|Year : 2019 | Volume
| Issue : 2 | Page : 44-49
Surgery for incarcerated inguinal hernia: Outcomes with Lichtenstein versus open preperitoneal approach
Cuihong Jin, Yingmo Shen, Jie Chen, Fuqiang Chen, Min Liu, Fan Wang, Fenglin Zhao
Department of Hernia and Abdominal Wall Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
|Date of Submission||25-Dec-2018|
|Date of Acceptance||24-Jan-2019|
|Date of Web Publication||10-May-2019|
Dr. Yingmo Shen
Department of Hernia and Abdominal Wall Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100043
Source of Support: None, Conflict of Interest: None
BACKGROUND AND AIM: Incarcerated inguinal hernia comprises a significant portion of surgical emergencies, and represents about 5%–15% of all operated inguinal hernias. Tension-free repair with mesh placement is the preferred technique for elective surgery due to its low recurrence rate. However, limited information is available on the usage of synthetic mesh in the emergent treatment because of the potentially infected surgical fields, especially in case of concomitant bowel resection. The aims of this study were to evaluate the results of mesh-based emergency hernioplasty and compare the outcomes of incarcerated inguinal hernia repair with synthetic mesh in Lichtenstein or open preperitoneal approach and to identify the risk factors for postoperative complications.
METHODS: A total of 151 patients with incarcerated inguinal hernia that underwent surgery between January 2013 and December 2017 were included in this retrospective study. Demographics, surgical details, and outcomes such as surgical-site infection and recurrence were collected. Univariate analysis was employed to identify risk factors for overall complications.
RESULTS: A total of 61 patients received Lichtenstein hernial repair, whereas 90 patients received open preperitoneal repair. Overall morbidity occurred in 21 patients. There was no significant difference between the two groups in terms of postoperative complications. Univariate risk factors for overall complications were age >65 years, duration of incarceration ≥8 h, American Society of Anesthesiologists grade ≥III, cardiopathy, bronchial asthma, indirect inguinal hernia, and strangulation. In multivariate analysis, no risk factors were found associating with a higher rate of overall morbidity.
CONCLUSION: As for incarcerated inguinal hernia, both Lichtenstein and open preperitoneal approach with mesh are safe and effective.
Keywords: Hernia, hernioplasty, incarceration, mesh
|How to cite this article:|
Jin C, Shen Y, Chen J, Chen F, Liu M, Wang F, Zhao F. Surgery for incarcerated inguinal hernia: Outcomes with Lichtenstein versus open preperitoneal approach. Int J Abdom Wall Hernia Surg 2019;2:44-9
|How to cite this URL:|
Jin C, Shen Y, Chen J, Chen F, Liu M, Wang F, Zhao F. Surgery for incarcerated inguinal hernia: Outcomes with Lichtenstein versus open preperitoneal approach. Int J Abdom Wall Hernia Surg [serial online] 2019 [cited 2022 Jul 4];2:44-9. Available from: http://www.herniasurgeryjournal.org/text.asp?2019/2/2/44/257980
| Introduction|| |
Incarcerated inguinal hernia manifests as an acutely irreducible inguinal mass, which requires timely surgery because it may eventuate in the strangulation and gangrene of the intestine; it represents between 5 and 15% of groin hernial repairs.,,,, It is generally accepted that most inguinal hernias should be operated on electively using synthetic mesh. However, there are few reports on the surgical outcomes of mesh-based emergency hernioplasty for incarcerated inguinal hernia. The use of prosthetic material is conventionally avoided, especially in a potentially infected surgical field. However, it has been challenged by some recent results.,,, The objective of this retrospective study is to evaluate the results of mesh-based emergency hernioplasty, compare the outcomes of incarcerated inguinal hernia repair with synthetic mesh in Lichtenstein or open preperitoneal approach, and identify the risk factors of postoperative complications.
| Methods|| |
This was a retrospective, nonrandomized study. A total of 151 consecutive adult patients who underwent open emergency hernioplasty for incarcerated inguinal hernia between January 2013 and December 2017 were included. Patients with incarcerated recurrent inguinal hernia and complications requiring laparotomy were excluded from this study. Patients who died in the postoperative period due to systemic complications, as well as who were lost during the follow-up period, were also excluded. Incarceration was defined based on the clinical examination with irreducible inguinal mass, with or without signs and symptoms of bowel obstruction. Emergency hernioplasty was defined as a surgical intervention performed within 6 h after hospital admission. The surgical access and type of anesthesia were decided by the surgeon and anesthetist according to their habits and knowledge. Patients were divided into two groups based on the applied surgical technique as follows: patients who underwent Lichtenstein repair were assigned to Group 1, and those who underwent open preperitoneal hernia repair were assigned to Group 2. In Lichtenstein group, a polypropylene mesh was used, and for open preperitoneal group, we separated the peritoneum and abdominal transverse compartment in the inner ring and created preperitoneal space. Mostly, we used EasyProsthesis D10 patch (TransEasy Company, Bengaluru, Karnataka, India) via the anterior approach, which is 10 cm in diameter, 30 g in wight with a pore-size of 4-5 mm, and in rare cases, we used Kugel patch (Bard Company, New Jersey, USA). Data were retrospectively retrieved from the medical files, including demographic information, surgical details, and clinical outcomes. Ethics Committee's approval was received for this study.
Demographics and characteristics of both groups were descriptively analyzed. For comparisons, data were determined as median (P25, P75). Chi-square and Mann–Whitney U-test were employed. P < 0.05 was considered statistically significant. Statistical Package for the Social Sciences version 22 (SPSS Inc., Chicago, IL, USA) for Windows was used to perform the statistical analyses. Multivariate logistic regressions were performed for studying the factors associated with complications.
| Results|| |
A total of 151 patients underwent emergency inguinal hernioplasty, 61 of them (40.4%) received Lichtenstein hernia repair, whereas 90 patients (59.6%) received open preperitoneal repair, involving 127 (84.1%) men and 24 (15.9%) women. The mean age of the whole patients was 76 years. The mean duration of incarceration time was 24 h in both the groups. It was determined that 29 (47.5%) patients in Group 1 and 40 (44.4%) patients in Group 2 had comorbidities. There was no significant difference between the two groups in terms of age, gender, body mass index, duration of incarceration, American Society of Anesthesiologists (ASA) grade, and comorbidities (P > 0.05) [Table 1].
All patients were operated successfully. In Group 1, 48 (78.7%) patients underwent surgery under local anesthesia and 13 (21.3%) under general anesthesia, and in Group 2, 68 (75.6%) operations were performed under local anesthesia and 22 (24.4%) under general anesthesia. There was no statistically significant difference between the two groups in terms of the anesthetic methods (P > 0.05).
There were 6 (9.8%) direct inguinal hernias, 50 (82.0%) indirect inguinal hernias, and 5 (8.2%) mixed hernias in Group 1; and in case of Group 2, there were 25 (27.8%) direct inguinal hernias, 58 (64.4%) indirect inguinal hernias, and 7 (7.8%) mixed hernias. There were more direct inguinal hernias in Group 2. This may be caused by selection bias. In Group 1, 39 (63.9%) patients had hernias on the right side and 22 (36.1%) had hernias on the left side. In Group 2, 67 (74.4%) patients had their hernias on the right side and 23 (25.6%) had hernias on the left side. There was no statistically significant difference between the two groups in terms of hernial localization (P > 0.05).
In Group 1, the contents of the incarcerated hernia were omentum in 14 (23.0%) patients, a loop of small bowel in 41 (67.2%) patients, and colon in 4 (6.7%) patients; one patient suffered from incarcerated adipose tissue and one patient from incarcerated undescended testicle. Moreover, three (4.9%) of them were strangulated. In Group 2, the contents of the incarcerated hernia were omentum in 29 (32.2%) patients, a loop of small bowel in 52 (57.8%) patients, and colon in 5 (5.6%) patients; four (4.4%) patients combined other incarcerated contents including oviduct, urinary bladder, medial umbilical ligament, and ascites. Moreover, 10 (11.1%) of them were strangulated. There were no statistically significant differences between the two groups in terms of hernial contents and the rate of strangulation (P > 0.05).
Two patients in this study underwent intestinal resection and anastomosis; one in Group 1 and the other in Group 2. The mean time of operation was 70 min in Group 1 and 65 min in Group 2. There were no statistically significant differences between the two groups in terms of intestinal resection rate and time of operation (P > 0.05) [Table 2].
The mean time of hospital stay was 6 days in both the groups. The mean follow-up time was 20 months in Group 1 and 22 months in Group 2. In Group 1, three (4.9%) patients had hematomas/seromas, whereas one (1.6%) had wound infection, three (4.9%) had foreign body sensation, one (1.6%) suffered chronic pain, one (1.6%) had recurrence, and one (1.6%) had sepsis. In Group 2, five (5.5%) patients had hematomas/seromas, whereas two (2.2%) had wound infection, two (2.2%) had foreign body sensation, two (2.2%) suffered chronic pain, and none had recurrence. Two patients died during the follow-up period, one died from a heart failure in Group 1, and the other died from acute hepatic failure. There was no fistula and ileus in both the groups. There were no statistically significant differences in terms of length of hospital stay, follow-up time, and postoperative complications (P > 0.05) [Table 3].
On univariate analysis, patients aged ≥65 years; with incarceration duration ≥8 h; with ASA grade III or IV; and with cardiopathy or bronchial asthma medical history, indirect inguinal hernia, and strangulation had a significant higher risk for overall complications [Table 4].
In multivariate analysis, no interaction was found between the potential risk factors and the rate of overall complications; none of these potential risk factors can be predictive factors of overall complications [Table 5].
| Discussion|| |
Incarcerated inguinal hernia is one of the most common urgent surgical conditions, which occurs when the protrusion can no longer be returned because the hernial content is plugging the defect. The viscus may become strangulated if the blood supply to the contained structure is shut off. Thus, an emergent operative intervention is often required. For the inguinal hernias, the risk of strangulation varies between 0.29% and 2.9%.,,,
With progresses in surgical techniques and development of systematic materials, it is well accepted that mesh-based elective inguinal hernia repair surgery has become a safe procedure that carries satisficed outcomes, especially a lower recurrence rate. Yung Wong et al. retrospectively analyzed 11,012 adult patients in the past decade and found significantly higher emergency re-admission rate for open repair. A conventional viewpoint is that prosthetic mesh should be avoided, especially in a septic environment such as in case of concomitant bowel resection. Surgeons have a concern about the infection-related problems that might occur due to possible bacterial translocation in the presence of intestinal obstruction.
In our work, 151 patients with incarcerated inguinal hernia were included undergoing mesh-based emergency hernioplasty, and there was no significant difference between the Lichtenstein and open preperitoneal approaches. The rate of overall complications was 13.9%, no mesh-related complications were found, and even bowel resection was done. Thus, we believe that it is safe to use mesh in emergency hernial repair, and the outcomes are acceptable. Some recent studies also have confirmed this conclusion. Lohsiriwat and Lohsiriwat found Lichtenstein hernioplasty to be a safe and effective operation for nonstrangulated incarcerated inguinal hernia, with a recurrence rate of 10% in a long-term follow-up period, and chronic groin pain and inguinal paresthesia were rare.
In this sutdy, we usually used the Easy-Prothesis D10 to preform the surgery. The mesh is made out of polypropylene, with a diameter of 10 cm. Regarding to the size of the mesh, it should be big enough to cover the area of myopectineal orifice, and according to the references, the length of MPO is about 7.6 cm, and the width is about 6.5 cm in Chinese patients. Therefor we think that a mesh measured with 10 cm in diameter is able to completely override the MPO during the open preperitoneal hernia repair. Unlike the TAPP or TEP technique, it's difficult and impractical to place a flat 10 cm by 15 cm mesh in open preperitoneal approach with a small incision. Whether it would result in higher recurrence rate, observation with a greater number of patients and long-term follow-up should be preformed for confirmation. For incarcerated hernial cases, our center tends to use laparoscopy exploration, especially for those patients whose inguinal mass had been reduced or those considering femoral hernia, and the general anesthesia could reduce the pain and tension that may result in satisfactory muscular relaxation. This was not tested in our work because most of the patients could not be treated with general anesthesia or pneumoperitoneum considering their old age and accompanying abnormal cardiorespiratory function or insufficient preoperative fasting and water deprivation. Hence, the emergency surgery should be performed and monitored by both the surgeon and anesthetist.
In our work, seven factors were associated with overall complications, namely age >65 years, duration of incarceration ≥8 h, ASA grade ≥III, cardiopathy, bronchial asthma, indirect inguinal hernia, and strangulation. The factor reported as the sole factor affecting morbidity. It is easy to explain their role in the general complications, for all of these factors reflect the status of the patient as a whole. Usually, incarcerated hernias require more frequent bowel resections, but in our work, there were only two cases which underwent bowel resections, and none of them suffered from postoperative complications. Further studies are needed with larger sample size to verify the conclusion.
The present study has its limitations. As it is a retrospective study, the lack of randomization is a major problem. Our study cohort is limited, and the number of postoperative complications such as recurrence was too low to perform the analysis. We hope to have more conclusive results in further studies, which can be well designed with larger sample size.
| Conclusion|| |
Our study confirmed that mesh repair for incarcerated inguinal hernia could be used and appears to be safe both in Lichtenstein and open preperitoneal approaches. Larger prospective cohort studies should be performed to confirm our findings.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gallegos NC, Dawson J, Jarvis M, Hobsley M. Risk of strangulation in groin hernias. Br J Surg 1991;78:1171-3.
Rai S, Chandra SS, Smile SR. A study of the risk of strangulation and obstruction in groin hernias. Aust N
Z J Surg 1998;68:650-4.
Ohana G, Manevwitch I, Weil R, Melki Y, Seror D, Powsner E, et al.
Inguinal hernia: Challenging the traditional indication for surgery in asymptomatic patients. Hernia 2004;8:117-20.
Pesić I, Karanikolić A, Djordjević N, Stojanović M, Stanojević G, Radojković M, et al.
Incarcerated inguinal hernias surgical treatment specifics in elderly patients. Vojnosanit Pregl 2012;69:778-82.
Lohsiriwat D, Lohsiriwat V. Long-term outcomes of emergency Lichtenstein hernioplasty for incarcerated inguinal hernia. Surg Today 2013;43:990-4.
Derici H, Unalp HR, Nazli O, Kamer E, Coskun M, Tansug T, et al.
Prosthetic repair of incarcerated inguinal hernias: Is it a reliable method? Langenbecks Arch Surg 2010;395:575-9.
Sawayama H, Kanemitsu K, Okuma T, Inoue K, Yamamoto K, Baba H, et al.
Safety of polypropylene mesh for incarcerated groin and obturator hernias: A retrospective study of 110 patients. Hernia 2014;18:399-406.
Bessa SS, Abdel-fattah MR, Al-Sayes IA, Korayem IT. Results of prosthetic mesh repair in the emergency management of the acutely incarcerated and/or strangulated groin hernias: A 10-year study. Hernia 2015;19:909-14.
Tatar C, Tüzün İS, Karşıdaǧ T, Kızılkaya MC, Yılmaz E. Prosthetic mesh repair for incarcerated inguinal hernia. Balkan Med J 2016;33:434-40.
Leubner KD, Chop WM Jr., Ewigman B, Loven B, Park MK. Clinical inquiries. What is the risk of bowel strangulation in an adult with an untreated inguinal hernia? J Fam Pract 2007;56:1039-41.
Akinci M, Ergül Z, Kulah B, Yilmaz KB, Kulacoǧlu H. Risk factors related with unfavorable outcomes in groin hernia repairs. Hernia 2010;14:489-93.
Yang S, Zhang G, Jin C, Cao J, Zhu Y, Shen Y, et al.
Transabdominal preperitoneal laparoscopic approach for incarcerated inguinal hernia repair: A report of 73 cases. Medicine (Baltimore) 2016;95:e5686.
Yung Wong KC, Ho Lam JC, Pik Lau GS. Elective adult inguinal hernia repair in public hospitals in Hong Kong: Changes within a decade. Surg Pract 2017;21:13-22.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]