Anatomopathologic analysis of synchronically

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1 POLSKI PRZEGLĄD CHIRURGICZNY 2009, 81, 5, /v Anatomopathologic analysis of synchronically operated bilateral inguinal hernias Antoni Ścierski Grossburgwedel Hospital, Teaching Hospital of Medical University in Hannover Department of General and Visceral Surgery Ordynator: dr med. A. Ścierski The aim of the study was statistic evaluation of anatomopathologic changes of synchoperated groin hernias. Material and methods. In , 2099 patients were operated due to inguinal hernias times the operation was conducted unilaterally, 756 (36.2%) bilaterally (1512 hernias). Patients were divided into three age groups: A 45 years of age, B years of age and C 65 years of age. Results. Among those operated bilaterally and synchronically the most frequent were lateral hernias, constituting from 57.2% to 69.8%, medial from 21.41% to 28.4%, combined from 8.81% to 14.52% of all operated hernias in all age groups. Hernias size I (<1.5 cm) constituted among bilateral hernias 29.66% of cases in age group A and 15% in age group C. For unilateral hernias the numbers were respectively 32.95% and 8.32%. Hernias size III (>3 cm) made up for bilateral hernias 26.14% of cases in age A, for unilateral hernias that was 18.9%. In age group C the figures were respectively 47.05% and 47.54%. Hernias size II in all age groups constituted from 37.95% to 48.15% of all cases. Recurrent hernias constituted 8.46% of operated bilateral hernias (128 cases). Among unilateral hernias, 124 recurrent cases were operated (9.23%). Femoral hernias coexisted among 25 men (1.75%) and 10 women (11.9%) operated bilaterally and among 41 patients operated unilaterally (3.05%). Conclusions. In case of bilateral hernias there was no correlation found between coexistence of femoral hernia and age of patients; among men they were mainly left, and in case of women right side cases. Among unilaterally operated patients the coexistence of femoral hernia was observed more frequently in the elderly group, among women mostly on the right side. Key words: inguinal bilateral hernias, inguinal unilateral hernias, anatomopathologic changes, appearance of hernias Groin hernias have accompanied men since we took standing erect position. Hernias operations are one of the most frequently conducted surgeries. The origins of scientific classification of hernias date back to the end of XIX century. There is still no uniform division and full data regarding etiopathogenesis of hernias available (1). Reports about synchexistence and bilateral operations of groin hernias are sparse and incomplete. Purpose of thesis: Statistic evaluation of anatomopathologic changes of sync-operated groin hernias. Statistic Data about hernias were introduced immediately after operation to electronic data base. Statistic analysis was conducted with the use of statistic programme SPSS version 15.0 (SPSS, Chicago, IL, USA). Statistic calculations were carried out using paired Student s t-test, Mann-Whitney s U-test and Pearson s c²-test. Material and methods In there were 2099 patients operated in our clinic because of inguinal hernias.

2 Anatomopathologic analysis of synchronically operated bilateral inguinal hernias patients were operated unilaterally, 756 (36.2%) bilaterally. Size and type of hernia as well as the occurrence of it in relation to age and sex of patients were evaluated. The control group constituted simultaneously operated patients with unilateral hernias. Type and size of hernia was evaluated according to Schumpelick s classification with own modifications (2). The classification is based on the evaluations of: 1) site of occurrence of hernia: Medial medial to inferior epigastric vessels (M), lateral laterally to these vessels (L) and combined occurring on both sides of epigastric vessels (Mc) as well as femoral hernias (F); 2) diameter of hernia s entrance measured at the level of or in the cavity of fascia transversalis, or internal inguinal ring: I diameter < 1.5 cm; II diameter cm; III diameter > 3 cm. In case of combined hernias (Mc) the size is the sum of cavities which is given in brackets. Recurrent hernias were marked with a letter R and a consecutive number of recurrences. Example: Mc II(MI LI) RF means recurrent combined hernia of medial entrance of diameter <1.5 cm and lateral entrance of diameter <1.5 cm, coexisting femoral hernia. Physical examination included standardised examination of both groins with USG (3). Operation was carried out with the use of laparoscopic technique TEP (3). 714 men (94.45%) and 42 women were sync-operated bilaterally (5.55%). Control group constituted 1343 patients operated unilaterally. The group consisted of 1120 men (83.4%) and 223 women (11.6%). Patients were divided into three age groups: A up to 45 years of age, B from 46 to 64 years of age and C over 65 years of age. Results Average age of synchronically operated men was 55 years of age, and for women 51. Age range in men was from 17 to 97 years of age and in women from 19 to 82 years of age. Age of the patients from A age group averaged 35 years of age, from group B 56 and from C 72 years of age. In women it averaged respectively 34, 56 and 75 years of age. The differences occurring in respect to gender of patients are not statistically significant (p>0.05). Average age of men operated unilaterally was 55 years of age and women 59 years of age. Lack of statistical differences between average age of the patients operated unilaterally and bilaterally. Table 2 presents combination of types of hernias in women and men for bilateral hernias. Bilateral hernias show statistically significant tendency to occurrence of the same type of hernia on both sides (p<0.01). For all age groups and both genders the coexistence of hernia s type is present in 59.7% to 86.3% cases. Table 3 presents incidence of unilateral hernias in age groups according to their types. Lateral groin hernias were more frequent than medial and combined (49,53%, 35,06%, 15.41%). (Lack of statistical differences regarding age and gender of the patients (c²= 5.793, significance asymptote 0.16) as well as in age groups (p>0.01)). In control group of hernias operated unilaterally, lateral hernias were also more frequent than medial and combined (61.5%, 25.98% and 12.52%). Similarly to the case of bilateral hernias. Here is no statistical significance in respect to age and gender of the patients. Next table shows the size of hernia depending on the age of patient. Table 1. Patients operated in years Female Male Przepukliny jednostronne / One-site hernia right left 16,6% right left 83,4% Bilateral hernia 42 5,55% ,45% Together ,62% ,38%

3 238 A. Ścierski Table 2. Bilateral hernia combination of types of hernia M right L right Mc right Together left Male all age groups M left L left Mc left together right Female all age groups M left Male and female all age froups L left Mc left together right M left L left Mc left together right Table 3. One-site hernias. Appearance of hernias according to type of hernia Age group A M 93 21,41% Age group B L ,8% Age group C Mc 38 8,81% Age group A M ,4% Age group B L ,8% Age group C Mc 67 13,8% Age group A M % Age group B L ,2% Age group C Mc 63 14,8% All age groups M ,98% L ,5% Mc ,52% In age group A, hernias size I make up 29.66% of all hernias. In age group C their share falls to 15%. By contrast, the share of hernias size III rises from 24.16% in age group A to 47.05% in age group C. In all age groups the share of hernias size II is similar. Statisti- cally significant are the size differences for hernias size I and III for all age groups. (Correlations are statistically significant at the level of 0.01 (bilateral). In group of hernias operated unilaterally, the rules of hernias incidence and statistical significance are similar. Inguinal recurrent hernias were operated 128 times (8.46%), more often on the right side (p>0.01). The results are shown in tab. 5. Bilateral recurrent hernias were operated synchronically in 25 patients (3.3%) including one woman. In control group of patients operated unilaterally recurrent hernias were operated 124 times (9.23%), 58 times on right and 66 times on left side (p>0.01). The results are shown in consecutive tab. 6. In hernias operated synchronically, coexistence of inguinal and femoral hernias was observed in 25 men (1.75%)* and 10 women (11.9%)* (*calculated for the amount of hernias operated). Among men, the most frequently Table 4. Appearance of hernias according to age groups and their greatness (for one-side and bilateral hernias) Przepukliny obustronne / Bilateral hernias Przepukliny jednostronne / Onesite hernias Grupa wiekowa A / age group A I ,66% ,95% II ,17% ,15% III ,16% 82 18,9% Grupa wiekowa B / age group B I ,52% 89 18,39% II ,86% ,31% III ,72% ,30% Grupa wiekowa C / age group C I 66 15% 35 8,23% II ,95% ,23% III ,05% ,54%

4 Anatomopathologic analysis of synchronically operated bilateral inguinal hernias 239 Table 5. Operations of recurrence hernias bilateral Hernias Right site Left site Age group A Age group B Age group C Together Table 6. Operations of recurrence hernias one-side hernias Right site Left site Age group A Age group B Age group C Together observed was the combination with medial hernias (18 times), in women with lateral hernias (6 times). Bilateral coexistence of femoral hernias was found in three women and two men. In men, there is lack of relation between occurrence of femoral hernias and the age of patients. In women, over a half of cases regarded patients over 65 years of age. Among men we noticed more frequent coexistence of medial hernia with femoral one, in women- with lateral. Among 41 patients operated unilaterally, coexistence of femoral hernia was found in 22 men (1.96%) and 19 women (8.5%). Similarly, also here we observed more frequent coexistence of medial hernia with femoral hernia, while in women with lateral one. Discussion Groin hernias accompany man during all his life. Keith releases incidence for hernias in Great Britain at 2% among men and 0.3% among women (4). Prevalence in men below 25 years of age equals 18/ , and increases at the age of up to 40/ and reaches at the age of over 75 47/ For the entire population prevalence was 24/ (5). In relation to increase in prevalence depending on age, it could be expected that the operations in the group of older patients would be more frequent. In our series of patients, quantities of patients operated in groups A and C are equal. We observe increased number of patients operated in age group B. Existing differences are statistically significant for the patients operated bilaterally(p<0.01), but are not for the patients operated unilaterally (p>0.01). In the period in question 756 patients with groin bilateral hernias were operated synchronically (36.2% of all operated patients). Number of hernias operated by us synchronically is higher than the figures given by most of the statistics 13.6% Aerztekammer Westfalen- Lippe (6); 4.45% Kald A. (7); 11,7% Aufenaker et al. (8); 11% Velanoviich (9); 22.26% Brunocilla et al. (10). Only Misra et al. (11) give higher figures regarding synchronically operated hernias, reaching 54%. Small quantity of hernias operated synchronically might be caused by: 1) imperfection of clinical examination (unilateral examination), 2) too strict classification criteria to surgery on the other side, 3) unwillingness to synchronic treatment caused by the fear of complications or 4) postoperative oedemas of penis and scrotum in case of conventional surgeries, 5) existing account modules (in some countries unilateral operations are paid equally with bilateral ones). Considerable quantity of bilateral operations on the other hand can be caused by preventive qualification to the surgery on the other side. In order to check whether there is no suspicion of preventive qualification for surgeries on both sides in case of our patients, we analysed once again our cases, qualifying the patients in cases of coexistence of hernia size I with bigger hernia on opposite side (size II and III) to the group of unilateral hernias. After this type of changes, there were 551 cases left in the group of bilateral hernias (26.25%), which also made up higher figure than in other works presenting numbers of synchronic bilateral operations. In cases of bilateral synchronic operations, lateral hernias were more frequent in all age groups and for each from operated sides than other types of hernias ( Pearson s correlation 0.324, p<0.001). The same fact we observed in patients operated unilaterally (Pearson s correlation 0.244, p<0.001). Our observations do not match the reports of Kalda et al. (12), who in the group of operated patients found 52% medial hernias, 41% lateral and 4% combined. Similarly Serpell et al. (13) as well as Miller et al. (14) observed converse proportions of incidence of medial and

5 240 A. Ścierski lateral hernias in case of hernias operated synchronically. Only Amid et al. (15) do not give this converse ratio of hernias for hernias operated bilaterally. Urologists (11) during urological surgeries find 22.6% patients with bilateral hernias in which there are 68% of medial hernias and only 32% of lateral ones. Therefore they make an assumption that one of the factors causing occurrence of these hernias may be shortages of collagen. They are to be responsible for weakening of fascia transversalis and therefore causing incidence of medial hernias (16). Analysing the size of groin hernias we observe both in bilateral and unilateral hernias, higher ratio of hernias size III in age group C. On the contrary, there is less hernias size I in this age group. These differences in incidence are statistically significant for unilateral and bilateral hernias (p<0.01). Number of recurrent hernias is among the hernias operated synchronically similar on both sides. In age groups B and C in recurrent hernias there is an ascendance of medial hernias (differences statistically significant p<0.01), which can confirm assumptions by Connor et al. (16), that the shortages of collagen in fascia transversalis cause hernias in older people. We do not observe this increased number of medial hernias in patients operated by us unilaterally. Coexistence of femoral hernia is given depending on the gender at 2 to 7% (17-21). Regarding hernias operated bilaterally where the femoral hernias were found, we observed higher ratio of women with medial hernias that is shown by statistics (22, 23, 24). The more frequent incidence of femoral hernias in elderly women which we observed is concurrent with observations found in references (25). It is explained by increasing with age atrophy of hip, lumbar and comb muscles (26). Asymmetric incidence of tight hernia with the preference of the right side (27) was confirmed by us only in relation to women. In men we observed ascendance of the femoral hernias on the left side. Mikkelsen et al. (28) create a term of a high risk group for patients with femoral hernias. The group includes elderly patients previously operated due to groin hernia. Frequent incidence of femoral hernias observed by Mikkelson et al. is explained also by anatomic changes after operations of groin hernias in run of inguinal ligament and broadening of inguinal canal (29). Conclusions 1. Synchronic groin hernias occur more frequently than it is given by collective statistics. 2. In all age groups and in both genders the coexistence of the same type of hernia was observed the most frequently (from 59.7% to 86.3%). 3. The reason for small number of synchronic operations may be connected with inexact examination of the opposite side or in scheduling second operation for later term. 4. The most frequently occurring form of hernias are lateral hernias. They occur with the same frequency in unilateral and bilateral cases. 5. The older the patients are, the higher percent share of bigger hernias and lower share of small hernias. 6. Coexistence of groin and femoral hernias among synchronically operated hernias is found more often in the group of elderly patients. This correlation is not found in the group of patients operated unilaterally. 7. In the group of women incidence of femoral hernia is more frequently observed on the right side. references 1. Miserez M, Alexandre J, Campanelli G et al.: The European hernia society groin hernia classifcation: simple and easy to remember. Hernia 2007; 11: Ścierski A: Operacje przepuklin pachwinowych z dostępu przedotrzewnowego. W: Kostewicz W (red.) Chirurgia laparoskopowa. Wyd. 1. PZWL, Warszawa 2002; s Ścierski A, Roechte F: Przydatność badń ultrasonograficznych w diagnostyce przepuklin pachwinowych. Wideochirurgia; 2007; 2(6); Keith A: On the origin and nature of hernia. Br J Surg 1923; 11: Abramson JH, Gofin J, Hoop et al.: The epidemiology of inguinal hernia: A survey in West Jerusalem. J Epidemiol Comm Health 1978; 32:

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