Who will repair the next open inguinal hernia? Educational consequences of declining open surgery volumes

PURPOSE: Over the past two decades, laparoscopic repair has increasingly replaced open techniques for elective groin hernia surgery in Denmark. This transition has profoundly altered the case mix and surgical exposure. The implications for surgical training, competence maintenance, and future service provision remain largely unexplored. METHODS: Using prospectively collected data from the Danish Inguinal Hernia Database, we conducted an updated nationwide cohort analysis of elective groin hernia repairs from 1998 to 2025. Surgical techniques were classified as open (primarily Lichtenstein repair) or minimally invasive (primarily laparoscopic TAPP repairs, including robot-assisted). Annual procedure volumes, departmental distribution in 2025, and cumulative reoperation rates after Lichtenstein and TAPP repairs were analyzed. RESULTS: A total of 296,864 unique elective repairs in 277,666 groins were analyzed. Open repair accounted for only 19% of unilateral repairs in 2025, while 80% were performed minimally invasive. Open procedures were unevenly distributed across departments: of 40 Danish departments performing Lichtenstein repair in 2025, only four performed more than 100 repairs annually, while 18 performed fewer than 20. Cumulative reoperation rates after Lichtenstein repair have increased significantly across consecutive five-year periods, whereas reoperation rates after TAPP repair did not show a comparable increase. CONCLUSION: Open inguinal hernia repair is now a low-volume operation, with declines in long-term outcomes. Maintaining broad competence in open repair through traditional surgical training pathways no longer seems realistic. Centralizing open hernia surgery at dedicated centers or with specialized surgeons, along with a stronger emphasis on laparoscopic training, may be necessary to preserve quality, safety, and training opportunities.