Inguinal Hernia and Certain Risk Factors

Author(s): J. Flich, J. L. Alfonso, F. Delgado, M. J. Prado and P. Cortina

Source: European Journal of Epidemiology, Vol. 8, No. 2 (Mar., 1992), pp. 277-282
Published by: Springer
Stable URL: http://www.jstor.org/stable/3521158
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Eur. J. Epidemiol. 0392-2990
EUROPEAN Vol. 8, No. 2
March 1992, p. 277-282
JOURNAL
OF
EPIDEMIOLOGY

INGUINAL HERNIA AND CERTAIN RISK FACTORS

J. FLICH*, J.L. ALFONSO**", F. DELGADO*, M.J. PRADO**, P. CORTINA**

*Departamento de cirugia - Hospital Peset - Aleixandre.
**Departamento de Medicina Preventiva Y Salud Publica - Universidad de Valencia - Avda.
Blasco Ibaifez, 17 - 46010 Valencia - Spain.

Key words: Risk factors - Inguinal hernia

The are several studies on inguinal hernias that give some clues about the association between
this type of hernia and certain risk factors. This association was suspected long ago but had not been
demonstrated.
The present study tries to correlate the origin of inguinal hernias and the physical effort of the
subjects in accordance with their work activity. The results of this study show that physical effort, as
a risk factor, is closely related to the appearance of inguinal hernias. A person whose work involves
lifting or other strenuous exertion has a higher risk than those whose jobs are less stenouous (p <
0.05). This conclusion was reached after taking into account not only the weight lifted but also the
number of years in this activity.

INTRODUCTION However, a shift in the visceral weight from the

center of the abdomen to the groin (seen only in
The present information about the origin of beings) could cause the rupture (31). Lifting
human
inguinal hernia, indicates that alterations in the with different weights, different sizes and
efforts
different
collagen fiber of the transversalis fascia (9, 32, 34, 39, frecuencies influence the appearance of the
40) permit the appearance of the disease. But,hernia. the This hypothesis constitutes the basis of this study.
factors that produce these alterations are still under
discussion.
According to some studies (24), when an upright MATERIAL AND METHODS
position is adopted, the weak spot of the abdominal
wall is protected by the transversalis fascia. The study was carried out in the Departmen
Other studies published long ago demonstratedSurgery "A" of the General Hospital of Valencia
that heavy lifting increased the visceral pressure (10)
health care center has a target population based on
and that this factor could generate the hernia.geographical distribution of the city of Valencia
Increased pressure on a transversalis fascia could
patient is sent by the general practitioner or speci
break its fibers. Posterior studies have focused on the in surgery or arrives at the emergency room of his
type of work being done by the patient when the accord.
symptoms first appear (13, 14, 26) and they report that The selection of cases and controls was
there is no significant relationship between the type of automatic. The 128 cases were all patients w
work and the appearance of hernia. inguinal hernias treated in 1986 in the hospital
average time between diagnosis and operation w
Corresponding author. years. All were in-patients for surgery.

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 Flich J. et al. Eur. J. Epidemiol.

The 174 controls were selected from the same Another point measured was the duration of the
geographic area. They were randomly selected from interview, no significant difference between cases and
the total population tabulated at the health care controls was found (p > 0.05).
centre. Six were rejected because they had a previous The data were processed using the SPSS-X
clinical history of umbilical hernia or eventration. statistical package. The data codes were objectively
Other similar or closely-related illnesses were taken processed. The following statistical tests for
into account when selecting and rejecting controls in comparison were used: (t-test, Chi-square, simple
order to avoid an epidemiologically biased controlregression, and analysis of variance).
group. The procedure was a follows:
The study was retrospective, the patient had to be
diagnosed as having inguinal hernia. We used - Comparison of each factor (except physical effort)
interview for cases and controls. between cases and controls in order to determine
The variables in this study were classified into differences between the two. groups. We examined
three groups. The first group of guestions elicited different anatomical types of hernias among the
general information (age, sex, weight, height, and cases.
alcohol and tobacco consumption). The second group
included variables related to the effort factor (this was- A study of physical effort, including in
the result of other variables such as type of work, lenght of time in activity. For this rea
lifting activity, and time worked in his/her life). The categories were used for this variable in
third group of variables had to do with the disease with other authors (26): 1) No effort,
(anatomical type of inguinal hernia, previous involving no effort and sedentary w
antecedents and causes related to the appareance of included; 2) light, standing work inv
the disease). occasional lifting of not too heavy w
Certains measures were taken to control the medium, when weight was lifted more f
reliability of the answers. After several months, and 20 4) high, when the effort was daily
randomly-selected patients were re-interviewed. No
significant differences were found between the first The inclusion of an effort category (ea
and second interviews. It can therefore be concluded can present different categories in the cou
that work activities were accurately recorded. her life), depended on the type of work carr

TABLE 1. - A comparison considering each factor of the study.

Factors Cases Controls Significance

Mean Age 50.23 50.82 T-Test ? 0.10

M 107 151
Sex X /P > 0.10
F 21 23

Mean weight (kg) 68.15 69.69 T-Test/P ? 0.10

Mean height (cm) 166 167 T-Test/P ? 0.10

No 59 74

Tobacco X2 /P > 0.10

Yes 69 100

? 20 daily 61 78
No of cigarettes X /P 0.10
? 40 daily 8 22

Years of smoking 32.72 30.84 T-Test ? 0.10

No 78 86

Alcohols cons. X /P > 0.10

Yes 50 88

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Vol. 8, 1992 Inguinal hernia and certain risk factors

the longest period of time. TABLE 2. -Relative

Coinciding factorsrisk was of
at the appearance used
measuring risks (25). To avoid biases in the the Hernia or Disease. Cases only.
distributions of the sample, we ranked the cases and
controls by age and sex.
Type of Hernia N. Effort Total

RESULTS Indirect 33 41 74

Direct 18 16 34
When we compared the cases and controls for
each factor examined in the study, we found that Double
there 7 3 10
were no differences in age and sex distributions. Other
Crural 3 7 10
risk factors studied for which no differences were
found were weight, height and smoking habitsTotal 61 67 128
(number of cigarettes and years of smoking). Alcohol
consumption, however, showed a significant X2 /P > 0.10
difference (p < 0.05) (Table 1).
We tested the conditions involved in the origin of
the inguinal hernia according to different anatomical
types. Half of the cases reported no correlation TABLE 3 - A comparison of some factors in the cases.
between the hernia and a specific cause. Most of the
cases reporting such a correlation had crural hernias Type of Hernia Height Age Weight Yrs. Smoking
(Table 2).
There were no differences in the other risk factors
Indirect 168 51.66 68.83 32.05
studied, such as age, weight and years of smoking. Direct 164 55.00 68.67 30.38
However, we observed a significant difference in mean
Double 167 55.90 68.10 42.60
height (p < 0.05). Indirect hernias were found in the
Crural 159 56.20 61.40 41.66
tallest individuals (168 cm), followed by double (167
cm), direct (164 cm) and crural hernias (159 cm) Anoa/P < 0.05 Anoa/P > 0.10
(Table 3).

TABLE 4. - Occupations Reported by subjects, according to effort catego

No effort Light effort Medium effort High effort

Office worker Barber Agriculture Port loader

Porter Filling-station Construction Load & Unload
Driver Securyti Guard House Maidin Gas Dealer
Tailor Electrician (More than 3 hses) Metal Melter
Teacher Shop Assistant Violent Sports Quarry work
Night Watchman Maintenance Sailor Acrobat
Salesperson Car Sprayer Day Labourer
Student Jeweller Miner
Bank Clerk House Maid Scrap-Yd. Dealer C. T. TL.
Unemployed Wood Carver Cabinet-maker 29 15 44
String Musician Waiter Furniture Coverer
Newsagent Carpenter
C. T. TL. Car Dealer Mechanic
Baker
10 41 51 Glass Dealer
C. T. TL.Butcher
Butcher
51 78 129 Self-Employed

C. T. TL.
154 170 324

Total activities (Some. for some subjects) in, memory: 548; cases: 224; controls: 304
C: cases, T: controls, TL: Total.

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 Flich J. et al. Eur. J. Epidemiol.

To study the TABLE

"effort factor"
6. - Average time of exposure to effort in f
occupation, jobs were
each category, classified
cases and controls.
shown in Table 4.
The cases were then divided into two categories.
The first category included the two groups Effort
with categories Average years of exposure
greater effort and the second category consisted of the
groups with lower effort (Table 5). A significant Cases Controls T-Test
difference was found, with a relative risk of 2.41 (p <
0.05).
Other categories were tested, and it was possible No 1.32 5.15 P 0.001
to observe significant differences between the cases
Light 8.42 10.88 P ? 0.10
Medium 24.99 18.55 P ? 0.005
TABLE 5. - A comparison between the subjects
included in the effort categories. High 40.65 35.63 P 0.005

Cases Controls

Effort: High + Medium 111 127 TABLE 7. - Time of exposure to

controls. Intervals of nineteen y
Effort: No + Light 17 47
128 174
Relative risk: 2.41
Years of effort Cases Controls Risk

X2/p - 0.05
0 1 10 1.00
Effort: Light + Medium + High 127 164
Effort: No 1 10 1-10 12 49 2.45
128 174
Relative risk: 7.74 20-39 40 50 8.00
X2/P 5 0.05
40-69 75 65 11.54
Effort: High 37 16
Effort: No + Light + Medium 91 158
128 174
128 174
Relative risk: 4.01
X2/P 5 0.01
X2/P - 0.0001

Effort: High 37 16
Effort: No 1 10
Regression
coefficient 0.83 0.46
38 26
Relative risk: 23.12 Statistical
significance P < 0.01 N.S.
X2/P _ 0.0001

TABLE 8. - Categories and time of exposure to effort; a comparison of cases and control

Effort

Years of Effort Light + Medium High Risk

Cases Controls Risk Cases Controls

1-19 22 55 4.00 19 14 13.57

29-39 26 33 7.87 13 2 65.00
40-69 41 36 11.38 5 0

X2/P < 0.001 X2/P ? 0.05

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Vol. 8, 1992 Inguinal hernia and certain risk factors

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