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We read with great interest the recent article by Wu J. J [1]. The authors investigated the risk of performing inguinal hernia repair in the elderly. The authors found that mortality was similar across age groups in elective repair, and emergent inguinal hernia repair carries a very high risk of death in the elderly. We would like to congratulate the authors on their work; however, we have several comments on performing inguinal hernia repair in elderly. First, although there are many different procedures in inguinal hernia repair methods, however, depending on the stress impact on individual’s general condition, the following two categories are typical, the laparoscopic procedures under general anesthesia, and the open technique with local anesthesia, such as Lichtenstein procedure [2]. When evaluating the operative risk of inguinal hernia repair, it usually not the patient’s age, but the specific procedure you will take is an even more important factor. In my opinion, the Lichtenstein procedure with local anesthesia can be safely tolerated regardless of patient’s age; thus, old age usually should not considered as a contraindication to elective inguinal hernia repair. Actually, in our current series, we had several patients over 90 years, and two patients of 100 years, successfully underwent open inguinal hernia repair under local anesthesia. Second, the authors grouped patients by age into three categories: <65, 65–79, and >80, in my opinion when considering elderly patients in inguinal hernia repair, unlike in other abdominal surgical procedures, the criteria for elderly may be regarded at least 80 years or even older, there are no sense to differentiate patients <65 and 65–79 years for inguinal hernia repair. Third, we should bear in mind that the elderly tend to have a higher incidence of emergent inguinal hernia repair and higher incidence of bowel resection due to the presence of inguinal hernia [3], which contributes to the higher mortality rate in old patients. Thus, the higher mortality rate in elderly in emergency, clearly not due to the hernia repair itself, but from a complex surgical procedure other than inguinal hernia repair, such as bowel obstruction and bowel resection, from this point, elder patients should be advised to receive inguinal hernia repair as early as possible. Our fourth point of view is on the issue of watchful waiting of patients with minimally symptomatic inguinal hernias. Although Watchful waiting, especially in the elderly population, has been argued for many years, and some believe that it is a safe method, however, with a extended follow-up of up to a maximum follow-up of 11.5 years, the cross-over rate (from watchful waiting to surgery) was 68%, and it was higher (79%) in patients over 65 years [4], and this higher cross-over rate was underestimated in short-term follow-up [5].
We, therefore, feel that the elderly should be encouraged to receive elective inguinal hernia repair, not only due to the safety of receiving elective procedure, but also due to the fact that higher cross-over rate will be counted in the future, and a more complex procedure may be needed and even more harmful in elderly. Therefore, why not eradicate the conceivable higher risk later on just by a minimal risk procedure even in quite higher age?
References
Wu JJ, Baldwin BC, Goldwater E, Counihan TC (2016) Should we perform elective inguinal hernia repair in the elderly? Hernia (Epub ahead of print)
Simons Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J, de Lange D, Fortelny R, Heikkinen T, Kingsnorth A, Kukleta J, Morales-Conde S, Nordin P, Schumpelick V, Smedberg S, Smietanski M, Weber G, Miserez M (2009) European hernia society guidelines on the treatment of inguinal hernia in adult patients. Hernia 13:343–403
Hernández-Irizarry R, Zendejas B, Ramirez T, Moreno M, Ali SM, Lohse CM, Farley DR (2012) Trends in emergent inguinal hernia surgery in Olmsted County, MN: a population-based study. Hernia 16:397–403
Fitzgibbons RJ Jr, Ramanan B, Arya S, Turner SA, Li X, Gibbs JO, Reda DJ (2013) Investigators of the Original Trial. Long-term results of a randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias. Ann Surg 258:508–515
Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, Dunlop DD, Reda DJ, McCarthy M Jr, Neumayer LA, Barkun JS, Hoehn JL, Murphy JT, Sarosi GA Jr, Syme WC, Thompson JS, Wang J, Jonasson O (2006) Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA 18(295):285–292
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Li, J., Zhang, W. Letter to the editor: “Should we perform elective inguinal hernia repair in the elderly?” by Wu J. J. et al. (Hernia. 2016 Jul 20. [Epub ahead of print]). Hernia 21, 821–822 (2017). https://doi.org/10.1007/s10029-017-1574-2
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DOI: https://doi.org/10.1007/s10029-017-1574-2