© Borgis - Postępy Nauk Medycznych 8/2014, s. 542-546
*Krzysztof Barski, Mariusz Gregorczyk, Wiesław Tarnowski
Operacje przepuklin ze wskazań nagłych: doświadczenia jednego ośrodka
Emergency surgery of incarcerated abdominal wall hernias: a single centre experience
Department of General, Oncological and Gastrointestinal Surgery, Medical Centre of Postgraduate Education, Professor Witold Orłowski Independent Public Clinical Hospital, Warszawa
Head of Department: prof. Wiesław Tarnowski, MD, PhD
Wstęp. Nagłe operacje uwięźniętych przepuklin są związane z większą zachorowalnością i śmiertelnością w porównaniu do zabiegów w trybie planowym. Odpowiednia kwalifikacja do operacji i dokładna kontrola pooperacyjna są wysoce zalecane.
Cel pracy. Zaprezentować retrospektynie wyniki leczenia pacjentów ze zdiagnozowaną uwięźniętą przepukliną i porównać wyniki z najnowszą literaturą.
Materiał i metody. Przenalizowano pacjentów operowanych w Oddziale Klinicznym Chirurgii Ogólnej i Przewodu Pokarmowego w Szpitalu im. Prof. W. Orłowskiego Centrum Medycznego Kształcenia Podyplomowego od stycznia 2010 do grudnia 2013 roku. Porównywano następujące czynniki: wiek, płeć, rodzaj przepukliny, objawy przy przyjęciu, choroby towarzyszące, przebyte operacje, wskaźnik masy ciała (BMI), grupa według American Society of Anesthesiologists (ASA), czas operacji, zawartość worka przepuklinowego, metoda operacji, czas hospitalizacji, komplikacje i śmiertelność.
Wyniki. 26 pacjentów zostało zoperowanych (18 mężczyzn). Średnia wieku wynosiła 58 lat. Średni czas hospitalizacji to 4 dni. Średni wynik BMI – 29 kg/m2. 7 pacjentów było operowanych z grupą III według ASA, w 13 przypadkach grupa ASA wynosiła II. W większości przypadków zawartością worka było jelito cienkie, w żadnym przypadku nie wymagało resekcji. Średni czas trwania operacji wyniósł 82 minuty. Komplikacje zaobserwowano w 4 przypadkach, z których 2 wymagały reoperacji. Odnotowano jeden zgon, ale związany z chorobami towarzyszącymi.
Wnioski. Zaprezentowany materiał jest podobny z wynikami z analizowanej literatury. Podczas gdy metody leczenia przepuklin pachwinowych są szeroko opisane, kolejne badania powinny skupić się na pozostałych rodzajach przepuklin ściany brzusznej.
Introduction. Emergency repair of incarcerated hernia has increased morbidity and mortality rate comparing to elective procedures. Adequate qualification for the procedure and careful follow-up are highly recommended.
Aim. To present retrospectively patients diagnosed and treated for incarcerated hernia and compare the results with the latest literature.
Material and methods. Patients operated in the Department of General and Gastrointestinal Surgery in Orlowski Hospital Medical Center for Postgraduate Education in Warsaw between January 2010 and December 2013 were analyzed. Following factors were compared: age, sex, hernia type, symptoms at the admission, comorbidities, past medical history, Body Mass Index (BMI), American Society of Anesthesiologists (ASA) class, duration of procedure, contents of the hernial sac, method of hernia repair, duration of hospital stay, complications and mortality.
Results. 26 patients were operated (18 males). Mean age was 58 years. Mean duration of hospital stay was 4 days. Mean BMI was 29 kg/m2. 7 patients were operated with ASA class III, in 13 cases ASA was II. In most of the cases the ontent of the hernia sac was ileum, none of which needed necrotic resection. Mean duration of the procedure was 82 minutes. Complications were observed in 4 cases, 2 of which required reoperation. There was one death, but associated with comorbidities.
Conclusions. Presented material is similar to the results from analyzed litrature. Acute abdominal wall hernia is a complex surgical issue. Since methods of emergency treatment of inguinal hernias are widely analyzed, future studies should focus on other types of abdominal wall hernias.
Hernioplasty is a procedure associated with specific types of complications and risk of recurrence. The numbers may vary depending on the used technique and accompanying risk factors (1, 2). Although, all types of hernias have a recommendation for elective procedure, incarceration or strangulation are often causes of admission to the surgical wards. Among all types of abdominal wall hernias, inguinal, femoral, epigastric and umbilical hernias carry the greatest risk of incarceration (3). Strangulated hernias are unable to be reduced manually and need emergency surgery. Emergency status of the operation increases the morbidity and mortality. Incarcerated hernia is one of the main indication for intestinal resection (4, 5). Many studies evaluate the factors affecting outcomes of emergency hernioplasty (6-8). Despite rapid development of methods of elective hernias repair, an emergency hernioplasty can be challenging for the surgeon. This group of patients requires careful attendance and adequate follow-up.
We would like to present a retrospective analysis of cases of incarcerated hernias treated in our clinic.
Material and methods
We analyzed retrospectively patients operated in Department of General, Oncological and Gastrointestinal Surgery in Orlowski Hospital Medical Center for Postgraduate Education in Warsaw between January 2010 and December 2013. Patients data was gathered from the medical records and operating room records. Patients follow-up was obtained from outpatient surgical clinic records and by phone survey. The following variables were analyzed: age, sex, hernia type, symptoms at the admission, comorbidities, past medical history, Body Mass Index (BMI), American Society of Anesthesiologists (ASA) class, duration of surgical procedure, contents of the hernial sac, method of hernia repair, duration of hospital stay, complications and mortality.
Inguinal and femoral hernia
Between January 2010 and December 2013, sixteen patients (3%) underwent emergency hernia repair out of 490 admitted and operated for inguinal hernia. Femoral hernia repair had urgent status in two cases out of 13 patients (15%). Mean age was 61 years (range 21 to 88). There were 14 male and 4 female. Two patients were diagnosed with groin hernia. Mean duration of hospital stay was 4 days (range 3 to 6). Dominating symptoms were abdominal pain (18/18), nausea and vomiting (5/18), irreducible manually mass in the inguinal region (3/18) and flatulence (3/18). Comorbidities were noted in 13 patients (hypertension, diabetes, ulcer disease, epilepsy, cardiac dysrhythmia). Two patients had previously elective hernia repair and was admitted with a recurrence. Mean BMI was 25 kg/m2 (range from 19 to 30 kg/m2). Blood tests prior to operation evaluated leukocytosis in 7 cases. 8 patients were operated with ASA class II, 5 patients with ASA class III. Lichtenstein hernia repair was performed in 4 cases, Shouldice method in 4 cases, Halstead method in 4 cases, Basini method in 1 case, 3 patients had anatomic hernia repair. Content of the hernia sac was ileum (7/18), omentum (3/18), colon (2/18), urinary bladder (2/18) and preperitoneal tissue (1/18). None of the patients required necrotic bowel resection. Mean duration of the surgery was 92 minutes (range 60 to 180). Major complications were noted in 2 cases. There was one reoperation in the first postoperative day because of bleeding from the wound. One patient, 2 months after hernia repair, required bowel resection secondary to iatrogenic perforation. Postoperative mortality was noted in one patient who had significant coexisting disease (2 years after hernia repair). No deaths related to hernia surgery was recorded. No hernia recurrence was observed.
Between January 2010 and December 2013, 116 patient underwent epigastric hernia repair, out of whom five had emergency operation (4.3%). Mean age was 51 years (range from 28 to 80), two were male. Hospital stay ranged from 3 to 5 days. Dominating symptom at the admission to the hospital was abdominal pain (5/5), 2 patients complained additionally about nausea. Comorbidities were recorded in 4 patients (arterial hypertension, diabetes, Hashimoto disease). One patient, 3 years before admission, underwent elective surgery of epigastric hernia. Mean BMI was 32 kg/m2 (range from 25 to 40 kg/m2). Three patients blood tests revealed leukocytosis. Three patients were operated with ASA class II, one case of ASA class III. Hernia sac in 2 cases contained ileum, colon and preperitoneal tissue in one case each. Mean operating time was 85 minutes (range 50 to 140 minutes). Post-dural-puncture headache was the only postoperative complication, observed in one case. No major complication, no deaths, no recurrence were noted in the follow-up.
In the analyzed period, 69 patients had umbilical hernia repair, 3 procedures (4%) were performed as an emergency. Mean age was 53 years (range 22 to 83), 2 were male. Hospital stay ranged from 3 to 5 days. All of the patients complained about abdominal pain, one also about nausea and vomiting. Each patient had coexisting diseases (arterial hypertension, alcoholism, Prader-Willi syndrome). Mean BMI was 36 kg/m2 (range from 27 to 56 kg/m2). One patient was operated with ASA class III, one case of ASA class II. Ileum was found in hernia sac in 1 patient, in 2 cases it contained omenutum, which once had to be resected. Mean duration of the surgery was 63 minutes (range 30 to 100). One patient, with Prader-Willi syndrome and significant high BMI (56 kg/m2), required reoperation 4 months after the primary hernia repair. This patient was diagnosed with subcutaneous fluid collection, which was drained successfully. No deaths, no recurrence of the hernia were observed in the follow-up.
Indications for emergency hernia operation has been widely discussed in the literature, mainly because of a high probability of complications, which increase the mortality rate. A large number of articles published recently gives an impression of rapid development of minimally invasive surgery in the emergency treatment of abdominal wall hernias.
In total, 24 papers were reviewed in our article. Most of the authors (17) focus on emergency surgery of groin hernias. Only 6 articles covered all types of abdominal wall hernias. Only one paper focused on ventral hernias. 16 articles discuss open methods of abdominal wall hernias surgery, 13 of which refer to inguinal hernias and only 3 concern open surgery of acute abdominal and groin hernias. 9 articles focus on minimally invasive methods used in diagnosing acute hernias, out of which 8 refer to groin hernias and one concern abdominal and groin hernias. One paper compares open and minimally invasive surgery of acute groin hernias. Only one article describes minimally invasive treatment of acute abdominal wall hernias.
Since emergency surgery of abdominal hernias is associated with increased morbidity and mortality rate, some authors tried to answer the question, what are the risk factors that contribute to this.
Kulah et al. (9) reported that complications occurred mainly in the cases that required necrotic bowel resection during the emergency surgery. Authors point out that comorbidities (cardiorespiratory system), delayed admission to the hospital, as well as higher ASA class may influence the morbidity and mortality rates. Authors highlight that elderly patients, if possible should undergo elective operations.
Similar conclusions were reached by Alvarez et al. (4). Authors again emphasize that a extended duration of the symptoms, delayed admission, coexisting diseases and high ASA class are statistically proven to be significant risk factors of treatment failure. Therefore, symptomatic hernias should be scheduled to elective surgery as soon as possible.
The next paper from this series by Tiernan et al. (10) proves, that excessive waiting time for elective repair and delays in diagnosis and treatment increase the risk of strangulation, bowel resection and overall mortality. We should do everything to shorten waiting lists for surgery. Then number of emergency groin hernia repair would decrease and those that will have elective operation would have less complications after the surgery.
Nilsson et al. (7) analyze if mortality after groin hernia surgery can be caused by delay in treatment. They find that emergency hernia surgery in contrast to elective hernia surgery is associated with appreciable mortality. Incarcerated hernia is the second most common cause of small bowel obstruction after adhesions and the leading cause of bowel strangulation. That is why groin examination of patients presenting bowel obstruction is of utmost importance in order to minimize delay to hernia surgery.
Powyżej zamieściliśmy fragment artykułu, do którego możesz uzyskać pełny dostęp.
Płatny dostęp do wszystkich zasobów Czytelni Medycznej
1. Paajanen H, Scheinin T, Vironen J et al.: Commentary: Nationwide analysis of complications related to inguinal hernia surgery in Finland: a 5 year register study of 55 000 operations. Am J Surg 2010; 199: 746-751.
2. Bay-Nielsen M, Kehlet H, Strand L et al.: Quality assessment of 26 304 herniorrhaphies in Denmark: a prospective nationwide study. Lancet 2001; 358: 1124-1128.
3. Szmidt J, Gruca Z: Podstawy chirurgii. [W:] Mackiewicz Z (red.): Przepukliny brzuszne. Medycyna praktyczna, Kraków 2009: 1047-1064.
4. Alvarez JA, Baldonedo RF, Bear IG et al.: Incarcerated groin hernias in adults: Presentation and outcome. Hernia 2004; 8: 121-126.
5. Simons MP, Aufenacker T, Bay-Nielsen M et al.: European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 2009; 13: 343-403.
6. Derici H, Unalp HR, Bozdag AD et al.: Factors affecting morbidity and mortality in incarcerated abdominal wall hernias. Hernia 2007; 11: 341-346.
7. Nilsson H, Nilsson E, Angerås U et al.: Mortality after groin hernia surgery: delay of treatment and cause of death. Hernia 2011; 15: 301-307.
8. Lohsiriwat V, Sridermma W, Akaraviputh T et al.: Surgical Outcomes of Lichtenstein Tension-Free Hernioplasty for Acutely Incarcerated Inguinal Hernia. Surg Today 2007; 37: 212-214.
9. Kulah B, Duzgun AP, Moran M et al.: Emergency hernia repairs in elderly patients. Am J Surg 2001; 182: 455-459.
10. Tiernan JP, Katsarelis H, Garner JP et al.: Excellent outcomes after emergency groin hernia repair. Hernia 2010; 14: 485-488.
11. Gul M, Aliosmanoglu I, Kapan M et al.: Factors Affecting Morbidity and Mortality in Patients Who Underwent Emergency Operation for Incarcerated Abdominal Wall Hernia. Int Surg 2012; 97: 305-309.
12. Hoffman A, Leshem E, Zmora O et al.: The combined laparoscopic approach for the treatment of incarcerated inguinal hernia. Surg Endosc 2010; 24: 1815-1818.
13. Özkan E, Yildiz MK, Cakir T et al.: Incarcerated abdominal wall hernia surgery: relationship between risk factors and morbidity and mortality rates (a single center emergency surgery experience). Ulus Travma Acil Cerrahi Derg 2012; 18: 389-396.
14. Wysocki A, Poźniczek M, Krzywoń J et al.: Lichtenstein Repair for Incarcerated Groin Hernias. Eur J Surg 2002; 168: 452-454.
15. Elsebae MMA, Nasr M, Said M: Tension-free repair versus Bassini technique for strangulated inguinal hernia: A controlled randomized study. Int J Surg 2008; 6: 302-305.
16. Karatepe O, Adas G, Battal M et al.: The comparison of preperitoneal and Lichtenstein repair for incarcerated groin hernias: A randomised controlled trial. Int J Surg 2008; 6: 189-192.
17. Atila K, Guler S, Inal A et al.: Prosthetic repair of acutely incarcerated groin hernias: a prospective clinical observational cohort study. Langenbecks Arch Surg 2010; 395: 563-568.
18. Lohsiriwat D, Lohsiriwat V: Long-term outcomes of emergency Lichtenstein hernioplasty for incarcerated inguinal hernia. Surg Today 2013; 43: 990-994.
19. Ferzli G, Shapiro K, Chaudry G, Patel S: Laparoscopic extraperitoneal approach to acutely incarcerated inguinal hernia. Surg Endosc 2004; 18: 228-231.
20. Saggar VR, Sarangi R: Endoscopic totally extraperitoneal repair of incarcerated inguinal hernia. Hernia 2005; 9: 120-124.
21. Deeba S, Purkayastha S, Paraskevas P et al.: Laparoscopic Approach to Incarcerated and Strangulated Inguinal Hernias. JSLS 2009; 13: 327-331.
22. Wu CC, Kang JC, Huang YM: Laparoscopic Transabdominal Preperitoneal Hernioplasty for Reduction En Masse of an Incarcerated Inguinal Hernia: A Case Report. J Gastrointest Surg 2012; 16: 1433-1435.
23. Sauerland S, Agresta F, Bergamaschi R et al.: Laparoscopy for abdominal emergencies. Surg Endosc 2006; 20: 14-29.
24. Shah RH, Sharma A, Khullar R et al.: Laparoscopic repair of incarcerated ventral abdominal wall hernias. Hernia 2008; 12: 457-463.
25. Gonenc M, Bozkurt MA, Kapan S et al.: Acutely incarcerated abdominal wall hernia: what if it is a consequence? Hernia 2013 Oct 12 [Epub ahead of print].
26. Piccolo G, Cavallaro A, Lo Menzo E et al.: Hernioscopy: A Simple Application of Single-port Endoscopic Surgery in Acute Inguinal Hernias. Surg Laparosc Endosc Percutan Tech 2014; 24: 5-9.