The American Journal of Surgery (2015) 209, 468-472

Midwest Surgical Association

Outcomes and charges associated with

outpatient inguinal hernia repair according to
method of anesthesia and surgical approach
Adam L. Bourgon, D.O.*, Justin P. Fox, M.D., M.H.S.,
Jonathan M. Saxe, M.D., Randy J. Woods, M.D.
Department of Surgery, Boonshoft School of Medicine, Wright State University, Dayton, OH, USA

KEYWORDS:
Inguinal hernia;
Outcomes;
Readmission;
Anesthesia;
Ambulatory surgery

Abstract
BACKGROUND: We conducted this study to compare short-term outcomes and charges between
methods of hernia repair and anesthesia in the outpatient setting.
METHODS: Using New Yorks state ambulatory surgery databases, we identified discharges for
patients who underwent inguinal hernia repair. Patients were grouped by method of hernia repair.
We compared hospital-based acute care encounters and total charges across groups.
RESULTS: Locoregional anesthesia (5.2%) experienced a similar frequency of hospital-based
acute care encounters within 30 days of discharge when compared with patients receiving general
(6.0%) or having a laparoscopic procedure (6.0%). Risk-adjusted charges increased across groups
(locoregional 5 $6,845 vs general 5 $7,839 vs laparoscopic 5 $11,340, P , .01).
CONCLUSION: Open inguinal hernia repair under local anesthesia reduces healthcare charges.
Published by Elsevier Inc.

Inguinal hernia repair is one of the most common

general surgical procedures performed with over 500,000
in 2006, many of these occurring in ambulatory surgery
centers.1 For inguinal hernia repair, the approach to intraoperative anesthesia varies by surgeon, anesthesia provider,
and patient population. Although many patients undergo
general anesthesia (GA), the use of local anesthesia has
long been used for repair of inguinal hernias in patients
with a high burden of medical comorbidity.2
Disclaimers: The views expressed in this article are those of the authors
and do not reflect the official policy of the United States Air Force, Department of Defense, or the US Government.
There were no relevant financial relationships or any sources of support
in the form of grants, equipment, or drugs.
* Corresponding author. Tel.: 1937-208-2485; fax: 937-341-8258.
E-mail address: adambourgon@gmail.com
Manuscript received July 18, 2014; revised manuscript September 22,
2014

0002-9610/$ - see front matter Published by Elsevier Inc.

http://dx.doi.org/10.1016/j.amjsurg.2014.09.021

Each method of anesthesia has its own risk-benefit profile

and several studies have been conducted to analyze their
impact on patient outcomes following inguinal hernia repair.
Although most studies have found no difference in overall
complications according to the method of anesthesia, others
have suggested that local anesthesia may lead to better
perioperative pain control and earlier discharge.3,4 However,
with short hospital stays in the outpatient setting, complications may occur after discharge leading to additional care
in hospital emergency departments or inpatient wards.
As healthcare providers strive to provide high value care
and patients face higher out-of-pocket medical costs, it is
important to understand how anesthetic selection impacts
patient outcomes and overall charges. Few studies have
evaluated the relationship among costs, outcomes, and
anesthetic method in a multipayer, multicenter setting.
Therefore, we conducted this study of patients undergoing
outpatient inguinal hernia surgery using administrative data

A.L. Bourgon et al.

Outcomes and charges associated with inguinal

to compare charges and outcomes. We hypothesized that

the total charges for GA would be significantly higher
compared with local anesthesia.

Methods
We conducted a retrospective cohort study using data
from the 2009 to 2010 New York ambulatory surgery,
inpatient, and emergency department databases. These data
are collected by the New York State Department of Healths
Office of Quality and Patient Safety and made available to
researchers through the Agency for Healthcare Research and
Qualitys Healthcare Cost and Utilization Project. These data
are a census of discharges from free-standing and hospitalaffiliated ambulatory surgery centers; acute care, nonfederal,
community hospitals; and emergency department visits not
resulting in hospital admission. Each ambulatory surgery
center discharge abstract contains up to 20 Current Procedural Terminology (CPT) procedural codes; 15 diagnostic
International Classification of Diseases, Ninth Revision,
Clinical Modification (ICD-9-CM) codes; and information
about patient demographics, anticipated payer, and discharge
disposition. New York was specifically chosen for study
because the ambulatory surgery database captures the
method of anesthesia provided. Additionally, all databases
contain unique variables, which allow patients to be followed
over time and across healthcare settings allow for subsequent
outcome assessment.
From the ambulatory surgery databases, we identified all
discharges associated with an inguinal hernia diagnosis
(ICD-9-CM 550.x) and repair (CPT 49505, 49507, 49520,
49521, 49650, and 49651) between July 1, 2009 and
September 30, 2010 among state residents who were at
least 18 years of age (n 5 17,226). We excluded discharges
where the method of anesthesia was not recorded (n 5
1,155). Next, we sequentially excluded discharges where
the patients discharge disposition was missing or recorded
as death, immediate hospital transfer, or left against medical advice (n 5 13). This was done to ensure all patients
were at risk for subsequent readmission or emergency
department visit after discharge. Among patients with more
than one discharge meeting the above criteria during the
study time period (n 5 241), we selected the first discharge
for study inclusion. Patients were then grouped according
to whether GA or locoregional (LR) anesthesia was used.
Because of its prominence and close link with GA, we
created a third group for patients treated laparoscopically.
Our primary outcomes were total charges associated
with the initial discharge and hospital readmissions or
treat and release emergency department visits within
30 days of discharge. Total charges are a defined variable in
the database and were used for subsequent analysis. The
postdischarge encounters were identified from corresponding state inpatient and emergency department. All hospital
postdischarge outcomes were then attributed to the ambulatory surgery center where surgery was performed.

469

We collected data regarding the patients sociodemographics, medical history, and surgical encounter. Patient
sociodemographics were identified at the time of ambulatory
surgery center discharge and included age, sex, and primary
payer (Medicare, Medicaid, Private, Other). We assessed a
patients medical history using the enhanced Elixhauser
algorithm. A patient was considered to have a chronic
medical condition if it was a listed diagnosis during the
initial ambulatory surgery center discharge or at any inpatient
discharge in the previous 6 months. We collapsed similar
diagnoses into clinically relevant groups. In a similar manner,
we assessed whether patients had an associated diagnosis of
benign prostatic hypertrophy (ICD-9-CM 600.x) or a smoking history (ICD-9-CM 305.1). Variables from the surgical
encounter we identified whether a laparoscopic (LAP)
approach was used (CPT 49650, 49651), and if the hernia
was bilateral (ICD-9-CM 550.02, 550.12, 550.92, 550.03,
550.13, 550.93), recurrent (ICD-9-CM 550.01, 550.11,
550.91, 550.03, 550.13, 550.93), or associated with obstructive symptoms (ICD-9-CM 550.0, 550.1).
First, patient characteristics are presented with descriptive statistics. Second, we compared total charges and
30 days between groups using t tests and chi-square tests,
respectively. Finally, to identify the independent relationship between method of anesthesia and our outcomes while
accounting for differences in patient populations, we constructed 3 regression models. For the dichotomous outcomes (hospital admission and emergency department
visit within 30 days), we constructed 2 multivariable logistic regression models. The covariates in these models
included those previously described and the method of
anesthesia. Results from this model are reports as odds ratios with 95% confidence intervals. For total charges, we
constructed a multivariable linear regression model. Similar
covariates were used for adjustment. Because total charges
were non-normally distributed, this variable was log transformed. After modeling, results were back transformed
with a smearing factor. Results from this model are reports
as least square means with 95% confidence intervals.
All analyses were conducted using SAS version 9.3
(SAS Institute, Cary, North Carolina). This study used
publicly available data that does not include patient
identifiers and was considered exempt by the Wright State
University Institutional Review Board.

Results
The final sample included 15,818 patients discharged
from 206 ambulatory surgery centers after undergoing
inguinal hernia repair. Most patients underwent an open
hernia repair with GA (n 5 7,905; 50.0%), followed by an
open repair with LR anesthesia (n 5 4,710; 29.8%) or LAP
repair (n 5 3,203; 20.2%). All patients who underwent LAP
repair had GA. Across all groups, most patients were male,
had private forms of insurance, and more than half had no
medical comorbidity. However, patients who had their

470

The American Journal of Surgery, Vol 209, No 3, March 2015

Table 1 Description of 15,818 outpatient inguinal hernia repairs in New York ambulatory surgery centers between June 2009 and
September 2010

Number of discharges
Age in years, median
(standard deviation)
Sex
Male
Female
Primary payer
Medicare
Medicaid
Private
Other
Medical comorbidity based on Elixhauser
No conditions
12 conditions
3 or more conditions
Surgical variables
Bilateral inguinal hernias
Recurrent inguinal hernia
Associated symptoms of obstruction

Open repair, locoregional

anesthesia

Open repair, general

anesthesia

Laparoscopic
repair

P
value

4,710
59.0

100.0
(16.9)

7,905
56.0

100.0
(16.7)

3,203
53.0

100.0
(15.0)

,.001

4,219
491

89.6
10.4

7,236
669

91.5
8.5

3,008
195

93.9
6.1

,.001
,.001
1,563
381
2,371
395
diagnoses
2,918
1,517
275

33.2
8.1
50.3
8.4

2,179
995
3,742
989

27.6
12.6
47.3
12.5

596
228
2,012
367

18.6
7.1
62.8
11.5

62.0
32.2
5.8

4,846
2,658
401

61.3
33.6
5.1

2,107
983
113

65.8
30.7
3.5

194
358
334

4.1
7.6
7.1

574
687
694

7.3
8.7
8.8

1,495
399
101

46.7
12.5
3.2

,.001

hernias repaired by the LAP approach more often had a

diagnosis of bilateral (LR 5 4.1% vs GA 5 7.3% vs LAP 5
46.7%, P , .001) or recurrent hernias (LR 5 7.6% vs GA 5
8.7% vs LAP 5 12.5%, P ,.001). In contrast, patients with a
coded diagnosis suggesting obstruction more commonly had
an open rather than a LAP repair (LR 5 7.1% vs GA 5 8.8%
vs LAP 5 3.2%, P , .001; see Table 1).
The overall hospital-based acute care rate did not vary
by method of repair; however, the healthcare charges
increased across groups (Table 2). After discharge, 5.2 to
Table 2

,.001
,.001
,.001

6.0% of patients sought care in an emergency department

or required a hospital admission within 30 days of surgery
(LR 5 5.2% vs GA 5 6.0% vs LAP 5 6.0%, P , .18). In
the adjusted analysis, patients undergoing an open repair
with GA or who had a LAP repair trended toward a higher
odds of hospital-based acute care encounters when
compared with an open repair with LR anesthesia; however,
the strength of this relationship is small (GA 5 1.12 [.95 to
1.32], LAP 5 1.35 [1.08 to 1.68]). Healthcare charges
increased significantly across groups. Despite risk

Association between surgical approach and inguinal hernia outcomes within 30 days of discharge

Total charges in US$

Unadjusted mean [95% CI]
Adjusted mean [95% CI]
Hospital-based acute care
Percent (%)
Unadjusted odds ratio [95% CI]
Adjusted odds ratio [95% CI]*
Hospital readmission
Percent (%)
Unadjusted odds ratio [95% CI]
Adjusted odds ratio [95% CI]*
Emergency department visits
Percent (%)
Unadjusted odds ratio [95% CI]
Adjusted odds ratio [95% CI]*

P
value

Open repair, locoregional

anesthesia

Open repair, general

anesthesia

Laparoscopic repair

$6,765 [6,6686,683]
$6,845 [6,7466,945]

$7,804 [7,7177,891]
$7,839 [7,7527,926]

$12,130 [11,92012,344]
$11,340 [11,12411,559]

5.2
Reference
Reference

6.0
1.15 [.981.34]
1.12 [.951.32]

6.0
1.16 [.961.41]
1.35 [1.081.68]

1.8
Reference
Reference

1.6
.85 [.641.12]
.92 [.691.23]

1.2
.65 [.44.95]
.79 [.511.22]

.08

3.8
Reference
Reference

4.7
1.24 [1.031.49]
1.17 [.971.41]

5.0
1.33 [1.071.66]
1.52 [1.191.95]

.02

,.001
,.001
.18

CI 5 confidence interval.
*Adjusted for age, sex, anticipated primary payer, 11 chronic medical conditions, smoking status, and whether the hernia was bilateral, recurrent, or
associated with obstructive symptoms.

A.L. Bourgon et al.

Outcomes and charges associated with inguinal

adjustment, patients undergoing open repair under LR anesthesia had lower healthcare charges than patients in the
other groups (LR 5 $6,845 [$6,746 to $6,945] vs GA 5
$7,839 [$7,752 to $7,926] vs LAP 5 $11,340 [$11,124 to
$11,559], P % .001).
The most common reason for emergency department
visit and hospital readmission for open LR and GA was
complications of surgical procedures or medical care.
For LAP repair, patients went to the emergency department
for genitourinary symptoms and for hospital readmissions for complications of surgical procedures or medical
care.
Several patient demographics, comorbidities, and hernia
characteristics were associated with hospital-based acute
care events following hernia repair. Several patient comorbidities, including cardiac arrhythmias (adjusted Odds Ratio
[AOR] 5 1.83 [1.39 to 2.40]), paralysis or neurologic
disorders (AOR 5 2.44 [1.59 to 3.74]), or known substance
abuse diagnoses (AOR 5 2.02 [1.28 to 3.19]), were
associated with more frequent hospital-based acute care
encounters. Benign prostatic hypertrophy and age were not
associated with increased odds of seeking care. Similarly,
patients with bilateral (AOR 5 1.48 [1.18 to 1.86]) or
recurrent hernias (AOR 5 1.24 [1.00 to 1.53]) had a higher
odds of returning to the hospital within 30 days of discharge.
Operating room time varied significantly between procedure groups with open hernia repair under local anesthesia
being shorter than either open hernia repair under GA or LAP
repair under GA (71.1 vs 84.2 vs 91.2 minutes, P , .001).
Revenue codes are reported for each discharge. In an exploratory analysis, we examined specific revenue codes and
charges across procedures. Charges for anesthesia ($319 vs
$457 vs $585, P , .001), pharmacy ($110 vs $143 vs $194,
P , .001), operating room ($3,467 vs $4,063 vs $4,669, P
, .001), supplies ($806 vs $930 vs $3,564, P ,.001), and recovery room ($776 vs $934 vs $1,088, P , .001) services all
significantly contributed to higher healthcare charges for patients treated by a LAP approach.

Comments
The method of outpatient inguinal hernia repair, when
stratified by type of anesthesia or surgical approach, does
not impact hospital-based acute care encounters following
discharge. However, the healthcare charges generated varied substantially across groups with an open inguinal hernia
repair performed under local anesthesia generating the least
healthcare charges. While not all patients will be candidates
for an open repair under local anesthesia, strong consideration should be given to this approach as it does not appear
to impact hospital-based acute care encounters and is
associated with fewer healthcare charges. As medicine
focuses on outcomes achieved relative to the costs of care,
further study should be undertaken to identify the most
cost-effective approach for hernia repair while maintaining
optimal outcomes.

471

Prior studies of inguinal hernia repair have found that

excellent patient outcomes can be achieved through a
variety of surgical approaches with each approach generating different amounts of healthcare charges.5,6 In this
study, we noted substantially higher healthcare charges
across methods or repair. This finding is consistent when
costs are estimated at 30 days, 1 year, and even when
a broader definition of cost to society is used.5,6
Hospital-based acute care, on the other hand, seem to be
comparable across approaches. Nordin et al4 found that patients undergoing repair under local anesthesia had less
early postoperative pain and nausea, had fewer issues
with urinary retention, and were able to be discharged
home more quickly, but no significant differences were
seen between groups at 30 days following surgery. In randomized trials comparing open and LAP approaches, patients undergoing a LAP repair were more likely to have
short-term complications; however, patients generally
experienced less pain and had an earlier return to work
with similar recurrence rates at 2 years when the surgical
procedure was performed by an experienced surgeon.7
Healthcare payers and private organizations are beginning
to monitor hospital-based acute care after outpatient surgery
as a marker of healthcare quality. In a recent study of over 3
million patients, 2 to 3% of patients undergoing outpatient
surgery will return to the hospital for an emergency
department visit or require hospital admission within
7 days of discharge.8 For hernia repair specifically, prior
studies had suggested a hospital admission rate of less than
2%.9 In this study, we found that up to 6.0% of patients returned to the hospital within 30 days. We may have identified
more frequent hospital-based acute care encounters for
several reasons, including the ability to identify events occurring at outside facilities, the inclusion of emergency department visits as well as hospital admissions, and our focus on
all-cause hospital-based acute care. As these outcomes
are increasingly being monitored, further efforts are needed
to identify patients at higher risk of return and systembased practices, which may limit their frequency.10
This article should be reviewed in the context of several
limitations. First, the healthcare charges evaluated are what
the ambulatory surgery center or hospital-based outpatient
department charged. These charges may not reflect what a
healthcare payer reimbursed for the services or the outof-pocket costs to the patient. Second, we focused solely on
short-term outcomes as measured by the need for hospitalbased acute care. Adverse events, which were addressed in
physician offices, are unavailable in the current data and
could not be evaluated. Additionally, long-term outcomes
such as hernia recurrence were not assessed in this study.
In conclusion, the surgeons approach to repair of an
inguinal hernia in the outpatient setting can have a significant impact on related healthcare charges. Performing
outpatient inguinal hernia repair via an open approach
under local anesthesia may reduce healthcare charges
associated with the procedure without adversely impacting
patients seeking hospital-based acute care.

472

References
1. Cullen KA, Hall MJ, Goloskinskiy A. Ambulatory surgery in the
United States, 2006. Natl Health Stat Rep 2009;28:125.
2. Cushing H. The employment of local anaesthesia in the radical cure of
certain cases of hernia, with a note upon the nervous anatomy of the
inguinal region. Ann Surg 1900;31:134.
3. Young DV. Comparison of local, spinal and general anesthesia for
inguinal herniorrhaphy. Am J Surg 1987;153:5603.
4. Nordin P, Zetterstrom H, Gunnarsson U, et al. Local, regional or general anesthesia in groin hernia repair: multicentre randomised trial.
Lancet 2003;362:8538.
5. Nordin P, Zetterstrom H, Carlsson P, et al. Cost-effectiveness analysis
of local, regional and general anesthesia for inguinal hernia repair using data from a randomized clinical trial. Br J Surg 2007;94:5005.
6. Song D, Greilich NB, White PF, et al. Recovery profiles and costs of
anesthesia for outpatient unilateral inguinal herniorrhaphy. Anesth Analg 2000;91:87681.
7. Neumayer L, Giobbie-Hurder A, Jonasson O, et al. Open mesh versus
laparoscopic mesh repair of inguinal hernia. N Engl J Med 2004;350:
181927.
8. Fox JP, Vashi AA, Ross JS, et al. Hospital-based, acute care after
ambulatory surgery center discharge. Surgery 2014;155:74353.
9. Majholm B, Engbaek J, Batholdy J, et al. Is day surgery safe? A
Danish multicentre study of morbidity after 57,709 day surgery procedures. Acta Anaesthesiol Scand 2012;56:32331.
10. Peter O, Director of White House Office of Management and Budget. Available at: http://www.whitehouse.gov/omb/blog/09/04/08/new
studyonhospitalreadmissions/. 2009. Accessed May 2014.

Discussion
Dr Scott Wilhelm (Cleveland, OH). My only concern
with your paper was the inclusion of your patients that underwent the laparoscopic repair. First of all, in regard to the laparoscopic hernia repairs as a surrogate marker for general
anesthetic cases, much of the cost difference is probably
due to more OR costs for equipment, time and procedure,
as it is considered an advanced laparoscopic procedure.
And I was curious if the New York database allowed you to
drill down into that data at all. Secondly, you probably
cant tell us what the method of locoregional anesthesia
was in the particular database, but Im curious at Wright
State, what do you use? Do you use ilioinguinal nerve blocks,
medications? Do you vary that by patient age or hernia type?
And then, lastly, my personal bias is that men who have
BPH and urinary retention tend to do better with locoregional
anesthetic during hernia repairs and have fewer issues with
need to return for catheters to the ER. Did you age or gender
strategy any of your results to try to clarify your data further?
Dr Bourgon: Number one, the laparoscopic being included,
when we first looked at the data, we did not pull out the laparoscopic group. And then thinking back on it, we decided we better, because the whole point of this study was to look at
locoregional versus general. So thats why we pulled it out.
The New York database does allow for you to pull out the actual
costs or the charges associated with each procedure and then
there are equipment charges and the OR charges. We are just
working on figuring out how to understand that information
and pull it out.

The American Journal of Surgery, Vol 209, No 3, March 2015

As for number two, New York State database. Its actually
available through the health care costs and utilization project,
which is the federal government system that multiple states
are involved in. Theres 32 states that participate in the state
ambulatory surgery and service database. Theres 47 that
participate in the inpatient database and 31 that participate in
the emergency department database. And this is all publicly
available information.
For number three, how would I do it myself? The
attendings I work there with, theres a variety of approaches.
Me, personally, I would do mostly a local and not a block.
Number four, we did look at ICD-9 coding for BPH, and
there was no increase in odds of the patient seeking
hospital-based acute care for those who had BPH listed.
Dr Jeffrey Bender (Oklahoma City, OK). Why did you
exclude death as an outcome? Second, locoregional anesthesia patients were cheaper than general or less charges
than general for open repair. Why?
Convince me its not just because the lower risk easier
operations were done under locoregional as opposed to
general. And, last, if you were having a hernia repair on
yourself next week, how do you want it done?
Dr Bourgon: So, number one, why did we exclude
death? Because we wanted to be able to have the cohort
at risk for readmission or seek hospital-based acute care,
so if somebody died, they werent going to be able to be readmitted to the hospital or go to the emergency department.
There was, I think, a total of two patients total for that. And
then why charges decreased for locoregional versus general
anesthesia, I think its an anesthesia cost. We havent nailed
down that number specifically and thats something else we
have to figure out with how are charges are listed in this
database to figure out where the money is coming from.
And then number three, how I would I have it done?
I would have a local anesthesia with MAC, a little Propofol.
Dr James R. DeBord (Peoria, IL). Were all the open
inguinal hernia repairs, whether they were general or local
sedation, treated with mesh?
Dr Bourgon: Im unsure of that from the database The
CPT codes only list it as inguinal hernia repair. It does not
list it as with mesh or without mesh.
Dr Raymond P. Onders (Cleveland, OH). One last
comment. I still think we do a disservice by talking about
charges, because we all know that none of the ambulatory facilities will get anything close to what we charge. The charges
for a laparoscopic case includes the amortization of the
equipment. That does not get reimbursed anymore. So, therefore, the reimbursement in my ambulatory surgery centers
since that work is almost exactly the same if I do it laparoscopic or open. So the true cost is the same. And so it is
just a margin of your profit that may change based on that.
So I think when we publish something like that,
everybody will say laparoscopic is more expensive. Nobody is getting reimbursed 13,000 for a laparoscopic
hernia. You are going to get about $1100, and so you
better figure out a way to make your margin okay.