Hernia (2005) 9: 156–159 DOI 10.1007/s10029-004-0311-9

O R I GI N A L A R T IC L E

B. Papaziogas Æ Ch. Lazaridis Æ J. Makris J. Koutelidakis Æ A. Patsas Æ M. Grigoriou G. Chatzimavroudis Æ K. Psaralexis Æ K. Atmatzidis

Tension-free repair versus modified Bassini technique (Andrews technique) for strangulated inguinal hernia: a comparative study Received: 31 October 2004 / Accepted: 7 December 2004 / Published online: 3 February 2005 Ó Springer-Verlag 2005

Abstract Background: To compare tension-free hernia repair to a modified Bassini technique (Andrew’s technique) used to treat complicated inguinal hernia.Methods: In the period 1990–2004, 75 patients were submitted to emergency operation because of strangulated inguinal hernia. 33 patients underwent tension-free repair utilizing a polypropylene mesh (group A), whereas the remaining 42 patients underwent a modified Bassini technique (group B). Results: Mean operative time was significantly longer for group B (91.5±9.3 min vs 75.7±10.5 min, p<0.05). Postoperative hospital stay was also significantly longer in group B compared to group A (10.3±3.4 days vs 4.5±2.1 days, p<0.01). Postoperative complication rate did not differ significantly between the two groups (5/33, 15.1% vs 5/ 42, 11.9%, p=n.s.). No mesh had to be removed. At follow-up (mean 9±4.2 years), there was one recurrence in group A (1/33, 3%) and two recurrences in group B (2/42, 4.7%) (p=n.s.). Conclusion: The presence of a strangulated inguinal hernia cannot be considered a contraindication for the use of a prosthetic mesh. Keywords Strangulated inguinal hernia Æ Mesh repair Æ Polypropylene Æ Bassini technique

Introduction Hernia incarceration is one of the most common surgical emergencies. Approximately 10% of inguinal hernias present as acutely incarcerated, necessitating an emergency hernia repair, whereas the probability of inguinal B. Papaziogas (&) Æ C. Lazaridis Æ J. Makris J. Koutelidakis Æ A. Patsas Æ M. Grigoriou G. Chatzimavroudis Æ K. Psaralexis Æ K. Atmatzidis 2nd Surgical Department of the Aristotle University of Thessaloniki, Fanariou str. 16, 551 33 Thessaloniki, Greece E-mail: [email protected] Tel.: +30-2310-992562 Fax: +30-2310-992563

hernia strangulation is estimated at between 0.29% and 2.9% [1, 2]. It is generally accepted that the operative repair of strangulated inguinal hernias is followed by increased postoperative morbidity and mortality compared to elective hernia repair. Tension-free repair has been established as the method of choice for the management of uncomplicated inguinal hernias [3, 4]. However, the use of mesh in cases of strangulated or incarcerated hernias remains controversial due to the potential risk of infection from the prosthetic material. Only a few studies have dealt with the use of biomaterials in emergency hernia repair [5, 6, 7, 8]. The aim of the present study was to compare tensionfree hernia repair to a modified conventional Bassini technique (Andrew’s technique) for the management of strangulated inguinal hernias.

Patients and methods During the period 1990–2004, 75 patients were operated on in our department due to strangulated inguinal hernia: 65 men and 10 women, with a mean age of 69.8±7.4 years. The mean duration between onset of symptoms and operation was 8.4±2.3 hours. 33 patients underwent tension-free repair utilizing a polypropylene mesh (group A), whereas the remaining 42 patients underwent a modified Bassini technique (Andrew’s technique). The demographic data for each group are shown in Table 1. The main criterion for the choice of the method was the preference of the surgeon. However, it is noteworthy that most of the patients in group A were operated on during the second half of the study period. The presence of intestinal ischemia or necrosis was not considered a contraindication for mesh repair, provided that there were no signs of generalized peritonitis or contamination of the surgical field. Four patients from group A (4/33, 12.1%) and ten patients from group B (10/42, 23.8%) underwent small bowel resection due to ischemic necrosis.

157 Table 1 Demographic data of the patients

Results

Parameter

Group A (n=33) (mesh repair)

Group B (n=42) (tension repair)

p

Age (years) Sex (male/female)

68.8±6.9 29/4

70.4±8.0 36/6

n.s. n.s.

ASA class: ASA I ASA II ASA III ASA IV

10 (30.3%) 12 (36.4%) 11 (33.3%) –

15 (35.7%) 14 (33.3%) 13 (31%) –

n.s. n.s. n.s. n.s.

Table 2 Type of inguinal hernias Type

Group A (n=33) (mesh repair)

Group B (n=42) (tension repair)

p

Indirect hernia Direct hernia Recurrent hernia Bowel resection

28 (84.8%) 5 (15.2%) 3 (11.1%) 4 (12.1%)

35 (83.3%) 7 (16.6%) 4 (9.5%) 10 (23.8%)

n.s. n.s. n.s. <0.05

Due to this significant difference in the incidence of bowel resection between the two groups, we further divided them into two subgroups (with or without bowel resection). All patients were operated on under spinal or epidural anesthesia. Postoperative analgesia was achieved by parenteral (i.m.) administration of dextropropoxyphene on demand of the patient. All patients received antibiotics postoperatively (second-generation cephalosporin) for at least two days. Mean operative time, length of postoperative hospital stay and postoperative complication rate were recorded. Furthermore, all patients were contacted by telephone and examined clinically for the detection of recurrence. Data are expressed as mean±SD. Statistical analysis was performed using the t-student and chi-square tests. Statistical significance was assumed if p<0.05.

Table 3 Results

No difference was noted between the two groups concerning the age, sex and preoperative physical status according to ASA (American Society of Anesthesiology) classification (Table 1). Furthermore, the distribution of the type of inguinal hernias was similar between the two groups. In group A, 28/33 (84.8%) patients had indirect and 5/33 (15.2%) patients had direct inguinal hernias, whereas in group B, 35/42 (83.3%) patients had indirect and 7/42 (16.6%) patients had direct hernias. Three of the patients in group A (3/33, 11.1%) and four patients in group B (4/42, 9.5%) had recurrent hernias (Table 2). The incidence of bowel resection was significantly higher in group B compared to group A (23.8% vs 12.1%, p<0.05). The mean operative time was significantly longer in group B (91.5±9.3 vs 75.7±10.5, p<0.05). However, the operative times did not differ significantly among patients with or without bowel resection between the two groups (Table 3). The postoperative hospital stay was significantly longer in group B compared to group A (10.3±3.4 vs 4.5±2.1, p<0.01). If only the patients without necrosis are considered (29 patients in group A and 32 patients in group B), the difference is still statistically significant (6.5±2.3 vs 4.2±2 days, p<0.05). But even among patients who underwent bowel resection (four patients in group A and ten patients in group B), the difference between the two groups, concerning postoperative hospital stay, remains significant (12.7±2.1 vs 5.1±2.2 days, p<0.01) (Table 3). The postoperative complication rate did not differ significantly between the two groups (5/33, 15.1% vs 5/42, 11.9%, p=n.s.). There were only two cases of seroma formation in group A which could be attributed directly to the implantation of the mesh. No significant difference was noted concerning the development of wound infection between the two groups (2/33, 6.1% vs 4/42, 9.5%, p=n.s.). No mesh had to be removed.

Parameter

Group A (n=33) (mesh repair)

Group B (n=42) (tension repair)

p

Mean operative time (min) Bowel resection Simple repair (no bowel resection)

75.7±10.5 90.3±11.2 70.3±9.4

91.5± 9.3 97.4±10.3 76.4±8.2

<0.05 n.s. n.s.

Postoperative stay (days) Bowel resection Simple repair (no bowel resection)

4.5±2.1 5.1±2.2 4.2±2.2

10.3±3.4 12.7±2.1 6.5±2.3

<0.01 <0.05 <0.05

Postoperative complications Bowel resection Simple repair (no bowel resection)

5 (15.1%) 3/4 (75%) 2/29 (6.9%)

5 (11.9%) 2/10 (20%) 3/32 (9.3%)

n.s. <0.05 n.s.

Recurrence rate Bowel resection Simple repair (no bowel resection)

1 (3%) 1/4 (25%) 0/29 (0%)

2 (4.7%) 2/10 (20%) 0/32 (0%)

n.s. n.s. n.s.

158

Follow-up ranged between six months and 15 years (mean 9±4.2 years). There was one recurrence in group A (1/33, 3%) and two recurrences in group B (2/ 42, 4.7%). The difference was not statistically significant (Table 3).

Discussion Although tension-free hernia repair is currently the gold standard for the treatment of uncomplicated hernia repair [3, 4], there are only a few reports concerning the use of mesh in cases of strangulated or incarcerated hernias. Only sporadic reports of relatively small patient series are found in the literature, which conclude that strangulation cannot be considered a contraindication for tension-free hernia repair [5, 6, 7, 8]. There is still some concern in the literature about the efficacy and safety of prosthetic hernia repair in the presence of contaminated or clean contaminated wounds [9]. However, many surgeons are ready to perform a mesh repair of an incisional hernia in a clean contaminated state (for example, after cholecystectomy or colectomy). Furthermore, the very good results obtained after prosthetic repair of parastomal hernias indicate that the presence of a contaminated field should no longer be considered a contraindication for the implantation of a mesh [9, 10, 11]. To our knowledge, this is the first study comparing the tension-free method to a conventional method for the repair of complicated inguinal hernias. Although our study is not randomized, it should lead to an suitable comparison between the two techniques. The incidence of bowel resection in group B (tension repair) was significantly higher compared to group A. Since intestinal resection is followed by increased hospital stay and increased incidence of postoperative complications compared to simple repair of a strangulated hernia, we further divided the two groups into two subgroups (with or without ischemic necrosis) in order to achieve a more accurate comparison between the two techniques. The increased incidence of bowel resection in group B can probably be attributed to our reluctance to perform mesh repair in the presence of a contaminated field in the first years of the study period. However, particularly over the last five years, the presence of bowel necrosis has not been considered a contraindication for the performance of mesh repair. The four patients in group A who underwent mesh repair after resection of the necrotic bowel showed no postoperative complications directly related to the implantation of the mesh. This fact encouraged us to apply the tension-free technique more frequently. However, in cases of severe generalized peritonitis, or evidence of severe infection of the surgical field, we still prefer the conventional method. The recurrence rate was higher in the conventional repair group, but the difference was not statistically

significant. The relatively small size of our sample does not allow a safe conclusion concerning this parameter. Over the last few years, a number of studies have appeared that describe the laparoscopic management of complicated inguinal hernia with relatively good results. Leibl et al. reported the repair of 194 incarcerated hernias using the transperitoneal approach, with postoperative morbidity of 2.8% and only one recurrence after 26 months [12]. These excellent results further strengthen the arguments for the use of tension-free repair in the management of complicated inguinal hernias [13, 14, 15]. However, the presence of necrotic bowel within the hernia usually limits the use of the laparoscopic approach, making its direct comparison to open conventional or tension-free repair difficult. Concerning the complication rate, we noted no significant difference between conventional and tensionfree repair. Only two cases of seroma formation were recorded (2/33, 6.1%), which were treated conservatively. The incidence of seroma formation is higher than the incidence reported in the literature after the management of uncomplicated hernia repair, but is in accordance with other studies reporting the use of meshes in complicated inguinal hernias. Wysocki reports an incidence of 5.2% (1/19 patients) of seroma formation after tension-free hernia repair of incarcerated hernias [8]. The incidence of wound infection (2/33, 6.1%) in group A is higher compared to the reported incidence after elective tension-free hernia repair. However, no difference was noted compared to the conventional hernia repair group. Pans et al. reported an incidence of wound infection of 5.7%. Surprisingly, none of the nine patients that had prosthetic mesh placed inside them after intestinal resection developed wound infection [16]. We believe the use of antibiotics for at least 2–4 days postoperatively may improve the incidence of wound infection after mesh implantation in wounds potentially contaminated with intestinal bacteria, along with meticulous preparation of the hernia and careful hemostasis [17]. In conclusion, strangulated inguinal hernias may be repaired safely with the use of a polypropylene mesh.

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