQIP publishes Public Use Files each year, which include deidentified patient data from hospitals nationally. Using the files from 2018–2020, we selected patients who underwent emergency hernia repair, either groin or ventral, by Current Procedural Terminology codes 49505–49659. An mFI-5 score was then calculated for each patient and patients with an mFI-5 score ≥2 were selected for inclusion. Of the 2,999,890 cases in the 2018–2020 Public Use Files, 1,893 cases met our inclusion and exclusion criteria and were included in our analysis (Figure 1).
Figure 1.
Flow diagram of study design.
PUF, public use file; ACS NSQIP, American College of Surgeons National Surgical Quality Improvement Program; CPT, Current Procedural Terminology; mFI-5, modified frailty index-5.
Statistical Methods
Descriptive statistics were calculated, including frequency distribution metrics for categorical variables such as mean, median, standard deviation (SD), and interquartile range (IQR). For continuous variables, minimum and maximum values were also calculated. χ2 test or Fisher’s exact test was used, as appropriate, to determine whether there was a difference in preoperative factors between procedure types.
30-Day Mortality and Discharge Destination
Multivariable logistic regression was utilized to assess the association between each outcome (30-day mortality and discharge destination), separately, and any potential predictor variable found to be significantly associated with the outcome in the univariable analysis. The univariable analysis used a 10% level of significance for inclusion in the multivariable logistic regression. Backward elimination was used to select the final model, with α level set to 5%. Hernia procedure type was forced to be in the final model regardless of its significance.
Days from Operation to Discharge (LOS)
Time-to-event analysis was used to assess the relationship between hospital LOS (days from operation to discharge) and any potential predictor variable found to be significantly associated with the outcome in the univariable analysis. In cases where the “event” of discharge was not observed during the study period, the number of days until death was used and the subject’s discharge status was classified as censored. Time to discharge was measured in days; hazard ratios (HRs) were calculated along with the associated 95% confidence intervals (CIs). Comparison of time to discharge between categorical variables was carried out using the Kaplan-Meier product limit method. The effects of demographic factors, procedure type, comorbidities, and preoperation complication variables were assessed using the log-rank test. Factors that appeared to be significantly associated with the event (P < .1) in the univariable analysis were included in the multivariable Cox proportional hazards regression model. Backward elimination was used to select the final model, with α level set to 5%. All analyses were carried out using SAS software version 9.4 (Cary, NC).
RESULTS
Preoperative Factors
1,893 patients met the study inclusion criteria. The majority were female (56.5%), white (76.7%), and 66–89 years old (58.2%). A minority were ≥90 years old (5.9%). Most patients underwent open hernia repair (83.6%). Table 1 includes a complete list of the descriptive statistics for this study population and the significance between each preoperative factor and procedure type.
Table 1.
Preoperative Factors by Procedure Type
| Characteristic (N, %) | Overall, N = 1,893 | Mis, N = 310 (16.4%) | Open, N = 1,583 (83.6%) | P-value |
|---|---|---|---|---|
| Sex | .80 | |||
| Female | 1,069 (56.5) | 173 (55.8) | 896 (56.6) | |
| Male | 824 (43.5) | 137 (44.) | 687 (43.4) | |
| Age | .004 | |||
| ≤65 | 731 (38.6) | 142 (45.8) | 589 (37.2) | |
| >65 | 1,162 (61.4) | 168 (54.2) | 994 (62.8) | |
| Race | .031 | |||
| Black | 305 (19.6) | 65 (25.5) | 240 (18.4) | |
| Other | 59 (3.8) | 10 (3.9) | 49 (3.8) | |
| White | 1,195 (76.7) | 180 (70.6) | 1,015 (77.8) | |
| Missing | 334 | 55 | 279 | |
| Anesthesia | .002 | |||
| General | 1,834 (96.9) | 309 (99.7) | 1,525 (96.4) | |
| Not general | 58 (3.1) | 1 (0.3) | 57 (3.6) | |
| Missing | 1 | 0 | 1 | |
| Body Mass Index | .002 | |||
| ≤30 | 698 (40.3) | 91 (32.2) | 607 (41.7) | |
| >30 | 1,035 (59.7) | 192 (67.8) | 843 (58.1) | |
| Missing | 160 | 27 | 133 | |
| Diabetes | 1,265 (66.8) | 225 (72.6) | 1,040 (65.7) | .019 |
| Smoker Status (within 1 year) | 330 (17.4) | 47 (15.2) | 283 (17.9) | .25 |
| Dyspnea | 273 (14.4) | 30 (9.7) | 243 (15.4) | .009 |
| Functional Status | .008 | |||
| Dependent | 347 (18.4) | 40 (13.0) | 307 (19.5) | |
| Independent | 1,536 (81.6) | 267 (87.0) | 1,269 (80.5) | |
| Missing | 10 | 3 | 7 | |
| Ventilator Dependent | 13 (0.7) | 0 (0.0) | 13 (0.8) | .14 |
| COPD | 518 (27.4) | 72 (23.2) | 446 (28.2) | .07 |
| CHF | 193 (10.2) | 20 (6.5) | 173 (10.9) | .02 |
| Hypertension | 1,816 (95.9) | 300 (96.8) | 1,516 (95.8) | .41 |
| Renal Failure | 47 (2.5) | 5 (1.6) | 42 (2.7) | .28 |
| Dialysis | 73 (3.9) | 9 (2.9) | 64 (4.0) | .34 |
| Cancer | 38 (2.0) | 6 (1.9) | 32 (2.0) | .92 |
| Wound Infection | 51 (2.7) | 5 (1.6) | 46 (2.9) | .20 |
| Steroid Usage | 114 (6.0) | 10 (3.2) | 104 (6.6) | .02 |
| Weight Loss | 44 (2.3) | 5 (1.6) | 39 (2.5) | .36 |
| Bleeding Disorder | 279 (14.7) | 24 (7.7) | 255 (16.1) | <.001 |
| Transfusion | 11 (0.6) | 1 (0.3) | 10 (0.6) | >.99 |
| Presepsis | 568 (30.0) | 82 (26.5) | 486 (30.7) | .14 |
| Prealbumin | .38 | |||
| <3.0 | 149 (9.5) | 20 (8.0) | 129 (9.8) | |
| ≥3.0 | 1,415 (90.5) | 229 (92.0) | 1,186 (90.2) | |
| Missing | 329 | 61 | 268 | |
| Pre-White Blood Cells | .003 | |||
| <12.0 | 1,256 (67.2) | 228 (74.5) | 1,028 (65.8) | |
| ≥12.0 | 612 (32.8) | 78 (25.5) | 534 (34.2) | |
| Missing | 25 | 4 | 21 | |
| Wound Class | <.001 | |||
| Clean | 1,671 (88.3) | 292 (94.2) | 1,379 (87.1) | |
| Infected | 222 (11.7) | 18 (5.8) | 204 (12.9) | |
| ASA Class | .019 | |||
| Disturbed | 1,744 (92.3) | 276 (89.0) | 1,468 (92.9) | |
| Not Disturbed | 146 (7.7) | 34 (11.0) | 112 (7.1) | |
| Missing | 3 | 0 | 3 | |
| Operation Time | .28 | |||
| <167 | 1,722 (91.0%) | 287 (92.6%) | 1,435 (90.7) | |
| ≥167 | 171 (9.0%) | 23 (7.4%) | 148 (9.3%) | |
MIS, minimally invasive surgery; COPD, chronic obstructive pulmonary disease; CHF, congestive heart failure.
30-Day Complications
Overall, 15.9% patients experienced a postoperative complication. The most common complications were 30-day readmission (12.3%), return to the operating room (5.0%), pneumonia (5.0%), on a ventilator for over 48 hours (4.7%), superficial surgical site infection (3.7%), sepsis (3.6%), unplanned reintubation (3.5%), blood transfusion (3.3%), urinary tract infection (2.8%), and septic shock (2.3%) (Table 2). On univariable analysis, there were no significant differences in 30-day complications between MIS or open hernia repairs aside from length of stay, detailed below.
Table 2.
Postoperative Complications by Procedure Type
| Postoperative Complication (N, %) | Overall (N = 1,893) | Mis (N = 310, 16%) | Open (N = 1583, 84%) | P-value |
|---|---|---|---|---|
| Mortality Within 30-days | 99 (5.3) | 15 (4.8) | 84 (5.3) | .74 |
| Discharge Not Home* | 372 (19.7) | 49 (16.0) | 323 (20.6) | .06 |
| Length of Stay, d, median [IQR] | 4.0 [2.0–7.0] | 3.0 [1.0–5.0] | 4.0 [2.0–7.0] | <.001 |
| Superficial Surgical Site Infection | 73 (3.9) | 7 (2.3) | 66 (4.2) | .11 |
| Pneumonia | 94 (5.0) | 19 (6.1) | 75 (4.7) | .30 |
| Wound Disruption | 24 (1.3) | 1 (0.3) | 23 (1.5) | .16 |
| Deep Incisional SSI | 17 (0.9) | 1 (0.3) | 16 (1.0) | .34 |
| Organ Space SSI | 53 (2.8) | 6 (1.9) | 47 (3.0) | .31 |
| Unplanned Intubation | 67 (3.5) | 11 (3.6) | 56 (3.5) | .99 |
| Pulmonary Embolism | 15 (0.8) | 3 (1.0) | 12 (0.8) | .72 |
| On ventilator > 48 hours | 88 (4.7) | 11 (3.6) | 77 (4.9) | .31 |
| Progressive Renal Insufficiency | 25 (1.3) | 3 (1.0) | 22 (1.4) | .79 |
| Acute Renal Failure | 25 (1.3) | 7 (2.3) | 18 (1.1) | .17 |
| Urinary Tract Infection | 53 (2.8) | 8 (2.6) | 45 (2.8) | .80 |
| Stroke with Neurological Deficit | 7 (0.4) | 1 (0.3) | 6 (0.4) | 1.00 |
| Cardiac Arrest | 35 (1.9) | 7 (2.3) | 28 (1.8) | .56 |
| Myocardial Infarction | 35 (1.9) | 6 (1.9) | 29 (1.8) | .90 |
| Bleeding Transfusions (Intraop/Postop) | 63 (3.3) | 6 (1.9) | 57 (3.6) | .14 |
| DVT/Thrombophlebitis | 16 (0.9) | 2 (0.7) | 33 (2.1) | 1.00 |
| Sepsis | 68 (3.6) | 10 (3.2) | 14 (0.9) | .70 |
| Septic Shock | 43 (2.3) | 10 (3.2) | 58 (3.7) | .22 |
| Return to Operating Room | 94 (5.0) | 13 (4.2) | 81 (5.1) | .49 |
| Still in hospital > 30 day | 16 (0.9) | 2 (0.7) | 14 (0.9) | 1.00 |
| Unplanned Reoperation | 94 (1.0) | 13 (4.2) | 81 (5.1) | .49 |
| Readmission | 233 (12.3) | 29 (9.4) | 204 (12.9) | .08 |
| C. Diff Infection | 14 (0.7) | 1 (0.3) | 13 (0.8) | .49 |
*Frequency Missing = 20 (N = 1873).
MIS, minimally invasive surgery; IQR, interquartile range; SSI, surgical site infection; DVT, deep vein thrombosis; C. Diff, clostridium difficile.
30-Day Mortality
Overall 30-day mortality rate was 5.23%. Among the 1,583 patients who underwent open surgery, 5.3% expired before 30 days (Table 2). Of the 310 patients who underwent MIS surgery, 4.8% expired. The multivariable model included hernia procedure type, sex, age, anesthesia technique, diabetes, dyspnea, and postoperative complications (Table 3). Hernia procedure type was not found to be associated with 30-day mortality (P = .57).
Table 3.
Final Multivariable Logistic Regression Model Assessing the Association between Hernia Procedure Type and 30-Day Mortality (N = 1892)
| Variable | Multivariable or (95% CI) | P-value |
|---|---|---|
| Procedure Type (MIS vs Open) | 1.21 (0.63, 2.31) | .57 |
| Sex (Female vs Male) | 0.45 (0.28, 0.72) | <.001 |
| Age in years (>65 vs ≤65) | 3.90 (2.06, 7.40) | <.001 |
| Anesthesia (Not general vs General) | 3.57 (1.40, 9.14) | .008 |
| Diabetes | 0.33 (0.21, 0.53) | <.001 |
| Dyspnea | 1.81 (1.06, 3.07) | .029 |
| Postoperative Complications | 20.08 (12.17, 33.12) | <.001 |
MIS, minimally invasive surgery.
Discharge Destination
The multivariable model for discharge destination included: hernia procedure type, race, age, diabetes, functional status, dialysis, wound class, American Society of Anesthesiologists (ASA) class, operation time and postoperative complications (Table 4). Hernia procedure type was not found to be associated with discharge destination (P = .98).
Table 4.
Final Multivariable Logistic Regression Model Assessing the Association between Hernia Procedure Type and Discharge Not to Home (N = 1538)
| Variable | Multivariable Odds Ratio (95% CI) | P-value |
|---|---|---|
| Procedure Type (MIS vs Open) | 0.99 (0.66, 1.49) | .98 |
| Race (Black vs White) | 0.94 (0.64, 1.37) | .73 |
| Race (Other vs White) | 0.20 (0.07, 0.60) | .004 |
| Age in years (>65 vs ≤65) | 4.08 (2.87, 5.78) | <.001 |
| Diabetes (with vs without) | 0.54 (0.40, 0.73) | <.001 |
| Functional Status (Dependent vs Independent) | 2.42 (1.75, 3.36) | <.001 |
| Dialysis | 2.34 (1.27, 4.31) | .006 |
| Wound clean (Infected vs Clean) | 1.81 (1.23, 2.66) | .003 |
| ASA Class (Disturbed vs Normal) | 2.42 (1.07, 5.47) | .03 |
| Postoperative complications (Y vs N) | 4.35 (3.13, 6.04) | <.001 |
| Operation Time (≥167 min vs <167 min) | 2.13 (1.37, 3.33) | <.001 |
MIS, minimally invasive surgery; ASA, American Society of Anesthesiologists.
Days from Operation to Discharge (LOS)
The median days from operation to discharge of the overall cohort was 4 days [2.0–7.0]. The multivariable Cox regression model included hernia procedure type, sex, age, body mass index, anesthesia technique, functional status, ventilator dependence COPD, CHF, acute renal failure, preoperative systemic sepsis, preoperative serum albumin, wound class, ASA class and operation time (Table 5). Out of 1,540 patients, 49 died in the hospital and were considered as censored. Open surgery was associated with a longer length of stay than MIS, 4 versus 3 days, respectively (Figure 2). This difference was statistically significant after adjusting for covariates, with a HR of 1.24 (95% CI: 1.07, 1.43) for MIS versus open surgery (P = .005).
Table 5.
Final Multivariable Cox Regression Model Assessing the Association between Hernia Procedure Type and Days from Operation to Discharge (LOS) (N = 1446)
| Variable | Multivariable Hazard Ratio (95% CI) | P-value |
|---|---|---|
| Procedure Type (MIS vs Open) | 1.24 (1.07, 1.43) | .005 |
| Sex (F vs M) | 0.67 (0.54, 0.84) | <.001 |
| Sex g(t) (F vs M) | 1.23 (1.07, 1.41) | .004 |
| Age in years (>65 vs ≤65) | 0.84 (0.75, 0.94) | .003 |
| Body Mass Index (>30 vs ≤30) | 0.81 (0.73, 0.92) | <.001 |
| Functional Status (Dependent vs Independent) | 0.67 (0.58, 0.77) | <.001 |
| Anesthesia (Not general vs General) | 2.11 (1.46, 3.07) | <.001 |
| Ventilator | 0.26 (0.14, 0.51) | <.001 |
| History of COPD | 0.79 (0.70, 0.89) | <.001 |
| History of CHF | 0.74 (0.62, 0.88) | <.001 |
| Renal Failure | 0.54 (0.37, 0.64) | <.001 |
| Pre-Sepsis | 0.49 (0.37, 0.64) | <.001 |
| Presepsis g(t) | 1.37 (1.17, 1.60) | <.001 |
| Prealbumin (≤3.0) | 1.71 (1.41, 2.06) | <.001 |
| Wound (Infected vs Uninfected) | 0.64 (0.54, 0.75) | <.001 |
| ASA Class. (Disturbed vs Undisturbed) | 0.68 (0.56, 0.84) | <.001 |
| Operation Time (≥167 min) | 0.63 (0.52, 0.76) | <.001 |
MIS, minimally invasive surgery; COPD, chronic obstructive pulmonary disease; CHF, congestive heart failure; ASA, American Society of Anesthesiologists.
Figure 2.
Postoperative length of stay.
In-hospital deaths were censored from analysis (49 out of 1,540 patients).
DISCUSSION
Overall, our findings were in agreement with other literature on the benefits of MIS in frail patients. Our study population was comprised of more females (56%) than males (44%), which is consistent with studies showing that women have higher likelihood of undergoing emergency femoral surgery compared to men (40.6% vs 28.1%) (4). Additionally, most patients in our study underwent open surgery (83.6%), compared to MIS (16.38%). This is also similar to other studies on hernia repairs showing that open repair is performed more frequently and especially in emergency settings.23–24
We found that MIS is both safe and effective compared to open surgery in frail patients who undergo emergency hernia repair. Our analyses indicate that MIS does not significantly increase mortality rates or impact discharge destination but more importantly, leads to shorter LOS in this unique patient population. Our findings are supported by a previous retrospective analysis of a heterogeneous patient population, which demonstrated that compared to open surgery, MIS is associated with a shorter LOS (3.5 days [1–11] vs 6.0 days [2.0–19.0], P = .015), as well as a shorter operative time, and lower morbidity rates in emergency hernia repair; however, it is important to note that these findings did not exclusively consider frail patients.23–24 While we did not find an impact of surgical approach on mortality, we were surprised to find that nongeneral anesthesia was associated with increased mortality. This likely represents selection bias, as general anesthesia is preferred for most patients who are expected to tolerate the physiologic alterations.
Discharge destination was chosen as a key outcome indicator because even short inpatient hospitalizations can lead to significant loss of functional status for frail patients. For example, Shehadeh et al11 found that frail patients are more likely to be discharged to a destination other than home (64.7%), compared to nonfrail patients after femoral hernia repair. Similarly, Chimukangara et al, showed that an mFI-5 score of ≥3 was the strongest predictor for a patient being discharged to a destination other than home, compared to procedure type (laparoscopic vs open; OR: 0.51, 95% CI: 0.28–0.95) in patients undergoing paraesophageal hernia repair.25 While we did not demonstrate a difference in discharge destination between MIS or open surgical approaches, this may be due to the relatively small difference in average length of stay between the groups (3 vs 4 days).
The benefits of MIS in frail patients may, in fact, be more significant than for more robust patients. Various studies show that 30-day mortality rates after abdominal hernia repair were significantly decreased by MIS compared to open surgery.23–24 The benefits of MIS approaches for elderly patients are consistent across various intraabdominal procedures.26 Complications and hospitalizations were lower for elderly individuals who underwent MIS versus open surgery, similar to a young patient population.26–27 Furthermore, elderly patients that underwent MIS colorectal resection had greater improvement in morbidity rates (20.2 vs 37.5, P = .01) and LOS (9.5 vs 13, P = .001), compared to younger patients.27 While these studies did not focus on the frail population, He et al,28 showed that laparoscopic inguinal hernia repair is safe for older patients, with no significant difference in postoperative pain, hospital LOS, time to recovery with activity, and recurrence rates between patients older or younger than 60 years old. Although old age is not always synonymous with frailty, previous literature and our study suggest that vulnerable patients like the frail population tolerate MIS without adverse impact.
Frailty has been widely accepted as a more accurate way of measuring a patient’s physiologic fitness than age when planning for surgery.8,29,30 The utilization of frailty indexes to decrease postoperative complications has been advocated by several studies and can specifically benefit elderly patients who undergo hernia repair surgery.19,31,32 In fact, Seib et al33 showed that after adjusting for age, there was stepwise increase in postoperative complications for frail patients who underwent common ambulatory general surgery operations. Our study suggests that these indexes are also useful in emergency hernia repair settings, as a tool to optimize surgical repair techniques. In a study done by Hall et al,31 implementation of a frailty screening initiative during preoperative evaluation, which triggered engagement of a multidisciplinary team for frail patients, reduced 30-day mortality rates from 12.2% to 3.8% (P < .001).31 These mortality rate improvements persisted at 180-days (23.9% to 7.7%, P < .001) and 365-days (34.5% to 11.7%, P < .001).31 The use of frailty scales should encourage collaboration between surgeons and other medical providers in elective and emergency perioperative settings.14,19,20
Various limitations to our study exist. Foremost, by utilizing a retrospective database, selection bias could influence our results. Surgeons are likely to choose more robust patients with less hemodynamic compromises, unfavorable comorbidities, or hernia-associated factors to pursue an MIS approach to repair. These factors may lead to improved outcomes for patients who undergo MIS surgery. Furthermore, retrospective databases are limited by potentially flawed data entry and additional analysis of contributing factors not included in the database is not possible. Specifically, the NSQIP database is limited because it only tracks morbidity and mortality rates 30-day postoperation, therefore it is unable to track long-term impact on patients’ health. The database also does not record certain preoperative patient information such as comorbidity severity, surgery causes, and specific outcomes that may be a result of patients’ procedures.34 In our study, we were unable to track operative factors such as bowel resection during hernia repair, which may have impacted the outcomes for patients who underwent MIS versus open surgery. Lastly, the generalizability of the NSQIP database may be limited since hospitals may only contribute deidentified patient information if they have a full-time “nurse-reviewer” to record and input data; this may cost up to $100,000 and can limit database contribution to only well-resourced, teaching hospitals.35
While the specific interventions and resources which should be targeted to frail patients undergoing emergent surgery are not well-defined, MIS approaches may confer benefit in the appropriate setting. Additional research focusing on optimizing perioperative and surgical care for frail patients with emergent surgical pathology is needed to further improve outcomes.
CONCLUSION
Our study demonstrates that a MIS approach to emergency hernia repairs in frail patients is safe and leads to shorter hospital LOS. While frail patients comprise a vulnerable population, they should not be excluded from surgical interventions in emergent situations. Rather, their care should be optimized to improve their outcomes. Prospective studies are needed to validate best-practices in treating frail surgical patients and to implement frailty-measurement indexes in emergency surgical settings.
Footnotes
Date of submission: September 4, 2024
Date of revision: January 6, 2025
Disclosure of Conflicts of Interest: The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.
Funding sources: none.
Contributor Information
Anna Distler, Department of Surgery, Northwell Health, New Hyde Park, New York, USA. (Drs. Distler, Salas Parra, Ahmed, Barrera, Patel, and Hansen).
Ruben Salas Parra, Department of Surgery, Northwell Health, New Hyde Park, New York, USA. (Drs. Distler, Salas Parra, Ahmed, Barrera, Patel, and Hansen).
Xueqi Huang, Biostatistics Unit, Northwell Health, New Hyde Park, New York, USA. (Dr. Huang).
Hanaa Ahmed, Department of Surgery, Northwell Health, New Hyde Park, New York, USA. (Drs. Distler, Salas Parra, Ahmed, Barrera, Patel, and Hansen).
Rafael Barrera, Department of Surgery, Northwell Health, New Hyde Park, New York, USA. (Drs. Distler, Salas Parra, Ahmed, Barrera, Patel, and Hansen).
Vihas Patel, Department of Surgery, Northwell Health, New Hyde Park, New York, USA. (Drs. Distler, Salas Parra, Ahmed, Barrera, Patel, and Hansen).
Laura Hansen, Department of Surgery, Northwell Health, New Hyde Park, New York, USA. (Drs. Distler, Salas Parra, Ahmed, Barrera, Patel, and Hansen).
References:
- 1.Pavithira GJ, Dutta S, Sundaramurthi S, Nelamangala Ramakrishnaiah VP. Outcomes of emergency abdominal wall hernia repair: experience over a decade. Cureus. 2022;14(6):e26324. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Dahlstrand U, Wollert S, Nordin P, et al. Emergency femoral hernia repair: a study based on a national register. Ann Surg. 2009;249(4):672–676. [DOI] [PubMed] [Google Scholar]
- 3.Madhok B, Nanayakkara K, Mahawar K. Safety considerations in laparoscopic surgery: a narrative review. World J Gastrointest Endosc. 2022;14(1):1–16. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Ceresoli M, Pisano M, Abu-Zidan F, et al. ; WSES MIS consortia. Minimally invasive surgery in emergency surgery: a WSES survey. World J Emerg Surg. 2022;17(1):18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Rizzoli R, Reginster JY, Arnal JF, et al. Quality of life in sarcopenia and frailty. Calcif Tissue Int. 2013;93(2):101–120. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Ahmed N, Mandel R, Fain MJ. Frailty: an emerging geriatric syndrome. Am J Med. 2007;120(9):748–753. [DOI] [PubMed] [Google Scholar]
- 7.Cassel CK, Cohen HJ, Larson EB, et al., eds. Geriatric Medicine. New York, NY: Springer; 1997. [Google Scholar]
- 8.Velanovich V, Antoine H, Swartz A, et al. Accumulating deficits model of frailty and postoperative mortality and morbidity: its application to a national database. J Surg Res. 2013;183(1):104–110. [DOI] [PubMed] [Google Scholar]
- 9.Song X, Mitnitski A, Rockwood K. Prevalence and 10-year outcomes of frailty in older adults in relation to deficit accumulation. J Am Geriatr Soc. 2010;58(4):681–687. [DOI] [PubMed] [Google Scholar]
- 10.Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of deficits as a proxy measure of aging. ScientificWorldJournal. 2001;1:323–336. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Shehadeh AA, McLaren GW, Collins JT, et al. Frailty as a predictor of surgical outcomes following femoral hernia repair. Am Surg. 2023;89(6):2254–2261. [DOI] [PubMed] [Google Scholar]
- 12.Solano QP, Howard R, Mullens CL, et al. The impact of frailty on ventral hernia repair outcomes in a statewide database. Surg Endosc. 2023;37(7):5603–5611. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Hewitt J, Carter B, McCarthy K, et al. Frailty predicts mortality in all emergency surgical admissions regardless of age. An observational study. Age Ageing. 2019;48(3):388–394. [DOI] [PubMed] [Google Scholar]
- 14.Kennedy CA, Shipway D, Barry K. Frailty and emergency abdominal surgery: a systematic review and meta-analysis. Surgeon. 2022;20(6):e307–e314. [DOI] [PubMed] [Google Scholar]
- 15.Elliott A, Phelps K, Regen E, Conroy SP. Identifying frailty in the emergency department-feasibility study. Age Ageing. 2017;46(5):840–845. [DOI] [PubMed] [Google Scholar]
- 16.Muscedere J. The need to implement frailty in the international classification of disease (ICD). J Frailty Aging. 2020;9(1):2–3. [DOI] [PubMed] [Google Scholar]
- 17.Subramaniam S, Aalberg JJ, Soriano RP, Divino CM. New 5-factor modified frailty index using American College of Surgeons NSQIP data. J Am Coll Surg. 2018;226(2):173–181.e8. [DOI] [PubMed] [Google Scholar]
- 18.Weaver DJ, Malik AT, Jain N, et al. The modified 5-item frailty index: a concise and useful tool for assessing the impact of frailty on postoperative morbidity following elective posterior lumbar fusions. World Neurosurg. 2019;124:e626–e632. [DOI] [PubMed] [Google Scholar]
- 19.Lin HS, Watts JN, Peel NM, Hubbard RE. Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC Geriatr. 2016;16(1):157. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Lee H, Lee E, Jang IY. Frailty and comprehensive geriatric assessment. J Korean Med Sci. 2020;35(3):e16. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Olmi S, Scaini A, Cesana GC, et al. Laparoscopic versus open incisional hernia repair: an open randomized controlled study. Surg Endosc. 2007;21(4):555–559. [DOI] [PubMed] [Google Scholar]
- 22.Misra MC, Bansal VK, Kulkarni MP, Pawar DK. Comparison of laparoscopic and open repair of incisional and primary ventral hernia: results of a prospective randomized study. Surg Endosc. 2006;20(12):1839–1845. [DOI] [PubMed] [Google Scholar]
- 23.Jacob R, Guy SB, Kamila L, et al. Comparison of emergent laparoscopic and open repair of acutely incarcerated and strangulated hernias-short- and long-term results. Surg Endosc. 2023;37(3):2154–2162. [DOI] [PubMed] [Google Scholar]
- 24.Mason RJ, Moazzez A, Sohn HJ, et al. Laparoscopic versus open anterior abdominal wall hernia repair: 30-day morbidity and mortality using the ACS-NSQIP database. Ann Surg. 2011;254(4):641–652. [DOI] [PubMed] [Google Scholar]
- 25.Chimukangara M, Helm MC, Frelich MJ, et al. A 5-item frailty index based on NSQIP data correlates with outcomes following paraesophageal hernia repair. Surg Endosc. 2017;31(6):2509–2519. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Weber DM. Laparoscopic surgery: an excellent approach in elderly patients. Arch Surg. 2003;138(10):1083–1088. [DOI] [PubMed] [Google Scholar]
- 27.Frasson M, Braga M, Vignali A, et al. Benefits of laparoscopic colorectal resection are more pronounced in elderly patients. Dis Colon Rectum. 2008;51(3):296–300. [DOI] [PubMed] [Google Scholar]
- 28.He Z, Hao X, Li J, et al. Laparoscopic inguinal hernia repair in elderly patients: single center experience in 12 years. Ann Laparosc Endosc Surg. 2017;2:88–88. [Google Scholar]
- 29.Farhat JS, Velanovich V, Falvo AJ, et al. Are the frail destined to fail? Frailty index as predictor of surgical morbidity and mortality in the elderly. J Trauma Acute Care Surg. 2012;72(6):1526–1531. [DOI] [PubMed] [Google Scholar]
- 30.Makary MA, Segev DL, Pronovost PJ, et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210(6):901–908. [DOI] [PubMed] [Google Scholar]
- 31.Hall DE, Arya S, Schmid KK, et al. Association of a frailty screening initiative with postoperative survival at 30, 180, and 365 days. JAMA Surg. 2017;152(3):233–240. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Perez AJ, Campbell S. Inguinal hernia repair in older persons. J Am Med Dir Assoc. 2022;23(4):563–567. [DOI] [PubMed] [Google Scholar]
- 33.Seib CD, Rochefort H, Chomsky-Higgins K, et al. Association of patient frailty with increased morbidity after common ambulatory general surgery operations. JAMA Surg. 2018;153(2):160–168. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Alluri RK, Leland H, Heckmann N. Surgical research using national databases. Ann Transl Med. 2016;4(20):393. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Sheils CR, Dahlke AR, Kreutzer L, Bilimoria KY, Yang AD. Evaluation of hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. Surgery. 2016;160(5):1182–1188. [DOI] [PubMed] [Google Scholar]