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Table of Contents
Year : 2023  |  Volume : 6  |  Issue : 1  |  Page : 6-13

Outcomes in the surgical management of giant inguinal hernias: A systematic review

1 Department of Surgery, University of Ilorin Teaching Hospital, Ilorin, Nigeria
2 Master of Public Health Student, Rutgers School of Public Health, New Jersey, USA

Date of Submission18-Jan-2023
Date of Decision08-Feb-2023
Date of Acceptance20-Feb-2023
Date of Web Publication30-Mar-2023

Correspondence Address:
Saburi O Oyewale
Department of Surgery, University of Ilorin Teaching Hospital, 241102 Ilorin, Kwara
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_4_23

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Giant inguinal hernia presents a range of unique challenges in its treatment. Detailing the potential complications and outcomes of treatment can motivate patients with giant inguinal hernias (GIH) to seek an early surgical intervention and raise awareness of the risks of neglecting the condition. The aim of this review is to identify the rates of complications, especially the abdominal compartment syndrome, and the causes of mortality encountered in the treatment of GIH. Furthermore, a new classification system for GIH is proposed. The search resulted in 1,926 papers, and 10 papers were included in the study. The majority of the studies were conducted on subjects living in sub-Saharan Africa. The most frequently performed procedure was Nylon Darning, accounting for 46.5% and only 53 (12.5%) were laparoscopic repair. There were four deaths reported in two studies. Two were caused by pulmonary embolism, whereas renal failure and abdominal compartment syndrome were the causes of one death each. After a proportional meta-analysis, the pooled complication rate of the surgical interventions was 39% (95% confidence interval: 0.18–0.59) with a random effect model I2 = 82.6%. There was no recurrence in any of the studies. The complication rate for treating giant inguinal hernia is high but mortality is low. There was zero recurrence despite some subjects undergoing modified Bassini repair. Further research is needed to identify predictors of abdominal compartment syndrome and intra-abdominal hypertension. The proposed classification also requires further study on a large scale.

Keywords: Giant inguinal hernia, LMIC, morbidity, mortality

How to cite this article:
Oyewale SO, Ariwoola AO. Outcomes in the surgical management of giant inguinal hernias: A systematic review. Int J Abdom Wall Hernia Surg 2023;6:6-13

How to cite this URL:
Oyewale SO, Ariwoola AO. Outcomes in the surgical management of giant inguinal hernias: A systematic review. Int J Abdom Wall Hernia Surg [serial online] 2023 [cited 2023 Jun 9];6:6-13. Available from: http://www.herniasurgeryjournal.org/text.asp?2023/6/1/6/372936

  Background Top

In sub-Saharan Africa and some Low-Middle-Income-Countries (LMIC), the majority of the patients with surgical diseases never get to the hospital nor are treated in a substandard health care facility with associated morbidity and mortality.[1] The annual incidence of inguinal hernia, in sub-Saharan Africa, could be as high as 175 per 100,000 and only 40% of such are operated.[2]

When standing, a giant hernia is one that extends below the mid-thigh or one containing more than 20% of the abdominal viscera.[3] The prevalence of giant inguinal hernias (GIH) is uncertain, as most research on the topic consists of individual case reports and a limited number of case series. However, the majority of its incidence occur in the rural communities of the LMICs where access to healthcare is problematic. This can be ascribed to factors including patient financial hardship,[4],[5] surgery anxiety,[6] and lack of knowledge about potential risks associated with delayed presentation.[6] In addition to these, there is an increased incidence of skin infections[7] and difficulty in sexual activity due to the buried phallus.[4] Hence, the majority of the patients tend to present with psychosocial issues which range from reduced socialization and low self-esteem.[4] In addition, social withdrawal has been associated with loss of income and perpetual poverty.

GIH are associated with the distortion of groin anatomy. These include the stretching of the scrotal skin and dartos muscle, thickening of scrotal wall, lengthening of spermatic cord, displacement of testes, and the loss of domain.[3] These could constitute a significant challenge in the surgical management of giant hernias, especially in a resource-poor setting. In a prospective study by Bierca et al.,[8] there was an increased risk of early complications in patients with giant hernias.

Even though the majority of donations to healthcare in LMIC are for infectious disease programs, elective inguinal hernia repair has been found to be more cost-effective (US$12.88–$78.18/disability-adjusted life years (DALY) averted)[9] than the use of antiretroviral therapy (US$300–US$500/DALY averted).[10] Hence, the incorporation of basic surgical services into public health programs could strengthen the overall well-being of patients.

The morbidity of surgically treating a giant inguinoscrotal hernia has not been brought up in any way. Hence, we determined the rates of complication, especially the abdominal compartment syndrome, and the causes of mortality which were encountered in the treatment of GIH. This might help spread awareness among those who have inguinal hernias about the complications of neglect and encourage them to seek surgical treatment early.

  Materials and Methods Top

This study is based on the research question: What is the complication rate of treating giant hernias surgically? In accordance with PRISMA-P guidelines,[11] this review was registered on the PROSPERO registry for systematic review with identification number: CRD42022373294.

Search strategy: The databases such as PubMed, Google scholar, and Scopus were systematically searched, and the retrievable studies were used. Furthermore, manual searches were conducted on the references of the retrieved articles. We also used the Google Scholar’s forward citation search feature to look for further papers that cited the included studies. The search terms of PubMed were as shown in [Table 1]. The last search was conducted on November 26, 2022.
Table 1: Showing the PubMed search strategy

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Qualification criteria for study consideration

Inclusion criteria

Included are either retrospective or prospective studies on the complications of giant hernias in adults published in English in the last 40 years. The context is adults presenting with giant inguinal hernia undergoing surgical treatment. The investigated outcome is the morbidity (both intraoperative and postoperative) and mortality of patients with GIH.

Exclusion criteria

The exclusion criteria are studies on case reports, commentaries, case series, articles with fragmented data and articles not discussing the outcomes of intervention. Qualitative and quantitative syntheses were performed on the selected studies.

Article screening and selection

Study records

Rayyan was used for the whole screening process. A multi-step method was used for article screening and selection. This was done independently by the two authors. Whenever there was a disagreement between the two authors on article inclusion, an agreement was obtained by turning to the inclusion criteria.

Risk of bias

Using the ROBINS-I tool, we evaluated the included articles’ quality. The ROBVIS tool was used to create traffic and summary plots.[12]

Data extraction and analysis

The data extraction and analysis were done with meta essentials.[13] The extracted information was inserted into an Excel spreadsheet. This sheet shall include the names of authors, number of participants, type of study, year of publication, study design, morbidities, and mortalities.

We derived the pooled prevalence with 95% confidence interval (CI) of the complications of procedures conducted on giant hernias. The I2 was used to determine the heterogeneity of the gathered data. A random effects model was used when I2 is >50% and a fixed-effects model when I2 < 50%.

  Results Top

The search was done from October 28, 2022, to November 26, 2022, and it yielded 1,926 papers. After reviewing the abstracts, 1,839 articles were excluded. In that, 81 papers had a full text review [Figure 1] and 10 papers,[5],[6],[8],[14],[15],[16],[17],[18],[19],[20] which met the inclusion criteria, were studied in-depth [Table 2]. The articles included patients recruited between 2009 and 2021. The total number of procedures that were carried out in these studies was 424. The majority of the studies were based on subjects living in the sub-Saharan Africa.
Figure 1: The flow diagram of the systematic review

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Table 2: Showing the characteristics of the included studies

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Using the ROBINS-I tool in assessing the bias, three studies had low risk, four studies had serious risk, two with moderate risk, and one had critical risk. An overall summary was presented in the summary plot in [Figure 2] and [Figure 3].
Figure 2: Traffic plot

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Figure 3: Summary plot

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Majority of the patients had modified Bassini repair and Nylon Darn repair, 46.5% and 23.6%, respectively. The other surgical procedures are as listed in [Table 3] and [Figure 5].
Table 3: Showing the procedures for giant inguinal hernia

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Figure 5: Procedures performed on patients with GIH

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Only four deaths were recorded in this review.[6],[20] One died during the intra-operative period, due to abdominal compartment syndrome.[6] Two patients had pulmonary embolism,[20] and one died of renal failure in the postoperative period.[20]

The shown in [Table 4]. The complication rate, after the various surgical intervention, was 39% (95% CI: 0.18–0.59) with a random effect model I2 = 82.6%. This meta-analysis is represented in the forest plot in [Figure 4].
Table 4: Showing the complications of procedures

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Only four patients, in two studies,[6],[18] had abdominal compartment syndrome. Two of them had an emergency exploratory laparotomy with exclusive skin closure.[6] The third patient died during the operation [Table 5]. The fourth patient was managed nonoperatively.[18] There was no recurrence in any of the study. In addition, no geniturinary complication was noted in any of the studies.
Table 5: Showing the proposed modification of Trakarnsanga classification of GIH

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  Discussion Top

The rate of complications of inguinal hernia repair was between 8% and 10%.[21],[22] Our review has shown that the pooled rate of complication is 38.7%. This is unusually high.

The recurrence rate for inguinal hernia repair is between 12% and 13%.[23],[24] In a district in the United States, the incidence rate of recurrence of inguinal hernia following repair has reduced from 66/100,000 to 26/100,000.[25] However, the reports on tissue-based repair from around the world did not show any significant drop in the rate of recurrence.[26] According to Stoppa,[27] there is a low recurrence associated with the repair of huge and voluminous groin hernias. There was no recurrence in our systematic review. This could be due to the short duration of follow-up as majority of the studies had a follow-up of less than 3 years.

The chronicity of GIH is associated with the redistribution of abdominal content into the hernia sac with a consequently reduced tonicity of the anterior abdominal wall muscle. The development of increased intra-abdominal pressure has been associated with the atrophy of internal oblique muscles and anterior abdominal wall in rats.[28] Perhaps, this could be extrapolated to humans. The presence of a loss of domain is one of the cardinal problems associated with the treatment of GIH. The Tanaka index has been used as a tool in describing the loss of domain especially in giant ventral hernias. The loss of domain is defined as when the index is greater than 20%[29] and this has been used as a tool in the management of some patients with GIH.[30] Only one study[18] in our review described the use of preoperative progressive pneumoperitoneum. In addition to the stretching of the scrotal skin, other pathology associated with GIH includes visceroptosis with concomitant elongation of the vascular pedicles.[31]

There are various challenges with the preexisting classification of GIH. In the classification by Muhammad Hussain Laghari,[20] type 1 class does not include a landmark for diagnosing GIH. Furthermore, the classification by Trakarnsagna et al.[32] generalized that type 2 and type 3 GIHs require increased abdominal volume procedures or the resection of the contents of the hernia sac. In addition, it does not take into account the possibility of loss of domain of the abdominal cavity. Several studies[33],[34],[35] have shown that many patients with GIH did not develop abdominal compartment syndrome postrepair and only one study,[18] in our review, described the use of preoperative progressive pneumoperitoneum. Hence, we propose a modification in the Trakarnsagna classification. This is as follows: Type 1: Sac descends below the mid-thigh, but above an imaginary horizontal line midway between mid-thigh and superior patellar border. (1a) There is neither visceromegaly of sac contents nor a loss of domain. (1b) There is visceromegaly of sac contents and no loss of domain. (1c) There are visceromegaly of sac contents and loss of domain. Type 2: Sac descends below the imaginary horizontal line midway between mid-thigh and superior patellar border, but not extending beyond the superior patellar border. (2a) There is visceromegaly of sac contents and no loss of domain. (2b) There is a loss of domain with visceromegaly of sac contents. Type 3: Sac descends or extends beyond the superior patellar border. (3a) There is visceromegaly of sac contents but no loss of domain. (3b) There is a loss of domain with visceromegaly of sac contents [Table 5] and [Figure 6].
Figure 6: The classification of GIH

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Whereas laparoscopic repair of hernia is commonly done in the developed countries, its adoption in Africa has been limited by the high cost of equipment and lack of training opportunities for surgeons and other paramedics.[36] As a result of these, there are limited studies on the use of laparoscopic techniques for hernia repair in Africa.[37],[38],[39],[40],[41],[42] In our review, out of 424 procedures, only 53 (12.5%) were laparoscopic repair for GIH.[17],[19] These studies were on subjects outside the sub-Saharan Africa (China and Egypt).

The HerniaSurge international guidelines[43] failed to address strategies for the treatment of GIH. This is a notable omission by the group. In order to avoid differences in outcome, future reviews and guidelines must include the management of GIH.

The limitations of this review are the nonincorporation of randomized study, the nonassessment of the publication bias, and not using the Clavien Dindo classification for complications. The subgroup analysis comparing the sub-Saharan African countries to other advanced countries was not possible.

Areas for further research include to determine the risk factors for complications in GIH, the predictors of the loss of domain, and abdominal compartment syndrome.

  Conclusion Top

The management of GIH is not clearly defined, because the majority of the available data are from small case series and case reports. This systematic review showed that there is an unusually high complication rate in the surgical treatment of GIH. Also, there is no recurrence in all the studies in this review and there is an associated low incidence of abdominal compartment syndrome. We have also suggested a modification in the existing classification of GIH, which would still require further validation with a large volume of participants.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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