Operation Hernia to Ghana

Non reducible inguinal hernias in Malawi: an occupational hazard

PURPOSE

Inguinal hernias are one of the most common surgical conditions worldwide. Due to limited surgical access in low- and middle-income countries, many hernias present emergently; however, data on the resultant outcome disparities is limited. We, therefore, sought to describe the epidemiology, clinical features, and outcomes of incarcerated inguinal hernias at a tertiary center in Malawi.

METHODS

This is a retrospective analysis of the acute care surgery registry at Kamuzu Central Hospital in Lilongwe, Malawi. All patients > 13 years admitted with a non-reducible inguinal hernia from 2013 to 2019 were included. The primary outcome was in-hospital mortality. A Poisson multivariable regression determined factors associated with increased risk of mortality.

RESULTS

A total of 297 patients presented with non-reducible inguinal hernias, the majority of which were young (median age 38), male (93.6%), farmers (47.8%). Of the 81% who underwent surgery, 55% were delayed ≥ 24 h. 19.5% of hernias were strangulated. Overall mortality was 5.4%. Increased age (RR 1.06, 95% CI 1.01-1.12), shock index ≥ 1 (RR 4.82, 95% CI 1.45-16.09), and delay ≥ 24 h from presentation to operative intervention (RR 11.24, 95% CI 1.55-81.34) resulted in an increase in relative risk of mortality.

CONCLUSION

Non-reducible inguinal hernias largely affect young male farmers in Malawi. Delays to care can limit economic productivity for this rural population, as well as, yield considerable risk of mortality. While specific patient and institutional factors must be further elucidated, increased awareness, public health prioritization, and surgical capacity building is needed to reduce further hernia-related morbidity and mortality.

Hernioplasty using low-cost mesh compared to surgical mesh in low- and middle-income countries: a systematic review protocol

OBJECTIVE

This review aims to assess the differences in surgical outcomes between hernioplasty using low-cost mesh and surgical mesh in adults undergoing elective hernioplasty in low- and middle-income countries.

INTRODUCTION

The use of untreated mosquito netting in inguinal hernioplasty in low- and middle-income countries has been well described in the literature, with two recent limited systematic reviews finding equivalent postoperative surgical outcomes. This comprehensive review, across a wider set of databases and gray literature, will assess a broader set of outcomes including patient and surgeon preference and sterility, report more granular complication outcomes, and include other low-cost mesh alternatives such as resterilized surgical mesh and indigenous products, alongside mosquito net mesh.

INCLUSION CRITERIA

Adult patients undergoing elective inguinal hernioplasty with mesh in low- and middle-income countries.

METHODS

Electronic bibliographic databases (PubMed, Embase, Scopus, Web of Science and the Cochrane Library) and gray literature databases and trial registers will be searched for experimental studies, either randomized or quasi-randomized controlled trials, comparing hernioplasty with surgical mesh versus low-cost mesh, published in any language from 2000 to the present. Two independent reviewers will conduct the literature search, screen titles and abstracts, assess full-text studies for inclusion, assess methodological quality using the Cochrane Risk of Bias 2 tool, and extract data using a custom extraction tool. Synthesis will involve pooling for statistical meta-analysis with either a random-effects or fixed-effects model, as appropriate, and where this is not possible, findings will be presented in narrative form.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019136028.

Resterilized Polypropylene Mesh for Inguinal Hernia Repair

Purpose:

The use of prosthetic biomaterials for reconstructing and reinforcing the posterior wall of the inguinal canal reduces the incidence of hernia recurrence. Cost, availability of mesh, and perhaps reluctance to adopt a new technique are factors which prevent widespread practice of hernioplasty in low-resource settings. Use of resterilized mesh significantly reduces the cost of hernioplasty and is safe.

Patients and Methods:

Sheets of 30 cm × 30 cm polypropylene mesh were cut into 16 cm × 8 cm to produce mesh strips which were repackaged into SELFSEAL^® (Medical Action Industries Inc., USA) sterilizing pouches measuring 90 mm × 230 mm and autoclaved. At repair, the strips are shaped to fit the anatomy of the posterior wall of the inguinal canal, a slit created at one end and applied in Lichtenstein repair of inguinal hernias. Patients were monitored for seroma collection and wound infection up to 2 weeks postoperative period.

Results:

Sixty inguinal hernia repairs were done in 58 patients using the resterilized mesh; two cases being bilateral. One patient (1.7%) had seroma collection at 2 weeks which was aseptically aspirated. We did not record any case of wound infection.

Conclusion:

The use of sterilized polypropylene mesh for the repair of inguinal hernias is safe and reduced the cost of hernioplasty by reducing the cost of polypropylene mesh. This technique is recommended in low-resource settings.

Ethnicity-related differences in inguinal canal dimensions between African and Caucasian populations and their potential impact on the mesh size for open and laparoscopic groin hernia repair in low-resource countries in Africa

Introduction

Access to surgery in Africa is significantly limited. Treatment outcomes in Africa differ significantly compared to those achieved in Europe or the US. Therefore, to popularise tension-free repair, it is essential to determine the economically justified mesh size for the African population.

Aim

To conduct anthropometric evaluation of the inguinal canal in African and European patients to determine its potential consequences for the mesh size for open and laparoscopic hernia repair.

Material and methods

The measurements were made in 44 adult males in Africa (group I) and were compared to measurements in 45 consecutive Caucasian males (group II). The mean age of patients was respectively 48.3 and 51.2 years.

Results

There was no statistically significant difference in the internal ring diameter between groups (2.2 vs. 2.1 cm; p = 0.58). The distance between the pubic tubercle and the inferomedial border of the internal inguinal ring was significantly shorter in group I (3.8 vs. 5.1 cm; p < 0.001). A similar difference was found in the length of transverse arch aponeurosis (2.9 vs. 4.0 cm; p < 0.001). The distance between the pubic tubercle and anterior superior iliac spine in group I was approximately 2 cm shorter on each side (10.0 vs. 11.8 cm; p < 0.001).

Conclusions

The anatomical differences in inguinal dimensions between Central African and European populations support the potential need to adjust the standard size of synthetic mesh used for hernia repair to the needs of local populations. The significantly smaller dimensions of the inguinal canal in African males may allow the use of smaller meshes.

Transient Femoral Nerve Palsy Following Ilioinguinal Nerve Block for Inguinal Hernioplasty

Background

Elective inguinal hernia repair in young fit patients is preferably done under ilioinguinal nerve block anesthesia in the ambulatory setting to improve throughput, save cost, and increase patient satisfaction. A rare complication of ilioinguinal nerve block is transient femoral nerve palsy (TFNP).

Objectives

The aim of this study is to examine the incidence of TFNP among adults undergoing ambulatory inguinal hernia repair under ilioinguinal nerve block.

Patients and Methods

Patients 18 years and older in the American Society of Anesthetists classes I and II who underwent ambulatory inguinal hernia repair over a 3-year period under ilioinguinal nerve block only were assessed for evidence of TFNP. All patients had power on the ipsilateral limb checked 30 min before and 1 h after the procedure. TFNP was considered present if there was sensory loss over the anterior aspect of the thigh, weakness of extension at the knee joint, or reduction in power of the ipsilateral limb.

Results

One hundred and twelve patients were involved in the study; 90 (80.3%) males and 22 (19.6%) females with the mean age of 45.7 years. All had normal power (Grade 5) in the ipsilateral limb before instituting the nerve block. Postoperatively, 3 (2.6%) patients had grade 4 and recovered normal power over a 2-6-h period and were subsequently discharged.

Conclusion

TFNP is a rare complication of ilioinguinal nerve block which delays patient discharge postambulatory hernioplasty.

Humanitarianism in surgery

PURPOSE

Humanitarianism is by definition a moral of kindness, benevolence and sympathy extended to all human beings. In our view as surgeons working in underserved countries, humanitarianism means performing the best operation in the best possible circumstances with high income country (HIC) results and training in-country surgeons to do the same. Hernia Repair for the Underserved (HRFU), a not for profit organization, is developing a long term public health initiative for hernia surgery in Western Hemisphere countries. We report the progress of HRFUs methods to render humanitarian care.

METHODS

In a collaborative effort, Creighton University and the Institute for Latin American Concern developed an outpatient surgery site for hernia surgery in Santiago, Dominican Republic. Based on this experience, we developed a sustainable care model by recruiting American and European Hernia Society expert surgeons, staff members they recommended, building relationships with local and industry partners, and selecting local surgeons to be trained in mesh hernioplasty. HRFU then extended the care model to other Western Hemisphere countries.

RESULTS

Between 2004 and 2015, the HRFU elective hernia morbidity and mortality rates for 2052 hernia operations were 0.7 and 0%, respectively. This is consistent with outcomes from HICs and confirms the feasibility of a public health initiative based on the principles of the Preferential Option for the Poor.

CONCLUSIONS

HRFU has recorded HIC morbidity and mortality rates for hernia surgery in low and middle income countries and has initiated a new surgical training model for sustainability of effect.

Variability in mortality following caesarean delivery, appendectomy, and groin hernia repair in low-income and middle-income countries: a systematic review and analysis of published data

BACKGROUND

Surgical interventions occur at lower rates in resource-poor settings, and complication and death rates following surgery are probably substantial but have not been well quantified. A deeper understanding of outcomes is a crucial step to ensure that high quality accompanies increased global access to surgical care. We aimed to assess surgical mortality following three common surgical procedures--caesarean delivery, appendectomy, and groin (inguinal and femoral) hernia repair--to quantify the potential risks of expanding access without simultaneously addressing issues of quality and safety.

METHODS

We collected demographic, health, and economic data for 113 countries classified as low income or lower-middle income by the World Bank in 2005. We did a systematic review of Ovid, MEDLINE, PubMed, and Scopus from Jan 1, 2000, to Jan 15, 2015, to identify studies in these countries reporting all-cause mortality following the three commonly undertaken operations. Reports from governmental and other agencies were also identified and included. We modelled surgical mortality rates for countries without reported data using a two-step multiple imputation method. We first used a fully conditional specification (FCS) multiple imputation method to establish complete datasets for all missing variables that we considered potentially predictive of surgical mortality. We then used regression-based predictive mean matching imputation methods, specified within the multiple imputation FCS method, for selected predictors for each operation using the completed dataset to predict mortality rates along with confidence intervals for countries without reported mortality data. To account for variability in data availability, we aggregated results by subregion and estimated surgical mortality rates.

FINDINGS

From an initial 1302 articles and reports identified, 247 full-text articles met our inclusion criteria, and 124 provided data for surgical mortality for at least one of the three selected operations. We identified 42 countries with mortality data for at least one of the three procedures. Median reported mortality was 7·9 per 1000 operations for caesarean delivery (IQR 2·8-19·9), 2·2 per 1000 operations for appendectomy (0·0-17·2), and 4·9 per 1000 operations for groin hernia (0·0-11·7). Perioperative mortality estimates by subregion ranged from 2·8 (South Asia) to 50·2 (East Asia) per 1000 caesarean deliveries, 2·4 (South Asia) to 54·0 (Central sub-Saharan Africa) per 1000 appendectomies, and 0·3 (Andean Latin America) to 25·5 (Southern sub-Saharan Africa) per 1000 hernia repairs.

INTERPRETATION

All-cause postoperative mortality rates are exceedingly variable within resource-constrained environments. Efforts to expand surgical access and provision of services must include a strong commitment to improve the safety and quality of care.

FUNDING

None.

Changing Epidemiology of Intestinal Obstruction in Ghana: Signs of Increasing Surgical Capacity and an Aging Population

INTRODUCTION

This study aimed to describe the epidemiology and outcomes of intestinal obstruction at a tertiary hospital in Ghana over time.

METHODS

Records of all patients admitted to a tertiary hospital from 2007 to 2011 with intestinal obstruction were identified using ICD-9 codes. Sociodemographic and clinical data were compared to a previously published series of intestinal obstructions from 1998 to 2003. Factors contributing to longer than expected hospital stays and death were further examined.

RESULTS

Of the 230 records reviewed, 108 patients (47%) had obstructions due to adhesions, 50 (21%) had volvulus, 22 (7%) had an ileus from perforation and 14 (6%) had intussusception. Hernia fell from the 1st to the 8th most common cause of obstruction. Patients with intestinal obstruction were older in 2007-2011 compared to those presenting between 1998 and 2003 (p < 0.001); conditions associated with older age (e.g., volvulus and neoplasia) were more frequently encountered (p < 0.001). Age over 50 years was strong factor of in-hospital death (adjusted OR 14.2, 95% CI 1.41-142.95).

CONCLUSION

Efforts to reduce hernia backlog and expand the surgical workforce may have had an effect on intestinal obstruction epidemiology in Ghana. Increasing aging-related pathology and a higher risk of death in elderly patients suggest that improvement in geriatric surgical care is urgently needed.

Do hernia operations in african international cooperation programmes provide good quality?

BACKGROUND

Hernia is especially prevalent in developing countries where the population is obliged to undertake strenuous work in order to survive, and International Cooperation Programmes are helping to solve this problem. However, the quality of surgical interventions is unknown. The objective of the present study was to evaluate the quality of hernia repair processes carried out by the Surgical Solidarity Charity in Central African States.

MATERIALS AND METHODS

A total of 524 cases of inguinal hernia repair carried out in Cameroon and Mali during 2005 to 2009 were compared with 386 cases treated in a Multicentre Spanish Study (2003). General data (clinical, demographic, etc.), type of surgery, complications, and effectiveness and efficiency indicators were collected.

RESULTS

Preoperative studies in the Spanish group were greater in number than in the African group. The use of local anesthesia was similar. Antibiotic prophylaxis was higher in the African group (100% to 75.4%). The use of mesh was similar. The incidence of hematomas was higher in the Spanish group (11.61% to 4.61%), but the incidence of infection of the wound and of hernia recurrence was similar, although follow-up was only carried out in 20.97% in the African group (70% in the Spanish group). Hospital stay of more than 24 h was higher in the Spanish group.

CONCLUSIONS

The standard quality of surgery for the treatment of hernia in developing countries with few instrumental means, and in sub-optimal surgical conditions is similar to that provided in Spain.

The cost effectiveness of early management of acute appendicitis underlies the importance of curative surgical services to a primary healthcare programme

INTRODUCTION

Appendicitis in the developing world is a cause of significant preventable morbidity. This prospective study from a regional hospital in South Africa constructs a robust cost model that demonstrates the cost effectiveness of an efficient curative surgical service in a primary healthcare-orientated system.

METHODS

A prospective audit of all patients with acute appendicitis admitted to Edendale Hospital was undertaken from September 2010 to September 2011. A microcosting approach was used to construct a cost model based on the estimated cost of operative and perioperative interventions together with the associated hospital stay. For cost analysis, patients were divided into the following cohorts: uncomplicated appendicitis, complicated appendicitis with localised intra-abdominal sepsis, complicated appendicitis with generalised intra-abdominal sepsis, with and without intensive care unit admission.

RESULTS

Two hundred patients were operated on for acute appendicitis. Of these, 36% (71/200) had uncomplicated appendicitis and 57% (114/200) had perforation. Pathologies other than appendicitis were present in 8% (15/200) and these patients were excluded. Of the perforated appendices, 45% (51/114) had intra-abdominal contamination that was localised while 55% (63/114) generalised sepsis. The mean cost for each patient was: 6,578 ZAR (£566) for uncomplicated appendicitis; 14,791 ZAR (£1,272) for perforation with localised intra-abdominal sepsis and 34,773 ZAR (£2,990) for perforation with generalised intra-abdominal sepsis without intensive care admission. With intensive care admission it was 77,816 ZAR (£6,692). The total cost of managing acute appendicitis was 4,272,871 ZAR (£367,467). Almost 90% of this total cost was owing to advanced disease with abdominal sepsis and therefore potentially preventable.

CONCLUSIONS

Early uncomplicated appendicitis treated appropriately carries little morbidity and is relatively inexpensive to treat. As the pathology progresses, the cost rises exponentially. An efficient curative surgical service must be regarded as a cost effective component of a primary healthcare orientated system.

Role of UK Hospitals in Supporting Surgical Training in Africa

There are significant problems surrounding lack of access to surgical services, surgical training and surgical safety in Africa. There are many reasons for this. A recent report suggests that the ongoing healthcare workforce crisis is set to get worse in sub-Saharan Africa, with an estimated shortfall of 800,000 health professionals by 2015 and a required additional wage bill of approximately US $2.6 billion. Reasons include a lack of medical school places to meet demand; poor wages, facilities and infrastructure; impact of the HIV/AIDS epidemic; and migration to urban areas and developed countries. For example, although Kenya has trained 300 surgeons since 1972 only 120 of them remain in public service, with 27 of its 63 district hospitals having no qualified surgeons.

Hunterian Lecture. Hernia surgery: from guidelines to clinical practice

INTRODUCTION

Over the last 30 years, hernia surgery has developed into an evidence-based practice assisted by the development of guidelines.

MATERIALS AND METHODS

Prior to 1993, best practice in the UK was a nylon darn repair under general anaesthesia as an inpatient with prolonged recovery. The publication of The Royal College of Surgeons of England (RCSE) Guidelines on Groin Hernia Repair stimulated debate and coincided with the introduction of mesh hernioplasty and laparoscopic techniques. Further evolution of hernia management has occurred to enable the production of the European Hernia Society (EHS) guidelines in 2008.

RESULTS

The EHS guidelines cover all aspects of abdominal wall surgery including: indications for operation; investigations; organising surgical care; techniques; local anaesthesia; after-care, complications and outcome; and information for patients.

CONCLUSIONS

Surgeons have many choices when selecting an appropriate hernia operation for an individual patient. The EHS guidelines provide a basis for this decision-making.