The association between HBA1C level and the outcome of hernia surgery in diabetic patients managed at a tertiary center: A retrospective cohort study

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However, its specific association with hernioplasty outcomes remains uncertain. This study aims to evaluate the relationship between HbA1C levels and the outcomes of hernia surgery in diabetic patients treated at a tertiary care center. Methods Data were collected from 301 diabetic patients, categorized into controlled (HbA1C < 7%) and uncontrolled (HbA1C ≥ 7%) groups, who underwent hernioplasty at King Abdulaziz Medical City (KAMC) between September 1, 2017, and September 1, 2022. Patient records were analyzed to explore the association between diabetes and hernia surgery outcomes, including complications, infections, and recurrence, as well as to compare the outcomes of different surgical techniques (open and laparoscopic). Results Of the 301 patients, this study included only 140 (46.5%) diabetic individuals who underwent hernia surgery at the Ministry of National Guard Health Affairs (MNGHA) in Riyadh between 2017 and 2022. Preoperative uncontrolled HbA1C levels were not statistically significant for wound infection (p = 0.706) or hernia recurrence (p = 0.075) within a one-year follow-up period. However, a statistically significant difference was observed in the prevalence of hypertension between the controlled and uncontrolled HbA1C groups (p = 0.039). Conclusion This study indicates that HbA1C levels do not significantly influence complications or infections following hernia surgery, particularly regarding wound infections and recurrence. However, HTN was found to be statistically significant and warrants further investigation. Additionally, no statistical significance was identified between elevated BMI (>30 kg/m2) and HbA1C groups (p = 0.081), which may be attributed to the limited sample size of this study. 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F1000Research 2025, 14 :394 ( https://doi.org/10.12688/f1000research.162204.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article The association between HBA1C level and the outcome of hernia surgery in diabetic patients managed at a tertiary center: A retrospective cohort study [version 1; peer review: 1 approved with reservations, 1 not approved] Abdullah Alghamdi https://orcid.org/0009-0004-6726-4366 1,2 , Heythem Alzamel 1-3 , Abdulmajeed Aljabr https://orcid.org/0009-0005-6965-789X 1,2 , [...] Omar Alsalem 1,2 , Ibrahim Momen 1,2 , Osama Mujammami 1,2 , Rifan Alyami 1,3 Abdullah Alghamdi https://orcid.org/0009-0004-6726-4366 1,2 , Heythem Alzamel 1-3 , [...] Abdulmajeed Aljabr https://orcid.org/0009-0005-6965-789X 1,2 , Omar Alsalem 1,2 , Ibrahim Momen 1,2 , Osama Mujammami 1,2 , Rifan Alyami 1,3 PUBLISHED 04 Apr 2025 Author details Author details 1 King Abdullah International Medical Research Center, Riyadh, 11481, Saudi Arabia 2 Collage of Medicine, King Saud bin Abdulaziz University for Health Sciences, Ar Rimayah, 14611, Riyadh, Saudi Arabia 3 King Abdulaziz Medical City, Ministry of National Guard-Health Affairs (MNGHA),, Riyadh, Saudi Arabia Abdullah Alghamdi Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Heythem Alzamel Roles: Conceptualization, Funding Acquisition, Investigation, Project Administration, Resources, Software, Supervision, Validation, Writing – Review & Editing Abdulmajeed Aljabr Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Omar Alsalem Roles: Conceptualization, Data Curation, Investigation, Methodology, Project Administration, Resources, Validation, Visualization, Writing – Original Draft Preparation Ibrahim Momen Roles: Data Curation, Investigation, Methodology, Resources, Software, Supervision, Validation, Writing – Original Draft Preparation Osama Mujammami Roles: Data Curation, Funding Acquisition, Investigation, Methodology, Resources, Validation, Writing – Original Draft Preparation Rifan Alyami Roles: Conceptualization, Formal Analysis, Funding Acquisition, Project Administration, Resources, Software, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background The literature indicates a link between HbA1C levels, infections, and postoperative complications across various surgical procedures. However, its specific association with hernioplasty outcomes remains uncertain. This study aims to evaluate the relationship between HbA1C levels and the outcomes of hernia surgery in diabetic patients treated at a tertiary care center. Methods Data were collected from 301 diabetic patients, categorized into controlled (HbA1C < 7%) and uncontrolled (HbA1C ≥ 7%) groups, who underwent hernioplasty at King Abdulaziz Medical City (KAMC) between September 1, 2017, and September 1, 2022. Patient records were analyzed to explore the association between diabetes and hernia surgery outcomes, including complications, infections, and recurrence, as well as to compare the outcomes of different surgical techniques (open and laparoscopic). Results Of the 301 patients, this study included only 140 (46.5%) diabetic individuals who underwent hernia surgery at the Ministry of National Guard Health Affairs (MNGHA) in Riyadh between 2017 and 2022. Preoperative uncontrolled HbA1C levels were not statistically significant for wound infection (p = 0.706) or hernia recurrence (p = 0.075) within a one-year follow-up period. However, a statistically significant difference was observed in the prevalence of hypertension between the controlled and uncontrolled HbA1C groups (p = 0.039). Conclusion This study indicates that HbA1C levels do not significantly influence complications or infections following hernia surgery, particularly regarding wound infections and recurrence. However, HTN was found to be statistically significant and warrants further investigation. Additionally, no statistical significance was identified between elevated BMI (>30 kg/m 2 ) and HbA1C groups (p = 0.081), which may be attributed to the limited sample size of this study. READ ALL READ LESS Keywords Hernia, HbA1c, Diabetics, Diabetes, Outcomes Corresponding Author(s) Abdullah Alghamdi ( [email protected] ) Close Corresponding author: Abdullah Alghamdi Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Alghamdi A et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Alghamdi A, Alzamel H, Aljabr A et al. The association between HBA1C level and the outcome of hernia surgery in diabetic patients managed at a tertiary center: A retrospective cohort study [version 1; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2025, 14 :394 ( https://doi.org/10.12688/f1000research.162204.1 ) First published: 04 Apr 2025, 14 :394 ( https://doi.org/10.12688/f1000research.162204.1 ) Latest published: 04 Apr 2025, 14 :394 ( https://doi.org/10.12688/f1000research.162204.1 ) Introduction Hernia is a prevalent condition worldwide, with an estimated 20 million hernia repair surgeries performed annually and a 2% lifetime risk of abdominal wall hernia development in men. 1 , 2 A 2016 systematic review titled “Diabetes and Risk of Surgical Site Infection” reported an increased risk of surgical site infections across most types of surgeries among diabetic patients, excluding obstetrical and gynecological procedures. 3 Additionally, a study conducted at the Department of Surgery, Mount Sinai Beth Israel, United States, involving 2,200 patients divided into two groups based on their HbA1C levels, found that elevated HbA1C (>6.5%) combined with dirty wounds or advanced age significantly increased the likelihood of postoperative infections. 4 Despite these findings, there is limited research on the relationship between HbA1C levels and the risk of infection or complications following hernioplasty, both globally and in Saudi Arabia. This retrospective study aims to investigate the association between HbA1C levels and hernia surgery outcomes in diabetic patients treated at a tertiary hospital Methods A retrospective study was conducted in the Department of Surgery at King Abdulaziz Medical City (KAMC), under the Ministry of National Guard Health Affairs (MNGHA), Riyadh, Saudi Arabia, from September 2017 to September 2022. The study received approval from the Institutional Review Board of the King Abdullah International Medical Research Center (KAIMRC). It included young and adult diabetic patients, encompassing those with uncontrolled diabetes mellitus (HbA1C ≥ 7%) and those with controlled diabetes mellitus (HbA1C < 7%) as a comparison group, who underwent hernioplasty surgery and met the eligibility criteria. The study involved patients of both genders, aged 20 to 85 years, who underwent hernioplasty via open or laparoscopic techniques, with or without mesh, and received treatment at KAMC. The exclusion criteria included patients undergoing long-term steroid therapy and those receiving chemotherapy within six months prior to surgery. A formal sample size calculation was not required, as all cases meeting the study’s case definition during the specified period were considered for inclusion. Data from 301 patients were retrieved from the “BESTcare” healthcare database ( https://ngha.med.sa/English/AboutNGHA ). Of these, only 140 patients fulfilled the inclusion and exclusion criteria. Patients who failed to meet the eligibility requirements, including those without recorded HbA1C levels, were excluded. The collected data were transferred to an Excel sheet for review, selection, and analysis by the research team. The dataset included demographic information (age, gender, preoperative BMI), surgical complications (postoperative wound infection, postoperative abscess, recurrence), diabetic complications, laboratory parameters (hemoglobin level, preoperative HbA1C level), the type of hernioplasty surgery (open vs. laparoscopic procedures), and diagnoses of comorbid conditions such as cardiovascular diseases, hypertension (HTN), chronic kidney disease (CKD), liver disease, or lung disease. Recurrence was defined as a diagnosis made by a physician and documented in the healthcare system records (BestCare). Wound infection was identified based on the definition provided by the Centers for Disease Control and Prevention (CDC). Although HbA1C levels were measured preoperatively, postoperatively, and during follow-up, the statistical analysis primarily focused on preoperative HbA1C levels. This decision was made because there were no significant variations among the three measurements that would affect the results. Statistical analysis and data management were performed using SPSS software, version 26 for Windows. Descriptive statistics were employed to summarize the dataset. Continuous variables were presented as medians with interquartile ranges, while categorical variables were reported as frequencies (n) and percentages (%). The Student's t-test was utilized to compare continuous variables, and categorical variables were analyzed using the Chi-square test or Fisher's exact test. Binary logistic regression was applied to assess the association between preoperative HbA1C (categorized) and outcomes, including wound infection and recurrence. All statistical tests were two-sided, with a significance level set at p < 0.05. Patient confidentiality and anonymity were strictly maintained by excluding identifiers from the dataset. All data, both electronic and physical, were securely stored within the MNGHA premises and were accessible only to the research team. The STROBE checklist has been utalized to adhere to international guidelines for reporting retrospective studies. 20 Furthermore, the collected data has also been made available in the repository. 20 Results This study initially included 147 diabetic patients who underwent hernia surgery at the Ministry of National Guard Health Affairs (MNGHA) in Riyadh between 2017 and 2022. However, due to missing data in some cases, the final analysis was conducted on 140 patients who met the inclusion criteria with complete data. The gender distribution was nearly equal, with males comprising 52.1% (n=73) and females 47.9% (n=67). Most patients were aged between 47 and 69 years, with a mean age of 58 years and a median age of 57 years (IQR = 14). Regarding preoperative BMI, the majority of patients were classified as obese, with a median BMI of 31.215 (IQR = 9.04). Approximately one-third of the patients 27.14% (n=38) underwent open hernia repair, while the remaining 72.86% (n=102) underwent laparoscopic repair. Recurrence occurred in 21 patients (15%) within one year post-surgery, and 7 patients (5%) developed postoperative wound infections. Preoperative HbA1C values were recorded, revealing that 91 patients had uncontrolled HbA1C levels (≥7%). Additionally, 10 patients (7.14%) were diagnosed with chronic kidney disease, and 84 patients (60%) had hypertension ( Table 1 ). Table 1. Patients demographics, characteristics, and HbA1C groups. Variable Total (n= 140), frequency %, median Preoperative HbA1C < 7% (n= 49) Preoperative HbA1C ≥ 7% (n= 91) OR 95% confidence interval # p-value Statistical test Age 57.00 ‡ (14) 55 ‡ (18.0) 57 ‡ (13.0) 0.95 0.73-1.24 0.298 † T-test Males § 73 (52.1%) § 27 (55.10%) § 46 (50.54%) 1.07 0.68-1.69 0.768 * Pearson Chi-squared test Females § 67 (47.9%) § 22 (44.90%) § 45(49.45%) Preoperative BMI 31.215 ‡ (9.04) 32.3 ‡ (10.44) 30.39 ‡ (8.32) 1.23 0.92-1.63 0.081 † T-test CKD § 10 (7.14%) § 1 (2.04%) § 9 (9.89%) 2.53 0.52-12.23 0.078 ¶ Fisher exact test HTN § 84 (60%) § 24 (48.98%) § 60(65.93%) 0.63 0.39-0.99 0.039 ¶ Smoking § 11 (7.86%) § 5 (10.20%) § 6 (6.59%) 0.62 0.18-2.16 0.453 * Pearson Chi-squared test Open hernia repair § 38 (27.14%) § 17 (34.69%) § 21 (23.07%) 1.54 0.95-2.47 0.099 ¶ Fisher exact test Laparoscopic hernia repair § 102 (72.86%) § 32 (65.31%) § 70 (76.92%) Wound infection § 7 (5%) § 2 (4.08%) § 5 (5.49%) 0.72 0.15-3.34 0.669 * Pearson Chi-squared test Recurrence § 21 (15%) § 11 (22.44%) § 10 (10.99%) 0.38 0.14-0.99 0.043 * Postoperative hospital length of stay 1.56 ± (3.07) 2.19 ± (3.58) 1.26 ± (2.86) 1.28 0.92-1.78 0.065 † T-test ‡ median (interquartile range), or § numbers (%), or ± mean (standard deviation). # p- value is significant if less than 0.05 † T-test * Pearson Chi-squared test ¶ Fisher exact test A statistically significant difference was found between hypertensive patients and the uncontrolled HbA1C group (p = 0.039), with hypertension (HTN) being more common in the group with HbA1C ≥ 7% ( Table 1 ). The incidence of wound infection was 5 cases among patients with uncontrolled HbA1C and 2 cases in the controlled HbA1C group, with no statistically significant difference between the groups (OR 0.706; 95% CI 0.132–3.784; p = 0.706). Similarly, no significant difference was observed between the two groups for hernia recurrence, with 11 (22.44%) cases of recurrence in the controlled HbA1C group and 10 (10.99%) cases in the uncontrolled HbA1C group (OR 2.345; 95% CI 0.917–5.997; p = 0.075) ( Table 2 ). Table 2. Binary logistic analysis of HbA1C groups and clinical outcomes. Variable Preoperative HbA1C < 7% (n=49) Preoperative HbA1C ≥7% (n= 91) Odds Ratio (OR) 95% confidence interval p-value Wound infection 2 (4.08%) 5 (5.49%) 0.706 0.132-3.784 0.706 Recurrence 11 (22.44%) 10 (10.99%) 2.345 0.917-5.997 0.075 Discussion The results of this retrospective study indicate that there is no significant association between different HbA1C levels, whether controlled or uncontrolled, and the outcomes of hernia surgery in diabetic patients. However, a significant relationship was observed between hypertension and wound infection in the exposed group. In Saudi Arabia, hernia is a prevalent condition affecting both male and female adults. 5 A 2017 cross-sectional study in the northern region involving 1,567 patients found the prevalence of hernia to be 11.7%, with 85% of cases occurring in individuals aged 18 to 85 years. 5 Additionally, a 2017 nationwide study found that 38% of 500 participants had abdominal hernias, with prevalence increasing with BMI and decreasing in younger populations. 6 Hernia repair, whether performed through open or laparoscopic procedures, remains the primary treatment for all types of hernias. In recent years, mesh hernia repair has largely replaced non-mesh repair due to its superior postoperative outcomes. 7 A systematic review of 25 studies involving 6,293 participants revealed that mesh hernia repair reduces the risk of recurrence compared to non-mesh repair. It also showed that mesh repair is associated with shorter surgery times, enhanced postoperative pain relief, and a lower risk of neurovascular or visceral injuries. 8 Despite the advantages of mesh hernia repair, outcomes may still be influenced by the presence of diabetes mellitus. Diabetes mellitus generally affects immunity and increases the risk of infections. A retrospective study conducted in Canada investigated infection rates and mortality due to bacterial infections in over 500,000 diabetic patients and age-matched controls across two separate periods. The findings revealed significantly higher infection rates among individuals with diabetes, with bacterial infections being the most prevalent. 9 Diabetes mellitus represents a major global health concern, with an estimated 171 million diagnosed cases in 2000. 10 This number has steadily risen, reaching 366 million in 2011, and is projected to surpass 522 million by 2030. This global epidemic also affects the Kingdom of Saudi Arabia (KSA). The Saudi Ministry of Health reported that in 1992, approximately 0.9 million individuals had diabetes, a figure that increased to 2.5 million by 2010, marking a 2.7-fold rise in incidence. 10 The World Health Organization (WHO) has reported that Saudi Arabia ranks second in the Middle East and seventh globally in terms of diabetes prevalence. Approximately 7 million people in the country are affected by diabetes, with an additional 3 million individuals having pre-diabetes. 11 Diabetes mellitus is associated with a higher risk of complications, including delayed wound healing, increased susceptibility to infections, nutrient loss due to glycosuria, delayed extubation, and respiratory and circulatory abnormalities. 12 , 13 While several studies have highlighted differences in wound healing and postoperative outcomes between diabetic and non-diabetic patients, fewer have explored whether complications are more prominent in all diabetic patients or specifically in those with uncontrolled HbA1C levels. 4 Determining whether a significant difference exists between diabetic patients with uncontrolled HbA1C levels (>7%) and those with controlled levels (<7%) is valuable. Such findings could assist in managing surgical outcomes, guiding surgeons' decisions regarding elective surgeries. Numerous studies have explored the impact of diabetes mellitus on postoperative outcomes, yet the results remain inconclusive. Some research indicates that patients with high HbA1c levels, a history of diabetes, or preoperative hyperglycemia are more likely to experience increased postoperative infection rates. In fact, many surgeons suggest that individuals with diabetes often do not heal as well post-surgery as those without diabetes. 14 – 16 In our study, however, we found no significant association between HbA1C levels—whether controlled or uncontrolled—and postoperative outcomes. While the rate of wound infections was higher in patients with uncontrolled HbA1C, this difference was not statistically significant. Interestingly, a systematic review examining the relationship between HbA1C and sternal wound infections following adult cardiac surgery reported a substantially higher risk of infection when HbA1C levels exceeded 6-7%. 17 The lack of a significant finding in our study may be attributed to the small sample size or the fact that wound infection rates are influenced by multiple risk factors, not just HbA1C levels. These factors may include the type of surgical wound (e.g., clean vs. clean-contaminated), patient age, and surgical risk classification. 4 Our findings suggest that solely screening diabetic patients undergoing elective hernia surgery based on HbA1C levels is insufficient. A more comprehensive assessment, taking into account all relevant risk factors for wound infection and other postoperative complications, is essential. Although previous studies have indicated a significant association between hernia recurrence and diabetes in patients undergoing open umbilical hernia repair, 18 our study did not find a statistically significant difference in recurrence rates between patients with controlled and uncontrolled preoperative HbA1C levels, both postoperatively and during follow-up. This suggests that the risk of hernia recurrence may be inherent, regardless of whether the patient has controlled their HbA1C. Another possible explanation for the lack of significant differences between controlled and uncontrolled HbA1C groups could be the influence of other confounding factors, including the choice of surgical approach, BMI, age, gender, the presence of postoperative infection, smoking status, and other variables. The exact relationship between diabetes mellitus and hernia recurrence remains unclear, highlighting the need for further studies to explore this association more comprehensively. In this study, no significant association was found between open hernia repair and a higher likelihood of wound infection compared to laparoscopic hernia repair. This aligns with the findings of a second study, which reported that laparoscopic ventral hernia repair (LVHR) was significantly associated with fewer surgical site infections (SSIs) but more clinical cases of bulging compared to open ventral hernia repair (OVHR). 19 Similarly, a cohort study observed higher postoperative complications and hernia recurrence in laparoscopic procedures than in open ones, though these differences were not statistically significant. 18 The discrepancies between these findings could be attributed to factors such as demographic characteristics, patients’ awareness of postoperative care, or the sample size. Larger, more inclusive studies are needed to clarify the outcomes of these different surgical approaches. We recognize several limitations in our study. The inclusion criteria were broad, encompassing all diabetic patients who underwent hernia surgery, without specifying the type of hernia, as this would have further reduced the sample size. While we acknowledge that the sample size is relatively small, we believe that our study is the first to focus on a sufficiently small group of diabetic patients, allowing for an in-depth analysis to assess whether HbA1c levels, as an independent factor, influence postoperative infection rates specifically in hernia surgery cases. Conclusion Our study contributes to the existing knowledge in clean wound surgery (e.g., hernia) by demonstrating that the rates of wound infection and recurrence among patients with uncontrolled HbA1c were not statistically significant. However, a significant relationship was observed between hypertension and HbA1c levels. Future research should investigate the interaction between comorbid conditions (e.g., hypertension), HbA1c levels, and the incidence of postoperative wound infections. Reporting guidelines Figshare: STROBE Checklist for The association between HBA1C level and the outcome of hernia surgery in diabetic patients managed at a tertiary center: A retrospective cohort study, 10.6084/m9.figshare.28560725 . 20 Ethics Ethical approval was obtained in 30 May 2023 from the Institutional Review Board (IRB) of the King Abdullah International Medical Research Center (KAIMRC) with the approval number of (IRB/1297/23). Patient confidentiality and anonymity was strictly upheld, with no identifying information collected. All data, in both digital and physical formats, was secured and recorded in a password-protected Excel sheet, accessible exclusively to the research team. Furthermore, all data was securely maintained within the premises of the Ministry of National Guard Health Affairs (MNGHA). Data availability statement Underlying data Figshare: The association between HBA1C level and the outcome of hernia surgery in diabetic patients managed at a tertiary center: A retrospective cohort study, 10.6084/m9.figshare.28560725 . 20 This project contains the following underlying data: FigShare data collection without identifiers.xlsx Data are available under the terms of the Creative Commons Zero (CC0) "No rights reserved" data waiver References 1. Şeker G, Kulaçoğlu H, Őztuna D, et al. : Changes in the Frequencies of Abdominal Wall Hernias and the Preferences for Their Repair: A Multicenter National Study From Turkey. Int. Surg. 2014 Sep 1 [cited 2023 Dec 5]; 99 (5): 534–542. PubMed Abstract | Publisher Full Text Reference Source 2. Dabbas N, Adams K, Pearson K, et al. : Frequency of abdominal wall hernias: is classical teaching out of date?. JRSM Short Reports. 2011 Jan; 2 (1): 1–6. PubMed Abstract | Publisher Full Text | Free Full Text 3. Martin ET, Kaye KS, Knott C, et al. : Diabetes and Risk of Surgical Site Infection: A Systematic Review and Meta-analysis. Infect. Control Hosp. Epidemiol. 2015 Oct 27; 37 (1): 88–99. PubMed Abstract | Publisher Full Text Reference Source 4. Blankush JM, Leitman IM, Soleiman A, et al. : Association between elevated pre operative glycosylated hemoglobin and post-operative infections after non-emergent surgery. Ann. Med. Surg. 2016 Sep; 10 : 77–82. (2049-0801). PubMed Abstract | Publisher Full Text 5. AhmedAlenazi A, Alsharif MM, Hussain MA, et al. : Prevalence, risk factors and character of abdominal hernia in Arar City, Northern Saudi Arabia in 2017. Electron. Physician. 2017 Jul 25; 9 (7): 4806–4811. PubMed Abstract | Publisher Full Text | Free Full Text Reference Source 6. Al-juaid R, Mahfouz MM: Prevalence and risk factors of abdominal hernia among Saudi population. J. Family Med. Prim. Care. 2021; 10 (8): 77–82. Blankush JM, Leitman IM, Soleiman A, Tran T. Association between elevated pre operative glycosylated hemoglobin and post-operative infections after non-emergent surgery. Annals of Medicine and Surgery. 2016 Sep;10(2049-0801):77–82. Publisher Full Text 7. Klingensmith ME, Vemuri C, Fayanju OM, et al. : The Washington manual of surgery. Philadelphia: Wolters Kluwer; 2016. 8. Lockhart K, Dunn D, Teo S, et al. : Mesh versus non- mesh for inguinal and femoral hernia repair. The. Cochrane Database Syst. Rev. 2018 Sep 13; 2018 (9): CD011517. PubMed Abstract | Publisher Full Text | Free Full Text 9. Shah BR, Hux JE: Quantifying the Risk of Infectious Diseases for People With Diabetes. Diabetes Care. 2003 Feb 1 [cited 2019 Sep 16]; 26 (2): 510–513. Publisher Full Text Reference Source 10. Alotaibi A, Perry L, Gholizadeh L, et al. : Incidence and prevalence rates of diabetes mellitus in Saudi Arabia: An overview. Journal of Epidemiology and Global Health. 2017 Dec; 7 (4): 211–218. PubMed Abstract | Publisher Full Text 11. Al Dawish MA, Robert AA, Braham R, et al. : Diabetes Mellitus in Saudi Arabia: A Review of the Recent Literature. Curr. Diabetes Rev. 2016 [cited 2019 Dec 12]; 12 (4): 359–368. PubMed Abstract | Publisher Full Text 12. Hoogwerf BJ: POSTOPERATIVE PATIENT. Med. Clin. North Am. 2001 Sep; 85 (5): 1213–1228. PubMed Abstract | Publisher Full Text 13. Wang J, Chen K, Li X, et al. : Postoperative adverse events in patients with diabetes undergoing orthopedic and general surgery. Medicine. 2019 Apr 5; 98 (14). Reference Source 14. Humphers JM, Shibuya N, Fluhman BL, et al. : The Impact of Glycosylated Hemoglobin and Diabetes Mellitus on Wound-Healing Complications and Infection After Foot and Ankle Surgery. J. Am. Podiatr. Med. Assoc. 2014 Jul; 104 (4): 320–329. PubMed Abstract | Publisher Full Text 15. Han HS, Kang SB: Relations between Long-term Glycemic Control and Postoperative Wound and Infectious Complications after Total Knee Arthroplasty in Type 2 Diabetics. Clin. Orthop. Surg. 2013; 5 (2): 118–123. PubMed Abstract | Publisher Full Text | Free Full Text 16. Wang R, Panizales MT, Hudson MS, et al. : Preoperative glucose as a screening tool in patients without diabetes. J. Surg. Res. 2014 Jan 1 [cited 2023 Feb 3]; 186 (1): 371–378. PubMed Abstract | Publisher Full Text 17. Biancari F, Giordano S: Glycated Hemoglobin and the Risk of Sternal Wound Infection After Adult Cardiac Surgery: A Systematic Review and Meta-Analysis. Semin. Thorac. Cardiovasc. Surg. 2019 Mar; 31 : 465–467. (1532-9488). PubMed Abstract | Publisher Full Text 18. Donovan K, Denham M, Kuchta K, et al. : Predictors for recurrence after open umbilical hernia repair in 979 patients. Surgery. 2019 Oct; 166 (4): 615–622. PubMed Abstract | Publisher Full Text 19. Liang MK, Berger RL, Li LT, et al. : Outcomes of Laparoscopic vs Open Repair of Primary Ventral Hernias. JAMA Surg. 2013 Nov 1; 148 (11): 1043–1048. PubMed Abstract | Publisher Full Text 20. Alghamdi A: The association between HBA1C level and the outcome of hernia surgery in diabetic patients managed at a tertiary center: A retrospective cohort study. Dataset. figshare. 2025. Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 04 Apr 2025 ADD YOUR COMMENT Comment Author details Author details 1 King Abdullah International Medical Research Center, Riyadh, 11481, Saudi Arabia 2 Collage of Medicine, King Saud bin Abdulaziz University for Health Sciences, Ar Rimayah, 14611, Riyadh, Saudi Arabia 3 King Abdulaziz Medical City, Ministry of National Guard-Health Affairs (MNGHA),, Riyadh, Saudi Arabia Abdullah Alghamdi Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Heythem Alzamel Roles: Conceptualization, Funding Acquisition, Investigation, Project Administration, Resources, Software, Supervision, Validation, Writing – Review & Editing Abdulmajeed Aljabr Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Omar Alsalem Roles: Conceptualization, Data Curation, Investigation, Methodology, Project Administration, Resources, Validation, Visualization, Writing – Original Draft Preparation Ibrahim Momen Roles: Data Curation, Investigation, Methodology, Resources, Software, Supervision, Validation, Writing – Original Draft Preparation Osama Mujammami Roles: Data Curation, Funding Acquisition, Investigation, Methodology, Resources, Validation, Writing – Original Draft Preparation Rifan Alyami Roles: Conceptualization, Formal Analysis, Funding Acquisition, Project Administration, Resources, Software, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 04 Apr 2025, 14:394 https://doi.org/10.12688/f1000research.162204.1 Copyright © 2025 Alghamdi A et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Alghamdi A, Alzamel H, Aljabr A et al. The association between HBA1C level and the outcome of hernia surgery in diabetic patients managed at a tertiary center: A retrospective cohort study [version 1; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2025, 14 :394 ( https://doi.org/10.12688/f1000research.162204.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 04 Apr 2025 Views 0 Cite How to cite this report: Aguilar LT. Reviewer Report For: The association between HBA1C level and the outcome of hernia surgery in diabetic patients managed at a tertiary center: A retrospective cohort study [version 1; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2025, 14 :394 ( https://doi.org/10.5256/f1000research.178361.r405968 ) The direct URL for this report is: https://f1000research.com/articles/14-394/v1#referee-response-405968 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 11 Sep 2025 Luis Tallón- Aguilar , Virgen del Rocío University Hospital, Seville, Spain Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.178361.r405968 I have carefully reviewed the manuscript by Dr. Alghamdi et al., entitled “The association between HBA1C level and the outcome of hernia surgery in diabetic patients managed at a tertiary center: A retrospective cohort study” , submitted for consideration in F100Resarch. ... Continue reading READ ALL I have carefully reviewed the manuscript by Dr. Alghamdi et al., entitled “The association between HBA1C level and the outcome of hernia surgery in diabetic patients managed at a tertiary center: A retrospective cohort study” , submitted for consideration in F100Resarch. The authors present a retrospective analysis of diabetic patients undergoing hernia repair, divided into two groups according to their HbA1c levels, and compare surgical outcomes. The topic is relevant, and the study addresses an important clinical question. However, several issues require clarification and further elaboration before the manuscript can be considered for indexing. Major comments: The results show no differences in SSI or recurrence, yet other key outcomes in hernia surgery—such as SSO or readmission—were not assessed. These variables are essential to provide a more comprehensive evaluation of postoperative morbidity. The only statistically significant difference reported was hypertension, a finding with limited clinical relevance in the context of abdominal wall surgery. The absence of statistical significance in infection and recurrence rates may be attributable to the limited sample size (only 7 infections and 21 recurrences). The small number of events limits the power of the study and the strength of its conclusions. The cutoff used to stratify patients was HbA1c >7%, whereas 6.5% has been more commonly adopted in the literature (e.g., Blankush et al., reference 4). The rationale for choosing 7% instead of 6.5% should be clarified. The study population covers the period 2017–2022, yet patients treated after this period were excluded without explanation. The reasons for this restriction should be stated. In the descriptive data, the authors classify repairs as open or laparoscopic but do not specify the type of hernia (inguinal, umbilical, primary ventral, incisional, parastomal, recurrent, etc.). This is a critical omission, as the anatomical site and complexity substantially influence outcomes. Similarly, the authors do not report how many patients underwent mesh versus non-mesh repair, nor do they detail mesh type, placement, or fixation, all of which are relevant for interpreting the results. It would be highly informative to include data on non-diabetic patients from the same cohort. This would help determine whether diabetes itself is a risk factor independently of HbA1c levels. Minor comments: The acronym HTN should be defined at first use. Reference 7 should be carefully reviewed. In summary, while the manuscript addresses a clinically relevant question, several methodological and reporting issues limit the strength and interpretability of the findings. Addressing the points raised above would considerably improve the quality of the work. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Abdominal wall reconstruction, hernia surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Aguilar LT. Reviewer Report For: The association between HBA1C level and the outcome of hernia surgery in diabetic patients managed at a tertiary center: A retrospective cohort study [version 1; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2025, 14 :394 ( https://doi.org/10.5256/f1000research.178361.r405968 ) The direct URL for this report is: https://f1000research.com/articles/14-394/v1#referee-response-405968 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Huang LC. Reviewer Report For: The association between HBA1C level and the outcome of hernia surgery in diabetic patients managed at a tertiary center: A retrospective cohort study [version 1; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2025, 14 :394 ( https://doi.org/10.5256/f1000research.178361.r386089 ) The direct URL for this report is: https://f1000research.com/articles/14-394/v1#referee-response-386089 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 14 Jun 2025 Li-Ching Huang , Vanderbilt University Medical Center, Nashville, USA Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.178361.r386089 Table 1 – please add mesh used status (Yes vs No), mesh type, hernia width, hernia length, operation time, recurrent hernia (Yes vs No), wound status, hernia grade, ASA class. Please add the variables that ... Continue reading READ ALL Table 1 – please add mesh used status (Yes vs No), mesh type, hernia width, hernia length, operation time, recurrent hernia (Yes vs No), wound status, hernia grade, ASA class. Please add the variables that were mentioned in methods section to Table 1. Please provide the details of wound infection. Was any covariable adjusted in the logistic regression model? If it is simple logistic regression model, please remove wound infection and recurrence from table 1 to avoid using multiple statistical methods to exam the same hypothesis. Please define the follow up window for outcomes in method section. Please define the primary outcome and secondary outcomes. The patients in HbA1C < 7% had longer postoperative hospital length of stay. Please provide the reasoning behind this. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: statistical analysis I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Huang LC. Reviewer Report For: The association between HBA1C level and the outcome of hernia surgery in diabetic patients managed at a tertiary center: A retrospective cohort study [version 1; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2025, 14 :394 ( https://doi.org/10.5256/f1000research.178361.r386089 ) The direct URL for this report is: https://f1000research.com/articles/14-394/v1#referee-response-386089 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 04 Apr 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 1 04 Apr 25 read read Li-Ching Huang , Vanderbilt University Medical Center, Nashville, USA Luis Tallón- Aguilar , Virgen del Rocío University Hospital, Seville, Spain Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Aguilar L. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 11 Sep 2025 | for Version 1 Luis Tallón- Aguilar , Virgen del Rocío University Hospital, Seville, Spain 0 Views copyright © 2025 Aguilar L. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions I have carefully reviewed the manuscript by Dr. Alghamdi et al., entitled “The association between HBA1C level and the outcome of hernia surgery in diabetic patients managed at a tertiary center: A retrospective cohort study” , submitted for consideration in F100Resarch. The authors present a retrospective analysis of diabetic patients undergoing hernia repair, divided into two groups according to their HbA1c levels, and compare surgical outcomes. The topic is relevant, and the study addresses an important clinical question. However, several issues require clarification and further elaboration before the manuscript can be considered for indexing. Major comments: The results show no differences in SSI or recurrence, yet other key outcomes in hernia surgery—such as SSO or readmission—were not assessed. These variables are essential to provide a more comprehensive evaluation of postoperative morbidity. The only statistically significant difference reported was hypertension, a finding with limited clinical relevance in the context of abdominal wall surgery. The absence of statistical significance in infection and recurrence rates may be attributable to the limited sample size (only 7 infections and 21 recurrences). The small number of events limits the power of the study and the strength of its conclusions. The cutoff used to stratify patients was HbA1c >7%, whereas 6.5% has been more commonly adopted in the literature (e.g., Blankush et al., reference 4). The rationale for choosing 7% instead of 6.5% should be clarified. The study population covers the period 2017–2022, yet patients treated after this period were excluded without explanation. The reasons for this restriction should be stated. In the descriptive data, the authors classify repairs as open or laparoscopic but do not specify the type of hernia (inguinal, umbilical, primary ventral, incisional, parastomal, recurrent, etc.). This is a critical omission, as the anatomical site and complexity substantially influence outcomes. Similarly, the authors do not report how many patients underwent mesh versus non-mesh repair, nor do they detail mesh type, placement, or fixation, all of which are relevant for interpreting the results. It would be highly informative to include data on non-diabetic patients from the same cohort. This would help determine whether diabetes itself is a risk factor independently of HbA1c levels. Minor comments: The acronym HTN should be defined at first use. Reference 7 should be carefully reviewed. In summary, while the manuscript addresses a clinically relevant question, several methodological and reporting issues limit the strength and interpretability of the findings. Addressing the points raised above would considerably improve the quality of the work. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Abdominal wall reconstruction, hernia surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (0) Aguilar LT. Peer Review Report For: The association between HBA1C level and the outcome of hernia surgery in diabetic patients managed at a tertiary center: A retrospective cohort study [version 1; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2025, 14 :394 ( https://doi.org/10.5256/f1000research.178361.r405968) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-394/v1#referee-response-405968 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Huang L. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 14 Jun 2025 | for Version 1 Li-Ching Huang , Vanderbilt University Medical Center, Nashville, USA 0 Views copyright © 2025 Huang L. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Table 1 – please add mesh used status (Yes vs No), mesh type, hernia width, hernia length, operation time, recurrent hernia (Yes vs No), wound status, hernia grade, ASA class. Please add the variables that were mentioned in methods section to Table 1. Please provide the details of wound infection. Was any covariable adjusted in the logistic regression model? If it is simple logistic regression model, please remove wound infection and recurrence from table 1 to avoid using multiple statistical methods to exam the same hypothesis. Please define the follow up window for outcomes in method section. Please define the primary outcome and secondary outcomes. The patients in HbA1C < 7% had longer postoperative hospital length of stay. Please provide the reasoning behind this. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise statistical analysis I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Huang LC. Peer Review Report For: The association between HBA1C level and the outcome of hernia surgery in diabetic patients managed at a tertiary center: A retrospective cohort study [version 1; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2025, 14 :394 ( https://doi.org/10.5256/f1000research.178361.r386089) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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