Abstract
Purpose
To investigate the impact of the COVID-19 pandemic on the clinical impact of the clinical outcomes of robotic inguinal hernia repair.
Methods
Patients who underwent RIHR 2 years before and after March 10, 2020, were included in this retrospective study and assigned accordingly to the pre- or post-COVID group. Pre-, intra-, and postoperative variables including patients’ demographics, hernia characteristics, complications, and hernia recurrence rates were compared between groups.
Results
183 (94.5% male) and 141 (96.4% male) patients were assigned to the pre- and post-COVID groups, respectively. Patient demographics and medical comorbidities did not differ between groups. Operative time was approximately 40 min longer in the post-COVID group (p < 0.001) with higher rates of bilateral IHR (pre-COVID: 30.1% vs. post-COVID: 46.4%, p = 0.003). Mesh material differed between groups with predominance of polyester mesh in the pre-COVID group vs. polypropylene in the post-COVID one. Median hospital length of stay (LOS) was 0 days in both groups, and same-day discharge rates were 93.4% pre-pandemic and 92.8% post-pandemic (p = 0.09). There were no pulmonary complications recorded in either group or no cases of COVID-19 detected within two weeks postoperatively in the post-COVID group. Seromas were more frequent in the post-COVID group (pre-COVID: 2 vs. post-COVID: 8, p = 0.018) and no hernia recurrences were recorded.
Conclusion
This is the first study to describe the impact of COVID-19 on RIHR. Clinical outcomes and hernia-specific complications were not impacted by the COVID-19 pandemic.
Keywords: COVID-19, Robotic, Inguinal hernia repair, Outcomes
Introduction
The COVID-19 virus spread rapidly across the globe during the past two years with more than 600 million cumulative cases as of September 2022 [1]. In the initial phase, the unexpected surge in cases disrupted the healthcare sector by putting a strain on resources and personnel. Elective treatments and surgeries were postponed across all specialties to decelerate the spread of the virus through unnecessary hospital admissions [2]. On March 10, 2020, a state of emergency was declared in Massachusetts in response to the unprecedented crisis. Surgical procedures were limited to emergent cases in an effort to reallocate resources toward the pandemic response [3]. To avoid overcrowding the hospitals by shortening stays, several interventions were gradually carried out in an outpatient setting across many disciplines [4, 5].
Inguinal hernia repair (IHR), one of the most performed surgeries worldwide with more than 20 million cases annually [6], is typically performed as an outpatient procedure. In addition, the minimally invasive approach has become more appealing thanks to reduced postoperative pain and accelerated return to work, along with the possibility of a same-day discharge [7, 8]. IHR was of interest in this study to understand if the pandemic caused a shift in what is considered to be a straightforward and routinely performed procedure.
With the pandemic constraining the medical sector, this study aimed to evaluate the impact of COVID-19 on clinical outcomes of robotic IHR (RIHR). We hypothesized that clinical results for RIHR would not differ after the COVID-19 pandemic.
Materials and methods
Patient selection and study groups
A review of a prospectively maintained database of consecutive patients who underwent RIHR in a suburban teaching hospital between February 2012 and August 2022 was performed. Based around the state of emergency declared in Massachusetts on March 10, 2020, two groups of RIHR were formed: the pre-COVID group (from March 2018 to March 2020) and the post-COVID group (from March 2020 to March 2022). Cases of concomitant procedures with RIHR were excluded from the study. All procedures included in this study were performed past all of the learning curve phase defined in a study that has been previously published [9]. For the post-COVID timeframe, patients underwent their procedures only if they have tested negative for the COVID-19 virus. All medical records were thoroughly examined to assess if there were any cases of pre- or postoperative COVID-19 contraction. No particular measures in the selection criteria, technical operation, or clinical pathways were taken, asides from the mandatory COVID-19 testing.
Variables
Preoperative, intraoperative and postoperative variables were: patient demographics [age, sex, body mass index (BMI as kg/m2)], the American Society of Anesthesiologists classification scores (ASA), comorbidities [hypertension (HTN), myocardial infarction (MI), coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), smoking (defined as active smoking within three months of operation), history of previous wound infection)], hernia side (right or left) and type (direct, indirect, femoral), complex hernia (previous posterior repair, previous open prostatectomy, incarcerated hernia, scrotal hernia), procedural setting (elective or emergency), hernia content (omentum, small intestine, colon), mesh material (polypropylene or polyester), mesh dimensions (cm), mesh fixation method, the operative time, the estimated blood loss (mL, EBL), intraoperative complications if present, postoperative pain scores [(according to 0–10 verbal scale which was assessed immediately after surgery in post-anesthesia care unit-(PACU)], pain medication used as morphine milligram equivalent (MME), the hospital length of stay (LOS—defined as the difference between postoperative discharge date and index operation date), emergency department (ED) revisit, hospital readmission within 30-days, and postoperative complications during follow-up visits. All postoperative complications were categorized according to the Clavien–Dindo classification system [10]. Morbidity scores were measured using the Comprehensive Complication Index (CCI®, University of Zurich, Zurich, Switzerland) [11]. Surgical-site events (SSEs) were further categorized into surgical-site infections (SSIs), surgical-site occurrences (SSOs—seromas and hematomas), surgical-site occurrences requiring procedural interventions (SSOPIs), and recurrences, if present [12, 13].
As part of routine care, all postoperative patients were clinically evaluated at two postoperative intervals: within three weeks, and then at three months. Further follow-up was performed on a semi-annual and annual basis.
Statistical analysis
Statistical analysis was performed using the SPSS software pack (Statistical Package for Social Sciences for Windows version 28 software). Categorical variables were reported as the frequency with percentage [n (%)] and continuous variables as mean ± SD or median (interquartile range, IQR), as appropriate. Categorical variables were analyzed using Pearson chi-Square or Fisher’s exact test, and continuous variables using the Independent-Sample t test (for normal distributions) or Mann–Whitney U Test (for non-normal distributions). A p value lower than 0.05 was considered statistically significant.
Results
A total of 321 patients underwent RIHR during the study period, with 183 (57%) patients in the pre-COVID group and 138 (43%) in the post-COVID group. Patient demographics and hernia characteristics did not differ between groups except with incarcerated hernia, which was more frequently seen in the post-COVID group (Table 1). No previous infections with the COVID-19 virus were noted in the post-COVID group. Additionally, no patients contracted the virus within two weeks after their procedure. The rate of emergent cases did not differ between groups [6 (3.3%) pre-COVID vs. 12 (6.5%) post-COVID, p = 0.191]. In terms of hernia contents, greater percentages of omentum were observed in the post-COVID group than the pre-COVID group (p = 0.023; 8.2 vs. 16.7%, respectively), whereas rates of incarcerated small bowel and colon did not differ between groups (p = 0.133 and p = 0.642, respectively). The rate of bilateral hernia repair was higher for the post-COVID group (p = 0.003; 30.1 vs. 46.4%).
Table 1.
Comparison of preoperative variables between the study groups
| Pre-COVID | Post-COVID | p value | |
|---|---|---|---|
| (n = 183) | (n = 138) | ||
| Age (years), mean ± SD | 58.3 ± 16.3 | 58.5 ± 14.9 | 0.922 |
| Sex, male, n (%) | 173 (94.5) | 133 (96.4) | 0.595 |
| BMI (kg/m2), mean ± SD | 26.4 ± 5 | 27.2 ± 5.2 | 0.177 |
| ASA Score, median (IQR) | 2 (2–3) | 2 (2–3) | 0.651 |
| HTN, yes, n (%) | 67 (36.6) | 64 (46.4) | 0.086 |
| CAD, yes, n (%) | 22 (12) | 18 (13) | 0.865 |
| COPD, yes, n (%) | 13 (7.1) | 9 (6.5) | 1.000 |
| Smoking, yes, n (%) | 37 (20.2) | 19 (13.8) | 0.14 |
| DM, yes, n (%) | 22 (12) | 13 (9.4) | 0.477 |
| Hx of wound infection, yes, n (%) | 0 (0) | 2 (1.4) | 0.102 |
| Left-sided hernia | 112 (61.2) | 94 (68.1) | 0.24 |
| Direct, n (%) | 36 (19.7) | 32 (23.2) | 0.491 |
| Indirect, n (%) | 78 (42.6) | 62 (44.9) | 0.733 |
| Femoral, n (%) | 3 (1.6) | 0 (0) | 0.131 |
| Recurrent, n (%) | 10 (5.5) | 15 (10.6) | 0.092 |
| Right-sided hernia | 126 (68.9 | 108 (78.3) | 0.076 |
| Direct, n (%) | 35 (19.1) | 31 (22.5) | 0.488 |
| Indirect, n (%) | 93 (50.8) | 76 (55.1) | 0.498 |
| Femoral, n (%) | 3 (1.6) | 1 (0.7) | 0.465 |
| Recurrent, n (%) | 12 (6.6) | 16 (11.6) | 0.161 |
| Complex hernia, yes, n (%) | 67 (36.6) | 65 (47.1) | 0.067 |
| Previous posterior repair, yes, n (%) | 7 (3.8) | 13 (9.4) | 0.06 |
| Prostatectomy, yes, n (%) | 2 (1.1) | 6 (4.3) | 0.079 |
| Incarcerated hernia, yes, n (%) | 27 (14.8) | 37 (26.8) | 0.011 |
| Scrotal hernia, yes, n (%) | 51 (27.9) | 26 (18.8) | 0.066 |
BMI body mass index, ASA American society of anesthesiologist, HTN hypertension, CAD coronary artery disease, MI myocardial infarction, COPD chronic obstructive pulmonary disease, DM diabetes mellitus, SD standard deviation
Comparison of intraoperative variables is provided in Table 2. Mesh material and size, fixation method, and operative time significantly differed between groups. With further bivariate comparisons that stratified patients according to the studied group and complexity of the hernia, the duration of bilateral hernia repairs was found to be longer than unilateral repairs in each stratified sample (p < 0.001). The median (min–max) EBL was higher in the pre-COVID group (5–250 mL) than in the post-COVID group (2–30 mL). One patient with a history of previous open IHR in the pre-COVID group suffered from intraoperative bleeding secondary to inferior epi-gastric vessel injury during pre-peritoneal dissection due to extensive adhesions. The bleeding was controlled with clips. In the post-COVID group, only one patient experienced an intraoperative complication due to a prior history of bladder surgery and posterior repair. Consequently, the bladder was injured during dissection of an anatomically distorted pre-peritoneal plane and was eventually repaired with superficial sutures. In one patient with a massive scrotal hernia in the post-COVID group, RIHR was completed with an open reduction of the hernia content and division of the hernia sac.
Table 2.
Comparison of intraoperative variables between the two groups
| Pre-COVID | Post-COVID | p value | |
|---|---|---|---|
| (n = 183) | (n = 138) | ||
| Mesh sizes | |||
| Length, cm, median (IQR) | 16 (16–16) | 17.3 (17.3–17.3) | < 0.001 |
| Width, cm, median (IQR) | 12 (12–12) | 12.4 (12.4–12.4) | < 0.001 |
| Mesh material | |||
| Polypropylene, n (%) | 7 (3.8) | 136 (98.6) | < 0.001 |
| Polyester, n (%) | 176 (96.2) | 2 (1.4) | < 0.001 |
| Operating time, min, median (IQR) | 58 (40–88) | 95 (74–126) | < 0.001 |
| Estimated blood loss, mL, median (IQR) | 5 (5–5) | 5 (5–5) | < 0.001 |
| Mean ± 95% CI | 8 (4.8–11.3) | 6.6 (5.9–7.4) | 0.449 |
| Intraoperative complications, n (%) | 1 (0.5) | 1 (0.7) | 1.000 |
IQR interquartile range, CI confidence interval
Values in bold indicate a p-value < 0.05
The median (IQR) pain scores were 4 (3–6) in the post-COVID group and 3 (2–5) in the pre-COVID group (p < 0.001). In both groups, the median (IQR) MME was 5 (0–10, p = 0.489). The median (max) hospital LOS did not differ between groups [p = 0.749; 0(10) days for pre-COVID group vs. 0(20) days for post-COVID group]. Same-day discharge rate was 93.4% for pre-COVID group vs. 92.8% for post-COVID group (p = 0.827).
Eight patients (4.4%) required an emergency room visit within 30 days of discharge in the pre-COVID group vs. five (3.6%) patients in the post-COVID group (p = 0.784). One (0.7%) patient in the post-COVID group required hospital readmission due to a hematoma. Twenty-three (12.6%) patients in the pre-COVID group did not attend any postoperative visits, while 15 (10.9%) patients in the post-COVID group were noted as lost to follow-up (p = 0.728). Overall postoperative complication rates did not differ between the two groups (p = 0.560); with 19 (11.9%) patients in the pre-COVID group experiencing one or more postoperative complications vs. 11 (8.9%) patients in the post-COVID group. Complications are summarized in Table 3.
Table 3.
Comparison of the postoperative complications between the two groups
| Pre-COVID | Post-COVID | p value | |
|---|---|---|---|
| (n = 160) | (n = 123) | ||
| Clavien–Dindo classification | |||
| Grade-I, n (%) | 16 (10) | 9 (7.3) | 0.528 |
| Grade-II, n (%) | 0 (0) | 2 (1.6) | 0.106 |
| Grade-IIIA, n (%) | 0 (0) | 0 (0) | N/A |
| Grade-IIIB, n (%) | 2 (1.3) | 0 (0) | 0.213 |
| Grade-IVA, n (%) | 1 (0.6) | 0 (0) | 1.000 |
| CCI® score, mean (max) | 1.6 (42.4) | 1 (20.9) | 0.42 |
| SSEs, n (%) | 9 (5.6) | 10 (8.1) | 0.475 |
| SSI, n (%) | 0 (0) | 0 (0) | N/A |
| SSOs, n (%) | 7 (4.4) | 10 (8.1) | 0.213 |
| Seroma, n (%) | 2 (1.3) | 8 (6.5) | 0.018 |
| Hematoma, n (%) | 5 (3.1) | 2 (1.6) | 0.703 |
| SSOPI, n (%) | 0 (0) | 0 (0) | N/A |
| Recurrence, n (%) | 2 (1.3) | 0 (0) | 0.507 |
CCI® Comprehensive complication index, SSEs surgical-site events, SSI surgical-site infection, SSOs surgical-site occurrences, SSOPI surgical-site occurrence procedural intervention
Values in bold indicate a p-value < 0.05
Discussion
The COVID-19 pandemic severely disrupted the healthcare sector and forced many hospitals to halt surgical procedures to maximize efforts to control the virus. However, as conditions improved, same-day procedures were gradually re-introduced as patients were less likely to become exposed to the virus. As one of the most common procedures worldwide, IHR benefits from a reduced length of stay and is most often performed in an outpatient setting. Therefore, our study aimed to assess the impact of the COVID-19 virus on RIHR through a comparison of pre- and post-COVID clinical outcomes.
In our cohort, patient demographics did not differ between both groups, with age comparable in the pre- and post-COVID era. No cases of prior, active or postoperatively contracted cases of COVID-19 were recorded in our data. Furthermore, comorbidities were similar as well, particularly for pulmonary etiologies, such as chronic obstructive pulmonary disease (COPD). Interestingly, the pre-COVID group had almost double the number of smokers. Although there were no statistical differences between groups, the lower number of smokers in the post-COVID group might suggest reluctance to undergo any surgical procedure as smoking has been associated with higher mortality [14]. Operative time was significantly higher in the post-COVID group, which could be attributed to the higher proportion of bilateral inguinal hernias. Regarding postoperative outcomes, no significant complications were recorded in either group. Recurrence rates did not differ between the pre- and post-COVID eras. However, a higher number of seromas were noted in the post-COVID group during the follow-up period. One possible explanation for this result is the different type of mesh material used as a shift from polyester to propylene was seen. Although most articles in the literature do not associate polypropylene mesh material with the increased risk of seroma formation [15, 16], and this result must be investigated in future studies.
In an international snapshot evaluating the impact of COVID-19 on elective IHR, the proportion of older patients with higher comorbidities was significantly reduced. Additionally, many patients reported reluctance to undergo elective IHR [17]. This finding was also seen in a study by Gomez et al., in which the authors compared rates of inguinal hernia-related encounters between the pre-COVID and post-COVID eras. They reported a 21% reduction in elective IHR, and a 17% decrease in emergency department visits for inguinal hernias, whereas emergent IHR were comparable [18]. In a study comparing the rate of strangulated and non-reducible inguinal hernias, Mulita et al. reported a significant increase in rates of both presentations [19]. In our study, the number of elective and emergent cases was comparable between both groups. Therefore, the pandemic did not seem to hinder the willingness of patients to undergo RIHR or the surgeons to perform the procedures at our institution. However, it is essential to highlight the difference in time frames selected for each study. While other authors opted for shorter periods, our work aimed to evaluate the longer-term impact of COVID-19 on IHR.
In terms of pulmonary complications, none were recorded in either group. Additionally, no cases of COVID-19 contraction were noted within 2 weeks postoperatively. At the beginning of the pandemic, aerosolization of the virus was believed to increase the transmission rate. Consequently, minimally invasive surgery was considered an increased risk for COVID-19 contraction due to the possibility of suspended viral particles in the smoke escaping from the trocars. However, these claims were refuted as no evidence supported such speculations. [20].
Our study has limitations. Its retrospective and single-center nature limits the generalizability of our findings, as the hospitals were affected differently during the pandemic, depending on the region, demographics, and countries.
In conclusion, this is the first study to describe the impact of the COVID-19 on RIHR by comparing of clinical outcomes between the pre- and post-pandemic eras. Rates of medical and hernia-specific complications were not altered by the pandemic.
Funding
No funding was received for this study.
Declarations
Conflict of interest
Drs. Georges Kaoukabani, Alexander Friedman, Jenna Bahadir, Naseem Bou-Ayash, Kelly Vallar, and Fahri Gokcal have no conflicts of interest or financial ties to disclose. Dr. Omar Yusef Kudsi has received a teaching course and/or consultancy fees from Intuitive Surgical, Bard-Davol, and W.L. Gore outside the submitted work.
Ethical approval
The database used for this study approved by the Institutional Review Board.
Human and animal rights
All procedures performed in studies involving human participants were under the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent
Informed consent was obtained from all individual participants included in the study.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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