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| REVIEW ARTICLE |
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| Year : 2018 | Volume
: 1
| Issue : 2 | Page : 37-41 |
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Thromboembolic prophylaxis in hernia surgery
Henry Hoffmann, Ralph Fabian Staerkle, Philipp Kirchhoff
Department of Surgery, University Hernia Center, University Hospital Basel, Basel, Switzerland
| Date of Submission | 04-Jul-2018 |
| Date of Acceptance | 17-Jul-2018 |
| Date of Web Publication | 16-Aug-2018 |
Correspondence Address:
Dr. Henry Hoffmann
Department of Surgery, University Hernia Center, University Hospital Basel, Spitalstrasse 21, 4031 Basel
Switzerland
 Source of Support: None, Conflict of Interest: None  | 3 |
DOI: 10.4103/ijawhs.ijawhs_14_18
INTRODUCTION: Thromboembolic prophylaxis (TP) is an effective strategy to reduce the risk of thromboembolic events such as deep vein thrombosis and pulmonary embolism. In the absence of patient- and procedure-related risk factors, the risk of thromboembolic events is considerably low among surgical patients. Since hernia repair is thought to be a low-risk procedure, the role of TP in patients undergoing hernia surgery is a matter of debate.
METHODS: A systematic search of the literature was conducted in Medline/PubMed and the Cochrane database. Forty-eight relevant publications were identified.
RESULTS: Overall, there is a paucity of studies specifically investigating the impact of TP in patients undergoing hernia surgery. Available studies demonstrate that the risk of thromboembolic events with TP in inguinal hernia repair is approximately 0.1%, comparable to other low-risk procedures. Lower rates of thromboembolic events are seen in outpatient surgery. Laparoscopy and implanted mesh in the groin do not increase the risk of thromboembolic events.
CONCLUSION: Due to the limited data, no recommendation for or against TP in hernia surgery can be made. Further studies are urgently needed to investigate the effect of TP on the risk of thromboembolic events in patients undergoing hernia repair.
Keywords: Hernia surgery, thromboembolic prophylaxis, thrombosis
How to cite this article:
Hoffmann H, Staerkle RF, Kirchhoff P. Thromboembolic prophylaxis in hernia surgery. Int J Abdom Wall Hernia Surg 2018;1:37-41 |
| Introduction | |  |
Thromboembolic events (TEs) such as deep vein thrombosis (DVT) occur at an annual incidence of about 1 per 1000 adults, increasing with advanced age.[1],[2] Beside, patient-related risk factors (e.g., malignancy, advanced age, obesity, varicosis, and DVT in patient history),[3] surgery itself significantly increases the incidence of thromboembolic events.[2] According to the American College of Chest Physicians (ACCP), the prevalence of DVT in general surgical patients can reach up to 40% depending on the type and duration of the procedure.[4],[5] However, a recent retrospective database analysis of 1.4 million patients undergoing surgery under general anesthesia between 2005 and 2011 demonstrated an overall rate of TE of 0.96%, comprising a DVT rate of 0.71% and a pulmonary embolism (PE) rate of 0.33%.[6] Considering that a liable test for early identification of TE is not available yet,[4] the importance of preventive strategies in surgical patients must be highlighted. There are only limited data on the incidence of TE in abdominal wall hernia repair. In the absence of patient- and procedure-related risk factors,[1],[2],[3] TE in hernia repair is rare, classifying these interventions as low-risk or moderate-risk procedures.[7] However, introduction of laparoendoscopic approaches for inguinal hernia repair has raised the question, whether the applied pneumoperitoneum may increase the risk for DVT by increasing intra-abdominal pressure altering the vascular flow patterns.[8],[9],[10] Despite the insufficient data on the effect of thromboembolic prophylaxis (TP) in inguinal hernia repair, current guidelines[11] recommended TP at least in patients with risk factors.[3] Accordingly, most surgeons apply TP to their patients[12] since acute PE following DVT is a potentially preventable and life-threatening condition with mortality up to 50%.[13],[14],[15]
Considering the low rate of TE in hernia surgery, the question arises as to whether TP can further reduce the rate of TE in hernia surgery. It was now aimed to answer that key question through a review of the literature.
| Methods | | |
A systematic search of the literature was conducted in Medline/PubMed and the Cochrane database up until the end of May 2018. The following search terms were used: “TP” and “surgery␅, “TP” and “hernia,” “deep vein thrombosis prophylaxis” and “hernia,” “thrombotic prophylaxis” and “hernia surgery,” “anticoagulation prophylaxis” and “hernia,” and “prophylaxis of venous thromboembolism (VTE)” and “hernia”. In addition, a manual search of the references was performed to identify relevant publications. The literature search identified a total of relevant publications, which form the basis for the following review.
| Results | | |
General considerations in surgical thromboembolic prophylaxis
Indication and choice of surgical TP should be based on the individual patient risk, taking surgery-related and patient-related risk-factors into account.[3] Patient-related risk factors for developing thromboembolic events are:[3]
- Catabolic underlying disease
- Presence of malignancy
- Age >60 years
- Treatment on Intensive Care Unit
- Dehydration
- Thrombophilia and genetic disposition such as AP resistance or protein C and S deficit
- Obesity (body mass index [BMI] >30 kg/m2)
- Comorbidities such as cardiovascular disease, metabolic, endocrine, and pulmonary disease, and inflammatory diseases
- Anamnesis of DVT or history of DVT in 1st-grade relatives
- Hormone replacement therapy
- Contraceptive estrogen therapy
- Varicose veins
- Pregnancy or delivery within the last 6 weeks.
Procedure-related risk factors for thromboembolic events are:[6],[16]
- Prolonged duration of surgery
- Lower extremity surgery
- Major general and orthopedic surgery.
Physical preventive strategies
There are several preventive strategies to minimize the risk for thromboembolic events in surgery. One of the main pillars is early mobilization of the patients.[17] The role of compression stockings for prevention of TE remains controversial.[17] Although there is no study supporting the benefit of compression stocking regarding TE prevention, no study has shown any harming effect neither.[18],[19] The current ACCP guidelines recommend (Grade 2C) mechanical prophylaxis with intermittent pneumatic compression (IPC) over no prophylaxis as an alternative to low-dose unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) for patients at moderate risk for VTE.[17] However, IPC has no indication in most hernia repair patients to prevent TE. Furthermore, there is only weak evidence regarding its benefits comparing to graduated compressions stockings.[20]
Heparin
Heparin is a natural derived anticoagulant preventing blood clotting and augmentation of existing clots in the bloodstream. Heparin itself has no direct thrombolytic effect but supports other thrombolytic processes. UFH and its LMWH derivatives such as enoxaparin, dalteparin, or tinzaparin effectively prevent DVT and PE in patients with increased risk, although LMWH seems more effective preventing DVT compared to UFH.[21],[22] Heparin activates the primary serpin inhibitor of blood clotting proteinases, antithrombin, both by an allosteric conformational change mechanism that specifically enhances factor Xa inactivation and by a ternary complex bridging mechanism that promotes the inactivation of thrombin and other target proteinases.[23],[24],[25] A serious complication of heparin administration is the heparin-induced thrombocytopenia (HIT), which is an immune complication of heparin therapy caused by antibodies to complexes of platelet factor 4 (PF4) and heparin.[26] The anti-PF4/heparin antibodies develop commonly after heparin exposure. However, only a subset of sensitized patients progresses to life-threatening complications of thrombocytopenia and thrombosis.[27] The risk of developing a HIT is 2.6% for UFH and 0.2% for LMWH.[27],[28] Therewith, LMWH should be used over UFH as front-line heparin therapy for postoperative TP.[21],[22] [Table 1] shows all approved LMWH and polysaccharides for DVT prophylaxis.[29] | Table 1: Approved low-molecular-weight heparin and polysaccharides for deep vein thrombosis prophylaxis
Click here to view |
Alternative medications for thromboembolic prophylaxis
Indication for other medications than heparin and its derivatives can be HIT or allergic predisposition against heparin. Besides warfarin (Vitamin K antagonist), this group of medication contains non-Vitamin K oral anticoagulants (NOACs), which are direct and specific inhibitors of the coagulation factors II A (Dabigatran) and Xa (Apixaban, Rivaroxaban, and Edoxaban). Their main indications are secondary prevention of VTE and prevention of stroke and systemic embolism in patients with atrial fibrillation.[30],[31] However, due to the inconsistent literature, indications of NOAC during thrombolysis, surgery, and bleeding events are lacking higher levels of recommendation.[32]
Thromboembolic prophylaxis in hernia surgery
Data regarding TE following inguinal and ventral hernia repair are limited. There are no meta-analyses, randomized controlled trials or prospective comparative cohort studies. In a recent observational database study of 28,782 male patients undergoing unilateral inguinal hernia repair over a 10-year time period, the overall rate of perioperative VTE was 0.18% within 90 days after surgery.[33] The incidence of VTE in the first 90 days following inguinal hernia surgery was 7.61/1000 persons per years. Compared to the general population, the authors identified higher age, higher BMI >30 kg/m2, and inpatient procedures as risk factors for VTE. The most vulnerable time period for developing VTE after inguinal hernia repair was the 1st month after surgery with a 2.3- and 3.5-fold increased risk for VTE following outpatient surgery and inpatient surgery, respectively.[33] Another retrospective database study including 2484 patients undergoing inguinal hernia repair with and without TP, of whom 1854 patients received TP and 630 did not; one patient from each group developed VTE,[34] questioning the need for TP in inguinal hernia repair in the absence of risk factors.
Since the introduction of laparoscopic procedures in hernia surgery, it is a matter of debate if laparoscopy itself may lead to higher risks of thromboembolic events due to increased abdominal pressure and (reversed) Trendelenburg position during surgery.[35],[36] The rates of VTE following laparoscopic procedures appear to be low.[5] There are no data regarding the specific association of TE and laparoendoscopic hernia repair. A prospective study investigating a total of 2384 patients undergoing laparoscopic surgery combined with perioperative LMWH TP, reported 8 cases of DVT (0.33%) and no PE.[37] Another review including 153,832 laparoscopic cholecystectomies using various types of TP, the average rates of clinical VTE, PE, and fatal PE were 0.03%, 0.06%, and 0.02%, respectively.[38]
It is also a matter of debate whether implanted inguinal meshes are altering the blood flow in the femoral vessels, which may prone the patient toward a higher risk of thromboembolic events. There is one animal study with rats, which suggest that fibrosis due to implanted polypropylene meshes on the vessel can negatively affect vessel blood flow due to mechanical pressure.[39] One study prospectively investigated the postoperative blood flow of the common femoral vain (CFV) using blinded Echo-Doppler in 250 patients undergoing open inguinal hernia repair with implantation of a nonabsorbable mesh.[40] They demonstrated a temporarily slow venous flow in the ipsilateral CFV, which did not lead to an increase in the incidence of VTE.
Most patients with planned inguinal hernia repair undergo day surgery. Considering that inguinal hernia repair carries a low-risk of venous TE, the risk-benefit profile of TP should be accurately balanced against the risk of bleeding, considering that PE is the most common preventable cause of hospital death.[41] Patients undergoing day surgery usually return sooner to normal activity.[42] Accordingly, the risk of TE in the outpatient population is low.[4],[5] However, careful risk stratification of the individual thromboembolic risk should be current routine in planning day surgery hernia procedures. In patients with concomitant VTE risk factors,[3] the use of pharmacological prophylaxis is recommended if bleeding risk is not increased.[41]
Based on these data, most hernia societies recommend TP for patients undergoing hernia repair. The International Endohernia Society recommends that TP should be given in accordance with the presence of risk factors for the individual patient.[43] The Hernia Interest Group of South Africa suggests that general surgical principles of DVT prophylaxis should be followed in patients undergoing ventral hernia repair.[44] However, the SAGES guidelines do not include any specific advice regarding TP in laparoscopic hernia repair.[40]
| Discussion | | |
The risk of thromboembolic events such as DVT and PE in hernia surgery is considerably low, questioning the routine use of TP in such patients. However, most surgeons regularly apply TP to their hernia patients[12] to potentially prevent PE, which causes most in-hospital deaths after surgery.[13],[14],[15] Thus, indication for TP should carefully be based on patient- and procedure-related risk factors balancing the benefits of TP against the risk of perioperative bleeding. Special care must be taken in patients with coagulopathy or inadequately discontinued antiplatelet or anticoagulation medication, since they have a significantly higher risk for onset of postoperative secondary bleeding in inguinal and ventral hernia repair.[45],[46]
Laparoscopic surgery with applied pneumoperitoneum does not increase the risk of TE in general surgical procedures.[5],[37],[38] Although specific data on the effect of laparoscopy in hernia surgery are missing, the same effect can be assumed in laparoscopic hernia repair, since the pressure level of pneumoperitoneum is comparable to other laparoscopic procedures. In addition, the anti-Trendelenburg position during laparoscopic cholecystectomy or procedures in the upper gastrointestinal tract with its unfavorable effects on the venous backflow may not apply in laparoscopic hernia surgery, since patients are rather set up in Trendelenburg postition (transabdominal preperitoneal and totally extraperitoneal) or in neutral position (laparoscopic intraperitoneal onlay mesh).
Considering that, in most countries, inguinal hernia repair is increasingly performed as a day surgery,[47],[48] the effect of TP in day-surgery patients still remains unclear. Since inpatient procedures are supposed to be a risk factor for thromboembolic events,[33] day surgery with immediate mobilization and ambulation of the patient seems protective against the development of thromboembolic events.[4],[5],[42] Accordingly, TP may be omitted in day-surgery patients as long as they do not have further risk factors.[3]
However, based on the current data, no strong recommendation for or against routine TP in hernia surgery can be given, which is reflected in the recommendations of hernia societies.[40],[43],[44]
| Conclusion | | |
Due to the limited data in TP in hernia surgery patients, general principles of individual patient- and procedure-risk stratification should be followed and adopted in patients undergoing hernia surgery. TP should at least be administrated in patients with moderate or high risk for thromboembolic events. Further studies are urgently needed to specifically explore the impact of TP in patients undergoing hernia repair.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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