Expanded indications for preperitoneal hernia repair: The high risk patient

Abstract

The medically compromised patient with an inguinal hernia (primary or recurrent) is often denied surgical intervention because of potential risk. We have treated hernias in 36 “extremely high risk” patients using the preperitoneal approach. Twenty-one patients (58 per cent) had a recurrent inguinal hernia after one or more previous repairs. Eighty per cent of the patients were over the age of 70 years; six of them also had significant chronic obstructive pulmonary disease. Preperitoneal inguinal herniorrhaphy was performed using spinal or epidural anesthesia in all cases. In eight of the patients with lung disease, the operation was performed with the patient's upper torso elevated 30 degrees. Prosthetic material was used in only two repairs (5 per cent). There were no deaths, no significant pulmonary complications, and no wound infections. All patients were discharged within 4 days, which seems acceptable when compared with the length of hospitalization for primary hernia repair under local anesthesia (2 days) and for major reconstruction of recurrent inguinal hernia (6 days). The preperitoneal approach seems safe and reliable in this group of patients, with its low morbidity and absent recurrence rate, especially in patients with recurrent hernias. Good regional anesthesia is essential and alternative patient positioning useful. This approach is recommended as safe in high risk patients who require hernia repair to prevent incarceration or obstruction.