Mortality after elective and emergency surgery for inguinal and femoral hernia

Summary The aim of this study was to investigate mortality following elective and emergency groin hernia surgery. Information concerning 17 591 inguinal and 579 femoral hernia operations, including death of patients within 30 days of surgery, were prospectively recorded in the Swedish Hernia Register over a period of six years. Elective surgery for groin hernia is known to be a low-risk procedure. Mortality within 30 days of surgery was compared with the mortality of the general Swedish population using the standard mortality rate (SMR). Of all inguinal and femoral hernia repairs 5.1 % and 35.2 % respectively, were performed as an emergency. Following elective inguinal hernia repair the SMR for men fell significantly below unity. No significant differences between observed and expected mortality were observed following inguinal hernia surgery on females or following elective femoral hernia surgery on either gender. The reduced SMR found after elective hernia repair in men is most likely attributable to patient selection. After elective surgery on patients 70 years or older there is a tendency towards a reduction in SMR of the same order of size as for patients analysed as one group which, however, did not reach statistical significance. Mortality following both inguinal and femoral emergency procedures is increased five- to ten-fold compared to the 30-day mortality in the general population. A further increase in postoperative mortality is noted following emergency surgery with bowel resection.     

Herniorrhaphy in patients aged 80 years or more. A prospective analysis of morbidity and mortality.

OBJECTIVE--To find out the morbidity and mortality after repair of groin hernias in patients aged 80 years or more, and to identify factors that add to the risk of hernia repair. DESIGN--Prospective open study. SETTING--All general surgical departments in Ringk?bing County, Denmark. SUBJECTS--All 39 patients aged 80 years and over who were admitted with hernias during a one year period (1990). OUTCOME MEASURES--Morbidity and mortality. RESULTS--Three patients refused operation, and of the remaining 36, 15 (42%) were admitted as emergencies (5 of whom were already waiting for elective repair of their hernias). The median age was 84 years (range 80-90) and 23 (64%) were men, 31 patients had inguinal hernias, 4 had femoral hernias, and one an obturator hernia. There were six major and two minor complications after 14 emergency operations (57%), and one minor complication after 22 elective operations (5%, p = 0.0007). Two patients died, both after emergency operations (14%). CONCLUSION--Elective hernia repair can be carried out safely even in the presence of serious coexisting disease, and emergency hernia repair carries a high risk of complications even in the absence of coexisting disease.     

Prospective evaluation of 6895 groin hernia repairs in women

BACKGROUND: Although 8 per cent of groin hernia repairs are performed in women, there is little published literature relating specifically to women. This study compared differences in outcome between women and men after groin hernia repair. METHODS: Data collected prospectively in the Swedish Hernia Register between 1992 and 2003 were analysed, including 6895 groin hernia repairs in women and 83 753 in men. RESULTS: A higher proportion of emergency operations was carried out in women (16.9 per cent) than men (5.0 per cent), leading to bowel resection in 16.6 and 5.6 per cent respectively. During reoperation femoral hernias were found in 41.6 per cent of the women who were diagnosed with a direct or indirect inguinal hernia at the primary operation. The corresponding proportion for men was 4.6 per cent. The hernia repair was not classified as a standard operation (e.g. Shouldice, Lichtenstein, Plug/Mesh, TAPP/TEP) in 38.2 per cent of women and 11.2 per cent of men. Women had a significantly higher risk of reoperation for recurrence than men, and techniques associated with the lowest risk for reoperation in men had the highest risk in women. CONCLUSION: A greater proportion of women than men require emergency groin hernia repair, with consequently higher rates of bowel resection, complications and death. Surgical techniques developed for use in men may put women at unnecessary risk.     

Femoral hernias: a register analysis of 588 repairs

Summary From 1 January 1992 to 31 December 1997 18,281 inguinal hernias and 588 femoral hernias were recorded in the Swedish Hernia Register. The aim of the present study was to characterise these femoral hernias and to evaluate the reoperation rate following their repair. 64% of all femoral hernias were located in the right groin and 36% in the left groin (p < 0.001). The male to female ratio for femoral hernia was 1:1.6; mean ages of patients with femoral and inguinal hernia were 63.4 ± 17.1 and 59.1 ± 16.4 years, respectively (p < 0.001). Emergency surgery and bowel resection at emergency surgery were more common with femoral than with inguinal hernia. The rate of ambulatory surgery was lower for femoral hernia than for inguinal hernia, mainly due to the higher emergency rate for femoral hernia. At three years the cumulative incidence of reoperation was 4.6% (95% confidence interval 2.4–6.8%) for femoral hernia and 4.0% (95% confidence interval 3.6–4.4%) for inguinal hernia (p > 0.05). Male sex and postoperative complications were associated with a significantly increased risk of reoperation following femoral hernia repair. The relative risk of reoperation was not affected by patient age, elective/emergency surgery, primary/recurrent hernia or hernia side. Repair techniques using mesh were associated with a lower reoperation rate than techniques without mesh, although the difference did not reach statistical significance.     

Complicated presentations of groin hernias.

Elective repair of simple (uncomplicated) inguinal and femoral hernias avoids incarceration and bowel obstruction (complicated presentations). To identify factors that perturb this strategy, we analyzed the records of 1,859 consecutive nonpediatric patients with groin hernias. Incarceration or bowel obstruction prompted operation in 22 of 77 (29%) women and in 15 of 34 (44%) patients with femoral hernia. Patients presenting with bowel obstruction were significantly older than those with incarceration only and/or uncomplicated presentation, and 13 of 25 (52%) required resection of necrotic bowel. Mortality was limited to five patients of advanced age with groin hernia and bowel obstruction. Four of the five patients had undergone resection of necrotic bowel. Complicated presentations of groin hernias are associated with a higher proportion of women and patients with femoral hernias. Gangrenous bowel was encountered only in those patients with groin hernia and bowel obstruction. Early diagnosis and elective repair of uncomplicated hernias should remain our strategy in patients of all ages.     

���꣨���䣩Ů�Ը��ɹ�����ϼ����Ʒ���ѡ��

??Diagnosis and treatment options of inguinal hernia in elderly women CHEN Si-meng. Department of General Surgery??the First Affiliated Hospital of Nanjing Medical University??Nanjing 210029??China
Abstract The proportion of females in the aged groin hernia is higher than that in the total adult groin hernia. The proportion of emergency surgery for groin hernia and mortality rate of hernia surgery in older women are higher than those of older men. The performance of groin hernia with only inguinal region or pelvic pain is not uncommon in elderly female. For the diagnosis of those hidden hernias, that sonographic imaging examination and other methods, can be used, even laparoscopic exploration. Therefore, for the elderly female groin hernia, it is recommended to choose elective surgery as soon as possible, so as to reduce the risk of more morbidity and mortality of emergency surgery. Preperitoneal hernia repair is recommend to those patients, including totally extraperitoneal prosthetic (TEP) and transabdominal preperitoneal prosthetic (TAPP). For some frail elderly, or surgeon whose skill is limited, plug hernia repair or mesh-plug hernia repair is also a good choice.     

Incarcerated groin hernias in adults: Presentation and outcome

Despite universal acceptance of the value of elective hernia repair, many patients present with incarceration or strangulation, which are associated with significant morbidity and mortality. We reviewed 147 patients who underwent emergency surgery for incarcerated groin hernias during a 10-year period in order to analyze the presentation and outcome in our practice. Median age of the patients was 70 years. There were 77 men and 70 women. Femoral hernias were seen in 77 patients and inguinal hernias in 70. Coexisting diseases were found in 82 cases (55.8%). Bowel resection was required in 19 patients (12.9%). The overall and major morbidity rates were 41.5% and 9.6%, respectively. The mortality rate was 3.4%. Longer duration of symptoms, late hospitalization, concomitant diseases, and high ASA class were found to be significant factors linked with unfavorable outcomes. Because of high morbidity and mortality associated with incarceration, elective repair of groin hernias should be done whenever possible.     

老年（高龄）女性腹股沟疝诊断及治疗方案选择

老年腹股沟疝（包括股疝）中的女性比例高于成人各年龄段腹股沟疝总体中的女性比例。老年女性腹股沟疝的急诊手术比例、疝手术的病死率均高于男性。老年女性腹股沟疝仅以腹股沟区疼痛或盆腔疼痛为表现的并不少见,对于隐匿疝的诊断须结合超声检查等影像学检查方法,甚至可以腹腔镜探查。因此,对于老年女性腹股沟疝,建议尽早选择择期手术,降低高龄急诊手术并发症发生率以及可能死亡的风险。老年女性腹股沟疝手术推荐腹膜前疝修补术,包括完全腹膜外疝修补术（TEP）、经腹腔腹膜前疝修补术（TAPP）等,在病情特殊或手术技术有限的情况下,网塞或网塞平片疝修补术也是一种很好的选择。     

Female ‘groin’ hernia: totally extraperitoneal (TEP) endoscopic repair seems the most appropriate treatment modality

Background

About 30% of all female ‘groin’ hernias are femoral hernias, although often only diagnosed during surgery. A Lichtenstein repair though, as preferred treatment modality according to guidelines, would not diagnose and treat femoral hernias. Totally extraperitoneal (TEP) hernia repair, however, offers the advantage of being an appropriate modality for the diagnosis and subsequent treatment of both inguinal and femoral hernias. TEP therefore seems an appealing surgical technique for women with groin hernias.

Methods

This study included all female patients ≥18?years operated for a groin hernia between 2005 and 2009.

Results

A total of 183 groin hernias were repaired in 164 women. TEP was performed in 85% of women; the other 24 women underwent an open anterior (mesh) repair. Peroperatively, femoral hernias were observed in 23% of patients with primary hernias and 35% of patients with recurrent hernias. There were 30 cases (18.3%) of an incorrect preoperative diagnosis. Peroperatively, femoral hernias were observed in 17.3% of women who were diagnosed with an inguinal hernia before surgery. In addition, inguinal hernias were found in 24.0% of women who were diagnosed with a femoral hernia preoperatively. After a follow-up of 25?months, moderate to severe (VAS 4-10) postoperative pain was reported by 8 of 125 patients (6.4%) after TEP and 5 of 23 patients (21.7%) after open hernia repair (P?=?0.03). Five patients had a recurrent hernia, two following TEP (1.4%) and three following open anterior repair (12.5%, P?=?0.02). Two of these three patients presented with a femoral recurrence after a previous repair of an inguinal hernia.

Conclusion

Femoral hernias are common in women with groin hernias, but not always detected preoperatively; this argues for the use of a preperitoneal approach. TEP hernia repair combines the advantage of a peroperative diagnosis and subsequent appropriate treatment with the known good clinical outcomes.     

Lichtenstein repair for incarcerated groin hernias.

OBJECTIVE: To evaluate the use of Lichtenstein tension-free repair for incarcerated groin hernias. DESIGN: Prospective consecutive series. SETTING: Tertiary academic surgery department, Poland. SUBJECTS: 27 patients whose incarcerated groin hernias were operated on between November 1997 and June 2001. INTERVENTION: Tension-free hernia repair by the Lichtenstein technique. MAIN OUTCOME MEASURES: Morbidity, recurrence rates and mortality. RESULTS: There were 2 postoperative deaths unrelated to implantation of the mesh (myocardial and cerebral infarction). In 1 patient a subcutaneous fluid collection was noted and was successfully treated by evacuation of the fluid. The remaining 24 patients had no complications during follow-up (mean 18 months, range 2-42 months). CONCLUSION: Monofilament polypropylene mesh can be successfully used not only in elective operations, but also in emergency operations for incarcerated inguinal hernias.     

The inheritance of groin hernia: a systematic review

Background

Groin hernia has been proposed to be hereditary; however, a clear hereditary pattern has not been established yet. The purpose of this review was to analyze studies evaluating family history and inheritance patterns and to investigate the possible heredity of groin hernias.

Methods

A literature search in the MEDLINE and Embase databases was performed with the following search terms: genetics, heredity, multifactorial inheritance, inheritance patterns, sibling relations, family relations, and abdominal hernia. Only English human clinical or register-based studies describing the inheritance of groin hernias, family history of groin hernias, or familial accumulation of groin hernias were included.

Results

Eleven studies evaluating 37,166 persons were included. The overall findings were that a family history of inguinal hernia was a significant risk factor for the development of a primary hernia. A family history of inguinal hernia showed a tendency toward increased hernia recurrence rate and significantly earlier recurrence. The included studies did not agree on the possible inheritance patterns differing between polygenic inheritance, autosomal dominant inheritance, and multifactorial inheritance. Furthermore, the studies did not agree on the degree of penetrance.

Conclusion

The literature on the inheritance of groin hernias indicates that groin hernia is most likely an inherited disease; however, neither the extent of familial accumulation nor a clear inheritance pattern has yet been found. In order to establish whether groin hernias are accumulated in certain families and to what extent, large register studies based on hernia repair data or clinical examinations are needed. Groin hernia repair (inguinal and femoral hernia) is among the most commonly performed gastrointestinal surgical procedures [1]. Emergency groin hernia surgery is associated with increased mortality, increased patient-related morbidity, and increased hospital stay compared with elective groin hernia procedures [2, 3]. Identifying patients at high risk of developing groin hernia would therefore provide the possibility of timely elective surgical intervention, thus reducing the rate of emergency procedures. It could also potentially make way for individualized surgical methods in the future.     

Risk of femoral hernia after inguinal herniorrhaphy

BACKGROUND: Small case series have suggested an increased risk of femoral hernia after previous inguinal herniorrhaphy, but no large-scale data with complete follow-up are available. METHODS: Data were extracted from the Danish Hernia Database covering the interval from 1 January 1998 to 1 July 2001, and included 34 849 groin hernia repairs. RESULTS: Of 1297 femoral hernia repairs, 71 patients had previously had an operation for inguinal hernia within the observation period. These 71 femoral hernias represented 7.9 per cent of all reoperations for groin hernia recorded in the database. The median time to reoperation for a 'recurrent' femoral hernia after previous inguinal herniorrhaphy was 7 months, compared with 10 months for inguinal recurrences. The risk of developing a 'recurrent' femoral hernia after previous inguinal herniorrhaphy was 15 times higher than the rate of femoral hernia repair in the general population. CONCLUSION: This study of 34 849 groin hernia repairs demonstrated a 15-fold greater incidence of femoral hernia after inguinal herniorrhaphy compared with the spontaneous incidence. These femoral recurrences occurred earlier than inguinal recurrences, suggesting that they were possibly femoral hernias overlooked at the primary operation.     

A STUDY OF THE RISK OF STRANGULATION AND OBSTRUCTION IN GROIN HERNIAS

Background : Complications that develop in groin hernias, such as irreducibility and obstruction, with or without strangulation may make an easily treatable condition a life-threatening one. Identification of risk factors that may predict development would help place the patient in a high-risk group. Priority admission and early elective surgery for such a patient would avoid significant mortality and morbidity. Methods : This is a 10-year combined prospective and retrospective study of children and adults. Records of complicated groin hernias were identified from July 1985 to July 1995 from the outpatient department and available inpatient medical records. The same number of controls of simple uncomplicated hernias were then chosen using random number tables from among the large number belonging to the same time period. These two groups were then compared and analysed using statistical methods for age, sex, side of hernia, site of hernia (inguinal/femoral), duration of hernia, length of the waiting list for elective surgery, and contents of the hernial sac along with some other parameters to identify patients with high–risk factors. Results : Age was found to be a significant risk factor and predicted complications in both elderly adults and very young children. Sex of the patient (male) and side of hernia (right) were significant risk factors in children only. Site of hernia was an important risk factor and adults with femoral hernia were most likely to experience complications. Duration of hernia for less than a year proved to be the most important risk factor for both children and adults. The majority of patients with complicated hernias had not presented earlier in the outpatient department, which implies that most hernias that become complicated do so within a very short time before patient referral. Mortality was high in patients with coexisting diseases, while morbidity was affected by viability of contents of the hernial sac which in turn was directly affected by duration of irreducibility or delay in presentation. Conclusions : The risk factors useful in predicting complications in an adult patient with groin hernia were age (older age group), duration of hernia (short duration), type of hernia (femoral more than inguinal) and coexisting medical illness. In children, the risk factors were age (very young), gender (male), short duration of hernia and side (right side).     

Longterm results of a prospective study of 225 femoral hernia repairs: indications for tissue and mesh repair

BACKGROUND: Femoral hernias are uncommon, and there are relatively few clinical studies of longterm outcomes after repair. Although the McVay repair has been classically described, the infrainguinal plug technique has gained popularity in recent years. Evidence supporting these repairs is sparse. STUDY DESIGN: A prospective study of elective femoral hernia repairs was done at the Shouldice Hospital from June 1999 until June 2003. The tissue-based complete groin repair (CGR) and a preperitoneal mesh repair were performed for specific indications. Patients were followed annually for 5 years to examine for recurrences and complications. RESULTS: Two hundred fifty-six patients were enrolled, with 225 completing 5 years of followup. Median age was 55 years, and hernias on the right side were more common (63.1%). Concurrent inguinal hernias were found in 115 patients (51%), and 41 (18.2%) had a previous inguinal hernia repair. A complete groin repair was performed in 120 patients and a preperitoneal mesh repair in 78. The remaining had an infrainguinal mesh repair. The overall recurrence rate was 3.1%, with a median time to recurrence of 12 months. There was no significant difference between mesh and suture repairs. Chronic postoperative pain was experienced by 20 patients (8.9%). CONCLUSIONS: Femoral hernias can be repaired electively with a tissue-based or a preperitoneal mesh technique, with durable longterm results. Mesh repair is indicated for recurrent femoral hernias, inguinofemoral hernias, prevascular hernias, association with concurrent direct hernias, and, if tension is anticipated, with complete groin repair. Infrainguinal mesh repair is used only when there has been a successful previous inguinal hernia repair.     

Groin hernias in women

A consecutive series of 255 women with primary groin hernias repaired electively over a five-year period, was reviewed. There were 271 hernias; the majority, 182 (67%) were indirect inguinal hernias, 35 (14%) were direct, and 54 (20%) were femoral. There were no major post-op complications and no recurrences. Most patients presented with a swelling but in 13 cases there was pre-operative discomfort only. Groin pain in women should arouse suspicion of an occult hernia. Lichtenstein repair for inguinal hernia is easier than in men, and as effective.     

Risk factors related with unfavorable outcomes in groin hernia repairs

Purpose

Hernia repairs are a common surgical procedure, and are associated with a significant cost. Despite the acceptance of the advantages of early elective hernia repairs, the incidence of emergency admissions with complicated presentations remains high, and the natural history of an untreated hernia is not obvious. This study aimed to define risk factors related with unfavorable outcomes in groin hernia repairs.

Methods

We analyzed the records of 685 elective or emergency repairs of groin hernias between December 2005 and June 2009. Patient age ranged from 17 to 85 years, with 240 (35%) of patients being older than 60 years of age. Indirect inguinal hernias were the most common hernia type in both sexes of patients. Coexisting cardiopulmonary problems were noted in 294 male and 33 female patients. American Society of Anaesthesiologists (ASA) grades 3 and 4 were encountered in 61 (9%) patients. Data were analyzed by chi-square test.

Results

Significantly high incarceration and strangulation rates were found in females and femoral hernia type. The overall morbidity rate was 7%, major complications 3%. No mortality was observed in the series and postoperative complications were significantly more common in patients with high ASA score and severe coexisting cardiopulmonary problems. Advanced age, delayed admission, femoral type hernia and female sex were also linked with unfavorable outcomes.

Conclusions

The risk of complicated presentation and unfavorable outcome in patients with groin hernia is significant in the presence of factors such as advanced age, femoral hernia, female sex, delayed admission, severe coexisting cardiopulmonary problems and high ASA score. Although it is difficult to estimate the natural history of untreated hernia, hernia repairs of patients with the above-mentioned risk factors should be timely and elective.     

Management of groin hernias in patients with ascites.

The records of 18 cirrhotic patients with ascites and groin hernias (20 inguinal and one femoral) were retrospectively reviewed. Eleven patients underwent repair of their groin hernias (total of 13 repairs). Ten herniorrhaphies were performed electively, two were performed urgently because of recent difficult reduction, and one was performed emergently for incarceration without strangulation. No major and four minor postoperative complications occurred. There were no perioperative deaths or ascites leaks. Of the 13 hernias in 11 patients undergoing repair, 12 (92%) were available for follow-up. In this group, the 12 groin hernia repairs were followed for a mean of 25 months. One recurrence (8%) occurred 11 months after repair. In this same group of patients, five umbilical hernias were repaired, with three recurrences (60%). From this retrospective study, it appears that serious complications from groin hernias in cirrhotics are not common, and elective repair can usually await control of ascites. Additionally, for appropriately selected patients with ascites, elective inguinal hernia repair can be performed safely, with an acceptable rate of recurrence.     

Adult groin hernias

Inguinal hernias are common, affecting one in four men in their lifetime. They are much less common in women with a lifetime risk of about 3%. Consequently, inguinal hernia repair is one of the commonest operations with more than 20 million operations performed annually worldwide. Africans have a much higher incidence of hernias than Caucasians and this is thought to be because of the anatomical configuration of the African pelvis. Many hernias in poorer countries are not repaired, so that presentation as an emergency and indeed mortality due to complications are much more often seen than in more affluent societies.     

Hernia repair in elderly patients

Background This study evaluates a 5-year experience of the management of the most frequent abdominal wall hernias in an elderly population. Methods From April 1990 to December 1995, 231 inguinal, 12 femoral and seven umbilical hernias were repaired in 221 patients (mean age 74 (range 66–93) years). Concomitant diseases were present in 157 patients, A mesh repair was performed with ‘tension-free’ or ‘plug’ techniques in all but 23 inguinal and two femora! hernia repairs, in which the Bassini or Shouldice procedures were adopted. Ten emergency hernia repairs were performed for strangulation. A total of 232 operations, including four emergency hernia repairs, were carried out under local anaesthesia. Results There was no perioperative mortality. Acute intestinal bleeding occurred 2 days after surgery in a patient with colonic diverticular disease. Urinary retention occurred once following emergency hernia repair under general anaesthesia and twice after elective hernia repair under local anaesthesia. Local complications included four scrotl haematomas (2 per cent), three wound infections (1 per cent) and one case of orchitis with atrophy after repair of a recurrent hernia. There was one recurrence after a Bassini repair and one after Shouldice inguinal herniorrhaphy. No recurrence was observed after mesh repair. Conclusion Local anaesthetic mesh hernia repair is safe and effective in elderly patients. Age should be no bar to elective hernia repair. This policy should avoid the complications of emergency operation.     

Inguinal hernia: Challenging the traditional indication for surgery in asymptomatic patients

Background: It is generally accepted that most inguinal hernias should be operated on electively in order to avoid the high morbidity and mortality associated with incarceration and small bowel obstruction. The present study reassesses the indication for surgery in asymptomatic inguinal hernia patients. Methods: We analyzed profiles, separately, for elective and emergency inguinal herniorrhaphies and compared the morbidity and mortality rates. Results: Two hundred randomly selected elective hernia repairs were compared with 67 incarcerated cases. Postoperative complications were more common following emergency (23.9%) than elective repair (10.5%); however, in both groups, minor complications predominated. The mortality rate in the incarcerated group (6%) was clearly linked with a high preoperative American Society of Anesthesiologists (ASA) score. A bowel resection rate of 4.5% was found in the incarcerated cases, which was not correlated with mortality. Conclusions: Patients with asymptomatic inguinal hernia and unfavorable medical conditions should be recommended an elective repair, preferably under local anesthesia, to avoid the high mortality associated with an emergency operation.