Open Access | Research Article
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
A clinico-epidemiological study of complicated external hernia
*Corresponding author: Lalit Kishore
Mailing address: Department of Surgery, Dr. Sampurnanand
medical college, Jodhpur, Rajasthan, India.
Email: drlalitkishore@gmail.com
Received: 01 September 2020 / Accepted: 23 November 2020
DOI: 10.31491/CSRC.2020.12.062
Abstract
Background: Abdominal wall hernias are among the most commonly encountered surgical problem. Irreducibility, obstruction, and strangulation are its commonest complications which usually presents as acute emergencies. Emergency repair of complicated hernias is associated with poor prognosis and a high rate of postoperative complications even with better care, improved anesthetic management and advanced surgical
techniques.
Methods: The aim of the study was to evaluate incidence, morbidity, and mortality in complicated hernia and
to compare with it non-complicated hernia. This study was conducted in the Department of General Surgery,
Dr. Sampurnanand Medical College, Jodhpur, Rajasthan, from July 2018 to December 2019 on twenty-eight
patients of complicated hernia and compared with similar no of uncomplicated hernia patients.
Results: The mean age of the patients was 52 years with male to female ratio of 11:3 in the complicated external hernia group. The majority of the patient (60.7%) underwent herniorrhaphy, followed by hernioplasty
(14.3%). Most of the patients (89.2%) survived without any post-operative morbidity, 7.1% of them developing wound sepsis while 3.5% of patients died after surgery due to septic shock.
Conclusion: Complicated external hernias occur in all age groups but are more common in older age and show preponderance in males. All patients present with irreducible swelling with no cough impulse. The indirect inguinal hernia is the most common type and herniorrhaphy is the most preferred operative procedure in the complicated hernia. Wound sepsis was the most common complication. Morbidity and mortality may be attenuated with proper surgical and post-operative management.
Keywords
Abdominal wall hernia; complicated hernia; herniorrhaphy; hernia
Introduction
Abdominal wall hernias are among the most common
of all surgical problems. Hernias are relatively innocuous diseases in itself and they commonly present as
uncomplicated reducible swellings and can be operated in an elective setting with negligible morbidity and
mortality [1]. PWhen they complicate as irreducibility,
obstruction and strangulation, and it compels the patient to present as an emergency [2, 3], and management
Research Article of these cases are associated with high morbidity and
mortality in both developing and developed countries
[4, 5]. A hernia is termed as complicated when it becomes irreducible, incarcerated, strangulated or recurrent. Complication becomes grievous when the blood supply of its contents is seriously impaired, rendering gangrene imminent.
The reason for the hernia to go into complications is
because of the hesitancy of the patient to come out
with complaints and refusal for surgery in an early
stage. The complications make an easily treatable condition into a life-threatening one. Early diagnosis and
elective repair is a safe and effective strategy for patients of all ages that avoid incarceration, strangulation
and their complications [6]. Although we have made great progress in treating hernia the management of its complications has progressed only a little. The aim of the study was to evaluate incidence, morbidity and mortality in complicated hernia and to compare with it non-complicated hernia.
Material and Methods
This observational comparative study was conducted
in the Department of General Surgery, Dr. S N Medical
College, Jodhpur, Rajasthan from July 2018 to December 2019. All patients with groin, epigastric, umbilical/
Para-umbilical, lumbar, or any type of hernia with age
more than 16 years presented with pain with irreducibility, features s/o intestinal obstruction-like Pain
abdomen, abdominal distension, vomiting, constipation/obstipation, hypotension, tachycardia shock and
features s/o peritonitis were included in the study. All
patients studied in reference to symptoms, duration of
symptoms, type of hernia, management, morbidity and
mortality, and hospital stay. Patients were divided into
Group A (complicated) and Group B (uncomplicated).
Patients below the age of 16 years and who refused to
give consent were excluded from the study.
All patients were subjected to basic hematological &
necessary radiological investigations (USG), chest X-ray, and abdomen X-ray erect view. All symptomatic
patients were assessed for emergency surgery and
written informed consent was obtained. Under general
or spinal anesthesia, transverse/inguinal/midline incision was made according to clinical presentation. Intraoperative finding like a site of constriction, contents
of the sac, viability of contents was noted then contents
were reduced, the sac is ligated and hernioplasty was
performed. If the content was gangrenous intestine,
Resection and anastomosis were done followed by
Herniorapphy (modified bassini repair). Postoperatively managed according to standard protocol. Statistical analysis was performed using Chi-square. P < 0.05
was considered statistically significant.
Results
Twenty-eight patients were admitted from July 2018
to December 2019 with the complicated external hernia and were considered as group A. Total of 250 cases
of uncomplicated external hernia were admitted from
July 2018 to December 2019 out of the 28 patients
were randomly selected for study and considered as
group B.
Complicated external hernias were observed between
66 to 75 years (35.7%). Although complication was reported in as young as 22 years to 85 years with a mean age of 52 years. In group B, patients were in the age
range of 26-85 years with a mean age of 55 years, but
here also the majority of patients (28.6%) belonged to
the 66-75 years age group. On applying a Chi-square
test, P = 0.744, statistically not significant(Chi-sqare =
3.498, df = 6, P = 0.744.), shown in table 1.
Discussion
The external abdominal wall hernia is most commonly
encountered in surgical practices. When they presented as complicated hernia, the prognosis is poor even
after standard protocol management. In the present
study, complicated external hernias were observed
between 66 to 75 years (35.7%). Although complication was reported in as young as 22 years to 85 years
with a mean age of 52 years. In group B, patients were in the age range of 26-85 years with a mean age of 55
years. Kulah et al. [7] observed the mean age for complicated external hernia was 55 years, with 42.9% of patients aged more than 60 years. Alavarez et al. [8] also
observed that 66.7% of cases were more than 65 years
of age.Hence, it is evident from the present study the
incidence of complications increases with advancing
age. In the present study, the incidence of complicated
external hernia was more in males (78.6%), with male
to female ratio of 11:3, indicating a high incidence of
complicated external hernia among male patients. Similar male predominance was observed in other studies
by Kulah et al. [7] (65%), Alvarez et al. [8] (52.4%), Hariprasad et al. [9] (95%), and Prakash et al. [10] (94.3%).
In the present study, 57.1% of patients had indirect
inguinal hernias. Among them, right-sided indirect inguinal hernias were predominant (32.1%). Epigastric
(17.9%), para-umbilical (14.3%) and umbilical hernias
(10.7%) were also observed as complicated hernia.
In the present study, 64.3% of patients had irreducible
hernia, 28.9% had obstructed hernia and 7.1% had
strangulated hernia depicted in Figure 1. Hariprasad et
al. [9] observed incarceration in 70% of cases and strangulation in 30% of cases. Prakash [10] observed 23% of
patients of irreducible hernia, 63% of obstructed hernia, and 14% of strangulated hernia. Kappikeri et al.
[11] observed 44% of cases of irreducible hernia, 36%
of obstructed hernia, and 20% of cases of strangulated
hernia. Kulah et al. [7] observed 41.6% of patients with
irreducible hernia, 19.7% with obstructed hernia, and
38.7% with strangulated hernia.
In our study, 57.1% of patients had indirect complicated inguinal hernia where the deep ring was the commonest site for constriction of the hernia, followed by
epigastric 17.9%, para-umbilical 14.3% and umbilical
hernia 10.7%. Rectus sheath was the commonest site of obstruction in epigastric, umbilical, and paraumbilical hernia. Similarly, Prakash et al. [10] reported deep
ring as the commonest site of constriction (71.4%) in
groin hernia. Hariprasad et al. [9] also concluded that
the site of obstruction in most patients was seen at the
deep inguinal ring (92.5%), whereas in the case of direct inguinal hernia obstruction was at the neck of the
sac.
Omentum alone was the commonest content of the
complicated hernial sac (46.4%), followed by omentum
with bowel loop (32.1%), small bowel only (10.7%),
colon only (10.7%) and omentum with colon (14.3%).
Hariprasad et al. [9] found that only omentum as the viable content in most (32.5%) cases, followed by omentum and small bowel in 30% cases, small bowel alone
and sigmoid colon one case each, and large bowel with
omentum in 10% cases. Andrew et al. [12] reported the
small bowel as the commonest content of incarcerated
inguinal hernia; followed by omentum. In the study of
Kulah et al. [7] also, the contents of the hernial sac were
only ileum in 39.7% patients, only omentum in 27.1%
patients, ileum with omentum in 10.9% patients, and
only colon in 28.5% patients. Alvarez et al. [8] found
the only omentum as the content of the hernial sac in
37.4% patients, only ileum in 27.2% patients, ileum
with omentum in 10.8%, only colon in 4.1%, colon
with omentum is 1.4%. Prakash et al. [10] found small
bowel as the commonest content (74.3%) followed by
omentum (25.7%). Kappikeri et al. [11] observed the
small intestine to be the commonest content of the
hernia sac (54%), followed by the omentum (18%).
In the control group, most of the patients (92.9%) had
omentum as the content of the hernial sac, followed by
pre-peritoneal fat in epigastric hernia (7.1%).
In the present study, only 7.1% had gangrenous content, the rest of the patients (92.9%) had viable content depicted in Figure 2. Kappikeri et al. [11] observed
the non-viable content in 12% of patients. Alvarez et
al. [8] observed that 12.9% of patients had gangrenous
content in the sac. Hariprasad et al. [9] also observed
the non-viable bowel content in 22.5% of cases. In the
control group, all patients (100%) had viable content
in their sacs.
Most of the patients (60.7%) underwent herniorrhaphy, followed by hernioplasty (14.3%), exploratory
laparotomy with repair (14.3%), and resection of gangrenous segment with end to end anastomosis with
herniorrhaphy (10.7%) shown in Table 3. Hariprasad et al. [9] observed that herniorrhaphy was done in all
cases (100%) for closure, and modified Bassini’s repair was performed in inguinal hernias. Laparotomy and
repair was done in 25% of cases. Prakash et al. [10] also reported that the optimum procedure for hernia repair
was herniorrhaphy which was done in 82.8% of cases
whereas herniorrhaphy along with resection anastomosis was done in 8.6% cases and herniorrhaphy
along with the repair was done in 8.6% of cases. Kappikeri et al. [11] concluded that herniorrhaphy was the
commonest (74%) surgical procedure performed for
complicated inguinal hernias, while 14% of patients
underwent hernioplasty, 12% of patients of strangulation with non-viable bowel required resection and
anastomosis followed by herniorrhaphy. In the control
group, most patients (92.9%) underwent mesh hernioplasty, while 7.1% underwent herniorrhaphy.
In our study, 89.2% survived without any post-operative morbidity, while only 7.1% of them developing
wound sepsis and 3.5% of patients died after surgery
due to septic shock depicted in Table 4.
Haapaniemi et al. [13] observed that 5.5% of cases died,
3% of them due to associated medical illness and 2.5%
from septicemia. He found that mortality increase in
emergency repair of hernia and in patients who had a
bowel resection. Hariprasad et al. [9] also observed that
the common postoperative complication was wound
infection (22.5%) and scrotal seroma (17.5%) followed
by scrotal hematoma (7.5%). Septicemia, multi-organ
failure, and death occurred in 2.5% of cases. Prakash
et al. [10] observed wound infection as a complication
in 11.5% of patients. Kappikeri et al. [11] observed 6%
mortality among the cases, 2% of patients due to ischemic heart disease, while 4% of cases expired following bowel resection in a strangulated hernia. In Group
B, none of the patients (0%) had encountered any
post-operative complication and all patients (100%) survived after surgery.
The duration of most operated patients (50%) was 4
to 7 days in hospital, while 7.1% patients required a
hospital stay for more than 15 days, and another 7.1%
patients required 1-3 days of stay shown in Table 5.
In the study of Kappikeri et al. [11], most of the patients
(46%) were discharged within 11-15 days. In the control group, most patients (92.9%) spent 4 to 7 days in
hospital, with 7.1% patients required between 8 to 10
days of stay. All patients were followed up to 6 months,
however, no complications were noted.
Conclusion
Complicated external hernias occur in all age groups but are more common in older age and show preponderance in males. All patients present with irreducible swelling with no cough impulse. The indirect inguinal hernia is the commonest type and right-sided inguinal hernia predominated as compared with left. Herniorrhaphy was the most preferred operative procedure in complicated hernia. Morbidity and mortality may be attenuated with proper surgical and post-operative management.
Declarations
Financial support
No financial assistance was taken.
Conflict of interest
The author declares that there is no conflict of interest.
Ethical disclosure
Ethical committee approval was obtained prior to study.
References
1. Zinner, M.J., Ashley, S.W., Hernias. (2007)Maingot’s Abdominal Operations. Journal of the American College of
Surgeons,12th Ed: 103-140.
2. Martínez-Serrano, M. Á., Pereira, J. A., Sancho, J. J.,
López-Cano, M., Bombuy, E., Hidalgo, J., & Study Group
of Abdominal Hernia Surgery of the Catalan Society of
Surgery. (2010). Risk of death after emergency repair of
abdominal wall hernias. Still waiting for improvement.
Langenbeck’s Archives of Surgery, 395(5), 551-556.
3. Derici, H., Unalp, H. R., Bozdag, A. D., Nazli, O., Tansug,
T., & Kamer, E. (2007). Factors affecting morbidity and
mortality in incarcerated abdominal wall hernias. Hernia, 11(4), 341-346.
4. Tsumura, H., Ichikawa, T., Hiyama, E., Murakami, Y., &
Sueda, T. (2004). Systemic inflammatory response syndrome (SIRS) as a predictor of strangulated small bowel
obstruction. Hepato-gastroenterology, 51(59), 1393-
1396.
5. Jancelewicz, T., Vu, L. T., Shawo, A. E., Yeh, B., Gasper, W.
J., & Harris, H. W. (2009). Predicting strangulated small
bowel obstruction: an old problem revisited. Journal of
Gastrointestinal Surgery, 13(1), 93-99.
6. Rai, S., Chandra, S. S., & Smile, S. R. (1998). A study of the
risk of strangulation and obstruction in groin hernias.
Australian and New Zealand journal of surgery, 68(9),
650-654.
7. Kulah, B., Kulacoglu, I. H., Oruc, M. T., Duzgun, A. P., Moran, M., Ozmen, M. M., & Coskun, F. (2001). Presentation
and outcome of incarcerated external hernias in adults.
The American journal of surgery, 181(2), 101-104.
8. Alvarez, J. A., Baldonedo, R. F., Bear, I. G., Solis, J. A. S., Alvarez, P., & Jorge, J. I. (2004). Incarcerated groin hernias in
adults: presentation and outcome. Hernia, 8(2), 121-126.
9. Hariprasad, S., & Srinivas, T. (2017). Clinical study on
complicated presentations of groin hernias. Int J Res
Med Sci, 5(8), 3303-8.
10. Prakash, S., Samraj, A., & Muthukumaran, G. (2017).
A study on groin hernias presenting as acute surgical
emergencies in adults. International Surgery Journal,
4(12), 3866-3872.
11. Kappikeri, V., & Kalaskar, N. N. (2019). A clinical study
of complicated inguinal hernias. International Surgery
Journal, 6(5), 1608-1612.
12. Andrews, N. J. (1981). Presentation and outcome of
strangulated external hernia in a district general hospital. British Journal of Surgery, 68(5), 329-332.
13. Haapaniemi, S., Sandblom, G., & Nilsson, E. (1999). Mortality after elective and emergency surgery for inguinal
and femoral hernia. Hernia, 3(4), 205-208.