A Pilot Study of Local Anesthesia for Inguinal Hernia Surgery in Older Adults

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Inguinal hernia repair – the most common general surgery operation in the U.S. – provides a unique opportunity to improve outcomes for older adults by changing surgical practice. Nearly 80% of inguinal hernia operations are performed under general anesthesia versus 15%-20% using local anesthesia. Although some studies suggest that exposure to general anesthesia can cause cognitive and physical decline in older adults, the evidence for choosing an anesthesia technique for inguinal hernia repair in older adults is inconclusive. Several studies demonstrated that using local anesthesia for hernia repair reduced morbidity by one-third, unplanned admissions by 20%, and operative time and costs by 15%, while other studies showed no significant differences. Unfortunately, these studies have significant shortcomings that limit their applicability for older adults. In particular, prior studies mostly involved younger and healthier patients, with no analysis of whether potential benefits of local anesthesia were greater in older adults. We conducted the first large, population-based study that evaluated how local and general anesthesia affect outcomes in older adults. Using an instrumental variable approach to analyze a large retrospective cohort of older adults, we identified a strong association between local anesthesia and improved intra-, peri-, and postoperative outcomes. This proposal is the next logical step toward verifying those findings in a multisite randomized clinical trial. The applicant is an assistant professor in surgery whose long-term career goal is to integrate expertise in implementation science and clinical trials to promote patient-centered outcomes for older adults before, during, and after surgery. The project goal is to obtain preliminary data to inform design of a multisite randomized trial comparing general versus local anesthesia for inguinal hernia repair in adults aged 65 years and older. We hypothesize that using local rather than general anesthesia for inguinal hernia repair in older adults will Aim 1: Identify patient- centered outcomes to measure in a randomized clinical trial of local versus general anesthesia, and evaluate how patient perceptions of hernia surgery affect anesthesia selection. Aim 2: Identify potential barriers to use of local anesthesia and potential outcomes for a randomized trial from the perspective of surgeons, anesthesiologists, and hospital leadership. reduce morbidity and enhance quality of life. We propose the following specific aims: Aim 3: Conduct a pilot randomized study to assess and refine study procedures and determine feasibility of recruitment, randomization, and retention for a multisite randomized trial of local versus general anesthesia in older adults having inguinal hernia surgery. Expected outcomes of the study are (1) crucial preliminary data to inform design of a multisite trial comparing local versus general anesthesia for hernia repair in older adults, and (2) training in and knowledge of clinical trials that will synergize with my background in implementation science and position me to take a national leadership role in surgical aging research.