Page 70 - International guidelines for groin hernia management

Hernia

Evidence in literature surgical mortality increased 8.7% per 1-year age increase.
As an example, the calculated mortality risk for a 25-year-
A 2011 systematic review summarized mortality rates old male operated on for primary IH was 0.0065% and was
following elective and emergent IH repairs. The review postulated to be 125 times higher (0.81%) for a 65-year-old
encompassed 85,585 operations reported in 14 publications male undergoing operation for a recurrent IH with
over a 50-year period. The average reported mortality was obstruction. These calculations were found to be in
0.5% (range 0–2%) representing 470 patients. 136 agreement with outcomes seen in national hernia
An average mortality rate of 5.8% was found for registries. 141
emergent IH repair. Of 7404 emergent hernia operations From 1992 to 2005, data on 107,838 groin hernias were
reported in 18 publications during the same study period, entered in the Swedish Hernia Register. 32 Five thousand
22% were performed for femoral hernias and bowel two hundred and eighty of 104,911 (5.1%) IHs were treated
resections were done in 14% of the emergent hernia emergently compared with 1068 of 2927 (36.5%) femoral
operations. Factors associated with a statistically signifi- hernias. Twenty-two percent of the operations in women
cant increase in morbidity and mortality included: age over were for femoral hernia versus 1% in men. In both men and
49 years, delayed presentation to hospital, presence of a women, operation for femoral hernia (including emergent
femoral hernia, non-viable bowel, and ASA class above operation) was associated with a sevenfold mortality
two. 136 increase. Mortality for elective hernia repair was not higher
The INCA Trialists’ Collaboration published a meta- than the background mortality recorded in the national
analysis in 2011 on which approach—operation or obser- Cause-of-Death register, but increased sevenfold after
vation—would be best for asymptomatic or mildly symp- emergent operations and 20-fold with bowel resec-
tomatic male IH patients. A literature review and a Markov tion. Seventeen percent of women and 5.1% of men
model of relevant parameters like mortality associated with underwent emergent surgery. The overall standardized
elective or emergent hernia repair were incorporated into mortality ratio (observed/expected death in the population)
the meta-analysis. The mortality associated with elective within 30 days following hernia repair was 1.4 in men and
IH was 0.2% (596 of 242,207 patients). The mortality 4.2 in women. In elective surgery, this ratio was lower,
associated with emergent IH repair (excluding femoral 0.67 and 0.85, respectively. Cardiovascular disease
hernias) was 4% (715 of 18,092 patients). 137 accounted for 59% of the observed mortality in elective
A 1996 study analyzed data from 30,675 IH operations cases. 32
performed on patients of all ages, during the period Another Swedish Hernia Register study looked at 3980
1976–1986 in a geographically defined population. The patients operated on for femoral hernia. Women were at
study included data on the nine percent of patients who increased risk for emergent operation, 40.6 versus 28.1% in
underwent an emergent operation. Of note, emergent men. Emergent femoral hernia operation was associated
operations were much more common in patients over with a tenfold increase in mortality. The mortality risk of
50 years of age. On average, emergent operation patients elective femoral hernia operation did not exceed that of the
were older than elective operation patients and had a sig- general population. 22
nificantly greater postoperative mortality rate. No deaths A registry study of patients who died within 30 days of
138 135
were reported in day surgery patients. surgery examined causes of treatment delay and death.
Another study on elective hernia repair in the elderly In 37% of patients with signs of bowel obstruction, docu-
found a tenfold increase in mortality for non-agenarians mentation was missing on physical examination of the
versus octogenarians (3 versus 0.3%, respectively). 139 groin. These patients had an increased time-to-surgery
A Scottish audit of mortality following hernia surgery when compared with patients with a palpable lump.
reported 91 fatalities (18 elective) in 28,760 inguinal and Women and those with femoral hernias were significantly
femoral hernia operations on a surgical ward or within less likely to have a groin examination done.
30 days of surgery during the period 1994–1997. Mortality A cohort study from the Danish Hernia Database of
was 0.8% following IH repair, and 3.1% following femoral 29,033 elective groin hernia repairs analyzed: 30-day
hernia repair. Cardiopulmonary and neurological diseases postoperative morbidity, prolonged length of stay, and
were the principle comorbidities in the patient death. Morbidity increased with age. Regional anesthesia
140
population. was associated with an increased risk of complications.
A cost-utility analysis of treatment options for IH done Thirty-day mortality following elective hernia repair was
at Massachusetts General Hospital and Harvard Medical 0.12%. 142 Another Danish multicenter study of 57,709 day
School analyzed data from over 1.5 million adult patients. surgery procedures reported no day-surgery-related
Data from national databases and 51 RCTs were analyzed. deaths. 143
A mathematical model derived from the data predicted that

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