# Inguinal Hernia Recurrence in Adults in Romania: A Five-Year Nationwide Analysis of Surgical Practice and Health System Disparities

## TL;DR

This study analyzed inguinal hernia recurrence in Romania over five years, highlighting disparities in surgical care and health system challenges.

## Contribution

The study provides a nationwide analysis of hernia recurrence in Romania, linking disparities to hospital sector and surgical approach.

## Key findings

- Reintervention rates varied widely (0.58% to 4.88%), indicating limitations in administrative coding for recurrence tracking.
- Public hospitals handled most cases and complex patients, while laparoscopic access was concentrated in academic centers.
- Shorter hospital stays in private hospitals suggest differences in patient selection and care pathways.

## Abstract

Introduction: Recurrent inguinal hernia remains a clinically relevant outcome that is difficult to quantify in the absence of national prospective registries. In Romania, structural differences between public and private hospitals may further influence recurrence-related care, access to minimally invasive surgery, and resource utilization. This study aimed to assess recurrence patterns after inguinal hernia repair at a national level, with emphasis on reinterventions, patient-related risk factors, and health system disparities. Methods: A nationwide retrospective cohort study was conducted using administrative DRG data from the Romanian National Health Insurance House. All adult patients undergoing inguinal hernia repair in 2019 were identified and followed for five years (2019–2023). Reintervention was used as a proxy for recurrence. Surgical approach, hospital sector, length of stay, reimbursement, patient migration, geographic distribution, and comorbidities were analyzed using descriptive statistics and multivariable logistic regression to explore factors associated with laparoscopic approach and reintervention. Results: Among the 18,185 patients who underwent inguinal hernia repair in 2019, reintervention rates during follow-up ranged from 0.58% to 4.88%, a variability that reflects inherent limitations of administrative coding. Most reinterventions occurred in the year of the index surgery, suggesting early technical failure. Public hospitals managed the majority of cases and disproportionately absorbed recurrent and clinically complex patients. Access to laparoscopic repair was uneven and concentrated in large academic centers. Length of hospital stay declined gradually in public hospitals but remained consistently shorter in private institutions, reflecting differences in patient selection and care pathways. Reimbursement by The National Health Insurance House was similar for open and laparoscopic procedures. Conclusions: Recurrent inguinal hernia care in Romania is shaped by system-level disparities extending beyond surgical technique. Further progress requires reimbursement reform, establishment of a national hernia registry, and expansion of laparoscopic training to ensure equitable access to high-quality hernia care.