Abdominal wall hernias: symptoms and outcome

Chung, Lucia P. S. (2014) Abdominal wall hernias: symptoms and outcome. MD thesis, University of Glasgow.

Abstract

Introduction and Aims
Pain is the most common symptom associated with hernias but there is little in the literature on its effects on an individual’s physical activity or quality of life. Up to one-third of patients with an inguinal hernia have no symptoms from the hernia. Repair of a ventral hernia is a common operation and increasing in frequency. Many operations for hernia are on patients with minimal symptoms but data on outcomes are lacking.
The aims of the studies are to: assess the frequency of pain and its effects on physical activity and quality of life in patients with inguinal and ventral hernias; to determine the long term outcome of patients with a painless inguinal hernia randomised to observation or operation; to assess the long term outcomes of patients with an asymptomatic ventral hernia managed by a period of observation; and to examine the incidence of umbilical hernias in a general adult population and establish the long term outcome of patients with an umbilical hernia.

Patients and Methods
All patients undergoing operation for an elective inguinal or ventral hernia over a 16 month period were asked to complete a questionnaire recording data on baseline characteristics, a 4-point Verbal Rating Scale (VRS) and Visual Analogue Scale (VAS) of their pain. They also completed the short form Brief Pain Inventory (BPI) to assess pain severity and interference.
160 men aged 55 years or more with an asymptomatic inguinal hernia were randomised to observation or operation. Clinical follow up was undertaken at a median of 5 years and final follow up at a minimum of 6 years from randomisation. Ventral hernia patients presenting to a surgical clinic over a one year period were identified and those who were asymptomatic were followed up either by annual clinical examination or review of their electronic case records. All new patient referrals to a general surgical clinic over a year without a previous history of abdominal surgery were examined for clinical evidence of an umbilical hernia. All general practitioner referrals with an umbilical hernia were assessed for symptoms and both groups were followed up by review of their electronic case records.

Results
124 patients (72 inguinal, 52 ventral), completed the pain questionnaire and 93 (75%) registered pain on the BPI. There was good correlation between VRS, VAS and BPI scores (Correlation Coefficient >0.8). Patients with a ventral hernia had more pain (P=0.037), interference with mood (P=0.027), sleep (P=0.004), relations with other people (P=0.019), and enjoyment of life (P=0.029) than their inguinal hernia counterparts.
At a median follow up of 7•5 (range 6•2–8•2) years in patients with an asymptomatic inguinal hernia randomised to observation or operation, 46 of the 80 in the observation group had converted to an operation. The estimated conversion rate for the observation group using the Kaplan–Meier method was 16% (95 % confidence interval 9 to 26%) at 1 year, and 72% (59 to 84%) at 7•5 years. The main reason for conversion was pain in 33 men, and two presented with an acute hernia. Over a one year period 112 patients were identified with 115 ventral hernias. 62 (55%) had an asymptomatic hernia, 14 of whom opted for operation. 48 patients with 50 asymptomatic hernias participated in the study. At a median follow up of 6.2 years (IQR 5.8-6.9 years) 3 (6%) patients converted to operation due to pain.
The incidence of umbilical hernia in the general population was 2.4% (15 or 622 patients) and all were asymptomatic with only 2 who were aware of their hernia. 36 patients were referred by their general practitioner for assessment of an umbilical hernia and 18 were asymptomatic. 28 of the 36 underwent operation of which 3 (Kaplan-Meier estimate 10% (95% CI 3% – 30%)) required re-operation for a recurrent hernia at a median follow-up of 6.1 years (IQR 5.8 – 6.2 years). Of the 15 patients with an incidental hernia, 2 (Kaplan-Meier estimate 15% (95% CI 3% – 44%)) required an operation for pain at a median follow-up of 6.1 years (IQR 5.9 – 6.4 years).

Conclusions
The BPI is an easy and effective way of assessing pain and its impact on physical activity and quality of life in patients with an inguinal or ventral hernia. Most patients with a painless inguinal hernia develop symptoms over time and will require an operation therefore surgical repair is recommended for medically fit patients with a painless inguinal hernia. In contrast, a policy of non-operation is a satisfactory alternative for patients with an asymptomatic ventral hernia although further studies in this area are required to confirm these outcomes. Umbilical hernias are common in the adult population and most cause no symptoms and are unlikely to become symptomatic. Clinical trials are necessary to assess the value of operation in patients with an asymptomatic umbilical hernia.

• Item Type: Thesis (MD)
• Qualification Level: Doctoral
• Keywords: hernia, abdominal wall hernia, inguinal hernia, incisional hernia, umbilical hernia, ventral hernia, quality of life, pain, symptoms, outcome, Brief Pain Inventory, Visual Analogue Scale, Verbal Rating Scale
• Subjects: R Medicine > RD Surgery
• Colleges/Schools: College of Medical Veterinary and Life Sciences > School of Medicine, Dentistry & Nursing
• Supervisor's Name: O'Dwyer, Professor Patrick J
• Date of Award: 2014
• Depositing User: Miss Lucia PS Chung
• Unique ID: glathesis:2014-5168
• Copyright: Copyright of this thesis is held by the author.
• Date Deposited: 23 Jun 2014 12:59
• Last Modified: 23 Jun 2014 13:00
• URI: https://theses.gla.ac.uk/id/eprint/5168