Safety and Feasibility of Laparoscopic Transabdominal Preperitoneal Hernia Repair for Octo- and Nonagenarians

Abstract

Background:

The feasibility of laparoscopic hernia repair in octo- and nonagenarians has not been investigated in detail. The aim of this retrospective study was to evaluate the safety and feasibility of laparoscopic hernia repair in octo- and nonagenarians.

Methods:

This study included 607 patients who underwent transabdominal preperitoneal laparoscopic hernia repair at our hospital between April 2014 and October 2020. Patients were divided into an over 80 group (112 patients aged 80 years and older) and a control group (495 patients younger than 80 years). The clinical outcomes were compared between the groups. In addition, among patients aged 80 years and older, those who underwent elective laparoscopic hernia repair (laparoscopic group: 111 patients) were compared with patients who underwent elective open hernia repair during the same study period (open group: 79 patients).

Results:

The number of patients who underwent bilateral hernia repair was significantly larger in the over 80 group (26.7% versus 11.7%, P < .001). The incidence of postoperative complications was not significantly different between the over 80 group and the control group. Compared with open group, the number of patients who underwent bilateral hernia repair was significantly larger in the laparoscopic group (27.0% versus 2.5%, P < .001). The incidence of postoperative complications (2.7% versus 10.1%) and the incidence of readmission (0.9% versus 6.3%) were significantly greater in the open group.

Conclusions:

Laparoscopic hernia repair in octo- and nonagenarian patients yields safe and noninferior outcomes. Laparoscopic hernia repair in octo- and nonagenarian patients is considered more suitable for detecting and repairing contralateral hernias simultaneously.

Introduction

The lifelong cumulative incidence of inguinal hernia repair is reported to be 27%–42.5% for men and 3%–5.8% for women, and age is a risk factor for developing an inguinal hernia.¹ As the population ages, surgeons have greater opportunities to treat elderly patients with groin hernias.

Traditionally, groin hernias have been treated by open surgery, although during the past decade, laparoscopic hernia repair has become one of the standard procedures for repairing groin hernias.^1–4 Several reports have suggested the feasibility of laparoscopic hernia repair in elderly patients.^5–8 However, the age cutoff values in those studies varied, and the number of octo- and nonagenarian patients who underwent laparoscopic repair in those reports was relatively small. In this study, we divided the patients who underwent transabdominal preperitoneal (TAPP) hernia repair into patients older than and younger than 80 years and compared the perioperative outcomes.

In addition, the superiority of laparoscopic hernia repair compared with open hernia repair in octo- and nonagenarians has not been investigated in detail. Thus, a comparison between laparoscopic and open hernia repair in patients older than 80 years was performed.

Materials and Methods

Study patients

Between April 2014 and October 2020, a total of 607 patients underwent laparoscopic TAPP groin hernia repair at Fujinomiya City General Hospital. These patients were included in this retrospective study. Of them, 112 patients were older than 80 years (over 80 group), whereas the other 495 patients were younger than 80 years (control group). Patient characteristics and perioperative outcomes were compared between the groups. In the over 80 group, 1 patient underwent emergency surgery, whereas the other 111 patients underwent elective surgery (laparoscopic group). During the same period, 79 patients older than 80 years underwent elective open groin hernia repair (open group).

Comparisons were also performed between the laparoscopic group and the open group. At our institution, if a patient was considered unsuitable for general anesthesia, open repair with local or lumbar anesthesia was selected. Otherwise, laparoscopic or open repair was selected at the surgeon's discretion. Therefore, patients with severe comorbidities or patients with a history of major lower abdominal surgery were generally allocated to the open group. Patients with an obturator hernia or an incisional hernia and patients who underwent emergency open hernia repair were all excluded from this study.

We accessed patient records so that we could review and compare clinical variables and outcomes. The study protocol was approved by the institutional review board of Fujinomiya City General Hospital. Informed consent was waived for this retrospective study.

Clinical variables assessed

Following clinical variables were reviewed: sex, age, American Society of Anesthesiologists physical status (ASA-PS), comorbidities, body mass index (BMI), presence of incarceration at first visit, emergency or elective surgery, history of lower abdominal surgery, internal use of anticoagulant medicine, hernia side and location, size of hernia orifice, and time from onset to surgery. We also reviewed the following perioperative variables: operation time, postoperative length of stay, simultaneous repair on the contralateral side, use of intestinal resection, use of a mesh prosthesis, postoperative complications, development of hernia recurrence, mortality, and readmission. Complications were classified according to the 2004 grading system reported by Dindo et al.,⁹ and complications of grade II or more were considered clinically significant.

Statistical analyses

Study variables are shown as the number and percentage of patients, percentage of cases, or mean values. Each cutoff value was determined according to the median value or a receiver operating characteristic curve. Between-group differences in nominal variables were analyzed by Pearson's chi-square test, and continuous variables were compared using the Mann–Whitney U test. The Software Package for the Social Sciences, version 11.5J for Windows 10 software program (SPSS, Chicago, IL, USA), was used for all statistical analyses, and a P-value of <.05 was considered significant.

Results

Comparison of patient characteristics between the over 80 group and the control group

The 607 patients included 540 (88.9%) males and 67 (11.0%) females who ranged in age from 16 to 93 years (mean, 66.5 years) (Table 1). The over 80 group included 104 octogenarians and 8 nonagenarians. The number of female patients was significantly larger in the octogenarian group (18.7% versus 9.2%, P = .003). The number of patients with an ASA-PS score of 3 was significantly larger in the over 80 group (16.9% versus 5.2%, P < .001). The number of patients who had taken anticoagulant medicine at the first visit was significantly larger in the over 80 group (30.3% versus 12.7%, P < .001).

Table 1.

Results of Univariate Analyses of Preoperative Clinical Variables in the Over 80 Group and the Control Group

	Over 80 group (n = 112)	Control group (n = 495)	P
Sex ratio (male/female)	91/21	449/46	.003
Mean age (years)	83.9 ± 3.3	62.6 ± 12.7	<.001
ASA-PS (class 1 or 2/3)	93/19	469/26	<.001
Comorbidities, n (%)
Renal failure	3 (2.6)	5 (1.0)	.161
COPD	2 (1.7)	13 (2.6)	.604
Coronary heart disease or chronic heart failure	9 (8.0)	23 (4.6)	.147
BMI (kg/m²) (n = 104 and 451)	22.3 ± 2.7	23.0 ± 2.8	.098
Visiting with incarceration, n (%)	5 (4.4)	21 (4.2)	.916
Emergency operation, n (%)	1 (0.8)	3 (0.6%)	.734
History of lower abdominal surgery, n (%)	17 (15.1)	86 (17.3)	.576
Anticoagulant medicine, n (%)	34 (30.3)	63 (12.7)	<.001
Femoral hernia, n (%)	9 (8.0)	12 (4.4)	.003
Recurrent hernia, n (%)	4 (3.5)	9 (1.8)	.247
Hernia orifice >3 cm (n = 112 and 494), n (%)	31 (27.6)	144 (29.0)	.756
Time from onset to surgery >1 year (n = 110 and 489), n (%)	34 (30.9)	160 (32.7)	.713

ASA-PS, American Society of Anesthesiologists physical status; BMI, body mass index; COPD, chronic obstructive pulmonary disease.

The number of patients with a femoral hernia was significantly larger in the over 80 group (8.0% versus 4.4%, P = .003). Other preoperative clinical characteristics, including the presence of comorbidities, BMI, presence of incarceration at the first visit, number of patients who underwent emergency operation, history of lower abdominal surgery, recurrent hernia, number of patients with a hernia orifice >3 cm, and number of patients with a time from onset >1 year, were not significantly different.

Comparison of perioperative outcomes between the over 80 group and the control group

The operation time was not significantly different between the groups (101.7 minutes in the over 80 group and 93.7 minutes in the control group) (Table 2). The postoperative length of stay (2.7 days in the over 80 group and 2.4 days in the control group) was not significantly different. The number of patients who underwent bilateral hernia repair simultaneously was significantly larger in the over 80 group (26.7% versus 11.7%, P < .001). One patient in the over 80 group required intestinal resection. A mesh prosthesis was used in all the 607 patients. There was no significant difference in the incidence of postoperative complications or wound or mesh infection. There were no cases of hernia recurrence or mortality among the 607 patients. The number of patients who required readmission was not significantly different between the groups.

Table 2.

Results of Univariate Analyses of Surgical Outcomes Between the Over 80 Group and the Control Group

	Over 80 group (n = 112)	Control group (n = 495)	P
Mean operation time (minutes)	101.7 ± 42.2	93.7 ± 30.7	.099
Mean unilateral repair (minutes) (n = 82 and 437)	87.9 ± 22.3	88.4 ± 25.7	.795
Mean bilateral repair (minutes) (n = 30 and 58)	139.2 ± 10.6	134.1 ± 34.8	.708
Postoperative length of stay (days)	2.7 ± 2.0	2.4 ± 1.0	.619
Bilateral repair, n (%)	30 (26.7)	58 (11.7)	<.001
Intestinal resection, n (%)	1 (0.8)	0	.035
Without mesh prosthesis, n (%)	0	0	—
Postoperative complications^a, n (%)	3 (2.6)	8 (1.6)	.446
Wound infection, n (%)	1 (0.8)	7 (1.4)	.567
Mesh infection, n (%)	0	1 (0.2)	.662
Hernia recurrence, n (%)	0	0	—
Mortality, n (%)	0	0	—
Readmission^b, n (%)	1 (0.8)	9 (1.8)	.487

Complications regarded as grade 2 or more according to the Clavien–Dindo classification. Postoperative complications in the over 80 group included: aspiration pneumonia (n = 1), neurogenic bladder dysfunction (n = 1), and internal hernia (n = 1), whereas those in the control group included: wound infection (n = 3), mesh infection (n = 1), necrosis of remnant omentum (n = 1), hematoma (n = 1), pneumonia (n = 1), and internal hernia (n = 1).

The reason for readmission in the over 80 group included: postoperative pain (n = 1), whereas those in the control group included: duodenal ulcer (n = 1), wound infection (n = 2), mesh infection (n = 1), internal hernia (n = 1), and operation for contralateral side (n = 4).

Comparison of patient characteristics between the laparoscopic group and the open group

The patients included 158 (83.1%) males and 32 (16.8%) females who ranged in age from 80 to 95 years (mean, 84.5 years) (Table 3). The open group included 67 octogenarians and 12 nonagenarians. The mean age was significantly higher in the open group (83.9 years versus 85.5 years, P = .006). The number of patients with chronic obstructive pulmonary disease (1.8% versus 20.2%, P < .001) and coronary heart disease or chronic heart failure (8.1% versus 31.6%, P < .001) was significantly larger in the open group. The number of patients who presented with incarceration was significantly larger in the open group (3.6% versus 13.9%, P < .001). The number of patients with a history of lower abdominal surgery was significantly larger in the open group (15.3% versus 39.2%, P < .001).

Table 3.

Results of Univariate Analyses of Preoperative Clinical Variables in the Laparoscopic Group and the Open Group in Octo- and Nonagenarians

	Laparoscopic group (n = 111)	Open group (n = 79)	P
Sex ratio (male/female)	90/21	68/11	.364
Mean age (years)	83.9 ± 3.2	85.5 ± 4.0	.006
ASA-PS (class 1 or 2/3)	92/19	60/19	.239
Comorbidities, n (%)
Renal failure	3 (2.7)	5 (6.3)	.219
COPD	2 (1.8)	16 (20.2)	<.001
Coronary heart disease or chronic heart failure	9 (8.1)	25 (31.6)	<.001
BMI (kg/m²) (n = 104 and 70)	22.3 ± 2.7	21.8 ± 2.5	.260
Visiting with incarceration, n (%)	4 (3.6)	11 (13.9)	.009
History of lower abdominal surgery, n (%)	17 (15.3)	31 (39.2)	<.001
Anticoagulant medicine, n (%)	34 (30.6)	31 (39.2)	.217
Femoral hernia, n (%)	8 (7.2)	8 (10.1)	.475
Recurrent hernia, n (%)	4 (3.6)	3 (3.7)	.944
Hernia orifice >3 cm (n = 112 and 97), n (%)	31 (27.9)	30 (37.9)	.073
Time from onset to surgery >1 year (n = 110 and 100), n (%)	34 (30.6)	18 (22.7)	.263

ASA-PS, American Society of Anesthesiologists physical status; BMI, body mass index; COPD, chronic obstructive pulmonary disease.

Comparison of perioperative outcomes between the laparoscopic group and the open group

The operation time was significantly longer in the laparoscopic group (101.7 minutes in the laparoscopic group and 84.7 minutes in the open group, P = .002) (Table 4). However, it was not significantly different among the patients who underwent unilateral hernia repairs or bilateral ones, respectively. The postoperative length of stay (2.5 days in the laparoscopic group and 3.5 days in the open group) was not significantly different.

Table 4.

Results of Univariate Analyses of Surgical Outcomes Between the Laparoscopic Group and the Open Group in Octo- and Nonagenarians

	Laparoscopic group (n = 111)	Open group (n = 79)	P
Mean operation time (minutes)	101.7 ± 42.3	84.7 ± 27.6	.002
Mean unilateral repair (minutes) (n = 81 and 77)	87.5 ± 22.0	83.3 ± 26.2	.160
Mean bilateral repair (minutes) (n = 30 and 2)	139.2 ± 10.6	137.0 ± 43.8	>.999
Postoperative length of stay (days)	2.5 ± 1.4	3.5 ± 4.4	.573
Local or lumbar anesthesia, n (%)	0	54 (68.3)	<.001
Bilateral repair, n (%)	30 (27.0)	2 (2.5)	<.001
Intestinal resection, n (%)	0	0	—
Without mesh prosthesis, n (%)	0	0	—
Postoperative complications^a, n (%)	3 (2.7)	8 (10.1)	.030
Mortality, n (%)	0	0	—
Wound infection, n (%)	1 (0.8)	0	.397
Mesh infection, n (%)	0	1 (0.2)	.234
Hernia recurrence, n (%)	0	1 (1.2)	.234
Readmission^b, n (%)	1 (0.9)	5 (6.3)	.035

Complications regarded as grade 2 or more according to the Clavien–Dindo classification. Postoperative complications in the laparoscopic group included: aspiration pneumonia (n = 1), neurogenic bladder dysfunction (n = 1), and internal hernia (n = 1), whereas those in the open group: mesh infection (n = 1), intestinal stenosis (n = 1), hernia recurrence (n = 1), aspiration pneumonia (n = 1), respiratory tract infection (n = 2), pleural effusion (n = 1), and Clostridium difficile infection (n = 1).

The reason for readmission in the laparoscopic group included: postoperative pain (n = 1), whereas those in the open group included: mesh infection (n = 1), intestinal stenosis (n = 1), hernia recurrence (n = 1), and operation for contralateral side (n = 2).

The number of patients who underwent bilateral hernia repair simultaneously was significantly larger in the laparoscopic group (27.0% versus 2.5%, P < .001). No patients required intestinal resection. A mesh prosthesis was used in all th190 patients. The incidence of postoperative complications was significantly higher in the open group (2.7% versus 10.1%, P = .030). There were no cases of mortality. One patient (1.2%) in the open group developed hernia recurrence. The number of patients who required readmission was significantly larger in the open group (0.9% versus 6.3%).

Discussion

Our study revealed that laparoscopic TAPP hernia repair in octo- and nonagenarians yields acceptable outcomes in patients younger than 80 years. Moreover, laparoscopic TAPP hernia repair for octo- and nonagenarians shows higher rate for detecting and repairing bilateral side hernias simultaneously. In addition, although patient characteristics were not compatible between the laparoscopic group and the open group, laparoscopic TAPP hernia repair showed lower incidence of postoperative complications and readmission than open hernia repair.

Previously, several authors claimed the feasibility of laparoscopic hernia repair in octogenarians by comparing patients younger than and older than 80 years who underwent laparoscopic hernia repair. Vigneswaran et al. reported noninferior outcomes of totally extraperitoneal (TEP) hernia repair in octogenarians, except for readmission and length of stay; however, the number of patients older than 80 years who underwent laparoscopic TEP was only 13.¹⁰ Wakasugi et al. reviewed the records of 43 patients older than 80 years who underwent single-incision laparoscopic TEP and suggested noninferior outcomes in these patients compared with those in younger patients.¹¹

Regarding laparoscopic TAPP hernia repair, Egawa et al. reviewed the records of 26 patients older than 80 years and showed that age was not a risk factor for developing postoperative complications.¹² To the best of our knowledge, our study included the largest number of patients older than 80 years who underwent laparoscopic hernia repair among previous single-institution studies, and the results strongly support the safety and feasibility of laparoscopic TAPP hernia repair in octo- and nonagenarians.

Laparoscopic hernia repair is considered a suitable procedure for checking for the presence of occult lesions on the contralateral side.^13–15 This distinctive feature is not included in open hernia repair. The incidence of occult contralateral hernia increases with age and was reported to be 20.8% in patients older than 80 years.¹⁶ Therefore, it is reasonable to select laparoscopic hernia repair if a patient older than 80 years is suitable for general anesthesia. Our comparison between the octogenarian group and the control group also suggests the superiority of laparoscopic hernia repair in octo- and nonagenarian patients requiring simultaneous bilateral hernia repair.

Some factors increase the difficulty of laparoscopic hernia repair, even in patients suitable for general anesthesia, including a history of major lower abdominal surgery or radical prostatectomy.¹⁷ In addition, if the patient is diagnosed with a recurrent hernia after laparoscopic hernia repair, open surgery is considered a more suitable procedure.¹ However, for patients with a recurrent hernia after open hernia repair, laparoscopic surgery is considered more suitable. In our study, 13 of the 607 patients who underwent laparoscopic hernia repair were diagnosed with a recurrent hernia, and all of them underwent open hernia repair. Surgeons have to select an adequate surgical strategy, depending on each patient's characteristics.

Another study designed to demonstrate the feasibility of laparoscopic hernia repair compared patients who underwent laparoscopic hernia repair and those who underwent open hernia repair. Whereas a recent meta-analysis demonstrated a lower rate of acute and chronic pain after laparoscopic repair,¹⁸ only a few studies evaluated the superiority or inferiority of laparoscopic hernia repair in octo- and nonagenarians. Hernandez-Rosa et al. studied 31 patients older than 80 years who underwent laparoscopic hernia repair and 73 patients who underwent open hernia repair.¹⁹

Hope et al. compared 23 patients who underwent laparoscopic hernia repair and 58 patients who underwent open hernia repair.²⁰ Each study suggested noninferior outcomes of laparoscopic hernia repair in octogenarians. Dallas et al. compared 31 patients who underwent laparoscopic hernia repair and 84 patients who underwent open hernia repair and suggested a shorter recovery time and duration of pain in the laparoscopic repair group.²¹ In addition, Pallati et al. demonstrated that, compared with laparoscopic surgery, open repair was a risk factor for developing morbidity, as in our study.²²

In our study, the number of patients who underwent bilateral hernia repair simultaneously was significantly larger in the laparoscopic group. The lower incidence of bilateral hernia repair in the open group might be derived from the invasiveness of open bilateral hernia repair. Surgeons might become distressed when performing bilateral repair because of the invasiveness of the double incision.

There are some limitations associated with this study. First, it was retrospective in nature and was performed at a single center. Second, regarding the comparison between laparoscopic hernia repair and open repair, patients with severe comorbidities generally underwent the open procedure. Therefore, further study is needed to establish the superiority of laparoscopic repair in octo- and nonagenarians.

Conclusions

Laparoscopic hernia repair in octo- and nonagenarian patients yields safe and acceptable outcomes. Laparoscopic hernia repair in octo- and nonagenarian patients is considered more suitable for detecting and repairing contralateral hernias simultaneously.

Footnotes

Authors' Contributions

Conception and design by A. Kohga and A. Kawabe. Data collection and analysis were performed by A. Kohga Article writing and approval of the article by all authors. All authors agree with the content of the article. All authors contributed to the acquisition of data, writing, and revision of this article.

Ethical Statement

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.

Data Sharing

Data sharing request will be considered by the management group on written request to the corresponding author.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

References

HerniaSurge Group. International guidelines for groin hernia management. Hernia, 2018; 22:1–165.

EU Hernia Trialists Collaboration. Laparoscopic compared with open methods of groin hernia repair: Systematic review of randomized controlled trials. Br J Surg, 2000; 87:860–867.

Schmedt

, Sauerland

, Bittner

. Comparison of endoscopic procedures vs Lichtenstein and other open mesh techniques for inguinal hernia repair: A meta-analysis of randomized controlled trials. Surg Endosc, 2005; 19:188–199.

Köckerling

, Stechemesser

, Hukauf

, Kuthe

, Schug-Pass

. TEP versus Lichtenstein: Which technique is better for the repair of primary unilateral inguinal hernias in men?. Surg Endosc, 2016; 30:3304–3313.

Bowling

, El-Badawy

, Massri

, et al. Laparoscopic and open inguinal hernia repair: Patient reported outcomes in the elderly from a single centre—A prospective cohort study. Ann Med Surg (Lond), 2017; 22:12–15.

Liu

, Yu

, Wu

, Lin

, Chueh

, Tsai

. Feasibility and safety of elective laparoscopic total extraperitoneal preperitoneal groin hernia repair in the elderly: A propensity score-matched comparison. Clin Interv Aging, 2018; 13:195–200.

Chung

, Choi

, Kim

, Choi

. Feasibility of totally extraperitoneal (TEP) laparoscopic hernia repair in elderly patients. Hernia, 2019; 23:299–303.

Bates

, Divino

. Laparoscopic surgery in the elderly: A review of the literature. Aging Dis, 2015; 10;6:149–155.

Dindo

, Demartines

, Clavien

. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg, 2004; 240:205–213.

10.

Vigneswaran

, Gitelis

, Lapin

, et al. Elderly and octogenarian cohort: Comparable outcomes with nonelderly cohort after open or laparoscopic inguinal hernia repairs. Surgery, 2015; 158:1137–1143; discussion 1143–1144.

11.

Wakasugi

, Tei

, Anno

, et al. Single-incision totally extraperitoneal inguinal hernia repair is safe and feasible in elderly patients: A single-center experience of 365 procedures. Asian J Endosc Surg, 2016; 9:281–284.

12.

Egawa

, Nakamura

, Manabe

, Iwasaki

, Noshiro

. Incidence of postoperative complications in transabdominal preperitoneal repair for groin hernia is influenced by poor performance status rather than by old age. Ann Gastroenterol Surg, 2019; 3:318–324.

13.

van den Heuvel

, Beudeker

, van den Broek

, Bogte

, Dwars

. The incidence and natural course of occult inguinal hernias during TAPP repair: Repair is beneficial. Surg Endosc, 2013; 27:4142–4146.

14.

Griffin

, Harris

, Tang

, Skelton

, Reed

, Harris

. Incidence of contralateral occult inguinal hernia found at the time of laparoscopic trans-abdominal pre-peritoneal (TAPP) repair. Hernia, 2010:14:345–349.

15.

Kohga

, Kawabe

, Okumura

, Yamashita

, Isogaki

, Suzuki

. Laparoscopic repair is a treatment of choice for selected patients with incarcerated obturator hernia. Hernia, 2018; 22:887–895.

16.

Fukushima

, Yokoyama

, Miwa

, et al. Impact of age on groin hernia profiles observed during laparoscopic transabdominal preperitoneal hernia repair. Surg Endosc, 2019; 33:2602–2611.

17.

Sakon

, Sekino

, Okada

, Seki

, Munakata

. Laparoscopic inguinal hernioplasty after robot-assisted laparoscopic radical prostatectomy. Hernia, 2017; 21:745–748.

18.

Bullen

, Massey

, Antoniou

, Smart

, Fortelny

. Open versus laparoscopic mesh repair of primary unilateral uncomplicated inguinal hernia: A systematic review with meta-analysis and trial sequential analysis. Hernia, 2019; 23:461–472.

19.

Hernandez-Rosa

, Lo

, Choi

, Colon

, Boudourakis

, Telem

, Divino

. Laparoscopic versus open inguinal hernia repair in octogenarians. Hernia, 2011; 15:655–658.

20.

Hope

, Bools

, Menon

, Scott

CM 3rd

, Adams

, Hooks

WB 3rd

. Comparing laparoscopic and open inguinal hernia repair in octogenarians. Hernia, 2013; 17:719–722.

21.

Dallas

, Froylich

, Choi

, et al. Laparoscopic versus open inguinal hernia repair in octogenarians: A follow-up study. Geriatr Gerontol Int, 2013; 13:329–333.

22.

Pallati

, Gupta

, Bichala

, Gupta

, Fang

, Forse

. Short-term outcomes of inguinal hernia repair in octogenarians and nonagenarians. Hernia, 2013; 17:723–727.