Abstract

Abstract Acknowledgments This study was supported by NIHR Global Health Research Unit Grant (NIHR16.136.79) and a project research grant from Portuguese Hernia and Abdominal Wall Society (Sociedade Portuguesa de Hernia e Parede Abdominal). The funders had no role in study design or writing of this report. The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR or the UK Department of Health and Social Care. Background Technologies such as mesh and minimally invasive surgery (MIS) are recommended for inguinal hernia repair, but access and expertise varies significantly across different contexts. This study aimed to assess variability in the use of these two technologies, and evaluate their safety. Methods This was a pre-planned analysis of adults undergoing elective inguinal hernia repair in a prospective, international, cohort study between 30 January and 21 May 2023. Recurrent hernias and open midline approach were excluded. The primary outcome was the placement of mesh during open repair. The secondary outcome was adoption of MIS. A mixed-effects logistic regression model was used to identify factors associated with the adoption of these two technologies. Results This analysis included 14,768 patients from 612 hospitals in 81 countries: 8,916 (60.4%) from high-, 2,575 (17.4%) from upper-middle-, 2,642 (17.9%) from lower-middle and 635 (4.3%) from low-income countries. Mesh use in open surgery decreased from high- to low-income countries (98.9%, 94.4%, 82.3%, 72.1% respectively). MIS was adopted in less than a quarter of patients (3,661/14,768, 24.7%), and also decreased across income groups (29.3%, 27.6%, 12.5%, 1.1%). Surgery in a low-middle income country was associated with both lower mesh use (adjusted odds ratio 0.02, 0.01–0.06, p < 0.001) and lower MIS (0.11, 0.07–0.18, p < 0.001). Conclusion Global priority is to increase access and training programmes for mesh inguinal hernia repair in low-middle income countries. Expanding the role of MIS in well-resourced settings will require expansion of dedicated training programmes and a focus on patients who will have the most clinical benefit.