Abstract
PURPOSE
In 2003, randomized trials demonstrated potentially improved outcomes when local instead of general anesthesia is used for inguinal hernia repair. Our study aimed to evaluate how the use of local anesthesia for this procedure changed over time following the publication of the trials’ level 1 evidence.
METHODS
We used the 1998–2018 Veterans Affairs Surgical Quality Improvement Program database to identify adults who underwent open, unilateral inguinal hernia repair under local or general anesthesia. Our primary outcome was the percentage of cases performed under local anesthesia. We used a time series design to examine the trend and rate of change of the use of local anesthesia.
RESULTS
We included 97,437 veterans, of which 22,333 (22.9%) had hernia surgery under local anesthesia. The median age of veterans receiving local anesthesia remained stable at 64–67 years over time. The use of local anesthesia decreased steadily, from 38.2% at the beginning year to 15.1% in the final year (P < 0.0001). The publication of results from randomized trials (in 2003) did not appear to increase the overall use or change the rate of decline in the use of local anesthesia. Overall, we found that the use of local anesthesia decreased by about 1.5% per year.
CONCLUSION
The utilization of local anesthesia for inguinal hernia repair in the VA has steadily declined over the last 20+ years, despite data showing equivalence or superiority to general anesthesia. Future studies should explore barriers to the use of local anesthesia for hernia repair.
Keywords: Inguinal hernia repair, Time series, Local anesthesia, General anesthesia
INTRODUCTION
Inguinal hernia surgery is the most common operation performed by general surgeons in the United States [1, 2]. The operation can be performed safely under either local or general anesthesia, but the optimal anesthesia modality remains controversial. Results from two randomized clinical trials comparing outcomes of inguinal hernia repair using local or general anesthesia were published in 2003 [3–5]. Whereas one trial showed that local anesthesia offered superior short-term outcomes, including fewer complications, reduced costs, and shorter operative times, the other showed similar morbidity and operative time, with decreased pain with local anesthesia only in the early postoperative period [3–5].
Although the two trials offered different results, they provided level 1 evidence that outcomes of inguinal hernia surgery under local anesthesia are at least equivalent to outcomes under general anesthesia. This finding is especially relevant in light of recent guidelines for surgical care of older adults that were issued jointly by the American College of Surgeons and the American Geriatrics Society [6]. These guidelines encourage surgeons to consider alternatives to general anesthesia because several observational studies suggested that exposure to general anesthesia may increase the risk of short- and long-term cognitive decline [7, 8].
Despite evidence that local anesthesia offers outcomes at least equivalent (and potentially superior) to surgery under general anesthesia, a low percentage of inguinal hernia repairs are done under local anesthesia [9, 10]. However, no recent studies have evaluated trends in the use of local versus general anesthesia for inguinal hernia repair or explored whether the relative use of local versus general anesthesia may have been influenced by the publication of results from the two seminal randomized trials.
The purpose of our study was to evaluate changes over time in the use of local anesthesia for inguinal hernia repair, and in particular, whether any changes occurred following the publication of evidence from the two randomized trials. We hypothesized that the use of local anesthesia would increase following the publication of level 1 evidence indicating that local was at least equivalent to general anesthesia for hernia repair.
MATERIALS AND METHODS
Patient selection and data sources
After receiving institutional review board approval at the North Texas Veterans Affairs Health Care System, we queried the Veterans Affairs Surgical Quality Improvement Program database to select patients who underwent elective, initial inguinal hernia repair from 1998–2018, as indicated by common procedural terminology code 49505 (open, initial inguinal hernia repair). We excluded those who underwent any other procedure, those with concurrent procedures not consistent with an inguinal hernia repair, those younger than 18 years of age, and those undergoing urgent/emergent procedures.
Outcomes
Our outcome of interest was the percentage of open inguinal hernia repairs each year performed under local rather than general anesthesia.
Statistical analysis
To perform simple descriptive statistics for presentation in Table 1, we divided patients into 5-year increments and used chi-square analysis and Kruskal-Wallis tests to identify between-group differences. Adjustments for multiple comparisons were not made, and therefore may contribute to type 1 errors. To assess the year-over-year trend in the use of local anesthesia over time, we employed an interrupted time series analysis with an AR(1) pattern to account for autocorrelation. Because the trend of local utilization was roughly linear, no transformations of the dependent variable were necessary. Stata 16.1 was used for analysis (StataCorp; College Station, TX), with significance set at P < 0.05 for all comparisons.
Table 1.
Patient characteristics over timea
| Years 1998–2003 | Years 2004–2008 | Years 2009–2013 | Years 2014–2018 | P value | |||||
|---|---|---|---|---|---|---|---|---|---|
| General | Local | General | Local | General | Local | General | Local | ||
| N=20,061 | N=24,326 | N=27,139 | N=25,911 | ||||||
| N = 13,426 | N = 6,635 | N = 17,697 | N = 6,629 | N = 22,186 | N = 4,953 | N = 21,795 | N = 4,116 | ||
| Age, year [IQR] | 59 [19] | 67 [20] | 60 [17] | 64 [18] | 62 [13] | 65 [16] | 65 [13] | 67 [13] | <0.05 |
| Male, N (%) | 13,359 (99.5) | 6,609 (99.6) | 17,605 (99.5) | 6,606 (99.7) | 22,074 (99.5) | 4,928 (99.5) | 21,673 (99.4) | 4,097 (99.5) | 0.8 |
| Race/ethnicity, N (%) | <0.05 | ||||||||
| Caucasian | 8,133 (60.6) | 4,596 (69.3) | 9,888 (55.9) | 4,153 (62.7) | 14,048 (63.3) | 3,289 (66.4) | 14,766 (67.8) | 2,971 (72.2) | |
| African American | 1,903 (14.2) | 600 (9.0) | 2,659 (15.0) | 577 (8.7) | 3,547 (16.0) | 580 (11.7) | 3,682 (16.9) | 596 (14.5) | |
| Hispanic | 342 (2.6) | 151 (2.3) | 458 (2.6) | 137 (2.1) | 654 (3.0) | 126 (2.5) | 794 (3.6) | 116 (2.8) | |
| Other | 50 (0.4) | 23 (0.4) | 100 (0.6) | 50 (0.8) | 176 (0.8) | 41 (0.8) | 222 (1.0) | 38 (0.9) | |
| Unknown | 2,998 (22.3) | 1,265 (19.1) | 4,592 (26.0) | 1,712 (25.8) | 3,761 (17.0) | 917 (18.5) | 2,331 (10.7) | 395 (9.6) | |
| American Society of Anesthesiologists class, N (%) | <0.05 | ||||||||
| 1 | 1,085 (8.1) | 444 (6.7) | 1,016 (5.7) | 294 (4.4) | 991 (4.5) | 198 (4.0) | 740 (3.4) | 123 (3.0) | |
| 2 | 7,284 (54.3) | 2,903 (43.8) | 8,499 (48.0) | 2,770 (41.8) | 9,336 (42.1) | 2,062 (41.6) | 8,473 (38.9) | 1,568 (38.1) | |
| 3+ | 5,057 (37.7) | 3,288 (49.6) | 8,181 (46.2) | 3,565 (53.8) | 11,857 (53.4) | 2,690 (54.3) | 12,582 (57.7) | 2,425 (58.9) | |
| Postgraduate year (PGY) of surgeon of record, N (%) | <0.05 | ||||||||
| Attending alone | 4,283 (31.9) | 2,794 (42.1) | 6,177 (34.9) | 3,101 (62.6) | 10,212 (46.0) | 3,101 (62.6) | 11,612 (53.3) | 2,819 (68.5) | |
| PGY 1 | 2,659 (19.8) | 1,388 (20.9) | 3,089 (17.5) | 720 (14.5) | 2,320 (10.5) | 720 (14.5) | 1,590 (7.3) | 294 (7.1) | |
| PGY 2 | 2,078 (15.5%) | 713 (10.8) | 2,685 (15.2) | 334 (6.7) | 2,834 (12.8) | 334 (6.7) | 2,262 (10.4) | 253 (6.2) | |
| PGY 3 | 1,559 (11.6) | 702 (10.6) | 1,977 (11.2) | 323 (6.5) | 2,212 (10.0) | 323 (6.5) | 2,178 (10.0) | 253 (6.2) | |
| PGY 4 | 847 (6.3) | 252 (3.8) | 1,179 (6.7) | 144 (2.9) | 1,339 (6.0) | 144 (2.9) | 1,014 (4.7) | 125 (3.0) | |
| PGY 5 | 1,696 (12.6) | 680 (10.3) | 2,263 (12.8) | 308 (6.2) | 3,004 (13.5) | 308 (6.2) | 2,920 (13.4) | 332 (8.1) | |
| PGY > 5 | 304 (2.3) | 106 (1.6) | 327 (1.9) | 23 (0.5) | 265 (1.2) | 23 (0.5) | 219 (1.0) | 40 (1.0) | |
| Inpatient status, N (%) | 841 (6.3) | 298 (4.5) | 943 (5.3) | 233 (3.5) | 958 (4.3) | 147 (3.0) | 770 (3.5) | 107 (2.6) | <0.05 |
| Wound classification, N (%) | <0.05 | ||||||||
| Clean | 13,019 (97.0) | 6,467 (97.5) | 17,006 (96.1) | 6,402 (96.6) | 21,519 (97.0) | 4,831 (97.5) | 21,199 (97.3) | 4,020 (97.7) | |
| Clean/contaminated | 401 (3.0) | 163 (2.5) | 676 (3.8) | 221 (3.3) | 651 (2.9) | 118 (2.4) | 582 (2.7) | 91 (2.2) | |
| Contaminated | 4 (0.03) | 4 (0.06) | 12 (0.07) | 5 (0.08) | 13 (0.06) | 3 (0.06) | 12 (0.06) | 4 (0.1) | |
| Infected | 2 (0.01) | 1 (0.02) | 3 (0.02) | 1 (0.02) | 3 (0.01) | 1 (0.02) | 2 (0.01) | 1 (0.02) | |
| Diabetes, N (%) | <0.01 | ||||||||
| None | 12,295 (91.6) | 5,999 (90.4) | 16,128 (91.1) | 6,045 (91.2) | 19,827 (89.4) | 4,465 (90.2) | 19,371 (88.9) | 3,634 (88.3) | |
| Oral medications | 612 (4.6) | 332 (5.0) | 1,212 (6.9) | 444 (6.7) | 1,751 (7.9) | 349 (7.1) | 1,782 (8.2) | 340 (8.3) | |
| Insulin | 212 (1.6) | 136 (2.1) | 357 (2.0) | 140 (2.1) | 608 (2.7) | 139 (2.8) | 642 (3.0) | 142 (3.5) | |
| Preoperative dyspnea, N (%) | <0.05 | ||||||||
| None | 12,269 (91.4) | 5,741 (86.5) | 16,439 (92.9) | 5,921 (89.3) | 20,684 (93.2) | 4,525 (91.4) | 20,433 (93.8) | 3,754 (91.2) | |
| With minimal exertion | 971 (7.2) | 750 (11.3) | 1,128 (6.4) | 635 (9.6) | 1,456 (6.6) | 407 (8.2) | 1,288 (5.9) | 329 (8.0) | |
| At rest | 43 (0.3) | 53 (0.8) | 40 (0.2) | 31 (0.5) | 46 (0.2) | 21 (0.4) | 74 (0.3) | 33 (0.8) | |
| Preoperative functional status, N (%) | <0.05 | ||||||||
| Independent | 13,075 (97.4) | 6,357 (95.8) | 17,434 (98.5) | 6,483 (97.8) | 21,917 (98.8) | 4,857 (98.1) | 21,455 (98.4) | 4,016 (97.6) | |
| Partially/totally dependent | 351 (2.6) | 278 (4.2) | 263 (1.5) | 145 (2.2) | 266 (1.2) | 95 (1.9) | 288 (1.3) | 92 (2.2) | |
| Preoperative sepsis, N (%) | 2 (0.01) | 2 (0.03) | 2 (0.01) | 1 (0.02) | 1 (0.0) | 1 (0.02) | 0 (0.0) | 0 (0.0) | <0.05 |
| Preoperative smoking, N (%) | 4,927 (36.7) | 2,025 (30.5) | 6,448 (36.4) | 2,005 (30.3) | 7,719 (34.8) | 1,464 (29.6) | 6,739 (30.9) | 1,192 (29.0) | <0.05 |
| Preoperative congestive heart failure, N (%) | 89 (0.7) | 87 (1.3) | 59 (0.3) | 52 (0.8) | 44 (0.2) | 16 (0.3) | 1,607 (7.4) | 432 (10.5) | <0.05 |
| Preoperative stroke with deficit, N (%) | 286 (2.1) | 194 (2.9) | 334 (1.9) | 154 (2.3) | 389 (1.8) | 126 (2.5) | 399 (1.8) | 116 (2.8) | <0.05 |
| Preoperative stroke without deficit, N (%) | 215 (1.6) | 153 (2.3) | 313 (1.8) | 148 (2.2) | 478 (2.2) | 131 (2.6) | 485 (2.2) | 126 (3.1) | <0.05 |
| Preoperative hemiplegia, N (%) | 152 (1.1) | 105 (1.6) | 161 (0.9) | 65 (1.0) | 180 (0.8) | 66 (1.3) | 202 (0.9) | 39 (1.0) | <0.05 |
| Preoperative transient ischemic attack, N (%) | 191 (1.4) | 140 (2.1) | 338 (1.9) | 168 (2.5) | 449 (2.0) | 142 (2.9) | 432 (2.0) | 84 (2.0) | <0.05 |
| Preoperative bleeding disorder, N (%) | 125 (0.9) | 89 (1.3) | 285 (1.6) | 143 (2.2) | 702 (3.2) | 167 (3.4) | 770 (3.5) | 139 (3.4) | <0.05 |
| Preoperative chemotherapy, N (%) | 24 (0.2) | 28 (0.4) | 41 (0.2) | 22 (0.3) | 30 (0.1) | 11 (0.22) | 37 (0.2) | 6 (0.2) | <0.05 |
| Preoperative steroid use, N (%) | 147 (1.1) | 115 (1.7) | 137 (0.8) | 118 (1.8) | 194 (0.9) | 61 (1.2) | 226 (1.0) | 62 (1.5) | <0.05 |
| Preoperative pneumonia, N (%) | 4 (0.03) | 4 (0.06) | 5 (0.03) | 5 (0.08) | 3 (0.01) | 1 (0.02) | 6 (0.03) | 0 (0.0) | <0.05 |
| Open wound infection preoperatively, N (%) | 23 (0.2) | 23 (0.4) | 49 (0.3) | 23 (0.4) | 62 (0.3) | 18 (0.4) | 95 (0.4) | 19 (0.5) | <0.05 |
| Weight loss of 10% preoperatively, N (%) | 94 (0.7) | 68 (1.0) | 128 (0.7) | 71 (1.1) | 170 (0.8) | 56 (1.1) | 177 (0.8) | 48 (1.2) | 0.8 |
| Chronic obstructive pulmonary disease, N (%) | 973 (7.3) | 785 (11.8) | 1,421 (8.0) | 749 (11.3) | 1,983 (8.9) | 590 (11.9) | 2,120 (9.7) | 550 (13.4) | <0.05 |
| Preoperative dialysis, N (%) | 29 (0.2) | 24 (0.4) | 68 (0.4) | 36 (0.5) | 107 (0.5) | 21 (0.4) | 148 (0.7) | 27 (0.7) | <0.05 |
| Acute renal failure preoperatively, N (%) | 9 (0.07) | 4 (0.06) | 11 (0.06) | 5 (0.08) | 19 (0.09) | 3 (0.06) | 14 (0.06) | 6 (0.2) | <0.05 |
For ease of presentation, the operative years are grouped in this table; however, we analyzed trends in anesthesia use as a year-over-year difference.
RESULTS
Patient characteristics
There were 97,437 patients included in our analysis. In total, 22,333 (22.9%) received local anesthesia as the primary anesthesia modality for their inguinal hernia repair. During the period we studied, the use of local anesthesia for inguinal hernia repair steadily decreased, from 33.1% during the initial years (1998–2003) to 15.9% during the final study years (2014–2018; P < 0.001). The median age of patients receiving local anesthesia was older than for patients receiving general anesthesia (66 years vs. 62 years; P < 0.001). As shown in Table 1, the median age of patients who received local anesthesia fluctuated slightly during the study period, ranging from 64–67 years. The median age of patients receiving general anesthesia steadily increased from 59 years [IQR 19] in the initial period to 65 years [IQR 13] (P < 0.001) by the end period. The overall comorbidity burden, reflected by American Society of Anesthesiology scores, increased steadily over time in both the local and general anesthesia groups. Additional patient characteristics for the local and general anesthesia cohorts are shown in Table 1.
The use of local anesthesia declined steadily and was not affected by the publication of results from randomized trials
As shown in Figure 1, the overall use of local anesthesia for inguinal hernia repair decreased by an average of 1.5% per year (95% CI −0.8% to −2.2%; P < 0.001) from 1998–2018. The rate of decline in the use of local anesthesia did not significantly change following the publication of results from the previously mentioned randomized controlled trials in 2003 (−1.2% per year after 2003; 95% CI −0.9% to −1.5%). Additionally, there was no immediate change in the use of local anesthesia for inguinal hernia repair following the publication of findings from the clinical trials (−0.07%; 95% CI 3.13% to −3.28%; P = 0.9).
Fig 1.
The use of local anesthesia for inguinal hernia repair has decreased steadily over the last 20 years, and the rate of decline was not affected by the publication of evidence from randomized trials comparing local to general anesthesia
DISCUSSION
We found that the use of local anesthesia for inguinal hernia repair decreased steadily from 1998–2018, despite the publication of findings from two randomized controlled trials which suggested that local anesthesia offered superior or equivalent perioperative outcomes compared to general anesthesia. Our findings are consistent with older studies showing low utilization rates for local anesthesia, and suggest that there are likely additional barriers to the use of local anesthesia other than data on relative efficacy [10].
We had originally hypothesized that the surgical practice in question would change following the publication of evidence from two well-designed randomized trials. Nordin et al. (2003), who randomly assigned 616 patients undergoing inguinal hernia repair to local, general, or spinal anesthesia, found that patients who received local anesthesia had a significantly reduced incidence of early postoperative complications (15%) compared to general (44%) and regional (48%) anesthesia (P < 0.001) [3]. The difference in complication rates was especially profound for patients who required postoperative urinary catheterization for urinary retention after regional (29%) and general (8%) anesthesia, which was greater than the rate for local anesthesia (0%) [3]. In a follow-up cost analysis paper, the same authors demonstrated a reduction in perioperative cost of 15.0% when local was used as an alternative to general anesthesia [4]. Although there is data in the literature that use of local anesthesia is cost effective relative to general anesthesia, reimbursements may vary across countries and regions, which could influence the choice of anesthesia modality. In a separate randomized controlled trial, O’Dwyer et al. (2003) found that local anesthesia reduced movement-related pain compared to general anesthesia (23.3% vs. 31.4%; P = 0.04), but there were no other differences in outcomes of interest, including mobility at 24 or 72 hours, time to recovery of normal activities, or cognitive function [5]. O’Dwyer et al. did find that patients who received local anesthesia were less likely to recommend the same hernia operation to someone else, although recommendation rates were high for both local (84%) and general anesthesia (95%) [5].
The reason for the steady decline in local anesthesia use is unclear. It might be that surgeons and anesthesiologists have become more comfortable offering general anesthesia to older and sicker patients, decreasing the role for local anesthesia. Additionally, surgeons might worry that patients could feel more pain or discomfort during a procedure under local anesthesia, and this might result in poor reviews for the surgeon and hospital. Further, the decline in the use of local anesthesia may have become a self-fulfilling prophecy. As fewer surgeons use local anesthesia in their routine practice, fewer residents receive enough training to be comfortable with this technique. Those residents are then unable to train future generations to perform surgery under local, and this trend carries over into the next generation despite potential benefits to patients. Although our study is not able to determine which of these reasons might contribute to the decline in the use of local, we plan to conduct qualitative studies to address this important question.
While our study demonstrates that the use of local anesthesia has decreased over time, there are several limitations that should be acknowledged. First, as mentioned above, we can only describe trends in anesthesia use but cannot yet determine why the trends exist. Additionally, we are only able to evaluate which anesthesia modality was ultimately used. Our dataset cannot determine whether patients were offered local anesthesia but declined, or whether only general anesthesia was considered. Additionally, our study population consisted solely of VA patients and may not be representative of national trends outside the VA health system. However, there is no reason to assume that VA surgeons would be more or less likely than other surgeons to use local anesthesia for this common procedure. Lastly, the increasing use of minimally invasive techniques for inguinal hernia repair may have an effect on the overall frequency of open inguinal hernia repair, but was not included in this analysis. Although the reasons for decline aren’t clear, the decrease in local anesthesia generally corresponded with an increase in the use of general anesthesia. As fewer surgeons perform operations during local anesthesia, the opportunities for the next generation to train using this technique also diminishes.
CONCLUSIONS
The use of local anesthesia for inguinal hernia repair has steadily declined, despite the publication of evidence from randomized controlled trials reporting equivalent or improved perioperative outcomes and recommendations from surgical and geriatric societies encouraging the use of local over general anesthesia. We plan to follow this study with a qualitative evaluation involving surgeons, anesthesiologists, patients, and hospital leadership to identify potential barriers and facilitators to the greater use of local anesthesia.
Funding
This work was supported by a GEMSSTAR grant from the National Institute of Aging (1R03AG056330; for C.J.B.). Dr. Brown was supported, in part, by a VA Rehabilitation R&D Merit Award (1 I01 RX001995). MB acknowledges funding support from National Institutes of Health Beeson K76AG057022 and additional support from National Institutes of Health P30AG028716 and the Duke Anesthesiology Department.
The authors would like to thank Dave Primm of the UT Southwestern Department of Surgery for help in editing this article.
Footnotes
Conflicts of interest
The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.
Code availability
The Stata code with be available upon request.
Ethics and consent
The study was approved by the North Texas Veterans Affairs Health Care System Institutional Review Board. Informed consent was waived.
Consent for publication
All authors have reviewed the manuscript and have approved of the final version.
Presented at the 2021 Association of Veterans Affairs Surgeons Annual Meeting (April 2021)
Availability of data and material
The data is not publicly available and will not be available as the dataset contains identifiable information and must be kept within the Veterans Affairs server.
REFERENCES
- 1.U.S. Department of Health and Human Service NIoDaDaKD. Digestive diseases statistics for the United States..https://www.aafp.org/afp/2013/0615/p844.html-afp20130615p844-b2. Published 2010. Accessed 2019.
- 2.Rutkow IM. (2003) Demographic and socioeconomic aspects of hernia repair in the United States in 2003. Surg Clin North Am. 83(5): 1045–1051, v–vi. doi: 10.1016/S0039-6109(03)00132-4. [DOI] [PubMed] [Google Scholar]
- 3.Nordin P, Zetterstrom H, Gunnarsson U, Nilsson E. (2003) Local, regional, or general anaesthesia in groin hernia repair: multicentre randomised trial. Lancet. 362(9387):853–858. 10.1016/S0140-6736(03)14339-5 [DOI] [PubMed] [Google Scholar]
- 4.Nordin P, Zetterstrom H, Carlsson P, Nilsson E. (2007) Cost-effectiveness analysis of local, regional and general anaesthesia for inguinal hernia repair using data from a randomized clinical trial. Br J Surg. 94(4):500–505. doi: 10.1002/bjs.5543. [DOI] [PubMed] [Google Scholar]
- 5.O’Dwyer PJ, Serpell MG, Millar K, et al. (2003) Local or general anesthesia for open hernia repair: a randomized trial. Ann Surg. 237(4):574–579. doi: 10.1097/01.SLA.0000059992.76731.64 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Mohanty S, Rosenthal RA, Russell MM, Neuman MD, Ko CY, Esnaola NF. (2016) Optimal Perioperative Management of the Geriatric Patient: A Best Practices Guideline from the American College of Surgeons NSQIP and the American Geriatrics Society. J Am Coll Surg. 222(5):930–947. doi: 10.1016/j.jamcollsurg.2015.12.026. [DOI] [PubMed] [Google Scholar]
- 7.Chen CW, Lin CC, Chen KB, Kuo YC, Li CY, Chung CJ. (2014) Increased risk of dementia in people with previous exposure to general anesthesia: a nationwide population-based case-control study. Alzheimers Dement. 10(2):196–204. doi: 10.1016/j.jalz.2013.05.1766. [DOI] [PubMed] [Google Scholar]
- 8.Hussain M, Berger M, Eckenhoff RG, Seitz DP. (2014) General anesthetic and the risk of dementia in elderly patients: current insights. Clin Interv Aging. 9:1619–1628. doi: 10.2147/cia.s49680. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Bhattacharya SD, Vaslef SN, Pappas TN, Scarborough JE. (2012) Locoregional versus general anesthesia for open inguinal herniorrhaphy: a National Surgical Quality Improvement Program analysis. Am Surg. 2012;78(7):798–802. [PubMed] [Google Scholar]
- 10.Balentine CJ, Meier J, Berger M, et al. (2020) Using local rather than general anesthesia for inguinal hernia repair is associated with shorter operative time and enhanced postoperative recovery. Am J Surg. May;221(5):902–907. doi: 10.1016/j.amjsurg.2020.08.024. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data is not publicly available and will not be available as the dataset contains identifiable information and must be kept within the Veterans Affairs server.