The Best Method to Repair Diaphragmatic Hernias:  Comment on “Comparative Analysis of Diaphragmatic Hernia Repair Outcomes Using the Nationwide Inpatient Sample Database”

Paul et al¹ queried the Nationwide Inpatient Sample database from 1999 to 2008 to determine the comparative effectiveness of various approaches to the repair of uncomplicated diaphragmatic hernia. Primary end points were in-hospital mortality and morbidity. They also compared comorbidities, use of mechanical ventilation postoperatively, length of hospital stay, and discharge home or to a skilled nursing facility by both univariable and multivariable analyses. In a large cohort of 38 764 patients, they found that the overwhelming majority of operations were open, either abdominal (74.4%) or thoracic (17.0%). Mortality was low (1.1% or less) for all procedures. The open thoracic approach resulted in the longest length of stay, greater ventilator use, and greatest risk of pulmonary embolism. The laparoscopic abdominal approach had the shortest length of stay and fewer discharges to a skilled nursing facility. Most centers used predominantly an open abdominal or thoracic approach, not both; the laparoscopic abdominal and open thoracic approaches were used more frequently in urban teaching hospitals. Paul and colleagues suggest that this is the first comparative effectiveness study of methods of diaphragmatic hernia repair and show very limited use of the laparoscopic approach across the United States despite its better short-term postoperative outcome and 20 years of clinical studies showing its safety and efficacy.