“Manuel Ascunce Domenech” Provincial Hospital

Camagüey

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Surgery of  inguinal hernia

 in the elderly patient

 

 

Authors:  Jorge Luis Reguero Hernández (*)                         Tutor: Lic. Blanca Marrero Núñez (4)

                 Mauro Castelló González (*)                                         

                 Elena Zimmerman Hernández (**)                         Assessor: Dr. Oliverio Agramonte Burón (44)

                 Erlys Ventura Combarro (***)

 

*     Medical Student Fourth Year

**   Medical Student Sixth Year

*** Medical Student First Year

4     Full Professor of English

44  First Degree Specialist in General Surgery. Assistant Professor

 


maurocg@shine.cmw.sld.cu       gs@finlay.cmw.sld.cu  

 

 


CONTENT


      Home                                Method                          Bibliografical References

      Abstract                            Results

      Introduction                     Discussion       

      Objectives                         Conclusions              

 

                                                               

 

ABSTRACT

 

Inguinal hernia is a frequent pathology in the elderly patient and surgery in this age group has a high risk. A descriptive study of 84 patients of over 60 years of age having had inguinal hernia surgery between January and December, 1999, at the Surgery Department of the “Manuel Ascunce Domenech” Provincial Hospital, was made with a view to knowing the surgical outcome. The age mean in this group was 72 years, and the proportion between men and women was 8:1. Associated illnesses appeared in  22.52 % of them. The anesthesia most employed was spinal, and acupuncture permitted hernia repair in 6 cases. Postoperative complications were presented in 36.84 % of the patients, and the mean postoperative hospitalization was 2.75 days. Hernia repair in an elderly population can have a favorable outcome despite the complications.

Key words: inguinal hernia, elderly

 

                               

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INTRODUCTION

 

Hernias of the abdominal wall are defined as the protrusion of a viscus from the abdominal cavity, in which it is commonly contained, due to a failure in the wall structure, or as the abnormal protrusion of an organ or tissue through a parietoabdominal opening. Approximately 75 % of these occur in the inguinal region and it is estimated that 25 % of men and 2 % of women develop inguinal hernias during their lifetimes. (1)

After the age of 50 the frequency of this pathology increases and the diminishing of muscular power, which is common to old age, is considered to be a predisposing factor (2). In our country, more than 12 % of the population is 60 years old or over, and in 2025 the expectancy is that 1 out of 4 Cubans will be in this age group, due to a lower birth rate and an increase in health conditions an medical care. Both these factors combine and determine the high frequency with which our surgeons find inguinal hernias in geriatric patients. Former studies made at the “Manuel Ascunce Domenech” Provincial Hospital with regard to emergency surgery in patients over 60 years, show that complications with hernias are the most frequent pathology (3).

Surgery for an elderly patient represents an important decision for the surgeon. Generally, there are a number of physiological disturbances in these patients which generate illnesses responsible for the appearance of frequent complications due to surgical and anesthesic aggression (4).

There are studies at present, which assess the results of elective surgery for an elderly, with a view to determine if the benefits to be derived actually override the risks we mention. Some authors agree in not considering age as a barrier for elective repair of inguinal hernia, sustaining that this procedure prevents the complications of the emergency surgery, and is also greatly appreciated by the patients. Hospitalization can be reduced to a minimum in this fashion (5,6). Others have shown that emergency treatment involves high mortality (7), for complications such as incarcerated and strangulated hernias, may convert an easily treatable condition into a dangerous threat to life. However, other investigations show that mortality is high in patients with associated illnesses independently of the surgery used (5).

                           

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General objective:

 

To determine the outcome of inguinal hernia surgery in geriatric patient performed in the “Manuel Ascunce Domenech” Provincial Hospital.

 

Specific objectives:

1.      To distribute the patients according to age, sex and localization of the hernia.

2.      To identify the associated illnesses present in these patients, as well as the anesthesia employed.

3.      To determine the main trans and postoperative complications in view of the type of surgery performed.

4.      To determine the length of postoperative hospitalization.

 

                             

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METHOD

 

A transversal descriptive study is made of patients presenting inguinal hernias who had surgery on this account at the “Manuel Ascunce Domenech” Provincial Hospital, Camagüey, from January to December of 1999. The universe was considered to be all patients sixty years old or over, having had hernia surgery in the Surgery Department of the aforementioned Institution in the period consigned. All of them (eighty-four patients) constituted the sample, in order to illustrate the results obtained in this age group.

The variables used were age, associated illnesses, type of surgery, type of anesthesia, trans and postoperative inhospital complications and postoperative hospitalization.

The data was taken from these patients’ hospital charts, filed in the Statistic Department of the Institution. This data and the results were presented using tables, in absolute and relative frequencies for statistic analysis of the variables.

                           

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RESULTS

 

Table #1. Distribution of the patients according to age and sex.

                “Manuel A. Domenech” Provincial Hospital, 2000

 

                       Sex

             Age

Male

No

Female

No    

Total

No     %

 

 

 

 

60 – 69

32 

6  

38     45.24

70 –79

32

2

34     40.48

80 – 89

9 

1

10     11.90

90 and older

2 

-

  2       2.38

 

 

 

 

Total

75  

 9 

 84   100.00

 

Data base: Hospital charts

 

The most representative age group was from 60 to 69 years, with 38 patients, which constitutes the 45.24% of the series. The oldest patient was 101 years old. The age mean was 72 years. The male sex was predominant over the female in a ratio of 8:1.

 

Table #2. Localization of the inguinal hernia

 

Localization

No

%

 

 

 

Right

49

58.33

Left

34

40.48

Bilateral

 1

 1.19

 

 

 

Total

84

100.00

 

Data base: Hospital charts

 

The most frequent localization in these patients was the right side. The only patient presenting bilateral inguinal hernia had both repaired at the same time. Out of the total, 7 hernias were recurrent, 4 urgent and 3 elective.  

 

Table #3. Illnesses associated to the hernia pathology.

 

Associated illnesses

No

%

 

 

 

High blood pressure

9

37.50

Heart diseases

5

20.83

Diabetes mellitus

3

12.50

Prostatic hyperplasia

3

12.50

Cerebrovascular diseases

2

8.33

Hyperthyroidism

1

4.17

Asthma

1

4.17

 

 

 

Total

24

      100.00

 

Data base: Hospital charts

 

Only 19 patients had associated illnesses to their hernia pathology, 22.62 %. Of these, 3 had more than 1 pathology, which in all cases included Diabetes mellitus. High blood pressure was the most frequent, present in 9 patients.

 

 

Table #4.  Anesthesia used in accordance with the type of surgery performed.

 

 

Type of surgery performed

Anesthesia

  Elective                             Urgent

                      No                %                 No                 %

 

 

General Endotracheal

                        7               10.61              10                55.56

Spinal

                      51               77.27                8                44.44

Local with sedation

                        2                 3.03                -                     -

Acupuncture

                        6                 9.09                -                     -

 

 

Total

                      66              100.00              18             100.00

 

Data base: Hospital charts

 

In elective surgery spinal anesthesia prevailed in 77.27 % of the cases, whereas only 10.61 % required general endotracheal. Also, elective surgery permitted the use of local anesthesia and acupuncture in 8 patients, who constitute 9.52 % of total.

 

 

 

Table #5. Main complications regard to the type of surgery

 

 

Type of surgery performed

Total

Complications

       Elective        Urgent

  No         %       

 

 

 

          Transoperative

       (9)                   (3)   

(12)     100.00 

                          Hypotension

           5                      2

    7        58.34

Anesthesic        Changes in cardiac frequency

           3                      -

    3        25.00

       Changes in cardiac rhythm

 

           1                      -

    1          8.33

Surgical            Lesion of spermatic vessels

            -                      1

    1          8.33

 

 

 

         Postoperative

       (1)                    (6)

 (7)       100.00

                         Wound hemathoma

           1                      1

    2        28.57     

                         Wound infection

           -                       3

    3        42.86

                          Inhospital bronchoneumonia

           -                       2

    2        28.57

 

 

 

Total

         10                     9

  19      100.00

 

Data base: Hospital charts

 

A total of 13 patients developed complications (15.48 %). Transoperative complications were more frequent in elective surgery, prevailing those related to anesthesia. Only  1.19 % of the series had surgical complications. The postoperative complications occurring during admission (36.84 %) were associated almost entirely to urgent surgery, wound infection being the most common.

 

 

Table #6. Postoperative hospitalization according to the type of surgery

 

 

Type of surgery

Total

Hospital stay (days)

Elective        Urgent

  No       %

 

 

 

Less than 1

            23                     -

                 23      27.38

From 1 to 3

            38                   10

                 48      57.14

From 4 to 7

             3                      3

                   6        7.14

More than 7

             2                      5

                   7        8.33

 

 

 

 

Data base: Hospital charts

 

The greatest number of patients (84.57 %) was admitted for less than 3 days after surgery. Of the 84 patients undergoing surgery, 23 were ambulatory, which permitted their stay in hospital to be less than 1 day. It was found that of the 7 patients who remained in hospital for the longest (more than 7 days) 71.43 % had urgent surgery. In general the mean for hospitalization was 2.75 days.

 

Table #7. Hospitalization with regard to the type of anesthesia used

 

 

Hospital stay (days)                                          Total

Anesthesia

Less than1    From 1 to3    From 4 to7      More than7      No   %

 

 

General Endotracheal

      -                    9                   3                     5                17    20.24

Spinal

    17                  37                   3                     2                59   70.24

Local with sedation

      1                    1                   -                      -                  2     2.38

Acupuncture

      5                    1                   -                      -                  6     7.14

 

 

Total

    23                  48                  6                      7                84  100.00

 

Data base: Hospital charts

 

Spinal anesthesia afforded the shortest hospitalization and allowed for the greatest number of ambulatory cases. General endotracheal provided the longest stay. Acupuncture was used in 7.14 % of the patients undergoing surgery.

                           

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DISCUSSION

 

Most authors coincide in affirming that inguinal hernia is a pathology more frequent in men and that the majority of patients develop inguinal hernias on the right side (1,2,8-10), which is in agreement with the results obtained in this investigation.

As for concomitant illnesses present in elderly patients having had inguinal surgery, there are studies that find high mortality in this age group (5). Diabetes mellitus has been associated to a low survival in patients over 75 years (11). Gianetta et al. (6) report that in a series of 231 elderly patients (66 to 93 years), 157 of which had illnesses associated to the inguinal hernias, there was no mortality after surgery. In our study no mortality was found in spite of the fact that a fifth of these patients presented at least one associated illness, and that Diabetes mellitus constituted 12.5 % of these.

According to Palumbo et al., local anesthesia prevents complications when repairing hernias in the elderly (7,12). In the series studied by Gianetta, 92.8 % were operated under local anesthesia, and he reports its effectiveness in the absence of complications due to its use. In another study, local anesthesia permitted hospitalization of less than a day in 60 % of the 189 patients over 80 (13). In this investigation only 2.38 % of the 84 cases had surgery with local anesthesia. Other authors state that conscious sedation allows amnesia to be achieved with low morbidity in the majority of patients undergoing local anaesthetic procedures. This should result in increased patient acceptance (14).

In the literature reviewed there are no reports of the use of acupuncture as anesthesia method in this type of surgery. On the other hand, it is found that 54 patients had a hospital stay of less than 3 days with the use of spinal anesthesia.

There are authors who state that elderly patients, specifically those over 70, have an increasing incidence of wound infection (15). Others have found up to a 1% of complication in their series (6). 3.57 % of the series we present developed wound sepsis. Although only in a small proportion, the wound hemathoma is present as a complication in some studies (6,15) and specifically in our series 2 cases are reported representing 2.38 %.

In general it was found that the emergency patients in this investigation develop more postoperative complications than those with elective surgery. Spish et al. report  that 7% of this type of complications responded to urgent procedures in a study of 189 patients over 80 years (11 conforming to these criteria). The same author reports that the mean postoperative hospitalization in his study was 2.2 days, similar to that obtained in this investigation.

                            

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CONCLUSIONS

 

Based on the results obtained, we can conclude that in all patients studied, the male sex prevailed and the most frequent inguinal hernia was on the right side. High blood pressure was the most frequent illness found associated with hernia pathology. The anesthesia most used was spinal, and acupuncture proved to be useful for a faster recovery. Postoperative complications were more observed in patients with elective surgery, wound sepsis being the most frequent. The greater part of the patients remained in hospital less than 3 days after surgery and the spinal anesthesia was the cause of a shorter hospital period for them.

                            

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BIBLIOGRAFICAL REFERENCES

 

1-     Sabiston D. Textbook of Surgery. 15 th ed. Philadelphia: W. B. Saunders Company. 1997.

2-     Zavaleta D. Hernias. En: Romero Torres R. Tratado de Cirugía. México D. F.: Nueva Editorial Interamericana. 1988: 1245-74.

3-     González L. Abdomen agudo geriátrico [Trabajo para obtar por el Título de Especialista de 1er grado en Cirugía General] 1993. Hosp. Prov. MAD. Camagüey.

4-     Chameca M. Evaluación del riesgo pre-anestésico en el anciano. Rev SILAC 1997; 5(1): 7-9.

5-     Rai S, Chandra SS, Smile SR. A study of the risk of strangulation and obstruction in groin hernias. Eur J Surg 1999; 165(4): 326-32.

6-     Gianetta E, de Cian F, Cunco S, Friedman D, Vitale B, Marinari G et al. Hernia repair in elderly patients. Br J Surg 1997; 84(7): 983-5.

7-     Palumbo P, Pulcini M, Vietri F, Turano R, Gallinaro L, Montesano G et al. Surgery of inguinal hernia in the geriatric patient. Klin Khir 1997; 5(6): 40-2.

8-     Schwartz S, Shires T, Spencer F. Abdominal wall hernias. En: Schwartz. Principles of Surgery. USA: Mc Graw-Hill. 1994: 541-3.

9-     Rutkow IW, Robbins AW. Groin Hernia. En Cameron JL. Current Surgical Therapy. USA. Mosby 5th Ed: 481-90.

10- Ponka JL. The Ponka Approach To The Repair Of Groin Hernias. En Nyhus LM, Baker RJ. Mastery of Surgery. USA: Little, Brown & Co. 1992: 234-5

11- Gunnarsson U, Degerman M, Davidsson A, Heuman R. Is elective hernia repair worthwhile in old patients ?. Klin Khir 1998; (4): 46-7.

12- Guzmán VG, Medina OR, Sánchez WM, Zaga IM, Caneda MM. Comparación entre la anestesia local y el bloqueo peridural en plastia inguinal Rev. méd. IMSS 1995; 33(2):157-60.

13- Spirch S, Martella B, Militello C, Nistri R, De Santis L, Ciardo L et al. Surgery of inguinal and femoral hernia in the elderly. Chir Ital 1997; 49(4-5): 53-5.

14- McFarlane ME. Analgesia-sedation for day-case inguinal hernia repair. A review of patient acceptance and morbidity West Indian Med J 2000; 49(2):158-60

15- Bendavid R. Complications of groin hernia surgery. Surg Clin of North Amer 1998; 78(6): 1089-97.

 

                            

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