J. B. Meier1,2, M. Berger3, T. Hogan1,4, M. Cullum5, S. C. Lee4, C. S. Skinner4, C. J. Brown6,7, C. J. Balentine1,2 1University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA 2VA North Texas Health Care System,Department Of Surgery,Dallas, TX, USA 3Duke University Medical Center,Departmet Of Anesthesiology,Durham, NC, USA 4University Of Texas Southwestern Medical Center,Department Of Population And Data Sciences,Dallas, TX, USA 5University Of Texas Southwestern Medical Center,Division Of Psychology,Dallas, TX, USA 6University Of Alabama at Birmingham,Division Of Gerontology, Geriatrics, And Palliative Care,Birmingham, Alabama, USA 7Birmingham/Atlanta VA,Geriatric Research, Education, And Clinical Center,Birmingham, AL, USA
Introduction:
The American College of Surgeons and the American Geriatrics Society have urged surgeons to explore alternatives to general anesthesia for older adults to enhance surgical recovery. Inguinal hernia repair is the most common procedure performed by general surgeons in the United States with over 800,000 operations annually. However, the benefits of local versus general anesthesia for patients aged 65 years and older have not been established. We hypothesized that using local rather than general anesthesia for inguinal hernia surgery would reduce postoperative complications for older adults but would be less beneficial for younger patients
Methods:
We used data from the 2014-2017 American College of Surgeons National Surgical Quality Improvement Program to identify patients aged 18 years and older having elective open inguinal hernia repair for unilateral hernias under local or general anesthesia. Our primary outcome was incidence of postoperative complications. Secondary outcomes included operative time, readmissions, and estimated costs. We used propensity matching to compare outcomes for the local and general anesthesia cohorts, and divided patients into groups based on age (75+, 65-74, and <65 years). We then used a published value for operating room cost to calculate the potential cost savings associated with increased use of local anesthesia
Results:
We found that 11,417 patients had inguinal hernia surgery under local anesthesia and 46,477 under general anesthesia. Patients undergoing surgery with local anesthesia were generally older (median age 65 years versus 59 years) with more comorbidities. For patients aged 75 years and older, local anesthesia was associated with a 1% reduction in complications (95% CI -1.7% to -0.3%, p<0.005) without significant differences in operative time or readmissions. Patients aged 65-74 experienced shorter operative times of 2.5 minutes (95% CI -3.6 to -1.4, p<0.001) with local anesthesia but had similar rates of complications and readmissions compared to general anesthesia. Patients younger than 65 years experienced shorter operative times of 4 minutes but saw no difference in complications or readmissions. Additionally, we estimated that a 50% increase in use of local anesthesia for inguinal hernia surgery for all age groups could save the US healthcare system $45 million annually.
Conclusion:
Using local rather than general anesthesia for inguinal hernia repair offers different benefits depending on patient age. The oldest patients experience fewer complications, while younger patients spend less time in the operating room. Even though the absolute benefits of local anesthesia may be small, the surgery is so common that these effects have a large impact on the US healthcare system. Our findings suggest that regardless of age, surgeons should consider using local anesthesia for inguinal hernia surgery