# Disparities in minimally invasive surgery for elective inguinal hernia repair across Europe: secondary analysis of an international cohort study

## TL;DR

Minimally invasive surgery for hernia repair is used much more in Western Europe than in Southern Europe, showing big differences in access to advanced surgical techniques.

## Contribution

The study reveals significant regional disparities in minimally invasive surgery adoption for hernia repair across Europe.

## Key findings

- Western Europe had the highest use of minimally invasive surgery (70.6%), while Southern Europe had the lowest (15.4%).
- Bilateral hernias, high-volume surgeons, and private hospitals were linked to higher use of minimally invasive surgery.
- Southern Europe needs targeted efforts to improve access to advanced surgical techniques.

## Abstract

Healthcare systems in Europe vary in funding, accessibility, and spending per capita, potentially influencing patient access to advanced surgical techniques. This study aimed to provide a snapshot of the utilization of minimally invasive surgery for elective inguinal hernia repair across Europe.

This was a secondary analysis of an international, prospective observational study of inguinal hernia repairs conducted between 30 January and 21 May 2023. Adults undergoing elective inguinal hernia repair in Europe were included in the present analysis. The four European regions according to the United Nations geoscheme (Southern, Eastern, Northern, and Western Europe) were compared. A multilevel multivariable logistic regression model was used to explore factors associated with use of minimally invasive surgery.

A total of 8355 patients from 254 hospitals across 23 European countries were included: 5590 from Southern, 587 from Eastern, 1541 from Northern, and 637 from Western Europe. Most hospitals were public (88.8%) and tertiary level (49.9%). Patient and hernia characteristics were generally similar, except Western Europe reported higher rates of bilateral hernias (25.9% versus 14.1% overall). Minimally invasive surgery was performed in 26.0% of patients, 70.6% in Western, 37.9% in Northern, 46.5% in Eastern, and 15.4% in Southern Europe. Multivariable regression showed significant regional disparities. Multivariable regression also identified bilateral hernias (adjusted odds ratio 14.33 (95% confidence interval 11.76 to 17.47), surgeons with experience of ≥ 201 procedures (odds ratio 3.54, 2.75 to 4.54), and private hospitals (odds ratio 2.80, 1.03 to 7.65) as factors associated with greater use of minimally invasive surgery.

Significant disparities in minimally invasive surgery for elective inguinal hernia repair exist across Europe. Targeted initiatives should especially prioritize Southern Europe to ensure equitable access to advanced techniques.

Minimally invasive surgery (MIS) utilization in elective inguinal hernia repair varies significantly across Europe. In this analysis of 8355 patients from 23 countries, the highest rate of adoption of MIS was in Western Europe (70.6%) and the lowest in Southern Europe (15.4%). Factors associated with increased MIS use included bilateral hernias, high-volume surgeons, and private hospitals, highlighting the need for targeted efforts to improve access, particularly in Southern Europe.