Hernia (2006) 10:395400
DOI 10.1007/s10029-006-0121-3
O RI G I NAL ART I C LE
The outcomes of open tension-free hernioplasty in elderly
patients
Marcelo A. Beltrn Karina S. Cruces
Received: 6 June 2006 / Accepted: 17 July 2006 / Published online: 17 August 2006
Springer-Verlag 2006
Abstract
Background The outcomes of open tension-free her-
nioplasty have been evaluated for elderly patients and
compared with other techniques without prosthesis or
analyzed in elderly patients without a control group
constituted by younger patients. Our aim was to com-
pare the outcomes of open tension-free hernioplasty
between elderly patients and younger patients applying
the recently developed Quantitative and Qualitative
Measurement Instrument (QQMI).
Methods From January 1997 to December 2003, 731
male patients were electively operated on for inguinal
hernia at our institution. We studied 688 patients
(94%). Forty-three (6%) were excluded: 12 died of
causes unrelated to inguinal surgery and 31 were lost to
follow-up. The follow-up period ranged from 22 to
106 months, mean 87 8.5 months.
Results Recurrence developed in seven patients
(1%): six were patients younger than 70 years old. The
Wnal mean QQMI score for patients younger than 70
years old was 10.4, signiWcantly higher than the score of
8.9 for elderly patients.
Conclusion The outcomes of open tension-free her-
nioplasty were better in patients younger than 70 years
old than the outcomes for elderly patients.
M. A. Beltrn K. S. Cruces
Department of Surgery,
Hospital De Ovalle, Ovalle, Chile
M. A. Beltrn (&)
P.O. Box 308, Plazuela Baquedano 240,
Ovalle, IV Region, Chile
e-mail: beltran_01@yahoo.com
Keywords Open tension-free hernioplasty
Lichtenstein Inguinal hernia Elderly patients
Introduction
The repair of inguinal hernia is one of the most fre-
quent surgical procedures performed by surgeons [1
14]. The open tension-free Lichtenstein hernioplasty
(LH) constitutes the current gold standard for the elec-
tive repair of inguinal hernia in men [18]. Inguinal
hernia in patients older than 71 years old is a common
pathological condition seen in surgical departments
and emergency units; as a consequence, surgeons must
often perform inguinal hernia surgery in these elderly
patients [26, 79, 15]. Many authors have reported the
characteristics and outcomes of inguinal hernia surgery
in the elderly [914], and some studies have compared
the LH with other techniques that did not use prosthe-
sis or have analyzed the surgical outcomes in elderly
patients without a control group of younger patients [9,
1114]. The aim of the present study was to compare
the outcomes of LH in elderly patients with the out-
comes of LH in younger patients, applying the recently
developed Quantitative and Qualitative Measurement
Instrument (QQMI) [8].
Patients and methods
The records of all adult patients undergoing elective
inguinal hernia repair at our institution from January
1997 to December 2003 were reviewed. During that
period, 731 male patients underwent LH; of them, 688
patients (94%) completed the follow-up. Forty-three
123
396 Hernia (2006) 10:395400

patients (6%) were excluded: there were 12 deaths
(1.7%), none related to LH, and 31 patients (4.2%)
were lost to follow-up. Consequently, we studied 558
patients (81%) 70 years of age or younger and 130
(19%) elderly patients 71 years of age or older. The
follow-up consisted of a personal interview and physi-
cal examination and was performed from June to Octo-
ber 2005. The QQMI was applied during the interview.
The follow-up period ranged from 22 to 106 months,
with a mean of 87 8.5 months.
Study design
The design corresponds to qualitative and quantitative
research comparing surgical outcomes in a consecutive
non-randomized controlled sample with a prospective
longitudinal phase. The study applies a disease-speciWc
measurement instrument designed for the purpose of
measuring the LH outcomes [8]. For all patients, a pro-
tocol including categorical and continuous variables
was completed together with a pre-printed QQMI
sheet. Information about complications, preoperative
and postoperative symptoms gathered from patients
during the interview was compared with data from the
clinical record.
ClassiWcation and deWnitions
We classiWed inguinal hernias according to Gilbert
[16], Rutkow and Robbins [17]. We deWned elderly
patients as any patient of 71 years of age or older.
Chronic inguinodynia was deWned as the spectrum of
pain developed over the surgical site that persisted for
more than 1 year after a surgical procedure aimed to
repair an inguinal hernia was performed [18].
QQMI
the satisfaction of the patient with his surgery and
explore the reasons why patients are satisWed or not with
surgery, also exploring the reasons why they would
undergo another hernia surgery or not. The Wnal score
obtained allows for stratiWcation of the results into Wve
levels of LH outcomes [8].
Statistical analysis
Continuous variables were expressed as the mean
standard deviation; categorical variables were
reported as a percentage. The comparative analysis
was performed with Students t test for categorical vari-
ables and the Pearson chi2 test for continuous vari-
ables. Fisher's exact test was used if any expected value
in a 2 2 table was less than 5. The statistical signiW-
cance level was deWned at P < 0.05. Data were ana-
lyzed with the statistical software SPSS version 11.0
(Chicago, Ill.).
Results
Indirect hernia type 1 was more frequent in patients
younger than 70 years of age. In elderly patients,
indirect hernia type 3, direct hernia type 4 and com-
bined hernia type 6 were more frequent. A higher
non-signiWcant proportion of recurrent hernias was
repaired in elderly patients (Table 1). Eighty-two
percent of the patients younger than 70 years of age
did not have associated morbidity, and 68% of the
elderly patients presented with one or more associ-
ated medical diseases. A higher proportion of
patients younger than 70 years of age had a body
mass index (BMI) higher than 30 and consumed
tobacco, alcohol or both. Most elderly patients had
previous surgery, principally urological procedures
(Table 2).

This instrument has seven items designed to measure

the domains of health-related quality of life: physical, Table 1 ClassiWcation
psychological and social. Additionally, it permits the <70 years >71 years P
structured evaluation and report of the surgical out-
N: 558 (%) N: 130 (%)
comes of inguinal hernioplasty. Item 1 measures the psy-
chological domain and introduces the patient and Type
interviewer to the interview. Item 2 measures the 1 260 (47) 14 (11) <0.001
2 82 (15) 23 (18) NS
patients social domain and evaluates preoperative
3 85 (15.2) 30 (23) NS
symptoms. Item 3 measures the physical domain and 4 100 (18) 41 (31.5) <0.05
evaluates late complications. Item 4 addresses early 5 12 (2) 7 (5.4) NS
postoperative complications and most of the surgical 6 19 (3) 15 (11.5) <0.05
outcomes traditionally reported. Item 5 measures the Class
physical and social domains. Items 6 and 7 measure the Primary 475 (85) 102 (78.5) NS
Recurrent 83 (15) 28 (21.5) NS
psychological, physical and social domains; they evaluate

123
Hernia (2006) 10:395400 397

Table 2 Past clinical history developed in 60 patients younger than 70 years and 19
Medical a
<70 years >71 years P elderly patients and persisted in seven and ten
patients, respectively (Fig. 1 ). Eighty-one complica-
N: 558 (%) N: 130 (%)
tions developed in 67 patients younger than 70 years
Arterial hypertension 118 (21) 74 (57) <0.02 and 63 complications in 46 elderly patients (item 4,
Diabetes 39 (7) 6 (4.6) NS Tables 3 and 4). There were seven recurrences (1%) in
Chronic heart disease 8 (1.4) 35 (27.5) <0.001 the whole series; six recurrences developed in patients
Chronic lung disease 21 (3.7) 8 (6) NS
younger than 70 years and one in elderly patients
Neurological diseases 4 (0.7) 2 (1.5) NS
Gastrointestinal diseases 6 (1) 11 (8.4) NS (Table 4). Physical performance was improved in
Chronic kidney disease 1 (0.2) 4 (3) NS 91.4% patients younger than 70 years and 35.4% eld-
Psychiatric disorders 2 (0.3) 1 (0.7) NS erly patients (item 5, Table 3). Most patients in both
None 457 (82) 42 (32.4) <0.001
groups were satisWed with their surgery; stated reasons
Body mass index >30 165 (29.5) 23 (18) <0.05 were the possibility to return to work and move with-
Habits
Cigarette smoking 134 (24) 17 (13) <0.05 out any nuisance in patients younger than 70 years and
Alcohol consumption 306 (55) 58 (44.6) <0.05 the absence of preoperative inguinodynia, inguinal
Surgicalb bulge and improvement of mobility in elderly patients.
Urological 108 (19.3) 94 (72) <0.001 The reasons why some patients were unsatisWed with
Biliary 201 (36) 56 (43) NS their surgery were chronic inguinodynia and hernia
Hepatic 13 (2.3) NS
Gastric 5 (1) 3 (2.3) NS
recurrence (item 6, Table 3). Ninety-three percent of
Intestinal 3 (0.5) 7 (5.4) NS the patients younger than 70 years and 51.5% of the
Colonic 4 (0.7) 9 (7) NS elderly patients would undergo another inguinal her-
Appendectomies 217 (39) 68 (52.3) <0.05 nia surgery. Seven percent of the patients younger
Otherc 37 (6.6) 35 (27) <0.05
than 70 years and 48.5% of the elderly patients would
a
Some patients could have one or more medical morbidities not undergo another surgery, and the reasons stated
b
Some patients could have one or more surgeries were diVerent; in patients younger than 70 years, the
c
Thyroid, orthopedic and incisional hernia surgery most frequent reason was the fear of complicationsin
the postoperative period; in elderly patients, the main
The majority of patients in both groups stated that reason was the advanced age of the patient (item 7,
they felt very good or excellent regarding their ingui- Table 3). The Wnal QQMI score highlights the higher
nal hernia surgery (item 1, Table 3). Preoperative proportion of elderly patients with 810 points and the
symptoms associated to inguinal hernia persisted in
two elderly patients and six patients younger than
70 years (item 2, Table 3). Postoperative inguinodynia
25
< 70 years
> 71 years

Table 3 Final outcomes according to the QQMI 20

QQMI items <70 years >71 years P

15
Patients (%)

14,6
N: 558 (%) N: 130 (%) P=NS

How do you feel about your inguinal hernia surgery? 10,7

10
Excellent 520 (93) 111 (85.4) NS 7,7
Very good 13 (2.3) 10 (8) NS
Good 12 (2.1) 4 (3) NS 5 P<0,05
Better 5 (1) 3 (2.3) NS
Same as before 5 (1) 2 (1.5) NS 1,2
Bad worse 3 (0.5) 3 (2.3) NS 0
Preoperative inguinodynia 6 (1) 2 (1.5) NS 1 - 60 days > 12 months
Chronic inguinodynia 7 (1.2) 10 (7.7) <0.05
-5
Postoperative 81 (14.5) 63 (48.4) <0.02
complications Inguinodynia
Improvement of physical 510 (91.4) 46 (35.4) <0.001
performance Fig. 1 A small proportion of patients with postoperative inguin-
Satisfaction with surgery 543 (97) 125 (96) NS odynia persisted with this symptom for less than 60 days. Seven
Would undergo 520 (93) 67 (51.5) <0.001 patients younger than 70 years of age and ten elderly patients
another surgery developed chronic inguinodynia that persisted for more than
1 year after surgery

123
398 Hernia (2006) 10:395400

Table 4 (item 4) Did you have any complication after your sur- 115
< 70 year
gery? > 71 years 89

<70 years <71 years P 95

N: 558 (%) N: 130 (%)

Patients (%)
75 48,4
Patients with 67 (12) 46 (35.4) <0.05 40,7
complications 55
Complicationsa 81 (14.5) 63 (48.4) <0.05
Urinary retention 11 (2) 26 (20) <0.05
Testicular swelling 16 (2.8) 10 (7.7) <0.05 35
3,8 4,6
Local echymoses 19 (3.4) 11 (8.4) NS 2,3
Local hematomab 21 (3,7) 8 (6) NS 15 1,6 1,2 2,7 5,4
Recurrencec 6 (1) 1 (0.7) NS
Pneumonia 2 (1.5) NS
Hydrocele 4 (0.7) 1 (0.7) NS -5
0 - 3 VB 4-5B 6-7G 8 - 9 VG 10 - 11 E
Surgical site seroma 2 (0.3) 4 (3) NS
Foreign material Wstula 1 (0.2) NS Score
a Fig. 2 Qualitative and quantitative measurement instrument for
Some patients could have one or more complications
b the results of Lichtenstein hernioplasty: VB very bad, B bad, G
Eleven local hematomas were explored: six in patients younger
than 70 years of age and Wve in patients older than 71 years of age good, VG very good, and E excellent. Notice the signiWcant diVer-
c
ence (P < 0.05) favoring patients younger than 70 years of age in
One patient younger than 70 years of age not yet resolved the excellent (E) outcomes level
(recurrent hernia secondary to Lichtenstein hernioplasty)

signiWcant majority of patients younger than 70 years Discussion

with 11 points. The mean QQMI score for patients
younger than 70 years was 10.4, signiWcantly higher The outcomes of surgical procedures seen from the
than the mean QQMI score of 8.9 for elderly patients point of view of patients are diVerent than the same
(Table 5). outcomes seen by surgeons [1921]. This frequently
Final QQMI outcomes demonstrated that in 94.4% unrecognized fact has led to the development of ques-
of patients younger than 70 years and 89% of elderly tionnaires and measurement instruments for surgical
patients, the outcomes were classiWed as very good or procedures with the aim to analyze the outcomes from
excellent. In the 10 to 11 points levels, the diVerence the points of view of patients and surgeons [6, 8, 19,
signiWcantly favored patients younger than 70 years of 21]. A validated generic quality-of-life measurement
age (Fig. 2). The mean length of stay in patients youn- instrument like the SF-36 has been applied associated
ger than 70 years was 1.6, signiWcantly lower than the to speciWc questionnaires over a speciWc pathology or
2.1 days for elderly patients (P < 0.05). surgical procedure like LH [19]; this design has some
disadvantages: (1) the complexity of completing, mea-
suring and interpreting the SF-36 abbreviated instru-
Table 5 Final QQMI score ment; (2) the socio-cultural level and education of the
Points <70 years >71 years P patient does not always allow its application; (3) this is
a written instrument, frequently sent by mail, and not
N: 558 (%) N: 130 (%)
always welcomed or returned for the reasons previ-
0 1 (0.2) NS ously stated. In 1989, Irving Lichtenstein stated that
1 2 (1.5) NS written questionnaires are notoriously inexact [1]. The
2 5 (1) 1 (0.7) NS QQMI is based on the concepts of health-related qual-
3 3 (0.5) 2 (1.5) NS
4 2 (0.3) 2 (1.5) NS ity-of-life and Lichtenstein recommendations. It struc-
5 5 (1) 4 (3) NS tures the evaluation of the patient based on a speciWc
6 4 (0.7) NS questionnaire that is associated with information gath-
7 11 (2) 3 (2,3) NS ered from the clinical records and allows a complete
8 7 (1.2) 21 (16.1) <0.05
9 22 (4) 42 (32.3) <0.001 and accurate evaluation of the outcomes of inguinal
10 99 (18) 37 (28.4) <0.05 hernioplasty [8].
11 399 (72) 16 (12.3) <0.001 Inguinal hernia frequently aVects elderly patients
Mean SD 10.4 1.5 8.9 1.9 <0.05 due to a weakened abdominal wall associated with
SD Standard deviation diverse risk factors and pathology, increasing intraab-

123
Hernia (2006) 10:395400
dominal pressure [13, 14, 22]. An important proportion
of elderly patients requires emergency surgery because
they suVer complications of the inguinal hernia [9, 13
15, 22]. For these patients, the morbidity rate ranges
from 3.7 to 58.3% and the mortality rate from 0 to
14%. These are the reasons why inguinal hernia should
be electively repaired principally in the elderly [3, 10
14, 22]. In this series, most hernias were indirect. In
patients younger than 70 years, hernias type 1 with a
small sac and a slightly dilated internal ring predomi-
nated. In elderly patients, indirect hernias types 2 and 3
with bigger sacs and more dilated internal rings related
to a longer time of evolution of the hernia were fre-
quent. In elderly patients, direct inguinal hernias type 4
and combined hernias type 6 were commonly found;
this denotes the weakened inguinal posterior wall asso-
ciated with older age, higher incidence of systemic
pathology, nutritional and metabolic problems and
higher intraabdominal pressure [9, 13, 14, 2225]. The
higher proportion of recurrent hernias operated on in
elderly patients represents the recurrence of herni-
orrhaphies operated on before the use of prosthetic
repairs was Wrmly established in our institution.
Among risk factors for the development of inguinal
hernias and related surgical complications, associated
systemic pathology, BMI over 30 and the consumption
of tobacco and alcohol have been described [3, 913].
In this series, 32.4% of the elderly patients did not have
associated systemic pathology. Patients younger than
70 years of age had a signiWcantly lower proportion of
associated pathology, the most frequent being arterial
hypertension and chronic heart and lung diseases;
these Wndings are in accord with previous reports [13].
The higher proportion of associated pathology in eld-
erly patients explains why the repair of their inguinal
hernias did not improve the physical performance in
64.6% of the patients. In 29.5% of the patients younger
than 70 years and in 17.7% of the elderly patients, the
BMI was higher than 30. This signiWcant diVerence
favoring patients younger than 70 years was related to
the nutritional status and economic income of this
group of patients. Tobacco smoking is not frequent
among our patients, but the opposite is true for the
consumption of alcohol; an important proportion of
patients younger than 70 years consume alcohol.
The QQMI item 1 is an introductory item and habit-
ually sets the tone of the interview and the possible
Wnal score [8]. The results of this item in both groups
were similar. Chronic inguinodynia was deWned as
inguinal pain that can be severe and debilitating or
mild and aggravating, and represents a problem that
requires long-term treatment [18, 2629]. Inguinodynia
is also the most frequent symptom referred to during
399
the preoperative period by inguinal hernia patients [6,
18, 2629]. Preoperative inguinodynia remained in 1%
of the patients younger than 70 years and 1.5% of the
elderly patients; these rates were similar to previously
reported rates [6, 8]. Postoperative inguinodynia is a
frequent event that eventually resolves without any
speciWc treatment; whenever the pain persists for more
than 1 year, it is considered chronic inguinodynia [5, 6,
18, 2629]. In some cases, the pain is really severe, and
many therapeutic strategies have been proposed to
resolve it [18, 29, 30]. Eleven percent of the patients
younger than 70 years and 14.6% of the elderly
patients developed postoperative inguinodynia. After
60 days, it resolved in most patients. Inguinodynia
remained in 1.2% of the patients younger than 70 years
and 7.7% of the elderly patients; this was a signiWcant
diVerence for one of the most important parameters
for the evaluation for LH outcomes [6, 18]. Frequently
reported complications include local hematoma and
echymoses, scrotal edema, postoperative pneumonia
and urinary retention [5, 6, 11, 12, 14]. Hemorrhagic
complications were the most frequent complications
developed in this series; elderly patients also had an
important rate of urinary retention. Urinary retention
in elderly patients was related to urological diseases
and to the kind of anesthesia used. The recurrence rate
was similar between patients younger than 70 years
and elderly patients (1.1 and 0.7%, respectively). The
general recurrence rate was 1%, within the expected
rate for this surgery [18].
Item 6 investigate the satisfaction of the patient with
LH and the reasons for this satisfaction. Most patients
were satisWed in both groups. However, the reasons for
this satisfaction were diVerent. In patients younger
than 70 years, the main reason was the fact of returning
to work without any nuisance; this fact was in accord
with the composition of this group, with most patients
in their productive years. In elderly patients, the rea-
sons for satisfaction were the resolution of preopera-
tive inguinodynia and inguinal bulge that in most cases
had made normal movement diYcult. The willingness
to undergo another inguinal surgery is an important
parameter that previously has been validated for the
evaluation of LH [6, 8]. Most patients younger than
70 years stated that they would undergo another sur-
gery; however, a signiWcant proportion of elderly
patients would not. Patients who would undergo
another inguinal hernia repair would do that because
they felt that LH resolved their problem. Elderly
patients who would not undergo another surgery state
that the reason for this was advanced age; in patients
younger than 70 years, the reasons stated were the
presence of current chronic inguinodynia and fear of
123
400
the postoperative complications suVered. The general
tendency, frequently signiWcant, was towards better
outcomes in patients younger than 70 years of age. This
is a fact habitually presumed. The Wnal QQMI score
demonstrates that patients younger than 70 years had
better outcomes compared with elderly patients.
Conclusion
The outcomes of Lichtenstein hernioplasty according
to the QQMI are better for patients younger than
70 years of age than for elderly patients.
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