Inguinal hernia (IH) is the most common type of hernia, accounting for 75% of abdominal wall hernias. IH repair is one of the most frequently performed surgeries in general surgery, constituting 10-15% of all surgical procedures and ranking as the second most common surgical intervention after appendectomy (1,2). Elective surgery for IH is performed to prevent complications, the most significant of which are incarceration and strangulation (3).
Strangulation can lead to high morbidity and even mortality (2,3). Although the exact rate of complicated IHs is not known, it is traditionally estimated to be around 5% (3). In two different prospective randomized studies in the literature, this rate was reported as 1% by O'Dwyer et al. (4) and 0.3% by Fitzgibbons et al. (5). Postoperative complication rates for elective IH repairs range from 6% to 20%, and mortality rates range from 0% to 0.6%, whereas for emergency incarcerated inguinal hernia (IIH) surgeries, these rates vary between 5% and 60% in various studies (4-8). In this study, adult patients operated on urgently for incarcerated IHs were analyzed to evaluate their presentation characteristics and clinical outcomes.
MATERIALS AND METHODS
The files of patients who presented to the Şişli Etfal Training and Research Hospital emergency surgical unit with IIH and underwent surgery between January 2005 and January 2010 were retrospectively reviewed. Emergency surgical indications included peritoneal irritation findings and non-reducible hernias. Cases were evaluated in terms of age, gender, hernia location, surgical findings, performed surgery, and mortality-morbidity rates. Time to presentation was defined as the time from the onset of symptoms related to incarceration to hospital admission, and delays of more than 48 hours were considered "late presentations." Non-reducible external hernias were defined as "incarceration," and the presence of intraoperative ischemia and necrosis in addition to non-reducibility was defined as "strangulation." ASA (American Society of Anesthesiologists) scoring was used for preoperative risk assessment. McVay procedure was performed for femoral hernias, while the Bassini method was applied for all other cases.
Postoperative complications were classified into two categories: local and systemic. Systemic complications included pulmonary, cardiac, cerebrovascular, and renal postoperative issues, while local complications were analyzed as surgical site infections, hematomas, and seromas. Patients were followed for at least one month, including outpatient clinic visits, to assess postoperative surgical site infections. Age, gender, hernia type, comorbidities, ASA score, type of anesthesia, surgical repair method, resections, postoperative complications, hospital stay duration, and mortality were analyzed.
RESULTS
The mean age of 38 operated cases was 45 years (17-85), with a female-to-male ratio of 30:8 (Table 1). Hernias were located on the right side in 24 patients (63%) and on the left side in 14 patients (37%). The Bassini procedure was sufficient in 34 IH cases (89%), while the McVay procedure was applied for femoral hernias. Additional interventions were performed in five cases (11%). One patient underwent partial small bowel resection with anastomosis, while four patients underwent partial omentectomy. The patient requiring small bowel resection was a female with a femoral hernia. Of the four omentectomies, three were in males and one in a female, with one of the males also having a femoral hernia. Postoperative pain was noted in one case, and seromas in two cases (Table 2). These complications were resolved with medical treatment. The average hospital stay was 3.6 days. During a follow-up period of 36 months (range: 8-45 months) for 28 patients, recurrence occurred in three cases. No mortality was observed.
DISCUSSION
IHs are common problems encountered by surgeons and carry a significant risk of complications when strangulated. Strangulated IHs represent a surgical emergency associated with high morbidity and mortality. Therefore, elective surgeries should be performed to avoid complications.
Femoral hernias are considered a high-risk group among IIHs and frequently lead to complicated presentations. Femoral hernias account for 3% of IHs and constitute a small proportion of elective repairs (8). However, in emergency presentations with incarceration and strangulation, the rate of femoral hernias can rise to 20-40%, as seen in our study, which found a rate of 11% (Table 3) (7-9). In a study by Glasgow et al., involving 2105 cases of femoral hernias over 17 years, the incidence of femoral hernias reached 38% in the female patient group. The high frequency of emergency IIHs in women in our study is attributed to the higher incidence of femoral hernias in this gender (8).
Elective repair of femoral hernias and the female gender are considered risk factors for emergency incarcerated hernia repairs (9). Emergency surgery for IHs is required in 6-20% of cases due to incarceration (10,11). Various intestinal organs may be involved in IHs (11-12), necessitating intestinal resection in 5-15% of strangulated IHs due to necrosis (5-10).
In our study, one patient underwent partial small bowel resection with anastomosis, and four underwent partial omentectomy. The patient requiring bowel resection was a female with a femoral hernia, while the four omentectomies included three males and one female, one of whom also had a femoral hernia.
Preoperative preparation is often inadequate in emergency cases, which typically involve elderly patients. Duan et al. (13) reported higher postoperative complication rates in elderly patients. In our study, three patients with postoperative pain or seroma were over 60 years old.
Prolonged symptoms of incarceration can lead to local and systemic intestinal changes (13). Some studies suggest no relationship between the severity of damage and the duration of strangulation; however, Kurt et al. (14) emphasized that incarceration lasting longer than six hours poses a risk for intestinal resection.
Our retrospective study found morbidity rates of 8%, including seromas in two patients and manageable postoperative pain in one. Our findings align with previous literature that postoperative morbidity increases with delayed incarceration and intestinal resection cases (13-15).
Elective surgeries for IHs remain essential to minimizing morbidity and mortality risks. Mesh repair is increasingly preferred for both elective and emergency settings due to lower recurrence rates and acceptable complication profiles. Our clinic has transitioned to routine use of polypropylene mesh for incarcerated and strangulated IHs. IHs remain one of the most common conditions in general surgery and should be operated on electively whenever possible. Emergency surgery is imperative for patients presenting with incarceration symptoms to minimize morbidity and mortality.
