|Year : 2015 | Volume
| Issue : 1 | Page : 9-14
Groin Hernias at the Wesley Guild Hospital Ilesa, Nigeria: Characteristics and emerging patterns of repair
Amarachukwu C Etonyeaku1, Olalekan Olasehinde2, Ademola Talabi3, Akinbolaji A Akinkuolie1, Elugbaraonu A Agbakwuru3, Rotimi A David2
1 Department of Surgery, Obafemi Awolowo University Teaching Hospital Complex, Wesley Guilds Hospital Unit, Ilesa; Department of Surgery, Obafemi Awolowo University, Ile-Ife, Nigeria
2 Department of Surgery, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife Hospital Unit, Ile-Ife, Osun State, Nigeria
3 Department of Surgery, Obafemi Awolowo University, Ile-Ife; Department of Surgery, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife Hospital Unit, Ile-Ife, Osun State, Nigeria
|Date of Acceptance||12-Jan-2015|
|Date of Web Publication||20-Jul-2015|
Dr. Amarachukwu C Etonyeaku
Department of Surgery, Obafemi Awolowo University Teaching Hospital Complex, Obafemi Awolowo University, Ile-Ife, Osun State
Source of Support: None, Conflict of Interest: None
Objectives: We sought to determine the current trends in groin hernia characteristics and surgical care in our hospital. Materials and Methods: A prospective descriptive study from Wesley Guild Hospital Ilesa Nigeria: A tertiary hospital unit in a semi-urban community. All adults who had groin hernia repair between September 2008 and August 2013 were reviewed for age, gender, occupation, hernia type, repair technique and anaesthesia, complications of surgery and duration of hospital stay were analyzed for descriptive and inferential statistics. The main outcome measures were post-operative complications and recurrence. Results: Totally, 270 patients with 296 hernias were treated. Majority were males (256; 94.8%). The modal age group was 51-60 years (20.4%). Hernias were unilateral in most patients (251; 93%) with the majority of them right-sided (162/270; 60%). There were 295 inguinal hernias and one femoral hernia. Indirect inguinal hernia was most common (205 patients; 73.3%); while 79 (27.7%) were direct and 11 (4%) pantaloon hernias. Repairs were for recurrent hernias in 17 cases (3.8%) while 64 patients (23.7%) presented with complications requiring emergency operation. Local anesthesia (LA) was most commonly used (80.7%), and day-case surgery was common (206, 76.3%). Nylon darn (155; 52.4%), mesh hernioplasty (94, 31.8%) and Bassini (43; 14.5%) techniques were commonly used. Morbidity (17, 6.3%) was mainly from the surgical site infection (6, 2.2%). Mortality rate was 0.7%. Follow-up ranged from 3 to 30 months (mean = 9.8 months); no recurrence was recorded. Conclusion: Most repairs are now done using LA as day-case procedures. Mesh hernioplasty is becoming popular.
Keywords: Groin, hernia, patterns, repair
|How to cite this article:|
Etonyeaku AC, Olasehinde O, Talabi A, Akinkuolie AA, Agbakwuru EA, David RA. Groin Hernias at the Wesley Guild Hospital Ilesa, Nigeria: Characteristics and emerging patterns of repair. Niger J Surg Sci 2015;25:9-14
|How to cite this URL:|
Etonyeaku AC, Olasehinde O, Talabi A, Akinkuolie AA, Agbakwuru EA, David RA. Groin Hernias at the Wesley Guild Hospital Ilesa, Nigeria: Characteristics and emerging patterns of repair. Niger J Surg Sci [serial online] 2015 [cited 2019 Aug 22];25:9-14. Available from: http://www.njssjournal.org/text.asp?2015/25/1/9/161215
| Introduction|| |
Groin hernias are common reasons for general surgical referrals by general practitioners.  It constitutes a significant portion of the general surgeon's workload. Hernia repair is acclaimed as one of the most commonly performed elective surgical operations worldwide with up to a million repairs performed in Europe and USA annually. ,,, Over the years, groin hernia repair has undergone several modifications aimed at reducing recurrence and other morbidities while maintaining cost effectiveness. This includes: Changes in technique, (tissue based versus tension free/prosthetic repairs), protocol for care (day-case versus short stay), method of anesthesia, (local versus regional/general anesthesia), and the Surgical approach (open versus laparoscopic). ,,,,,,,,,, Currently, the goal of groin hernia repair is to achieve a cost-effective, tension free repair that allows for early return to work with little or no morbidity.
This study set out to evaluate the trend of groin hernia repair in our practice over a 5 years period.
Our facility is a tertiary (referral) hospital in Southwest Nigeria with two hospital units in Ile-Ife and Ilesa (about 30 km apart). It enjoys clientele from the coastal city of Lagos to the hinterlands of South Western, North Central and Eastern Nigeria. Over years, the care of the patient with groin hernia has changed mirroring global trends and best practices. We aim to share our experience over the last 5 years.
| Materials and Methods|| |
This is a descriptive, prospective study conducted between September 1, 2008 and August 31, 2013. The study involved all consecutive patients 15 years and above who had groin hernia repair at the Wesley Guild Hospital Ilesa, a hospital unit of the Obafemi Awolowo University Teaching Hospitals Complex Ile-Ife. Data on age, gender, occupation, type of hernia, repair technique and anesthesia, complications of surgery and duration of hospital stay were entered into a preformed datasheet by the unit resident doctor. The data were collected in three stages: Preoperative (in the outpatient clinic or emergency room during routine work-up for surgery: Addressing the socio-demographic characteristics), postoperative (in the recovery room or shortly before discharge: Addressing the operative findings and techniques) and in the outpatient clinic, for day-cases, and ward for those admitted (information on postoperative complications, and updating of missed data set). The data thus obtained were analyzed for averages and simple percentages and inferential statistics using the Statistical Package for the social sciences (SPSS) version 20 (property of IBM corporation: © copy right IBM Corporation and its licensors 1989, 2011). Para-metric test for statistical significance amongst variables was done. P ≤ 0.05 was taken to be significant. The results are presented as tables and charts.
| Results|| |
A total of 296 hernia operations and 270 patients were studied during this period. This constitutes 24.8% of all surgeries done within the study period. 206 patients (73.3%) had elective surgery while 64 (23.7%) others were done as emergencies: Representing 21.3% of all emergency operations performed during the study period. Of those who had elective repair, eight (3%) were done during elective open prostatectomy for benign prostatic hyperplasia.
Of the 270 patients, there were 256 males (94.8%) and 14 females (5.2%) with a male: female ratio of 18:1. Their ages ranged from 15 to 87 years with a mean age of 50.1 (±18.1) years. [Table 1] shows the age and gender characteristics of the patients.
One hundred and fifty-four (57%) patients were engaged in vocations which involved physical exertion or lifting of heavy items (mainly farmers, laborers, mechanics, sawmill operators) while the remainder (n = 116, 43%) were engage in sedentary activities (students, teachers, clergy, civil servants). Although hernias were relatively more common in those engaged in laborious tasks, this relationship was not statistically significant (P = 0.577). 79 (29.3%) had a family history of groin hernia while the 191 (71.7%) patients had no positive family history. The presence of a positive family history did not have any statistically significant relationship with the age of occurrence of the hernia (P = 0.949) or the type of hernia (P = 0.203).
In majority of patients, the hernias were unilateral (251/270; 93%), of these, 162 (60%) were on the right side, 89 (33%) were on the left side, while 19 patients (7%) had their hernias on both sides of the groin [Table 2]. Bilateral hernias were common in patients above 50 years and those engaged in laborious vocations but not so in those with positive family history of hernia. Indirect hernias were most common accounting for 69.3% of cases while direct and pantaloon hernias were found in 26.7% and 3.7% of cases respectively. Direct hernias were found to be more common after the sixth decade of life although this did not reach statistical significance. Similarly right sided preponderance was more common in the first five decades of life while there was no predilection for side after the sixth decade of life; and this was found to be statistically significant (P = 0.001). Most of the repairs were for primary hernias (253; 93.7%) while only 17 patients (6.3%) presented with recurrent hernias. The 17 patients that presented with recurrent hernias had their first surgery either at a private hospital (n = 10) or in a general/district hospital (n = 7). At presentation, majority of the patients (206; 73.3%) had reducible hernias, while 26 (9.6%), 24 (8.9%) and 14 (5.2%) had incarcerated, obstructed or Strangulated hernias respectively. Obstructed hernias were more common in the first five decades of life, but this was not statistically significant (P = 0.075).
Local anesthesia (LA) was the anesthesia of choice in most instances 216 (80.0%), followed by general and spinal anesthesia in 48 (17.8%) and 6 (2.2%) of cases respectively.
Nylon darn was the most commonly used technique followed by Lichtenstein mesh repair, both exceeding the traditional Bassini repair method [Figure 1]. Overall complication rate was about 7% with surgical site infection and scrotal hematoma being the most common complication [Table 3]. There was a statistically significant relationship between the complications and the method of hernia repair (P < 0.005); with relatively more complication rates with Bassini (14.3%) when compared with nylon darn (5.6%) and mesh (4.6%) techniques. Complications were also more common among patients with indirect hernias compared with those with direct hernias (P < 0.05). Similarly, patients with complicated hernias at presentation had more postoperative complications (P < 0.05) and longer hospital stay (P < 0.05) than those with reducible hernias.
Most of the patients were managed as day-cases (209, 77.4%) while the 61 patients (22.6%) required hospital admission for variable periods of time ranging from 1-day to 20 days (mean = 2.1 ± 2.8). There were two mortalities accounting for a mortality rate of 0.7%. Both patients had strangulated hernias (one each of inguino-scrotal and femoral hernia). The remaining 268 patients were followed-up for 3-30 months (mean = 9.8 ± 6.6). There were no cases of recurrence recorded within this period.
| Discussion|| |
Inguinal hernia repair occupies a major place in surgical practice in terms of volume and prevention of avoidable morbidity and mortality. The number of inguinal hernia operations in our study representing about a quarter of all operations reflects this fact. The low overall number of patients treated per year is comparable to earlier work by Irabor.  (Ibadan) and Garba.  (Zaria). There has been a steady rise in the number of private hospitals offering specialist surgical care, and more patients enroll for free surgeries at district and basic health centers that are sponsored by politicians and nongovernmental organizations and faith-based groups. All these could have limited the number of patients seen and the frequency of surgery within the period of study. The age and gender distribution observed in our study is congruent with the earlier series on the disease. ,,, The reason for this propensity particularly among males may be due to the congenital weakness of the inguinal rings occasioned by the descent of the testes. The involvement of more males in laborious activities may also be a contributory factor. The type of vocation one engages in and presence of a family history of groin hernia had been suggested as probable risks for development of the disease. , We were able to establish this association in 57% (154) and 29.3% (79) of our patients respectively, but the fact that none of these reached statistical significance may be a pointer to the multi-factorial or complex nature of the etiopathogenesis of hernia;  and the limitations inherent in the small sample size. Similarly, we could not establish that a positive family history of hernia influenced the age at which hernia occurred in our patients (P = 0.949). Some researchers have however reported a strong relationship between family history and nature of vocation on occurrence of inguinal hernia. , We believe a large scale population based study could help elucidate the epidemiological risk factors in our populace.
Most hernias were unilateral and on the right side (about 53% of all hernias treated). This has been thought to be due to the late descent of the right testis and thus delay in the obliteration of the processus vaginalis.  The reasons for the preponderance of bilateral hernia in patients older than 50 years and in those engaged in laborious vocations, but not so in those with positive family history of hernia, may be due to a high intra-abdominal pressure from lifting heavy objects, bladder outlet obstruction that is more common in that age group and a probably weak anterior abdominal wall from ageing. This observation is reinforced by the larger number of direct hernia amongst this age group in our study. The relatively low prevalence rate of recurrent hernias (n = 10; 3.4%) can be attributed to under-reporting. All our patients with recurrent hernia had their previous surgery at a private hospital or a General hospital. While this may be a reflection of poor technique, we opine however that any recurrence of hernia done in our facility may well have presented at another facility for re-operation. In the absence of a hernia registry, tracking of patients for a recurrence rate would be difficult if not impossible, as most patients would be lost to follow-up. This may account for the dearth of research on the epidemiology of recurrent hernias in Nigeria. Surgical emergencies occasioned by hernia complication remains rife in our center as 21.3% of all hernias treated were done on an emergency basis. The high rate of emergency surgery was occasioned by the late presentation of patients that had been attributed to ignorance and poverty. ,
Local anesthesia has progressively attained the status of the preferred anesthetic technique for uncomplicated hernia as it has been demonstrated to be effective and well tolerated. ,,,, Spinal anesthesia was reserved for those done as an adjunct to an open prostatectomy, or recurrent hernia. Patients requiring surgery for intestinal obstruction and suspected bowel gangrene had general anesthesia. Ambulatory ("day-case") surgery was achieved in all patients with uncomplicated hernia, whereas patients with complicated hernias had to stay a variable length of days beyond 24 h.
Nylon darn technique of inguinal hernia repair is the most commonly used method of repair and probably reflects the preference of the surgeon and the surgical unit. Many more cases of mesh hernioplasty are being done. This may be due to the availability and perhaps affordability of the mesh; and possibly the acceptability of the practice by the surgical unit. However, it had been advocated that there is a need for caution with the use of mesh: As not all hernia require mesh for repair.  In our hospital fewer hernia repairs are being done using Bassini and Shouldice repair; it appears to be that the techniques are applied for teaching purposes nowadays. The fact that nylon darn was the most commonly used tissue based method in our study may perhaps indicate a departure from the traditional Bassini technique that is associated with high recurrence.  The search for a suitable alternative in the absence of mesh, or when mesh is not advisable as in complicated cases, may have led to the choice of darning as an alternative being relatively easier to perform with lower recurrence rates.  Its ease of execution may also have given it an edge over the Shouldice technique that is technically more demanding, though with the best outcome amongst the tissue-based methods. ,,, Mesh repair technique is currently gaining more acceptances in our setting as reflected by the increasing number of cases done. Thus, one would expect fewer cases of recurrent hernias in our practice as the years go by.
However, it is worthy of note that the number of complicated hernias at presentation has not significantly changed when compared with the earlier report from the center by Adesunkanmi et al.  This subset of patients may not be suitable for mesh repair due to the potentially higher risk of surgical site infection.
Earlier works on groin hernias had identified factors that promote adverse outcome of surgery. These include advanced age, complicated hernia especially those requiring bowel resection, and co-morbid diseases. ,, Our postoperative complication rate of about 7% was comparable to studies done in other centers  but lower than the study reported by Mabula and Chalya  It is not surprising that complication occurred more with indirect inguinal hernia which may extend into the scrotum; thus increasing the risk of incarceration, obstruction or gangrene which are known to have adverse impact on surgical outcome. ,, The mortalities recorded were from patients who had emergency surgery for strangulated hernia: Which required bowel resection. The procedures were complicated with intra-abdominal sepsis and septicemia that progressed to multiple organ failure and death. There was no mortality from direct hernia that is in consonance with works by Nilsson et al.  this may be due to the wide neck of the hernia sac which reduces the risk of obstruction or gangrene of the hernia content(s).
Though we did not record any recurrence amongst the patients we managed, including those who presented with recurrent hernia, we do believe that the mean follow-up period (9.8 ± 6.6 months) was rather short to make a categorical statement on recurrence. And as earlier mentioned the patient might elect to seek a remedy elsewhere in the event of any recurrence. The zero recurrence rates may also be a reflection of the trend toward a tension free repair and the rather small sample size.
| Conclusion|| |
Most of our groin hernia repair was done as day-case procedure using LA. Nylon darn technique and mesh hernioplasty were the preferred methods of inguinal hernia repair in our center. There is need to evaluate those who really need mesh hernioplasty. There is also need for a large scale population-based study on the epidemiology and epidemiological risk factors for hernia in Nigeria, and a long-term study to ascertain recurrences rates amongst the various repair techniques in Nigeria. This can be achieved through establishing and promoting a hernia society and a hernia register.
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[Table 1], [Table 2], [Table 3]
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