Impact of surgical approach on complications by sex following ventral and incisional hernia repair.

Objective: Female patients are more likely than male patients to experience postoperative complications following hernia repair, but the drivers of this phenomenon remain unexplored. Whether surgical approach differentially impacts the likelihood of postoperative complications by sex following ventral and incisional hernia repair (VIHR) remains unknown.

Methods: Adult patients from the Michigan Surgical Quality Collaborative Core Optimization Hernia Registry (MSQC-COHR) were included in this study. MSQC-COHR is a representative, random sample of adult patients from 70 hospitals across Michigan. All elective VIHR performed between January 1, 2020, to September 30, 2023, were included. The primary outcome was any 30-day complication. A multivariable logistics mixed effects model was used to measure the adjusted associations between the observed covariates and the likelihood of 30-day complications. Sex and surgical approach were interacted to test for potential differential effects of surgical approach on 30-day complications by sex.

Results: Among 10,675 patients who underwent elective VIHR, 254 (2.4%) experienced postoperative complications. Of these, 152 (59.8%) patients were female. In bivariate analyses, female patients more often experienced a 30-day complication, regardless of operative approach (3.3% vs. 1.7%, p < 0.001). By surgical approach, female patients were found to have 4.2% (95% CI: 3.2-5.1) probability of 30-day complications after open repair, versus 1.5% (95% CI: 1.0-2.1) following MIS VIHR. Male patients had 2.1% (95% CI: 1.5-2.7) probability of 30-day complications after open repair, versus 1.5% (95% CI: 0.9-1.9) following MIS VIHR. Comparatively, female patients were 2.7 times more likely to experience complications after open repair compared to MIS repair, while male patients were 1.4 times more likely to have complications after open vs. MIS repair.

Conclusions: Following both open and MIS VIHR, female patients have a higher risk of postoperative complications compared to male patients, with this risk increasing after open repairs. The outcome disparity persists even after accounting for differences in comorbidities and hernia characteristics. Although this sex-based outcome disparity is not fully eliminated, MIS approaches mitigate the gap, suggesting that MIS repairs should be prioritized in female patients when feasible.