The use of mesh for inguinal hernia repair in northern Ghana

Outcomes After Inguinal Hernia Repair With Mesh Performed by Medical Doctors and Surgeons in Ghana

Importance

Inguinal hernia is the most common general surgical condition in the world. Although task sharing of surgical care with nonsurgeons represents one method to increase access to essential surgery, the safety and outcomes of this strategy are not well described for hernia repair.

Objective

To compare outcomes after inguinal hernia repair with mesh performed by medical doctors and surgeons in Ghana.

Design, Setting, and Participants

This prospective cohort study was conducted from February 15, 2017, to September 17, 2018, at the Volta Regional Hospital in Ho, Ghana. Following successful completion of a training course, 3 medical doctors and 2 surgeons performed inguinal hernia repair with mesh according to the Lichtenstein technique on 242 men with primary, reducible inguinal hernia.

Main Outcomes and Measures

The primary end point was hernia recurrence at 1 year. The noninferiority limit was set at 5 percentage points. Secondary end points included postoperative complications at 2 weeks and patient satisfaction, pain, and self-assessed health status at 1 year.

Results

Two-hundred forty-two patients were included; 119 men underwent operations performed by medical doctors and 123 men underwent operations performed by surgeons. Preoperative patient characteristics were similar in both groups. Two-hundred thirty-seven patients (97.9%) were seen at follow-up at 2 weeks, and 223 patients (92.1%) were seen at follow-up at 1 year. The absolute difference in recurrence rate between the medical doctor group (1 [0.9%]) and the surgeon group (3 [2.8%]) was -1.9 (1-tailed 95% CI, -4.8; P < .001), demonstrating noninferiority of the medical doctors. There were no statistically significant differences in postoperative complications (34 [29.1%] vs 29 [24.2%]), patient satisfaction (112 [98.2%] vs 108 [99.1%]), severe chronic pain (1 [0.9%] vs 4 [3.7%]), or self-assessed health (85.9 vs 83.7 of 100) for medical doctors and surgeons.

Conclusions and Relevance

This study shows that medical doctors can be trained to perform elective inguinal hernia repair with mesh in men with good results and high patient satisfaction in a low-resource setting. This finding supports surgical task sharing to combat the global burden of hernia disease.

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.

Mesh versus suture repair of primary inguinal hernia in Ghana

Background

Most patients in Ghana undergo suture repair for primary inguinal hernia. Although there is strong evidence from high‐income country settings to indicate superiority of mesh repair for inguinal hernia, the evidence to support the safety and effectiveness of mesh repair in the Ghanaian setting is limited. This study aimed to compare hernia recurrence rates following suture versus mesh repair in Ghana.

Methods

Men aged 18 years or over presenting with symptomatic, reducible inguinal hernias were included. Over the first 6 months all consecutive patients were enrolled prospectively and underwent a standardized suture repair; an equal number of patients were subsequently enrolled to undergo mesh repair. The primary outcome was hernia recurrence within 3 years of the index operation. Multivariable analysis was adjusted for age and right or left side. Adjusted odds ratios (ORs) with 95 per cent confidence intervals are reported.

Results

A total of 116 sutured and 116 mesh inguinal hernia repairs were performed. Three years after surgery, follow‐up data were available for 206 of the 232 patients (88·8 per cent). Recurrence occurred significantly more frequently in the suture repair group (23 of 103, 22·3 per cent) than in the mesh group (7 of 103, 6·8 per cent) (P = 0·002). In multivariable analysis, suture repair was independently associated with an increased risk of recurrence (OR 4·51, 95 per cent c.i. 1·76 to 11·52; P = 0·002).

Conclusion

In Ghana, mesh inguinal hernia repair was associated with reduced 3‐year recurrence compared with sutured repair. Controlled dissemination across Ghana should now be assessed.

Use of commercial mesh for hernia repair in a low resource setting: experience after 500 cases

BACKGROUND

The use of mesh has revolutionized the management of hernias in many parts of the world. There is, however, limited experience on its use in sub-Saharan Africa. This study describes a single hospital experience after 500 cases of mesh hernia repairs in a sub-Saharan African country.

METHODS

We reviewed the records of the first 500 cases of abdominal wall hernia operations performed using commercial mesh since year 2007. Socio-demographic characteristics, hernia type, method of repair and outcome data were analyzed and presented as descriptive statistics.

RESULTS

The first 500 cases of mesh hernia repairs were performed between 2007 and 2017 during which a total of 1,175 hernia operations were carried out, mesh repair accounting for 42.5% of the total. There was a progressive rise in the uptake of mesh repairs over time, with mesh repairs overtaking tissue based repairs in the last few years of the review. Inguinal hernia was by far the commonest indication for mesh use (80.4%), followed by incisional hernia (9%). Polypropylene mesh was the most common type of mesh used in about 96.2% of cases. Overall, there were seven recurrences (1.4%) at a mean follow-up period of 15.3 months (1-108 months) CONCLUSION: In spite of resource limitations, the use of mesh for hernia repairs continues to rise and has overtaken tissue-based repairs in a sub-Saharan African setting. Results show good outcomes justifying continued use.

Local Research Catalyzes National Surgical Planning Comment on "Global Surgery - Informing National Strategies for Scaling Up Surgery in Sub-Saharan Africa"

In 2015 the Lancet Commission on Global Surgery (LCoGS) argued that surgical care is important to national health systems along with the economic viability of countries. Gajewski and colleagues outlined how the Commission’s blueprint has been implemented in sub-Saharan Africa, including two funded research projects that were integrated into national surgical plans. Here, we outline how the five processes proposed by Gajewski and colleagues are critical to integrate research, policy, and on-the-ground implementation. We also propose that, moving forward, the most pressing adjunct in many low- and middle-income countries (LMICs) may be a better characterization of rural surgical practices through rigorous research along with models that enable lessons to inform national policy.