An inguinal hernia is an abdominal wall defect occurring in the groin region (1, 2) and is one of the most common surgical conditions worldwide, with approximately 20 million repairs performed annually (3). The prevalence increases with age, from 0.25% at 18 years to 4.2% between 75 and 80 years (4). In the United States, more than 800,000 inguinal hernias are repaired each year (5, 6). In China, 14.19% of the population is aged ≥65 years, slightly above the global average (7) and hernia incidence is increasing. Between 1990 and 2019, India, China, and Brazil accounted for 39% of global cases, with China reporting 1.95 million cases during this period (8). Given this increasing prevalence in elderly populations, understanding the optimal surgical approach becomes crucial, as patient age and associated comorbidities significantly influence treatment decisions and outcomes.

Factors associated with an increased risk of developing an inguinal hernia include male sex, advanced age, low body mass index, prior prostate surgery, systemic connective tissue disorders, previous radiation therapy, and a family history of hernias, as indicated by epidemiological studies (9). The first incidence peak occurs during infancy, while the second is seen in the fourth decade of life (10). Men have a higher lifetime prevalence of inguinal hernias than women, ranging from 27%–43% (11). It is also more common in elderly adults due to diminished abdominal wall strength and other medical conditions that increase intra-abdominal pressure, notably chronic obstructive pulmonary disease and benign prostatic hyperplasia (12).

Patients with inguinal hernia typically present with a groin bulge that may gradually enlarge over time (9). While urgent surgical intervention is required in certain situations, most cases are managed electively (13). Emergency surgery is indicated when there is sudden, severe abdominal pain suggestive of incarceration (14). Compared with younger individuals, elderly patients experience higher rates of postoperative mortality and morbidity (15, 16). Although older adults with comorbidities may have minimal symptoms and relatively low short-term risk, the optimal timing for intervention remains uncertain (17). Some researchers recommend early elective repair in elderly patients with comorbidities, whereas others support close monitoring in young, otherwise healthy individuals (18, 19). Notably, a Swedish study reported that the mortality rate for elective hernia repair is low, even among patients over 80 years of age (0.58%) (20). Surgical repair remains the most effective treatment for inguinal hernia (21).

The choice between open repair and laparoscopic mesh repair depends on patient characteristics, anticipated operative time, and complication risk (4). Over the past two decades, numerous studies have compared these approaches (8). The Lichtenstein open mesh repair is a well-established technique with a recurrence rate below 1% (22), but chronic pain remains a notable complication, affecting 5%–10% of patients and reported in up to 63% of cases (23). Since the introduction of laparoscopic techniques by Watson et al. in 1993 (24). Debate has continued regarding their advantages and disadvantages, particularly in elderly patients. Laparoscopic inguinal hernia repair (LIHR) has gained popularity worldwide due to advances in minimally invasive surgery, offering reduced wound complications, lower recurrence rates, and faster recovery (25–27). However, open repair remains necessary in patients with coagulopathy, significant preperitoneal adhesions, or extraperitoneal hemorrhage (28). In elderly patients with poor cardiopulmonary reserve or intolerance to general anesthesia, open repair under regional anesthesia is generally preferred (29).

This study seeks to determine the optimal surgical approach for managing inguinal hernias in patients aged ≥65 years. In surgical research, outcomes refer to measurable clinical results following an intervention, including postoperative complications, chronic pain, length of hospital stay, recovery time, and recurrence rates (8, 11, 30). Evaluating these outcomes provides objective evidence to guide the selection between open and laparoscopic inguinal hernia repair, particularly in elderly patients. Therefore, we conducted a retrospective analysis to compare the clinical outcomes of laparoscopic and open inguinal hernia repair in this population.

Data analysis was conducted using IBM SPSS version 27 (IBM Corp., Armonk, NY) and GraphPad version 8. Continuous variables were analyzed by calculating medians, while categorical variables were assessed using frequencies and percentages. The distribution of numerical variables was assessed using the Shapiro–Wilk test, indicating an abnormal distribution and confirming the appropriateness of non-parametric testing. Medians and non-parametric independent tests, specifically the Mann–Whitney U test, were utilized for analysis. We utilized chi-square analysis or Fisher's exact test to compare categorical data, contingent upon the number of participants in each category. We conducted univariate and multivariate binary logistic regression analyses to identify predictive factors. A p-value less than 0.05 was deemed statistically significant in the statistical analyses.

The surgical management of inguinal hernia remains a significant healthcare challenge, with over 20 million procedures performed annually worldwide, representing 75% of all abdominal wall hernias (16). The condition disproportionately affects males (27%) compared to females (3%) (31), with increasing prevalence anticipated as global demographics shift toward an aging population (32). Despite the high frequency of inguinal hernia repair among elderly patients (aged 65 and older) (33), there remains a notable research gap regarding the optimal surgical approach for this demographic. The objective of this investigation is to assess the comparative effectiveness of laparoscopic and open hernia repair in elderly patients.

Our comparative analysis of open and laparoscopic inguinal hernia repair groups revealed several significant findings. Notably, neither group experienced mortality, and laparoscopic intervention demonstrated fewer complications, reduced chronic pain, and faster recovery times, consistent with previous research (8, 29, 34, 35). These advantages likely stem from smaller surgical incisions and improved postoperative wound healing dynamics. Our findings align with earlier studies (36), examining open preperitoneal inguinal hernia repair outcomes.

The study identified significant correlations between open inguinal hernia repair and various parameters, including age, hernia site, hernia sac size, hospital stay duration, and operation time. While laparoscopic repair offers numerous advantages (37), it typically requires longer operative times, reflecting the established learning curve for surgeons adopting these techniques (30). Extended operative duration in laparoscopy may result in elevated expenses attributable to factors such as increased consumption of surgical supplies, prolonged anesthesia duration, and extended hospital admissions. Although laparoscopy typically incurs lower overall costs relative to open surgery due to diminished hospital stays and expedited recovery, an elongated laparoscopic procedure can undermine some of these advantages (38). Although all procedures were performed by the same team of senior surgeons, the extended operation time in the laparoscopic group may be attributed to additional patient preparation and port placement requirements.

Contrary to previous studies highlighting concerns about anticoagulant and thrombolytic medications affecting bleeding tendencies in elderly patients (28, 39, 40). Our analysis showed no significant differences in bleeding or hematoma formation between approaches, possibly due to effective preoperative medication management. Laparoscopic inguinal hernia repair (LIHR) demonstrated several advantages, including reduced intraoperative blood loss, shorter hospital stays, and quicker return to normal activities compared to open repair (8, 41). The study identified LIHR as an independent factor in reducing postoperative pain, consistent with previous research showing minimal chronic pain following laparoscopic repair (42).

A crucial factor is the anesthetic requirement, LIHR generally requires general anesthesia, but OIHR may be conducted under local or regional anesthesia, rendering it more acceptable for patients who are not candidates for general anesthesia (43). In our cohort, all laparoscopic repairs (100%) were executed under general anesthesia, whereas the majority of open repairs (86.6%) were carried out under local or regional anesthesia. No postoperative cardiovascular problems were seen in either group (0% vs. 0%). This finding contrasts with earlier reports suggesting that regional anesthesia in elderly patients may increase the risk of cardiac and thromboembolic events (16). In addition other extensive research, such as Mayer et al. (2016), which indicated that cardiovascular or thromboembolic problems occurred in 1.2%–1.8% of older patients having inguinal hernia surgery with regional anesthesia (17). Wang et al. (2024) recently showed that ultrasound-guided local nerve block mitigated cardiopulmonary impairment, with cardiovascular events occurring in less than 1% of older individuals (44). In contrast to the stated rates, our result of 0% problems indicates that thorough preoperative cardiac assessment and meticulous anesthetic selection may have enhanced perioperative safety in our patient cohort, and maybe due to small sample size.

This study has limitations inherent to its retrospective, single-center design. The modest sample size (n = 384), reliance on medical-record abstraction, and involvement of multiple surgeons may introduce measurement variability and limit external validity. Importantly, the surgical approach (open vs. laparoscopic) was determined by clinical judgment rather than randomization; therefore, selection bias (confounding by indication) is possible. Although we adjusted for age, ASA class, hernia characteristics, anesthesia type, and major comorbidities, residual confounding from unmeasured factors cannot be excluded. In addition, 12-month follow-up may underdetect late recurrences and long-term pain outcomes. These constraints support the need for prospective, multicenter studies ideally randomized or using propensity-based methods with longer follow-up and standardized complication grading.

This study confirms that laparoscopic inguinal hernia repair provides superior postoperative outcomes compared to the open approach in patients aged 65 years and older, including reduced complication rates, decreased chronic pain, and shorter hospital stays. Key determinants of surgical outcomes were hernia sac size, anatomical location, and anesthesia type, with complex hernias requiring advanced surgical expertise and individualized anesthetic planning. Although laparoscopic repair was associated with longer operative times, open surgery emerged as an independent risk factor for chronic postoperative pain.

From a clinical governance perspective, these findings support the integration of laparoscopic repair as the preferred approach for eligible elderly patients into institutional surgical guidelines. Hospitals could consider adopting structured preoperative assessment protocols to optimize patient selection particularly evaluating comorbidities, anesthetic tolerance, and hernia complexity to ensure both safety and effectiveness. Furthermore, given the long-term benefits for patient recovery and reduced resource utilization, investment in laparoscopic training and equipment may align with broader hospital policy goals of improving surgical quality metrics and cost efficiency.

Future multicenter prospective studies with larger elderly cohorts will be valuable for refining these recommendations and potentially informing national guidelines on inguinal hernia management in this high-risk population.