Research prioritization in hernia surgery: a modified Delphi ACHQC and VHOC expert consensus

This study identified the top 11 contemporary, clinically relevant research topics in hernia surgery through a modified Delphi consensus methodology. Our results provide a research agenda derived from an expert consensus between the ACHQC and VHOC, two national organizations dedicated to the delivery of high-quality patient care through research and evidence-based practices, that may be used in the prioritization of the design and funding of clinical trials in hernia surgery.

The primary aim of research priority setting is to identify the most relevant and feasible areas of study in order to optimize the use of resources and generate prospective clinical studies that will most meaningfully impact patient management and care. Critical components of research prioritization include clearly defined priority criteria, a systematic and transparent methodology, and engagement of key stakeholders [6]. While there is no gold standard approach, we used a modified Delphi process which has been successfully utilized in prior research prioritization work identifying the top 10 research priorities in varying specialties [9‐11].

Scrimgeor et al. published research prioritization in hernia surgery in 2022. In this study, the Scottish Surgical Research Group and the British Hernia Society conducted a modified Delphi process across 16 countries and six continents with a broad group of stakeholders including patients, healthcare professionals, professors, and surgical trainees. Their results highlight 14 research priorities in hernia surgery [18]. Interestingly, a predominant theme in their results was an emphasis on defining outcome measures. For example, three priority questions were: “What are the most important patient outcomes following hernia surgery?”, “What are the most important outcome measures for incisional hernia repairs?” and “What are the optimal outcome measures following hernia surgery?”. Another theme illustrated by their findings was the need to clarify the incidence, etiology, and prevention strategies of chronic pain after hernia surgery [18]. Significant differences exist between the results of the current study and that of Scrimgeor et al. We found that our research priorities focused primarily on exploring, rather than defining, outcomes between groups with different management strategies. For example, two questions involved comparing suture/plication versus mesh repair for patients with diastasis recti (#7, #9), while another involved comparing concomitant diastasis repair to hernia repair alone (#2). Another theme was the comparison of outcomes in patients managed with an expectant management strategy versus surgical repair for inguinal (#3) and parastomal hernias (#8). These differences in our findings may be largely attributed to the variations in our methodologies. Firstly, our research questions were generated using a structured review of published clinical guidelines. In contrast, Scrimgeor et al. generated research questions using individual viewpoints submitted by stakeholders. Furthermore, our panel was restricted to hernia surgeons practicing in the U.S., while Scrimgeor et al. recruited stakeholders of different professions and experience levels, as well as members of the public using a dedicated Twitter^® account. It is therefore difficult to ascertain whether this disparity is a result of differing research priorities globally or due to the composition of panel members and their respective familiarity with current evidence. While the ACHQC is comprised of diverse members with regard to practice setting, years in practice, and gender, all members, and therefore the entirety of our panel, are currently practicing hernia surgeons. As such, it follows that research questions from this panel would be more specific to the management of commonly encountered clinical scenarios compared to a broader panel.

Ultimately, by comparing the results of research prioritization across diverse contexts, we are able to underscore topics of particular importance. Both our work and that of Scrimgeor et al. identified the impact of different types of mesh, long-term outcomes of intraperitoneal mesh repairs, and strategies for the management of chronic groin pain as topics with a current need for future research. Similarly, by juxtaposing previous research prioritization topics with contemporary ones, questions that have remained unanswered are brought forth. In 2014, Stefanidis et al. published 40 research topics in gastrointestinal and endoscopic surgery, of which six questions were related to hernias [19]. Over the past decade and into the present, there remains a demand for evidence on the outcomes of primary versus mesh repairs, the safety of permanent mesh in contaminated procedures, and the quality-of-life benefit following hernia repair. The recognition of these shared research priorities enables researchers to maximize research impact via the funding and design of multi-center clinical trials that address both the most current pressing research questions and those that have remained unresolved.

Before studies can be designed to undertake these research initiatives, it is important to highlight clinical research that is currently underway to minimize research waste and maximize efficiency. Two studies are presently ongoing that may offer valuable insight on occult inguinal hernias and the questions posed by priorities #3 and #11. An RCT comparing upfront surgical repair to the expectant management of occult inguinal hernias is currently recruiting patients with the aim of developing a decision tool and comparing outcomes (NCT04815707). Additionally, we await the results of a 15-year observational cohort study of 201 patients with occult ventral and inguinal hernias that may provide a greater understanding of the natural course of expectant management in these patients (NCT04683367). Lastly, research priority #10 may be addressed by a recently initiated RCT by Nielsen et al. for patients with primary ventral hernias who will be randomized to undergo an open or robotic repair, which may better our understanding of the role of robotic surgery in these cases (NCT05906017).

Several limitations in this study exist. Firstly, there is an absence of non-physician stakeholders. We intentionally chose to recruit hernia surgeon stakeholders to optimize collaboration and coordination among surgeon researchers who are familiar with the interpretation, design, and execution of multi-center research studies. However, in doing so, we excluded the patient perspective. Future efforts should aim to engage a more inclusive group of stakeholders to ensure research priorities reflect the needs and perspectives of the broader community and enhance research impact. It is critical for future research prioritization studies to consider patient values and concerns throughout the surgical process as patient-informed research agendas may steer research towards areas with the highest potential for improving patient experiences and outcomes.

Furthermore, we exclusively recruited participants from the ACHQC who attended the 2024 Quality Improvement Summit. Many general surgeons in the U.S. perform hernia surgery and are not affiliated with the ACHQC, and their interests may not be well-represented in this study. We acknowledge that our findings primarily provide insights into the U.S. perspective on hernia surgery research priorities, which may differ from other countries due to varying technical practices and healthcare systems.

Despite these limitations, we achieved a diverse panel of hernia experts representing different clinical practice settings and national geographical distribution with high retention (85.4%) between rounds. Furthermore, our methodology was transparent, simple to execute and highly reproducible. While specific to the U.S. context, our findings offer valuable insights into research priorities in hernia surgery and may serve as a benchmark for comparative studies in other countries.