Incarcerated groin hernias in adults: Presentation and outcome

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1 Hernia (2004) 8: DOI /s ORIGINAL ARTICLE J. A. A lvarez Æ R. F. Baldonedo Æ I. G. Bear J. A. S. Solı s Æ P. A lvarez Æ J. I. Jorge Incarcerated groin hernias in adults: Presentation and outcome Received: 18 March 2003 / Accepted: 13 October 2003 / Published online: 19 November 2003 Ó Springer-Verlag 2003 Abstract Despite universal acceptance of the value of elective hernia repair, many present with incarceration or strangulation, which are associated with significant morbidity and mortality. We reviewed 147 who underwent emergency surgery for incarcerated groin hernias during a 10-year period in order to analyze the presentation and outcome in our practice. Median age of the was 70 years. There were 77 men and 70 women. Femoral hernias were seen in 77 and inguinal hernias in 70. Coexisting diseases were found in 82 cases (55.8%). Bowel resection was required in 19 (12.9%). The overall and major morbidity rates were 41.5% and 9.6%, respectively. The mortality rate was 3.4%. Longer duration of symptoms, late hospitalization, concomitant diseases, and high ASA class were found to be significant factors linked with unfavorable outcomes. Because of high morbidity and mortality associated with incarceration, elective repair of groin hernias should be done whenever possible. Keywords Groin hernia Æ Incarceration Æ Strangulation Æ Hernia repair Æ Complications Æ Mortality Introduction Groin hernias are among the most common problems encountered by surgeons and may have significant complications. Anterior abdominal wall hernia occurring with strangulation is a serious surgical emergency, as it is associated with high morbidity and mortality J. A. A lvarez (&) Æ R. F. Baldonedo Æ I. G. Bear J. A. S. Solís Æ P. A lvarez Æ J. I. Jorge Service of General Surgery, Hospital San Agustı n, Avilés, Spain josealvar@telecable.es Tel.: Fax: Present address: J.A.A lvarez Avenida de Galicia 46 3 A, Oviedo, Spain [1, 2]. It is generally agreed that a hernia should be electively repaired to avoid the complicated presentations [3]. Nevertheless, many remain undiagnosed or are reluctant to have surgical correction of hernias, and, as a result, many emergency procedures are performed for complications of neglected hernias. Compared to uncomplicated hernias, the treatment of which has made great progress in modern times, complicated hernias have been relatively neglected, for fear that their treatment may cause even greater risk to the patient than the hernia itself [4]. This report is of a consecutive series of 147 adults with incarcerated groin hernias during a 10-year period from a district general hospital in northern Spain with a catchment population of 180,000. We analyzed all incarcerated groin hernias in adults repaired on an emergency basis during the study period in order to evaluate the clinical presentation and outcome. Patients and methods The records of all adult who underwent emergency surgery for preoperative diagnosis of incarcerated groin hernia between January 1992 and December 2001 in our hospital were retrospectively reviewed. Incarceration was defined as irreducibility of an external hernia and strangulated hernia as irreducible with objective signs of ischemia or gangrene. The case notes were obtained and the following information recorded: age, sex, type of hernia, characteristics of clinical presentation, duration of symptoms, past medical history, and significant concomitant diseases, ASA class, type of anesthesia, contents of the hernial sac, surgical procedures, complications, duration of hospital stay, and mortality. Duration of symptoms was established as the period from the symptomsõ onset caused by incarceration to hospital admission. Significant concomitant diseases were represented by malignancies and severe major organ dysfunction and were defined as present if the patient was receiving specific drug therapy. Each patient was classified according to the physical status scale of the American Society of Anesthesiologists or ASA class (Table 1) [5], which assigns a risk level for surgery and anesthesia. Surgery was performed under local, spinal, or general anesthesia in accordance with the patientõs physiological status and the anesthetistõs opinion. The method of hernia repair was determined by the individual surgeonõs preference. The outcome was analyzed with respect to the hospital

2 122 Table 1 American Society of Anesthesiologists physical status classification Class I II III IV V stay, complications, and mortality within 30 days of the operation or before discharge from the hospital. Major complications were defined as those affecting major organ systems. Data were compiled and analyzed by using a commercial statistical software (SPSS for Windows, Chicago, Ill. USA). All continuous data are expressed as mean±sd; categorical variables are reported as a percentage. The statistical comparative analysis was performed by chi-square test (with YatesÕ correction where appropriate) for qualitative data. Fisher exact test was used instead of the chi-square test if any expected cell value in a 2 2 table was less than 5. Mann-Whitney U tests were used for quantitative data. Significance was defined as P<0.05. Results Description Healthy patient Mild systemic disease, no functional limitation Severe systemic disease that limits activity but is not incapacitating Severe systemic disease that is a constant threat to life Moribund patient unlikely to survive 24 h with or without an operation In event of emergency operation, Class I can be designated as Class II During the study period, a total of 230 underwent emergency operations for incarcerated external hernias. Of these, 147 (63.9%) had groin hernias, which were the object of the current study. The median age of the was 70±15.2 years, ranging from 24 to 96 years. Ninety-eight (66.7%) were over 65 years of age. Type and location of hernias and their distribution according to sex are shown in Table 2. There were 77 men (52.4%) and 70 women (47.6%). Fourteen (9.5%) had recurrent hernias (12 male and two female). Femoral hernias were seen in 77 cases and inguinal hernias in 70. Of all inguinal hernias, 53 cases (75.7%) were indirect and 17 (24.3%) direct. Inguinal hernias were significantly more common in male, while femoral hernias were more frequent in female. Inguinal and femoral hernias were more common on the right side in men and women, with a right-to-left ratio of 2:1 in both hernia types. The duration of hernia was only recorded in 74 cases (50.3%), and the mean duration was 6±7.5 years, ranging from 1 day to more than 40 years. Eight had hernias for more than 10 years. Nineteen hernias (12.9%) were chronically incarcerated (10 inguinal and nine femoral). The most common presenting clinical findings for emergency admission were an irreducible mass in the abdominal wall and localized pain seen in 133 cases (90.5%). Ninety-nine (67.3%) presented signs and symptoms of mechanical bowel obstruction. Duration of symptoms prior to admission varied from a few hours to 6 days with a mean duration of 1.7±0.9 days. Eighty-two (55.8%) presented within 24 h of symptoms onset, and 42 (28.6%) presented after 48 h. Significant concomitant medical illnesses were found in 82 cases (55.8%) (Table 3). In both sexes, essential hypertension and cardiovascular disorders were the commonest problems seen. Seventeen men had prostatic enlargement or a history of prostatectomy. Eight had been treated previously for a malignant disease. One hundred and one (68.7%) were ASA class II, 42 (28.6%) were ASA class III, and four (2.7%) were ASA class IV. There was no mortality in ASA class II, only three cases (7.1%) in ASA class III, and two (50%) in ASA class IV. Mortality was significantly related to ASA classification (P<0.0001). Morbidity rates were also found to be increased with the ASA classification, 31 cases (30.7%), 26 (61.9%), and four (100%) for ASA class II, III, and IV, respectively (P<0.0001). Surgical repair was performed under general anesthesia in 72 cases (49%), spinal anesthesia in 74 cases (50.3%), and local anesthesia in one (0.7%). General anesthesia was the most used technique in femoral hernias (53.2%), while spinal anesthesia was the most performed in inguinal hernias (55.7%). Contents of the hernial sac were only ileum in 55 (37.4%), only omentum in 40 (27.2%), ileum with omentum in 16 (10.8%), only colon in six (4.1%), ileum with colon in four (2.7%), colon with omentum in two (1.4%), testicle in four, appendix in three (2%), urinary bladder in two, MeckelÕs diverticulum in one patient, and preperitoneal tissue in 14 (9.5%). A strangulated hernia was seen in 61 cases (41.5%), and necrotic bowel resection was required in 19 (12.9%), 16 of them (84.2%) were older than 65 years. Small bowel resection was performed in 18 cases and colon resection in one case. The strangulation and bowel-resection rates, according to hernia types, are shown in Table 4. Femoral hernias carried a greater proportion of strangulation and bowel resection than inguinal hernias. Strangulation was found in two of the Table 2 Sex incidence and location of 147 incarcerated groin hernias Hernia types Sex Right hernia Left hernia Bilateral hernia Right/Left ratio Male/Female ratio Total Values in parentheses are percentages; * P< Inguinal Male (40.1) * Female (7.5) Femoral Male (12.3) Female (40.1) *

3 123 Table 3 Important coexisting diseases in 82 Values in parentheses are percentages Male Female Total Arterial hypertension 17 (22.1) 22 (31.4) 39 (26.5) Cardiovascular disorders 15 (19.5) 17 (24.3) 32 (21.8) Atrial fibrillation 6 6 Previous myocardial infarction 4 3 Valvular heart disease 2 2 Congestive heart failure 2 6 Myocardiopathy 1 Chronic obstructive pulmonary disease 13 (16.9) 2 (2.9) 15 (10.2) Diabetes mellitus 3 (3.9) 3 (4.3) 6 (4.1) Prostatic diseases 17 (22.1) 17 (11.6) Prostatic enlargement 13 Previous prostatectomy 4 Previous stroke 3 (3.9) 5 (7.1) 8 (5.4) Malignancy 5 (6.5) 3 (4.3) 8 (5.4) Chronic renal failure 2 (2.6) 1 (1.4) 3 (2.1) Cirrhosis 2 (2.6) 2 (1.4) Others 6 (7.8) 9 (12.9) 15 (10.2) 17 with direct inguinal hernia (11.8%) and in 17 of 53 (32.1%) with indirect inguinal hernia (P=0.09). Surgical techniques adopted for hernia repair are reported in Table 5. In the series, the tension-free hernioplasty was the most common preferred procedure. The other surgical procedures performed during hernia repair were three appendectomies, three orchidectomies, two hydrocelectomies, one MeckelÕs diverticulectomy, and one reparation of urinary bladder by incidental lesion, which was successfully repaired. The counter incision was required in 14 (9.5%). Eleven of the 14 (78.6%) who required an additional incision developed some type of complication. This circumstance was found to have significant influence on morbidity (P=0.003) but not on mortality. Considering all the series, there were postoperative complications in 61 cases (41.5%). Some type of complication was encountered in 48 of 98 (49%) older than 65 years and in 13 of 49 (26.6%) equal or below age 65 years (P=0.009). Major complications were noted in 14 cases (9.6%), 12 of whom (85.7%) had important concomitant diseases. The most frequent serious complications were pulmonary diseases in seven (4.8%) and cardiovascular disorders in five (3.4%). Pneumonia was seen in five cases and acute exacerbation of chronic obstructive pulmonary disease in two cases. Three experienced congestive heart failure, and one each had coronary artery disease and cardiac arrhythmia. Gastrointestinal bleeding occurred in two cases, and hepatic failure was seen in one patient with cirrhosis. Local wound complications developed in 42 (28.6%), of whom 17 had wound infections, 14 hematoma, ten seroma, and one wound dehiscence. Urinary retention was reported in six only after the removal of urinary catheter. Reoperations were necessary in four cases. The causes were necrosis of strangulated bowel, which was initially considered as viable in two cases, evisceration in one, and small bowel obstruction by adhesions in one other case. Postoperative mortality was recorded in five (3.4%), all of whom had significant coexisting illness and were over 65 years. There was no mortality in relation to hernia surgery. The causes of death were the following: respiratory failure in two who had chronic obstructive pulmonary disease (ASA class III and IV, respectively), sepsis in two who had undergone resection of necrotic bowel in reoperations (both ASA class III), and multiorgan failure in one case (ASA class IV). Mean hospital stay was 10±6.5 days, ranging from 1 43 days. Major postoperative complications carried longer periods of hospitalization (mean 17.9± 11.6 days). Overall and major morbidity and mortality were found in 48 cases (37.5%), 13 (10.1%), and five (3.9%) of 128 with viable bowel, and in 13 cases (68.4%), one (5.3%), and 0 (0%) of 19 after bowel resection, respectively (P=0.01, P=0.695, and P=0.495, respectively). The effects of factors, such as age, sex, hernia type, duration of hernia, late admission, concomitant diseases, ASA class, and anesthesiologic method on unfavorable outcome were statistically studied by univariate analysis Table 4 Strangulation and bowel-resection ratios, according to hernia types Hernia types Incarceration Strangulation Bowel-resection Inguinal 50 (71.4) 19 (27.1) 4 (5.7) Femoral 35 (45.5) 42 (54.6) 15 (19.5) Values in parentheses are percentages Table 5 Surgical techniques used for hernia repair Methods Patients Tension-free 45 (30.6) McVay 37 (25.2) Bassini 33 (22.4) Preperitoneal 32 (21.8) Values in parentheses are percentages

4 124 Table 6 Statistical analyses of factors responsible for unfavorable outcome Variables Strangulation Bowel resection Hospital stay days Morbidity a Mortality Values in parentheses are percentages; NS=No significant differences were observed; a Major complications; ASA=American Society of Anesthesiologists Age 65 years 17 (34.7) 3 (6.1) 7.5±4.7 2 (4.1) 0 (0) >65 years 44 (44.9) 16 (16.3) 11.3± (12.2) 5 (5.1) Significance NS NS P=0.000 NS NS Sex Male 27 (35.1) 6 (7.8) 9.7±6.8 7 (9.1) 3 (3.9) Female 34 (48.6) 13 (18.6) 10.4±6.2 7 (10.0) 2 (2.9) Significance NS P=0.05 NS NS NS Hernia type Inguinal 19 (27.1) 4 (5.7) 9.6±6.7 7 (10.0) 2 (2.9) Femoral 42 (54.5) 15 (19.5) 10.4±6.3 7 (9.1) 3 (3.9) Significance P= P=0.03 NS NS NS Duration of symptoms 10 years 19 (28.8) 5 (7.6) 9.1±6.7 6 (9.1) 1 (1.5) >10 years 5 (62.5) 2 (25.0) 8.0±4.1 3 (37.5) 2 (25.0) Significance NS NS NS P=0.05 P=0.03 Late hospitalization 48 h 41 (39.0) 14 (13.3) 8.6±5.1 6 (5.7) 1 (0.9) >48 h 20 (47.6) 5 (11.9) 13.5±8.2 8 (19.0) 4 (9.6) Significance NS NS P=0.000 P=0.03 P=0.03 Concomitant diseases No 21 (32.3) 6 (9.2) 7.7±4.4 2 (3.1) 0 (0) Yes 40 (48.8) 13 (15.9) 11.9± (14.6) 5 (6.1) Significance P=0.04 NS P=0.000 P=0.03 P=0.05 ASA class II 36 (35.6) 12 (11.9) 8.4±4.4 2 (2.0) 0 (0) III/IV 25 (54.3) 7 (15.2) 13.6± (26.1) 5 (10.9) Significance P=0.04 NS P=0.000 P=0.000 P=0.003 Type of anesthesia Spinal 24 (32.4) 9 (12.2) 8.8±6.3 6 (8.1) 2 (2.7) General 36 (50.0) 10 (13.9) 11.3±6.5 8 (11.1) 3 (4.2) Significance P=0.04 NS P=0.004 NS NS and are presented in Table 6. The length of hospital stay was significantly longer in with advanced age, delayed admission, concomitant medical illness, high ASA class, and in those with surgical repair performed under general anesthesia. Longer duration of symptoms, late hospitalization, coexisting disease, and high ASA class were found to be significant factors linked with morbidity and mortality. Discussion Despite universal acceptance of the value of elective hernia repair, strangulating groin hernias are still a frequent cause of acute abdomen [4]. This has been attributed not only to the fact that many, particularly elderly, incarcerate while they are on waiting lists for elective surgery [6], but also to other factors primarily responsible, such as a large proportion of hernias, particularly femoral, incarcerating before patient notification of the family doctor, lack of public awareness of the dangers of hernia incarceration, or reluctance on behalf of nonsurgical medical personnel to refer with known risk factors [7]. The median age was similar to that described in a previous report [1], and the relatively large number of older than 65 years was also published in another article [8]. Sex ratios according to type of hernia were consistent with previous publications [1, 8]. Rightsided inguinal and femoral hernias were more common than left ones. This ratio was higher than some studies [8, 9] and lower than the others [10]. Femoral hernias are found in only 2.3% of the hernia repairs of all types [11]; however, in clinical practice 20 40% of these hernias present as emergencies with strangulation or incarceration [2, 3, 12]. In contrast with other reviews of incarcerated hernias of all types where inguinal hernias predominated [1, 9], femoral hernias were the most frequent in our series. They comprised 69% of strangulating hernias, and bowel resection was more common in these than in inguinal hernias, as reported [10, 13]. The diagnosis is usually easier in incarcerated inguinal hernias than in femoral ones, but there is not any useful connection between clinical findings and bowel viability, since the definitive diagnosis of strangulation can be made only at the time of surgical exploration [1]. As previously mentioned [8, 10], the most frequently incarcerated viscera were, in decreasing frequency, small intestine, omentum, and colon. Open tension-free

5 125 hernioplasty was the method of repair most commonly used, in agreement with a recent trend [13, 14, 15, 16]. Management of incarcerated groin hernias is certainly not free from mortality. Past series recorded a mortality rate ranging from 2.6 9% [3, 8, 10]. Our percentage is near the lowest limit of this range. It is known that the mortality and the morbidity are related to the viability of entrapped bowel [1, 2, 3]. For this reason, it is necessary to emphasize the value of elective repairs before encountering incarceration. In this series, overall morbidity was significantly affected by bowel resection but not major morbidity nor mortality. Complications that develop in external hernias, such as irreducibility and obstruction, with or without strangulation may make an easily treatable condition a life-threatening one. Identification of risk factors that may predict development would help place the patient in a high-risk group. While not inherently impaired, the reserve capacity of the older individual to compensate for stress, metabolic derangement, and drug metabolism is increasingly limited. Functional disability occurs faster and takes longer to remediate, necessitating early preventive interventions [17]. Advanced age in the with incarcerated groin hernia has been associated with an unfavorable outcome [3, 12, 18]. In our experience, although this factor significantly affected overall morbidity, it was not a prognostic marker either for major morbidity or mortality. In spite of the higher proportion of strangulated cases and bowel resections in women and in femoral hernia type, neither female sex nor femoral hernia type have a significant negative influence on outcome, as described in a study on with incarcerated external hernias [9]. However, site of hernia (femoral) was an important risk factor in adults in another report [18]. In this series, there was not a significant difference between indirect and direct inguinal hernias with respect to strangulation rate, contrary to that reported in another article [19]. There are few and controversial studies in the literature examining the effect of the duration of hernias present on outcome. Postoperative complications have been found more commonly in with hernia more than 10 years [9]. We have found not only a high percentage of complications, but also a significantly higher mortality in these. This was contrary to another report [18] in which a higher risk for complications occurred in with a short history of herniation. Late hospitalization is generally considered to be an important factor determining resection and subsequent morbidity and mortality [1, 10, 20, 21]. Mostly, the cause of delay in admission is through the patientõs fault, but physiciansõ mistakes are also responsible in percentages varying from 12 33% [22, 23, 24]. Surprisingly, in this study, the resection requirement was not significantly affected by delayed hospitalization, but it was one of the main factors linked with unfavorable outcome. Concomitant diseases in with incarcerated groin hernias have been reported to be associated with poor outcome [18, 25]. We found that coexisting medical illness was an important determinant of morbidity. Moreover, this factor reached almost the statistical significance for mortality. The length of hospital stay was also encountered to be longer in with concomitant diseases. The ASA class considers the patientõs comorbidity and acute physiological disturbance and assigns a risk level for surgery and anesthesia. In a previous report of incarcerated anterior abdominal wall hernias, high ASA score was found to be an independent predictor of gangrenous bowel [26]. A significantly longer hospital stay and a significantly higher morbidity in elderly with ASA class III or IV who underwent emergency hernia repair was also reported [27]. In the present article, we not only confirmed a higher complications rate, but we also found a significantly higher mortality in with a high ASA grading. The effect of anesthesia on the outcome of hernia repair has been evaluated in the literature. In a report by Young [28] comparing type of anesthesia in elective inguinal herniorrhaphy, it was revealed that general and spinal anesthesia were associated with higher rates of postoperative complications. In another article by Kulah et al. [27], general anesthesia was not a factor affecting morbitity and mortality in emergency hernia repairs in elderly, suggesting that the majority of severe postoperative complications encountered with this anesthesiologic approach are directly related to coexisting diseases. This last circumstance was confirmed here, since, of 72 cases in the general anesthesia group, 29 (42.3%) were ASA class III or IV, while of 74 cases in the spinal anesthesia group, only 17 (22.9%) were ASA class III or IV (P=0.03). Therefore, apart from a longer hospital stay for with hernias repaired under general anesthesia, we could not identify general anesthesia type as a factor associated with a poor outcome. In conclusion, our experience demonstrates that complications following emergency groin hernia repair in adults is a serious problem and may make an easily treatable condition a lethal one. Bowel resections were mainly related to femoral hernia. Overall morbidity was significantly affected by bowel resection but not mortality. Longer duration of symptoms, late hospitalization, coexisting medical illness, and high ASA class were found to be responsible for unfavorable outcomes. Because of high morbidity and mortality associated with incarceration, early diagnosis and elective repair of uncomplicated groin hernias should be done whenever possible. Acknowledgements The authors would like to thank Ms. Marı a Jose Martínez Samalea for her support in the translation of this report. References 1. Andrews NJ (1981) Presentation and outcome of strangulated external hernia in a district general hospital. Br J Surg 68: Haapaniemi S, Sandblom G, Nilsson E (1999) Mortality after elective and emergency surgery for inguinal and femoral hernia. Hernia 3:

6 Oishi SN, Page CP, Schwesinger WH (1991) Complicated presentations of groin hernias. Am J Surg 162: Stoppa RE (1989) The treatment of complicated groin and incisional hernias. World J Surg 13: Owens WD, Felts JA, Spitznagel EL Jr (1978) ASA Physical Status Classifications: a study of consistency of ratings. Anesthesiology 49: Allen PI, Zager M, Goldman M (1987) Elective repair of groin hernias in the elderly. Br J Surg 74: McEntee GP, OÕCarroll A, Mooney B, Egan TJ, Delaney PV (1989) Timing of strangulation in adults hernias. Br J Surg 76: Hjaltason E (1981) Incarcerated hernia. Acta Chir Scand 147: Kulah B, Kulacoglu IH, Oruc MT, Duzgun AP, Moran M, Ozmen MM, Coskun F (2001) Presentation and outcome of incarcerated external hernias in adults. Am J Surg 181: Brasso K, Nielsen KL, Christiansen J (1989) Long-term results of surgery for incarcerated groin hernias. Acta Chir Scand 155: Glassow F (1985) Femoral hernia: Review of 2,105 repairs in a 17-year period. Am J Surg 150: Heydorn WH, Velanovich V (1990) A five-year U.S. Army experience with 36,250 abdominal hernia repairs. Am Surg 56: Sandblom G, Haapaniemi S, Nilsson E (1999) Femoral hernias: a register analysis of 588 repairs. Hernia 3: Wysocki A, Pozniczek M, Krzywon J, Strzalka M (2002) Lichtenstein repair for incarcerated groin hernias. Eur J Surg 168: The EU Hernia Trialists Collaboration (2002) Repair of groin hernia with synthetic mesh. Ann Surg 235: Herna ndez-granados P, Ontan o n M, Lasala M, Garcı a C, Arguello M, Medina I (2000) Tension-free hernioplasty in primary inguinal hernia. A series of cases. Hernia 4: Oskvig RM (1999) Special problems in the elderly. Chest 115 (suppl): Rai S, Chandra SS, Smile SR (1998) A study of the risk of strangulation and obstruction in groin hernias. Aust N Z J Surg 68: Kulacoglu H, Kulah B, Hatipoglu S, Coskun F (2000) Incarcerated direct inguinal hernias: a three-year series at a large volume teaching hospital. Hernia 4: Chamary VL (1993) Femoral hernias: intestinal obstruction is an unrecognized source of morbidity and mortality. Br J Surg 80: Brittenden J, Heys SD, Eremin O (1991) Femoral hernia: mortality and morbidity following elective and emergency surgery. J R Coll Surg Edinb 36: McEntee G, Pender D, Mulvin D, McCullough M, Naeeder S, Farah S, Badurdeen MS, Ferraro V, Cham C, Gillham N, Matthews P (1987) Current spectrum of intestinal obstruction. Br J Surg 74: Askew G, Williams GT, Brown SC (1992) Delay in presentation and misdiagnosis of strangulated hernia: prospective study. J R Coll Surg Edinb 37: Nesterenko IVA, Shovskii OL (1993) Outcome of treatment of incarcerated hernia. Khirurgiia (Mosk) 9: Nicholson S, Keane TE, Devlin HB (1999) Femoral hernia: an avoidable source of surgical mortality. Br J Surg 77: Golub R, Cantu R (1998) Incarcerated anterior abdominal wall hernias in a community hospital. Hernia 2: Kulah B, Duzgun AP, Moran M, Kulacoglu IH, Ozmen MM, Coskun F (2001) Emergency hernia repairs in elderly. Am J Surg 182: Young DV (1987) Comparison of local, spinal, and general anesthesia for inguinal herniorrhaphy. Am J Surg 153: