Journal reading

Presentation: Intern 黃世銘

Clinic Scenario

� 59 years old male patient

� Chief Complaint:

� Protruded mass over left inguinal area with

fullness sensation after keeping stand about

3~4 hours

� Past history:

� Bilateral inguinal hernia, reducible for 2 years

s/p right side hernia repair 5 months ago

� No other systemic disease, such DM, HTN

The Question

Mortality, Morbidity, and

bowel-resection rate

Outcome (Test)

Emergency operations for

incarcerated inguinal hernia

Comparison

Elective inguinal herniorrhaphyIntervention

(or exposure)

Asymptotic or minimally

symptomatic inguinal hernias

Population or Patient

Inguinal hernia: Challenging the traditional

indication for surgery in asymptomatic patients

Gil Ohana A Igor Manevwitch A Ruben Weil YedidiaMelki A Dan Seror A Eldad Powsner Zeev Dreznik

Hernia (2004) 8: 117–120

Introduction

� Most inguinal hernias should be operated on electively� High morbidity and mortality incarceration and

small bowel obstruction

� Background:� Elective inguinal herniorrhaphy：

� Postoperative complication rate: 7.5%–22%

� Mortality rate: 0%–0.6%

� Emergency operations for incarcerated inguinal hernia：� Morbidity rate: 19.5%–58%

� Mortality rate: 4.7%–10%

Introduction

� The bowel-resection rate in patients with incarcerated inguinal hernia are scarce to 16%

� Effect of bowel resection incarcerated inguinal hernia-associated mortality

� Emergent surgery and hernia strangulationseem the only circumstances that can be fatal

� Factors may influence the indications for inguinal hernia repair� Length of hernia history

� Medical status of the patient

� Functional compromise� Socioeconomic impact

controversial

Methods� Study Design:

� Retrospective, randomized intervention study with historical control subjects

� Time: Between 1992 and 2002

� Source: Division of Surgery Golda Campus Rabin Medical Center Petach Tiqva Affiliated with The Sackler School of Medicine, Tel Aviv University, Israel

Emergency hernia

repair for incarceration

or strangulation 67 of

these patients (2.9%)

Randomly selected

200 patients

Elective inguinal

herniorrhaphy

2,331 patients underwent

inguinal hernia repair

Methods

� Data gathered:� Age, Sex, Presenting symptoms or asymptomatic

patient

� Duration the patient had his hernia before presentation

� Time that elapsed from the beginning of pain or discomfort to operation in cases of incarceration

� Clinical data � Significant concomitant diseases, Type of

anesthesia, Type of hernia repair and Length of stay

� Medical or surgical complications

� American society of Anesthesiologists score

Statistical analysis

� Result: Mean, proportion, or median

� Elective versus emergency groups

� Morbidity and Mortality rates

� Distribution of ASA scores

� Analysis

� Fisher exact test (with Odds Ratio)

� Mantel Haenszel chi-square test

� P values < 0.05 were considered significant

Result

Result

� Incarcerated inguinal hernia group

� Bowel-resection rate: 4.5% (3/67)

Conclusion� Hypothesis in the present study: Asymptomatic patients

with inguinal hernia should be observed until symptoms or complications (incarceration) ensue.

� Old age, lack of symptoms, and unfavorable medical conditions, may have influenced the referring physician or surgeon to postpone the elective repair

� Postoperative complications were significantly more common after emergency (23.9%) than elective repair (10.5%)

� Mortality rate:6% (emergency group) vs. 0% (elective group)� all deaths in patients classified as ASA score III or IV� Mortality rate in the incarcerated group is clearly linked with

high ASA score rather than directly related to surgical complications

Conclusion

� Bowel resection versus mortality rates� Bowel-resection rate of 4%–6% lifetime risk for

strangulation exists

� Bowel resection following strangulation is associated with elevated mortality rates

� Bowel-resection rate of 4.5% (3/67) was found among the incarcerated inguinal hernia group, lower than that reported in literature

�Correlation: No

� Mortality was found to be associated with a high ASA score, rather than with complications directly associated with the incarcerated

� hernia itself

Conclusion� Tingwald and Cooperman reported on 62 geriatric patients with

significant concomitant diseases

� Nehme reported10-year period including 1,496 patients aged 65 years or older with a total of 1,755 groin hernias

� Suggest: patients with asymptomatic inguinal hernias and unfavorable medical conditions (ASA Group III and IV) should be recommended an elective hernia repair, preferably under local anesthesia

4 (22.2%)0 (0%)Mortality

10 (55.6%)8 (18.2%)Morbidity

emergencyelectiveHerniorrhaphy

Local anesthesia was associated

with the lowest complication rate

All cardiovascular complications and

all deaths occurred in those receiving

either general or spinal anesthesia

7.5%1.3%Mortality

56%20%Morbidity

EmergencyelectiveHerniorrhaphy

local anesthesia had

the least sequelae

Thanks for your attention!!