Continuous use of anticoagulants in inguinal hernia repair - a systematic review and meta-analysis.

Abstract

Introduction: The perioperative management of anticoagulation in patients undergoing inguinal hernia repair remains a critical yet debated issue, requiring careful balance between thromboembolic risk and bleeding. Despite the prevalence of patients on chronic anticoagulation-and variability in clinical guidelines-evidence-based strategies are needed to guide perioperative decision-making, ensuring both patient safety and surgical efficacy. Furthermore, more evidence is needed comparing outcomes in patients on and off anticoagulation, particularly regarding postoperative outcomes. This study aims to assess and analyse existing data on the use of anticoagulants during inguinal hernia repairs.

Materials and methods: A comprehensive online search was conducted across databases (PubMed/MEDLINE, EMBASE, ClinicalTrials.gov, and Cochrane Library) from inception until March 2025. Observational studies and clinical trials exclusively comparing continued anticoagulation vs. no anticoagulation in patients undergoing inguinal hernia repair were included, with no restrictions on language. The primary outcomes were hematoma formation, and hematoma surgical intervention. Studies involving antiplatelets or fibrinolytics were excluded. Secondary outcomes included seroma formation, surgical site infection (SSI), operative time (OT), and length of stay (LOS). Meta-analysis was performed using R software (version 5) and heterogeneity was assessed using I² statistic.

Results: A total of 1,483 studies were screened, and 33 were fully reviewed. Four observational studies with 1,384 patients were analyzed. Among these, three studies employed open repair the surgical approach. Anticoagulation was used perioperatively in 549 patients (39.7%), with a mean age of 73.4 ± 9.3 years. The most common indication for anticoagulation was atrial fibrillation (31%), followed by a history of venous thromboembolism (20.4%). Patients undergoing inguinal hernia repair while on anticoagulation had a higher risk of hematoma formation (RD 0.06; 95% CI 0.04-0.09; p = < 0.00001; I² = 18%) compared to the control group. However, in two of the four studies analyzed, the anticoagulated group did not present a higher incidence of hematoma intervention versus the control group (0% vs. 0% and 0% vs. 25%). Two studies reported a higher rate of hematoma intervention in the anticoagulated group (53.6% vs. 0% and 25% vs. 0%). Operative time (61.1 ± 29.8 vs. 57.3 ± 24.4 min) and hospital length of stay (8.8 ± 5.3 vs. 2.9 ± 3.8 days) were also increased in the anticoagulated group. Nevertheless, the incidence of seroma and surgical site infection did not differ significantly between groups.

Conclusion: Perioperative anticoagulation in open inguinal hernia repair was associated with a higher risk of hematoma formation, prolonged operative time, and increased length of hospital stay. In contrast, other postoperative outcomes, including seroma formation, surgical site infection, and thromboembolic events did not significantly differ between anticoagulated and non-anticoagulated patients.