2020 General Surgery Presentations

Brooke A Pati, MD, Chan W Park, MD; Tripler Army Medical Center

INTRODUCTION: A large number of abdominal hernias require emergency surgery. This is concerning because abdominal wall hernias are very common, with inguinal hernia repair previously thought to be the most commonly performed operation in the United States. The typical indication for emergent abdominal hernia repair is incarceration. Current recommendations for asymptomatic abdominal wall hernias suggest elective repair. However, for many hernia locations such as inguinal, watchful waiting may also be a viable option. Alternatively, for femoral and other high-risk hernias, elective repair remains the standard of care despite symptomatology.Emergency operations remain one of the most common and challenging surgical emergencies associated with a significant burden for health care systems globally.

METHODS: A retrospective cohort review of National Inpatient Samples using International Classification of Disease, ninth revision codes to identify patients undergoing acute hernia repairs from 2007-2015 was performed. All cases that included a hernia in any of the procedure codes were included. Hernia was the primary code in just over half of the cases (53%). Multivariable logistic regression model was performed to identify clinically relevant risk factors and outcomes for acute hernia repairs.

RESULTS: We identified nearly 400,000 inpatient abdominal hernia repairs from Jan 1, 2007 to Sep 30, 2015. Umbilical hernia surgery alone had the highest incidence (21%), followed by inguinal (14%), and femoral (2%). Incisional, which included ventral and umbilical hernias made up 58% of cases. This differs from other studies that identify inguinal hernia as the most common. The umbilical hernia numbers from the NIS database are higher than previously described (6-14%). This is likely multi-factorial including an increase in incidentally found umbilical hernias during laparoscopy and an increase in repairing smaller umbilical hernias.

About half of surgeries were emergent and among all cases, 45.3% were incarcerated. Interestingly, the rate of incarcerated hernias increased each year from 2007 to 2015 (51% to 59%). Additionally, our analysis demonstrated that there was an increased likelihood of death for incarcerated hernia repair (OR 1.13; 95% CI =1.03,1.23; p=0.008).  Patient age was also identified as a significant risk factor for mortality, such that as age increased so did the adjusted odds-ratio of mortality.

CONCLUSIONS: Age and the presence of incarceration are associated with increased mortality in abdominal wall hernia surgery. Due to the rising rates of incarcerated abdominal wall hernia repairs and associated complications, elective repair should be considered after diagnosis to minimize the risk of adverse outcomes.