Tension-free by mesh-plug technique for inguinal hernia repair in elderly patients

Transcription

1 Scandinavian Journal of Surgery 99: , 2010 Tension-free by mesh-plug technique for inguinal hernia repair in elderly patients T. E. Pavlidis, N. G. Symeonidis, S. F. Rafailidis, K. Psarras, K. D. Ballas, M.E.Baltatzis, E. T. Pavlidis, G. N. Marakis, A. K. Sakantamis Second Propedeutical Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Constantinople, Thessaloniki, Greece Abstract Background: Elderly patients are steadily becoming a growing part of the population. The aim of this study is to evaluate the outcome of open inguinal hernia repair in patients aged over 65 years. Methods: From January 1999 to December 2008, a total of 719 patients underwent open tension-free inguinal hernia repair with mesh-plug; 301 among them were 65 years old. Results: Elderly patients had a mean age of 72.4 years (women 3.3%), while the mean age of younger patients was 48.7 years (women 5.7%). According to the ASA score, patients aged 65 years were at significantly higher risk than the younger patients. Spinal anesthesia was used most frequently in both groups. No significant differences were found in postoperative pain, mortality and recurrence. Morbidity and hospital stay were significantly higher in patients aged 65 years. Conclusions: Open hernia repair in the elderly is safe and well tolerated, but it is associated with higher morbidity and longer hospitalization. Key words: Groin hernia; inguinal hernia repair; open mesh repair ; tension-free repair; elderly patients; geriatrics Introduction Groin hernia repair is one of the most frequently performed operations in a general surgical department. As well as life expectancy increases, the incidence of inguinal hernia in the elderly population rises in parallel. The frequent occurrence of inguinal hernias in elderly patients is attributed to the weakened abdominal musculature which is a result of the progressive degenerative process and to the increased intraab- Correspondence: Theodoros E. Pavlidis M.D. A Samothraki Thessaloniki, Greece pavlidth@med.auth.gr; pavlidth@auth.gr dominal pressures needed for the evacuation of the bowels and the urinary bladder (1). The development of safe and tissue-tolerant prosthetic materials facilitated the advent of the tensionfree mesh repair introduced by Lichtenstein in Los Angeles, California, USA (2). Subsequently, the modification of mesh and plug technique was added by Rutkow (3). The recently developed techniques, along with their modifications (4 6), have already replaced the traditional herniorrhaphy techniques described by Bassini, Shouldice and other hernia surgeons. The basic advantage of the modern mesh technique either this is placed with the open or laparoscopic approach is that the repair is fashioned without tension. Tension-free repair ensures better local conditions resulting in a very low rate of recurrence (7 10). In cases of poor tissue quality such as in elderly patients, this type of reinforcement with the appropriate prosthetic material is considered necessary.

2 138 T. E. Pavlidis, N. G. Symeonidis, S. F. Rafailidis, et al. Advanced age is associated with declining physiologic health status. Elderly patients without major comorbidities can tolerate surgery, but the health of patients with serious concomitant diseases can be compromised by an acute exacerbation of the disease or an unexpected complication, which prolongs hospitalization (11). Surgery should only be performed after thorough preoperative evaluation and preparation. Undoubtedly, emergency surgery, which is required in complicated hernia, causes more postoperative complications than elective repair in properly prepared elderly patients. It has been reported that both morbidity and mortality are increased significantly in the emergency setting in the elderly (12 14). It is reasonable to assume that the risk of incarcerated or obstructed bowel increases with the age; it can reach even up to 40% (1). This case-series study evaluates the outcome of open inguinal hernia repair in the subgroup of patients aged 65 years compared with the younger patients. Patients and Methods The medical records and clinical notes of 301 patients 65 years of age and older were evaluated retrospectively from a total of 719 patients who underwent open inguinal hernia repair in this University Teaching Surgical Department over a 10 year period (January 1999 December 2008). They represent 41.9% of the total patients operated on for inguinal hernia. The following parameters were analyzed: age, gender, comorbid disease state, American Society of Anesthesiologists (ASA) score, type of anesthesia, type of inguinal hernia, postoperative pain, morbidity, mortality and length of hospital stay. Inguinal hernia type was classified according to Gilbert s classification (15). Femoral hernias were not included in the study. Preoperative risk was assessed according to the American Society of Anesthesiologists Physiological Status Classification System and scored from I to V (16). Score I represents the normal healthy patient, II mild systemic disease, III severe disease that limits activity, IV incapacitating disease that is a constant threat to life and V the moribund patient that is not expected to survive 24 hours. Table 1 Patient demographic and clinical characteristics. Number of patients Age ± ± 5.55 Gender Male 394 (94.3%) 291 (96.7%) Female 024 (5.7%) 010 (3.3%) ASA score Mean ASA score 1.52 ± ± 0.74 < ASA score (9.8%) 071 (23.6%) < Emergent repairs 014 (3.1%) 006 (1.8%) Recurrent hernias 031 (6.9%) 028 (8.35%) ASA, American Society of Anesthesiologists The same tension-free operative technique was performed in all patients using polypropylene mesh and plug. The mesh was placed on the transversalis fascia covering the plug. The latter was inserted into the inguinal ring (indirect hernia) or the posterior wall defect (direct hernia). Interrupted polypropylene 3 0 sutures were used to fix the mesh in position. No standard protocol of anesthesia was used and selection depended upon anesthesiologist s judgment and patient s preference. Prophylactic low molecular weight heparin was not routinely administered unless it was clearly indicated. One dose of second-generation cefalosporin at the beginning of the procedure was used routinely. Postoperative pain was evaluated during the first postoperative week according to the Visual Analogue Scale (VAS). The patients were instructed to score pain daily from 0 that represents no pain to 10 that represents the most severe pain. Patients were followed in out-patient basis at regular intervals (3, 6, 12 months). Scheduled follow-up lasted until one year postoperatively and patients could seek consultation freely thereafter. Statistical analysis was performed by using the Statistical Package for Social Sciences 13.0 for Windows (SPSS Inc., Chicago, IL). Continuous variables and proportions were compared by using Mann-Whitney U test and Fisher s exact test, respectively. P<0.05 was considered statistically significant. Results The demographic characteristics of patients aged < 65 and 65 years are shown in Table 1. The proportion of women did not differ significantly between the two groups (3.3% in the 65 group and 5.7% in the < 65 group, P = 0.132). The patients of the 65 group were found to have statistically higher mean ASA score of 1.91 ± 0.74, while younger patients had a mean ASA score of 1.52 ± 0.68 (P < 0.001). The percentage of high-risk patients (defined as having an ASA score 3) among those over 65 years old was significantly higher (23.6%), compared to that of the younger patients (9.8%) (P = < 0.001). Various comorbid conditions were reported in the elderly patients. Arterial hypertension (63%), ischemic heart disease (36%), non-insulin-dependent-diabetes (22%), cardiac arrhythmias (18%), heart failure (12%), chronic obstructive pulmonary disease (4%) and chronic renal failure (3%) were the most frequent concomitant medical problems encountered in this group of patients. Numerous elderly patients exhibited multiple comorbidities. Emergency hernia repair was necessary in 6 patients (1.8%) of the 65 group who presented with irreducible or strangulated inguinal hernias. In the < 65 group, the rate of emergency operations was slightly higher (3.1%, 14 patients), but without statistical difference (P = 0.244). Bilateral hernias occurred in 31 patients of the < 65 group (a total of 449 hernia repairs performed) and in 34 patients of the 65 group (335 hernia repairs). Among the elderly patients, 28 patients (8.35%) were operated on for recurrent hernias, most of them following a prior conventional herniorrhaphy. The frequency of recurrent hernias in the < 65 group was 6.9% (31 hernias), with-

3 Inguinal hernia repair in elderly 139 out statistical difference between the two groups (P = 0.445). The type of hernia according to the Gilbert classification with additions by Rutkow and Robbins, as encountered intraoperatively, is shown in Table 2. In both groups, type II hernia (indirect medium) was the most predominant type, followed by type III (indirect large) and type IV (direct large). The type of anesthesia administered did not exhibit significant differences between the two groups (Table 3). Spinal anesthesia was the type most frequently used in the patients < 65 years (28.7%), followed by local anesthesia (27.3%) and finally general and epidural anesthesia were reported having 23.4% and 20.6%, respectively. Similarly, spinal anesthesia was by far the most frequent type of anesthesia used in the 65 group (38.5%), followed by general anesthesia (29.6%). Local and epidural anesthesia were administered less frequently in 16.3% and 15.6% of the patients, respectively. Patients 65 years reported a mean postoperative VAS score for postoperative pain of 2.93 ± 1.67 (median score 3), which was similar to the mean score reported by <65 patients (2.90 ± 1.79, median score 2), without significant difference between the two groups (P=0.976). Morbidity rate in patients 65 years was 14.3%, which was significantly higher than the morbidity rate (5%) observed in the < 65 group (P < 0.001). No intraoperative complication was noted in either group. Early complications, which reflect the postoperative morbidity including wound complications and major complications as well as late sequels, are demonstrated in Table 4. Major complications in the 65 group included 1 case of pulmonary atelectasis, which developed into pneumonia, 1 case of cerebral stroke and 1 case of postoperative small bowel obstruction, which required reoperation. Wound seroma, hematoma and scrotal edema was recorded in 18 patients (4.3%) of the < 65 group and 38 patients (12.6%) of the 65 group. In 2 patients (one in each group) mesh infection occurred with persistent purulent fistula which necessitated reoperation and mesh removal. Urinary retention requiring bladder catheter was reported in 3 elderly patients and 2 patients of the < 65 group. The late sequels, namely numbness of the inguinoscrotal area and chronic pain, were mild and did not differ significantly between the two groups (P = 0.683). Two fatalities occurred in the 65 group (0.66%), one resulting from severe pulmonary infection and the other from an ischemic cerebrovascular event. Mortality was zero in the < 65 group, but no statistically significant difference was found between the two groups (P = 0.175). Hospital stay was significantly longer (P = 0.002) in the 65 group, resulting in a mean stay of 2.16 ± 1.16 days, while in the < 65 group the mean hospital stay was 1.87 ± 0.76 days. At follow-up a total number of 11 patients (1.5%) presented with a recurrent hernia, 8 patients from the < 65 group (1.9%) and 3 patients (1%) from the 65 group. Difference in recurrence between the two groups was not found statistically significant (P = 0.374). Postoperative results are demonstrated in Table 5. Table 2 Hernia type according to Gilbert s classification with additions by Rutkow and Robbins. Type Age < 65 years Age 65 years n (%) n (%) I (Indirect small) 064 (14.3%) 019 (5.7%) II (Indirect medium) 150 (33.4%) 102 (30.4%) III (Indirect large) 101 (22.5%) 089 (26.6%) IV (Direct large) 080 (17.8%) 079 (23.6%) V (Direct small) 029 (6.5%) 030 (8.9%) VI (Combined) 025 (5.6%) 016 (4.8%) Total Table 3 Type of anesthesia. Type Age < 65 years Age 65 years n (%) n (%) General 098 (23.4%) 089 (29.6%) Spinal 120 (28.7%) 116 (38.5%) Epidural 086 (20.6%) 047 (15.6%) Local 114 (27.3%) 049 (16.3%) Table 4 Complications following mesh-plug repair. Wound Complications 16 (3.8%)0 33 (10.9%) < Seroma Hematoma Mesh infection Scrotal edema 02 (0.48%) 05 (1.6%) Urinary retention 03 (0.71%) 02 (0.7%)0 1.0 Delirium 01 Major complications 00 (0%) (0.99%) Pulmonary infection 0 01 Stroke 0 01 Obstructive ileus 0 01 Late complications 09 (2.1%)0 05 (1.7%) Numbness Chronic pain Total (%) 30 (7.2%)0 48 (15.9%) < Table 5 Postoperative results. VAS score 2.9 ± ± Morbidity 21 (5%) 43 (14.3%) < Mortality 00 (0%) 02 (0.66%) Hospital stay 1.87 ± ± Recurrence 0.8 (1.9%) 03 (0.99%) VAS, Visual Analogue Scale

4 140 T. E. Pavlidis, N. G. Symeonidis, S. F. Rafailidis, et al. Discussion Elective inguinal hernia repair should be performed soon after diagnosis is made and following adequate preparation, even in the extremely elderly; the age or comorbidity should not be a barrier to it (17). The results of this study support further the above mentioned, despite the increase in morbidity and hospital stay. In our study, the morbidity in the elderly was approximately three times higher (14.3%) than that of the younger patients (5%). It should be noted that elderly patients had worse physical status and higher ASA score; additionally, they had more wound complications (10.9%) than younger patients (3.8%). Complications were managed successfully in all, but two cases, in which death occurred due to severe pulmonary infection and ischemic cerebrovascular event, respectively; despite of these deaths, mortality rate in the elderly remains low (0.66%) at fairly acceptable levels. In a large multicenter study from Sweden, mortality risk was similar to the background population regarding elective hernia repairs, but increased 7-fold after emergency repairs and 20-fold, when bowel resection was necessary (14). Tension-free technique with mesh-plug is a widely accepted technique with optimal results and minimal recurrence. In a multicenter randomized trial with 5-year follow-up the recurrence rate after Lichtenstein repair was 1.2% (7). The low recurrence rate in our study (1.5%) confirms the effectiveness of the technique used in the present study. The type of anesthesia used plays an important role in the outcome of hernia repair in elderly patients. Several studies have demonstrated the advantages of local anesthesia over the other types of anesthesia i.e. early ambulation, prevention of cardiopulmonary deficiencies, avoidance of paralytic ileus and urinary retention (13, 18 20). On the contrary, sideeffects of local anesthesia attributed to vagal stimulation, such as hypotension or bradycardia, have been occasionally reported (1). Some authors state that regional anesthesia techniques (spinal-epidural) have no documented benefits; as invasive techniques, they carry a low risk of rare neurological side effects and high risk of urinary retention (21). General anesthesia with short-acting drugs can be a valid alternative, but it is associated with the need for full preoperative workup and longer postoperative recovery. Despite its clear advantages, local infiltration is the anesthesia of choice only in public or private centers with special interest in hernia surgery and not in general surgical practice (22 24). In our study, spinal was the type of anesthesia most frequently used in the elderly patients (38.5%), followed by general anesthesia (29.6%). Local anesthesia was used in 27.3% in age < 65 years and in 16.3% in elderly. The low percentage of use of local anesthesia can be attributed to the higher incidence of larger hernias in elderly patients as well as the fear for increased intraoperative pain with subsequent disastrous hypotension. Prosthetic materials used in hernioplasty have various shapes and sizes, while new types of mesh have been developed to increase biocompatibility; they can either be fixed to the surrounding tissues with sutures, clips, glue or left without fixation (4 6, 25, 26). Postoperative pain is difficult to be assessed accurately, because of the variation of perception of pain between individuals. The VAS method employed in the present study can be considered as an indicative tool. Nevertheless, no significant difference was found in pain scoring between the two age groups, while the tension-free technique causes less pain in every case. Many patients experience chronic pain following mesh repair. This occasional pain is usually described as mild or moderate and is frequently related to physical activity. Its incidence was 5% at 2 months, decreasing to 3% after 12 months (27). Thus, surgeon s attention is shifted, nowadays, from recurrence to chronic pain or discomfort after mesh repair (28). In the present study, mild chronic pain or numbness was occurred in about 2%, without difference between the two age groups. Although stronger conclusions could be drawn from a controlled trial, in our study the results confirm that open tension-free technique with mesh-plug for inguinal hernia repair is simple, safe and applicable in elderly patients after adequate preparation and appropriate postoperative care. It is associated with higher, but acceptable, complication rate and hospitalization. The minimal postoperative pain and low recurrence rate mandate recommendation for timely elective repair of inguinal hernia. References 01. 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