Oleh : Ritma Eka Febriana (2012 1040 1011 032) Pembimbing : dr Bambang Arianto Sp.

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Background Methods

Incarcerated abdominal wall hernia (AWH) necessitate emergency intervention

Increase morbidity and mortality January 1998-january 2006 : 182 patients Retrospective Logistic regretions analysis Morbidity 43 (23,6%), mortality 9 (4,9%) Age, accompanying disease, ASA, strangulation, necrosis univariat analysis (significant with mortality) Intestinal necrosis, which was followed by bowel resection was the sole factor was affecting morbidity and mortality

Result
Conclution

Incarcerated AWH intestinal resection

Surgical treatment of incarcerated AWH is to repair the hernia with low morbidity and mortality and to decrease recurrence rate in long term follow up.

But, improvement in anesthesia, antisepsis, antibiotic and fluid resucitation morbidity and mortality following emergency surggery for incarcerated AWHs are still high

In this study, the aimed to investigate factors thatt effect morbidity and mortality in incarcerated AWH patients using logistic regression analysis

Urgent surgical interventions due to incarcerated AWH were performed in 182 patients in their clinics between january 1998 january 2006

No criterion was employed for repairing the defect

Patients anamnesis, DP, routine preoperative test (WB, BC, CT, X-ray, ECG), anesthesiologist, antibiotic 2nd gen cephalosporin

Factor that affect morbidity and mortality in incarcerated AWHs :

Investigated retrospectively by browsing the archives

Age Gender Duration of symptoms Accompanying diseases ASA score Type of anesthesia Presence of intestinal strangulation and necrosis Method preferred for hernia repair (primary repair vs repair with graft)

morbidity
Mayor and minor postoperative complications (anastomotic leak, pulmonary and cardiac complications, wound complications, etc) that prolonged hospitalization period

mortality
Death within 30days of surgery associated either directly or indirectly with the surgery
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logistic regression analysis

evaluate parameters that affect morbidity and mortality

These factors were first analyzed by univariate analysis

chi-square

t-tests

Factors statistically significant multivariate analysis;

statistical significance level was set to P < 0.05. Continuous, normally distributed data are expressed as means + SD.

MedCalc version 9.0.0.0 software was used for statistics.

Patients with hernias who received emergency surgery due to incarcerated AWHs:
Inguinal: 57.1% (n = 104), Umbilical : 20.3% (n =37), incisional : 12.1% (n = 22) femoral : 10.5% (n = 19)

Gender

Males : 62.6% (n = 114) Females : 37.4% (n = 68) mean age of patients was 57.71 + 17.72 (range: 1592) years
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Incarcerated inguinal and incisional hernias > Femoral and umbilical hernias > interval onset of symptoms - hospital admission averaged 12.73 + 7.52 (range: 1 39) h; among all patients, 83 patients had such accompanying diseases as COPD, coronary artery disease, CHF, HT, type 2 DM.

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High ASA scores (ASA III and IV) incarcerated inguinal hernias General anesthesia 65 (35.7%) and spinal anesthesia 117 (64.3%) General anesthesia was used at a statistically significant rate in umbilical and incisional hernia surgery (P < 0.001).

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(+) Hernias were simply reduced in 104 (57.1%) patients, (-) strangulations were detected in 78 (42.9%) patients during surgery. While Intestinal blood circulation recovered in 43 patients (23.6%) with strangulation, 35 patients (19.2%) received intestinal resection and anastomosis due to necrosis.

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Rate of intestinal resection in patients with incarcerated incisional and femoral hernias was slightly higher than that in patients with other types of incarcerated hernias, and the diference did not reach significance (P = 0.964). Primary hernia repair : 140 (76.9%) repair with graft (monofilament polypropylene mesh) : 42 (23.1%) patients >> incisional hernias
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Mean length of hospital stay was 4.50 + 3.41 (range 124) days. Postoperative morbidity occurred in 43 (23.6%) patients.

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Anastomotic leakage was observed; postoperative ileus in cases each;

intraabdominal abscess,

pneumonia,

intraabdominal hemorrhage,

urinary bladder injury,

Pulmonary embolism,

renal failure,

congestive heart failure and

myocardial infarction in one case each.

atelectasis,

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Local wound complications developed in 19 patients

infections : 11, Seroma : 5, hematomas : 2 wound dehiscence : 1

postoperative complications such as anastomosis failure, intraabdominal abscess, postoperative ileus and intraabdominal hemorrhage 7 cases relaparotomy

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A symptomatic period of longer than 8 h (P = 0.013), presence of accompanying disease (P < 0.001), high (III and IV) ASA score (P < 0.001),

general anesthesia (P = 0.025), presence of strangulation (P = 0.012), necrosis (P <0.001)

affect morbidity significantly by univariate analysis

necrosis was the sole factor affecting morbidity significantly by multivariate analysis (P= 0.004, odds ratio = 4.52).

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Postoperative mortality was recorded in nine (4.9%) patients who had major complications and accompanying diseases.
Anastomotic leakage and intraabdominal sepsis (three cases), postoperative ileus (two cases),

adult respiratory distress syndrome (one case),

pulmonary embolism (one case), congestive heart failure (one case) and myocardial infarction (one case) were the causes of death.
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Advanced age (>65;P = 0.023), presence of accompanying disease (P = 0.002), high (III and IV) ASA score (P < 0.001),

presence of strangulation (P < 0.001), necrosis (P < 0.001), and hernia repair with graft (P =0.049)

affect mortality significantly by univariate analysis

necrosis was the sole factor affecting mortality significantly by multivariate analysis (P = 0.019 , odd ratio = 12.23)
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literature
Dunne et al (multivariate analyses) COPD & low preOP albumin wound infection Coronary Artery Diseases, COPD, low preOP albumin, steroid hospital length of stay

study
Univariate analysis : Necrosis was significant for morbidity and mortality

after surgical treatment of incarcerated AWH : Mortality rates 1.4-13.4% Morbidity rates 19-30% Kurt et al higher risk of bowel resection for >65yo Alvarez et al risk postOP pulmonary and carvas complications length of hospital stay

No significant effect of advance age (>65) on morbidity Affect mortality by univariate analysis but not by multivariate logistic regression analysis in this study.

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literature
Incarcerated inguinal hernias Femoral and umbilical hernias

study
Incarserated inguinal and incisional hernias Femoral and umbilical hernias Gender did not significant affect morbidity and mortality

Gender has not been reported to affect morbidity and mortality

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literature
Bowel resection rate 7% in patient who received surgical intervention inguinal hernias incarseration in first 24h, and 27% in 48h Duration of symptomps : Mortality rates 1,4% in first 24h hernia surgery, 10% in 24-27h, 21% in >48h Kulah et al : significant rates strangulation, necrosis, morbidity, mortality and longer hospital stay in patients with late hospital admission

study
Hospital admission >6h after symptoms significant affect morbidity (using univariate) but not multivariate analysis

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literature
Golub et al. reported high ASA score to be one of the most significant independent risk factors affecting mortality Kulah et al. found that morbidity and mortality rates and length of hospital stay were increased in elderly incarcerated hernia patients with high ASA scores.

study
We did not detect any significant effect of high ASA score on morbidity and mortality using multivariate analysis, although there was a significant effect by univariate analysis in this study

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literature Type of anesthesia (spinal and general) has not been reported to affect postoperative morbidity in patients who have undergone emergency surgery although morbidity has been attributed directly to accompanying diseases Alvarez et al. reported increased length of hospital stay only in patients who received general anesthesia.

study type of anesthesia did not affect morbidity (since only univariate) but significant Effect of general anesthesia (in multivariate) on morbidity. Did not find a signifcant effect of anesthesia type on mortality using Logistic regression Analysis

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literature Used of monofilament polypropylene mesh repair during elective hernia surgery in patients with AWH is still debatable (+), (-)

study type of repair was not found to affect morbidity Affect mortality by univariate but not by multivariate analysis

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R E S U L T

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