Invited Commentary: “Provision of inguinal hernia surgery in first referral hospitals across low‐ and middle‐income countries: Secondary analysis of an international cohort study”

In the present publication by Dr. Picciochi and colleagues, the authors describe the current status of inguinal hernia surgery in middle- and low-income countries in a very sophisticated study protocol.1 It is the author's merit to present current data on the status of inguinal hernia care in 2023, funded by the NIHR Global Health Research Unit. The approach was to collect the results from over three hundred hospitals in middle- and low-income countries from all parts of the world regarding important characteristics of inguinal hernia surgery and finally to determine the outcome. The result of over 8100 patients showed that essential parameters of hernia surgery differed in first referral hospitals in middle- and low-income states. For example, 24-h emergency care was only available in almost 90% of cases. Based on the patient characteristics, the expected results showed that the majority of patients were young men with a mean age of around 40 years. However, the detailed workup showed that first referral hospitals had to treat a higher number of large so-called scrotal hernias. In relation to the key performance measurement, it was shown that only 67% of treatments in first referral units were covered by health insurance. When providing surgical care in first referral institutes, more than 31% of patients had to pay for the treatment out of their pockets. The use of a mesh was recorded as another important aspect of this analysis. In comparison to second- or third-degree hospitals, it was found that in the first referral care units, only 72% of all patients underwent surgery using alloplastic material. The complication rate in the first referral units was at least 19%. A worrying parameter was that care was provided by nonsurgical medical staff in at least 5% of cases. Minimally invasive care did not play a significant role in first referral hospitals, accounting for a good 9% of cases. It is the author's achievement to provide an important overview of the status of hernia care in first referral hospitals around the world. Whether the use of an alloplastic material serves as a quality criterion remains the subject of scientific discussion. Nevertheless, this aspect can be used as a key parameter for the quality of care. There may be a connection between the need to pay for the treatment out of pocket and the use of alloplastic materials. Important aspects that indicate potential for improvement are the question of the 24-h, 7 days a week emergency capacity, for example, for strangulated hernias. In this context, the analysis shows that at least 10% do not offer nighttime emergency care. The fact that at least 5% of hernia repairs are conducted by nonsurgical staff also indicates that first referral hospitals need additional support. In summary, this publication will provide a definitive basis for comparing inguinal hernia repairs around the world. The outstanding publication offers compelling evidence that first referral hospitals are the ones that need the most support, as this is where patients with the largest scrotal hernias and the highest number of symptomatic hernias are cared for. These institutes require the most attention to ensure that they have enough and adequately trained staff. Sven Petersen: Conceptualization; writing—original draft; writing—review & editing.