Small-Bowel Disorders and Abdominal Wall Hernia in the Elderly Patient

Intraperitoneal Tension-free Repair of a Small Midline Ventral Abdominal Wall Hernia: Randomized Study with a Mean Follow-up of 3 Years

Funding received from Cousin Biotech, Wervicq Sud, France, and CR Bard Inc., Cranston, RI. The aim of this prospective randomized study was to determine the long-term recurrence and complication rates after small abdominal wall hernia repair with two different bilayer prostheses. Hernia repair using prosthetic mesh material has become the preferred method of repair, because the recurrence rates are much lower than with conventional repair techniques. The use of a hernia bilayer patch, composite expanded polytetrafluoroethylene (ePTFE)-polypropylene, with intraperitoneal placement behind the hernia defect, through a small incision, may be efficient, safe, and cost-effective. This study is a randomized, single-institution trial, including 83 selected consecutive patients with primary (umbilical, epigastric) or incisional anterior abdominal wall defects from 2 to 5 cm. Hernia repair was performed by direct local access in ambulatory surgery; the prosthesis used was a circular bilayer with an inner face in ePTFE to avoid bowel adhesion. One group was treated with a Ventralex® Hernia Patch (Bard USA). The second group was treated with a Cabs'Air® Composite (Cousin Biotech France), which was delivered with two to four fixation sutures and a balloon to properly deploy the mesh intraperitoneally. Patients’ characteristics and operative and postoperative data were prospectively collected. The primary outcome was late recurrence. Secondary outcomes included, pain, discomfort and quality of life before and after (3 months) surgery using the SF-12 questionnaire, patient-surgeon satisfaction, and early and late complications. Among 98 patients, 83 were included in the study protocol between January 2007 and August 2011. The two groups were comparable according to pre- and intraoperative data. According to surgeon experience, placement of the Cabs'Air® device was significantly faster ( P = 0.01) and easier. At 3 months, there was significantly less pain and less discomfort for the Cabs'Air® group and patient satisfaction rate was higher. This was confirmed by all components of the SF-12 questionnaire. Long-term follow-up was available for 77 patients. The mean follow-up was similar for the two groups (42 months; range, 14 to 70 months). At this point, for the Ventralex® group, there were four recurrences (11.7%); one mesh infection; one small bowel obstruction; and six cases (15.7%) of severe pain resulting from a mass syndrome (shrinkage) with a sense of the presence of a foreign body. Six reoperations (15.6%) were required with explant of the prosthesis. There were no recurrences or late complications in the comparative group. The Ventralex® Hernia Patch is associated with inconsistent deployment, spreading, or shrinkage, which account for late complications and decreases the overlap, which contributes to the recurrence rate. The Cabs'Air®-associated balloon facilitates superior deployment of the prosthesis allowing for good fixation with four sutures.

Laparoscopic versus open ventral hernia repair in the elderly: a propensity score-matched analysis

BACKGROUND

Ventral hernia repair is common in the expanding aging population, but remains challenging due to their frequent comorbidities. The purpose of this study is to compare the surgical outcomes of open vs. laparoscopic ventral hernia repair in elderly patients.

METHODS

Patients ≥ 65 years of age that underwent elective open or laparoscopic ventral hernia repair were identified from the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database. To reduce potential selection bias, propensity scores were created for the likelihood of undergoing laparoscopic surgery based on patients' demographics and comorbidities. Patients were matched based on the logit of the propensity scores. Thirty-day surgical outcomes were compared after matching using Chi-square test for categorical variables and the Wilcoxon Rank-Sum test for continuous variables.

RESULTS

35,079 (71.1%) and 14,270 (28.9%) patients underwent open and laparoscopic ventral hernia repairs, respectively. Laparoscopic surgery was associated with a lower overall morbidity (5.9% vs. 9.1%; p < 0.001) compared to open repair. The incidence of surgical site infections (1.1% vs. 3.5%; p < 0.001), post-operative infections (2.7% vs. 3.6%; p < 0.001), and reoperation (1.7% vs. 2.1%; p = 0.009) were all lower after laparoscopic repair. All other major surgical outcomes were either better with laparoscopy or comparable between both treatment groups except for operative time.

CONCLUSION

Although open surgery remains the most prevalent in the elderly population, the results of this study suggest that laparoscopic surgery is safe and associated with a lower risk of overall morbidity, surgical site infections, and reoperation.

Evaluation of the use of component separation in elderly patients: results of a large cohort study with 30-day follow-up

BACKGROUND

The incidence of massive ventral hernias among the elderly will increase as the population ages. Advanced age is often viewed as a contraindication to elective hernia repair. A relationship between age and complications of component separation procedures for ventral hernias is not well established. This study evaluated the effect of age on the peri-operative safety of AWR.

METHODS

The 2005-2013 ACS-NSQIP participant use data were reviewed to compare surgical site infection (SSI), overall morbidity, and serious morbidity in non-emergent component separation procedures among all age groups. All patients were stratified into four age quartiles and evaluated. Baseline characteristics included age, body mass index (BMI) and ASA 3 or 4 criteria. Statistical analysis was performed using SPSS. Odds ratios (OR) and 95% confidence intervals were reported as appropriate.

RESULTS

4485 patients were identified. Majority of the cases were clean (76.8%). Patients were divided into the following quartiles based on age. The older quartile had a mean age of 72.7 ± 4.87 years. There were baseline differences in BMI and chronic comorbidity severity (measured by incidence of ASA score of 3 or 4) between the age groups, with the oldest group having lower BMI but higher rate of ASA 3 or 4 (p < 0.0001 for both). The rate of postoperative SSI was significantly different between age quartile groups (ranging from 16.3% from the youngest group to 9.4% for the oldest group, p < 0.0001). After adjusting for other baseline differences, advanced age was independently associated with lower SSI rate (OR 0.55, 95% CI 0.41-0.73). There was no significant difference in overall morbidity (p = 0.277) and serious morbidity (p = 0.131) between groups.

CONCLUSION

AWR is being performed with safety across all age groups. In selected patients of advanced age, AWR can be performed with similar safety profile and low SSI rate.

Tentacle-shaped mesh for fixation-free repair of umbilical hernias

Purpose

Mesh fixation and broad overlap represent an open issue in umbilical hernia repair. A proprietary-designed implant with tentacle straps at its boundary has been developed to ensure a suture-free repair and a broader coverage of the abdominal wall. The study describes the results of umbilical hernia procedures carried out with the tentacle-shaped implant and the related surgical technique.

Methods

A proprietary tentacle-shaped flat mesh having a central body with integrated radiating arms at its edge was used to repair large umbilical hernias in 62 patients. The implant was placed in preperitoneal sublay. The friction of the straps, crossing the abdominal wall thanks to a special needle passer, was intended to assure adequate grip to hold the implant in place assuring a fixation-free procedure and broad overlap of the hernia defect.

Results

In a mean follow-up of 48 months (range 10–62 months), 4 seromas and 2 ischemia of the navel skin occurred. No infections, hematomas, chronic pain, mesh dislocation, or recurrence has been reported.

Conclusions

The tentacle strap system of the prosthesis effectively ensured an easier implant placement avoiding the need for suturing the mesh. The arms of the implant ensured a proper orientation and stabilization of the mesh in association with a broad defect overlap. The specifically developed surgical procedure showed a quick postoperative recovery, a very low complication rate, and no recurrences even in the long term.

Safe and uncomplicated inguinal hernia surgery in the elderly – message from anesthesiologists to general surgeons

Introduction Elderly patients are often discouraged from surgery due to the risk of complications that increases with age. Aim We wanted to assess mortality, morbidity, and complications in patients older than 75 years who underwent elective or emergency inguinal hernia repair in a single center. Methods All patients older than 75 years who were operated on because of inguinal hernia in the Department of General and Colorectal Surgery, Medical University of Lodz between 2003 and 2015 were analyzed. Detailed information was collected with regard to patient demographics, mode of admission, comorbidities, type of intervention, applied anesthesia, and 30-day outcomes. Postoperative outcomes included medical and surgical complications, readmissions, and survival status. Results One hundred thirty-two patients older than 75 years were operated on for inguinal hernia, 16 (12.1%) in an emergency setting and 116 (87.9%) in an elective setting. Eighteen patients (13.6%) developed complications, 8 (50%) in the emergency group, and 10 (8.6%) in the elective group. In the emergency group, severe medical complications (Clavien-Dindo 4) were frequent, whereas in the elective group, severity of surgical and medical complications was not significantly different (Clavien-Dindo median score 2, p=0.6084), and these complications were classified as mild (Clavien-Dindo 1-2). One death occurred in the emergency group. Conclusion Inguinal hernia surgery in the elderly may be safe and effective in an elective setting and if regional anesthesia is used. Careful examination of patients before surgery and identification of potential risk factors associated with co-existing diseases are vital for reducing the risk of complications. Key point: Hernia surgery in patients older than 65 years is a low-risk intervention, if carried out in an elective setting.

Incarcerated incisional hernia of the sigmoid colon after appendectomy: A case report

•

Incisional hernia after appendectomy is rare because the incision is small.

•

Small bowel and omentum are commonly herniated through the weak abdominal wall.

•

Incisional hernia of the colon after appendectomy is extremely rare.

•

Computed tomography is a useful diagnostic tool for differentiating unusual abdominal wall mass.

Introduction

Incisional hernia after appendectomy is rare, affecting 0.4% to 0.9% of cases. The small bowel and omentum are commonly herniated through the abdominal wall defect, but incisional hernia of the sigmoid colon is extremely rare.

Case presentation

A 78-year-old man presented with a right lower quadrant abdominal wall mass on the previous McBurney incision site. He had a history of appendectomy for appendicitis 40 years ago. Computed tomography (CT) showed the sigmoid colon herniated thorough the abdominal wall defect. During the operation, a feces-impacted sigmoid colon was found protruding through the defect of the abdominal wall. Reduction of the sigmoid colon into the peritoneal cavity and herniorrhaphy with primary repair were performed.

Discussion

The ascending and descending colon are fixed into the retroperitoneum, whereas the transverse and sigmoid colon are not, which can allow these bowel segments to herniate through a weak abdominal wall just as small bowel loops do. However, incisional hernia of the colon is extremely rare. The diagnosis of incisional hernia can be easily made because a reducible abdominal wall mass can be detected by physical examination. In cases with rare type of hernia, CT can identify unusual types of abdominal hernias and differentiate hernias from neoplasms, inflammatory disease, and hematoma.

Conclusion

Although incisional hernia of the colon after appendectomy is extremely rare and preoperative diagnosis by physical examination is difficult, CT is a useful method to make the correct diagnosis, avoiding unnecessary invasive intervention, particularly in patients with an unusual abdominal wall mass.

Emergency groin hernia repair: implications in elderly

BACKGROUND

Groin hernia is one of the most frequently encountered pathologies occurring in old age and it is often the cause of emergency procedures. In our study we evaluate the impact of emergency procedures in over 75 patients compared to younger patients.

METHODS

We conducted a retrospective study about patients who underwent emergency hernioplasty between September 2007 and January 2013. Bilateral hernias and recurrences were excluded. We divided patients into two groups by age (under and over 75 years old) and then analyzed the early postoperative surgical complications.

RESULTS

A total of 48 patients were enrolled, 18 were included in under 75 group and 30 in over 75. In the older group we found a higher rate of comorbidity and also a significant higher rate of postoperative complications. Two patients of over 75 group died.

CONCLUSIONS

Our data suggests that a quick diagnosis and elective surgical procedures are desirable in order to avoid the complications that occur in emergency operations.

A Collective Review on Mesh-Based Repair of Umbilical and Epigastric Hernias

In accordance with the tension-free principles for other hernias, umbilical and epigastric hernia repair should probably be mesh-based. The number of randomized studies is increasing, most of them showing significantly less recurrences with the use of a mesh. Different devices are available and are applicable by several approaches. The objective of this review was to evaluate recent literature for the different types of mesh for umbilical and epigastric hernia repair and recurrences after mesh repair. A multi-database search was conducted to reveal relevant studies since 2001 reporting mesh-based repair of primary umbilical/epigastric hernia and their outcomes in adult patients. A total of 20 studies were included, 15 of them solely involved umbilical hernias, whereas the remaining studies included epigastric hernias as well. A median of 124 patients (range, 17-384) was investigated per study. Three quarters of the included studies had a follow-up of at least 2 years. Six studies described the results of laparoscopic approach, of which one reported a recurrence rate of 2.7 %; in the remaining studies, no recurrences occurred. Two comparative studies reported a lower incidence of complications and postoperative pain after laparoscopic repair compared to open repair. Seventeen studies reported results of open techniques, of which seven studies showed no recurrence. Other studies reported recurrence rates up to 3.1 %. A wide range of complication rates were reported (0-33 %). This collective review showed acceptable recurrence rates for mesh-based umbilical and epigastric hernia repair. A wide range of devices was investigated. A tendency toward more complications after laparoscopic repair was found compared to open repair.

Laparoscopic repair of incarcerated ventral abdominal wall hernias

BACKGROUND

The role of laparoscopy in the management of incarcerated (irreducible) ventral hernia remains to be elucidated. We present our experience of the laparoscopic repair of incarcerated primary ventral and incisional hernias over an 8-year period.

METHODS

A retrospective review of the records of 112 patients undergoing laparoscopic repair for incarcerated primary ventral and incisional hernias from January 1998 to February 2006 was performed. The patient demographics, perioperative data, and postoperative complications were assessed.

RESULTS

The procedure was completed entirely laparoscopically in 103 patients (91.9%) with the placement of intraperitoneal mesh. A sutured tissue repair (without mesh) was performed in seven patients and hernia repair was abandoned after laparoscopy in two patients. Five patients required limited conversion by a targeted skin incision for the resection of nonviable bowel (three patients) and to complete adhesiolysis within multiloculated hernial sacs (two patients). The contents of the hernial sacs were incarcerated omentum (42 patients), small bowel (28 patients), large bowel (six patients), and omentum and small bowel (34 patients). Of these, seven patients presented with signs of acute small-bowel obstruction. The mean size of the largest defect through which incarceration occurred was 3.5 +/- 1.6 cm (range 1.5-7.5 cm) and the mean size of the mesh used was 379 +/- 210 cm2 (range 225-780 cm2). The mean operative time was 96 +/- 40.8 min (range 50-170 min). Inadvertent enterotomy occurred in four patients during bowel reduction and adhesiolysis. In two patients, the enterotomy was repaired by total laparoscopy followed by mesh placement, and two patients required conversion to formal laparotomy due to long-segment tears and peritoneal contamination. The average postoperative hospital stay was 2.8 +/- 1.5 days (range 1-6.5 days). Postoperative complications occurred in 20.5% patients. There was no mortality. Hernia recurred in three patients at a mean follow-up of 48 +/- 28.3 months (range 1-84 months).

CONCLUSION

Laparoscopic ventral abdominal wall hernia repair can be safely performed with a low complication rate, even in incarcerated hernias. Careful bowel reduction with adhesiolysis and mesh repair in an uncontaminated abdomen with a 5-cm mesh overlap remain key factors for a successful outcome.

Predictors of recurrence in veteran patients with umbilical hernia: single center experience

BACKGROUND

Different medical and social conditions have been associated with primary and recurrent hernias. Possible predictors of recurrence after elective umbilical hernia repair have not been defined clearly. The aim of this study was to determine factors that predict recurrence in patients after elective repair of umbilical hernias.

METHODS

A 6-year retrospective review of patients with elective umbilical hernia repair at the Dallas VA Medical Center was performed. Clinical and pathologic data were evaluated by univariate analysis to identify predictive factors for recurrence.

RESULTS

A total of 244 patients underwent elective hernia repair within the study period (male, 96%; mean age, 56 y; Caucasian, 74%; African American, 14%; Hispanic, 8%). Because 15 patients were not compliant with follow-up requirements, 229 were eligible for the study. Ninety-seven underwent suture repair (42.4%) and 132 underwent mesh repair (57.3%). Eleven recurrences were identified (4.8%): 7 in the suture repair group (7.7%) and 4 in the mesh repair group (3%). Univariate analysis showed that patients likely to develop recurrences were as follows: African American (15.6% vs. 3.5%; P = .017), type II diabetics (14.2% vs. 2.6%; P = .002), patients with hyperlipidemia (9.2% vs. 2.6%; P = .028), and human immunodeficiency virus-positive patients (66.6% vs. 3.9%; P = .000).

CONCLUSIONS

Smoking, obesity, size of hernia, type of repair, or chronic obstructive pulmonary disease do not seem to predict recurrence of hernias in our VA population. African Americans, patients with type II diabetes, hyperlipidemia, and positive for human immunodeficiency virus, may have a higher risk for recurrence after elective umbilical hernia repair.

Intraperitoneal tension-free repair of small midline ventral abdominal wall hernias with a Ventralex hernia patch: initial experience in 51 patients

Midline ventral hernias are common. Tension-free mesh repair of ventral hernias is becoming popular due to the high recurrence rate with conventional techniques. We have used an open intraperitoneal technique using the Bard Ventralex hernia patch in midline ventral hernias (<or=3 cm). Fifty-one patients were treated (34 males and 17 females) with a mean age of 52.4 years (range 18-82). Forty-three patients were day cases. Operative times, analgesic use, overnight hospital stay and postoperative complications were recorded prospectively. The mean operative time was 30 min (range 10-68). Thirty-six patients required mild/moderate postoperative analgesia. Two patients had minor wound infections and one had seroma. There was one recurrence. Our early experience suggests that Ventralex hernia patch repair of small midline ventral hernias can be performed as a day case with minimal postoperative complications.

Retrospective comparison of mesh and sutured repair for adult umbilical hernias

Adult umbilical and paraumbilical hernia repair is associated with a high recurrence rate of 10-30%. Mesh repair has been reported to be associated with low recurrence rates. This study aims to compare sutured repair with prosthetic mesh repair to evaluate recurrence and infection rates. A retrospective study was conducted over an 8-year period including all the umbilical and paraumbilical hernia repairs performed by one consultant surgeon. The hernias were repaired using interrupted suture, Mayo overlap, flat mesh and mesh plug techniques. The study was based on case-note review, telephone and postal questionnaire survey. A total of 100 patients were studied, of which 70 had paraumbilical hernias, 28 had umbilical hernias and 2 had both types of hernia. Median age was 56 years (range 19-90 years). A total of 61 patients had suture repair (50 interrupted suture repair, 11 Mayo) and 39 had prosthetic mesh repair (33 mesh plug, 6 flat mesh). The median body mass index (BMI) was 31.2 (range 23.4-44.5) in the suture repair group and 33.3 (range 24.1-59.1) in the mesh group, with no significant statistical difference in BMI between the two groups (P>0.05). Median follow-up was 4.5 years (range 1-8 years). Recurrence rates for the suture and mesh repair groups were 11.5 and 0%, respectively (P=0.007). Infection rates for the suture and mesh repair groups were 11.5 and 0%, respectively (P=0.007). Our data suggest that prosthetic mesh repair is ideal for managing primary and recurrent umbilical hernias in both obese and non-obese patients.

Proyecto nacional para la gestión clínica de procesos asistenciales.Tratamiento quirúrgico de la hernia inguinal

INTRODUCTION

The high prevalence of surgical treatment for inguinal hernia (especially in general surgery) prompted the Spanish Association of Surgeons to perform a national study to identify the most important indicators.

OBJECTIVE

To analyze healthcare quality in elective surgery for inguinal hernia by evaluating scientific-technical quality, efficiency, effectiveness, and patient satisfaction.

MATERIAL AND METHODS

A prospective, longitudinal, descriptive study from diagnosis to postoperative follow-up was performed. Patients who underwent surgery for unilateral or bilateral, primary or recurrent inguinal hernias were included. Exclusion criteria were emergency surgery and associated surgical procedures. Clinical indicators were selected after a literature review.

RESULTS

Forty-six hospitals corresponding to 16 Autonomous Communities with a total of 386 patients participated in this study. The mean follow-up was 18 months. The mean age of the patients was 56.33 years and 88.3% were male. Half the patients (50.1%) were American Society of Anesthesiologists (ASA) grade I. A total of 95.6% did not comply with the protocol for preoperative tests of the Spanish Association of Surgeons. Antibiotic prophylaxis was used in 75.39% and thromboembolic prophylaxis was used in 40.04%. Ambulatory surgery was performed in 33.6%. Local anesthesia and sedation only were used in 16.36% of the patients. The most frequently used surgical procedures involved mesh repair (Lichtenstein 50%, Rutkow-Robbins 17.1%), laparoscopy was used in 5.2% of the patients, and the Shouldice technique was used in 8.5%. The mean length of hospital stay was 47.5 hours in inpatients and was 11.65 hours in patients who underwent ambulatory surgery. Notable among the complications was hematoma in 11.6%. Ninety-six percent of the patients were satisfied or highly satisfied. The most highly scored items in the satisfaction survey were those related to information, personal dealings with staff, and the staffs kindness. The lowest scored items dealt with punctuality and accessibility. Follow-up at 18 months showed a recurrence rate of 4.11% with a total recovery time estimated by patients of 7.26 weeks.

CONCLUSIONS

Analysis of the process revealed areas for improvement and strong points. Strong points consisted of up-to-date choice of surgical technique. The most frequently used techniques were tension-free procedures and the Shouldice technique. The following areas for improvement were identified: adherence to protocols for preoperative evaluation, increased use of ambulatory surgery, local anesthesia and sedation, appropriate use of antibiotic and thromboembolic prophylaxis in selected patients and a reduction in the length of hospital stay in inpatients. Patient satisfaction with the treatment was acceptable.

Mesh plug repair for paraumbilical hernia

BACKGROUND

The standard method of repair of paraumbilical hernia (PUH) is by the Mayo technique, using a double-breasted flap of the rectus sheath. The reproducibility of this technique in the hands of others is highly variable. The present study describes and evaluates the application of a Prolene mesh plug in the repair of PUH. The use of a mesh plug in hernia repair is not a new concept with previous investigators yielding consistently excellent results in the repair of femoral and inguinal hernias.

METHODS

The study is a retrospective analysis of hospital records and telephone interviews of 34 patients having undergone PUH repair using the mesh plug technique in the period March 1998- May 2002. There were 20 males and 14 females with a median age of 53 years (range 34-86 years). Seventy-six percent (26) of the patient sample was obese (median BMI 33). Whenever possible local anaesthetic was used. Principal outcome measures studied were post-operative complications, recurrences, length of stay in hospital, post-operative analgesia, duration of drain, return to normal activities and patient satisfaction.

RESULTS

Post-operative complications encountered included one case of seroma and a single wound infection with recurrence. Ninety-seven percent (32) of patients were satisfied with the procedure.

CONCLUSION

Mesh plug repair can be performed with minimal postoperative complications, low recurrence rate, minimal post-operative pain and achieving excellent patient satisfaction. Prosthetic mesh plug repair under local anaesthetic could become the standard treatment for PUH in adults.

Color Doppler sonography for ventral hernias in patients with acute abdomen: preliminary findings

PURPOSE

We assessed the usefulness of color Doppler sonography (CDUS) in evaluating the vascular status of ventral hernias and distinguishing incarcerated from nonincarcerated ventral hernias.

METHODS

In this prospective study, 10 patients who presented with acute abdomen and had ventral hernias underwent CDUS from August 1999 to May 2000. Patient age and sex and the clinical severity, mode of therapy, and outcome in these 10 patients were evaluated in relationship to the CDUS findings.

RESULTS

Five patients had readily visible flow in the bowel within the hernial sac on CDUS. Two of these 5 had spontaneous reduction under conservative treatment, and 3 had asymptomatic ventral hernias with acute abdomen caused by spontaneous bacterial peritonitis. Barely visible flow was visualized in the bowel by CDUS in 4 other patients. Three of these underwent emergency surgery because of peritoneal signs; 2 of them were found to have ischemic changes in the bowel. The fourth patient underwent a successful manual reduction. The remaining patient had absent flow in the bowel on CDUS and underwent emergency surgery, which revealed gangrenous changes in the bowel.

CONCLUSIONS

The intensity of the Doppler signals on CDUS appears to be a promising predictor of bowel viability in cases of ventral hernia. Thus, CDUS should impact the determination of the treatment plan, including whether to provide conservative treatment or surgery.

Aspectos atuais da herniorrafia no idoso

A hérnia no paciente maior de 65 anos, ainda hoje, admite questionamentos quanto à sua etiologia, evolução e manejo. As condições clínicas do paciente e a debilidade dos tecidos da parede abdominal multiplicam as dificuldades inerentes à herniorrafia. O manejo cirúrgico apropriado é o reparo eletivo precoce, que apresenta índices limitados de complicações, sendo de maneira geral uma operação segura. Em casos de emergência, tentativas de desencarceramento estão contra-indicadas, já que em idosos a sintomatologia de sepse intra-abdominal inicia1 é frustra. O tratamento cirúrgico deve ser preconizado, pois nas operações de emergência a morbi/mortalidade da herniorrafia está significativamente elevada. A presente revisão pretende analisar os fatores envolvidos no sucesso da herniorrafia no idoso, destacando os aspectos atuais do pré, trans e pós-operatório.

Hernia repair in elderly patients

BACKGROUND

This study evaluates a 5-year experience of the management of the most frequent abdominal wall hernias in an elderly population.

METHODS

From April 1990 to December 1995, 231 inguinal, 12 femoral and seven umbilical hernias were repaired in 221 patients (mean age 74 (range 66-93) years). Concomitant diseases were present in 157 patients. A mesh repair was performed with 'tension-free' or 'plug' techniques in all but 23 inguinal and two femoral hernia repairs, in which the Bassini or Shouldice procedures were adopted. Ten emergency hernia repairs were performed for strangulation. A total of 232 operations, including four emergency hernia repairs, were carried out under local anaesthesia.

RESULTS

There was no perioperative mortality. Acute intestinal bleeding occurred 2 days after surgery in a patient with colonic diverticular disease. Urinary retention occurred once following emergency hernia repair under general anaesthesia and twice after elective hernia repair under local anaesthesia. Local complications included four scrotal haematomas (2 per cent), three wound infections (1 per cent) and one case of orchitis with atrophy after repair of a recurrent hernia. There was one recurrence after a Bassini repair and one after Shouldice inguinal herniorrhaphy. No recurrence was observed after mesh repair.

CONCLUSION

Local anaesthetic mesh hernia repair is safe and effective in elderly patients. Age should be no bar to elective hernia repair. This policy should avoid the complications of emergency operation.

Abdominal wall hernias

Abdominal wall hernias are usually asymptomatic, discovered incidentally on physical examination. Emergency physicians, however, may be called on to deal with the potential life-threatening complications of abdominal wall hernias. This article discusses the anatomy, pathophysiology, and specific types of hernias in the adult and pediatric patient populations. Also covered are the complications of hernias, emergency interventions for hernia reduction, and urgent surgical consultation.