A mini review: Unexpected fatal consequences in groin hernia cases Re: Complications of Strangulated Hernia. Part I
A mini review: Unexpected fatal consequences in groin hernia cases
Dr. Jogenananda Pramanik Professor & Dean, Careers Abroad Institute School of Medicine, Dr Azzard Comrie, Senior Medical officer, Hargreaves Memorial Hospital, Dr. Clive C Lloyd, Consultant Surgeon, Mandeville Regional Hospital, #32, Hargreaves Avenue, Mandeville, Manchester, Jamaica, WI.
We read with interest and applauded the insightful discussion as reported by Robinson R. R in 1851 regarding complications of strangulated hernia cases leading to unexpected death (1).
The author aptly illustrated two complicated hernia cases with fatal consequences. The first patient died due to partial reduction of the herniated intestine which was obstructed at the internal ring in inguinal canal and the second patient died because a recurrent hernia that became complicated in an attempt to reduce en masse by the patient himself.
The standard method for inguinal hernia repair had changed little over a hundred years until the introduction of synthetic mesh, which is placed by either using an open approach or by using a minimal access laparoscopic technique for reinforcement of weak musculatures in inguinal region and reduce recurrence risk.
For inguinal hernia operations, standard mortality rate (SMR) after emergency and elective operations are 5.94 (4.99–7.01) and 0.63 (0.52–0.76) (2). However, overall mortality within 30 days after groin hernia operations is increased above that of the background population for all men and women (SMR, 1.40; 1.22–1.58 and 4.17; 3.16–5.40, respectively) (2).
Since there is no definite sign for early detection of strangulation of herniated tissue in inguinal hernia, it seems difficult for patients or their relatives to ascertain when to terminate “watchful waiting period” and decide to seek surgical procedures for remote rural area patients in particular. A third of patients scheduled for elective surgery have no pain, and severe pain is uncommon (1.5% at rest and 10.2% on movement) (3)
In present day surgical practice, elective hernia surgery is widely accepted as a low-risk procedure even at advanced age. However, an emergency operation for neglected groin hernia carries a substantial mortality risk (2).
In 21st century, it is observed widely that the surgical treatment of inguinal hernias is undergoing major metamorphosis, and the techniques for surgical repair is shifting from tissue- and suture-based repairs to mesh-based reinforcement of the hernia defect (4).
It is reported that for laparoscopic repairs of groin hernias, the total complication rate was 13.6%, of which 1.2% were intraoperative (5). The use of mesh during laparoscopic hernia repair is associated with a relative reduction in the risk of hernia recurrence of around 30-50% and there is no apparent difference in recurrence between laparoscopic and open mesh methods of hernia repair (6). However, Laparoscopic operation times are longer and there appears to be a higher risk of serious complication rate in respect of visceral (especially bladder) and vascular injuries.(6)
Our patients want their period of convalescence and rehabilitation to be uncomplicated in both short- and long-term outcome so as to return to their normal daily activities (4).
However, there is impending danger of fatal complications when patients themselves attempt to reduce hernia en masse or otherwise.
The general surgeon must take an account of nearly 150 years of improvements in inguinal hernia repair procedures and select an appropriate repair, with appropriate materials, for an individual patient (7).
It is also appropriate to examine the femoral canal during inguinal hernia operations in order not to overlook an associated femoral hernia with its particular risk for emergency surgery, bowel resection, and postoperative mortality. After groin hernia repair, women have a higher mortality risk than men due to a greater risk for emergency procedure irrespective of hernia anatomy and a greater proportion of femoral hernia. After femoral hernia operation, the mortality risk was increased 7-fold for both men and women. (2)
At the end, the final decision for inguinal hernia repair procedure and the specifics of the operation are left to the individual surgeon. However, selection of a procedure should be made in consultation with the patient after proper discussion and obtain a well-informed consent before surgery.
1. Robinson R.R. (1851) Complications of Strangulated Hernia. Part I. Lond J Med 1851;s 2-3:431
doi: https://doi.org/10.1136/bmj.s2-3.29.431 (https://www.bmj.com/content/s2-3/29/431)
2. Nilsson, H., Stylianidis, G., Nordin, P, (2007) Mortality after groin hernia surgery. Annals of Surgery, 245(4):656-660 DOI: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1877035/
3. Pramanik, J., Comrie, A., (2018) Strangulated hernia causing sudden unexpected death-A major concern. Re: Inguinal herniashttps://www.bmj.com/content/336/7638/269/rr
4. Stephenson, B.M., (2003) Complications of open groin hernia repairs. Surgical Clinic North America, 83(5), 1255–1278. DOI: https://doi.org/10.1016/S0039-6109 (03)00128-2
5. Tetik C1, Arregui ME, Dulucq JL (1994) Complications and recurrences associated with laparoscopic repair of groin hernias. A multi-institutional retrospective analysis. Surg Endosc, 8(11):1316-22; discussion 1322-3.
6. McCormack K1, Scott NW, Go PM., (2003) Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev. 2003; (1):CD001785.
7. Matthews, R. D., & Neumayer, L. (2008). Inguinal Hernia in the 21st Century: An Evidence-Based Review. Current Problems in Surgery, 45(4), 261-312. DOI: 10.1067/j.cpsurg.2008.01.002
Competing interests: No competing interests