Strangulated groin hernia in octogenarians

Abstract

The aim of the study was to determine risk factors for morbidity and mortality in patients older than 80 years, compared to younger patients, who undergo emergency strangulated groin hernia repair.
This is a retrospective study of patients who underwent emergency surgery for strangulated groin hernia repair during 14 years. Patients were divided by age into three groups: younger than 59 (group A), 60-79 (group B), and older than 80 years (group C). Patient data included age, gender, hernia type, sac content, comorbidities, and surgical outcomes.
Two hundred patients were included in the study. There was no difference between groups in sex, hernia localization, and the type of repair. More comorbidities were found in octogenarians compared to the younger patients [group C vs. D (A + B)]. Small bowel resections and ICU admissions were more frequent in patients over 60 years compared to younger patients, 19.6 and 32.7 % vs. 1.7 and 0 %, respectively. Surgery was longer in group B. The rate of postoperative complications, repeated surgery, length of admission, and mortality were significantly higher in octogenarian (group C). Multivariate analysis found that age is a significant factor in the occurrence of non-surgical postoperative complications, but not in surgical complications.
Emergency surgery for strangulated hernia repair in patients over 80 years is more complicated than in younger patients, mostly due to the existing comorbidities. In order to reduce the high morbidity and mortality rates in emergency surgery associated with this age group, elective hernia surgery in elderly should be considered in selected patients with severe symptoms affecting their daily life.

Full text

ORIGINAL ARTICLE
Strangulated groin hernia in octogenarians
Y. Azari •Z. Perry •B. Kirshtein
Received: 23 June 2013 / Accepted: 12 December 2013 / Published online: 24 December 2013
ÓSpringer-Verlag France 2013
Abstract The aim of the study was to determine risk
factors for morbidity and mortality in patients older than
80 years, compared to younger patients, who undergo
emergency strangulated groin hernia repair.
Methods This is a retrospective study of patients who
underwent emergency surgery for strangulated groin hernia
repair during 14 years. Patients were divided by age into
three groups: younger than 59 (group A), 60–79 (group B),
and older than 80 years (group C). Patient data included
age, gender, hernia type, sac content, comorbidities, and
surgical outcomes.
Results Two hundred patients were included in the study.
There was no difference between groups in sex, hernia
localization, and the type of repair. More comorbidities
were found in octogenarians compared to the younger
patients [group C vs. D (A ?B)]. Small bowel resections
and ICU admissions were more frequent in patients over
60 years compared to younger patients, 19.6 and 32.7 %
vs. 1.7 and 0 %, respectively. Surgery was longer in group
B. The rate of postoperative complications, repeated sur-
gery, length of admission, and mortality were significantly
higher in octogenarian (group C). Multivariate analysis
found that age is a significant factor in the occurrence of
non-surgical postoperative complications, but not in sur-
gical complications.
Conclusion Emergency surgery for strangulated hernia
repair in patients over 80 years is more complicated than in
younger patients, mostly due to the existing comorbidities.
In order to reduce the high morbidity and mortality rates in
emergency surgery associated with this age group, elective
hernia surgery in elderly should be considered in selected
patients with severe symptoms affecting their daily life.
Keywords Groin hernia Emergency surgery 
Strangulation Elderly Octogenarians Hernia repair
Introduction
Long life nowadays leads to an increased number of vari-
ous operations performed in elective or emergency settings
in elderly patients. Hernia repair is a common operation,
since inguinal hernia life risk is 27 % in men and 3 % in
women [1]. Inguinal hernia is the most frequent and is
usually fixed electively, while femoral hernia is relatively
rare and is more frequently incarcerating, thus requiring
urgent surgical intervention [2]. Elective hernia repair can
be performed safely even in the presence of accompanying
diseases, while emergency surgery hernia causes an
increased risk of complications even without accompany-
ing diseases [3]. Nowadays the tendency is to refrain from
elective operations in patients over the age of 80 because
their age alone is a risk factor. Only a few studies have
focused on the risks in the repair of strangulated hernia in
patients over the age of 80. The majority of researchers
attribute age as a significant risk factor for hernia repair in
this population. Martinez-Serranoet al. [4] showed that the
major risk factors for mortality in emergency hernia repairs
This study fulfilled part of the requirements for the MD degree
of Y. Azari.
Y. Azari Z. Perry B. Kirshtein
Department of Surgery A, Soroka University Medical Center,
Beersheba, Israel
Y. Azari Z. Perry B. Kirshtein (&)
Faculty of the Health Sciences, Ben Gurion University of the
Negev, POB 151, 84101 Beersheba, Israel
e-mail: borkirsh@bgu.ac.il
123
Hernia (2015) 19:443–447
DOI 10.1007/s10029-013-1205-5

are resected bowel, ASA score (American Society of
Anesthesiologists) Class III/IV, and age over 70 years. Up
until now, a conclusive method in preventing strangulated
hernia such as elective hernia repair has not been found in
elderly patients or patients with severe comorbidities,
although some studies showed that elective hernia surgery
under local anesthesia is a good alternative option in this
patient group [5,6]. The favorite treatment with low risk
for this group is still undetermined and therefore was the
focus of the present study.
In this study, we analyzed cases of strangulated groin
hernia repair in various age groups to find risk factors for
postoperative morbidity and mortality in octogenarians.
Patients and methods
The study population included all patients who underwent
strangulated groin hernia repair between 1997 and 2010 at
the Department of Surgery A, Soroka University Medical
Center in Beer-Sheva, Israel. After the study was approved
by the local Helsinki Committee, patient data were gath-
ered from the operating room database by ICD 9 codes
(Z5321, Z5304, Z5302, Z5301). Data were collected from
the medical charts and included demographics,
comorbidities, hernia type, surgery findings and outcomes,
and length of ICU and hospital stay.
Patients were divided into three groups: group A (aged
59 and younger), group B (60–79 years old), and group C
(older than 80 years). Subgroup D (A ?B) included
patients under the age of 80. Comparison was performed
between three (A, B, and C) and two groups (D and C).
Statistical analysis
Data collected were coded for confidentiality of participants
and retained in the database SPSS software (SPSS 17.0,
SPSS, Chicago, IL). The data were processed initially using
descriptive statistics and then inferential statistics by Para-
metric [ttest uncorrelated (unpaired ttest)] and non-para-
metric tests (Mann–Whitney and v
2
). Correlation test was
done using parametric correlations and a-parametric correla-
tions. Statistical significance was determined as p\0.05.
Results
The study included 200 patients [135 (67.5 %) males and
65 (32.5 %) females], who underwent emergency stran-
gulated hernia repair: 58 in group A, 76 in group B, and 66
Table 1 Patient data Group A
B59
Group B
60–79
Group C
C80
p
Number of patients (%) 58 (29) 76 (38) 66 (33)
Age (mean) 43.7 70.9 86.5
Female, n(%) 19 (32.8) 21 (27.6) 25 (37.9) 0.429
Mesh repair, n(%) 43 (74.1) 57 (75) 43 (65.2) 0.375
Hernia sac content, n(%)
Small bowel 8 (14.8) 26 (36.1) 34 (53.1) \0.001
Large bowel 5 (9.3) 23 (31.9) 9 (14.1)
Small and large bowel 0 (0) 3 (4.2) 2 (3.1)
Omentum 21 (38.9) 6 (8.3) 4 (6.3)
Other 20 (37) 14 (19.4) 15 (23.4)
Comorbidities, n(%)
Ischemic heart disease 1 (1.7) 23 (30.3) 32 (48.5) \0.001
Diabetes mellitus 1 (1.7) 13 (17.1) 11 (16.7) 0.013
Hypertension 2 (3.4) 35 (46.1) 32 (48.5) \0.001
Chronic obstructive pulmonary disease 1 (1.7) 13 (17.1) 11 (16.7) 0.013
Chronic renal failure 0 (0) 11 (14.5) 16 (24.2) \0.001
Hernia type
Indirect inguinal 29 (50.0) 36 (47.4) 24 (36.3) 0.685
Direct inguinal 18 (31.0) 25 (32.9) 24 (36.3)
Femoral 11 (19.0) 15 (19.7) 16 (24.2)
Hernia side
Right 29 (50.0) 38 (50.0) 38 (57) 0.613
Left 26 (44.8) 36 (47.4) 26 (39.3)
444 Hernia (2015) 19:443–447
123

in group C. Background characteristics were compared
between the groups (Table 1).
There was no difference between the groups in gender,
and location and side of the hernia. Omentum or other
content was frequently found in the hernia sac in group A,
while small and large intestines were often present in
groups B and C (p\0.001). On the other hand, small
bowel was frequent in octogenarians (group C) compared
to the younger patients (group D) (p=0.003).
Ischemic heart disease, diabetes, hypertension, chronic
obstructive pulmonary disease, and chronic renal failure
were the most recent comorbidities. Octogenarians had sig-
nificantly more additional pathologies in all variables com-
pared to younger patients in groups A and B. Comparison of
groups D and C revealed significant difference in coronary
heart disease, hypertension, and chronic renal failure.
Also, repeated surgery was more common in the elderly
in the three and two groups comparison due to additional
laparotomies for anastomotic leaks (p=0.035, p=0.047,
respectively).
Surgery outcomes are summarized in Table 2. The
overall postoperative surgical complication rate was sig-
nificantly higher in octogenarians compared to three and
two groups (p=0.015, p=0.013, respectively). Three
groups comparison found wound infection and sepsis as
prevalent significant surgical complications, as well as
cardiac (p=0.011) and respiratory complications
(p=0.012), and death related to surgery (p=0.017), in
patients in group C. Comparison of groups C and D did not
find any difference in the occurrence of postoperative
complications.
Examining the factors that influenced the existence of
surgical and non-surgical complications, we found that
hypertension, age, duration of surgery, and length of hos-
pitalization are the factors affecting surgical complications.
Conversely, factors leading to non-surgical complications
are gender, type of repair, and duration of hospitalization
when age was not a significant factor.
Surgery was longer in group B (p=0.002). Analysis of
variables affecting surgery length found that incision
enlargement (p=0.026) and bowel resection with anas-
tomosis (p=0.016) prolonged the surgery time, when the
model predicted the result by 21.4 %. Age was not a sig-
nificant prognostic factor in this model.
Postoperative admissions to the intensive care unit were
more frequent in octogenarians when we compared the
Table 2 Surgery outcomes Group A
B59
Group B
60–79
Group C
C80
p
Mean surgery time (±SD), min 49.57 (19.3) 64.67 (35.8) 50.8 (24.6) 0.002
Mean hospital stay (±SD), days 2.95 (1.2) 4.71 (2.8) 5.53 (4.7) 0.000
Mean ICU stay(±SD), days 0 (0) 0.89 (3.6) 1.03 (3.8) 0.142
Additional laparotomy at primary surgery, n(%) 0 (0) 2 (2.6) 2 (3) 0.428
Small bowel resection, n(%) 1 (1.7) 8 (10.5) 6 (9.1) 0.133
Repeated surgery, n(%) 0 (0) 6 (8) 7 (10.6) 0.047
30-day readmission, n(%) 2 (3.4) 4 (5.3) 6 (9.1) 0.399
Postoperative ICU admissions, n(%) 0 (0) 11 (14.5) 12 (18.2) 0.004
Intraoperative complications, n(%)
Bladder injury n(%) 0 (0) 1 (1.3) 2 (3) 0.378
Postoperative complications, overall, n(%) 4 (6.9) 20 (26.3) 28 (42.4) 0.000
Surgical 4 (6.9) 11 (14.5) 17 (25.8) 0.015
Wound infection 4 (6.9) 5 (6.6) 9 (13.6) 0.274
Sac seroma, hematoma 1 (1.7) 1 (1.3) 1 (1.5) 0.982
Paralytic ileus 0 (0) 1 (1.3) 0 (0) 0.44
Small bowel obstruction 0 (0) 3 (3.9) 1 (1.5) 0.255
Sepsis 0 (0) 3 (3.9) 7 (10.6) 0.022
Non-surgical
Cardiac 0 (0) 2 (2.6) 7 (10.6) 0.011
Pulmonary 0 (0) 5 (6.6) 9 (13.6) 0.012
Urinary 0 (0) 2 (2.6) 5 (7.6) 0.063
UTI 0 (0) 1 (1.3) 3 (4.5) 0.17
Acute urinary obstruction 0 (0) 1 (1.3) 2 (3) 0.378
Pulmonary emboli 0 (0) 1 (1.3) 1 (1.5) 0.657
Mortality, n(%) 0 (0) 4 (5.3) 8 (12.1) 0.017
Hernia (2015) 19:443–447 445
123

three groups (p=0.004) and the two groups (p=0.002).
However, the length of stay in the intensive care unit was
not statistically different. A multivariate analysis revealed
that comorbidities, repeated surgery, and duration of sur-
gery are the main causes leading to ICU admissions after
surgery, when age was not a prognostic factor. Analysis of
variables affecting the length of ICU stay found that lap-
arotomy, repeated surgery, organ failure, intestinal
obstruction, repeated admissions, pulmonary complica-
tions, urinary complications, sepsis, and gender predicted
the results by 77 %. Even in this model age by itself was
not a significant prognostic factor.
Hospital stay was significantly longer in octogenarians
(p\0.001). We built a model explaining prolonged hos-
pital admission in this group. We created a linear regres-
sion model that predicted by 58.7 % the length of
hospitalization. In this model, we found that hypertension,
diabetes, hospitalization in ICU, wound infection, paralytic
ileus, multiple organ failure, damage to the bladder during
surgery, thromboembolic or respiratory complications,
surgical complications, and duration of surgery were the
factors that affect the length of hospitalization. However,
age was not a significant predictive factor.
Logistic regression model for predictors of mortality
found that the bowel resection significantly affected mor-
tality (p\0.001). Other variables (age, sex, duration of
surgery, and diseases) were not significant predictors.
Discussion
The older population is increasing all the time due to
changes in the length of life. According to statistics, in
2030 there will be about 19 million people over the age of
85 in the USA [7]. Emergency surgeries are more com-
plicated in the elderly due to risk factors such as age itself
and age-related diseases, as well as by the fact that emer-
gency surgery itself is more complex. Our study showed a
prevalence of coronary heart disease, hypertension, and
chronic renal failure in octogenarians. Even the National
Institute on Aging (NIA) found that the higher the age, the
greater the likelihood of developing chronic diseases such
as diabetes, respiratory disease, cardiac disease, hyperten-
sion [8]. For this reason, older patients are not candidates
for elective surgery and most surgeons try to avoid elective
operations in elderly patients due to age and comorbidities.
Rorbaek-Madsen described the complication rate in elderly
patients after elective hernia surgery as 5 % and after
emergency surgery as 57 % [3].
Our results demonstrated significantly higher rates of
postoperative morbidity and mortality in octogenarians.
Several studies have shown the relationship between
advanced age, multiple comorbidities, complications, and
mortality in emergency hernia surgery. Martinez-Serrano
et al. [4] showed that age over 70 years and a high ASA
score are risk factors for death in strangulated abdominal
wall hernia surgery. Alvarez et al. [9] found comorbidities
and ASA score as risk factors in strangulated inguinal
hernia surgery. Recent studies considered the safety of
elective surgery in the elderly despite their having signifi-
cant comorbidities [5,6]. According to the data, we can
decide that age itself is not a risk factor for morbidity and
mortality, but is affected by the comorbidities often
accompanying the elderly. Urgent surgery and high level of
stress can worsen comorbidities during surgery and after it.
Bowel as a common hernia sac content is a risk for
strangulation and necrosis. Coronary heart disease, diabe-
tes, and other chronic diseases aggravate the blood supply
to the affected part of intestine and result in rapid necrosis
in these patients. Correlation between high ASA score and
bowel resection with a poor outcome of surgery in the
elderly is probably due to anastomotic leaks; sepsis was
demonstrated in the literature [10].
Sepsis and cardiac events were more common compli-
cations in patients over 60 years of age. In addition, this
population has longer hospital admissions after the surgery.
We assume a correlation between prolonged admission and
high bowel resection and anastomotic leakage rate. Rug-
giero et al. [11] showed that localization of the anastomosis
is a risk factor for leakage, and colorectal anastomosis is
prone to leakage. A relation between anastomosis leakage
and comorbidities such as diabetes, chronic renal failure,
and chronic obstructive pulmonary disease was also found
[12,13]. Other risk factors are poor blood supply to the
anastomosis area, bowel obstruction, and the use of corti-
costeroids [12]. Early relaparotomy and revision of anas-
tomosis can help in diagnosis of a leak and improve
surgical outcome. Bellows et al. [14] reported that respi-
ratory or neurological findings are the earliest markers for
anastomotic leaks. Another means for early detection of
complications is using exploratory laparoscopy for early
detection of life-threatening complication after open sur-
gery [15]. It allows visualization of anastomotic leak,
diverting the leaking bowel, and preventing severe sepsis
and wound complications.
Complications of elective surgery are significantly lower
in the elderly compared with emergency hernia surgery [3].
In our opinion, this is the reason that elective surgery
should be considered in patients over the age of 80.
Chronic constipation, medications, prostate hyperplasia,
and weakness of the muscles of the abdominal wall are
common risk factors for hernia and incarceration in
advanced age. Colorectal tumors are often the cause of
progressive constipation in this age group and should be
excluded prior to elective surgery. Careful preoperative
preparation, operative, and postoperative risk prediction,
446 Hernia (2015) 19:443–447
123

and appropriate follow-up after surgery decrease morbidity
and mortality. Elective surgery allows more options for
advanced resources in anesthesiology as well as a surgical
team of experienced senior surgeons.
Our study found more frequent ICU admissions in
octogenarians. Ozkan et al. [16] found a correlation
between the ASA score and hospitalization in intensive
care after abdominal surgery in the elderly Therefore, this
difference can be attributed to background disease in the
older group.
Necmi et al. found predictors for bowel resection in
strangulated inguinal hernia in elderly patients [17]. Delay
in the approach to medical care after the onset of symp-
toms, often due to disability, dementia, etc., and altered
blood supply followed by rapid bowel necrosis are proba-
bly the causes of intestinal resections. Small sample size
was the reason that our study did not show a difference
between age groups in bowel resections.
Information collected in the context of intraoperative
complications included only damage to the bladder, which
showed no significant difference. The main reason for
bladder injury is a sliding hernia and difficulty in identi-
fying the hernia sac due to thickening and edema of the sac
and changing anatomy of large hernias. Early detection of
bladder damage and repair of the lesion with two layers of
absorbable sutures and a catheter for 7–10 days is usually
sufficient for the treatment of this complication. Later
detection of urine leakage into the abdomen is dangerous
and can lead to death in older patients.
Study limitations
This work is retrospective and therefore limited informa-
tion was collected from patients’ charts. Other data such as
time of disease before hospital admission were not avail-
able. We do not have enough data about the level of sur-
gical experience of the surgeon (resident, chief resident,
senior), which can greatly affect the surgery outcome.
Conclusions
Emergency surgery for strangulated hernia repair in octo-
genarians is more complicated than in younger patients,
mostly due to the existing comorbidities. Watchful waiting
is safe in asymptomatic groin hernias, even in elderly
patients. Elective hernia surgery with subsequent preoper-
ative investigation and preparation can be considered in
elderly patients with symptomatic hernias severely affect-
ing their daily life.
Conflict of interest YA declares no conflict of interest, ZP declares
no conflict of interest, BK declares no conflict of interest.
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