Jebmh.com Original Research Article
Incidence of Inguinal Hernia Post Open Appendectomy - An Observational Study
Varun Dogra1, Ishfaq Ahmad Gilkar2, Umer Mushtaq3, Javid Ahmad Peer4, Yaqoob Hassan5, Farzanah Nawreen6
1Senior Resident, Department of General Surgery, Government Medical College, Jammu. 2Senior Resident, Department of General Surgery, Government Medical College, Srinagar, Kashmir. 3Senior Resident, Department of General Surgery, Government Medical College, Srinagar, Kashmir. 4Senior Resident, Department of General Surgery, Government Medical College, Srinagar, Kashmir. 5Senior Resident, Department of General Surgery, Government Medical College, Srinagar, Kashmir. 6Junior Resident, Department of General Surgery, Government Medical College, Srinagar, Kashmir.
ABSTRACT
BACKGROUND Acute appendicitis is the most common surgical emergency faced in today's world. Corresponding Author: Inguinal hernia is the most common type of hernia seen in surgical practice. It can Dr. Umer Mushtaq, Senior Resident, be of a direct and an indirect type. While the indirect type has a congenital cause, Department of Surgery, direct hernias are attributable to weakness of abdominal musculature. In this Government Medical College, study, we aim to calculate the incidence of inguinal hernia following open Srinagar, Kashmir. appendectomy from a tertiary care prospective. E-mail: [email protected] METHODS DOI: 10.18410/jebmh/2019/584
This was a prospective observational study that was carried out over a period of Financial or Other Competing Interests: three years. All patients who visited our OPD and had a history of Open None. Appendectomy were included in the study. After a thorough history, a comprehensive physical examination was carried out in these patients to rule out How to Cite This Article: any evidence of inguinal hernia. The data was tabulated in the form of tables and Dogra V, Gilkar IA, Mushtaq U, et al. graphs. Incidence of Inguinal Hernia Post Open Appendectomy - An Observational Study.
J. Evid. Based Med. Healthc. 2019; 6(43), RESULTS 2814-2817. DOI: There were 918 patients in the study out of which 488 were male- and 430 were 10.18410/jebmh/2019/584 female-patients. There were 64 cases of inguinal hernia in this study which amounts to an incidence rate of 6.97%. However, it is the relation of direct right Submission 05-10-2019, Peer Review 11-10-2019, inguinal hernia to open appendectomy which catches attention. It alone has an Acceptance 26-10-2019, incidence of 4.90% which can largely be attributed to damage to nerves during Published 28-10-2019. the procedure.
CONCLUSIONS
There is a high incidence of inguinal hernia associated with open appendectomy which could be avoided to a large extent if the surgical principles are followed.
KEYWORDS Appendectomy, Inguinal Hernia, Appendicitis
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BACKGROUND RESULTS
Appendix is a worm like tubular structure present in Right This study was conducted in the Department of Surgery, Iliac Fossa originating from Caecum. Although considered a Government Medical College, Jammu w.e.f. 01st May 2016 vestigial organ in past, it has assumed importance of an to 30th April 2019 and included patients with a history of organ with functions of immunity in today’s era.1,2,3,4 Acute Open Appendectomy. appendicitis is the most common surgical emergency faced There were 918 patients in the study which comprised of in today's world.5 Although a lot many cases are managed 488 male and 430 female patients (Figure 1) which conservatively these days, appendectomy remains the corresponds to 53% and 47% respectively. procedure of choice to treat acute appendicitis. Although laparoscopy has gained importance in the western world, open appendectomy still remains the most widely carried out operation as far as appendicitis is concerned.6 Hernia is defined as the protrusion of an organ or the part of an organ through the body wall containing it. Inguinal Hernia is the most common type of hernia seen in surgical practice. It consists mainly of a direct and an indirect type. While indirect type has a congenital cause, direct hernias are Figure 1. Sex Distribution attributable to weakness of abdominal musculature.7 It was Hoguet, who in 1911 first demonstrated the association of All the patients were grouped according to their age as drained appendectomy with inguinal Hernia. He attributed shown in table 1. Majority of patients were in the age group damage to ilioinguinal and iliohypogastric nerves during of 11-20 years which also corresponds to the highest open appendectomy as the cause of weakness of anterior number of cases of appendicitis in this group while the least abdominal wall musculature and hence inguinal hernia.8 number of patients were in age group of 31 - 40 years. Mean In this study we aim to calculate the incidence of age- 8.143, standard deviation-9.0 inguinal hernia following open appendectomy from a tertiary care prospective. Age Group (In Years) Males Females Total < 10 97 83 180 11 - 20 131 103 234 21 - 30 49 70 119 METHODS 31 - 40 58 39 97
41 - 50 67 78 145 51 - 60 86 57 143 This was an observational prospective observational study Total 488 430 918 that was carried out over a period of three years with effect Table 1. Age Distribution from 01st May 2016 to 30th April 2019 at Government In our study of 918 patients we found patients who Medical College, Jammu. All those patients who visited our developed hernia post-Appendicectomy were predisposed OPD and had a history of Open Appendectomy were by underlying complicated pathology like abscess adhesions included in the study. After a thorough history, a as shown in table and figure-2 with coef. Of variation-0.326 comprehensive physical examination was carried out in these patients to rule out any evidence of Inguinal Hernia. Appendicitis Types With Hernia Without Hernia Baseline investigations like complete blood count, kidney Complicated 42 243 function test, liver profile, chest and abdominal x-ray, ultra- uncomplicated 22 611 sonography were done, some of the patients in whom there Table 2. Appendicitis Types was any suspicion of underlying pathology contrast enhanced CT abdomen and pelvis and colonoscopy was performed. The examination consisted of inspection, palpation, percussion and auscultation and included various tests such as Cough impulse, three finger test, etc. These findings were later confirmed with an ultrasound examination. The data was tabulated in form of tables and graphs. Patients above the age of 60 years, patients with known history of any connective tissue disease, patients with history of any other abdominal surgical intervention in the past and patients with midline Incision were excluded from the study. Figure 2. Appendicitis Types
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Out of the total 918 patients who were examined via Our study reported an incidence rate of 4.90% (table physical examination and ultrasonography, 64 were found to and figure 2) for Right Direct Inguinal Hernia post have inguinal hernia with 48 having Right sided and 16 appendectomy which can largely be attributed to damage to having left sided inguinal hernia. 56 had direct while 08 had nerves during the procedure. Similar results have also been indirect inguinal hernia (Table 2). All these 64 were male published in literature earlier in various studies done at patients. different times.11 In our study of 918 patients males were slightly predominant with 53% of males and 47% females, Direct Inguinal Indirect Inguinal Majority of patients were in the age group of 11- 20 years Types Total Hernia Hernia (table and figure-1 & 3) which also corresponds to the Right Inguinal Hernia 45 03 48 highest number of cases of appendicitis in this group similar Left Inguinal Hernia 11 05 16 12 Total 56 08 64 observations were encountered by Hormoz Mahmoudvand Table 3. Types of Hernia Post Appendectomy et al in there study of 264 patients The occurrence of this disease is seen mostly in the second and third decades of life, with slightly more common among in men. In our study of 918 patients we found patients who developed hernia post-Appendicectomy were predisposed by underlying complicated pathology like abscess adhesions as shown in table and figure-2 similar observations were encountered by Hormoz Mahmoudvand12 they found that the predisposition of hernia in patients with a history of infection is 2.5 times patients with no history of hernia, they also emphasised that chances of hernia in patients with Phlegmon appendix is almost 3.2 times the patients with purulent appendix and also chances are also 32% higher in perforated appendix Figure 3. Types of Post Appendicectomy Hernia than purulent appendix. With the advancement in surgery especially minimal access surgery the incidence of post Its seen that there were 64 cases of inguinal hernia in appendectomy inguinal hernia has been reduced to very this study which amounts to a incidence rate of 6.97%. much as compared to previous literature reason being small However, it is the relation of Direct right inguinal hernia to port site entry points leading to lesser nerve damage and open appendectomy which catches attention. It alone has this is also supported in literature by many authors. Hormoz an incidence of 4.90%. p-value of <0.005 which is Mahmoudvand12 et al concluded in there study that chance statistically significant. of development of inguinal hernia in patients who were operated using the open method was 3.32 times patients operated using the laparoscopic method.
DISCUSSION
This was an observational prospective observational study CONCLUSIONS
that was carried out over a period of three years with effect from 01st May 2016 to 30th April 2019 at Government Open appendectomy is perhaps the most extensively studied Medical College, Jammu. This study was aimed to and performed surgical intervention, more so in developing demonstrate the importance of meticulous surgery and countries. As such it is of great importance to respect preserving nerves during appendectomy. The ilioinguinal surgical planes while performing such a procedure. nerve is out of reach of surgeon during conventional open Disregard to follow surgical principles can cause havoc to appendectomy, however it is the damage to iliohypogastric patient’s life both immediate and late. As open branch that can lead to weakness of posterior wall of appendectomy is usually one of the first procedures a Hesselbach's triangle leading to Direct Inguinal Hernia. It resident is taught, it becomes quite important that the runs downwards and inwards between internal oblique resident learns the complexity of every step that seems to muscle and transversalis muscle. The conventional Mc be performed with so much ease by the seasoned operator. Burney incision runs roughly parallel to the nerve and hence There is a high incidence of inguinal hernia associated with any attempt to cut the muscle in place of separating its fibres open appendectomy which could be avoided to a large along its direction may result in damage to this nerve leading extent if the surgical principles are followed. to more chance of Inguinal hernia.9 Incisions much below
the anterior superior iliac spine can lead to denervation of segmental nerves which course downwards. Other reasons REFERENCES for inguinal hernia post appendectomy include use of drains and wound infections. Also tying sutures too tightly in [1] Herrinton JL. The Vermiform appendix: its surgical internal oblique and transversalis muscle can lead to damage history. Contemp Surg 1991;39:36-44. to iliohypogastric nerve.10
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