Assessing the impact of short-term surgical education on practice: a retrospective study of the introduction of mesh for inguinal hernia repair in sub-Saharan Africa

An Analysis of Participant Preferences Regarding Virtual Versus In-person Format of Orthopaedic Surgery Educational Materials in Low- and Middle-Income Countries

INTRODUCTION

The University of California, San Francisco Institute for Global Orthopaedics and Traumatology Surgical Management and Reconstructive Training (SMART) course has instructed orthopaedic surgeons from low-resource countries on soft-tissue reconstruction. Before the COVID-19 pandemic, the course was conducted in-person; however, it was transitioned to a virtual format during the pandemic. The aim of this study was to determine participant preferences regarding a virtual or in-person SMART course format.

METHODS

Survey data were collected via e-mail after each SMART course using RedCap or Qualtrics. Statistical analyses were conducted using Stata.

RESULTS

There were 247 survey respondents from 44 countries representing all world regions, with Africa (125, 51%) the most represented. Of those who attended both an in-person and virtual course, most (82%) preferred the in-person format. In addition, all measured course outcomes were significantly better for participants attending the in-person course. The most common reason for not attending an in-person course was the cost of travel (38, 51%).

DISCUSSION

This study demonstrated a preference toward in-person learning for the SMART course. In addition, those surgeons participating in the in-person course endorsed increased positive outcomes from the course. Increased emphasis should be placed on in-person surgical skills training for low-resource surgeons.

Relevance of Antibiotic Prophylaxis in Non-Mesh Inguinal Hernia Repair in Remote and Poor Medical Settings in Sub-Saharan Africa

Background: Because of the poor local medical conditions, and because the surgical site infection (SSI) rate after hernia repair in sub-Saharan Africa is higher than in developed countries, deployed surgeons within Role 2 usually perform non-mesh inguinal herniorrhaphy. Regarding antimicrobial prophylaxis, the latter currently is not recommended in non-mesh inguinal hernia repairs. Our study aimed at assessing the relevance of antibiotic prophylaxis in non-mesh inguinal hernia repair within a Role 2 surgical structure deployed in sub-Saharan Africa. Methods: From January 1 to December 31, 2019, we conducted a non-randomized prospective study in a French Role 2 military surgical structure deployed to Abidjan, Republic of Côte d'Ivoire. We included all patients presenting with uncomplicated inguinal hernia. All subjects underwent open herniorrhaphy through a groin incision. The primary endpoint was the occurrence of an SSI. Results: We recorded 120 open hernia repairs. Antimicrobial prophylaxis was administered in 70 interventions (60%). An SSI was reported in 13 cases (11%). Multivariable logistic regression analysis of SSI occurrence, according to the administration of intra-operative antimicrobial prophylaxis, showed a 0.219 odds ratio with a 95% confidence interval of 0.05-0.84 and p = 0.028. This finding was in favor of its significant protective effect on the risk of SSI after open non-mesh inguinal hernia repair, taking into account the American Society of Anesthesiologists score, Body Mass Index, and recurrence status. Conclusion: Administration of intra-operative antimicrobial prophylaxis in open non-mesh inguinal hernia repair in remote and poor medical settings, for example during deployment conditions as in our study, was associated with a reduction of the SSI rate.

The State of Surgical Task Sharing for Inguinal Hernia Repair in Limited-Resource Countries

BACKGROUND

In limited-resource countries, the morbidity and mortality related to inguinal hernias is unacceptably high. This review addresses the issue by identifying capacity-building education of non-surgeons performing inguinal hernia repairs in developing countries and analyzing the outcomes.

METHODS

PubMed was searched and included are studies that reported on task sharing and surgical outcomes for inguinal hernia surgery. Educational methods with quantitative and qualitative effects of the capacity-building methods have been recorded. Excluded were papers without records of outcome data.

RESULTS

Seven studies from African countries reported 14,108 elective inguinal hernia repairs performed by 230 non-surgeons with a mortality rate of 0.36%. Complications were reported in 4 of the 7 studies with a morbidity rate of 14.2%. Two studies reported on follow-up: one with no recurrences in 408 patients at 7.4 months and the other one with 0.9% recurrences in 119 patients at 12 months. Direct comparison of outcomes from trained non-surgeons to surgeons or surgically trained medical doctors is limited but suggests no difference in outcomes. Quantitative capacity-building effects include increase in surgical workforce, case volume, elective procedures, mesh utilization, and decreased referrals to higher level of care institutions. Qualitative capacity-building effects include feasibility of prospective research in limited-resource settings, improved access to surgical care, and change in practice pattern of local physicians after training for mesh repair.

CONCLUSION

Systematic training of non-surgeons in inguinal hernia repair is potentially a high-impact capacity-building strategy. High-risk patients should be referred to a fully trained surgeon whenever possible. Randomized study designs and long-term outcomes beyond 1 year are needed.

Improving surgical education in East Africa with a standardized hernia training program

INTRODUCTION

Inguinal hernias are among the most common surgical diseases in Africa. The current International HerniaSurge Guidelines recommend mesh-based surgical techniques in Low Resource Settings (LRS). This recommendation is currently unachievable in large parts of Africa due to the unaffordability of mesh and lack of appropriate training of the few available surgeons. There is, therefore, a need for formal training in mesh surgery. There is an experience in Hernia Repair for the Underserved in Central and South America, however, inadequate evidence of structured training in Africa.

MATERIAL AND METHODS

Since 2016, the aid Organizations, Surgeons for Africa and Operation Hernia have developed and employed a structured hernia surgical training program for postgraduate surgical trainees and medical doctors in Rwanda. This course consists of lectures on relevant aspects of hernia surgery and hands-on training in operating theatres. The lectures emphasize anatomy and surgical technique. All parts of the training were evaluated. Formal pre-course evaluation was conducted to assess the personal surgical experience of the trainees.

RESULTS

Over a 3-year period, a structured hernia training programme was employed to train a total of 36 surgical trainees in both mesh and also non mesh hernia surgery. The key principle in this course is the continuous competence assessment and feedback. Evidence is provided to demonstrate improvement in surgical skills as well as knowledge of surgical anatomy which is essential to acquiring surgical competency. With self-assessment, expressed on a Likert scale, the participants could improve the theoretical knowledge about hernias from median 4.4 (on a scale of 1-10) before training to 8.4 after the training. The specific knowledge about anatomy could be improved in the same assessment from 4.8 before training to 8.1. after the training. After training course 12 of the 36 participants (33.33%) were able to carry out both suture- and mesh-based operations of simple inguinal hernias completely and independently. 20 of the 36 participants (55.55%) required only minimal supervision and only four participants (11.11%) required surgical supervision even after the completion of the course.

CONCLUSION

We have demonstrated that, medical personnel in Africa can be trained in mesh and non-mesh hernia surgery using a structured training programme.

The use of mesh for inguinal hernia repair in northern Ghana

BACKGROUND

Despite the recognition that inguinal hernia (IH) repair is cost-effective, repair rates in low- and middle-income countries remain low. Estimated use of mesh in low- and middle-income countries also remains low despite publications about low-cost, noncommercial mesh. The purpose of our study was to assess the current state of IH repair in the northern and transitional zone of Ghana.

MATERIALS AND METHODS

A retrospective review of surgical case logs of IH repairs from 2013 to 2017 in 41 hospitals was performed. Multivariate logistic regression was used to determine predictors of mesh use.

RESULTS

Eight thousand eighty male patients underwent IH repair. The range of IH repair in each region was 96 to 295 (overall 123) per 100,000 population. Most cases were performed at district hospitals (84%) and repaired nonurgently (93%) by nonsurgeon physicians (66%). Suture repair was most common (85%) although mesh was used in 15%. The strongest predictor of mesh use was when a surgeon performed surgery (odds ratio [OR] 3.13, P <0.001), followed by surgery being performed in a teaching hospital (OR 2.31, P <0.001). Repair at a regional hospital was a negative predictor of mesh use (OR 0.08, P <0.001) as was the use of general anesthesia (OR 0.40, P = 0.001).

CONCLUSIONS

Most IH repairs are performed in district hospitals, by nonsurgeon physicians, and without mesh. Rates of repair and the use of mesh are higher than previous estimates in Ghana and Sub-Saharan Africa but not as high as high-income countries.

International guidelines for groin hernia management

INTRODUCTION

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.

METHODS

An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

CONCLUSIONS

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

The East African Training Initiative. A Model Training Program in Pulmonary and Critical Care Medicine for Low-Income Countries

Despite an extensive burden of lung disease in East Africa, there are remarkably few pulmonary physicians in the region and no pulmonary subspecialty training programs. We developed a unique training program for pulmonary medicine in Ethiopia. The East African Training Initiative (EATI) is a 2-year fellowship program at Tikur Anbessa (Black Lion) Specialized Teaching Hospital, the largest public hospital in Ethiopia and the teaching hospital for the Addis Ababa University School of Medicine. The first year is devoted to clinical care and procedural skills. Lectures, conferences, daily inpatient and outpatient rounds, and procedure supervision by visiting faculty provide the clinical knowledge foundation. In the second year, training in clinical research is added to ongoing clinical training. Before graduation, fellows must pass rigorous written and oral examinations and achieve high marks on faculty evaluations. Funding derives from several sources. Ethiopian trainees are paid by the Ethiopian Ministry of Health and the Addis Ababa University School of Medicine. The World Lung Foundation and the Swiss Lung Foundation supply travel and housing costs for visiting faculty, who receive no other stipend. The first two trainees graduated in January 2015, and a second class of three fellows completed training in January 2016. All five presented research abstracts at the annual meetings of the International Union Against Tuberculosis and Lung Disease in 2014 and 2015. The EATI has successfully provided pulmonary medicine training in Ethiopia and has capacity for local leadership. We believe that EATI could be a model for other resource-limited countries.

Centralized, capacity-building training of Lichtenstein hernioplasty in Brazil

BACKGROUND

In Brazil, access to healthcare varies widely by community. Options for repair of surgically correctable conditions, such as inguinal hernias, are limited. A training program was instituted to expand access to Lichtenstein hernioplasty.

METHODS

Between September, 2014 and September, 2015, 3 orders of training series took place in São Paulo, Brazil. Participating surgeons received training and assessments from expert trainers using the Operative Performance Rating Scale (OPRS). Those who completed training successfully were invited to become trainers. OPRS scores were compared between training series. Outcomes were documented up to 6 months post-training.

RESULTS

The 3 orders of training series resulted in 45 surgeons trained and 213 hernias repaired. Eleven trainees subsequently became trainers. Mean post-training OPRS scores were 4.4 (scale of 5) and did not vary significantly between training series. The overall complication rate was 4.7%, with no hernia recurrences or reoperations at 6 months.

CONCLUSIONS

Competency-based training generates a regional network of surgeons proficient in Lichtenstein hernioplasty. Each training session progressively expands patient access to high quality operations in underserved communities in Brazil.