Introduction

Major ambulatory surgery (MAS) refers to same day surgical procedures performed under general, regional or local anesthesia, requiring a brief postoperative monitoring; the patient returns home with no overnight stay¹. The main drawback of ambulatory surgery is the selection of eligible patients to preserve the same efficacy and safety achieved with hospitalization².

This modality has evolved considerably. Hernia repair is one of the most feasible surgeries for ambulatory management^3-4 and the one with the greatest experience gained⁵.

The prevalence of this disorder is between 10 and 15% in the general population and increases over the years: is 8% in the group of patients between 25 and 40 years, and 30% in those > 75 years⁶.

Octogenarians are a demographically growing group that have changed the epidemiology of the surgical patient⁷. This increase in life expectancy often makes surgeons face older patients with abdominal wall hernias^8,9.

For this reason, there is a growing interest in ambulatory surgical management in this group of patients, and several recent studies have suggested that MAS is safe^10,11, despite some groups prefer a conservative approach^12-14. The decision to accept elderly patients into an ambulatory surgery unit should always be based on a careful assessment of comorbidities and surgical risk².

The aim of this study was to analyze our experience with ambulatory surgery, in terms of applicability, safety and efficacy, to treat inguinal hernia in patients > 80 years, at the Hospital Privado de Comunidad in the city of Mar del Plata between January 2008 and December 2017, and compare this group with patients between 50 and 79 years.

Material and methods

This retrospective and observational study was developed in the Section of Abdominal Wall Surgery of the Hospital Privado de Comunidad, Mar del Plata, Argentina. Data from all the open inguinal hernia repair procedures performed using the Lichtenstein technique between January 2008 and December 2017 were analyzed.

The information was retrieved from the electronic medical records of the Section of Abdominal Wall Surgery of the Hospital Privado de Comunidad in Mar del Plata.

The study was evaluated by the Review Committee on Clinical Trials of the institution. All the patients signed an informed consent form at the time of admission authorizing the use of their data.

The study included all 80-year-old patients or greater of both sexes who had undergone open inguinal hernia repair within our MAS program and with at least one month of postoperative follow-up. These patients were retrospectively compared with similar patients aged 50-79 years who were treated during the same period.

Only residents of the city with availability of a caregiver during the night and access to a telephone are eligible for the MAS program, which includes no overnight stay and post-operative medical evaluation through the Post Anesthetic Discharge Scoring System (PADSS)¹⁵ (Table 1).

Unilateral and bilateral abdominal hernias were included. All the patients with these abdominal wall defects with indication of surgical repair and who are eligible for the MAS program are admitted to the Ambulatory Surgery Unit, which is located within the hospital.

Patients who did not meet the requirements of the MAS program, those with emergency incarcerated inguinal hernia, or treated with oral anticoagulants or with a history of psychiatric disorders were excluded.

The following variables were analyzed: age, sex, main comorbidities (Charlson mordibity index¹⁶), American Society of Anesthesiologists (ASA) score¹⁷, type of hernia (Nyhus classification¹⁸), type of anesthesia, operative time, PADSS, postoperative morbidity, unanticipated admission, rehospitalization and mortality.

All the patients received antibiotic prophylaxis with intravenous cephazolin 1 g at the beginning of the intervention and underwent open inguinal repair with the Lichtenstein technique¹⁹.

A contact phone number was provided at discharge to report problems or possible complications. The patients returned to the hospital for a routine check-up visit within the first month after surgery.

Results

Between January 2008 and December 2017, 520 patients > 50 years underwent conventional open inguinal repair. Twenty-nine patients were excluded following the exclusion criteria. Of the 491 remaining patients, 27.1% (133 patients) were > 80 years and 358 (72.9%) made up the group between 50 and 79 years (Figure 1).

Mean age was 83 years (median: 82 years; range 80-95) in the group > 80 years and 71.6 years (median 73 years) in the group between 50 and 79 years, and 82.7% and 81.8%, respectively, were men. Table 2 shows the demographic data in both groups.

A total of 560 inguinal hernia repair procedures were performed, and 142 were belonged to the group > 80 years; 61.5% were right inguinal hernias (47.1% in the control group, p = 0.0045; 95%, CI 1.17- 2.76], 31.6% left inguinal hernias (p = NS) and 6.9% were bilateral (16.4% in the control group, p = 0.005; 95% CI, 0.15- 0.77). The following type of hernias were reported: 77.5% were indirect hernias, 16.9% were direct hernias, 3.5% were mixed hernias and 2.1% were femoral hernias (73%, 22.2%, 4.1% and 0.7% for the control group, respectively, without statistically significant differences).

In the group of male patients > 80 years, 118 hernia repair surgeries were performed, of which 20.3% were inguinoscrotal (3.8% for the control group, p = < 0.0001 [95% CI 3- 14.2]).

The mean Charlson comorbidity index was statistically similar in both groups (6.8 in > 80 years and 4.9 in the control group). However, the prevalence of cardiovascular and metabolic comorbidities was significantly higher in the group > 80 years (p = 0.002; 95% CI, 1.26-3.12; and p = 0.02; 95% CI, 1.07-3.41, respectively).

There were no significant differences in mean body mass index (BMI), ASA score, type of anesthesia and operative time between both groups (Table 2).

In terms of hospital length of stay, 96.2% of the patients > 80 years were ambulatory surgery patients (97.8% for the control group, p = NS). Thus, 3.8% of the patients > 80 years and 2.8% of those in the control group required unexpected admission (p = NS). The reasons for unexpected admission in patients > 80 years were hematoma (n =1). patient’s willingness to stay at hospital (n = 3) and low PADSS (n = 1). In the control group, unexpected admission (10 patients, 2.8%) was due to patient’s willingness (n = 3), low PADSS (N = 5), acute urinary retention (n = 1) and hematoma (n = 1).

Overall postoperative morbidity was 9.75%: 13.5% in> 80 years and 8.4% in the control group (p = NS). Postoperative morbidity is detailed in Tables 3 and 4.

In the control group, two patients underwent reoperation, one due to sigmoid colon perforation (laparoscopy and externalization of the colon) and the other due to hematoma. There no rehospitalizations or deaths in the series.

Discussion

The increase in life expectancy and the progressive aging of the population has generated a series of changes in the management of abdominal wall defects. The characteristics of these defects, associated with the morbidity inherent to this age group, represent a challenge when choosing a surgical strategy for the treatment of inguinal hernias.

Many authors consider that the conservative approach is the best option in this particular group of patients^14-17. In a retrospective cohort study carried out in Argentina on 93 patients > 75 years, Ferreyra et al. concluded that elderly patients have higher morbidity and mortality associated with surgery, and therefore it is necessary to select those who will undergo hernia repair. In that study, the cumulative incidence of complications of conservative management was 4 to 10 times higher than in other series, but it is not clear that the risk of incarceration outweighs the risk associated with surgery in these patients, thus a personalized assessment is required in each case.

The European Hernia Society reports increased morbidity and mortality in elderly patients undergoing elective hernia repair. In contrast, in a retrospective review of 19,683 patients > 65 years, Wu et al.¹⁸ reported that elective inguinal hernia repair is safe in most elderly patients, despite their associated comorbidities. In emergency surgery, mortality and complications increase dramatically, suggesting that elective surgery should be offered to this population. Pallati et al.¹⁹ conducted a review of 2377 patients > 80 years and reported that morbidity and mortality was increased in nonagenarians but not in octogenarians, and was also higher in emergency procedures, so it is necessary to electively repair inguinal hernias in this population.

Traditionally, elderly patients have been considered unsuitable for ambulatory surgery. However, there is evidence in the literature suggesting that even with ASA score grade 3, the risk of postoperative complications, adverse events, unanticipated admission or hospitalization is not greater in elderly patients. An Italian study by Palumbo et al.²⁰, which compared 160 patients >80 and < 55 years undergoing ambulatory inguinal hernia repair, showed that there were no significant differences between the two groups, and that even surgery was better tolerated in the elderly group.

In our study we did not find any differences between the groups of patients analyzed in terms of postoperative morbidity and unanticipated admission. Of the total number of patients undergoing repair of a primary inguinal hernia, 203 patients who underwent laparoscopic surgery were excluded from the control group, which shows a selection in this group, and that those patients not suitable for the laparoscopic approach are more similar to the population of the study (> 80 years of age), since they have more comorbidities. For this reason, we did not find differences in the Charlson morbidity index. However, cardiovascular and respiratory diseases and other chronic diseases such as diabetes, hypertension, peripheral vascular disease and smoking habits should be carefully assessed, as they increase postoperative morbidity; thus, patients with these conditions should be excluded from MAS programs.

According to Palumbo et al.²⁰, the ASA score is not an obstacle for this modality of care, and patients with ASA grade 3 are also candidates for ambulatory surgery with no differences with the control group of young patients. In a case-control study conducted by Ansell et al.²¹ on 28,921 patients (3.1% with an ASA score grade 3) there were no significant differences between the groups in unanticipated admission and postoperative morbidity. In our study, the ASA score did not represent a predictive factor for admission to the MAS program; yet, as there were no patients with ASA grade 4 in our series, so they deserve a thorough analysis.

We did not observe significant differences in hospital length of stay between the two groups; therefore, ambulatory surgery is possible in all the patients. In addition, there were no differences in unanticipated admission or overall and age-adjusted postoperative morbidity.

In our experience, elderly patients > 80, when properly selected and treated, have good outcomes, which are similar to those obtained in younger patients.

Conclusion

Postoperative morbidity and unanticipated admission are similar to those of younger patients, in whom this modality is widely accepted.

Ambulatory surgery for open inguinal hernia repair in patients > 80 years is a safe and effective strategy.