- Email: [email protected]
Complicated presentations of groin hernias
Complicated Scott N. Oishi,
MD,
Presentations
Carey P. Page,
MD, FACS,
Wayne
Elective repair of simple (uncomplicated) inguinal and femoral hernias avoids incarceration and bowel obstruction (complicated presentations). To identify factors that perturb this strategy, we analyzed the records of 1,859 consecutive nonpediatric patients with groin hernias. Incarceration or bowel obstruction prompted operation in 22 of 77 (29%) women and in 15 of 34 (44%) patients with femoral hernia. Patients presenting with bowel ohstmction were significantly older than those with incarceration only and/or uncomplicated presentation, and 13 of 25 (52%) required resection of necrotic bowel. Mortality was limited to five patients of advanced age with groin hernia and bowel obstruction. Four of the five patients had undergone resection of necrotic bowel. Complicated presentations of groin hernias are associated with a higher proportion of women and patients with femoral hernias. Gangrenous bowel was encountered only in those patients with groin hernia and bowel obstruction. Early diagnosis and elective repair of uncomplicated hernias should remain our strategy in patients of all ages.
of Groin Hernias H. Schwesinger,
MD,
FACS, sari Antonio,TWS
lective repair of inguinal and femoral hernias is E safe and effective strategy that avoids incarceratic and strangulation and their complications. The adva tages of early elective repair are most evident in childrc under the age of 3 in whom the morbidity and mortali of untreated groin hernia are impressive. Application this approach, however, is dependent on accurate diagn sis of the hernia and on both the surgeon and the patie being amenable to elective repair. Review of our rece experience with nonpediatric groin hernias indicates th factors that either delay the diagnosis of groin hernias that contribute to deferral of definitive elective operatic are associated with more complicated presentations. PATIENTS
AND METHODS
We analyzed the records of patients aged 15 years ai older undergoing repair of groin hernias between M; 1982 and May 1990 at our two teaching hospitals. T1 presentations of those without incarceration presenti for elective repair were categorized as “simple” or “u complicated.” “Complicated” presentations were dividl into two groups, those presentations with incarceratic and those presentations with bowel obstruction. Observ tions recorded for each patient included the type of PI sentation, age, gender, location of the groin hernia, cox plications, outcome, and length of hospitalization. Da analysis for three-group comparisons used analysis variance for continuous data and chi-square for discre observations with p <0.05 accepted as significant. Iden fication of the group(s) responsible for significant difft ences was by separate t-test or chi-square analysis wit1 <0.017 accepted as significant for comparison betwe the three groups. RESULTS
From the Department of Surgery, University of Texas Health Science Center, and Audie L. Murphy Memorial Veterans’ Hospital, San Antonio, Texas. Requests for reprints should be addressed to Carey P. Page, MD, University of Texas Health Science Center San Antonio, Department of Surge& 7703 Floyd Curl Drive, San Antonio, Texas 78284-7842. Presented at the 43rd Annual Meeting of the Southwestern Surgical Congress, Las Vegas, Nevada, April 2 l-24,199 1.
568
THE AMERICAN JOURNAL OF SURGERY
During this 8-year interval, 1,859 patients (1,782 m and 77 women) came to surgical attention because oft presence of a groin hernia or a complication resulti from it. Table I depicts the age distribution for the ent group, as well as by gender and hernia type. The ages men and women were similar, but patients with fema hernias were older. Nineteen of the 34 femoral hemj (56%) occurred in women who represented only 4% oft study population. The type of presentation was the prime determinant the length of hospitalization, complication rate, and 01 come. Table II groups patients according to presentatic Significant intergroup differences were noted in age, ge der, and type of hernia. Women and alI patients wi femoral hernias were at significantly increased risk. 1 carceration or bowel obstruction prompted operation 22 of 77 (29%) women and in 15 of 34 (44%) patier with femoral hernias. None of the patients presenti
VOLUME 162 DECEMBER 1991
TABLE I Age Distribution Gender All Patients (n = 1,859)
Men (n = 1,782)
Age 2 SD (yr)
52 -)_17.6
52 t 17.7
Age (no.) 15-30 31-45 46-60 61-75 76-90 >90
306 346 428 646 129 4
Type of Hernia
(n = 1,859)
297 329 401 828 124 3
(n = 1,859) Women (n = 77)
lnguinal (n = 1,825)
51 k17
52 + 17.7
9 17 27 18 5 1
Femoral (n = 34) *
59 + 14.8
305 342 415 636 123 4
1 4 13 10 6 0
*p < 0.05
with incarceration who did not have an associated bowel obstruction required bowel resection. Patients presenting with bowel obstruction were significantly older. All patients, except one who was “‘observed” on a medical service for 48 hours, underwent surgical treatment after adequate resuscitation and stabilization. Despite prompt management, 13 of 25 (52%) required resection of ne erotic bowel. Complications in those patients with “simple” presentations were largely related to the surgical wound and to the urinary tract. The wound infection rate in this group was 1.3%. Three patients (0.2%) underwent secondary operations for control of bleeding in the surgical wound during the early postoperative period. Wound complications continued to predominate in those patients who underwent operation for incarceration without bowel ob struction, with the wound infection rate rismg to 8.7%. In the group presenting with bowel obstruction, the wound infection rate was 12% with five secondary operations being required (two for tracheotomy, two for early postoperative recurrent mechanical bowel obstruction, and one for wound dehiscence). Septic multiorgan failme accounted for the remaining serious complications in four patients, and pulmonary embolism was responsible in one other patient (Table III). Mortality was limited to five patients of advanced age (68,79,81,81, and 83), all of whom presented with groin hernia and bowel obstruction. This group included one woman and two men with femoral hernias and one woman and one man with inguinal hernias. Four of the five patients had undergone resection of necrotic bowel (two small bowel, two colon) and died of septic multiorgan failure. The remaining death was caused by a postopera tive pulmonary embolus. In the group with bowel ob struction, the patient’s age appeared to be the prime determinant of survival (Table IV).
TABLE II Gender, Hernia Type, Age, and Outcome by Type of Presentation
No. Men Women lnguinal Femoral Age -c SD (yr) LOS (d) Complications
Simple
Incarcerated
Bowel Obstruction
1,777 1,722 (97%) 55 (3%)” 1,758 (99%) 19 (1%)’ 51.7 * 17.5 1.9 2 2.29 110 (6%)
57 45 (79%) 12 (21%) 50 (88%) 7 (12%) 50.3 lr 20.8’ 4.81 + 6.02 8 (14%) -
25 15 (60%) 10 (4O%)f 17 (68%) 8 (32%)* 65.6 lr. 14.5* 17.12 ? 17.05* 9 (36%)* 5 (20%)
-
‘p
CO.017 simple versus incarcerated.
lp
~0.017
tp ~0.017
incarcerated versus bowel obstruction bowel obstruction verws simple.
LOS = length of stay.
TABLE III Complications by Preeentatlon Simple No. Anesthetic Alcohol CNS Wound Urinary Cardiac Lung Bowel Reoperation Septic MOF
1,777 12 3 0 57 24 3 8 6 3 0
Incarcerated
Bowel Obstruction
57 1 0 0 5 0 0 1 2 0 0
25 0 0 1 3 0 2 2 2 5 4’
CNS = central nervous system; MOF = muitiorgan failure. “Renal, pulmonaty. cardiac, and bowl complications noted as a portion of septic
COMMENTS Elective repair of groin hernias before the complications of incarceration and strangulation occur is a safe
MOF are not separately categorized. Total number of complications is greater than total number ot patients with complications. Some patients experienced more than one complication.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 162 DECEMBER 1991
569
TABLE IV Patients with Groin Hernia and Bowl Obstruction: Determinants of Outcome Death
Survival No. Femoral hernia Bowel resection Women Age k SEM (y)
20 5 9 0 62.36 2 3.3
NS NS NS *
5 3 4 2 70.64 f 2.72
NS = not significant. ‘p = 0.026.
and effective strategy. Significant inguinal hernias in adolescents and adult males are generally obvious to experienced examiners, They occur in an expected population, they are well described in both our written and clinical educational material, and they are common. The diagnosis of femoral hernias in men and women and of inguinal hernias in women is not so unambiguous. Femoral hernias may be overlooked for lack of proper examination or confused with other processes such as lymphadenitis that are relatively common in the groin. In addition, femoral hernias are a product of age and increased intra-abdominal pressure and are proportionally more common in women. Most clinicians are less experienced in the examination of the inguinal canal in women. The topographic anatomy of the inguinal canal is less obvious, and inguinal hernias are notably less common in women than in men. They are, therefore, less likely to be pursued, diivered, and repaired. In elderly patients, age and the presence of co-morbid factors may distract both the patient and the physician from the diagnosis and elective repair of groin hernias. This experience persists despite repeated reports of successful repair of these hernias in the elderly with mortality rates of 0% to 2% in an elective setting versus IO?&to 20% in an emergency situation [Z-3]. This study focuses on individuals over 15 years of age and examines the reasons for which they came to the surgeon’s attention, as well as the possible influences of age, gender, and type of hernia on both presentation and outcome. Our findings of an increased proportion of women and of femoral hernias in patients with complicated presentations and of significantly older age in patients with groin hernia and bowel obstruction are consistent with the published observations of Dennis and Enquist [4], Pollak and Nyhus [ 51, and Heydom and Velanovich [6J. The mortality in our series (0.3% overall and 20% for patients with bowel obstruction) is likewise similar to that of previous reports [4,7]. Although our series includes proportionally twice as many patients over age 60 as the Army’s worldwide 5-year series of 29,907 groin hernias [a, our conclusions relating to mortality and morbidity are similar, that is, unfavorable outcomes are associated with female gender, complicated presentations, and advanced age. Both studies also confi’ied that femoral hernias are proportionally more complicated. 570
THE AMERICAN JOURNAL OF SURGERY
In our review, we found that the term “strangulated” was conceptually sound, but noted that it was clinically flawed in terms of predicting viability of the contents of the incarcerated hernia. Only 10% to 15% of all incarcerated hernias contain necrotic bowel [4,7,8], The definitive diagnosis of “strangulation” can be made only at the time of exploration. Pekoe [8], in his prospective review of 118 patients with incarceration/strangulation, stated that he could find “. . . no definite criterion to differentiate incarcerated hernia with viable contents from that with nonviable contents.” This observation is largely the reason we selected “incarceration” and “bowel obstruction” as groupings for “complicated” presentation. Both are clinically obvious and correlate better with the ultimateviability of entrapped bowel. Of our 57 patients with only incarceration, we encountered no dead bowel. Contrariwise, in patients presenting with bowel obstruction and an incarcerated groin hernia, 52% required resection of necrotic bowel.
CONCLUSIONS We conclude that complicated presentations of groin hernias (incarceration and bowel obstruction) are associated with a higher proportion of women and are more likely to be located in the femoral canal. Both are settings in which the initial diagnosis may be difficult to establish. The mortality rate after repair of complicated hernias continues to be associated with advanced age and resection of necrotic bowel. The absence of bowel obstruction in patients with incarcerated hernias should provide some reassurance that the bowel trapped within the hernia is still viable. Alternatively, the presence of bowel obstruo tion should signal a higher likelihood of necrotic contents. Early diagnosis and elective repair of uncomplicated hernias should remain our strategy. We should give special attention to clinical settings in which groin hernia may be more difficult to diagnose (women, femoral hernias) or easier to defer elective repair (advanced age).
REFERENCES 1.Tingwald G, Cooperman M. Inguinal and femoral hernia repair in geriatric patients. Surg Gynecol Obstet 1982; 154: 704-6. 2. Williams J, Hale H. The advisability of inguinal hemiorrhaphy in the elderly. Surg Gynecol Obstet 1966; 122: 100-4. 3. Pot&a J, Brush B. Experiences with the repair of groin hernia in 200 patients aged 70 or older. J Am Geriatr Sot 1974; 22: 18-24. 4. Dennis C, Enquist IF. Strangulating external hernia. In: Nyhus LM, Condon RE, editors. Hernia. 2nd ed. Philadelphia: JB Lip pincott, 1978: 279-99. 5. Pollak R, Nyhus LM. Complications of groin hernia repair. Surg Clin North Am 1983; 63: 1363-71. 6. Heydorn WH, Velanovich V. A five-year U.S. army experience with 36,250 abdominal hernia repairs. Am Surg 1990; 56: 596-600. 7. Brasso K. Nielsen KL, Christiansen J. Long-term results of surgery for incarcerated groin hernia. Acta Chir Stand 1989; 155: 583-5. 8. Bekoe S. Prospective analysis of the management of incarcerated and strangulated inguinal hernias. Am J Surg 1973; 126: 665-8.
VOLUME 162 DECEMBER 1991
DISCUSSION James H. Thomas (Kansas City, KS): The mortality
rate in patients with complicated presentations in this study was a function of advanced age and the requirement for the resection of necrotic bowel. The presence of obstruction resulted in a mortality rate of approximately 20%. Interestingly, obstruction was associated with a 50% risk of ischemic bowel. What was the mortality rate of simple versus strangulated obstruction? You looked at age as a predictor of outcome or mortality, but I am also interested in whether you examined some other determinant of surgical risk such as that as used by the American Society of Anesthesiologists (ASA). Did you assess this in terms of predicting outcome? Were your herniorrhaphies performed under local or general anesthesia? And do you have any suggestions for the group in terms of managing the patient who has an obstructed hernia in which there is an increased risk of strangulation? Do you approach this through the groin or through the abdomen? Finally, it is clear that we must find some way to improve the accuracy of the diagnosis of femoral hernias and hernias in the female. Do you have any suggestions on how this might be accomplished?
Byron McGregor (Reno, NV): Among those patients who had complicated courses or who died, how many had previously been fitted for trusses or been seen and declined an elective operation? What might that say for your conclusions? Scott N. Oishi (closing): Dr. Thomas, we did look at the ASA classification of the patients in the study group. While the patients with bowel obstruction seemed to be predominantly ASA class III or IV, patients in the other two groups also had underlying medical problems. There was no statistically significant difference between groups based on ASA classification. General anesthesia was used in all patients with bowel obstruction. Our operative approach in a patient with incarceration and bowel obstruction is prsperitoneal, so that we are able to examine and evaluate the bowel and proceed to a transabdominal incision if nonviable bowel is discovered. It is clear that the diagnosis of mguinal and femoral hernias in women and of femoral hernias in men is difficult. If the results of the physical examination are inconclusive, we reexamine the patient at a later date. Hemiography might also be useful. Dr. McGregor, none of the patients in the bowel obstruction group had been treated with trusses preoperatively.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 162 DECEMBER 1991
571
MD,
Presentations
Carey P. Page,
MD, FACS,
Wayne
Elective repair of simple (uncomplicated) inguinal and femoral hernias avoids incarceration and bowel obstruction (complicated presentations). To identify factors that perturb this strategy, we analyzed the records of 1,859 consecutive nonpediatric patients with groin hernias. Incarceration or bowel obstruction prompted operation in 22 of 77 (29%) women and in 15 of 34 (44%) patients with femoral hernia. Patients presenting with bowel ohstmction were significantly older than those with incarceration only and/or uncomplicated presentation, and 13 of 25 (52%) required resection of necrotic bowel. Mortality was limited to five patients of advanced age with groin hernia and bowel obstruction. Four of the five patients had undergone resection of necrotic bowel. Complicated presentations of groin hernias are associated with a higher proportion of women and patients with femoral hernias. Gangrenous bowel was encountered only in those patients with groin hernia and bowel obstruction. Early diagnosis and elective repair of uncomplicated hernias should remain our strategy in patients of all ages.
of Groin Hernias H. Schwesinger,
MD,
FACS, sari Antonio,TWS
lective repair of inguinal and femoral hernias is E safe and effective strategy that avoids incarceratic and strangulation and their complications. The adva tages of early elective repair are most evident in childrc under the age of 3 in whom the morbidity and mortali of untreated groin hernia are impressive. Application this approach, however, is dependent on accurate diagn sis of the hernia and on both the surgeon and the patie being amenable to elective repair. Review of our rece experience with nonpediatric groin hernias indicates th factors that either delay the diagnosis of groin hernias that contribute to deferral of definitive elective operatic are associated with more complicated presentations. PATIENTS
AND METHODS
We analyzed the records of patients aged 15 years ai older undergoing repair of groin hernias between M; 1982 and May 1990 at our two teaching hospitals. T1 presentations of those without incarceration presenti for elective repair were categorized as “simple” or “u complicated.” “Complicated” presentations were dividl into two groups, those presentations with incarceratic and those presentations with bowel obstruction. Observ tions recorded for each patient included the type of PI sentation, age, gender, location of the groin hernia, cox plications, outcome, and length of hospitalization. Da analysis for three-group comparisons used analysis variance for continuous data and chi-square for discre observations with p <0.05 accepted as significant. Iden fication of the group(s) responsible for significant difft ences was by separate t-test or chi-square analysis wit1 <0.017 accepted as significant for comparison betwe the three groups. RESULTS
From the Department of Surgery, University of Texas Health Science Center, and Audie L. Murphy Memorial Veterans’ Hospital, San Antonio, Texas. Requests for reprints should be addressed to Carey P. Page, MD, University of Texas Health Science Center San Antonio, Department of Surge& 7703 Floyd Curl Drive, San Antonio, Texas 78284-7842. Presented at the 43rd Annual Meeting of the Southwestern Surgical Congress, Las Vegas, Nevada, April 2 l-24,199 1.
568
THE AMERICAN JOURNAL OF SURGERY
During this 8-year interval, 1,859 patients (1,782 m and 77 women) came to surgical attention because oft presence of a groin hernia or a complication resulti from it. Table I depicts the age distribution for the ent group, as well as by gender and hernia type. The ages men and women were similar, but patients with fema hernias were older. Nineteen of the 34 femoral hemj (56%) occurred in women who represented only 4% oft study population. The type of presentation was the prime determinant the length of hospitalization, complication rate, and 01 come. Table II groups patients according to presentatic Significant intergroup differences were noted in age, ge der, and type of hernia. Women and alI patients wi femoral hernias were at significantly increased risk. 1 carceration or bowel obstruction prompted operation 22 of 77 (29%) women and in 15 of 34 (44%) patier with femoral hernias. None of the patients presenti
VOLUME 162 DECEMBER 1991
TABLE I Age Distribution Gender All Patients (n = 1,859)
Men (n = 1,782)
Age 2 SD (yr)
52 -)_17.6
52 t 17.7
Age (no.) 15-30 31-45 46-60 61-75 76-90 >90
306 346 428 646 129 4
Type of Hernia
(n = 1,859)
297 329 401 828 124 3
(n = 1,859) Women (n = 77)
lnguinal (n = 1,825)
51 k17
52 + 17.7
9 17 27 18 5 1
Femoral (n = 34) *
59 + 14.8
305 342 415 636 123 4
1 4 13 10 6 0
*p < 0.05
with incarceration who did not have an associated bowel obstruction required bowel resection. Patients presenting with bowel obstruction were significantly older. All patients, except one who was “‘observed” on a medical service for 48 hours, underwent surgical treatment after adequate resuscitation and stabilization. Despite prompt management, 13 of 25 (52%) required resection of ne erotic bowel. Complications in those patients with “simple” presentations were largely related to the surgical wound and to the urinary tract. The wound infection rate in this group was 1.3%. Three patients (0.2%) underwent secondary operations for control of bleeding in the surgical wound during the early postoperative period. Wound complications continued to predominate in those patients who underwent operation for incarceration without bowel ob struction, with the wound infection rate rismg to 8.7%. In the group presenting with bowel obstruction, the wound infection rate was 12% with five secondary operations being required (two for tracheotomy, two for early postoperative recurrent mechanical bowel obstruction, and one for wound dehiscence). Septic multiorgan failme accounted for the remaining serious complications in four patients, and pulmonary embolism was responsible in one other patient (Table III). Mortality was limited to five patients of advanced age (68,79,81,81, and 83), all of whom presented with groin hernia and bowel obstruction. This group included one woman and two men with femoral hernias and one woman and one man with inguinal hernias. Four of the five patients had undergone resection of necrotic bowel (two small bowel, two colon) and died of septic multiorgan failure. The remaining death was caused by a postopera tive pulmonary embolus. In the group with bowel ob struction, the patient’s age appeared to be the prime determinant of survival (Table IV).
TABLE II Gender, Hernia Type, Age, and Outcome by Type of Presentation
No. Men Women lnguinal Femoral Age -c SD (yr) LOS (d) Complications
Simple
Incarcerated
Bowel Obstruction
1,777 1,722 (97%) 55 (3%)” 1,758 (99%) 19 (1%)’ 51.7 * 17.5 1.9 2 2.29 110 (6%)
57 45 (79%) 12 (21%) 50 (88%) 7 (12%) 50.3 lr 20.8’ 4.81 + 6.02 8 (14%) -
25 15 (60%) 10 (4O%)f 17 (68%) 8 (32%)* 65.6 lr. 14.5* 17.12 ? 17.05* 9 (36%)* 5 (20%)
-
‘p
CO.017 simple versus incarcerated.
lp
~0.017
tp ~0.017
incarcerated versus bowel obstruction bowel obstruction verws simple.
LOS = length of stay.
TABLE III Complications by Preeentatlon Simple No. Anesthetic Alcohol CNS Wound Urinary Cardiac Lung Bowel Reoperation Septic MOF
1,777 12 3 0 57 24 3 8 6 3 0
Incarcerated
Bowel Obstruction
57 1 0 0 5 0 0 1 2 0 0
25 0 0 1 3 0 2 2 2 5 4’
CNS = central nervous system; MOF = muitiorgan failure. “Renal, pulmonaty. cardiac, and bowl complications noted as a portion of septic
COMMENTS Elective repair of groin hernias before the complications of incarceration and strangulation occur is a safe
MOF are not separately categorized. Total number of complications is greater than total number ot patients with complications. Some patients experienced more than one complication.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 162 DECEMBER 1991
569
TABLE IV Patients with Groin Hernia and Bowl Obstruction: Determinants of Outcome Death
Survival No. Femoral hernia Bowel resection Women Age k SEM (y)
20 5 9 0 62.36 2 3.3
NS NS NS *
5 3 4 2 70.64 f 2.72
NS = not significant. ‘p = 0.026.
and effective strategy. Significant inguinal hernias in adolescents and adult males are generally obvious to experienced examiners, They occur in an expected population, they are well described in both our written and clinical educational material, and they are common. The diagnosis of femoral hernias in men and women and of inguinal hernias in women is not so unambiguous. Femoral hernias may be overlooked for lack of proper examination or confused with other processes such as lymphadenitis that are relatively common in the groin. In addition, femoral hernias are a product of age and increased intra-abdominal pressure and are proportionally more common in women. Most clinicians are less experienced in the examination of the inguinal canal in women. The topographic anatomy of the inguinal canal is less obvious, and inguinal hernias are notably less common in women than in men. They are, therefore, less likely to be pursued, diivered, and repaired. In elderly patients, age and the presence of co-morbid factors may distract both the patient and the physician from the diagnosis and elective repair of groin hernias. This experience persists despite repeated reports of successful repair of these hernias in the elderly with mortality rates of 0% to 2% in an elective setting versus IO?&to 20% in an emergency situation [Z-3]. This study focuses on individuals over 15 years of age and examines the reasons for which they came to the surgeon’s attention, as well as the possible influences of age, gender, and type of hernia on both presentation and outcome. Our findings of an increased proportion of women and of femoral hernias in patients with complicated presentations and of significantly older age in patients with groin hernia and bowel obstruction are consistent with the published observations of Dennis and Enquist [4], Pollak and Nyhus [ 51, and Heydom and Velanovich [6J. The mortality in our series (0.3% overall and 20% for patients with bowel obstruction) is likewise similar to that of previous reports [4,7]. Although our series includes proportionally twice as many patients over age 60 as the Army’s worldwide 5-year series of 29,907 groin hernias [a, our conclusions relating to mortality and morbidity are similar, that is, unfavorable outcomes are associated with female gender, complicated presentations, and advanced age. Both studies also confi’ied that femoral hernias are proportionally more complicated. 570
THE AMERICAN JOURNAL OF SURGERY
In our review, we found that the term “strangulated” was conceptually sound, but noted that it was clinically flawed in terms of predicting viability of the contents of the incarcerated hernia. Only 10% to 15% of all incarcerated hernias contain necrotic bowel [4,7,8], The definitive diagnosis of “strangulation” can be made only at the time of exploration. Pekoe [8], in his prospective review of 118 patients with incarceration/strangulation, stated that he could find “. . . no definite criterion to differentiate incarcerated hernia with viable contents from that with nonviable contents.” This observation is largely the reason we selected “incarceration” and “bowel obstruction” as groupings for “complicated” presentation. Both are clinically obvious and correlate better with the ultimateviability of entrapped bowel. Of our 57 patients with only incarceration, we encountered no dead bowel. Contrariwise, in patients presenting with bowel obstruction and an incarcerated groin hernia, 52% required resection of necrotic bowel.
CONCLUSIONS We conclude that complicated presentations of groin hernias (incarceration and bowel obstruction) are associated with a higher proportion of women and are more likely to be located in the femoral canal. Both are settings in which the initial diagnosis may be difficult to establish. The mortality rate after repair of complicated hernias continues to be associated with advanced age and resection of necrotic bowel. The absence of bowel obstruction in patients with incarcerated hernias should provide some reassurance that the bowel trapped within the hernia is still viable. Alternatively, the presence of bowel obstruo tion should signal a higher likelihood of necrotic contents. Early diagnosis and elective repair of uncomplicated hernias should remain our strategy. We should give special attention to clinical settings in which groin hernia may be more difficult to diagnose (women, femoral hernias) or easier to defer elective repair (advanced age).
REFERENCES 1.Tingwald G, Cooperman M. Inguinal and femoral hernia repair in geriatric patients. Surg Gynecol Obstet 1982; 154: 704-6. 2. Williams J, Hale H. The advisability of inguinal hemiorrhaphy in the elderly. Surg Gynecol Obstet 1966; 122: 100-4. 3. Pot&a J, Brush B. Experiences with the repair of groin hernia in 200 patients aged 70 or older. J Am Geriatr Sot 1974; 22: 18-24. 4. Dennis C, Enquist IF. Strangulating external hernia. In: Nyhus LM, Condon RE, editors. Hernia. 2nd ed. Philadelphia: JB Lip pincott, 1978: 279-99. 5. Pollak R, Nyhus LM. Complications of groin hernia repair. Surg Clin North Am 1983; 63: 1363-71. 6. Heydorn WH, Velanovich V. A five-year U.S. army experience with 36,250 abdominal hernia repairs. Am Surg 1990; 56: 596-600. 7. Brasso K. Nielsen KL, Christiansen J. Long-term results of surgery for incarcerated groin hernia. Acta Chir Stand 1989; 155: 583-5. 8. Bekoe S. Prospective analysis of the management of incarcerated and strangulated inguinal hernias. Am J Surg 1973; 126: 665-8.
VOLUME 162 DECEMBER 1991
DISCUSSION James H. Thomas (Kansas City, KS): The mortality
rate in patients with complicated presentations in this study was a function of advanced age and the requirement for the resection of necrotic bowel. The presence of obstruction resulted in a mortality rate of approximately 20%. Interestingly, obstruction was associated with a 50% risk of ischemic bowel. What was the mortality rate of simple versus strangulated obstruction? You looked at age as a predictor of outcome or mortality, but I am also interested in whether you examined some other determinant of surgical risk such as that as used by the American Society of Anesthesiologists (ASA). Did you assess this in terms of predicting outcome? Were your herniorrhaphies performed under local or general anesthesia? And do you have any suggestions for the group in terms of managing the patient who has an obstructed hernia in which there is an increased risk of strangulation? Do you approach this through the groin or through the abdomen? Finally, it is clear that we must find some way to improve the accuracy of the diagnosis of femoral hernias and hernias in the female. Do you have any suggestions on how this might be accomplished?
Byron McGregor (Reno, NV): Among those patients who had complicated courses or who died, how many had previously been fitted for trusses or been seen and declined an elective operation? What might that say for your conclusions? Scott N. Oishi (closing): Dr. Thomas, we did look at the ASA classification of the patients in the study group. While the patients with bowel obstruction seemed to be predominantly ASA class III or IV, patients in the other two groups also had underlying medical problems. There was no statistically significant difference between groups based on ASA classification. General anesthesia was used in all patients with bowel obstruction. Our operative approach in a patient with incarceration and bowel obstruction is prsperitoneal, so that we are able to examine and evaluate the bowel and proceed to a transabdominal incision if nonviable bowel is discovered. It is clear that the diagnosis of mguinal and femoral hernias in women and of femoral hernias in men is difficult. If the results of the physical examination are inconclusive, we reexamine the patient at a later date. Hemiography might also be useful. Dr. McGregor, none of the patients in the bowel obstruction group had been treated with trusses preoperatively.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 162 DECEMBER 1991
571