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Femoral and Inguinal Hernia: How to Minimize Adverse Outcomes Following Repair
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Groin hernia is common, and each year 200 repairs per 100 000 adult inhabitants are performed in Sweden. Groin hernias are either inguinal or femoral (2-4%). Elective repair is not associated with an excess mortality, but adverse outcomes include recurrence and long-term pain. Emergency procedures have a 4% mortality rate with an increased risk for bowel resection and postoperative complications. The aim of this thesis was to identify risk factors for adverse outcomes and to propose measures to improve groin hernia treatment.

Twenty-three per cent of female hernias were femoral. Thirty-six per cent of femoral hernias, and 5% of inguinal hernias, have emergency procedures. Females (OR 1.47) and patients above 65 years-of-age (OR 2.24) were at higher risk for emergency repair. Bowel resection was performed in 23% of emergency femoral repairs, and the 30-day mortality was 10 times that of an age- and gender-matched population. The majority of emergency patients were unaware of their hernia, and one third had previously had no groin symptoms.

Femoral repairs were at larger risk for recurrence than inguinal repairs. The surgical techniques with least risk for recurrence were preperitoneal mesh repairs (open HR 0.28, and laparoscopic HR 0.31). Long-term pain was present in 24% of femoral hernia patients, of whom 5.5% described pain interfering with daily activities. The only factor predicting the risk for long-term pain was pain preoperatively. Pain decreased with time.

In a randomized study on inguinal hernia, TEP resulted in less pain six weeks after surgery than Lichtenstein repair performed under local anesthesia (LLA). TEP patients were to a larger extent able to perform sporting activities. No difference was seen in intra-operative complications.

Femoral hernias should be given high priority for repair and preperitoneal techniques should be used. Earlier diagnosis, in the elective setting, is probably difficult to attain. Heightened awareness in the emergency department is required. TEP is safe, and results in less pain than LLA six weeks after surgery. A widening of indications for TEP in primary inguinal hernia repair is justifiable.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Uppsaliensis , 2011. , 57 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 728
Keyword [en]
femoral hernia, inguinal hernia, adverse outcome, complication, recurrence, chronic pain, long-term pain, emergency, mortality, TEP, Lichtenstein, local anesthesia
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-162203ISBN: 978-91-554-8236-7 (print)OAI: oai:DiVA.org:uu-162203DiVA: diva2:460097
Public defence
2012-01-13, Enghoffsalen, Ing 50, Akademiska Sjukhuset, Uppsala, 13:15 (English)
Opponent
Supervisors
Available from: 2011-12-20 Created: 2011-11-26 Last updated: 2012-01-03Bibliographically approved
List of papers
1. Emergency Femoral Hernia Repair A Study Based on a National Register
Open this publication in new window or tab >>Emergency Femoral Hernia Repair A Study Based on a National Register
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2009 (English)In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 249, no 4, 672-676 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To describe the characteristics of femoral hernias and outcome of femoral repairs, with special emphasis on emergency operations. Background: Femoral hernias account for 2% to 4% of all groin hernias. However, the lack of large-scale studies has made it impossible to draw conclusions regarding the best management of these hernias. Methods: The study is based on patients 15 years or older who underwent groin hernia repair 1992 to 2006 at units participating in the Swedish Hernia Register. Results: Three thousand nine hundred eighty femoral hernia repairs were registered, 1490 on men and 2490 on women: 1430 (35.9%) patients underwent emergency surgery compared with 4.9% of the 138,309 patients with inguinal hernias. Bowel resection was performed in 22.7% (325) of emergent femoral repairs and 5.4% (363) of emergent inguinal repairs. Women had a substantial over risk for undergoing emergency femoral surgery compared with men (40.6% vs. 28.1%). An emergency femoral hernia operation was associated with a 10-fold increased mortality risk, whereas the risk for an elective repair did not exceed that of the general population. In elective femoral hernias, laparoscopic (hazard ratio, 0.31; 95% confidence interval, 0.15-0.67) and open preperitoneal mesh (hazard ratio, 0.28; confidence interval, 0.12-0.65) techniques resulted in fewer re-operations than suture repairs. Conclusions: Femoral hernias are more common in women and lead to a substantial over risk for an emergency operation, and consequently, a higher rate of bowel resection and mortality. Femoral hernias should be operate with high priority to avoid incarceration and be repaired with a mesh.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-129143 (URN)10.1097/SLA.0b013e31819ed943 (DOI)000264899100022 ()
Available from: 2010-08-09 Created: 2010-08-05 Last updated: 2017-12-12Bibliographically approved
2. Chronic Pain After Femoral Hernia Repair: A Cross-Sectional Study
Open this publication in new window or tab >>Chronic Pain After Femoral Hernia Repair: A Cross-Sectional Study
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2011 (English)In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 254, no 6, 1017-1021 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE:

To explore the prevalence of and to identify possible risk factors for chronic pain after surgery for femoral hernia.

BACKGROUND:

Chronic pain has become a very important outcome in quality assessment of inguinal hernia surgery. There are no studies on the risk for chronic pain after femoral hernia surgery.

METHODS:

The Inguinal Pain Questionnaire was sent to 1967 patients who had had a repair for primary unilateral femoral hernia between January 1, 1997 and December 31, 2006. A follow-up period of at least 18 months was chosen. Answers from 1461 patients were matched with data recorded in the Swedish Hernia Register and analyzed.

RESULTS:

Some degree of pain during the previous week was reported by 24.2% (354) of patients. Pain interfered with daily activities in 5.5% (81) of patients. Emergency surgery (OR = 0.54; 95% CI = 0.40-0.74) and longer time since surgery (OR = 0.93; 95% CI = 0.89-0.98 for each year added) were associated with lower risk for chronic postoperative pain, whereas a high level of preoperative pain was associated with a higher risk for chronic pain (OR = 1.17; 95% CI = 1.10-1.25). Surgical technique was not found to influence the risk for chronic pain in multivariate logistic regression analysis.

CONCLUSIONS:

Chronic postoperative pain is as important a complication after femoral hernia surgery as it is after inguinal hernia surgery. In contrast to inguinal hernia surgery, no risk factor related to surgical technique was found. Further investigations into the role of preoperative pain are necessary.

Keyword
hernia, chronic pain, long-term post operative pain, femoral, complication, questionnaire
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-162197 (URN)10.1097/SLA.0b013e31822ba9b6 (DOI)000297375200027 ()21862924 (PubMedID)
Available from: 2011-11-27 Created: 2011-11-25 Last updated: 2017-12-08Bibliographically approved
3. Little Chance of Preventing Emergency Surgery for Femoral Hernia: Symptoms and Signs Prior to Presentation are Often Not Present
Open this publication in new window or tab >>Little Chance of Preventing Emergency Surgery for Femoral Hernia: Symptoms and Signs Prior to Presentation are Often Not Present
2011 (English)Article in journal (Refereed) Submitted
Keyword
hernia, femoral hernia, emergency surgery, emergency repair, symptoms, presentation
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-162201 (URN)
Available from: 2011-11-27 Created: 2011-11-26 Last updated: 2012-01-03Bibliographically approved
4. TEP under General Anesthesia is Superior to Lichtenstein under Local Anesthesia in terms of Pain Six Weeks after Surgery: Results from a Randomized Trial
Open this publication in new window or tab >>TEP under General Anesthesia is Superior to Lichtenstein under Local Anesthesia in terms of Pain Six Weeks after Surgery: Results from a Randomized Trial
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2012 (English)Manuscript (preprint) (Other academic)
Keyword
TEP, Lichtenstein, hernia, inguinal hernia, randomised, RCT, local anesthesia, postoperative pain, pain
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-162202 (URN)
Available from: 2011-11-27 Created: 2011-11-26 Last updated: 2012-01-03

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