Incarcerated Groin Hernias in Adults

8/14/2019 Incarcerated Groin Hernias in Adults

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O R I G I N A L A R T I C L E

J. A. A lvarez R. F. Baldonedo I. G. BearJ. A. S. Sols P. A lvarez J. I. Jorge

Incarcerated groin hernias in adults: Presentation and outcome

Received: 18 March 2003 / Accepted: 13 October 2003 / Published online: 19 November 2003 Springer-Verlag 2003

Abstract Despite universal acceptance of the value ofelective hernia repair, many patients present withincarceration or strangulation, which are associated withsignificant morbidity and mortality. We reviewed 147

patients who underwent emergency surgery for incar-cerated groin hernias during a 10-year period in order toanalyze the presentation and outcome in our practice.Median age of the patients was 70 years. There were 77men and 70 women. Femoral hernias were seen in 77patients and inguinal hernias in 70. Coexisting diseaseswere found in 82 cases (55.8%). Bowel resection wasrequired in 19 patients (12.9%). The overall and majormorbidity rates were 41.5% and 9.6%, respectively. Themortality rate was 3.4%. Longer duration of symptoms,late hospitalization, concomitant diseases, and highASA class were found to be significant factors linkedwith unfavorable outcomes. Because of high morbidity

and mortality associated with incarceration, electiverepair of groin hernias should be done whenever possible.

Keywords Groin hernia Incarceration Strangul-ation Hernia repair Complications Mortality

Introduction

Groin hernias are among the most common problemsencountered by surgeons and may have significantcomplications. Anterior abdominal wall hernia occur-ring with strangulation is a serious surgical emergency,

as it is associated with high morbidity and mortality

[1, 2]. It is generally agreed that a hernia should beelectively repaired to avoid the complicated presenta-tions [3]. Nevertheless, many patients remain undiag-nosed or are reluctant to have surgical correction of

hernias, and, as a result, many emergency procedures areperformed for complications of neglected hernias.Compared to uncomplicated hernias, the treatment ofwhich has made great progress in modern times, com-plicated hernias have been relatively neglected, for fearthat their treatment may cause even greater risk to thepatient than the hernia itself [4].

This report is of a consecutive series of 147 adultspatients with incarcerated groin hernias during a 10-yearperiod from a district general hospital in northern Spainwith a catchment population of 180,000. We analyzed allincarcerated groin hernias in adults repaired on anemergency basis during the study period in order to

evaluate the clinical presentation and outcome.

Patients and methods

The records of all adult patients who underwent emergency surgeryfor preoperative diagnosis of incarcerated groin hernia betweenJanuary 1992 and December 2001 in our hospital were retrospec-tively reviewed. Incarceration was defined as irreducibility of anexternal hernia and strangulated hernia as irreducible with objec-tive signs of ischemia or gangrene. The case notes were obtainedand the following information recorded: age, sex, type of hernia,characteristics of clinical presentation, duration of symptoms, pastmedical history, and significant concomitant diseases, ASA class,type of anesthesia, contents of the hernial sac, surgical procedures,complications, duration of hospital stay, and mortality.

Duration of symptoms was established as the period from thesymptoms onset caused by incarceration to hospital admission.Significant concomitant diseases were represented by malignanciesand severe major organ dysfunction and were defined as present ifthe patient was receiving specific drug therapy. Each patient wasclassified according to the physical status scale of the AmericanSociety of Anesthesiologists or ASA class (Table 1) [5], which as-signs a risk level for surgery and anesthesia. Surgery was performedunder local, spinal, or general anesthesia in accordance with thepatients physiological status and the anesthetists opinion. Themethod of hernia repair was determined by the individual surgeonspreference. The outcome was analyzed with respect to the hospital

Hernia (2004) 8: 121126DOI 10.1007/s10029-003-0186-1

J. A. A lvarez (&) R. F. Baldonedo I. G. BearJ. A. S. Sols P. A lvarez J. I. JorgeService of General Surgery,Hospital San Agustn, Avile s, SpainE-mail: [email protected].: +34-985-276879Fax: +34-985-123052

Present address: J. A. A lvarezAvenida de Galicia 463 A,33005 Oviedo, Spain


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stay, complications, and mortality within 30 days of the operationor before discharge from the hospital. Major complications weredefined as those affecting major organ systems.

Data were compiled and analyzed by using a commercial sta-tistical software (SPSS for Windows, Chicago, Ill. USA). All con-tinuous data are expressed as meanSD; categorical variables arereported as a percentage. The statistical comparative analysis wasperformed by chi-square test (with Yates correction whereappropriate) for qualitative data. Fisher exact test was used insteadof the chi-square test if any expected cell value in a 22 table was

less than 5. Mann-Whitney Utests were used for quantitative data.Significance was defined as P


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17 patients with direct inguinal hernia (11.8%) and in 17of 53 (32.1%) with indirect inguinal hernia (P=0.09).

Surgical techniques adopted for hernia repair are re-ported in Table 5. In the series, the tension-free her-

nioplasty was the most common preferred procedure.The other surgical procedures performed during herniarepair were three appendectomies, three orchidectomies,two hydrocelectomies, one Meckels diverticulectomy,and one reparation of urinary bladder by incidentallesion, which was successfully repaired. The counterincision was required in 14 patients (9.5%). Eleven ofthe 14 patients (78.6%) who required an additionalincision developed some type of complication. Thiscircumstance was found to have significant influence onmorbidity (P=0.003) but not on mortality.

Considering all the series, there were postoperativecomplications in 61 cases (41.5%). Some type of com-

plication was encountered in 48 of 98 patients (49%)older than 65 years and in 13 of 49 (26.6%) equal orbelow age 65 years (P=0.009). Major complicationswere noted in 14 cases (9.6%), 12 of whom (85.7%) hadimportant concomitant diseases. The most frequentserious complications were pulmonary diseases in sevenpatients (4.8%) and cardiovascular disorders in fivepatients (3.4%). Pneumonia was seen in five cases andacute exacerbation of chronic obstructive pulmonarydisease in two cases. Three patients experienced con-gestive heart failure, and one each had coronary arterydisease and cardiac arrhythmia. Gastrointestinal bleed-ing occurred in two cases, and hepatic failure was seen in

one patient with cirrhosis.

Local wound complications developed in 42 patients(28.6%), of whom 17 had wound infections, 14 hema-toma, ten seroma, and one wound dehiscence. Urinaryretention was reported in six patients only after the

removal of urinary catheter. Reoperations were neces-sary in four cases. The causes were necrosis of strangu-lated bowel, which was initially considered as viable intwo cases, evisceration in one, and small bowelobstruction by adhesions in one other case.

Postoperative mortality was recorded in five patients(3.4%), all of whom had significant coexisting illness andwere over 65 years. There was no mortality in relation tohernia surgery. The causes of death were the following:respiratory failure in two patients who had chronicobstructive pulmonary disease (ASA class III and IV,respectively), sepsis in two patients who had undergoneresection of necrotic bowel in reoperations (both ASA

class III), and multiorgan failure in one case (ASA classIV). Mean hospital stay was 106.5 days, ranging from143 days. Major postoperative complications carriedlonger periods of hospitalization (mean 17.911.6 days). Overall and major morbidity and mortalitywere found in 48 cases (37.5%), 13 (10.1%), and five(3.9%) of 128 patients with viable bowel, and in 13 cases(68.4%), one (5.3%), and 0 (0%) of 19 patients afterbowel resection, respectively (P=0.01, P=0.695, andP=0.495, respectively).

The effects of factors, such as age, sex, hernia type,duration of hernia, late admission, concomitant diseases,ASA class, and anesthesiologic method on unfavorable

outcome were statistically studied by univariate analysis

Table 3 Important coexistingdiseases in 82 patients

Values in parentheses arepercentages

Male patients Female patients Total patients

Arterial hypertension 17 (22.1) 22 (31.4) 39 (26.5)Cardiovascular disorders 15 (19.5) 17 (24.3) 32 (21.8)

Atrial fibrillation 6 6Previous myocardial infarction 4 3Valvular heart disease 2 2Congestive heart failure 2 6Myocardiopathy 1

Chronic obstructive pulmonary disease 13 (16.9) 2 (2.9) 15 (10.2)

Diabetes mellitus 3 (3.9) 3 (4.3) 6 (4.1)Prostatic diseases 17 (22.1) 17 (11.6)

Prostatic enlargement 13Previous prostatectomy 4

Previous stroke 3 (3.9) 5 (7.1) 8 (5.4)Malignancy 5 (6.5) 3 (4.3) 8 (5.4)Chronic renal failure 2 (2.6) 1 (1.4) 3 (2.1)Cirrhosis 2 (2.6) 2 (1.4)Others 6 (7.8) 9 (12.9) 15 (10.2)

Table 4 Strangulation and bowel-resection ratios, according tohernia types

Herniatypes

Incarcerationpatients

Strangulationpatients

Bowel-resectionpatients

Inguinal 50 (71.4) 19 (27.1) 4 (5.7)Femoral 35 (45.5) 42 (54.6) 15 (19.5)

Values in parentheses are percentages

Table 5 Surgical techniques used for hernia repair

Methods Patients

Tension-free 45 (30.6)McVay 37 (25.2)Bassini 33 (22.4)Preperitoneal 32 (21.8)

Values in parentheses are percentages

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and are presented in Table 6. The length of hospital stay

was significantly longer in patients with advanced age,delayed admission, concomitant medical illness, highASA class, and in those with surgical repair performedunder general anesthesia. Longer duration of symptoms,late hospitalization, coexisting disease, and high ASAclass were found to be significant factors linked withmorbidity and mortality.

Discussion

Despite universal acceptance of the value of elective

hernia repair, strangulating groin hernias are still a fre-quent cause of acute abdomen [4]. This has beenattributed not only to the fact that many patients, par-ticularly elderly patients, incarcerate while they are onwaiting lists for elective surgery [6], but also to otherfactors primarily responsible, such as a large proportionof hernias, particularly femoral, incarcerating beforepatient notification of the family doctor, lack of publicawareness of the dangers of hernia incarceration, orreluctance on behalf of nonsurgical medical personnel torefer patients with known risk factors [7].

The median age was similar to that described in a

previous report [1], and the relatively large number ofpatients older than 65 years was also published in an-other article [8]. Sex ratios according to type of herniawere consistent with previous publications [1, 8]. Right-sided inguinal and femoral hernias were more commonthan left ones. This ratio was higher than some studies[8, 9] and lower than the others [10].

Femoral hernias are found in only 2.3% of the herniarepairs of all types [11]; however, in clinical practice 2040% of these hernias present as emergencies with stran-gulation or incarceration [2, 3, 12]. In contrast with otherreviews of incarcerated hernias of all types where inguinalhernias predominated [1, 9], femoral hernias were the most

frequent in our series. They comprised 69% of strangu-lating hernias, and bowel resection was more commonin these than in inguinal hernias, as reported [10, 13].

The diagnosis is usually easier in incarcerated ingui-nal hernias than in femoral ones, but there is not anyuseful connection between clinical findings and bowelviability, since the definitive diagnosis of strangulationcan be made only at the time of surgical exploration [1].As previously mentioned [8, 10], the most frequentlyincarcerated viscera were, in decreasing frequency,small intestine, omentum, and colon. Open tension-free

Table 6 Statistical analyses offactors responsible forunfavorable outcome

Values in parentheses arepercentages; NS=No signifi-cant differences were observed;a Major complications;ASA=American Society ofAnesthesiologists

Variables Strangulationpatients

Bowel resectionpatients

Hospitalstay days

Morbiditypatients a

Mortalitypatients

Age 65 years 17 (34.7) 3 (6.1) 7.54.7 2 (4.1) 0 (0)

>65 years 44 (44.9) 16 (16.3) 11.36.9 12 (12.2) 5 (5.1)Significance NS NS P=0.000 NS NS

SexMale 27 (35.1) 6 (7.8) 9.76.8 7 (9.1) 3 (3.9)

Female 34 (48.6) 13 (18.6) 10.46.2 7 (10.0) 2 (2.9)Significance NS P=0.05 NS NS NS

Hernia typeInguinal 19 (27.1) 4 (5.7) 9.66.7 7 (10.0) 2 (2.9)Femoral 42 (54.5) 15 (19.5) 10.46.3 7 (9.1) 3 (3.9)

Significance P=0.0008 P=0.03 NS NS NS

Duration of symptoms 10 years 19 (28.8) 5 (7.6) 9.16.7 6 (9.1) 1 (1.5)

>10 years 5 (62.5) 2 (25.0) 8.04.1 3 (37.5) 2 (25.0)Significance NS NS NS P=0.05 P=0.03

Late hospitalization 48 h 41 (39.0) 14 (13.3) 8.65.1 6 (5.7) 1 (0.9)

>48 h 20 (47.6) 5 (11.9) 13.58.2 8 (19.0) 4 (9.6)Significance NS NS P=0.000 P=0.03 P=0.03

Concomitant diseasesNo 21 (32.3) 6 (9.2) 7.74.4 2 (3.1) 0 (0)Yes 40 (48.8) 13 (15.9) 11.97.3 12 (14.6) 5 (6.1)

Significance P=0.04 NS P=0.000 P=0.03 P=0.05

ASA classII 36 (35.6) 12 (11.9) 8.44.4 2 (2.0) 0 (0)III/IV 25 (54.3) 7 (15.2) 13.68.6 12 (26.1) 5 (10.9)

Significance P=0.04 NS P=0.000 P=0.000 P=0.003

Type of anesthesiaSpinal 24 (32.4) 9 (12.2) 8.86.3 6 (8.1) 2 (2.7)General 36 (50.0) 10 (13.9) 11.36.5 8 (11.1) 3 (4.2)

Significance P=0.04 NS P=0.004 NS NS

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hernioplasty was the method of repair most commonlyused, in agreement with a recent trend [13, 14, 15, 16].Management of incarcerated groin hernias is certainlynot free from mortality. Past series recorded a mortalityrate ranging from 2.69% [3, 8, 10]. Our percentage isnear the lowest limit of this range. It is known that themortality and the morbidity are related to the viabilityof entrapped bowel [1, 2, 3]. For this reason, it is nec-essary to emphasize the value of elective repairs beforeencountering incarceration. In this series, overall mor-bidity was significantly affected by bowel resection butnot major morbidity nor mortality.

Complications that develop in external hernias, suchas irreducibility and obstruction, with or withoutstrangulation may make an easily treatable condition alife-threatening one. Identification of risk factors thatmay predict development would help place the patient ina high-risk group. While not inherently impaired, thereserve capacity of the older individual to compensatefor stress, metabolic derangement, and drug metabolismis increasingly limited. Functional disability occurs fas-ter and takes longer to remediate, necessitating early

preventive interventions [17]. Advanced age in the pa-tients with incarcerated groin hernia has been associatedwith an unfavorable outcome [3, 12, 18]. In our experi-ence, although this factor significantly affected overallmorbidity, it was not a prognostic marker either formajor morbidity or mortality.

In spite of the higher proportion of strangulated casesand bowel resections in women and in femoral herniatype, neither female sex nor femoral hernia type have asignificant negative influence on outcome, as describedin a study on patients with incarcerated external hernias[9]. However, site of hernia (femoral) was an importantrisk factor in adults in another report [18]. In this series,

there was not a significant difference between indirectand direct inguinal hernias with respect to strangulationrate, contrary to that reported in another article [19].

There arefew andcontroversial studies in the literatureexamining the effect of the duration of hernias present onoutcome. Postoperative complications have been foundmore commonly in patients with hernia more than10 years [9]. We have found not only a high percentage ofcomplications, but also a significantly higher mortality inthese patients. This was contrary to another report [18]in which a higher risk for complications occurred inpatients with a short history of herniation.

Late hospitalization is generally considered to be an

important factor determining resection and subsequentmorbidity and mortality [1, 10, 20, 21]. Mostly, the causeof delay in admission is through the patient s fault, butphysicians mistakes are also responsible in percentagesvarying from 1233% [22, 23, 24]. Surprisingly, in thisstudy, the resection requirement was not significantlyaffected by delayed hospitalization, but it was one of themain factors linked with unfavorable outcome.

Concomitant diseases in patients with incarceratedgroin hernias have been reported to be associated withpoor outcome [18, 25]. We found that coexisting medical

illness was an important determinant of morbidity.Moreover, this factor reached almost the statistical sig-nificance for mortality. The length of hospital stay wasalso encountered to be longer in patients with concom-itant diseases.

The ASA class considers the patients comorbidityand acute physiological disturbance and assigns a risklevel for surgery and anesthesia. In a previous report ofincarcerated anterior abdominal wall hernias, high ASAscore was found to be an independent predictor ofgangrenous bowel [26]. A significantly longer hospitalstay and a significantly higher morbidity in elderly pa-tients with ASA class III or IV who underwent emer-gency hernia repair was also reported [27]. In the presentarticle, we not only confirmed a higher complicationsrate, but we also found a significantly higher mortality inpatients with a high ASA grading.

The effect of anesthesia on the outcome of hernia re-pair has been evaluated in the literature. In a report byYoung [28] comparing type of anesthesia in electiveinguinal herniorrhaphy, it was revealed that general andspinal anesthesia were associated with higher rates of

postoperative complications. In another article by Kulahet al. [27], general anesthesia was not a factor affectingmorbitity and mortality in emergency hernia repairs inelderly patients, suggesting that the majority of severepostoperative complications encountered with thisanesthesiologic approach are directly related to coexis-ting diseases. This last circumstance was confirmed here,since, of 72 cases in the general anesthesia group, 29(42.3%) were ASA class III or IV, while of 74 cases in thespinal anesthesia group, only 17 (22.9%) were ASA classIII or IV (P=0.03). Therefore, apart from a longerhospital stay for patients with hernias repaired undergeneral anesthesia, we could not identify general anes-

thesia type as a factor associated with a poor outcome.In conclusion, our experience demonstrates that com-

plications following emergency groin hernia repair inadults is a serious problem and may make an easilytreatable condition a lethal one. Bowel resections weremainly related to femoral hernia. Overall morbidity wassignificantly affected by bowel resection but not mortality.Longer duration of symptoms, late hospitalization,coexisting medical illness, and high ASA class were foundto be responsible for unfavorable outcomes. Because ofhigh morbidity and mortality associated with incarcera-tion, early diagnosis and elective repair of uncomplicatedgroin hernias should be done whenever possible.

Acknowledgements The authors would like to thank Ms. Mara JoseMartnez Samalea for her support in the translation of this report.

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Incarcerated Groin Hernias in Adults