About one in 10 patients undergoing hernia repair surgery expressed misgivings afterward, with no obvious reason, researchers found.

So, what might be the unobvious reasons? That was the question Ryan Howard, MD, and colleagues at the University of Michigan in Ann Arbor sought to address, though their initial attempt to pierce the mystery fell short of definitive answers.

What they did find, according to a presentation by Howard at the Society of American Endoscopists and Gastrointestinal Surgeons (SAGES) annual meeting, was that overtly negative surgical outcomes clearly are by no means the only reason.

He reported an analysis of post-discharge surveys administered routinely in a 70-hospital consortium in Michigan, 30-90 days after the operation. Among other things, the survey asks patients whether they regretted having the procedure and how strongly on a five-point scale. For purposes of the current study, responses to this item were stratified into either “some regret” (ratings 1-4) or no regret (rating 5). Howard’s group also had clinical records and other information on patients and the procedures they underwent, including age, sex, race, insurance status, and year and type of surgery.

In follow-up surveys administered to 6,156 patients who underwent inguinal hernia repair surgery in 70 Michigan hospitals from 2017 to 2020, 9% indicated they had some regret about having the procedures. But only 1% had complications, 5% sought emergency treatment after surgery, 1% were readmitted, and 1% needed surgical revision (An individual patient could be included in multiple categories).

That meant that a substantial number of those with regrets afterward had reasons other than a clearly bad experience, Howard said.

Although the data Howard reported in his formal presentation didn’t include whether pain was a contributing factor, an audience member asked about it afterward and Howard replied that the survey did ask about postoperative pain; an initial look indicated it couldn’t fully account for the disparity, he said.

So was it issues of cost? Scarring? Continuing or new symptoms that didn’t count as a complication and that the patient decided to live with? Unrealistic expectations? That’s for future research to address.

“There are unexplored things that probably have to do with the decision-making process,” Howard said. Later, he said, “We want to follow this up with qualitative interviews” to get at the not-so-obvious reasons behind regret, which he noted is a “complex emotion.”

Efforts by his group in the current analysis to identify specific patient factors that might contribute to decision regret didn’t yield much. Women were more likely to express regret than were men (who made up more than 90% of patients in the study), as were tobacco users. On the flip side, patients who had a robotically assisted procedure were less likely to have regrets (OR 0.70, 95% CI 0.56-0.86) relative to open surgery. Other factors such as insurance status, race, and age were not independently associated with likelihood of regret.

That robotic surgery was tied to less regret was an interesting finding, said SAGES session co-moderator John D. Mellinger, MD, of Southern Illinois University in Springfield, who asked whether there might be a “psychological component to [patients’] consent around the technique.”

It seems likely, Howard agreed. “I think it has a lot to do with expectation-setting preoperatively. Patients have a perception of what the robot represents, what it means in terms of pain, and what it offers in terms of technology. We’ve done other work that’s showed us that, what a patient is anchored to preoperatively, what their expectations are, can be one of the strongest predictors of their actual experience.”

What might that mean for preoperative patient discussions was on the mind of another audience member. “Based on your presentation here, if I were counseling a patient, I’d tell them they have about a 10% chance of having regret after having hernia repair. What do I tell them about the chance of having decision regret if they decide not to?”

“It’s tough,” Howard admitted. “Given that one in 10 chance, I think that’s important for patients to know. How has this changed how I counsel patients? It really involves drawing out what their preferences are, and maybe being a little less heavy-handed… about the operation.

“There’s plenty of cases that could go either way,” he continued. “If a patient wants to watch and wait, which we know is safe, then we can go with that feeling.”