Local versus general anesthesia in initial open inguinal hernia repair with prolonged operative time: A propensity-score matched study from the ACS-NSQIP database

Patients who undergo open inguinal hernia repair (OIHR) can be either under general anesthesia (GA) or local anesthesia (LA). Despite the lack of conclusive evidence favoring perioperative outcomes with GA, GA remains the predominant anesthesia in OIHR. Furthermore, in complex OIHR with prolonged operative times, it remains unclear if LA or GA should be the preferred choice. This study aimed to compare the 30-day postoperative outcomes for patients undergoing prolonged initial OIHR under LA versus GA. Patients who underwent initial OIHR were selected from ACS-NSQIP database from 2005-2021. Only cases with prolonged operative times (>third quartile) were selected. A 1:1 propensity-score matching was used to create balanced groups in demographics and baseline characteristics between patients under LA and GA. Thirty-day postoperative outcomes were compared between the groups. Among 51,905 patients with operative times over 76 minutes (third quartile), 6,708 (12.92%) were under LA, and 45,197 (87.08%) were under GA. Patients receiving LA had higher baseline risk but were less likely to be targeted minority groups. After propensity-score matching, patients who were under LA and GA had comparable mortality (0.19% vs 0.15%, p=0.68) and all other surgical complications. In initial OIHR with perceived complexity and prolonged operative time, LA and GA may be considered equivalent choices. Further RCTs may be necessary to determine the optimal anesthesia choice in these cases.