Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 26  |  Issue : 2  |  Page : 33-38

Recurrent inguinal hernia in Ile-Ife Nigeria: Characteristics and outcome of management


1 Department of Surgery, Obafemi Awolowo University; Department of Surgery, Obafemi Awolowo University Teaching Hospital Complex, Ile Ife, Nigeria
2 Department of Surgery, Obafemi Awolowo University, Ile Ife, Nigeria
3 Department of Surgery, Ladoke Akintola University of Technology Teaching Hospital, Osogbo, Osun State, Nigeria
4 Department of Surgery, Obafemi Awolowo University Teaching Hospital Complex, Ile Ife, Nigeria

Date of Web Publication12-Jun-2017

Correspondence Address:
Amarachukwu Chiduziem Etonyeaku
Department of Surgery, Obafemi Awolowo University, Ile-Ife, Osun State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njss.njss_7_16

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  Abstract 


Background: There are very few reports addressing patients' characteristics, patterns, and outcome of treatment of recurrent inguinal hernia irrespective of the method of hernia repair. Purpose: The purpose of this study is to evaluate the patients and disease characteristics, treatment and early outcome of surgery for recurrent inguinal hernia. Patients and Methods: The medical records of patients who had repair of recurrent inguinal hernia at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife from January 1, 2004, to December 31, 2013 were reviewed for demographics, number and place of previous repair, technique of repair, intraoperative findings at repair of recurrence, and outcome of this intervention. Data generated were analyzed for frequencies, percentages and Fisher exact test for statistical significance. Results: Forty-one recurrent hernia repairs were done during the period, constituting 3.2% of all hernia repaired. The male:female ratio was 40:1. Mean age was 56.1 ± 17.7 years. Most cases were first-time recurrences 36 (87.8%), reducible 35 (85.4%) and were electively repaired. Six (14.6%) were complicated requiring emergency repair. Recurrence within 1 year of earlier repair was common (36.6%). Relatively, more patients 22 (53.7%) had their primary repair in nonspecialist centers (P < 0.05) while only eight patients had their primary repairs in specialist centers. Lichtenstein and Nylon Darn techniques were common repair methods for recurrent hernia. Overall complication rate was 36.6% (n = 15) with wound hematoma being the most predominant 11 (25.6%). There was no record of re-recurrence over 3–60-month period (mean = 6 months). Conclusion: Place of the previous repair was associated with increased risk for hernia recurrence. Tension-free repair remains pivotal in recurrent hernia repair.

Keywords: Etiopathogenesis, recurrent inguinal hernia, Southwestern Nigeria


How to cite this article:
Agbakwuru EA, Etonyeaku AC, Olasehinde O, Kolawole AO, Talabi AO, Akinkuolie AA, Wuraola FO. Recurrent inguinal hernia in Ile-Ife Nigeria: Characteristics and outcome of management. Niger J Surg Sci 2016;26:33-8

How to cite this URL:
Agbakwuru EA, Etonyeaku AC, Olasehinde O, Kolawole AO, Talabi AO, Akinkuolie AA, Wuraola FO. Recurrent inguinal hernia in Ile-Ife Nigeria: Characteristics and outcome of management. Niger J Surg Sci [serial online] 2016 [cited 2017 Aug 17];26:33-8. Available from: http://www.njssjournal.org/text.asp?2016/26/2/33/207754




  Introduction Top


Inguinal hernia repair has been ranked as one of the most commonly performed general surgical operations worldwide.[1],[2],[3],[4] Most of these studies address the management of primary inguinal hernias using various techniques that have evolved over the years. Common criteria for measuring the outcome of care in inguinal hernia repair are based on recurrence rate and chronic postoperative groin pain. Recurrence, which perhaps is the most important outcome measure, is usually discussed in relation to various techniques with prosthetic (mesh implant) repairs recording least recurrence rates.[5],[6],[7] However, there are fewer studies that assessed recurrent inguinal hernias with regards to patients' characteristics, patterns, and outcome of treatment irrespective of the method of repair used. These studies were largely from the developed nations [8],[9],[10] with very little contribution from developing countries which have their own peculiar characteristics: in terms of large hernia sizes, high rate of emergency presentations, and limited resources and personnel.[11],[12],[13],[14]

This study seeks to report patterns and outcome of management of recurrent hernia in a developing community in southwestern Nigeria. It is hoped findings from this study will help to improve the literature from developing countries on recurrent inguinal hernia. We reviewed all cases of recurrent inguinal hernia repaired in our hospital aimed to determine the prevalence, patients' characteristics, probable risk factors associated with the disease, the operative technique adopted, and outcome of treatment in terms of postoperative complications and re-recurrence.


  Patients and Methods Top


The case files of all patients who had repair of recurrent inguinal hernia at the Obafemi Awolowo University Teaching Hospitals Complex between January 1, 2004, and December 31, 2013, were extracted from medical record department and reviewed. The age, gender, number of previous repair, place of previous repair, interval between index repair and recurrence, operative findings, type of repair done, nature of anesthesia used, postoperative complications, and duration of follow-up were extracted and entered into a spreadsheet. The data obtained was analyzed for frequencies and measures of central tendencies using the statistical package for the social sciences SPSS version 22. (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp). Results were presented as tables and charts while a statistical relationship between variables was determined using Fisher's exact test with statistically significant levels set at P ≤ 0.05.


  Results Top


A total of 41 patients, comprising 40 males and one female were operated for recurrent inguinal hernias out of about 1268 cases of inguinal hernia repairs undertaken during the study period representing 3.2% of cases. The patients' ages ranged from 15 to 80 years with a mean age of 56.1 (±17.7) years. The modal age group was 60–69 years (23.3%) and over half of the patients were in the age group 50–79 years [Figure 1]. Majority of the patients (26/41, 63.4%) were either farmers or artisans [Table 1]. Thirty-six (87.8%) of the herniae were recurring for the first time, while five cases (12.2%) had previous failed attempt (s) at repair of a recurrent hernia. Twenty-three patients (56.1%) had right-sided hernia, 14 patients (34.1%) had left-sided hernia while the remaining four patients had bilateral recurrences. Further assessment showed that 26 patients had indirect hernias (63.4%), 12 patients (29.3%) had direct, while three patients (7.3%) had pantaloon hernia. Thirty-five patients (85.4%) presented at the outpatient clinic with reducible hernias while six patients (14.6%) presented in emergency with complicated hernias (intestinal obstruction or bowel ischemia). Majority of the patients 22 (53.7%) had previous repair at nonspecialist centers (either a district or community based private hospitals) and were only referred for management of the recurrence. Eight (19.5%) patients had their primary surgery at specialist hospitals, while 11 patients (26.8%) had no records detailing the place of previous repair [Figure 2]. The hospital setting where primary surgery was done appeared to influence the chance of recurrence (Fisher's exact test P< 0.05). Among the eight patients who had repair in specialist hospitals, six were previously repaired in our hospital while the remaining two were repaired in some other specialist hospitals. The method of repair was not known in any of the cases that were referred to our center. However, Bassini technique was used in five out of the six recurrent herniae (83.3%) previously done in our center, while Shouldice technique was used in the remainder one patient (16.6%), none had mesh repair. Other probable risk factors for the recurrence among the patients, which was identified at surgery, are as shown in [Table 2]. Fifteen (36.6%) of the patients had recurrent hernia within 1 year of earlier repair, while 6 (14.6%) and twenty (48.8%) recurred within 1–5 years and after 5 years, respectively. The majority of the recurrent herniae were repaired using local anesthesia 27 (65.8%), while 7 (17.1%) patients each were done using spinal and general anesthesia, respectively. Open Lichtenstein (mesh) and Nylon Darn repair techniques were the preferred modes of repair of recurrent hernia in this study [Figure 3]. The four patients with bilateral recurrent inguinal hernia had 5 direct inguinal hernia and 3 indirect types. They all had associated bladder outlet obstruction from benign prostatic hyperplasia (BPH). Moreover, all four had mesh repair of both herniae during open (transvesical) prostatectomies for their BPH without an adverse outcome. The five patients with failed previous attempt(s) at repair of the recurrent disease also had Lichtenstein repair. Postoperative complications occurred in 15 patients (36.6%); and comprised wound hematoma 11 (25.6%), chronic groin pain 1 (2.4%), hydrocele 1 (2.4%), wound infection 4 (9.8%), and testicular atrophy 1 (2.4%). Some patients had multiple complications [Table 3], especially those that had a third repair (failed second attempt). The patients who had postoperative testicular atrophy and chronic groin pain were also those who had a third surgery (repair of a re-recurrence hernia). There was no record of recurrence, in all the patients, within the follow-up period (ranged from three-sixty months) with a mean of 6.7 ± 1.5 months.
Figure 1: The age distribution of patients operated for recurrent inguinal hernia diseases. (P = 0.083 and central in position)

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Table 1: Occupation of patients

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Figure 2: Comparison between the duration of index recurrence and nature of center where last surgery was done (P = 0.120 and central in position)

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Table 2: Risk factors associated with inguinal hernia recurrence

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Figure 3: Method of repair for recurrent inguinal hernia

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Table 3: Frequency of postoperative complications following repair of a recurrent inguinal hernia

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  Discussion Top


The major criterion used to assess the success of inguinal hernia repair is the rate of recurrence, and this has formed the basis for comparison of different repair methods. When a hernia recur, it poses a challenge not only to the surgeon who undergoes the rigors of operating on tissues with distorted anatomy but also to the patient who has to undergo the process of another repair with its attendant psychological and financial stress. Reoperation on a recurrent inguinal hernia would increase the risk of injury to the spermatic cord or its associated structures; and distorted tissue planes could also increase the chances of future recurrences. Thus, a recurrent hernia is as much a bad occurrence to the surgeon as it is to the patient and every effort should be made to prevent it. Understanding the various factors associated with recurrence of hernia is key to preventing its occurrence and its effective management.[8],[15],[16],[17]

Risk factors for recurrent hernia have been well documented in literature. These include age of the patient, gender, obesity, occupation, presence of intercurrent diseases causing increased intra-abdominal pressure or impaired wound healing, connective tissue disease, smoking, poor repair technique, surgical site infection, and family history of similar disease.[16],[17],[18] In most of our patients, a common risk factor of recurrence observed was lifting of heavy objects. This is not surprising as most of the patients were farmers and artisans who were often involved in menial vocations warranting lifting of heavy objects which may exert tension on a hernia repair leading to recurrence. A sizeable proportion of the patients had no record of probable risk factors associated with hernia recurrence, especially as no mention was made of the body mass index (BMI). Disappointingly still, there were few records of weight of the patients, while their heights were not recorded making retrospective computation of the BMI impossible. These constitute major limitations of the study.

Old age as a risk factor for inguinal hernia recurrence [19] is thought to be due to attrition of connective tissue in elderly people. Although we recorded peak prevalence among patients aged 60–69-year-old, this was not statistically significant (P > 0.05); and thus, we could not establish that advanced age is a risk factor for hernia recurrence in this study. This could be a result of the small sample size.

Males are at higher risk of inguinal hernia recurrence compared with females. Whereas the entire floor of the inguinal canal can be completely obliterated in females, in males a passage needs to be retained for the transmission of the spermatic cord thereby leaving room for a possible recurrence. Findings of significant male predominance in this study may well reflect higher prevalence of primary groin hernia in males compared to females.[1],[8],[9],[11],[12],[13],[14] Some authors opine that when primary inguinal hernia rates are corrected for gender bias, the recurrence rates between males and females may not be statistically different and that the female gender could well be a probable risk factor for recurrence.[18]

Findings in this review showed that the type of hernias, mode of presentation, and level of expertise of the primary surgeon are perhaps determinants of hernia recurrence. We observed that most of the recurrent hernias were indirect rather than the direct variety. This finding may be a reflection of the type of hernias seen in the West African subregion which are predominantly fairly advanced indirect inguinal,[14] with 14%–25% of them presenting as surgical emergencies.[11] They were treated mostly by nonspecialist, perhaps with tension associated tissue-based repair techniques.[1],[2],[3],[12],[13],[14] Given the late stage of hernia at presentation, proper identification, and dissection of hernia sac and appropriate isolation of the spermatic cord may be a challenge particularly for nonspecialists who performed the majority of these operations. This could explain the high rate of recurrence following repair by nonspecialist surgeons noted in our study. On the contrary, in the developed world there are fewer cases of inguinoscrotal or complicated hernias [4],[20],[21],[22] with the majority of cases performed by specialists: some of which are solely dedicated to hernia repairs and are familiar with various methods to adopt depending on the type of hernia.[4],[5],[21],[23] Primary indirect hernia has been reported to be more common on the right,[24] and this has been attributed to the delayed in the descent of the right testis and obliteration of the right processus vaginalis.[25] The higher frequency of right-sided recurrent hernia in this study may be a reflection of the frequency of right-sided primary hernia in our practice. Furthermore, most of the recurrent herniae seen were also indirect hernia.

The majority of hernia recurrences recorded within 1 year of primary surgery could be attributed to poor repair technique as earlier suggested by Farooq, et al.[26] Poor repair techniques may be the reason for the high recurrence rate among the group of patients who had hernia repair at nonspecialist centers. Furthermore, during surgery for recurrence: As shown in [Table 2], the presence of inappropriate sutures such as chromic catgut and silk, or the complete absence of any suture or mesh at the site of previous repair would suggest poor repair techniques by the primary surgeon. Nilsson, et al. had in their study on hernia registers and specialization showed that hernia repair in a specialized center reduces inguinal hernia recurrence rate to 0.1%.[22] In instances where details of previous surgeries were available, most repairs are undertaken using the Bassini technique which itself is associated with tension and high recurrence rate.[5],[8],[16],[17] It is perhaps the recognition of this fact that has prompted more surgeons to utilize the Lichtenstein tension-free repair technique as shown by the growing number of publications on its use in our setting.[14],[21] It is pertinent to note that in our practice, there has been a progressive change in the technique used for the repair of recurrent hernias: shifting from the suture-based tension free repair (Darning technique) to the Lichtenstein (mesh) repair. The latter is the preferred method of repair in the past 2 years of the study. There is a present need for re-training of nonspecialists on contemporary effective and efficient hernia repair methods.

It is expected that complications following repair of recurrent hernia will be higher than that of primary hernia; and this was the case in our study with more than a third (36.6%) of our patients having at least one complication compared to a 12.8% rate in those who had primary hernia repair from an earlier study.[14] In a Danish study, first-time recurrence rate was reported to be 3.1% while the re-recurrence rate for those whole had failed repair of a recurrent hernia was 8.8%.[18] This disparity could be due to the more extensive dissection required with recurrent hernia and the risk of closure of the defect under tension if tissue based (Shouldice) or suture-based (Nylon Darn) repair techniques is adopted. Extensive dissection is associated with the risk of postoperative deep space collections (hematoma or seroma) which alongside tension repair would impair wound healing, promotes surgical site infection, and ultimately cause failure of the repair. Such challenges are better circumvented using prosthetic mesh to close the defect.

The lack of recurrence observed after a mean follow-up period of 6 months could perhaps be due to the expertise in our specialist center which relied on tension-free techniques such as mesh and Nylon Darn techniques.[23],[24],[26],[27] However, the full picture with regards to re-recurrence rate requires a longer follow-up period which also constitutes a major limitation of this study.

Limitation of the study

There was poor record keeping as some vital information like BMI, the presence of suture fragments at surgery, and the nature of scar from previous surgery were not recorded. Furthermore, a structured follow-up protocol was not in place, and most of the patients appeared to have been lost to follow-up.


  Conclusion Top


Recurrent indirect inguinal hernia is not uncommon in our practice. It shows a male preponderance and predilection for the right groin. Bilateral cases were associated with bladder outlet obstruction. The emergency presentation was common, and most cases followed the previous repair in nonspecialist centers. Open Lichtenstein (mesh) repair and Nylon darn technique were found to be useful in repair of recurrent hernia with the acceptable early outcome of treatment.

Recommendation

We recommend advocacy to improve early elective hernia repair. Tension-free repair techniques should be encouraged in primary hernia repair. There is a need for re-training nonspecialists in contemporary management of groin hernia. There is also need for further studies to evaluate the actual risk factor associated with recurrent hernia in our practice.

Acknowledgment

We acknowledge the surgeons in the department whose patients' records were reviewed in the study. Namely: Prof. Akinola DO, Lawal OO, Adesunkanmi ARK; Dr. Arowolo OA, Alatishe IO and Adisa AO.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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