Kohga2220

ANZJSurg.com
Emergency surgery versus elective surgery after reduction for patients
with incarcerated groin hernias
Atsushi Kohga , Akihiro Kawabe, Kiyoshige Yajima, Takuya Okumura, Kimihiro Yamashita,
Jun Isogaki and Kenji Suzuki
Division of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan
Key words
elective surgery, emergency surgery, incarcerated
hernia, post-operative complications, reduction.
Correspondence
Dr Atsushi Kohga, Division of Surgery, Fujinomiya
City General Hospital, 3-1, Nishiki-cho, Fujinomiya,
Shizuoka 4180076, Japan.
Email: [email protected]
A. Kohga MD; A. Kawabe MD; K. Yajima MD;
T. Okumura MD; K. Yamashita MD; J. Isogaki
MD; K. Suzuki MD.
Accepted for publication 13 March 2020.
doi: 10.1111/ans.15877
Abstract
Background: The feasibility and potential advantages of elective surgery after manual
reduction of incarcerated hernia (IH) have not been investigated in detail. Therefore, the aim
of this retrospective study was to compare perioperative outcomes of emergency surgery to
those of elective surgery after reduction of IH.
Methods: A total of 112 patients were preoperatively diagnosed with IH between January
2010 and April 2019. Patients were divided into an emergency group (76 patients underwent
emergency surgery: 21 patients received intestinal resection and 55 patients did not) and a
reduction group (36 patients underwent elective surgery after reduction and none required
intestinal resection). The outcomes between the groups were com- pared. A subgroup
analysis was also performed on the patients who did not require intes- tinal resection.
Results: In patients who did not undergo intestinal resection, the post-operative length of stay
was significantly shorter in the reduction group than in the emergency group (8.0 ver- sus 4.3
days, P < 0.001). The percentage of mesh prosthesis cases was significantly higher in the
reduction group (74.4% versus 100%, P = 0.001). The incidence of post-operative
complications was significantly lower in the reduction group (45.4% versus 13.8%, P
< 0.001). In all 112 patients, femoral hernia (P = 0.013, odds ratio = 4.76) and emergency
surgery (P = 0.008, odds ratio = 4.49) were found to be independent risk factors for developing post-operative complications.
Conclusions: Elective surgery after reduction showed more favourable outcomes in selected
patients. Moreover, emergency surgery was an independent predictor for post- operative
complications.
Introduction
Incarcerated groin hernia is one of the most common surgical
emergencies. Patients with a delayed diagnosis often develop
conditions that require intestinal resection, resulting in a high
morbidity rate.1,2 Conventionally, incarcerated groin hernia is
treated by emergency surgery when intestinal strangulation is
suspected,3 while some patients are treated by elective surgery after
manual reduction.4 However, it has not been clear who is a candidate
for reduction and whether the reduction yields a supe- rior outcome
for the patient. Here, we compared the perioperative outcomes of
patients with incarcerated groin hernias who under- went emergency
surgery and those who underwent elective sur- gery after manual
reduction.
© 2020 Royal Australasian College of Surgeons
Methods
Study patients
Between January 2010 and April 2019, 76 patients preoperatively
diagnosed with inguinal or femoral hernia with intestinal incarceration underwent emergency surgery, while another 36 patients
underwent elective surgery after manual reduction at Fujinomiya
City General Hospital. Patients who were diagnosed with incarcerated obturator hernia, incarcerated incisional hernia or incarcerated
umbilical hernia were all excluded from this study. Patients who
developed an incarcerated hernia (IH) of the omentum were also
excluded. A total of 112 patients were included in this study and
were divided into an emergency group (n = 76) and a reduction
group (n = 36). Patients who were preoperatively considered to
ANZ J Surg (2020)
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Kohga et al.
have irreversible ischaemic changes in the incarcerated intestine
underwent emergency surgery. Otherwise, the choice of procedure,
emergency operation or reduction, was decided at the surgeon’s discretion. Therefore, patients with severe conditions were generally
allocated to emergency surgery in this retrospective study. We
accessed patient records so that we could review and compare the
clinical variables and outcomes between these two groups.
In addition, we performed subgroup analyses on the patients
without intestinal resection (55 patients in the emergency group
versus 36 patients in the reduction group) to accurately assess the
outcomes of each procedure that might be impacted by intestinal
resection.
The study protocol was approved by the institutional review board
of Fujinomiya City General Hospital. Informed consent was waived
for this retrospective study.
Clinical variables assessed
We reviewed the following clinical variables: sex, age, American
Society of Anesthesiologists physical status, presence of comorbidities, incarcerated side and site, previous history of hernia repair
on the ipsilateral side and time from onset to surgery. We also
reviewed the following perioperative variables: operation time, postoperative length of stay, total length of stay associated with the
incarceration, time to feeding after surgery, type of anaesthesia,
whether intestinal resection was performed, whether a mesh prosthesis was used, whether repair of a hernia on the contralateral side
was performed, post-operative complications, mortality and
readmission. Complications were classified according to the 2004
grading system of Dindo et al.,5 and complications of grade II or
more were considered clinically significant.
Statistical analyses
Study variables are shown as the number and percentage of patients,
percentage of patients or mean values. Between-group dif- ferences
in nominal variables were analysed by Pearson’s chi- squared test,
and differences in continuous variables were analysed by the Mann–
Whitney U-test. Multivariable logistic regression analysis was
performed to determine independent predictors of out- comes. All
statistical analyses were performed with the Statistical Package for
the Social Sciences, version 11.5J for Windows
10 (SPSS, Chicago, IL, USA). A P-value of <0.05 was considered
significant.
Results
Patient characteristics
The percentage of females was significantly lower in the reduction
group than in the emergency group (47.3% versus 27.7%, P
= 0.049). The mean age and percentage of patients with an American Society of Anesthesiologists physical status score of three were
not different between the groups. The presence of comorbidities,
including diabetes mellitus, chronic obstructive pulmonary disease
and coronary heart disease/chronic heart failure, was not different
between the groups. The ratio of the hernia side, right to left, was
also not different. The percentage of femoral hernias was significantly lower in the reduction group than in the emergency group
(59.2% versus 27.7%, P = 0.001). However, the percentage of
recurrent hernias was not different. The time from onset to surgery
was significantly longer in the reduction group than in the emergency group (2.1 versus 15.8 days, P < 0.001) (Table 1).
Perioperative outcomes
The operation time was not significantly different between the
groups. The post-operative length of stay was significantly shorter in
the reduction group than in the emergency group (10.6 versus
4.3 days, P < 0.001), while the total length of stay was not different. The time to feeding after surgery was significantly shorter in the
reduction group than in the emergency group (2.8 versus
0.6 days, P < 0.001). The percentage of cases with local, spinal or
epidural anaesthesia was significantly greater in the reduction group
than in the emergency group (11.8% versus 41.6%, P < 0.001).
Intestinal resection was required for 21 patients in the emergency
group, while no patients in the reduction group required this procedure (P < 0.001). The percentage of cases with mesh prosthesis use
was significantly higher in the reduction group than in the emergency group (55.2% versus 100%, P < 0.001). Laparoscopic surgery was performed in three patients in the emergency group, while
this surgery was performed in 15 patients in the reduction group (P
< 0.001). The percentage of cases with simultaneous repair of the
contralateral side was not different (Table 2).
Table 1 Results of univariate analyses of preoperative clinical variables in the emergency group and reduction group
Sex ratio (male/female)
Age (years), mean
ASA-PS (class 1 or 2/3)
Comorbidities
Diabetes mellitus
COPD
Coronary heart disease or chronic heart failure
Incarcerated side (left/right)
Inguinal/femoral hernia
Recurrent hernia
Time from onset to surgery (days), mean
Emergency group (n = 76)
Reduction group (n = 36)
P-value
40/36
77.4 T 11.1
63/13
26/10
77.5 T 9.4
31/5
0.049
0.064
0.665
9 (11.8%)
5 (6.5%)
9 (11.8%)
32/44
31/45
5 (6.5%)
2.1 T 2.7
5 (15.1%)
3 (8.3%)
2 (5.5%)
9/27
26/10
1 (2.7%)
15.8 T 25.6
0.759
0.736
0.296
0.079
0.001
0.404
<0.001
ASA-PS, American Society of Anesthesiologists physical status; COPD, chronic obstructive pulmonary disease.
© 2020 Royal Australasian College of Surgeons
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Reduction for incarcerated groin hernia
Table 2 Results of univariate analyses of surgical outcomes between the emergency group and reduction group
Emergency group (n = 76)
Reduction group (n = 36)
P-value
99.1 T 45.8
10.6 T 9.2
11.7 T 9.2
2.8 T 2.0
100.7 T 38.2
4.3 T 4.7
9.0 T 6.9
0.6 T 0.1
0.551
Operation time (min), mean
Post-operative length of stay (days), mean
Total length of stay (days), mean
Time to feeding (days), mean
Local, spinal or epidural anaesthesia
Intestinal resection
Without mesh prosthesis
Laparoscopic surgery
Repairing of the contralateral side
Post-operative complications† (grade II or more)
Paralytic ileus (grade II or more)
Post-operative complications (grade III or more)
Mortality
0.033
0.194
0.936
0.326
0.964
Post-operative complications in the emergency group included the following: aspiration pneumonia (n = 2 grade V, n = 1 grade II), dysphagia (n = 3 grade IVa,
n = 1 grade II), wound infection (n = 1 grade IIIa), paralytic ileus (n = 32 grade II), ischaemic colitis (n = 1 grade II), persistent inflammatory reaction (n = 2 grade II),
persistent fever (n = 1 grade II) and cholecystitis (n = 1 grade II), while those in the reduction group included pleural effusion (n = 1 grade IIIa), intestinal stenosis
(n = 1 grade IIIb), haematoma (n = 1 grade IIIa), paralytic ileus (n = 1 grade II) and bronchitis (n = 1 grade II). †Complications regarded as grade II or higher
according to the Clavien–Dindo classification. ‡The reason for readmission was surgery of contralateral side (n = 1), wound infection (n = 1) and intestinal stenosis (n = 1).
Table 3 Results of univariate analyses of preoperative clinical variables in the emergency group and reduction group in the patients without intestinal
resection
Emergency group (n = 55)
Reduction group (n = 36)
36/19
75.4 T 11.1
46/9
26/10
77.5 T 9.4
31/5
0.498
0.452
0.749
8 (14.5%)
3 (5.4%)
6 (10.9%)
22/33
30/25
5 (9.0%)
1.8 T 2.7
5 (15.1%)
3 (8.3%)
2 (5.5%)
9/27
26/10
1 (2.7%)
15.8 T 25.6
0.930
0.588
0.377
0.139
0.090
0.235
<0.001
Sex ratio (male/female)
Age (years), mean
ASA-PS (class 1 or 2/3)
Comorbidities
Diabetes mellitus
COPD
Coronary heart disease or chronic heart failure
Incarcerated side (left/right)
Inguinal/femoral hernia
Recurrent hernia
Time from onset to surgery (days), mean
P-value
ASA-PS, American Society of Anesthesiologists physical status; COPD, chronic obstructive pulmonary disease.
The incidence of post-operative complications of grade II or
higher was significantly lower in the reduction group than in the
emergency group (56.5% versus 13.8%, P < 0.001). Among these
cases, the incidence of paralytic ileus was significantly lower in the
reduction group than in the emergency group (42.1% versus 2.7%, P
< 0.001). However, the incidence of post-operative complications of
grade III or higher was not different. Two patients in the emer- gency
group died, and the cause was aspiration pneumonia (n = 2).
Readmission was required for two patients in the emergency group
and one patient in the reduction group. The reasons for readmission
were wound infection (n = 1), surgery of the contralateral side
(n
= 1) and intestinal stenosis (n = 1).
No recurrence of hernia occurred in these 112 patients.
Subgroup analysis: comparing patients who did
not undergo intestinal resection
Among patients who did not undergo intestinal resection, the preoperative clinical variables were not different except for time from
© 2020 Royal Australasian College of Surgeons
onset to surgery (1.8 versus 15.8 days, P < 0.001). Regarding surgical outcomes, the post-operative length of stay was significantly
shorter in the reduction group than in the emergency group (8.0
versus 4.3 days, P < 0.001). The time to feeding after surgery was
also significantly shorter in the reduction group than in the emergency group (1.1 versus 0.6 days, P < 0.001). The percentage of
local, spinal or epidural anaesthesia cases was significantly higher
in the reduction group than in the emergency group (14.5% versus
41.6%, P = 0.003). The percentage of patients receiving mesh prostheses was also significantly higher in the reduction group than in
the emergency group (74.4% versus 100%, P = 0.001) (Tables 3,4).
The incidence of post-operative complications of grade II or
higher was significantly lower in the reduction group than in the
emergency group (45.4% versus 13.8%, P < 0.001). Among these
cases, the incidence of paralytic ileus was significantly lower in the
reduction group than in the emergency group (34.5% versus 2.7%,
P < 0.001). In contrast, the incidence of post-operative complications of grade III or higher and the mortality and readmission rates
were not different.
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Kohga et al.
Table 4 Results of univariate analyses of surgical outcomes between the emergency group and reduction group in the patients without intestinal resection
Operation time (min), mean
Post-operative length of stay (days), mean
Total length of stay (days), mean
Time to feeding (days), mean
Local, spinal or epidural anaesthesia
Without mesh prosthesis
Laparoscopic surgery
Repairing of the contralateral side
Post-operative complications† (grade II or more)
Paralytic ileus (grade II or more)
Post-operative complications(grade III or more)
Mortality
Emergency group (n = 55)
Reduction group (n = 36)
P-value
87.0 T 33.0
8.0 T 6.5
9.1 T 6.5
1.1 T 0.1
100.7 T 38.2
4.3 T 4.7
9.0 T 6.9
0.6 T 0.1
0.054
0.450
0.003
0.001
0.328
0.001
0.588
0.247
0.822
Post-operative complications in the emergency group included the following: aspiration pneumonia (n = 2 grade V, n = 1 grade II), wound infection (n = 1 grade
IIIa), paralytic ileus (n = 19 grade II), ischaemic colitis (n = 1 grade II), persistent inflammatory reaction (n = 1 grade II) and persistent fever (n = 1 grade II), while
those in the reduction group included pleural effusion (n = 1 grade IIIa), intestinal stenosis (n = 1 grade IIIb), haematoma (n = 1 grade IIIa), paralytic ileus (n = 1
grade II) and bronchitis (n = 1 grade II). †Complications regarded as grade II or higher according to the Clavien–Dindo classification. ‡The reason for readmission
was surgery of contralateral side (n = 1), wound infection (n = 1) and intestinal stenosis (n = 1).
Table 5 Results of univariate and multivariate analyses of potential prognostic factors for developing post-operative complications of grade II or more
Sex
Male
Female
Age (years)
<80
≥80
ASA-PS
Class 1 or 2
Class 3
Incarcerated side
Left
Right
Femoral hernia
No
Yes
Recurrent hernia
No
Yes
Surgery
Emergency
After reduction
Intestinal resection
No
Yes
n
Complication† (n = 46)
No complication (n = 66)
66
46
22
24
44
22
57
55
23
23
34
32
94
18
37
9
57
9
41
71
15
31
26
40
57
55
13
33
44
22
106
6
43
3
63
3
76
36
41
5
35
31
91
21
30
16
61
5
P-value
Multivariate analysis
Odds ratio (95% CI)
P-value
0.046
0.257
2.051 (0.591, 7.113)
1
0.874
0.400
0.463
<0.001
0.013
1
4.769 (1.382, 16.455)
0.644
<0.001
0.008
4.492 (1.473, 13.700)
1
<0.001
0.143
1
2.555 (0.727, 8.980)
†Complications regarded as grade II or higher according to the Clavien–Dindo classification. ASA-PS, American Society of Anesthesiologists physical status; CI,
confidence interval.
Factors associated with the development of
post-operative complications
Femoral hernia (P = 0.013, odds ratio = 4.76) and emergency surgery (P = 0.008, odds ratio = 4.49) were found, by logistic regression analysis, to be independent risk factors for the development of
post-operative complications of grade II or higher (Table 5).
Discussion
Our study demonstrated that elective surgery after reduction was
significantly associated with several superior outcomes as follows:
shorter post-operative length of stay; shorter duration for starting
feeding; lower incidence of developing post-operative complications of grade II or higher; a higher percentage of local, spinal or
epidural anaesthesia cases; a higher percentage of mesh prosthesis
cases; and a higher percentage of laparoscopic surgeries. In addition, emergency surgery was found to be an independent risk factor
for developing post-operative complications of grade II or higher.
In elective surgery after reduction, surgeons can perform the
operation without handling a distended intestine. In contrast, in
emergency surgery with an anterior approach, surgeons must pull
through and handle the incarcerated intestine to check for the presence of irreversible ischaemic changes. These additional irritations
© 2020 Royal Australasian College of Surgeons
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Reduction for incarcerated groin hernia
to the incarcerated intestine are considered to be a cause of delayed
recovery of bowel movements, resulting in post-operative paralytic
ileus and longer hospital stays. Notably, in our study, two patients in
the emergency group died due to aspiration pneumonia. One was a
95-year-old female and the other was an 85-year-old male. Both
patients underwent anterior approach repair without intestinal resection. Our experiences suggest that emergency surgery for IH confers not only a high risk of developing post-operative complications
but also a risk of mortality, especially for elderly patients. In addition, elective surgery after reduction was not associated with a longer total hospital stay. This result also supports the feasibility of
elective surgery.
Another advantage of elective surgery is that surgeons can use
mesh prostheses to repair hernias without the risk of infection.
Recent reports have suggested the feasibility and safety of mesh
prosthesis use for IH repair, with a low incidence of mesh infection.6–
8 However, the incidence of wound infections in these patients is not
negligible compared with that in patients receiving elective surgery.
International guidelines published in 2018 weakly supported the use
of mesh prostheses for patients with IH.9 The minimization of the
potential risk of recurrence by using mesh pros- theses is one of the
important advantages of elective surgery.
In emergency surgery, general anaesthesia is usually selected
because of the need to handle the incarcerated intestine. In elective
surgery, it becomes easy for surgeons to select local, spinal or epidural anaesthesia instead of general anaesthesia. A recent report
demonstrated that local anaesthesia was significantly associated with
a lower incidence of post-operative complications.10 There- fore,
elective surgery after reduction may enable surgeons to avoid the
risk of developing post-operative complications in patients at high
risk during general anaesthesia.
A previous report suggested the feasibility of emergency laparoscopic surgery for IH.11–15 In addition, the 2018 International Hernia Association guidelines recommend laparoscopic inguinal
herniorrhaphy as an option for emergency cases.9 Laparoscopic surgery allows adequate observation of the incarcerated intestine. In
addition, laparoscopic surgery enables surgeons to simultaneously
check and repair contralateral side lesions.16 However, performing
emergency laparoscopic surgery for IH requires skill. Azin et al.
reported that, compared with open surgery, emergency laparoscopic
surgery was significantly associated with missed enterotomies.17
Therefore, it is currently difficult to conclude that laparoscopic
emergency surgery for IH is a standard procedure.
In addition, incarcerated groin hernias usually occur in elderly
patients, many of whom are taking anticoagulant drugs. A previous
report suggested that patients with anticoagulant drugs had a significantly higher risk of post-operative bleeding following laparoscopic and open inguinal hernia repair.18 Elective surgery is
preferable for these patients to avoid the risk of excess bleeding by
controlling these anticoagulant drugs.
Emergency surgery is the gold standard treatment for IH, and it is
considered the first choice to avoid intestinal injury caused by
delayed treatment and failure of manual reduction. In contrast, as we
have previously described, elective surgery after reduction might be
one option. However, if the incarcerated intestine has irre- versible
ischaemic changes or is perforated, elective surgery is
© 2020 Royal Australasian College of Surgeons
contraindicated, and the patient will require an emergency operation. Therefore, dividing patients into candidates for reduction is
crucial for surgeons. Previous reports have suggested several risk
factors predicting ischaemic bowel in patients with IH, including
femoral hernia, peritonitis, a lack of health insurance, skin changes
and hyponatraemia.19,20 In addition, computed tomography imaging provides useful information for assessing ischaemic changes in
the intestine.21,22 However, it has not been proven whether these
diagnostic features can be applied to patients with IH. Surgeons
should be meticulous when performing the manual reduction of
incarceration by referring to computed tomography images in addition to assessing the general condition and abdominal symptoms of
these patients, along with careful follow-up.
Manual reduction sometimes causes rare conditions, such as
reduction en masse or intestinal stenosis of Garré.23,24 We have
experience with one case of a patient with intestinal stenosis of
Garré, and this patient required readmission and reoperation. Surgeons should note that manual reduction can cause the development
of these rare conditions.
There were some limitations associated with this study. First, the
present study was retrospective in nature and was conducted at a single centre. Second, the choice of procedure, namely, emergency surgery or elective surgery after reduction, was at the surgeon’s discretion,
and patients who had severe conditions or could not achieve reduction
generally underwent emergency surgery. Therefore, strong biases that
affect the objectivity of the final statistical results might be present.
Third, as mentioned above, dividing patients into candidates for
reduction is an essential step for surgeons. Our study does not indicate
the universality and safety of manual reduction for IH. In addition, the
number of patients with femoral hernias and the number of female
patients were significantly greater in the emergency group than in the
reduction group, and there were strong biases in the comparison of
whole patients. However, in the subgroup analysis of the patients
without intestinal resection, there were fewer biases. Fur- ther study is
needed to establish which patients are candidates for the safe
performance of reduction.
In conclusion, in selected patients, elective surgery after reduction yielded more favourable outcomes than did emergency repair.
Emergency surgery was one of the independent predictors of postoperative complications.
Conflicts of interest
None declared.
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© 2020 Royal Australasian College of Surgeons