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Hernia (2006) 10:395400

DOI 10.1007/s10029-006-0121-3


The outcomes of open tension-free hernioplasty in elderly

Marcelo A. Beltrn Karina S. Cruces

Received: 6 June 2006 / Accepted: 17 July 2006 / Published online: 17 August 2006
Springer-Verlag 2006

Abstract Keywords Open tension-free hernioplasty

Background The outcomes of open tension-free her- Lichtenstein Inguinal hernia Elderly patients
nioplasty have been evaluated for elderly patients and
compared with other techniques without prosthesis or
analyzed in elderly patients without a control group Introduction
constituted by younger patients. Our aim was to com-
pare the outcomes of open tension-free hernioplasty The repair of inguinal hernia is one of the most fre-
between elderly patients and younger patients applying quent surgical procedures performed by surgeons [1
the recently developed Quantitative and Qualitative 14]. The open tension-free Lichtenstein hernioplasty
Measurement Instrument (QQMI). (LH) constitutes the current gold standard for the elec-
Methods From January 1997 to December 2003, 731 tive repair of inguinal hernia in men [18]. Inguinal
male patients were electively operated on for inguinal hernia in patients older than 71 years old is a common
hernia at our institution. We studied 688 patients pathological condition seen in surgical departments
(94%). Forty-three (6%) were excluded: 12 died of and emergency units; as a consequence, surgeons must
causes unrelated to inguinal surgery and 31 were lost to often perform inguinal hernia surgery in these elderly
follow-up. The follow-up period ranged from 22 to patients [26, 79, 15]. Many authors have reported the
106 months, mean 87 8.5 months. characteristics and outcomes of inguinal hernia surgery
Results Recurrence developed in seven patients in the elderly [914], and some studies have compared
(1%): six were patients younger than 70 years old. The the LH with other techniques that did not use prosthe-
Wnal mean QQMI score for patients younger than 70 sis or have analyzed the surgical outcomes in elderly
years old was 10.4, signiWcantly higher than the score of patients without a control group of younger patients [9,
8.9 for elderly patients. 1114]. The aim of the present study was to compare
Conclusion The outcomes of open tension-free her- the outcomes of LH in elderly patients with the out-
nioplasty were better in patients younger than 70 years comes of LH in younger patients, applying the recently
old than the outcomes for elderly patients. developed Quantitative and Qualitative Measurement
Instrument (QQMI) [8].

Patients and methods

M. A. Beltrn K. S. Cruces
Department of Surgery,
Hospital De Ovalle, Ovalle, Chile The records of all adult patients undergoing elective
inguinal hernia repair at our institution from January
M. A. Beltrn (&)
1997 to December 2003 were reviewed. During that
P.O. Box 308, Plazuela Baquedano 240,
Ovalle, IV Region, Chile period, 731 male patients underwent LH; of them, 688
e-mail: beltran_01@yahoo.com patients (94%) completed the follow-up. Forty-three

396 Hernia (2006) 10:395400

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

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-
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
Some patients could have one or more medical morbidities not undergo another surgery, and the reasons stated
Some patients could have one or more surgeries were diVerent; in patients younger than 70 years, the
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
< 70 years
> 71 years

Table 3 Final outcomes according to the QQMI 20

QQMI items <70 years >71 years P

Patients (%)

N: 558 (%) N: 130 (%) P=NS

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

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
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

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-
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-

Hernia (2006) 10:395400 399

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

400 Hernia (2006) 10:395400

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