|Year : 2020 | Volume
| Issue : 3 | Page : 73-79
Prosthetic implants in abdominal wall hernia repair: A work in progress in South East Nigeria
AU Ogbuanya1, CV Enemuo2
1 Department of Surgery, Alex Ekwueme Federal University Teaching Hospital; Department of Surgery, Ebonyi State University, Abakaliki, Ebonyi State, Nigeria
2 Department of Surgery, Alex Ekwueme Federal University Teaching Hospital, Abalaliki, Ebonyi State; Department of Surgery, University of Nigeria, Enugu Campus, Nigeria
|Date of Submission||29-May-2020|
|Date of Acceptance||27-Mar-2021|
|Date of Web Publication||07-Aug-2021|
Dr. A U Ogbuanya
Department of Surgery, Alex Ekwueme Federal University Teaching Hospital, PMB 102, Abakaliki, Ebonyi State
Source of Support: None, Conflict of Interest: None
Background: Globally, the demand for proper surgical services is on the increase, and subsequently, the need to universally adopt mesh implants for tensionless prosthetic repairs has become expedient. The hallmark of tension-free repair is the lower short- and long-term recurrence rates compared to suture-based techniques. The aim of this study was to document our early experience with the use of mesh in abdominal wall hernia repair.
Patients and Method: This was a prospective study of all adult patients with abdominal wall hernias treated with mesh implants from January 2009 to December 2015. Recurrence, bilaterality, inguinoscrotal or inguinolabial status and voluminous sizes were the main factors considered.
Results: A total of 110 patients with abdominal wall hernias had mesh implants repair. There were 66 (60.0%) males and 44 (40.0%) females. Majority (56.4%) were inguinal hernias followed by incisional hernias (20.9%). Of those with inguinal hernias, eight (12.9%) had bilateral hernias, 30 (48.4%) had primary inguinoscrotal hernias while 14 (22.6%) had recurrent inguinoscrotal hernias. Nearly a third (31.8%) of the entire patients had recurrent hernias. Nearly a third (31.8%) of the entire patients harbored recurrent hernias. Majority (82.7%) of the patients presented after 1 year of onset of the hernias. The overall complication rate was 12.7% and over 81% were discharged home by the 4th post-operative day. No recurrence or mortality was recorded.
Conclusion: The use of mesh implants to repair abdominal wall hernias in our environment is safe and effective. Most of the challenges relating to the acceptance of mesh, comorbid conditions and post-operative complications can be minimized through discussions and facilitated consultations.
Keywords: Abdominal wall reconstruction, post-operative morbidity, prosthetic hernia repair, surgical wound complication
|How to cite this article:|
Ogbuanya A U, Enemuo C V. Prosthetic implants in abdominal wall hernia repair: A work in progress in South East Nigeria. Arch Int Surg 2020;10:73-9
| Introduction|| |
Abdominal wall hernias are very common worldwide and represent a leading cause of morbidity and mortality in various parts of Africa.,,, Repairs of these hernias remain the oldest and commonest operations performed by general surgeons all over the world.,, Debate on the optimal repair method has continued over the years. Globally, the demand for proper health care is on the increase, and with time, the expectation of the quality and capacity of medical treatments has subsequently risen to bridge the gap between innovative technology (prosthetic mesh) and medieval treatment approaches.,
In the past, the legendary Bassini technique for inguinal hernias and a myriad of suture-based methods for other abdominal wall hernias constituted the gold standard for hernia repair worldwide, but the trend has changed in the industrialized nations largely due to the discovery of the more efficient tensionless repair with prosthetic meshes., However, in many parts of developing nations, especially sub-Saharan Africa, the utilization of non-mesh methods to repair abdominal wall hernias remain popular, even with hernias that have multiple prognostic indicators of early treatment failure or high recurrence index.,, The predominant reason for the above is the insufficient surgical and financial capacity to replace the Bassini and other suture-based methods with laparoscopic and prosthetic mesh repair.
Regrettably, most hernias in Africa are voluminous, requiring mesh for tension-free repair, but these prosthetic implants are often unavailable or unaffordable for most hernia patients in our resource-limited setting.,, The positive outcome measure in terms of lower short- and long-term recurrence, lesser post-operative pain and earlier return to work are the major attributes why prosthetic mesh repair is preferred to anatomic tissue-based repair techniques.,
Interestingly, the flavor of utilizing a prosthetic implant to repair abdominal wall hernias was rekindled in Africa and other developing nations by the European-led hernia aid workers who introduced sterilized mosquito net mesh as a useful alternative to standard commercial mesh., Warwick and colleagues, working under 'Operation hernia' program in Africa, reported on a large series of 1,748 consecutive patients with inguinal hernias from Nigeria, Ghana and Ivory Coast recruited over a five-year period. In their report, it was highlighted that the positive results of Lichtenstein repair are reproducible in Africans and stressed on the need to train the local surgeons and trainee surgeons in the technique described by Lichtenstein. In summary, complications occurred in only 1% of the repairs prompting the authors to recommend that it is safe to use mesh in Africans provided the surgeon has adequate experience and the level of sterility during the procedure is high.
Despite the documented safety and excellent post-operative profile of mesh hernia repair in the western communities and some parts of the developing nations including Nigeria, few surgeons have shown enthusiasm toward the use of mesh for hernia repairs in our center and this has led to scanty data on this repair method in Southeast Nigeria. The aim of this study was to document our early experience with the use of mesh in abdominal wall hernia repair in our institution.
| Patients and Method|| |
Design and setting
This study was a prospective descriptive study of all consecutive abdominal wall hernias repaired with mesh in our center from January 2009 to December 2015. One hundred and ten consecutive adult patients in the specialist surgical outpatient clinic of our hospital with abdominal wall hernias were scheduled for elective mesh repair. Patients aged 16 years and above and who harbored the following hernia types were included (a) inguinoscrotal or inguinolabial hernia, (b) recurrent hernia, (c) large ventral hernia (defect ≥4.0 cm), (d) bilateral groin hernia and (e) multiple ventral hernia. Patients who failed to give consent or those with complicated hernias, massive ascites, metastatic intra-abdominal tumors, incapacitating comorbid conditions and intra-abdominal or abdominal wall sepsis were excluded from the study. Informed consent was obtained from all the patients before they were enrolled into this study.
All consecutive patients with anterior abdominal wall hernias who presented during the 7- year period of the study were noted, but only those who fulfilled the inclusion criteria were further evaluated and counseled for prosthetic mesh repair. However, only 110 patients accepted and gave consent for mesh implantation and they form our study population. Each of the 110 patients was assessed clinically; the socio-demographic and detailed clinical data were recorded and entered into a proforma. Pre-operatively, patients were optimized according to needs. Consent for the operation was routinely obtained. Following appropriate skin incision, dissection down to the fascial plane using both instruments and diathermy approach was done, exposing the sac when present. The hernia sac contents and defect sizes were noted and recorded.
Using midline ventral and inguinal hernias as prototypes to describe the surgical procedures performed, dissection along the subcutaneous-fascia plane was continued laterally until at least 4 cm from the medial edges of the hernia defect was ensured. Subsequently, a polypropylene mesh of size ranges 7.5 cm × 15 cm through 15 cm × 15 cm to 30 cm × 30 cm was re-fashioned according to the size of the hernia defect and implanted in the onlay fashion using nylon 2/0 sutures to anchor it. Tube drain (urine bag) was inserted in those with extensive dissection in anticipation of post-operative seroma formation. Duration of the follow up ranged from 6 months to 11 years. Available patients were followed up for further 4 years after the end of the study in 2015 (till December 2019).
Data were analyzed using Statistical Package for Social Sciences (SPSS) software version 22.0 (IBM, Chicago, IL, USA, 2015). They were presented as mean, standard deviation, percentages and tables. 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 our hospital before commencement of the study. All research principles relating to studies on human subjects were adhered to during the study.
| Results|| |
During the period under survey, 725 (16.5%) patients with abdominal wall hernias out of a total of 4,400 general surgical patients were seen. But over three-fourths (77.2%, 560 hernia patients) harbored hernias that were deemed high risk for early recurrences after operative repair. These 560 patients were counseled for mesh repair, but only 19.6% (110 patients) ultimately received mesh implants. Financial constraints and fear of foreign body being implanted permanently in the body were the main reasons for low mesh uptake in this study. The patients whose hernias were repaired with meshes formed our study population. The ages of the patients ranged from 20 to 72 years with a mean of 43.41 ± SD 14.62. Majority (36.4%) of the patients were traders, followed by farmers (23.6 %), professionals (13.6%), artisans (10.0%), civil servants (9.1%), students (2.7%) and others (4.6%).
Majority (56.4%) of the patients had inguinal hernia followed by incisional hernia (20.9%). Patients with uncommon hernias like spigelian, femoral and lumbar made up 2.7% of the entire study population [Table 1]. Eight patients (7.3%) had bilateral inguinal hernias (six patients with primary bubonoceles and two with recurrent bubonoceles), making a total of 118 abdominal wall hernias in 110 patients. Thirty (27.3%) patients had primary inguinoscrotal hernias while 14 (12.7%) had recurrent inguinoscrotal hernias. The other clinicopathologic features of the hernias that formed the basis for selection in this study are shown in [Table 2]. The yearly incidence of the various hernias and mesh repair rates showed that 80.0% of the patients had mesh repairs in the last 3 years of the study [Table 3].
A negligible 3.6% of the patients presented within 6 months of noticing the hernia while 82.7% of the patients waited for more than 1 year before presenting to the specialist hernia clinic. Majority (92, 83.6%) of the patients had abdominal discomfort or pain associated with reducible hernias as the main symptom of their hernias [Table 4]. Nearly a third (31.8%) of the patients had recurrent hernias; two patients with recurrent bubonocele harbored bilateral hernia, giving a total of 37 recurrent hernias. Thirty-one (28.2%) patients had comorbidities. Some patients had two or more comorbid illnesses giving a total of 43 comorbidities. The comorbidities included hypertension (4), obesity (9), diabetes mellitus (4), chronic obstructive pulmonary disease (4), resolved hypertensive cardiac failure (2), human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (1), benign prostatic hyperplasia (6) and tuberculosis (1).
Anesthesia and surgical treatment
Majority (59.1%) of the patients were operated under general anesthesia. However, spinal anesthesia was the most frequent anesthetic technique for inguinal hernias (37, 59.7%), followed by general anesthesia (32.2%); the rest (5, 8.1%) were repaired under local infiltrative anesthesia. Majority (91.3%) of the incisional hernias were repaired under general anesthesia; the remaining two (8.7%) patients with infra-umbilical incisional hernias were operated under spinal anesthesia. All the repairs performed for inguinal hernias were done in the Lichtenstein fashion. For the other hernia types, onlay mesh repair method was utilized. Open approach was used in all the repairs.
Outcomes of surgical repair
The overall complication rate was 12.7%. No patient with bilateral hernia repair had complication on both sides. All, except one of the two secondary hydroceles, were managed conservatively. Over four-fifths (90, 81.8%) were discharged home within the fourth post-operative day. Only four (3.6%) patients stayed on admission beyond the seventh post-operative day mainly due to wound infections and stabilization of those who had acute exacerbation of medical illnesses. Sixteen (14.5%) stayed for 4-7 days after surgery. There was no mortality recorded and no recurrence was observed during the follow up period [Table 5]. Generally, 100.0% (110), 92.7% (102), 61.8% (68), 44.5% (49) and 29.1% (32) of the patients were available for follow up at 6 months, 1 year, 2 years, 5 years and 10 years, respectively. At the end of data collection for this first series in December 2015, follow up was continued for additional four.
| Discussion|| |
Abdominal wall hernias constitute a significant proportion of workload in general surgical practice worldwide. Globally, they account for 12-18% of general surgical procedures,, consistent with a figure of 16.5% observed in this series. In Asia, Mukesh and colleagues recorded a value of 22.0% following assessment of 320 unselected patients with abdominal wall hernias. The authors ascribed this higher rate of hernia in the general surgical output of their institution to high prevalence of patient-related risk factors like smoking, obstructive urinary disease and farming activities. Moreover, both pediatric and adult hernias were included. This difference in study design has a tendency to increase the hernia rate in the Asian series since many congenital inguinoscrotal, inguinolabial and primary midline ventral hernias were encountered and reported.
An important observation was the low proportion of elderly patients in this series (five patients, 4.5%) compared to a rate of 14.6% in Ibadan, Nigeria. In Zaria, Nigeria, 16.9% of the entire patients were aged 60 years and above corroborating with the results from Ibadan. These findings, perhaps, suggest an increased acceptance of prosthetic mesh implants among younger patients compared to older cohorts. Patients in this study were selected based on multiple factors that confer increased risk for recurrence after operative repair as well as on the basis of cosmetic disadvantages created by the presence of recurrent or large incisional, midline ventral and inguinoscrotal or inguinolabial hernias. These selection criteria probably influenced younger patients to accept prosthetic mesh repairs because they are more sensitive to their physical appearance, are more active and economically more productive. In Ibadan and Zaria, both in Nigeria, the patients were not selected by hernia characteristics and mesh repair was either not utilized at all (Zaria) or used in a proportion of the patients (Ibadan).,
Indeed, the adverse clinical parameters that formed the basis for recruitment in this study [Table 3] and [Table 4] were numerous and epidemiologically striking. The high rates of recurrent and voluminous hernias recorded in this series are worrisome and indicate a system with inefficient surgical services and an elective repair rate too low to meet the demand of a high hernia burden in our environment. Published data derived from hernias repaired under Plymouth Hernia Service, United Kingdom and Ghana, Africa, showed that 67.0% of the Ghanaian hernias extended into the scrotum compared with 6% in the UK group. Similar to our findings with respect to late presentation, the authors also determined that 85% of the Ghanaian inguinal hernias were present for more than 1 year, and of those, 37% had been present for more than 5 years. Literatures culled from Africa indicate that a quantum of these hernias were harbored for over 25 years before presentation.,,
It has been reported that inguinal hernias in Africa are voluminous, neglected, and that patients commonly present late with hernia complications and comorbidities.,, In summary, voluminous hernias and late presentation of patients with abdominal wall hernias are phenomenal in Africa and express a need for policy changes and interventions by the government, health managers and surgeons with special interest in hernia.
A recent international guideline recommends the use of mesh for primary abdominal wall hernias defect >2 cm, or those less than 2 cm but are recurrent, bilateral or occur in obese patients. Nevertheless, in a bid to enhance acceptance of mesh implant, we selected patients with primary midline ventral hernia defect ≥4 cm, akin to the selection criterion used in Enugu, Nigeria. The low cumulative rate (19.6%) of mesh utilization for repair of hernias in this series is most worrisome, considering the fact that the remaining 450 (80.4%) out of the 560 patients who also satisfied the selection criteria were counseled for mesh placement, yet, it could not be offered to them due to funds and other socio-cultural factors. These barriers to mesh utilization in sub-Saharan Africa have been observed by other authors,,, though in Ghana, a multi-faceted approach to expand the capacity and efficiency of hernia repair was launched recently under the auspices of Ghana Hernia Society (GHS).
However, more patients accepted mesh repair in the course of this study [Table 2]. The progress in mesh utilization over the years was due to the persistent enlightenments on the imperativeness of prosthetic meshes for the large or recurrent or bilateral hernias by the current authors. The increased use of prosthetic material in ventral hernia repair in our center recently is salutary—a change in treatment policy pioneered by the authors of this work. In future, the yearly repair rates of abdominal wall hernias with meshes in Africa are likely to upscale, if cost and socio-cultural barriers are contained.,,
A recent publication showed ethnicity-related differences in inguinal canal dimensions between African and Caucasian population. The significantly smaller dimensions of the inguinal canal in African males make it possible to use smaller mesh implant and reduce the cost of surgery. Indeed, access to surgery in Africa is significantly limited and this has led to global clamor for initiatives to improve human resources, reduce cost of surgery and improve transportation and public health facilities in the continent.
In Egypt, similar observations were made. Mesh repair in adult umbilical and incisional hernias increased from 32% (umbilical hernia) and 34.6% inguinal hernia in 2002 to 63.8% (umbilical hernia) and 90.7% inguinal hernia in 2006, respectively. However, unlike the current study where the highest proportion of prosthetic implants were in those with inguinal hernia, mesh implants for inguinal hernia in Egypt were rather low between 2.0% in 2002 and 17% in 2006. The reasons for this discrepancy are twofold. First, patients in Egypt were not selected but included all consecutive adult patients which comprised small and asymptomatic inguinal hernias that might not have been considered for mesh implants. Second, the authors noted that umbilical and incisional hernias were the commonest hernias in females in their series. The higher (22.7%) prevalence of umbilical hernia in that series compared to a rate of 3-15% in general population was noteworthy and reasons adduced included early marriage and repeated pregnancies. These reasons, and the often-large sizes of incisional and umbilical hernias, arguably, may explain why mesh was used more frequently in these hernias than inguinal hernias. In a similar study in females in Ile-Ife, Nigeria, mesh was used in 84.6% of the incisional hernias and in only 28.8% of the adult inguinal hernias. These findings suggest that cosmetic appearance is a strong determinant of mesh acceptance in female patients with midline ventral hernias.
Majority of the early post-operative complications like wound infection, seroma, hematoma and hemorrhages were mild and managed conservatively. The bladder laceration was managed conservatively by urethral catheterization after repair. Reports from previous studies support these findings.,,, The 1.8% rate of chronic groin pain is comparable to the rate of 4.8% reported in Sokoto, Nigeria, though rates of 10-37% after laparoscopic and open prosthetic mesh repair have been reported., Mba has earlier suggested that the higher incidence of chronic groin pain in western literatures could be related to technical errors associated with open or laparoscopic mesh repair, but the low rate in the current series, where open mesh repairs were performed, does not support that observation. Rather, it may be explained by racial differences and differences in the length of follow up and levels of adherence to follow up by the patients in the various studies. In fact, it has been observed that the prosthetic mesh provides a dynamic and tension-free closure of the posterior wall of the inguinal canal, thus, reducing the risk of chronic pain and recurrence.
The attrition rate during follow up was significant, but telephone interviews minimized the communication gaps that were mostly engendered by dilapidated road networks, long distances of patients' homes from hospitals, poverty, ignorance and incessant industrial disputes in the health sector. On a happier note, no recurrence was recorded during follow up. This study was limited by the negative attitudes toward follow up appointments in our environment. Overall, 92.7% (102), 61.8%(68), 44.5% (49) and 29.1% (32) of the patients were followed up systematically at 1 year, 2 years, 5 years and 10 years, respectively.
In conclusion, the use of mesh implants to repair voluminous and recurrent abdominal wall hernias in our environment is worthwhile and safe. Most of the challenges relating to acceptance of mesh, comorbid conditions, anesthetic maneuvers and operative complications can be reduced to manageable levels if adequate discussions and facilitated consultations among relevant health teams are performed pre-operatively. The pressing need for national health insurance for all in developing countries and other relevant advocacies and interventions by both government and non-government organizations cannot be overemphasized.
We acknowledge the technical support from the board of consultants, general surgery section of our institution.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ayandipo OO, Afuwape OO, Irabor DO, Abdurrazzaaq AI. Adult abdominal wall hernia in Ibadan. Ann Ib Postgrad Med 2015;13:94-9.
Mba N. Morbidity and mortality associated with inguinal hernia in Northwestern Nigeria. West Afr J Med 2007;26:289-92.
Ogbuanya AU, Emedike SC. Elective repair of uncomplicated inguinal hernia in South Eastern Nigeria. Asian J Med Sci 2015;7:90-5.
Mabula JB, Chalya PL. Surgical management of inguinal hernias at Bugando medical centre in Northwestern Tanzania: Our experiences in a resource-limited setting. BMC Res Notes 2012;5:585.
Stewart B, Khanduri P, McCord C, Ohene-Yeboah M, Uranues S, Rivera FV, et al
. Global disease burden of condition requiring surgery. Br J Surg 2014;101:e9-22.
Ohene-Yeboah M, Abantanga FA. Inguinal hernia disease in Africa: A common but neglected surgical condition. West Afr J Med 2011;30:78-83.
Oribabor FO, Amao OA, Akanni SO, Fatidinu SO. The use of non-treated mosquito net mesh cloth for a tension free inguinal hernia repair: Our experience. Niger J Surg 2015;21:48-51.
] [Full text]
Warwick A, Oppong C, Boatong DB, Kingsnorth A. Inguinal hernia repair is safe in Africa. East Cent Afr J Surg 2013;18:14-7.
Croitoru C, Stanek A. Far away from NHS – Hernia surgery in Nigeria and Kenya. Ulster Med J 2018;87:11-6.
Sangwan M, Sangwan V, Garg M, Mahendirutta P, Garg U. Abdominal wall hernia in a rural population in India – Is spectrum changing? J Epid 2013;3:135-8.
Garba ES. The pattern of adult external abdominal hernias in Zaria. Nig J Surg Res 2000;2:12-5.
Sander DL, Porter CS, Mitchell KC, Kingsnorth A. A prospective cohort study comparing the African and European hernia. Hernia 2008;12:527-9.
Bougard H, Coolen D, Beer R, Folscher D, Kloppers JC, Koto MZ, et al
. HIG (SA) guidelines for the management of ventral Hernias. S Afr J Surg 2016;54:13-28.
Ezeome ER, Nwajiobi CE. Challenges in the repair of large abdominal wall hernias in Nigeria: Review of available options in resource limited environments. Nig J Clin Pract 2010;13: 167-72.
Ohene-Yeboah M. Challenges of inguinal hernia surgery in Ghana. Postgraduate Med J Ghana 2016;5:15-9.
Ammar SA, Ismail T. Abdominal wall hernias in Upper Egypt. A different spectrum. East Cent Afr J Surg 2008;13:109-14.
Olasehinde O, Etonyeaku AC, Agbakwuru EA, Talabi AO, Wuraola F, Tanimola AG. Pattern of abdominal wall hernia in females: A retrospective analysis. Afri Health Sci 2016;16:250-4.
Mitura K, Koziet S, Michal P. Ethnicity-related differences in inguinal canal dimensions between African and Caucasian populations and their potential impact on the mesh size for open and laparoscopic groin hernia repair in low resource countries in Africa. Videosurgmininv 2018;13:74-81.
Pierides GA, Panjanen HE, Vironen JH. Factors predicting chronic pain after open mesh based inguinal hernia repair: A prospective cohort study. Int. J Surg 2016;29:165-70.
Seck M, Cisse M, Sall M, Gueye M, Toure A, Thiam O, et al
. Open tension free repair of inguinal hernias. The lichtenstein technique. Advantages and limits in an African context: A retrospective study of 109 cases. Internet J Surg 2017;34:e52788.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]