|Year : 2018 | Volume
| Issue : 2 | Page : 26-33
Delay in presentation and challenges of treatment of complicated abdominal wall hernias in rural Southeast Nigeria
Aloysius Ugwu-Olisa Ogbuanya1, David Amah2
1 Department of Surgery, Bishop Shanahan Specialist Hospital, Nsukka; Department of Surgery, Mater Misericordie Hospital, Afikpo; Department of Surgery, Alex Ekwueme Federal University Teaching Hospital, Abalaliki; Department of Surgery, Ebonyi State University, Abakaliki, Ebonyi State, Nigeria
2 Department of Surgery, Mater Misericordie Hospital, Afikpo, Nigeria
|Date of Submission||16-Apr-2020|
|Date of Decision||29-May-2020|
|Date of Acceptance||29-Jun-2020|
|Date of Web Publication||1-Aug-2020|
Dr. Aloysius Ugwu-Olisa Ogbuanya
Bishop Shanahan Specialist Hospital, Nsukka, Enugu State; Mater Misericordie Hospital, Afikpo, Ebonyi State; Department of Surgery, Alex Ekwueme Federal University Teaching Hospital, Abalaliki, Ebonyi State; Department of Surgery, Ebonyi State University, Abakaliki, Ebonyi State
Source of Support: None, Conflict of Interest: None
Background: Delay in presentation and treatment of abdominal wall hernias is phenomenal in Africa. The three-pronged problem of delayed presentation, multiple comorbidities, and advancing age makes management of complicated abdominal wall hernias more tasking and hazardous. The purpose of this study was to determine the causes of delayed presentation and treatment outcomes of complicated abdominal wall hernias in our environment. Patients and Methods: This was a 3-year multicenter prospective study of the causes of delayed presentation and treatment outcomes of complicated abdominal wall hernias in rural Southeast Nigeria. Results: A total of 138 patients with complicated abdominal wall hernias were enrolled and comprised of 117 males and 21 females. Of the entire patients, those with inguinal hernia represented 76.1% followed by umbilical hernia (8.0%). Only 18.1% presented within 24 h after the onset of complications, 24.6% between 24 and 48 h, 29.0% between 49 and 72 h, and 28.3% after 72 h. In the preoperative period, theater waiting time was 0–12 h in 10.9%, 13–24 h in 23.2%, 25–48 h in 39.1%, and >48 h in 18.1%. The major barriers against early presentation were financial constraint (23.9%) and treatment at alternative homes (15.9%). The overall morbidity rate was 58.0%, whereas the mortality rate was 13.8%. The bowel resection rate was 26.1%, and majority of the resection (77.8%) and deaths (73.7%) occurred in those who had overall delay beyond 72 h before surgical repair. Conclusion: The rates of morbidity and mortality were proportionally related to the length of delay in the presentation and duration of waiting time before operative repair.
Keywords: Abdominal, hernia, laparotomy, morbidity, resection
|How to cite this article:|
Ogbuanya AU, Amah D. Delay in presentation and challenges of treatment of complicated abdominal wall hernias in rural Southeast Nigeria. Niger J Surg Sci 2018;28:26-33
|How to cite this URL:|
Ogbuanya AU, Amah D. Delay in presentation and challenges of treatment of complicated abdominal wall hernias in rural Southeast Nigeria. Niger J Surg Sci [serial online] 2018 [cited 2020 Nov 30];28:26-33. Available from: https://www.njssjournal.org/text.asp?2018/28/2/26/291236
| Introduction|| |
Delay in presentation and treatment of abdominal wall hernia, a common but neglected disease, has a long history, especially in Africa., In many developing nations, ignorance, sociocultural beliefs, and financial impediments contribute significantly in the delay, with attendant late presentations and life-threatening complications.,,, Unfortunately, in the course of the avoidable delays, the hernias attain voluminous sizes and continue to increase in size as the ages of the patients advance.,,
Available data from published clinical studies showed that the treatment outcomes of complicated hernias at the extremes of life are uniformly associated with poor results compared to results in other age groups., Combined with multiple comorbidities, delayed presentation especially in emergency setting makes management of abdominal wall hernias more tasking and hazardous in the elderly patients., The tri-phasic pattern of the delay has been observed in Africans: delay before onset of complications, delay from onset of complication to initial presentation to a surgeon (including delayed referral from private or general hospital), and finally the in-hospital delay from operation waiting time.,,,, Results from several series indicate that the morbidity and mortality spectrum of surgical repairs of neglected, longstanding, voluminous, or complicated hernias are grievous across all ages compared with early repairs of uncomplicated small hernias.,,, In the classic manner, many congenital inguinoscrotal, inguinolabial, and primary midline ventral hernias remained overlooked till young adult age and/or middle age or even beyond, before presentation.,, At the time of first hospital contact, the hernias may be incarcerated, obstructed, strangulated, perforated, and, occasionally, presentation with spontaneous rupture of anterior abdominal wall with gut evisceration and/or external fecal fistulae may occur.,,, Even in the absence of these complications, delayed presentation of external abdominal wall hernias is associated with more troublesome postoperative aftermaths due to large sizes of the hernias and the concurrent comorbid illnesses in the older patients., In the past, strangulated external hernia accounted for half the cases of intestinal obstruction worldwide., However, this trend has changed, allowing obstruction from postoperative adhesive bands and in some series tumors to take over.,
In Kumasi, Ghana, Ohene-Yeboah examined 120 adult patents with strangulated external abdominal wall hernias and determined that the danger is not in the operation, but in the delay. In that series, bowel resection was done in 54% of those who had surgery 48–72 h after the onset of complication, but in only 10% of those that received operative treatment within 12 h of hernia complications. From the above figures in a neighboring country in the West African sub-region, the situation in Nigeria is not likely to be very different. Moreover, published data on this subject in our own locality are scanty and poorly documented. Therefore, a study aimed at the evaluation of the magnitude of morbidity and mortality from delayed presentation of abdominal wall hernia in rural Southeast Nigerian is justified. This study aimed to determine the causes of delay in the presentation and treatment of complicated abdominal wall hernia as well as the outcomes of treatment in two rural hospitals in Southeast Nigeria.
| Patients and Methods|| |
Design and setting
This was a descriptive prospective study of all patients with complicated abdominal wall hernia recruited over a 3-year period from January 2016 to December 2018. This was a multicenter study involving two mission hospitals in Southeast Nigeria where all the patients were managed.
One hundred and thirty-eight adult patients with complicated abdominal wall hernias, aged 16 years and above, were seen, examined, and scheduled for emergency surgery. Consent was obtained from all the patients before they were recruited to participate in the study.
Each patient was evaluated clinically at the accident and emergency (A/E) units. The sociodemographic and relevant clinical data were extracted from each patient or the relatives and recorded. At the A/E department, all the patients were initially resuscitated, investigated, and counseled properly before operative repair was done. The duration and reasons for delay before and after the onset of complications and the theater waiting time were recorded in a standard pro forma. Twelve patients had spontaneous reduction at A/E and were later scheduled for elective repair. Each patient was evaluated by a specialist anesthetist and planned for appropriate technique. The 12 patients who had spontaneous reduction and scheduled for elective repair were counseled for mesh implants (all harbored inguinoscrotal, recurrent or bilateral hernia). Only those who could not afford the cost of mesh implants were treated without mesh. Patients at moderate-to-high risk of deep-vein thrombosis (DVT) were commenced on DVT prophylaxis postoperatively. Basic and some special investigations (x-ray, serum electrolytes, urea and creatinine and blood sugar) were done preoperatively and patients worked up accordingly.
Intraoperatively, the nature (direct or indirect) of the hernia, defect size, the content, the state of the bowel (obstructed, strangulated, gangrenous, and perforated) were noted and recorded. A tube drain was inserted when indicated. Skin sutures were removed on the 10th–14th day postoperative day. Available patients were followed up for 24 months. Postoperative complications and length of hospital stay were noted and recorded.
Statistical data analysis
Data were analyzed using Statistical Package for Social Sciences software version 22.0 (IBM, Chicago, IL, USA, 2015). Descriptive statistics were employed to calculate categorical variables such as percentages. The results were presented in tables. Mean and standard deviation were used to summarize continuous variables. Where appropriate, Chi-square test was used to test for the level of significance of the variables. Confidence interval was calculated at 95% level and significance at 5% probability level (P < 0.05).
The proposal for this study was approved by the research and ethical committee of both hospitals before commencement of the study. All research principles relating to studies on human subject were adhered to during the study.
| Results|| |
During the 3 years period under consideration, a total of 138 patients with complicated abdominal wall hernias were managed surgically, representing 23.4% of the entire 590 abdominal wall hernias encountered. Patients with inguinal hernias comprised 76.1% (449) of the total abdominal wall hernias. The 138 patients with complicated abdominal wall hernias formed our study population. There were 117 males and 21 females, giving a male-to-female ratio of approximately 6:1. The ages of the patients ranged between 16 and 85 years, with a mean of 46.51 ± standard deviation 17.20.
Of the 138 patients with complicated cases, there were 103 (74.6%) patients with inguinal hernias and of these, 61 (59.2%) were strangulated at the time of presentation [Table 1]. There were 12 (11.7%) patients with bilateral inguinal hernias and of the remaining 91 unilateral cases, 66 (64.1%) were on the right and 25 (24.3%) on the left. Patients with inguinoscrotal hernias comprised 69.9% (72) of the entire patients with inguinal hernias, and the rest (31, 30.1%) harbored bubonoceles. Of the 138 patients, 17 (12.3%) harbored recurrent hernias, whereas 121 (87.7%) had primary hernias.
At the time of presentation, all the 138 patients had abdominal pain and irreducible abdominal mass. The other clinical features that were recorded at presentation are shown below [Table 2]. Before the onset of complications, 103 (74.6%) patients had lived with their hernias for more than 1 year and only nine (6.5%) patients gave a short history, lasting between 1 and 3 months. More than half (75, 54.3%) harbored the hernia more than 2 years before the complications developed; up to 39.9% (55) harbored their hernias 5 years or more before the onset of complications.
Only 25 (18.1%) patients presented within 24 h following the onset of complications, 34 (24.6%) presented between 24 and 48 h, 40 (29.0%) presented between 49 and 72 h, and the rest (39, 28.3%) waited till after 72 h from the onset of complications before presentation to the hospital. At the hospitals, waiting time before operation was significantly prolonged, mainly due to resuscitation time and other hospital bureaucratic bottlenecks. The waiting time was 0–12 h for 15 (10.9%) patients, 13–24 h for 32 (23.2%) patients, 25–48 h for 54 (39.1%) patients, and >48 h for 25 (18.1%) patients. All (100.0%) the deaths occurred in those who had delay more than 24 h before surgical intervention. Twelve (8.7%) patients had spontaneous reduction and later scheduled for elective repair in the next operation list. All the patients who had spontaneous reduction harbored hernias that were inguinoscrotal, bilateral, or recurrent. The various barriers to early presentation ranged from financial constraints, fear of surgery through alternative home treatments, to long distance between home and hospital [Table 3].
The impact of multi-step delay (duration of complication before presentation and waiting time before operation) on the intestinal resection rates, morbidity, and mortality is shown below [Table 4]. Thirty-six (26.1%) patients had comorbidities, but some had two or more comorbidities leading to a total of 69 comorbidities. The comorbidities were hypertension (26, 37.7), diabetes mellitus (8, 11.6%), benign prostatic hyperplasia (10, 14.5%), chronic obstructive pulmonary disease (6, 8.7), and obesity (7, 10.1). Urethral stricture, chronic liver disease, cardiac disease, chronic kidney disease, HIV/AIDS, and tuberculosis accounted for less than a fifth (12, 20.3%) of the 69 comorbid illnesses recorded.
|Table 4: Effects of delay (before presentation and waiting time) on bowel resection and morbidity and mortality rates|
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The postoperative morbidities are shown below [Table 5]. Approximately half (70, 50.7) of the patients stayed more than 7 days after operative repair mainly due to wound infections, intra-abdominal collections, anastomotic leakage, and comorbidities. Nineteen patients died in the peri-operative period, giving a mortality rate of 13.8%. Majority of the death occurred in those operated after 72 h (14, 73.7%) and between 49 and 72 h (four, 21.1%). All (19, 100.0%) the deaths occurred in those who had bowel resection.
| Discussion|| |
Majority of the patients in this series were males (84.8%), harbored inguinal hernias (74.6%), and presented later than 24 h (81.9%) after the onset of complications principally due to financial impediments and treatment at alternative homes. Worldwide, delayed treatment of abdominal wall hernia is a known cause of high morbidity and mortality.,,, The fact that about one-third (47, 34.1%) of the patients in this series were aged above 50 years and more than a quarter (36, 26.1%) had comorbidities made the surgical treatment of the patients more challenging. The relationship between advancing age and comorbidities has been highlighted and synergistically, both commonly lead to diminished physiologic reserve and predilection toward strangulation and/or gangrene.,, Perhaps, the associated comorbidities, high proportion of aging patients and prolonged delay after onset of complications compromised the outcomes in this study. Nevertheless, the current review provided a unique opportunity to evaluate the causes of delay in presentation and long operation waiting time in patients with complicated abdominal wall hernias in our environment and the poor outcomes associated with such delays.
In this series, the frequency of complicated hernias is six folds more common in males than females. Another important observation is the inguinal hernia preponderance (74.6%), which has been highlighted in previous studies.,,,, It has been reported that the persistently raised intra-abdominal pressures may increase the risk of strangulation of often enormous, longstanding inguinal hernias (due to downward disposition of the hernias), which, in the setting of regular strenuous activities, may explain the higher prevalence of strangulation in men.,, Moreover, inguinal hernias, the most common form of abdominal wall hernias, are more common in males due to congenital processus vaginalis that transmits the testes and cord in the embryonic period.,,,
In the current report, abdominal pain (98.6%) and irreducible abdominal mass (100.0%) remained the most frequent modes of presentation akin to observation from a semi-urban hospital in Ile-Ife, Nigeria. Sanjay et al. had similar experience in India and found that 100.0% of their patients managed for complicated groin hernias had both irreducibility and abdominal pain at the time of presentation. In a UK series, however, irreducibility (67.3%) came after abdominal pain (80.0%), in a review of 55 adult patients with emergency presentation of abdominal wall hernias. Critical analysis of the UK review showed that up to 29.0% (16 patients) of the patients were assessed and discharged by the surgical team due to insufficient clinical data to support hernia complication that required urgent surgical intervention. This subset of patients who were not considered for further assessment, but whose presenting features were recorded earlier, probably accounted for lower irreducibility rate reported by the authors.
The multi-staged delays that characterized the presentation and management of the patients in this series overlapped with results obtained from previous studies,,,,, and partly explained the poor treatment outcomes recorded. It is noteworthy that approximately three-quarter (74.6%) of the patients harbored their hernia at uncomplicated phase for more than 1 year without consulting a doctor, while more than a third (39.9%) had lived with their hernias for more than 5 years before complications developed. Late presentation of patients with hernias is common in Africa and has led to the development of voluminous hernias, loss of work hours due to the hernia, and heightened morbidity and mortality rates when the hernias are repaired emergently.,,,,
It has been shown that due to a longstanding history of inguinal hernia commonly observed in Africans, presentation during bubonocele and funicular stages is uncommon, rather late presentation with giant inguinoscrotal or inguinolabial hernias and some presenting for the first time with strangulated or obstructed hernia remained the usual finding., Delayed presentation after development of complication is two pronged, the first is patient related and the second is surgeon or hospital related. Time lost in hours is a critical index when complication is established, and sequelae with or without surgical treatment correlate with the duration of the complication before surgical intervention or before death occurred (for those that die before surgical operation).,,,,,, Unlike the precomplication stage, the of complication is the stage of visceral or omental entrapment at the hernia site and its degree is influenced by duration of entrapment, comorbidities, age of patients and complexity of the hernias (inguinoscrotal/inguinolabial or multiple hernias).,, Curiously, nearly half (38, 48.1%) of the 79 patients who presented after 48 h from the time of onset of complications have had their hernias progressed to strangulation compared to a strangulation rate of 4.0% in those admitted within 24 h of the onset of hernia complication. We also determined that 77.8%% (28) of the 36 patients that had bowel resection were operated after 72 h from the time complication developed; they either had significant delay before presentation to hospital or the delay was due to operation waiting time or both [Table 4]. Similarly, the resection rate was 0.0% among those that had surgery within 24 h of hernia complications, but rose steadily in the following 24–72 h, and became 43.1% after 72 h [Table 4].
In a referral hospital in Kumasi, Ghana, it was observed that 54.0% of those with strangulated external abdominal hernias who presented after 48 h had bowel resection, compared to 10% resection rate in those examined within 12 h of onset of complication. Mortality occurred at the rate of 9.7%, 12.2%, and 27.2% in those presenting 13–23 h, 24–47 h, and 48–72 h, respectively, after the onset of abdominal wall hernia complications. From the foregoing, it is a fact of life, therefore, that across many communities in Africa, late presentation of patients with abdominal wall hernias is common and associated with dangerous mortality and morbidity rates.
In this series, the operation waiting time at the stage of in-hospital management added to the difficulty that increased the overall operative morbidity and mortality. Our finding that nearly three-quarters (14, 73.7%) of deaths occurred in those who waited beyond 72 h before surgical intervention agrees with data culled from Ghana, Nigeria, Tanzania, and India.,,, Indeed, the danger is not in the operation, but in the delay, and many investigators have observed that such delays increase the risk of gangrene requiring bowel resection, thereby increasing operative morbidity and mortality.,,,,,
In a developing economy, there is great unmet surgical need and a major gap in knowledge related to surgery. In low -and middle-income countries (LMICs), surgical output is significantly limited by access; at the point of care, access is influenced by workforce, infrastructure, and patient-related factors and at the structural level by the organization of health systems. In most LMICs, access to safe surgery is hindered at both the point of care and the organization level. Sequel to this observation, late presentation of patients with hernias is commonplace in LMICs, creating a backlog of longstanding, neglected hernias; some of them become complicated and require emergent surgical intervention.,,, The barriers to early presentation adduced by patients in this study were legion [Table 3], but majority could be overcome through public enlightenment campaigns, functional national health insurance scheme (NHIS) program, facilitated specialist consultations, and construction of asphalt-based ring road networks to ease transportation. Ohene-Yeboah and Dally appeared to be in agreement with the above when they noted that, whatever the reasons for adult males in Kumasi and beyond walking around with large untreated inguinal hernias, the ability of the existing health-care system to identify and address these reasons or barriers constitutes a measure of good performance and efficiency. Nevertheless, there is a view that the efficiency of a health service is the extent to which it is capable of reducing preventable emergencies, of which abdominal wall hernia complication is a very good example.
In this discourse, financial impediment constituted the single-most important barrier to early management of complicated abdominal wall hernias at the pre- and in-hospital phases of the condition. However, the crux of the matter with abdominal wall hernias in our environment lies with low elective repair rates and subsequent pool of neglected, often voluminous hernias that may present emergently. Indeed, it is worrisome that 23.4% of all abdominal wall hernias repaired during this survey were performed for strangulation, obstruction, or incarceration. In addition to financial constraint, other barriers such as treatment at alternative homes, long distance between home and hospital, theater logistics, anesthetic cancellations, and other sociocultural practices were prominent in this review. Published clinical data from Tanzania, Sierra Leone, Ghana, and Malawi support the above findings.,,, In a population-based study in which participants completed an interviewer-administered questionnaire to determine the knowledge, attitude, and practices regarding inguinal hernia disease in Ghanaian males, 62.0% knew that a medical doctor can cure the hernia, however, 38.0% believed that a herbal or traditional practitioner can also cure the hernia. More so, of those who chose to see a doctor, only 33.3% expected to have surgical operation, the remaining 66.7% would prefer some form of nonsurgical treatment as surgery was considered too expensive or unsafe. Men who failed or delayed to seek medical advice cited high cost of surgery (48.8%), fear of death from anesthesia or fear of subsequent impotence or fear of complications (32.7%), preference for traditional treatment (12.8%), and long waiting time at hospitals (5.7%) as the reasons for their health-seeking behavior.
In Malawi, critical steps of training and certification of nonphysician clinicians have been adopted to upscale performance of common procedures such as cesarean section and hernia repairs in district hospitals where there is a dearth of trained surgeons. Although some researchers have questioned the effectiveness and safety of this response, the authors affirmed that it was born out of necessity to provide essential emergency and elective surgical services to the rural dwellers at the district level; otherwise, long distance from central hospitals would preclude these surgical services.
In Zaria, Nigeria, the causes of prolonged waiting time for emergency abdominal surgery in 398 patients were subdivided into interval between presentation and first contact with emergency room doctor (T1), time from contact to decision to operate (T2), time taken to resuscitate (T3), and time to commence operation (T4). Majority (53.8%) of the delays were due to financial constraint followed by delayed investigation results (24.1%). The authors concluded that the main constraints were poverty and institutional organizational problems.
Patel et al. published a review of barriers to surgical repair of groin hernia in Sierra Leon, from a series comprising predominantly of farmers and artisans living in rural area. Some of the key impediments to early presentation and elective repair of hernias identified by the authors were financial constraints, fear of an operation, no time for health care, no need for surgery, and nonavailability of health personnel or facility, in agreement with the results from this series and report from Tanzania.
The gold standard for the treatment of complicated abdominal wall hernias is operative repair. Surgery performed at auspicious times by a surgeon, especially a surgeon with interest in hernia repair, is gainful and has been shown to positively influence the outcomes of surgical repairs.,, It is an acceptable practice to attempt reduction of complicated hernia at the time of first contact with the patient, provided there are no features suggestive of strangulation or gangrene. When reduction is achievable, it can be tried and when successful, the operation is deferred till the next elective operating day, thereby converting a potentially emergency operation to an elective procedure with better peri-operative profile. We achieved a reduction rate of 8.7% (12 patients), which enabled prosthetic mesh implants to be used in 58.3% (seven patients) of them.
The complications recorded in this series were mostly related to the septic process (wound infection, intra-abdominal abscess, and respiratory infection), extent of surgical intervention (visceral injury, scrotal hematoma, and seroma), method of repair (recurrence), and multi-faceted causes (burst abdomen, entero-cutaneous fistulae, and chronic groin pain). The mortality rate of 13.8% documented in this study agrees with a value of 11.8% quoted in Kumasi, Ghana. In Ile-Ife, Nigeria, however, the mortality rate was 2.7%. The lower rate in Ile-Ife may be partly explained by the higher spontaneous reduction rate of 21.0%, which is far higher than the value of 8.7% obtained in this study. Curiously, no death or recurrence was recorded in a Western series comprising 43 patients managed for strangulated inguinal hernia. Stitch granuloma and superficial wound infection occurred in one and three patients, respectively. The differences in the operative outcomes of this series and ours were principally due to early presentation and prompt operative intervention in the Western series.
This study is limited by low adherence to follow-up after surgical repair as we found that nearly half (67, 48.6) of the patients dropped out from follow-up after 1 year. This affected our data on postoperative aftermaths. Another important limitation is the lack of enthusiasm by patients to volunteer accurate medical history probably due to fear of being reprimanded for presenting late or an intentional plot to attract sympathy and evade high medical bills. Five of our patients denied that they have been aware of the presence of abdominal swellings, but their history was not corroborated by close relatives who volunteered the correct information. The emergency nature of the presentation could have affected the accuracy of history given by those five patients as some of them would have been distracted by pain. Adesunkanmi et al. in Ile-Ife, Nigeria, observed that some of their cohorts failed to volunteer the history of irreducible groin swelling until asked or discovered during clinical examination and few patients denied that they were aware of their hernias before complication started akin to observations made in the index study.
| Conclusion|| |
In Nigeria, especially rural areas that appear to have been significantly marginalized in terms of health infrastructure, elective repair of abdominal wall hernia should be up scaled to avert emergency presentation and attendant high morbidity and mortality. The health-care system in Nigeria should increase the coverage of NHIS and provide necessary infrastructure and improve the human capacity in the rural and urban centers to cope with the hernia burden that is endemic in our country.
I acknowledge the technical support from the management of both hospitals. I also express my gratitude to the medical officers in the hospitals for their assistance during data acquisition.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]