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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 2  |  Page : 43-46

Risk of bowel resection in patients with hernia


Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia

Date of Web Publication6-Sep-2019

Correspondence Address:
Abdulmalik Altaf
Department of Surgery, Faculty of Medicine, King Abdulaziz University, P.O. Box: 80200, Jeddah 21589
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_44_18

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  Abstract 

Introduction: Repair of hernia is one of the most common general surgery operations. Strangulation of the hernia contents requiring bowel resection is one of the serious complications of hernias. The aim of the present study is to evaluate the risk factors of bowel resection in patients undergoing emergency surgical repair of hernia.
Methods: A retrospective study reviewed the medical records of all patients who underwent emergency surgery for hernia from January 2014 to December 2017 at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Patients were stratified into two groups: bowel resection was required (Group 1) or not (Group 2). Extracted patients' data for each group included four different fields: (1) personal data and patients' characteristics, (2) preoperative assessment, (3) intraoperative assessment, and (4) postoperative length of hospitalization and complications. The data were analyzed to determine the risk factors for bowel resection.
Results: A total of 83 patients underwent emergency surgery hernia repair during the study. A univariate multiple logistic regression model identified three variables that were independent risk factors for bowel resection: duration of symptoms >24 h (odds ratio = 6.093), previous abdominal surgery (odds ratio = 4.531), and high American Society of Anesthesiologists (ASA) classification score (odds ratio = 8.273).
Conclusion: Risk factors for bowel resection in emergency hernia repair include high ASA score, previous abdominal surgery, and prolonged the duration of symptoms. Further prospective studies are recommended to confirm the findings of this study.

Keywords: Bowel resection, hernia, ischemia, risk factors, strangulation


How to cite this article:
Altaf A, Algethmi WA. Risk of bowel resection in patients with hernia. Saudi Surg J 2019;7:43-6

How to cite this URL:
Altaf A, Algethmi WA. Risk of bowel resection in patients with hernia. Saudi Surg J [serial online] 2019 [cited 2019 Nov 13];7:43-6. Available from: http://www.saudisurgj.org/text.asp?2019/7/2/43/266213


  Introduction Top


Repair of hernia is one of the most common general surgery operations.[1] A hernia is defined as a bulge, protrusion, or projection of a part of an organ or the entire organ through the wall of its containing cavity.[2] Although there are different types of hernia, they are all treated for the same reason, avoiding complications. The most severe and frequent complications are strangulation and incarceration, with or without intestinal obstruction.[3],[4] Early diagnosis of incarceration is important to reduce the risk of ischemia and tissue necrosis. This prevents intestinal resection, which is required to treat bowel necrosis.[5],[6],[7],[8]

Previous studies have shown that many factors may increase the risk of bowel resection during hernia repair. Kurt et al. showed that bowel resection was more common in women, patients older than 65 years, patients with symptoms longer than 6 h, and patients with femoral or epigastric hernia.[9] Ozkan et al. confirmed that patients with hernia strangulation and necrosis usually require bowel resection more frequently.[10]

Little is known about the risk factors for bowel resection in hernia patients undergoing emergency hernia surgery in Saudi Arabia compared to studies conducted elsewhere.

The aim of the present study is to evaluate the risk factors of bowel resection in patients undergoing emergency surgical repair of hernia.


  Methods Top


A retrospective study reviewed the medical records of all patients who underwent emergency surgery for hernia between January 2014 and December 2017 at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. This study was approved by the institutional research ethical committee. Patients were stratified into two groups: bowel resection was required (Group 1) or not (Group 2). Extracted patients' data for each group included four different fields: (1) personal data and patients' characteristics such as age, gender, concomitant disease (diabetes mellitus, hypertension, cardiovascular disease, vascular diseases, and hepatic disease); (2) preoperative assessment consisting of type of hernia, duration of the symptoms at the moment of hospital admission, previous hernia or abdominal surgery, white blood cell count, American Society of Anesthesiologists (ASA) score, and type of anesthesia; (3) intraoperative assessment included presenting of intestinal obstruction or strangulation and whether intestinal resection was done or not; and (4) postoperative length of hospitalization and complications.

The results of the two groups were compared using the SPSS software 21.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistical analysis of the data was performed. T-test, Fisher's exact test, or Chi-square test was used to compare the two groups. P < 0.05 was considered statistically significant. A univariate multiple logistic regression model was constructed to determine the risk factor for bowel resection.


  Results Top


A total of 83 patients underwent emergency surgery hernia repair during the study. Comparing the characteristics of the patients in the two groups, more than half (43; 51.8%) of patients were male. Although more female patients required bowel resection than males (66.7% vs. 33.3%), this was not statically significant (P > 0.05). On the other hand, age, ASA classification, duration of symptoms, and previous abdominal surgery were significantly associated with bowel resection (P< 0.05). The rest of two groups' characteristics are summarized in [Table 1].
Table 1: Characteristics of patients with and without bowel resection

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Overall, inguinal hernia was the most common type of hernia in patients undergoing emergency repair (33 patients, 39.8%), followed by incisional hernia (21 patients, 28.9%). Nine patients required bowel resection, with the type of hernia being umbilical, femoral, and incisional (3 patients, 33.3% in each type). There was a statistical significance between the bowel resection and type of hernia as well as history of recurrent hernia (P< 0.05) [Table 2].
Table 2: Characteristic of hernia in both groups

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[Table 3] shows a univariate multiple logistic regression model which identified three variables that were independent risk factors for bowel resection: duration of symptoms >24 h (odds ratio = 6.093), previous abdominal surgery (odds ratio = 4.531), and high ASA classification score (odds ratio = 8.273).
Table 3: Risk factors for bowel resection

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  Discussion Top


Hernia is a common surgical condition that affects different age groups and may lead to significant complications. Despite all the advancement in clinical surgical care, hernia and recurrent hernia continue to pose a pathological burden, resulting in multiple issues including disability and socioeconomic implications.[11],[12] The development of strangulation and necrosis has high morbidity and mortality rates. Bowel resection may need a treatment for strangulated hernia with all its potential complications such as anastomotic leaks and postoperative surgical site infection.[13] Identifying risk factors for bowel resection in hernia patients may help recognize and early treat patients at such a risk.

In our results, of the 83 patients who had emergency surgery for hernia, 9 (10.8%) patients required bowel resection due to necrosis, whereas 74 (89.2%) patients only required hernia repair. We have found three independent risk factors for bowel resection in patients undergoing emergency hernia repair. First, prolonged duration of symptoms >24 h before surgery, which is in agreement with previous studies findings.[9],[14] This may be related to delays in patient admission and/or late patient presentation. Late patient presentation can be related to by socioeconomic factors and lack of health insurance that affect a timely access to hospital health care. Second, patients with previous history of abdominal surgery have a much higher risk of having bowel ischemia and resection. This appears to concur with previous results.[14] Third, a high ASA classification score is shown as an independent risk factor for performing bowel resection, which is also consistent with several other studies resulting in a higher risk for other complications and mortality.[7],[14],[15]

Performing bowel resection directly affects the outcome of patients undergoing emergency hernia repair.[3],[16] Postoperative hospitalization was significantly higher in patients who had bowel resection. Based on our results, we would recommend that patients diagnosed with uncomplicated hernia should always be counseled about emergency symptoms to avoid late clinical presentation if they turn to have potential strangulation. Hernia patients who present with emergency symptoms should be promptly diagnosed in the emergency room to avoid hospital delays in providing surgical treatment. As well, special attention and a fast track should be offered to those with a history of previous abdominal surgery and/or higher ASA score.

The limitations of this study are its retrospective nature and its conduction in a single center. Further prospective and multicenter studies are suggested for a broader assessment as needed.


  Conclusion Top


Risk factors for bowel resection in emergency hernia repair include high ASA score, previous abdominal surgery, and prolong the duration of symptoms >24 h. Educating patients at their initial diagnosis about emergency hernia symptoms might avoid late presentation to the emergency department. Timely emergency surgery especially for those at higher risk might lessen the odds of bowel resection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Fitzgibbons RJ Jr., Cemaj S, Quinn TH. Abdominal wall hernias. In: Mulholland MW, Doherty GM, Lillemoe KD, Maier RV, Simeone D, Upchurch GR, editors. Greenfields Surgery. Scientific Principles and Practice. 5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2011. p. 1159-98.  Back to cited text no. 1
    
2.
Dabbas N, Adams K, Pearson K, Royle G. Frequency of abdominal wall hernias: Is classical teaching out of date? JRSM Short Rep 2011;2:5.  Back to cited text no. 2
    
3.
Kulah B, Kulacoglu IH, Oruc MT, Duzgun AP, Moran M, Ozmen MM, et al. Presentation and outcome of incarcerated external hernias in adults. Am J Surg 2001;181:101-4.  Back to cited text no. 3
    
4.
Bekoe S. Prospective analysis of the management of incarcerated and strangulated inguinal hernias. Am J Surg 1973;126:665-8.  Back to cited text no. 4
    
5.
Akçakaya A, Alimoǧlu O, Hevenk T, Baş G, Sahin M. Mechanic bowel obstructions due to groin hernias. Ulusal Travma Dergisi 2000;6:260-5.  Back to cited text no. 5
    
6.
Alimoglu O, Kaya B, Okan I, Dasiran F, Guzey D, Bas G, et al. Femoral hernia: A review of 83 cases. Hernia 2006;10:70-3.  Back to cited text no. 6
    
7.
Derici H, Unalp HR, Bozdag AD, Nazli O, Tansug T, Kamer E. Factors affecting morbidity and mortality in incarcerated abdominal wall hernias. Hernia 2007;11:341-6.  Back to cited text no. 7
    
8.
Chamary VL. Femoral hernia: Intestinal obstruction is an unrecognized source of morbidity and mortality. Br J Surg 1993;80:230-2.  Back to cited text no. 8
    
9.
Kurt N, Oncel M, Ozkan Z, Bingul S. Risk and outcome of bowel resection in patients with incarcerated groin hernias: Retrospective study. World J Surg 2003;27:741-3.  Back to cited text no. 9
    
10.
Ozkan E, Yıldız MK, Cakır T, Dulundu E, Eriş C, Fersahoǧlu MM, et al. Incarcerated abdominal wall hernia surgery: Relationship between risk factors and morbidity and mortality rates (a single center emergency surgery experience). Ulus Travma Acil Cerrahi Derg 2012;18:389-96.  Back to cited text no. 10
    
11.
Hachisuka T. Femoral hernia repair. Surg Clin North Am 2003;83:1189-205.  Back to cited text no. 11
    
12.
Glanze WD, Anderson KN, Anderson LE, Urdang L, Swallow HH. Mosby Medical and Nursing Dictionary. 2nd ed. Saint Louis: The C. V. Mosby Company; 1986. p. 528.  Back to cited text no. 12
    
13.
Sartelli M, Coccolini F, van Ramshorst GH, Campanelli G, Mandalà V, Ansaloni L, et al. WSES guidelines for emergency repair of complicated abdominal wall hernias. World J Emerg Surg 2013;8:50.  Back to cited text no. 13
    
14.
Pesić I, Karanikolić A, Djordjević N, Stojanović M, Stanojević G, Radojković M, et al. Incarcerated inguinal hernias surgical treatment specifics in elderly patients. Vojnosanit Pregl 2012;69:778-82.  Back to cited text no. 14
    
15.
Alvarez JA, Baldonedo RF, Bear IG, Solís JA, Alvarez P, Jorge JI. Incarcerated groin hernias in adults: Presentation and outcome. Hernia 2004;8:121-6.  Back to cited text no. 15
    
16.
Rai S, Chandra SS, Smile SR. A study of the risk of strangulation and obstruction in groin hernias. Aust N Z J Surg 1998;68:650-4.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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