Herniorrhaphy in the elderly

Herniorrhaphy in the Elderly Benefits of a Clinic for the Treatment of External Abdominal Wall Hernias

Maximo Deysine,MD, RogerGrmson, PhD, and HarryS. Sctroff,MD, Northportand StonyBrook, New York I

Although the true incidence of external abdommal hernia m men over 65 years of age ISunknown, It 1s expected that by the end of 1985, an abdommal hernia will have developed m 130,000 (13 percent) of the approximately 10 mllhon men at risk [1] Followmg this general demographlc trend, the veteran population are also reaching old age m mcreasmg numbers [2,3] Because of such longevity, their medical care IS often complicated by a high mcldence of severe and progressive systemic disorders, often associated with alcohol, tobacco, and food abuse Consequently, these patients represent hlghrisk surgical candidates who present to the hospital with a variety of preoperative and postoperative problems Further comphcatmg the care of elderly veterans 1s the group’s 40 percent incidence of mhospital latrogemc comphcatlons [4,5] In addition, hermorrhaphy m the elderly has been associated m the past with disturbingly high morbidity and mortality rates which increases markedly with emergency operations [6-8] This article reviews our experience m the care of herniated patients and presents data suggesting that the creation of a unit dedicated to hermorrhaphy permits the performance of such operations with minimal morbidity and mortality m this age group Material and Methods In 1981, the Department of Surgery at the Northport Veterans Admuustratlon Medical Center created a chmc exclusively dedicated to the care of patients with abdomlnal wall hernias The clmlc, held once a week as an ambulatory facility, was directed throughout this time by the same attending surgeon, a senior member of the faculty (MD), assisted by rotating first-year surgical residents and phyaclan’s assistants Preoperative protocol Patients were referred to the hernia chmc by the personnel of the emergency room and all other hospital departments The first vlslt to the clinic From the Departments of Surgery and Commumty Medlclne Northport Veterans Admmlstratton MedIcal Center Northport, New York and the Unlverslty Hospital State Unwerslty of New York at Stony Brook Stony Brook New York Requests for reprints should be addressed to Maxlmo Deyslne, MD Department of Surgery Northport Veterans AdmlntstratconMedIcal Center Northport New York 11768

Volume 153, April 1987

included a complete history and physical exammatlon Because of the high incidence of intercurrent systemic diseases and poor health habits, a preoperative protocol was established which included the followmg steps (1) Whenever a systemic disorder was diagnosed, the patient was referred to the specific chmc to obtam optlmlzatlon of his present condition (2) In spite of our preference for local anesthesia, all patients had to be accepted by the anesthesia department as acceptable risks for general anesthesia This permitted a safe conversion from local to general anesthesia (3) The surgical procedure was thoroughly described to the patients, particularly stressing the sensations to be felt by them during the performance of local anesthesia (4) The patients were told how obesity creates a serious deterrent to good postoperative recovery Obesity was treated by referring our patients to the department of nutntlon, where a diet was prescribed (5) Patients were advised to curtail their alcohol and tobacco intake (6) Patients were given a brochure written m plain language explaining all aspects of their preoperative, perioperative, and postoperative care (7) The progress of the patients’ weight loss and the status of their systemic disorders were monitored m successive visits to the herma clinic Operative protocol: On the morning of the operation, the patients received a Fleet’s enema on the ward and were shaved We did not utilize routme prophylactic antlblotlcs In the operating room, the local anesthesia procedure was again described to the patient Throughout the operation, the patient’s arterial blood pressure, heart rate, and rhythm were monitored by an anestheslologlst, who at the same time titrated their level of intravenous sedation Patients were able to respond at all times to our request to cough or strain Trunkal and mflltratlve anesthesia was carried on utlhzmg 1 percent hdocame without epmephrme The mgumal region was explored, exposing all relevant anatomic structures The cremaster muscles were resected adequately to expose the posterior mgumal wall and the internal rmg Indirect sacs were ligated high and resected The majority of direct primary, sliding, and recurrent hernias were repaired by the Shouldice technique On occasion, a primary or recurrent hernia was repaired by the McVay technique For hemostasls, we encouraged mmlmal utlhzatlon of reabsorptlve material or electrocoagulatlon The repair was performed utilizing contmuous sutures of either polypropylene or Teflon@-

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et al

TABLE I

Breakdown of Hernlorrhaphiaa by Factors Tabulated Factor

Number

Patients evaluated Patlents operated on Hernlorrhaphles performed Pabents with postponed operations Patients with postponed operabons who had eventual tncarcerabon Pabents lost to follow-up Preoperative deaths Right Left Other lncomlng recurrent hernias Elective hernlorrhaphies Emergent herniorrhaphies Local anesthesia General anesthesia Direct Indirect Incarcerated Strangulated Basstnl repair MacVay procedure Shouldice procedure Morbidity Mortality Length of stay (d) l-3 4-8

237 226 241 11 2

Percentaae

388

120

2 F

loo

g k

4 5 126 92 23 26 234 7 203 36 124 94 2 5 63 21 114 3 1

52 2 36 1 95 107 97 29 64 2 15 7 56 6 43 1 06 2 36 96 52 1 24 0 41

112

46 4

braided Dacron@ sutures The quahty of the repalr was tested by requesting the patient to cough and strain The wound was carefully debrlded removing all seemingly devltahzed tissue, and thoroughly irrigated with copious normal salme solution The external oblique and Scarpa’s fascia were closed mdlvldually by contmuous stitches of polypropylene The hermorrhaphles were performed by first year surgical residents assisted at all times by the director of the hernia clmlc These residents were progressively tramed m all steps of hermorrhaphy until they were able to perform a complete operation Postoperative protocol If a systemic complication was anticipated, patients were allowed to remam a few hours m the recovery room Patients were ambulated 2 to 3 hours after the operation They were not given anything by mouth and received intravenous fluids for the next 24 hours, after which a regular diet was instituted Skm sutures were removed 24 hours after the operation and Stern-strips@ applied Patients were discharged as soon as possible, depending on social and family sltuatlons The patients were requested to adhere to the recommendations written m the brochure, which included sections about postoperative pain, wound swelling, and testicular comphcatlons They were instructed to consult the staff at any time after discharge Patients were reexamined at the chmc at 1 week, 1 month, and every 6 months thereafter for a proJected period of 7 to 10 years Patients were tabulated by age, presence of systemic coated

e

80

60

E g

40

Z

20 0

65-70

71-75

76-80

AGE

81-85

(years

86%

91- 95

1

Figure I Age distribution of our operated population

disorders, side of hermatlon, primary or recurrent hermatlon, elective or emergent operation, type of anesthesia, mcarceratlon or strangulation, type of repair, morbidity and mortality, and length of hospital stay (Table I) Statwtlcal analysw Utlhzmg the chl-square test, our rates of systemic comphcatlons and mortality were compared with those of the recently reported series dealing with hermorrhaphy on this age group [6-L?] The same statistical method was used to compare our present rate of emergent operations with that of three consecutive years before the mstltutlon of this program (1977 to 1979 versus 1980 to 1983) Results

In a 4 year period, a total of 722 hermorrhaphles were performed m patients of all ages Of these, 241 operations were carried out on 226 patients over 65 years of age Then mean age was 715 years (Figure 1) Imtlally, we evaluated 237 patients over 65 years old, of these, 220 were referred to consultative services for optimal treatment of then systemic dlsorders The other 17 were found to be free of slgmflcant contramdlcatlons In 11 patients, hermorrhaphy was postponed because the severity of their systemic condltlons precluded procedures even under local anesthesia Of these, mcarceratlon eventually occurred m two, necessltatmg emergency procedures which both survived Of the remaining nme patients, four were lost to follow-up and the other five died from the progression of their underlying diseases The age dlstrlbutlon 1s depicted m Figure 1 Table II depicts the incidence of maJor systemic disorders as encountered during each specific hermorrhaphy If a patient underwent bilateral hermorrhaphles, every systemic disorder was computed twice because the operations were performed on different

The American Journal of Surgery

Herniorrhaphy

dates and both the team and the patrent had to confront it on two different occasrons In agreement with the United States’ experience, our mcommg hermated population exhrbited a 10 percent incidence of recurrent hernias previously reparred m our mstrtutlon or elsewhere As shown m Table III, our comphcatlon rate was slgmficantly better than those published m the literature (chlsquare I 0 05) Since the creation of our chmc, the number of emergent procedures performed for mcarceratlon decreased ngmficantly, from 31 of 470 total procedures to 7 of 389 total procedures (7 percent versus 2 percent, chi-square 10 05) (Figure 2) Three patrents experienced slgmficant postoperative comphcatrons, and one died One had an eprsode of testicular swelling secondary to impaired venous return which led to atrophy In two other patients, postoperative urinary retention had to be relieved by transuretheral prostatlc resection Both recovered. A man who had not been seen previously m our chmc was admitted m septic shock with a large mcarcerated mgumoscrotal herma contammg strangulated small and large bowel Immedrately postoperatively he had an episode of vomltmg followed by massive aspiration and death No patients experienced a wound mfectlon and no recurrences had been detected at last follow-up Comments This series, one of the few dealing with the results of hermorrhaphy m the elderly, suggests that hermated patients older than 65 years of age benefit from

TABLE Ill

in the Elderly

Incidence ot Systemic Coqpllcatlons’

TABLE II

Complrcabon

Number

Arterrosclerobc heart disease Hypertension Chronrc obstructrve pulmonary disease Cancer Cirrhosis Diabetes Dementra Cerebrovascular accident Peripheral arterrosclerosrs Renal Insufficiency Total

Percentage

59 40 32

52 2 165 13 2

18 16 13 12

74 66 53 49 33 33 12

a a 3 209

86 7

Seventy-five percent of patients had one systemic disorder, 50 percent had two systemrc disorders, and 15 percent had three systemic disorders l

the services of a chmc speclahzmg m their care Immediately after its creation, our herma chmc, manned by a single attending surgeon, rotatmg surgical residents, and physicmn’s asastants, attracted the referral of patients with abdommal herma to an area of concentrated care, obvlatmg their referral to the general surgical chmc where they would be treated by different surgeons As Just noted, the annual emergency rate for mcarceratlon decreased slgmficantly after the chmc’s mstitutron Thereafter our percentage of emergencies (2 9 percent) became slgmficantly smaller than those reported by other mvestlgators (Table III) [6,8,9] This extremely low rate of emergent cases may have been a ngmf-

Comparbon of Results of Hemiorrhaphy In the Elderly Nehme

Trngwald & Cooperman [ 81

Williams & Hale [ 71

Present study*

>65

>70

>60

>65

1,044

44

222

273 26

a la

ISI Patient age (yr) Elective operation Hernrorrhaphy Number Percentage Systemic complications Number Percentage Death Number Percentage Emergent operation Hernrorrhaphy Number Percentage Systemic complrcations Number Percentage Death Number Percentage

59 26 5

234

3 12

4 la

14 13

235 183

la 29

48 26

131 55 7

10 55 5

25 52

la 76

4 22 2

6 125

7 29

1 14

Our systemic complication rates were srgnrflcantly drfferent when compared with the other studres by chr-square analysis (chi-square 10 05) l

Volume 153, April 1987

399

Deysine et al

.

42 r

\

.-.

./

\

0*

4977

4978

4979

l \

4980I 4984

e-0

4982 4983

OPiNlNG OF CLINIC

HERNIA

Figure 2 Number of emergency hemlorrhaphies performed for Incarceration or strangulation before andafter the creation of the hernia clinic

1cant factor 1n reducing mortality and morbldlty rates As shown 1n Table II, the maJor1ty of our patients had a variety of systemic disorders which could have produced serious perloperatlve or postoperative problems Accordingly, our staff became sensltlve to the need of avoiding postoperative compllcatlons and requested early consultations with other departments Correct preoperative evaluation was crucial to the recovery of patients for whom the hernlorrhaphy, usually a short procedure, could precipitate an imbalance 1n organs that had already lost a significant percentage of their functional reserve In some patients, the final steps 1n the stabillzat1on of their systemic disorders were achieved as inpatients, adding days to their hospital preoperative stay We believe, however, that this policy slgnlficantly shortened their postoperative hospital requlrements In spite of the group’s high incidence of serious systemic disorders and unhealthful living habits, our population had a slgnlficantly lower comphcat1on rate than that described by others Nehme [6] reported rate8 of 26 percent and 55 7 percent for local and systemic comphcatlons, respectively, and mortality rates of 13 percent and 7 6 percent 1n elective and emergent cases W1111amsand Hale [7] and Tlngwald and Cooperman [S] presented data very similar to that of Nehme [6] (Table III) Our patients experienced a 12 percent rate of comphcatlons, conslstlng of one episode of testicular damage and two patients 1n whom post,-operative urinary retention was relieved by ureteral prostatlc resection All recovered The only death occurred 1n a 69 year old patient who was operated on as an emergency under general

390

anesthesia with small and large bowel strangulated 1n a very large lngulnoscrotal hernia He died 1mmedlately after operation from massive aspiration of fecal vomiting This patient had not previously attended our clinic Occasionally, the presence of actively progressing artenoscleroas, hepatlc dysfunction, or cancer prevented an operation because the risk of an operative death loomed larger than that of strangulation Such patients were followed 1n our clinic, where we invariably urltne88ed the progressive enlargement of their hernias Most of them died from their underlymg disorders The hernias became strangulated 1n two of these patients, requiring emergency operation under local anesthesia Both survived and were subsequently discharged Many lnvestlgators have suggested that local anesthesia 1s preferable for hernlorrhaphy, except when the patient 18a child or insane We utilized 1t 1n most of the patients with 1ngu1nal and umb111cal hernlorrhaphles and 1n some of those with ventral hernias Our educational program helped patients understand the preoperative sensations associated with local anesthesia, increasing their acceptance and facilitating the procedure In addition, the constant presence of an anestheslologlst 1n the operatmg room permitted the close monltorlng of the patient’s vital functions and the proper titration of the sedation medication, as well as constant personal reassurance for the patient This interdepartmental collaboration improved patient care and facilitated the logistic direction of the program The few patients who d1d not tolerate local anesthesia were switched to general anesthesia Whenever a sudden cardiovascular change developed 1n a patient, such as hypertension or arrhythmia during the induction of local anesthesia, the procedure was lmmedlately canceled The patient was then allowed to stabilize 1n the recovery room and was reoperated on at a later date, after repeated consultations and pharmacologic readJustment We believe that our low morbidity and mortality rates were due to a variety of factors 1) Systematlzat1on of management improved results Residents became adept not only 1n the surgical technique but, most importantly, 1n the preoperative and postoperative care of elderly patients 2) Our adherence to a strict technical protocol including the minimal ut111zat1on of reabsorptlve material, the active debrldement of seemingly devitalized tissues, and thorough wound irrigation may have been important factors 1n the virtual ellmlnatlon of wound compllcatlons 3) In order to prevent postoperative vomiting and the danger of aspiration, we d1d not give our patients anything by mouth, instead utlhzmg intravenous hydration for 24 hours after the operation The risk of atelectasls and thromboembol1sm was diminished by ambulating the patients soon after the operation

The American Journal 01 Surgery

Herniorrhaphy n the Elderly

Although most series dealing with hermorrhaphy m the elderly make no mention of such comphcatlons, our population exhibited no recurrences durmg our albeit short-term follow-up It is possible that their low level of physical activity plays an important role m preventing such comphcatlons We conclude that hermorrhaphy can be performed on elderly patients with very low mortahty and morbidity rates as long as the personnel m charge of their care are aware of areas of potential comphcatlons and address them aggressively, early, and with a sense of urgency These results support the thesis that hermorrhaphy m the elderly should become the obJective of a hospital team created to coordmate the optimization of the patient’s organ reserve, standardize technique, and provide close postoperative momtoring Summary Elective abdominal hermorrhaphy carries morbidity and mortahty rates of 26 percent and 15 percent, respectively, m patients over 65 years of age. These figures climb to 55 percent and 15 percent during emergent surgery Our purpose was to mvestlgate if standardization of treatment could improve such results Our program stressed centralization of care m a hernia clmlc, early operation of patients at risk of mcarceratlon, optimization of underlying systemic disorders by consultative services, operation under local anesthesia, preoperative, operative, and postoperative protocol, and contmuity of care by senior personnel Over a 4 year period, we have performed 241 abdominal hermor-

Volume 153, April 1987

rhaphies m patients over 65 years of age (median age 715 years old) who exhibited an 84 percent mcldence of slgmficant preoperative systemic dlsorders Since the mceptlon of our program, our rate of emergent operation has decreased slgmficantly from 7 percent to 2 percent (chl-square 10 05) Our rate of systemic complications after elective operation was 12 percent and 0 after emergent operation. These data are statistically better than those reported m the literature (chl-square 10 05) These results suggest that the creation of a hernia chmc slgmficantly improves the care of herniated patients References 1 Vayda E, Mmdell WR, Rutkow IM A decade of surgery in Canada, England and Wales and tie Unrted States Arch Surg 1982 117 846-53 2 Horgan C, Taylor A, Wrlensky G Agrng veterans WIII they overwhelm the VA medrcal care system? Health Aff (MIwood) 1983,2 77-86 3 Sommers AR Long term care for the elderly and disabled, a new health priority New Engl J Med 1982, 307 221-6 4 Steel K, German PM, Crescenzi C. Anderson J latrogenlc illness on a general medrcal service at a university hospital N Engl J Med 1984,304 638-42 5 Jahnrgen 0, Hannon C, Laxson L, LaForce FM latrogenrc drsease in hosprtalrzed elderly veterans J Am Genatr Sot 1983,30 387-90 6 Nehme AE Groin hernra in elderly patients Am J Surg 1983, 146 257-60 7 Wrlliams JS, Hale HW The advisability of rngurnal herniorrhaphy in the elderly Surg Gynecol Obstet 1966, 122 lOO4 8 Trngwald GR, Cooperman M lnguinal and femoral hernia repair in geriatric patients Surg Gynecol Obstet 1982, 154 704-6

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