Population-based rates of hernia surgery in Ghana

Structured hernia surgery training program for general practitioners in Rwanda - feasibility and evaluation

BACKGROUND

Hernias are among the most common surgical conditions worldwide, with significant prevalence in Africa. However, according to recent WHO statistics, Africa faces a critical shortage of trained surgeons. Structured surgical training programs are also scarce. Since 2016, Surgeons for Africa in collaboration with Operation Hernia have developed structured training course on hernia surgery specifically for surgeons in Rwanda. Due to the severe shortage of surgeons, a new initiative was launched in 2023 to train general practitioners (GPs) to support the country's surgical care needs. This study aims to assess the feasibility and effectiveness of these training programs for general practitioners.

METHODOLOGY

Six standardized questionnaires were used to evaluate the structured training program before, during, and after the one-and-a-half-week courses conducted in Rwanda. Both trainees and trainers completed the relevant evaluations. The results were anonymized, ummarized using descriptive statistics, and statistically analysed. Trainers also assessed the surgical competence of each participant at the end of the course.

RESULTS

Between 2023 and 2024, 47 general practitioners received hernia surgery training in several Rwandan hospitals. The course significantly improved both the theoretical knowledge and practical surgical skills of the participants. Of the 47 GPs, 22 were able to independently perform simple inguinal hernia surgeries after the training. Three were able to perform complex inguinal hernia repairs independently. 12 participants required minimal supervision, while 22 required full supervision.

CONCLUSION

This study confirms the feasibility and effectiveness of a standardized hernia surgery training program for general practitioners in Rwanda. The results demonstrate the rogramme's potential to address the surgical care gap by enabling GPs to perform basic hernia surgeries.

Breaking Barriers: Ensuring Gender Neutral Care on Short Term Surgical Missions

INTRODUCTION

Gender discrimination is prevalent worldwide in medical and surgical care. In the setting of short-term surgical missions (STSMs) conducted to address the global burden of surgical disease, patient selection raises ethical considerations regarding equitable distribution of limited clinical resources. The goal of this study was to examine if equitable distribution of operative care between male and female patients occurs in STSMs.

METHODS

The International Surgical Health Initiative (ISHI) is a US based nonprofit, nongovernmental organization. Records from surgical missions to Ghana (2014-2023) and Sierra Leone (2013-2023) were analyzed to evaluate for gender equity in inguinal hernia repairs, the most common procedure performed. A control group was created from a literature review inclusive of all studies of inguinal hernia repairs that included over 500 patients and patient gender.

RESULTS

The review of 26 studies, representing 3,239,043 patients, demonstrated a gender distribution of 13% female. In Sierra Leone 246 inguinal hernia repairs were performed between 2013 and 2023. 28 (11.4%) of the hernia repairs were in females, which was not significantly different from the control group (P = 0.45). In Ghana 150 inguinal hernia repairs were performed between 2014 and 2023. 12 (8%) of the hernia repairs were in females. This was not significantly different from the control group (P = 0.07).

CONCLUSIONS

This is the first study investigating the gender equity conducted within the context of humanitarian surgical outreach. Equitable patient selection is a paramount consideration in STSMs, particularly to address gender-related disparities in surgical care.

Are LMICs Achieving the Lancet Commission Global Benchmark for Surgical Volumes? A Systematic Review

INTRODUCTION

The Lancet Commission on Global Surgery (LCoGS) set the benchmark of 5000 procedures per 100,000 population annually to meet surgical needs adequately. This systematic review provides an overview of the last ten years of surgical volumes in Low and Middle- Income-Countries (LMICs).

METHODOLOGY

We searched PubMed, Web of Science, Scopus, Cochrane, and EMBASE databases for studies from LMICs addressing surgical volume. The number of surgeries performed per 100,000 population was estimated. We used cesarean sections, hernia, and laparotomies as index cases for the surgical capacities of the country. Their proportions to total surgical volumes were estimated. The association of country-specific surgical volumes and the proportion of index cases with its Gross Domestic Product (GDP) per capita was analyzed.

RESULTS

A total of 26 articles were included in this review. In LMICs, on average, 877 surgeries were performed per 100,000 population. The proportion of cesarean sections was found to be high in all LMICs, with an average of 30.1% of the total surgeries, followed by hernia (16.4%) and laparotomy (5.1%). The overall surgical volumes increased as the GDP per capita increased. The proportions of cesarean section and hernia to total surgical volumes decreased with increased GDP per capita. Significant heterogeneity was found in the methodologies to assess surgical volumes, and inconsistent reporting hindered comparison between countries.

CONCLUSION

Most LMICs have surgical volumes below the LCoGS benchmark of 5000 procedures per 100,000 population, with an average of 877 surgeries. The surgical volume increased while the proportions of hernia and cesarean sections reduced with increased GDP per capita. In the future, it's essential to apply uniform and reproducible data collection methods for obtaining multinational data that can be more accurately compared.

The global, regional, and national burden and its trends of inguinal, femoral, and abdominal hernia from 1990 to 2019: findings from the 2019 Global Burden of Disease Study - a cross-sectional study

BACKGROUND

Inguinal, femoral, and abdominal hernia repairs are the most common surgical procedure worldwide. However, studies on hernia disease burden are notably limited, in both developed and low-income and middle-income countries (LMICs). We investigated temporal trends in the incidence and prevalence of inguinal, femoral, and abdominal hernias at global, regional, and national levels in 204 countries and territories from 1990 to 2019 using data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019).

MATERIALS AND METHODS

Annual incident cases, prevalent cases, age-standardized incidence rates (ASIRs), and age-standardized prevalence rates (ASPRs) of inguinal, femoral, and abdominal hernias between 1990 and 2019 were extracted from the GBD 2019 study and stratified by sex, age, and location. Percentage changes in incident cases and prevalent cases, and the estimated annual percentage changes of ASIRs and ASPRs were calculated to quantify the trends in the incidence and prevalence of inguinal, femoral, and abdominal hernias. Data analysis for the present study was conducted from 15 June 2022 to 15 July 2022.

RESULTS

Globally, there were 32.53 million [95% uncertainty interval (UI): 27.71-37.79] prevalent cases and 13.02 million (10.68-15.49) incident cases of inguinal, femoral, and abdominal hernias in 2019, which increased by 36.00% and 63.67%, respectively, compared with 1990. Eighty-six percent of the incident cases were males, the male-to-female ratio was 6 : 1, and most patients were aged 50-69 years. India (2.45 million), China (1.95 million), and Brazil (0.71 million) accounted for more than one-third (39%) of the incident cases worldwide. From 1990 to 2019, the ASIR and ASPR showed a decreasing trend worldwide, except in Central Sub-Saharan Africa, which had an increasing trend in ASIR and ASPR.

CONCLUSION

The global incident cases and prevalent cases of inguinal, femoral, and abdominal hernias increased substantially from 1990 to 2019, with a heavier burden observed in males, older adults, and in LMICs such as India and China. In addition, the ASIR and ASPR increased substantially in Central Sub-Saharan Africa. More efforts are warranted for hernia management to reduce the burden of inguinal, femoral, and abdominal hernias, such as by providing safe hernia surgical treatment for males, older adults, and LMICs.

Prevalence, incidence, repair rate, and morbidity of groin hernias in Sierra Leone: cross-sectional household study

BACKGROUND

Knowledge about the prevalence of groin hernias in sub-Saharan Africa is limited. Previous studies have demonstrated a higher incidence of the condition than the annual repair rate. This study aimed to investigate prevalence, incidence, annual repair rate, morbidity, and health-seeking behaviour of persons with groin hernias in Sierra Leone.

METHODS

This population-based, cross-sectional household survey on groin hernias in Sierra Leone was part of the Prevalence Study on Surgical Conditions 2020 (PRESSCO 2020). Those who indicated possible groin hernia were asked problem-specific questions and underwent physical examination to confirm or exclude the diagnosis.

RESULTS

3626 study participants were interviewed. The prevalence of untreated groin hernia was 1.1 per cent (95 per cent c.i. 0.8 to 1.5 per cent), whereas the prevalence of untreated and treated groin hernia was 2.5 per cent (95 per cent c.i. 2.0 to 3.0 per cent). The proportion of recurrence was 13.1 per cent. An incidence of 389 (95 per cent c.i. 213 to 652) groin hernia cases per 100 000 people per year was identified, while a population-based annual hernia repair rate estimation was 470 (95 per cent c.i. 350 to 620) per 100 000 people. Out of 39 participants with groin hernia, non-ignorable pain was reported by eight and 27 reported financial shortcomings as a reason for not seeking healthcare.

CONCLUSIONS

Groin hernias are common in Sierra Leone and although the repair rate might match the incidence, the existing backlog of untreated hernias is likely to remain. It may be possible to reduce the number of recurrences through improved management. Measures to reduce financial barriers to treatment seem crucial to improve the health of people with groin hernias in Sierra Leone.

Cost-Effectiveness Analysis of Inguinal Hernia Repair With Mesh Performed by Surgeons and Medical Doctors in Ghana

OBJECTIVES

Task-sharing is the pragmatic sharing of tasks between providers with different levels of training. To our knowledge, no study has examined the cost-effectiveness of surgical task-sharing of hernia repair in a low-resource setting. This study has aimed to evaluate and compare the cost-effectiveness of mesh repair performed by Ghanaian surgeons and medical doctors (MDs) following a standardized training program.

METHODS

This cost-effectiveness analysis included data for 223 operations on adult men with primary reducible inguinal hernia. Cost per surgery was calculated from the healthcare system perspective. Disability weights were calculated using pre- and postoperative pain scores and benchmarks from the Global Burden of Disease Study 2017.

RESULTS

The mean cost/disability-adjusted life-year (DALY) averted in the surgeon group was 444.9 United States dollars (USD) (95% confidence interval [CI] 221.2-668.5) and 278.9 USD (95% CI 199.3-358.5) in the MD group (P = .168), indicating that the operation is very cost-effective when performed by both providers. The incremental cost/DALY averted showed that task-sharing with MDs is also very cost-effective (95% bootstrap CI -436.7 to 454.9). The analysis found that increasing provider salaries is cost-effective if productivity remains high. When only symptomatic cases were analyzed, the mean cost/DALY averted reduced to 232.0 USD (95% CI 17.1-446.8) for the surgeon group and 129.7 USD (95% CI 79.6-179.8) for the MD group (P = .348), and the incremental cost/DALY averted increased by 45% but remained robust.

CONCLUSIONS

Elective inguinal hernia repair with mesh performed by Ghanaian surgeons and MDs is a low-cost procedure and very cost-effective in the context of the study. To maximize cost-effectiveness, symptomatic patients should be prioritized over asymptomatic patients and a high level of productivity should be maintained.

Economic evaluation of expanding inguinal hernia repair among adult males in Ghana

An unmet need for inguinal hernia repair is significant in Ghana where the number of specialist general surgeons is extremely limited. While surgical task sharing with medical doctors without formal specialist training in surgery has been adopted for inguinal hernia repair in Ghana, no prior research has been conducted on the long-term costs and health outcomes associated with expanding operations to repair all inguinal hernias among adult males in Ghana. The study aimed to estimate cost-effectiveness of elective open mesh repair performed by medical doctors and surgeons for adult males with primary inguinal hernia compared to no treatment in Ghana and to project costs and health gains associated with expanding operation services through task sharing between medical doctors and surgeons. The study analysis adopted a healthcare system perspective. A Markov model was constructed to assess 10-year differences in costs and outcomes between operations conducted by medical doctors or surgeons and no treatment. A 10-year budget impact analysis on service expansion for groin hernia repair through increasing task sharing between the providers was conducted. Incremental cost-effectiveness ratios for medical doctors and surgeons were USD 120 and USD 129 respectively per disability-adjusted life year (DALY) averted compared to no treatment, which are below the estimated threshold value for cost-effectiveness in Ghana of USD 371-491. Repairing all inguinal hernias (1.4 million) through task sharing between the providers in the same timeframe is estimated to cost USD 194 million. Total health gains of 1.5 million DALYs averted are expected. Inguinal hernia repair is cost-effective regardless of the type of surgical provider. Scaling up of inguinal hernia repair is worthwhile, with the potential to substantially reduce the disease burden in the country.

Prevalence and risk factors of abdominal hernia among Saudi population

Objective:

Studies assessing prevalence and risk factors of abdominal hernia are scarce in Saudi Arabia, that is why this study aimed to find out the prevalence and risk factors of abdominal hernia among the Saudi Population in 2020.

Methods:

A cross-sectional study was done on 500 participants. A pre-designed questionnaire included three sections: Section A consisted of sociodemographic, Section B had items for three dimensions: pain at the site of the hernia or the hernia repair, restriction of activities, cosmetic discomfort; Section C included medical history and other associated risk factors of hernia.

Results:

The prevalence of abdominal hernia in our study was found to be 38.8%. The participants in 18-25 years had less prevalence (21.2%). participants with BMI >25 (Overweight and Obese) had higher prevalence than others. The mean EuraHS-QoL score in participants who had abdominal hernia was significantly higher than patients who didn't have AH. Age >40 years, male gender, BMI >25, congenital anomalies, history of abdominal surgery, history of abdominal trauma, family history, grand multipara, chronic cough, chronic bronchitis, and smoking were potential predictive factors of AH.

Conclusion:

Abdominal hernia is a common problem in Saudi Arabia. Abdominal hernias are more common in men than women, there is an obvious relationship between obesity, history of abdominal surgery, history of abdominal trauma, family history and hernias. Early diagnosis, easily accessible health facilities and health education are important to prevent complications and improve quality of life.

Improving Global Surgical Oncology Benchmarks: Defining the Unmet Need for Cancer Surgery in Ghana

BACKGROUND

The Lancet Commission on Global Surgery (LCoGS) recommended an annual surgical rate at which low- and middle-income countries (LMICs) could achieve most of the population-wide benefits of surgery. However, condition-specific guidelines were not proposed. To inform rates of surgery for cancer, we sought to assess the current met and unmet need for oncologic surgery in Ghana.

METHODS

Data on all operations performed in Ghana over a one-year period (2014-15) were obtained from representative samples of 48/124 first-level and 12/16 referral hospitals and scaled-up for nationwide estimates. Procedures for cancer were identified by indication. Using modified LCoGS methodology with disease prevalence, Ghana's annual rate of cancer surgery was compared to that of New Zealand to quantify current unmet needs.

RESULTS

232,776 surgical procedures were performed in Ghana; 2,562 procedures (95%UI 1878-3255) were for cancer. Of these, 964 (37%) were surgical biopsies. The annual rate of procedures treating cancer was 2115 surgeries/100,000 cancer cases, or 21% of the New Zealand benchmark. Cervical, breast, and prostate cancer were found to meet 2.1%, 17.2%, and 32.1% of their respective surgical need.

CONCLUSIONS

There is a large unmet need for cancer surgery in Ghana. Cancer surgery constitutes under 2% of the total surgeries performed in Ghana, an important proportion of which are used for biopsies. Therapeutic operative rate is deficient across most cancer types, and may lag behind improvements in screening efforts. As cancer prevalence and diagnosis increase in LMICs, cancer-specific surgical capacity must be increased to meet these evolving needs.

Definitions for Loss of Domain: An International Delphi Consensus of Expert Surgeons

BACKGROUND

No standardized written or volumetric definition exists for 'loss of domain' (LOD). This limits the utility of LOD as a morphological descriptor and as a predictor of peri- and postoperative outcomes. Consequently, our aim was to establish definitions for LOD via consensus of expert abdominal wall surgeons.

METHODS

A Delphi study involving 20 internationally recognized abdominal wall reconstruction (AWR) surgeons was performed. Four written and two volumetric definitions of LOD were identified via systematic review. Panelists completed a questionnaire that suggested these definitions as standardized definitions of LOD. Consensus on a preferred term was pre-defined as achieved when selected by ≥80% of panelists. Terms scoring <20% were removed.

RESULTS

Voting commenced August 2018 and was completed in January 2019. Written definition: During Round 1, two definitions were removed and seven new definitions were suggested, leaving nine definitions for consideration. For Round 2, panelists were asked to select all appealing definitions. Thereafter, common concepts were identified during analysis, from which the facilitators advanced a new written definition. This received 100% agreement in Round 3. Volumetric definition: Initially, panelists were evenly split, but consensus for the Sabbagh method was achieved. Panelists could not reach consensus regarding a threshold LOD value that would preclude surgery.

CONCLUSIONS

Consensus for written and volumetric definitions of LOD was achieved from 20 internationally recognized AWR surgeons. Adoption of these definitions will help standardize the use of LOD for both clinical and academic activities.