European Journal of Cardiovascular Medicine

Hernia repair remains one of the most commonly performed general surgical procedures globally, particularly among the elderly population, where the incidence of abdominal wall hernias increases due to age-related tissue degeneration and comorbidities (1). Inguinal hernias, in particular, are frequently observed in older adults, and timely surgical intervention is essential to prevent complications such as strangulation and bowel obstruction (2). Traditionally, open mesh repair has been the gold standard for hernia surgery, especially in elderly individuals due to its simplicity and proven long-term efficacy (3). However, with advancements in minimally invasive surgery, laparoscopic techniques have gained significant traction and are increasingly being used in geriatric patients (4).

Laparoscopic hernia repair offers several advantages over open techniques, including reduced postoperative pain, shorter hospital stays, and earlier return to daily activities (5). Despite these benefits, the elderly population presents unique challenges due to the presence of multiple comorbidities, altered physiology, and decreased physiological reserve, which can influence the outcomes of any surgical intervention (6). The choice between laparoscopic and open hernia repair in the elderly must therefore be guided by a careful assessment of potential risks and benefits, as well as the patient's overall health status and surgical fitness (7).

Although several retrospective studies and meta-analyses have compared the outcomes of laparoscopic and open hernia repairs, data specific to elderly patients remain limited and often conflicting (8). There is a need for prospective, multicentric studies that comprehensively evaluate perioperative and postoperative outcomes in this age group to better guide clinical decision-making. This study was designed to compare the clinical outcomes of laparoscopic versus open hernia repair specifically in elderly patients, aiming to provide evidence-based guidance for optimal surgical management in this growing patient population.

This multicentric prospective study was conducted at three tertiary care hospitals. The study population included elderly patients aged 65 years and above who were diagnosed with a primary unilateral inguinal hernia and scheduled for elective surgical repair. Informed written consent was obtained from all patients prior to inclusion.

Study Design and Group Allocation
A total of 240 patients were enrolled and randomly allocated into two equal groups using a computer-generated randomization sequence. Group A (n=120) underwent laparoscopic hernia repair using the transabdominal preperitoneal (TAPP) technique, while Group B (n=120) underwent conventional open mesh repair via the Lichtenstein method. Patients with recurrent hernias, bilateral hernias, complicated hernias (strangulated/incarcerated), or severe cardiopulmonary comorbidities were excluded from the study.

Surgical Procedure
All surgeries were performed by experienced general surgeons with at least five years of surgical experience in both techniques. Standardized protocols were followed for preoperative preparation, anesthesia, and postoperative care in all centers. Laparoscopic procedures were conducted under general anesthesia, whereas open surgeries were performed under spinal or general anesthesia depending on patient suitability.

Outcome Measures
Primary outcome parameters included operative time, postoperative pain (measured using a 10-point Visual Analog Scale at 6, 24, and 48 hours), length of hospital stay, time to return to normal activities, and postoperative complications (wound infection, hematoma, urinary retention, seroma, and recurrence). Follow-up assessments were conducted at 1 week, 1 month, and 6 months postoperatively.

Data Analysis
All data were recorded in a predesigned proforma and entered into Microsoft Excel. Statistical analysis was performed using SPSS version 25.0. Continuous variables were expressed as mean ± standard deviation and compared using the independent t-test. Categorical variables were expressed as percentages and analyzed using the chi-square test or Fisher’s exact test, as appropriate. A p-value of <0.05 was considered statistically significant.

A total of 240 patients were enrolled in the study and completed follow-up. Group A (laparoscopic repair) and Group B (open repair) each comprised 120 patients. The demographic characteristics, including mean age and sex distribution, were comparable between the two groups, with no statistically significant differences (Table 1).

The mean operative time was significantly longer in the laparoscopic group (78.4 ± 10.6 minutes) compared to the open repair group (63.2 ± 9.8 minutes), with a p-value <0.001. However, patients in Group A experienced significantly lower postoperative pain at 24 hours (VAS score: 3.2 ± 1.1) than those in Group B (VAS score: 5.5 ± 1.4), which was statistically significant (p<0.001). The average hospital stay was shorter in the laparoscopic group (1.9 ± 0.7 days) than in the open group (3.1 ± 1.1 days), with a p-value <0.001. Additionally, the time to resume normal daily activities was significantly quicker in Group A (9.6 ± 2.3 days) than in Group B (14.2 ± 3.1 days) (Table 2).

Regarding postoperative complications, Group A reported a slightly lower rate (10%) compared to Group B (13%), but the difference was not statistically significant (p=0.48). The most common complications were wound seroma and superficial surgical site infection. There were no cases of recurrence in either group during the six-month follow-up period (Table 3).

These results highlight the advantages of laparoscopic hernia repair in elderly patients in terms of reduced postoperative pain, faster recovery, and shorter hospitalization, despite the longer operative time (Table 2, Table 3).

Table 1: Demographic Profile of Patients

Table 2: Perioperative and Recovery Outcomes

Table 3: Postoperative Complications

These findings clearly suggest that laparoscopic repair offers better short-term outcomes with acceptable complication rates in elderly patients undergoing hernia surgery (Tables 2 & 3).

The findings of this multicentric prospective study demonstrate that laparoscopic hernia repair offers significant advantages over the traditional open approach in elderly patients, particularly with respect to postoperative pain, hospital stay, and recovery time. These results support the growing preference for minimally invasive techniques in geriatric surgical care, aligning with previous reports in the literature (1,2).

The reduced postoperative pain observed in the laparoscopic group, as indicated by significantly lower VAS scores, is consistent with prior studies that emphasize the benefit of minimal tissue dissection in laparoscopic procedures (3,4). This factor not only enhances patient comfort but also minimizes the need for prolonged analgesic administration, reducing the risk of drug-related side effects in older individuals with multiple comorbidities (5).

The shorter hospital stay and faster return to daily activities in the laparoscopic group observed in this study are also noteworthy. Similar outcomes have been documented in meta-analyses and randomized trials comparing laparoscopic and open inguinal hernia repair, attributing the faster recovery to lower inflammatory response and earlier mobilization (6–8). These advantages are particularly relevant in the elderly, where extended hospitalization may predispose to complications such as nosocomial infections, thromboembolic events, and functional decline (9).

Although the operative time was significantly longer in the laparoscopic group, this is a known limitation of minimally invasive approaches, particularly during the learning curve of the surgical team (10). However, the clinical benefits of quicker postoperative recovery may outweigh the slightly prolonged intraoperative period, especially when performed by experienced surgeons in high-volume centers (11).

In terms of safety, both groups exhibited comparable postoperative complication rates. The incidence of surgical site infection was marginally lower in the laparoscopic group, which is in line with existing evidence suggesting that smaller incisions and reduced tissue exposure lower the risk of wound-related complications (12,13). Importantly, no cases of recurrence were recorded during the six-month follow-up in either group, indicating that both techniques are equally effective in the short term when performed with proper surgical technique and patient selection (14).

This study adds to the existing body of evidence supporting laparoscopic hernia repair in elderly patients. However, certain limitations must be acknowledged. Firstly, the follow-up period was relatively short, and long-term recurrence rates could not be assessed. Secondly, although the study was prospective and multicentric, some degree of inter-operator variability could have influenced the results. Future research with longer follow-up and inclusion of quality-of-life assessments may provide deeper insights into the long-term impact of both surgical approaches (15).

In conclusion, laparoscopic hernia repair appears to be a safe and effective option for elderly patients, providing better postoperative comfort, quicker recovery, and comparable complication rates when compared to open mesh repair. These findings support the integration of laparoscopic techniques into routine surgical care for the elderly, provided the procedure is performed by skilled teams with appropriate resources.

1. Xu Z, Zhao Y, Fu X, Hu W, Zhao C, Ge C, et al. Laparoscopic versus open inguinal hernia repair in aging patients: a propensity score matching-based retrospective study. Ther Clin Risk Manag. 2023;19:657–66.
2. Yoneyama T, Nakashima M, Takeuchi M, Kawakami K. Comparison of laparoscopic and open inguinal hernia repair in adults: a retrospective cohort study using a medical claims database. Asian J Endosc Surg. 2022;15(3):513–23.
3. Rana G, Armijo PR, Khan S, Bills N, Morien M, Zhang J, et al. Outcomes and impact of laparoscopic inguinal hernia repair versus open inguinal hernia repair on healthcare spending and employee absenteeism. Surg Endosc. 2020;34(2):821–8.
4. O'Reilly EA, Burke JP, O'Connell PR. A meta-analysis of surgical morbidity and recurrence after laparoscopic and open repair of primary unilateral inguinal hernia. Ann Surg. 2012;255(5):846–53.
5. Pokala B, Armijo PR, Flores L, Hennings D, Oleynikov D. Minimally invasive inguinal hernia repair is superior to open: a national database review. Hernia. 2019;23(3):593–9.
6. Zhao Y, Xu Z, Wang T, Zhou D, Tang N, Zhang S, et al. The impact of laparoscopic versus open inguinal hernia repair for inguinal hernia treatment: a retrospective cohort study. Health Sci Rep. 2023;6(4):e1194.
7. Raajeshwaren MA, Vijayakumar C, Dutta S, Ramakrishnaiah VP. Outcomes from early experience with laparoscopic inguinal hernia repair versus open technique: navigating the learning curve. Sultan Qaboos Univ Med J. 2024;24(2):186–93.
8. Sehat AJ, Oliver JB, Yu Y, Kunac A, Anjaria DJ. Increasing volume but declining resident autonomy in laparoscopic inguinal hernia repair: an inverse relationship. Surg Endosc. 2023;37(4):3119–26.
9. Wang K, Tan SS, Xiao Y, Wang Z, Peng C, Pang W, et al. Characteristics and treatments for pediatric ordinary and incarcerated inguinal hernia based on gender: 12-year experiences from a single center. BMC Surg. 2021;21(1):67.
10. Lee Y, Tessier L, Jong A, Zhao D, Samarasinghe Y, Doumouras A, et al. Differences in in-hospital outcomes and healthcare utilization for laparoscopic versus open approach for emergency inguinal hernia repair: a nationwide analysis. Hernia. 2023;27(3):601–8.
11. Saleh F, Okrainec A, D'Souza N, Kwong J, Jackson TD. Safety of laparoscopic and open approaches for repair of the unilateral primary inguinal hernia: an analysis of short-term outcomes. Am J Surg. 2014;208(2):195–201.
12. Memon MA, Cooper NJ, Memon B, Memon MI, Abrams KR. Meta-analysis of randomized clinical trials comparing open and laparoscopic inguinal hernia repair. Br J Surg. 2003;90(12):1479–92.
13. Holzheimer RG, Gaschütz N. Prophylaxis and treatment of acute and chronic postoperative inguinal pain (CPIP)—association of pain with compression neuropathy. J Surg Case Rep. 2020;2020(7):rjaa143.
14. Ayuso SA, Marturano MN, Katzen MM, Aladegbami BG, Augenstein VA. Laparoscopic versus robotic inguinal hernia repair: a single-center case-matched study. Surg Endosc. 2023;37(1):631–7.
15. Kudsi OY, Bou-Ayash N, Kaoukabani G, Gokcal F. Comparison of perioperative and mid-term outcomes between laparoscopic and robotic inguinal hernia repair. Surg Endosc. 2023;37(2):1508–14.