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| ORIGINAL ARTICLES |
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| Year : 2022 | Volume
: 5
| Issue : 2 | Page : 59-68 |
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Surgical repair of abdominal wall hernias in rural southeast Nigeria: Barriers, outcomes, and opportunities for change
Aloysius Ugwu-Olisa Ogbuanya1, Nonyelum Benedette Ugwu2
1 Department of Surgery Bishop Shanahan Specialist Hospital, Nsukka, Enugu State, Nigeria; Department of Surgery Mater Misericordie Hospital, Afikpo, Ebonyi State, Nigeria; Department of Surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA), Ebonyi State, Nigeria; Department of Surgery, Ebonyi State University, Abakaliki (EBSU), Ebonyi State, Nigeria
2 Department of Surgery Bishop Shanahan Specialist Hospital, Nsukka, Enugu State, Nigeria; Uwani General Hospital, Enugu State, Nigeria
| Date of Submission | 04-Nov-2021 |
| Date of Decision | 28-Nov-2021 |
| Date of Acceptance | 06-Dec-2021 |
| Date of Web Publication | 19-May-2022 |
Correspondence Address:
Dr. Aloysius Ugwu-Olisa Ogbuanya
Department of Surgery, Alex Ekwueme Federal University Teaching Hospital, PMB 102, Abakaliki, Ebonyi State
Nigeria
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijawhs.ijawhs_79_21
Background: Abdominal wall hernias constitute a significant cause of morbidity and mortality globally, but more importantly, they present a more pathetic situation in rural areas of sub-Saharan Africa and other developing nations. In our setting, the rate of elective repair is still too low and many cases present late, often with complications. This study aimed at documenting the spectrum, barriers to early repair, and factors that influence the outcomes of repair. Materials and Methods: A prospective study of adult patients surgically treated for abdominal wall hernia in rural southeast Nigeria between January 2014 and December 2019. Results: Overall, 975 patients were recruited: 706 (72.4%) had simple uncomplicated hernias, whereas the rest (269, 27.6%) presented in the emergency. Inguinal hernias comprised 74.1% of the cases followed by primary midline hernias (14.5%). Delayed presentation was common, with only 2.3% presenting within three months and the main reason being financial constraint (31.0%) followed by ignorance (12.2%). A third (324, 33.2%) of the patients harbored complete inguinoscrotal/inguinolabial hernias. Nearly a quarter (240, 24.6%) had comorbid illnesses, 14.9% harbored recurrent hernias, and more than a third (43.4%) had hernias with defect sizes >5 cm. Wound infection rates were 34.6% in the emergency group, 26.2% in the elderly, 20.7% for those with recurrent hernias, and 17.1% in those with comorbidities. Morbidity rates were greater in patients with hernia defects >10 cm (37.8%), inguinoscrotal/inguinolabial hernias (18.5%), and those who received bowel resection (56.7%). Generally, elevated wound infection and high overall morbidity rates were associated with emergency presentation (P = 0.000), advancing age (P = 0.030), procedures performed by a nonspecialist surgeon (P = 0.014), and large hernia variants (P = 0.000). Overall, mortality rate was 2.9%, but it was 9.7% in those with emergency repair. The main independent predictors of mortality were intestinal resection (P = 0.000), delayed presentation (0.003), advanced age (0.020), and comorbidities (P = 0.002). Conclusion: Delayed presentation, often in an emergency setup, is common among patients with abdominal wall hernias in our rural practice. Financial impediments and ignorance were the main barriers to early presentation and elective repair. Consequently, morbidity and mortality rates were high, especially in the setting of advancing age, delayed presentation, coexisting medical conditions, and bowel resection. Keywords: Abdominal hernia, barriers, mesh repair, mortality, recurrence
How to cite this article:
Ogbuanya AU, Ugwu NB. Surgical repair of abdominal wall hernias in rural southeast Nigeria: Barriers, outcomes, and opportunities for change. Int J Abdom Wall Hernia Surg 2022;5:59-68 |
How to cite this URL:
Ogbuanya AU, Ugwu NB. Surgical repair of abdominal wall hernias in rural southeast Nigeria: Barriers, outcomes, and opportunities for change. Int J Abdom Wall Hernia Surg [serial online] 2022 [cited 2023 Mar 20];5:59-68. Available from: http://www.herniasurgeryjournal.org/text.asp?2022/5/2/59/345514 |
| Introduction | |  |
Globally, the repair of abdominal wall hernias represents a significant proportion of a general surgeon’s workload, especially in rural communities where the unmet needs for safe surgical and anesthetic services are high, elective repair rate is very low, basic health facilities and competent health providers are scarcely available, and the overall burden of the disease takes a high toll on morbidity and mortality.[1],[2],[3],[4],[5],[6] In the past, voluminous hernias having the size of a human head were described with an assortment of names in Africans, principally due to longstanding, neglected cases.[7],[8],[9],[10] Indeed, it was common to encounter some hernias that extended below the knee and led to the accommodation of several viscera, giving rise to a “loss of domain.”[5],[7],[9],[11] However, recent published studies showed an epidemiological shift, with a steady rise in the rates of ambulatory hernia surgery output and a decline in both the rates of emergency presentations and the occurrence of giant hernias variously described as “African Enigma” and “African Puzzles” by the European Hernia Aid workers.[7],[8],[9],[11],[12] The main reasons adduced for the change were increases in the proportion of government and private-owned hospitals and the upscaling of elective hernia repairs in Low-and-Middle-Income Countries (LMICs).[3],[7],[12],[13]
Regrettably, in most rural settlements across Africa and other resource-constrained communities, the rate of elective repair is still below par, and many cases still present with complications such as incarceration, obstruction, strangulation, and gangrene; in extreme cases, evisceration or enterocutaneous fistulae may supervene.[5],[7],[12],[14],[15],[16],[17],[18],[19],[20] In a referral hospital in Bugando, Northwestern Tanzania, Mabula and colleagues found that 44.7% of 452 adult patients who received inguinal hernia repair presented late (five years after onset of symptoms), 66.8% harbored inguinoscrotal/inguinolabial hernias, and 29.7% had either obstructed or strangulated hernia.[16] Morbidity and mortality rates were 12.4% and 9.7%, respectively.[16] In a similar review at Mulago Hospital in Kampala, Uganda, Odula and Kakande presented a more disturbing report from a large series of 208 patients who had groin hernia repair over a 12-month period.[18] In that series, 76.9% presented in the emergency and significant complications developed in 41.8%.[18] Comparable results were recently observed in our unit, where 58.4% and 16.8% of patients with femoral and inguinal hernias, respectively, presented in an emergency setting.[3] In addition, postoperative complications and mortality rates were quoted at 40.7% and 10.4%, respectively, from a survey of 366 adult patients who underwent emergency groin hernia repair.[3]
The situation is similar across most African nations and other LMICs.[12],[15],[16],[17],[19],[21],[22],[23],[24] In the light of this consideration, it can be inferred that most sub-Saharan African countries and many parts of LMICs are still overwhelmed by abdominal wall hernia burden and very little has been done on a global scale to lift the resource-constrained nations away from the dismal state. Indeed, the current state in rural Southeast Nigeria appears desperate and calls for a strategic modeling that involves an awareness campaign, advocacy, training and retraining, intervention, and follow-up as part of accelerated, system-wide approaches that are similar to the pattern in the industrialized nations.[1],[4],[5],[10],[20] To achieve this and reach an informed decision, accurate epidemiological data, documentation, and current rates in terms of morbidity and mortality are required.
Published data on the surgical repair of abdominal wall hernias in Africa are poorly documented, especially in repairs performed at district, mission, and private hospitals located in remote rural communities in the continent and other developing nations. In the light of this consideration, this study was set to present a blend of district, mission, and private hospitals’ experiences in rural southeast Nigeria with a view to highlight the current challenges and outcomes of abdominal wall hernia repair and compare the results with available data from previous central and district hospitals findings. To the best of our knowledge, there is no previous organized report on this aspect of the subject in our environment, despite the large hernia repair outputs in our rural practice. Recently, we have noticed an increase in the number of ambulatory and elective repairs and there is a need for us to report our experience. Further, this study aimed at documenting the spectrum, current management, barriers to early repair, and factors that influence the outcomes of abdominal wall hernia repair in our resource-limited setting.
| Patients and Methods | | |
Design and setting
Ours was a multicenter prospective study involving four secondary health facilities, where all consecutive patients with abdominal wall hernia repaired surgically from January 2014 to December 2019 were evaluated. It was carried out at Bishop Shanahan Specialist Hospital, Nsukka, Enugu State, General Hospital, Nsukka, Enugu State, Mater Misericordiae Specialist Hospital, Afikpo, Ebonyi State, and Holy Foundation Hospital, Ikwo, Ebonyi State, all of which are located in Southeast Nigeria.
Subjects
All consecutive adult patients aged 16 years and older with a clinical diagnosis of abdominal wall hernia were seen and counseled for operative repair. Only those who gave consent and subsequently received operative treatment were included in this study. Patients with advanced intra-abdominal malignancies, debilitating illnesses, or massive ascites from any cause were excluded.
Procedure
At the surgery clinic, all the recruited patients were examined and their sociodemographic and clinical details were recorded and entered into a proforma. Special attention was focused on the mode of presentation, location of hernia, duration of illness before presentation, and barriers to early presentation/repair. For those with complicated hernias, urgent resuscitation and workup for emergency operation were routinely done. In the elective group, patients were admitted either on the morning of the surgery or a day before the surgery (for those with comorbidities, elderly patients, and patients living far distances from hospital). Basic blood and urine investigations were routinely done, whereas special tests and imaging studies were ordered when indicated.
Preoperatively, patients in the elective group with voluminous hernias, recurrence, bilateral inguinal/groin hernias, inguinoscrotal/inguinolabial hernias, and incisional or multiple primary midline hernias were routinely counseled for mesh repair. Anesthetic consultation was routinely sought, including those fixed under local infiltrative anesthesia. We routinely utilized antibiotic prophylaxis by using broad-spectrum antibiotics. It has been found that though elective hernia repair is a clean surgery, prophylactic antibiotic is of proven benefit in reducing the rate of surgical site infection (SSI) considering the peculiarities of our tropical environment. At the time of the operation, an appropriate skin incision was made and combined instrument and diathermy dissection was carried out till the sac with its contents was exposed and freed from surrounding structures. The technique of the repair and the extent of operation were determined by the clinical state of the hernia, mode of presentation, patients’ peculiarities, and whether mesh or anatomic methods were employed. Defect size was routinely estimated intraoperatively. A tube drain was inserted when indicated, and the skin sutures were removed on the 12th to 14th postoperative day. For the ambulatory cases, proper medical advice and discussions on wound care and drug medications were communicated to the patients/relatives before discharge. Patients were followed up actively for a variable period of 3–48 months. On several occasions, telephone interviews were arranged for those who defaulted from follow-up appointments and new dates were slated.
Data analysis
Data were analyzed by using Statistical Package for Social Sciences (SPSS) software version 22.0 (IBM, Chicago, IL USA, 2015). Data were presented as mean, standard deviations, percentages, and tables. The association between different variables was measured and compared by using Chi-square (χ2) test. Confidence interval was calculated at 95% level and significance at 5% probability level (P < 0.05).
Ethical approval
The protocol for this study was approved by the research and ethics committees of the hospitals before commencement of the study.
| Results | | |
Sociodemographic characteristics
During the period under review, 5,600 general surgical patients were seen, but 1,110 (19.8%) of them had abdominal wall hernias. Only 975 (87.8%) patients fulfilled the inclusion criteria and were further evaluated. There were 728 (747%) males and 247 (25.3%) females, giving a male-to-female ratio of 3:1. The majority (744, 76.3%) were farmers; the rest were artisans (75, 7.7%), traders (61, 6.3%), civil servants (30, 3.1%), professionals (16, 1.6%), and others (24, 2.5%). The ages of the patients ranged between 16 and 92 years, with a mean of 44.21 +/- SD 15.28.
Clinical presentation
The vast majority (722, 74.1%) had inguinal followed by primary midline (141, 14.5%) hernia. More than three-quarters (810, 83.1%) of the patients harbored their hernias one year or more before presentation. A negligible number (22, 2.3%) presented within three months from the onset of symptoms. Approximately two-third (640, 65.6%) lived with the disease for a variable period of 5–10 years before complications developed or elective presentation. In addition, more than a tenth (164, 16.8%) gave a longstanding history of 15 years or more. Elective presentation represented 72.4% of the cases; the rest (269, 27.6%) had emergency admissions [Table 1]. Several reasons were noted as barriers to early repair, and the chief among them was financial impediment (31.0%), followed by ignorance (12.2%) as shown later [Table 2]. No specific reasons were available in 5.2%. Approximately a quarter (240, 24.6%) of the cases had comorbidities ranging from hypertension (98, 10.1%), obesity (56, 5.7%), diabetes mellitus (48, 4.9%), tuberculosis (8, 0.8%), goiters (4, 0.4%), extra-abdominal malignancies (3, 0.3%), and others (23, 2.4%). Recurrent hernias accounted for 14.9% of all cases, whereas complete inguinoscrotal/inguinolabial and incomplete (funicular) inguinoscrotal/inguinolabial hernias represented more than half (51.9%) of all abdominal wall hernias and 70.1% of inguinal hernias [Table 3] and [Table 4].  | Table 3: Relationship between selected clinical indices and wound infection rates
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 | Table 4: Correlation of clinical/perioperative parameters and morbidities rates
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Anesthetic assessment and surgical treatment
The American Association of Anesthesiologists (ASA) scores of the patients were ASA I (591, 60.6%), ASA II (212, 21.7%), ASA III (156, 16.0%), ASA IV (12, 1.2%), and ASA V (4, 0.4%). ASA III, V, and V scores were associated with increased mortality (P = 0.000). Nearly half (336, 47.6%) of elective cases were fixed under general anesthesia/sedation, whereas a quarter (178, 25.2%) of the patients in this group had their hernias fixed under local infiltrative anesthesia; the rest (192, 27.2%) were sorted out under spinal anesthesia with or without sedation. In the emergency group, general anesthesia was utilized in nearly three-quarters (198, 73.6%) of the cases. The remaining 71 cases were operated under spinal (42, 15.6%), epidural (16, 5.9%), or conversion after spinal or epidural anesthesia (13, 4.8%). There was a statistically significant association between emergency repair on one side and general and spinal anesthetic techniques (P = 0.006) on the other side. Of the 269 patients with emergency presentation, only 22 (8.2%) had spontaneous reduction and were operated on the next elective operating date. Of the 247 (25.3%) cases that were ultimately repaired in an emergency setup, 58 (23.5%) had bowel resection with or without stoma. An additional two patients from the elective repair group had bowel resection on the following grounds: first, to establish intestinal continuity after the resection of multiple iatrogenic bowel injuries in a recurrent inguinoscrotal hernia and second, as part of a procedure to contain abdominal viscera for “loss of domain” in a 58-year-old male with bilateral giant inguinoscrotal hernias. Overall, bowel resection rate was 6.2%, but it was only 0.3% in the elective repair group [Table 4]. Of the 157 patients with obstructed/strangulated inguinal hernias, the majority (129, 82.2%) were fixed through the groin route, and the rest (28, 17.8%) needed a midline laparotomy incision. All the obstructed/strangulated femoral, Spigelia More Detailsn, and obturator hernias were repaired through a midline laparotomy approach. Of the 728 (706 elective admissions plus 22 from spontaneous reduction) patients who had elective repair, 188 (25.8%), 360 (49.5%), 125 (17.2%), 44 (6.0%), and 11 (1.5%) had mesh repair, nylon darn, simple repair, modified Bassini, and Shouldice repair, respectively. Prosthetic mesh implantation was associated with an increased requirement for general and regional anesthesia in patients with inguinal (P = 0.002), incisional (P = 0.000), primary midline (0.022), and other (P = 0.001) hernias.
Outcomes of surgical treatment
The main outcome measures assessed in this article were postoperative morbidities, hernia recurrence, and perioperative mortality rate (POMR). Among the 160 patients with postoperative morbidities, about three-quarters (121, 75.6%) developed wound infection [Table 3]. Seroma formation, intraperitoneal abscess collection, entero-cutaneous fistula, bladder injury, epididymal orchitis, burst abdomen, and others were noted in 78 (8.0%), 26 (2.7%), 3 (0.3%), 6 (0.6%), 22 (2.3%), 4 (0.4%), and 25 (2.6%) patients, respectively. Overall, there were 285 postoperative morbidities in 160 patients (some patients developed two or more postoperative morbidities), as shown next [Table 4]. The effects of some clinical indices on the wound infection rates are demonstrated next [Table 3]. Similarly, the relationship between some selected clinical parameters and the incidence of postoperative morbidities was equally noted [Table 4]. During follow-up, 23 (2.4%) recurrences were recorded. None occurred in cases repaired with mesh implants. Nearly two-third (14, 60.9%) occurred in the emergency group. Generally, recurrence rate was 5.7% in the emergency repair group and 1.3% in the elective group. The overall POMR was 2.9%. Majority (26, 92.9%) of the deaths occurred in cases repaired under emergency circumstances. Indeed, POMR was 9.7% for emergency and 0.3% for elective admissions. The main independent predictors of mortality are shown next [Table 5].
| Discussion | | |
Over the years, discussions on abdominal wall hernias in Africa and other developing nations were focused mainly on central hospital data despite the fact that greater proportions of the patients’ pool reside in the rural and semiurban areas.[5],[7],[16],[21],[22],[23],[24] This trend may be partly explained by the fact that most developing nations have an abysmally low ratio of district to central hospital locations, leading to a disproportionate distribution of surgeons in favor of tertiary/central institutions.[3],[5],[14],[24] However, in recent times, islands of reports on hernia repairs have continued to emerge from district, mission, and private hospitals in sub-Saharan Africa, albeit slowly.[8],[24],[25],[26],[27] Against this backdrop and the growing global clamor for universal health coverage, especially at district centers in sub-Saharan African communities where existing surgical capacity and safety leaves a lot to be desired, the flavor of this scientific article was strengthened by pooling data from government-owned (general hospital), mission, and private hospitals located at the district centers in southeast Nigeria.
Our patients’ population comprised predominantly young and middle-aged adults who were mostly subsistence farmers, artisans, and traders who reside in remote villages and semiurban areas of southeast Nigeria. In the current article, there was also male preponderance, reflecting the male dominance in the incidence of inguinal hernia, which elsewhere has been cited to be, by far, the most prevalent type of abdominal wall hernia globally.[3],[7],[15],[16],[20],[21],[22] These findings conform with data from similar published studies at district centers in Nigeria, Malawi, Kenya, and India[11],[14],[15],[26],[27] and reports from central hospitals in Tanzania, Nigeria, and Kampala.[16],[18],[22]
Inguinal hernias accounted for nearly three-quarters (74.1%) of all cases of abdominal wall hernias examined in this study, akin to previous reports from Africa, Asia, Europe, and the United States.[7],[16],[17],[20],[28],[29],[30] The order of occurrence of abdominal wall hernias in this study is: inguinal, incisional, umbilical, paraumbilical, epigastric, femoral, and others. This pattern overlapped with data culled from Nigeria,[9],[22] Ghana,[31] and the West,[20],[28],[29],[30] but it slightly varies from the results obtained from the Middle East[32] and India[17] where umbilical and paraumbilical hernia come before incisional hernia. In the Middle East and India, the reasons adduced for higher incidence of umbilical/paraumbilical/epigastric hernias were high incidence of chronic liver diseases (that predisposes to ascites and subsequent raised intra-abdominal pressure [RIP]), early pregnancy, and grand multiparity.[15],[17],[32]
In this review, multifaceted socioeconomic barriers contributed to delayed presentation in the emergency and elective groups [Table 2]. Financial limitation, the prime reason for delayed repair, was prominent in this series due to the low per capita income of the majority of the patients and the low coverage of the National Health Insurance Scheme (NHIS), as previously cited by other workers.[1],[3],[5],[8],[16],[24],[29] In recent times, the cost of surgical and anesthetic services has increased in both government-owned and private hospitals (perhaps due to the high exchange rate of dollar to naira), creating an additional layer of financial impediments on the patients. Previous reports from Ghana,[5],[12],[31] Nigeria,[7],[21],[22] and Tanzania[16] support the earlier findings. Ignorance and alternative treatment by herbalist and prayer homes contributed significantly to delayed presentation and repair. In remote villages and communities in sub-Saharan Africa, access to save surgical and anesthesia services is scarcely available.[8],[11],[24],[29],[33] The earlier observations, in synergy with poverty, paved the way for the proliferation of medically unqualified personnel and massive patronage by the vulnerable patients in the remote communities.[3],[11],[16],[29]
A striking observation in this study was the high rates of utilization of general and regional anesthesia to fix simple uncomplicated hernias and the low uptake of prosthetic meshes in the elective repair group. Previous investigators[5],[7],[16],[34],[35] working in Africa have reported this unusual situation; the reasons for the popularity of both general anesthesia and the anatomic method in the repair of uncomplicated hernias are not clear. Perhaps, the voluminous sizes of the hernias, the dearth of experience in the technique of local anesthetic infiltration, and the long tradition of utilizing general anesthesia or sedation to fix hernias, enshrined in surgical services of most institutions in Africa, may partly explain the predilection to general anesthesia by many African authors.[5],[7],[16],[18],[34]
The relatively low utilization of mesh in this study is worrisome, especially in patients with recurrent, bilateral, incisional, and voluminous hernias. In our rural setting, the additional cost of mesh implants, religious and cultural beliefs, fear of foreign body reactions, and lack of expertise on mesh placement have been identified as the key barriers to prosthetic mesh uptake for abdominal wall hernia repair.[5],[7],[16],[22],[34],[35],[36],[37] The use of re-sterilized mesh cloths and improvised mosquito cloth as useful alternatives to standardized mesh implants for tensionless repair of abdominal wall hernia has been reported by several authors.[5],[8],[17],[24],[25],[36] However, some authors have questioned the safety of nontreated mosquito nets as a substitute for prosthetic mesh in human subjects, bearing in mind that it was not originally designed for abdominal wall hernia reconstruction.[36] A more robust, population-based study is warranted to document the safety profile and effectiveness of both re-sterilized mesh and nontreated mosquito net cloth in human subjects.
In the current article, the majority of the anatomic repairs for inguinal hernias were performed by using nylon darn and the Modified Bassini method. In a referral hospital in Ile-Ife, Nigeria, Olasehinde and coworkers reported on a large series of inguinal hernia repair through the darning technique; they concluded that “darning” of the posterior wall of the inguinal canal was an ingenious method to prevent recurrence and recommended it as a useful alternative to mesh implants.[38] The utilization of Bassini technique and its various modifications to repair abdominal wall hernias has a long history worldwide.[5],[7],[16],[18],[20],[28],[29],[30] Though the Bassinni method has been largely abandoned in the developed nations due to the emergence of more effective tension-free prosthetic repair, many researchers working in sub-Saharan Africa have continued to utilize it as the preferred method of abdominal wall hernia repair.[5],[7],[18],[21],[34],[35],[36],[37],[38] It has been cited that many surgeons working in sub-Saharan Africa lack adequate clinical and epidemiological data on the evolution of hernia treatment and this may partly explain why the Bassini technique, though fraught with high recurrence and re-recurrence rates, is still popular in Africa.[5],[8],[12],[24],[25],[34]
At present, laparoendoscopic hernia repair is beginning to gain recognition in our teaching hospital (Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria) and a few other tertiary hospitals in Enugu, Lagos, Abuja, Ile-Ife, Ibadan, Kaduna, Ilorin, and Jos, all of which are in Nigeria. In April 2021, the first edition of the scientific workshop on laparoendoscopic hernia repair was launched in our center to kick-start the program. However, lack of laparoendoscopic accessories such as clips and the dearth of regular training and retraining have hampered the progress since laparoendoscopic surgery traditionally requires a long learning curve for proficiency. Currently, endo-hernia services in Nigeria are in progress, despite the fact that upper and lower gastrointestinal endoscopy and general laparoscopy as well as urologic and gynecologic procedures are well established in some centers in Nigeria.
The impact of several clinical and perioperative factors on the outcome measures evaluated in this study showed remarkable findings. In this article, advanced age at presentation (P = 0.030), presence of comorbidities (P = 0.011), emergency presentation (P = 0.000), and repair of recurrent hernia (P = 0.031) were associated with significant elevation in wound infection rates. We observed that a higher proportion of patients whose hernias were repaired in an emergency setting developed wound infection compared with elective repair (wound infection rate of 34.6% versus 4.0%). It has been shown that delayed presentation and development of strangulation with or without gangrene encourages bacterial colonization of the surgical field as well as systemic invasion by pyogenic organisms to initiate surgical site infection or systemic sepsis.[11],[19],[23] The overall wound infection rate of 12.4% observed in this study is comparable to the values previously quoted.[6],[7],[16]
Though wound infection was the most common postoperative morbidity recorded in this study, other major morbidities were recorded and the factors that influenced their development were assessed [Table 4]. In this discourse, it was a fact of life that all the patients with hernia defect size >10.0 cm developed postoperative complications. Postoperative morbidity was 56.7% in patients who received bowel resection, compared with 14.0% in those without bowel resection. These findings give credence to earlier reports that the repair of complex, voluminous hernias and repair performed under an emergency setup carry elevated risks of major postoperative complications.[3],[5],[9],[11],[19],[22] Previous investigators have observed that extensive tissue dissection, distorted anatomy of the anterior abdominal wall, loss of domain by abdominal viscera, and subsequent development of abdominal compartment syndrome (ACS) contribute to elevated rates of complications and poor outcome after operative repair of longstanding, voluminous hernias.[3],[5],[7],[9] In Enugu, Nigeria, Ezeome and Nwajiobi examined 41 consecutive patients with uncomplicated abdominal hernias, selected on the basis of the large sizes of their hernias.[9] Adverse postoperative outcomes ranged from wound infection in 31.6%, partial wound dehiscence in 21.1%, and postoperative respiratory distress in 7.8% to mesh infection and subsequent recurrence in 2.6%.[9] Perioperative mortality of 4.9% was quoted, with respiratory distress and respiratory failure believed to be responsible for the deaths.[9]
We observed the permissive effect of emergency presentation, delayed presentation, advanced age, comorbidities, and intestinal resection on the mortality of patients, especially for those who underwent emergency operation [Table 5]. Indeed, the duo of emergency presentation and intestinal resection significantly increased morbidity and mortality rates; mortality rates of 9.7% and 21.7% were recorded with emergency presentation and bowel resection, respectively, compared with 0.3% and 1.6% for those with elective presentation and no bowel resection, respectively [Table 5]. The problem with emergency presentation and intestinal resection is not only on the high rates of mortality and the number of complications recorded postoperatively, but rather, on the severity of these morbidities.[3],[4],[9],[11],[16],[24],[25],[39]
In this series, majority of the severe morbidities such as burst abdomen, atelectasis, anastomotic leakage, deep surgical site infection, and intra-abdominal abscesses were observed in those who had an emergency operation with or without bowel resection. As observed by previous workers in Nigeria and Ghana, both emergency presentation and bowel resection rates were highest among patients with strangulated femoral hernia, probably related to the danger of missed diagnosis and thus, delay in operation. Previous workers have noted that femoral hernias in elderly women may be mistaken for inflamed lymph nodes or lipomata, with serious clinical consequences.[3],[31],[39]
The recurrent rate of 2.4% recorded in this study is comparable to figures quoted by previous authors from similar studies.[6],[7],[16],[22],[40] It has been cited that recurrence after hernia surgery is the most important reference standard against which most hernia surgeons judge the effectiveness of a repair technique.[5],[7],[16],[40] It is noteworthy that no recurrence occurred in cases repaired with mesh and that 60.9% of the 23 recurrences occurred in the emergency repair group. Previous authors have linked wound infection and weak surgical scars to hernia recurrence, though an interplay of other modifiers such as mesh fixation techniques, the surgeon’s experience, hospital volume, obesity, smoking, hernia anatomy, and gender have been described.[7],[16],[40],[41]
It is noteworthy that the international guidelines on the management of abdominal wall hernia are encapsulated in our practice and other major referral centers in Nigeria. Guidelines regarding current classification and sub-classification of primary ventral and incisional hernias by the European Hernia Society, antibiotic prophylaxis, principles guiding mesh hernia repair, various laparoscopic approaches and their principles, and the World Society for Emergency surgery (WSES) guidelines for emergency ventral hernia repair are taken into consideration while attending to hernia patients in our practice. For instance, WSES has issued a grade 1A recommendation for the use of synthetic mesh repair in the cases of incarcerated ventral hernia without signs of bowel strangulation or concurrent intestinal resection.[41] On the other hand, owing to the increased likelihood of SSI in the cases of strangulated hernias without concomitant bowel resection, synthetic mesh repair should be used with caution in these circumstances (grade 2C recommendation).
Currently, to the best of the authors’ knowledge, there is no viable national Hernia Society in Nigeria. However, several humanitarian hernia aid volunteer services are conducted in Nigeria from time to time. These hernia aid services are carried out as medical outreach, especially in the rural and semiurban areas where elective hernia repairs and other elective surgical procedures are performed on a humanitarian basis. Some of the programs are sponsored by the federal government of Nigeria in the form of the Niger Delta Development Commission (NDDC) project. During these outreaches, health enlightenment campaigns on the need for early repair are performed. Other recognized humanitarian workers include regional arms of the Nigeria Medical Association (NMA), Medical and Dental Consultant Association of Nigeria (MDCAN), and the Association of Rural Surgical Practitioners of Nigeria (ARSPON), but none is registered as a Hernia Society yet.
| Conclusion | | |
Findings from this study indicated that abdominal wall hernias constitute a significant workload for the general surgeons working in rural hospitals in southeast Nigeria. Several barriers to early presentation and elective repair abound in the remote communities, the majority of which were patient-related. In the classic manner, majority of the patients presented late, often with complications and comorbid diseases, and the hernias were commonly voluminous, recurrent, or multiple. Hence, morbidity and mortality rates were unusually high. Moreover, the utilization of mesh implants and local infiltrative anesthesia to fix elective cases is grossly suboptimal in our local practice.
Recommendations
There is no gain saying that every rural and semiurban settlement needs a specialist surgeon with interest in hernias. A massive awareness campaign to educate rural and semiurban dwellers on the need for early and elective repair cannot be overemphasized. An advocacy for private–public partnership will be salutary; this will increase manpower, incentives and provide the rural hospitals with modern medical facilities. Findings from this study provided ample opportunities to review the effectiveness of our current surgical services and call for change toward the early elective repair of hernias, upscale the use of local infiltrative anesthesia in ambulatory hernia surgeries and wider coverage of NHIS as well as campaign and advocacy for the use of mesh implants.
Limitations
This study is limited by a relatively short follow-up period. A more robust randomized prospective study is warranted.
Acknowledgement
The authors acknowledge the technical support from the management of the four hospitals. They are also grateful to the medical officers in the hospitals for their assistance during data acquisition.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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