Is the age of >65 years a risk factor for endoscopic treatment of primary inguinal hernia? Analysis of 24,571 patients from the Herniamed Registry

Incarerated femoral hernia in women - A critical view on approach options

INTRODUCTION AND IMPORTANCE

In the literature there is few information on femoral hernias while best surgical approach to groin hernia in women is in recent discussion ([1], [2]). Focused on femoral hernia our purpose is to present a possible pathway for incarcerated female hernia approach demonstrated on four cases.

CASE PRESENTATION

Four female patients (77-90 y) with suspected incarcerated inguinal unilateral hernia undergoing repair at our department between December 2017 and December 2018 are presented. In three patients emergency laparoscopy by single port approach confirmed incarceration. Bowel was reduced and femoral hernia diagnosed. A TAPP repair was performed. The fourth patient had multiple previous abdominal operations due to anal carcinoma, so laparoscopic approach was not recommended. A transinguinal open approach also showed an incarcerated femoral hernia.

CLINICAL DISCUSSION

In case of suspected incarcerated inguinal hernia accurate identification of a femoral hernia is necessary especially in female elderly patients. If possible endoscopic approach is preferred and offers exploration of both sides, checking bowel for vitality and fixing the hernia. If bilateral hernia is present, both sides should be addressed. Surgeons not used to TAPP should perform diagnostic laparoscopy with reduction of hernia sac and check of content and switch to TEP if experienced or open procedure. If open approach is necessary checking for femoral hernia is also mandatory and preperitoneal mesh placement is recommended with or without ligation of inferior epigastric vessels.

CONCLUSION

Femoral hernias in women are not rare and in open repair techniques easily overseen. The endoscopic approach is preferred. With open approach the exploration via transversalis fascia is mandatory.

[Inguinal hernia operations-Always outpatient?]

Inguinal hernia operations represent the most frequent operations overall with 300,000 interventions annually in Germany, Austria and Switzerland (DACH region). Despite the announced political willingness and the increasing pressure from the legislator to avoid costly inpatient treatment by carrying out as many outpatient operations as possible, outpatient treatment has so far played a subordinate role in the DACH region. The Boards of the specialist societies the German Hernia Society (DHG), the Surgical Working Group Hernia (CAH of the DHG), the Austrian Hernia Society (ÖHG) and the Swiss Working Group Hernia Surgery (SAHC) make inroads into this problem, describe the initial position and assess the current situation.

Postoperative bleeding complications after endoscopic inguinal hernia repair in patients receiving anticoagulation agents, antiplatelet agents, or both

INTRODUCTION

In patients receiving chronic anticoagulation agents, antiplatelet agents, or both, perioperative antithrombotic therapy for inguinal hernia repair requires an understanding of potential side-effects-specifically, the postoperative bleeding risks. In the present study, we evaluated postoperative bleeding complications after transabdominal preperitoneal patch plasty (TAPP) in patients undergoing antithrombotic therapy.

METHODS

We retrospectively reviewed 413 patients who had undergone TAPP between February 2013 and June 2017. Individuals in the antithrombotic group received one of three regimens of perioperative antithrombotic therapy. The clinical indications for chronic anticoagulation agents (ie bridging therapy with unfractionated heparin), antiplatelet agents (ie continuation of aspirin), or both were followed. The antithrombotic group was compared to the control group in terms of surgical outcomes. We primarily focused on the incidence of postoperative bleeding complications.

RESULTS

A total of 83 patients received antithrombotic therapy. We observed significant differences between the groups in terms of mean age, ASA physical status, and length of postoperative stay. In contrast, postoperative complications were not significantly different between the antithrombotic and control groups (4.8% vs 5.5%, P = 0.818). In addition, a significantly greater postoperative bleeding rate was not observed in the antithrombotic group than in the control group (1.2% vs 0.6%, P = 0.566). Likewise, other complications were similar in both groups.

CONCLUSIONS

Antithrombotic therapy is not a risk factor for postoperative bleeding complications in patients who have undergone TAPP, suggesting its safety and efficacy in this patient population. Indeed, this group has the same incidence rates of morbidity and postoperative bleeding complications as patients who have not undergone antithrombotic therapy.

The reality of general surgery training and increased complexity of abdominal wall hernia surgery

INTRODUCTION

The Accreditation and Certification of Hernia Centers and Surgeons (ACCESS) Group of the European Hernia Society (EHS) recognizes that there is a growing need to train specialist abdominal wall surgeons. The most important and relevant argument for this proposal and statement is the growing acceptance of the increasing complexity of abdominal wall surgery due to newer techniques, more challenging cases and the required 'tailored' approach to such surgery. There is now also an increasing public awareness with social media, whereby optimal treatment results are demanded by patients. However, to date the complexity of abdominal wall surgery has not been properly or adequately defined in the current literature.

METHODS

A systematic search of the available literature was performed in May 2019 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library, with 75 publications identified as relevant. In addition, an analysis of data from the Herniamed Hernia Registry was performed. The percentage of patients with hernia- or patient-related characteristics which unfavorably impacted the outcome of inguinal and incisional hernia repair was also calculated.

RESULTS

All present guidelines for abdominal wall surgery recommend the utilization of a 'tailored' approach. This relies on the prerequisite that any surgical technique used has already been mastered, as well as the recognized learning curves for each of the several techniques that can be used for both inguinal hernia (Lichtenstein, TEP, TAPP, Shouldice) and incisional hernia repairs (laparoscopic IPOM, open sublay, open IPOM, open onlay, open or endoscopic component separation technique). Other hernia- and patient-related characteristics that have recognized complexity include emergency surgery, obesity, recurrent hernias, bilateral inguinal hernias, groin hernia in women, scrotal hernias, large defects, high ASA scores, > 80 years of age, increased medical risk factors and previous lower abdominal surgery. The proportion of patients with at least one of these characteristics in the Herniamed Hernia Registry in the case of both inguinal and incisional hernia is noted to be relatively high at around 70%. In general surgery training approximately 50-100 hernia repairs on average are performed by each trainee, with around only 25 laparo-endoscopic procedures.

CONCLUSION

A tailored approach is now employed and seen more so in hernia surgery and this fact is referred to and highlighted in the contemporaneous hernia guidelines published to date. In addition, with the increasing complexity of abdominal wall surgery, the number of procedures actually performed by trainees is no longer considered adequate to overcome any recognized learning curve. Therefore, to supplement general surgery training young surgeons should be offered a clinical fellowship to obtain an additional qualification as an abdominal wall surgeon and thus improve their clinical and operative experience under supervision in this field. Practicing general surgeons with a special interest in hernia surgery can undertake intensive further training in this area by participating in clinical work shadowing in hernia centers, workshops and congresses.

[HerniaSurge: international guidelines on treatment of inguinal hernia in adults : Comments of the Surgical Working Group Hernia (CAH/DGAV) and the German Hernia Society (DHG) on the most important recommendations]

SURGICAL TECHNIQUES

The HerniaSurge guidelines have the highest evidence with respect to a strong recommendation for mesh-based surgical techniques. This evidence is equally valid for the Lichtenstein procedure as for the minimally invasive procedures TEP/TAPP. In the case of discrete symptomatic or asymptomatic inguinal hernias, watchful waiting can be an option, taking into account health status and social circumstances. Femoral hernias, on the other hand, should be treated promptly with mesh insertion. Also favored are laparoendoscopic techniques. The Shouldice repair achieves the least recurrences from the suturing procedures and may be an acceptable alternative when indicated or when the patient does not desire mesh reinforcement. In this case, a detailed patient education is necessary.

MESH CHOICE

The complication potential of plastic meshes should be explained. The weight is no longer considered a suitable parameter for the classification of meshes and is no longer recommended for mesh selection. Large pore (>1-1.5 mm) monofilament implants have the best integration potential and should have a tear strength of approximately 16 Nm². Traumatic mesh fixation is only recommended for large medial hernias (M3-EHS). Primarily not recommended are Plug & Patch, double-layered plastic implants (such as the PHS system) or other three-dimensional devices, as this could affect both the anterior and posterior planar layers and complicate the complementary surgical technique in the event of recurrence. In addition, the higher costs have to be considered.

PERIOPERATIVE AND POSTOPERATIVE ASPECTS

Perioperative antibiotic prophylaxis in open repair procedures is recommended only in patients with an increased risk of infections. In laparoendoscopic procedures, antibiotic prophylaxis should not be performed or used with the utmost restraint. Careful preparation reduces chronic inguinal and testicular pain. In the case of interference of mesh and nerve, the nerve can be resected. A return to daily activity is recommended within 3-5 days.

QUALITY ASSURANCE

The documentation of patient data should be done by establishing hernia registers for quality assurance and for the development of further treatment options. The implementation of the guidelines is supported by HerniaSurge.

Incidence of postoperative complications in transabdominal preperitoneal repair for groin hernia is influenced by poor performance status rather than by old age

AIM

The present study was designed to evaluate the safety and feasibility of transabdominal preperitoneal (TAPP) repair for very old patients with groin hernia and to identify the risk factors predicting perioperative complications.

METHODS

A total of 140 patients treated by TAPP were reviewed retrospectively. They were divided into two groups: patients ≥80 years of age (≥80 years group; n = 26) and those <80 years of age (<80 years group; n = 114). Patient characteristics and surgical outcomes were then statistically compared between the two groups.

RESULTS

Number of patients with any comorbidities was significantly higher in the ≥80 years group than in the <80 years group (96.2% vs 61.4%, P = 0.003). There were no significant differences in surgical outcomes between the two groups. In the univariate analysis of perioperative complications, poor performance status (PS) (P = 0.014), lower hemoglobin level (P = 0.038) and lower albumin level (P = 0.016) were significantly associated with the occurrence of postoperative complications, and multivariate analysis showed that only poor PS was an independent factor (PS 0-2 vs 3-4: P = 0.034, OR 5.192 [95% CI; 1.137 to 23.71]).

CONCLUSIONS

This is the first report to show that the incidence of postoperative complications in TAPP repair for groin hernia is influenced by poor PS rather than old age. TAPP can be a safe surgical procedure for very old patients with a good PS, with benefits that are equal to those in young patients.

Coagulation and deep vein flow changes following laparoscopic total extraperitoneal inguinal hernia repair: a single-center, prospective cohort study

BACKGROUND AND PURPOSE

Venous thromboembolism (VTE) is a serious complication encountered in surgical practice. The purpose of this study was to identify changes in coagulation status and deep vein flow parameters, within 24 h postoperatively, for patients undergoing laparoscopic total extraperitoneal inguinal hernia repair (TEP).

METHODS

For 144 patients undergoing TEP, coagulation markers including prothrombin time (PT), partial thromboplastin time, thrombin time, D-dimer, fibrinogen, fibrin degradation products (FDP), and international normalized ratio (INR) were monitored preoperatively and in the first morning postoperatively. Echo-Doppler recordings preoperatively and again within 24 h postoperatively were completed for 23 patients to monitor lower extremity deep vein flow parameters including speed of flow (cm/s), diameter (cm), and cross-sectional area (cm²). Clinically significant VTE and other complications were recorded.

RESULTS

No significant VTE were diagnosed. Significant increases were seen in the first morning postoperatively for PT, D-dimer, FDP, and INR (P < 0.05). Stratified by age, except for those < 50 years, the ratio of value-outside-the-normal-range (VONR) for D-dimer and FDP increased significantly postoperatively for all age groups. Stratified by operation duration, a significant difference in the ratio of VONR in D-dimer was identified postoperatively between those with an operation duration < 60 min and ≥ 60 min. There were significant decreases in the iliac and common femoral vein flow velocity of the ipsilateral extremity postoperatively (P < 0.05).

CONCLUSIONS

Activated hypercoagulability and hampered lower extremity deep vein flow were observed immediately after TEP. DVT formation was more pronounced in older patients and for those with operation duration ≥ 60 min. Proper VTE risk stratification for laparoscopic inguinal hernia repair (LIHR) and prophylaxis early after LIHR should be important clinical considerations.

[Inguinal hernia repair in TAPP technique in a day-case surgery setting - at what price?]

BACKGROUND

TAPP surgery can be considered as a gold standard in inguinal hernia repair. Patients benefit of a faster reconvalescence and less pain compared to other techniques. TAPP surgery in Germany is performed in an in-patient setting routinely. However, according to European guidelines, inguinal hernia surgery should be considered as day-case surgery whenever possible.

OBJECTIVES

The safety of day-case surgery was examined in relation to postoperative pain, complications, comorbidities, recurrent inguinal hernia and bilateral procedures.

MATERIAL AND METHODS

In a retrospective, monocentric study we analyzed 522 elective inguinal hernia repairs using TAPP technique in a specialized hernia center. Supplemental data from Herniamed registry is analyzed.

RESULTS

Parts of the procedures should be performed in an in-patient setting, whereas a much larger number of cases should be carried out as day-case surgeries. Logistic regression analyses show that "age", "bilateral procedures" and "comorbidities" affect the complication rate. "Age" and "recurrent inguinal hernia" are risk factors for an increased need for analgetic medication. Furthermore, we present an actual distribution of day-case vs. in-patient surgeries in inguinal hernia repair based on data from the Herniamed registry.

CONCLUSION

A much larger part of procedures could safely be carried out as day-case surgeries. Based on a false incentive there is an incorrect steering in the German health system. These procedures cannot be carried out covering the costs as day-surgery cases. If there is no reevaluation of the proceeds of these procedures in a day-case surgery setting, the reasonable quality in treatment is compromised especially in inguinal hernia surgery.

Impact of age on postoperative outcomes in bariatric surgery

BACKGROUND

Age is often related to the increase of perioperative complications and reoperation rates. The authors aimed to determine the influence of age on outcomes of most commonly performed bariatric procedures.

METHODS

The retrospective study included patients qualified for primary Laparoscopic Sleeve Gastrectomy (LSG) or Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) in two academic hospitals. Patients were divided into two groups: ≥50 (21.2-26.9%) and <50 (57.6-73.1%) years old. Endpoints assessed the influence of patients' age on the perioperative and the one-year postoperative period.

RESULTS

Operative time was longer in the ≥50-year-old group, but only for LRYGB. There were no differences in the intraoperative adverse events, postoperative morbidity, reoperation and readmission rates between the groups. The risk of port site hernia was increased (OR: 4.23, CI: 1.49-12.06) in the ≥50-year-old group. The mean % of total weight loss 12 months after the bariatric procedure was comparable, but % of excess weight loss and % of excess body mass index loss were lower in the ≥50-year-old group (p = .033 and .032).

CONCLUSIONS

Bariatric surgery is safe and feasible in patients over 50 years old. The weight loss effect can be worse among patients over 50 years old; nevertheless, the treatment should be considered as effective.

Open versus robotic-assisted transabdominal preperitoneal (R-TAPP) inguinal hernia repair: a multicenter matched analysis of clinical outcomes

PURPOSE

To compare the perioperative outcomes of initial, consecutive robotic-assisted transabdominal preperitoneal (R-TAPP) inguinal hernia repair (IHR) cases with consecutive open cases completed by the same surgeons.

METHODS

Multicenter, retrospective, comparative study of perioperative results from open and robotic IHR using standard univariate and multivariate regression analyses for propensity score matched (1:1) cohorts.

RESULTS

Seven general surgeons at six institutions contributed 602 consecutive open IHR and 652 consecutive R-TAPP IHR cases. Baseline patient characteristics in the unmatched groups were similar with the exception of previous abdominal surgery and all baseline characteristics were comparable in the matched cohorts. In matched analyses, postoperative complications prior to discharge were comparable. However, from post discharge through 30 days, fewer patients experienced complications in the R-TAPP group than in the open group [4.3% vs 7.7% (p = 0.047)]. The R-TAPP group had no reoperations post discharge through 30 days of follow-up compared with five patients (1.1%) in the open group (p = 0.062), respectively. Multivariate logistic regression analysis which demonstrated patient age > 65 years and the open approach were risk factors for complications within 30 days post discharge in the matched group [age > 65 years: odds ratio (OR) = 3.33 (95% CI 1.89, 5.87; p < 0.0001); open approach: OR = 1.89 (95% CI 1.05, 3.38; p = 0.031)].

CONCLUSIONS

In this matched analysis, R-TAPP provides similar postoperative complications prior to discharge and a lower rate of postoperative complications through 30 days compared to open repair. R-TAPP is a promising and reproducible approach, and may facilitate adoption of minimally invasive repairs of inguinal hernias.

Feasibility and safety of elective laparoscopic total extraperitoneal preperitoneal groin hernia repair in the elderly: a propensity score-matched comparison

Background

Several studies of hernia registries have revealed that elderly patients have higher perioperative complication rates compared with younger patients. However, the incidence of hernia increases with the aging process. To evaluate the feasibility and safety of laparoscopic hernia repair in elderly patients (≥75 years), we conducted a prospective case-matched control study to compare perioperative outcomes between patients older and younger than 75 years.

Methods

Between September 2008 and July 2015, 572 consecutive patients undergoing endoscopic hernia repair were included in this prospective study. This case-matched control study was matched based on sex, American Society of Anesthesiologists score, and body mass index between patients younger and ≥75 years. The propensity-score matching of two groups was carried out on a 1:1 basis. Perioperative data were prospectively recorded for all patients including demographic data, operation time, length of hospital stay, narcotic dose, and complications.

Results

In the final analysis, 54 patients who were <75 years were extracted to match the 54 patients ≥75 years. These two groups had similar baseline characteristics excluding age. They also had similar perioperative outcomes in hernia recurrence, metachronous contralateral hernia occurrence, complication rate and chronic pain. The patients ≥75 years of age had lower requirements for analgesics than those who were <75 years of age (p=0.047).

Conclusion

This is the first comparative cohort study investigating the impact of aging in an Asian hernia population. Laparoscopic inguinal hernia repair is feasible and safe for older patients, with comparable perioperative outcomes to patients <75 years.

Endo-laparoscopic inguinal hernia repair: What is its role?

Hernia repair techniques vary greatly depending upon the setting, surgeons, insurance reimbursement systems, resources, and logistical capabilities. Open mesh repair is the most frequently used technique. Choosing the best technique for inguinal hernia repair is a challenge. There is no single technique to manage every type of hernia. Today, laparoscopy and robotics are at the forefront of advanced surgical tools and offer a range of options for general surgeons who are critically evaluating new procedures. However, before using a new procedure, such as endo-laparoscopic hernia repair, surgeons often ask the rhetorical question, "Why change?" The common considerations are the availability of equipment, familiarity with the anatomy when using these techniques, operative time, cost to the patient, and the potential need to convert to an open procedure. Additionally, we are now seeing a significant shift away from surgeon-defined benefits to patient-defined benefits. As patients become more aware of their options for hernia procedures and share their experiences, more and more patients are likely to demand a particular technique. Hence, hernia surgeons should be educated on the different techniques available for inguinal hernia repair, including endo-laparoscopic procedures. In this article, we review the existing literature on the current role of endo-laparoscopic inguinal hernia repair.

Risk factors for perioperative complications in inguinal hernia repair - a systematic review

The current literature suggests that perioperative complications occur in 8%–10% of all inguinal hernia repairs. However, the clinical relevance of these complications is currently unknown. In our review, based on 571,445 hernia repairs reported in 39 publications, we identified the following potential risk factors: patient age, ASA score, diabetes, smoking, mode of admission (emergency vs. elective surgery), surgery in low resource settings, type of anesthesia, and (in men) bilateral and sliding hernias. The most commonly reported complications are bleeding (0.9%), wound infection (0.5%), and pulmonary and cardiovascular complications (0.2%). In 3.9% of the included publications, a reliable grading of the reported complications according to Clavien-Dindo classification was possible. Using this classification retrospectively, we could show that, in patients with complications, these are clinically relevant for about 22% of these patients (Clavien-Dindo grade ≥IIIa). About 78% of all patients suffered from complications needing only minor (meaning mostly medical) intervention (Clavien-Dindo grade <III). Especially with regard to the low incidence of complications in inguinal hernia repair, future studies should use the Clavien-Dindo classification to achieve better comparability between studies, thus enabling better correlation with potential risk factors.

Sudden death caused by acute pulmonary embolism after laparoscopic total extraperitoneal inguinal hernia repair: a case report and literature review

PURPOSE

Laparoscopic repair of inguinal hernias is an increasingly popular method of herniorrhaphy, providing advantages, including lower wound infection rates, faster recovery times and less postoperative pain compared with open procedures. The perioperative incidence of venous thromboembolism (VTE), which comprises deep vein thrombosis and pulmonary embolism, in laparoscopic inguinal hernia repair is low, but VTE is still one of the most common causes of postoperative mortality. Moreover, the VTE risk assessment and prophylaxis in inguinal hernia patients is not well defined.

METHODS

We present an unusual case of sudden death owing to acute pulmonary embolism after undergoing total extraperitoneal inguinal hernia repair. Medline and PubMed databases were searched using the keywords mentioned below, and the literature on VTE risk assessment and prophylaxis in laparoscopic inguinal hernia repair is reviewed.

RESULTS

Laparoscopic inguinal hernia repair, which is regarded as a low risk procedure for VTE, has potential risks for VTE development in the perioperative period. The risks come from both surgical procedures and intrinsic patient characteristics.

CONCLUSIONS

Clinicians should consider both the strength of individual risk factors and the cumulative weight of all risk factors prior to surgery. A full VTE risk assessment is essential with proper prophylaxis measures especially in quality-of-life procedures.

Data and outcome of inguinal hernia repair in hernia registers - a review of the literature

Register-based observational studies in inguinal hernia repair deliver real-world data from very large patient populations and give answers to important clinical questions never evaluated in randomized controlled trials. Data from hernia registers can provide evidence of effectiveness of therapies in the general population. Hernia registers with high case load have existed in Sweden since 1992, in Denmark since 1998, and in Germany/Austria/Switzerland since 2009. In this review, the most important findings of register-based observational studies in inguinal hernia repair are presented. After an intensive literature search, 85 articles are relevant for this review. Numerous findings from these register-based studies have been incorporated into the various guidelines on inguinal hernia repair. These highlight the particular importance of hernia registers in answering key scientific and clinical questions in hernia surgery. The myriad of surgical techniques described – spanning more than 100 and with ongoing new additions – as well as the large number of associated medical devices call for, more than in other surgical disciplines, meticulous documentation of the methods used for the treatment of inguinal hernias.