Emergency Surgery for Complicated Large Midline Incisional Hernias in elderly: Is nihilistic attitude justified?

Nitin Vashistha, MS, FACS¹, Dinesh Singhal, MS, FACS, DNB, Surgical Gastroenterology¹, Sunil Choudhary, MS, FRCS², Raj Tobin, MD³. ¹Department of Surgical Gastroenterology, Max Super Speciality Hospital, ²Department of Plastic & Reconstructive Surgery, Max Super Speciality Hospital, ³Department of Anesthesiology, Max Super Speciality Hospital

Background: There is reasonable consensus that laparoscopic repair (LR) is the preferred modality for management of ventral hernias. However LR is technically difficult in patients with large incarcerated hernia, small defects with large hernia sacs, loss of domain and obesity. The scenario becomes particularly demanding when elderly patients with multiple co-morbidities present with such complex hernias. In view of high risk of adverse events, surgical intervention is often deferred by patients & / or surgeons. Many of these patients present as emergency with hernia associated complications such as obstruction & /or strangulation and pose even more formidable challenge for management.

We present our experience in management of complicated large incisional hernias.

Patients & Methods: From January 2013 to July 2018, consecutive patients with complicated large midline incisional hernia with defect ≥ 10 cm were retrospectively analysed.

Following initial optimisation in surgical intensive care unit emergency surgery was performed by same team of GI surgeons. For giant ventral hernia (≥ 15 cm) abdominal wall reconstruction was done by plastic surgery team. In the postoperative period patients were managed in SICU and were shifted out once they were hemodynamically stable and oral feeding had commenced.

Demographic data, operative details, postoperative outcomes and follow up was recorded from institutional electronic health record system.

Results: Study group comprised of 12 patients (1 male and 11 females) with a median age of 72 (range 38 -80) years. The body mass index for the cohort was 27 (range 21 -35.1). An overview is presented in Table 1.

At surgery, 04 patients were found to have strangulation of which 02 (one aged 80 years) died in early postoperative period. Of these 04 patients vacuum assisted closure was done in 2 while one each had component dissection & repair and onlay mesh repair due to large size (24 cm) of defect.

Of the 3 patients with wound related complications, one had necrosis of the skin while 2 developed seroma.

At a median follow up of 12 (range 2 -52) months, 2 patients (16.6) developed recurrent hernia.

All surviving patients have expressed satisfaction with outcomes with improvements in body image and health related quality of life.

Conclusions: Emergency repair for complicated large midline incisional hernias in elderly should preferably be performed at tertiary care centres with experienced teams. In such scenario, acceptable perioperative and medium term outcome can be attained in this high risk group of patients.

Image 1