Is Preoperative Withdrawal of Aspirin Necessary in Patients Undergoing Inguinal Hernia Repair?

Wee Boon Tan1, Wilson Ong2, Shen Tong2, Eva Lourdes1, Sujith Wijerathne1, Davide Lomanto, Prof1. 1Minimally Invasive Surgery Centre, Department of Surgery, National University Health System, Singapore, 2Yong Loo Lin School of Medicine, National University of Singapore

Introduction: Aging population and increasing incidence of cardiovascular disease makes anti-platelets such as aspirin widely used to reduce thrombotic events. Continuing aspirin through major non-cardiac surgery has been shown to reduce risk of major adverse cardiac events (MACE). However, this may lead to higher bleeding complications. Hence balancing bleeding with thromboembolic risk is a challenging task for the surgeon. While inguinal hernia repair is one of the commonest surgical procedures performed for this group of patients, there is a lack of consensus regarding peri-operative management of aspirin in them. Hence, we aim to investigate the safety profile of aspirin continuation in the perioperative period in patients undergoing elective primary inguinal hernia repair.

Methods: All patients that underwent elective primary inguinal hernia repair from 2007 to 2014 and were on aspirin pre-operatively were identified. The patients were divided into 2 groups: those who continue aspirin through the morning of the operation and those who have been advised to stop aspirin therapy 3 to 7 days prior to operation. All patients underwent either open Lichtenstein mesh repair or laparoscopic total extra-peritoneal (TEP) mesh repair. Outcomes measured include intraoperative blood loss, operative time, bleeding complications (bruising, hematoma) wound site complications (seroma, hematoma, recurrence) and MACE.

Results: Among 1841 patients who underwent elective primary inguinal hernia mesh repair, 142 (7.7%) patients were on preoperative aspirin. 57 patients underwent laparoscopic repair while 85 underwent open mesh repair. 27/57 (47.3%) from the laparoscopic group and 55/85 (64.7%) from the open group, were instructed to stop aspirin (p=0.040). There were no significant differences between those who stopped aspirin and those who continued in terms of intraoperative blood loss (Lap 2.5ml vs 8.5ml p=0.157; Open 10.1mls vs 8.2mls p=0.638) and operative timing (Lap: 92.8mins vs 96.2mins p=0.761, Open 88.1mins vs 78.5mins p=0.337). Immediate post-operative bleeding complications (Lap: 18.5% vs 13.3% p=0.592, Open: 5.5% vs 6.7% p=0.820) and follow-up wound complications (Lap 11.1% vs 10.0% p=0.891, Open 10.9% vs 16.7% p=0.450) were also similar between the two groups. Overall there was no MACE among those who underwent laparoscopic repair. 3 MACE were recorded in the open group (2 stopped aspirin vs 1 continued aspirin; p=0.943). There is no peri-operative mortality.

Conclusion: Our findings suggest that aspirin continuation is unlikely to increase blood loss or complications in both primary laparoscopic and open inguinal hernia repair. Continuation of aspirin is safe and should be preferred in patients with higher cardiovascular risk. 

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