An estimate of hernia prevalence in Nepal from a countrywide community survey

Hernia among Patients Admitted to the Department of Surgery of a Tertiary Care Centre

Introduction

Hernia is one of the most common surgical conditions causing disability and requiring hospital admission and surgery. The aim of this study was to find out the prevalence of hernia among patients admitted to the Department of Surgery of a tertiary care centre.

Methods

A descriptive cross-sectional study was conducted among patients admitted to the Department of Surgery between 14 April 2021 and 13 April 2023 and were collected from 1 July 2023 to 31 July 2023 from the hospital records. Ethical approval was obtained from the Institutional Review Committee. The patient admitted to the Department of Surgery was included and those with incomplete data were excluded. Convenience sampling was used. The point estimate was calculated at a 95% Confidence Interval.

Results

Out of 2057 patients, the prevalence of hernia was 247 (12.01%) (10.61-13.41, 95% Confidence Interval). A total of 31 (12.55%) hernias were irreducible and 15 (6.07%) were operated in the emergency setting. The most common type of hernia was inguinal hernia found in 169 (68.42%) and hypertension was the most common comorbidities found in 48 (19.43%).

Conclusions

The prevalence of hernia was similar to other studies done in similar settings. Hernia accounts for a major surgical burden in our setting. So, early diagnosis and treatment could reduce the morbidity and mortality related to it.

Keywords

hernia; inguinal hernia; prevalence; surgery; umbilical hernia.

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.

Worldwide magnitude of inguinal hernia: Systematic review and meta-analysis of population-based studies

This review pooled the magnitude of inguinal hernia based on the available population-based studies conducted throughout the world. We have searched for population-based articles reporting the magnitude of inguinal hernia on PubMed/Medline, EMBASE, Cochrane library and Google Scholar. Random-effect meta-analysis was carried out to pool the magnitude of inguinal hernia and its proportion between male and female subjects. To determine the presence of between-study heterogeneity, I2 and Cochran's Q methods were employed. Publication bias was evaluated by the Egger test and visual examination of a funnel plot. All statistical tests were conducted by Stata version 16 software. Ten population-based studies with a total population of 51,304,093 were incorporated to pool the magnitude of inguinal hernia. The pooled prevalence of inguinal hernia was 7.7% (95% confidence interval: 6.06-9.34). Subgroup analysis showed that the highest pooled prevalence of inguinal hernia (12.72%) was observed in Asia, On the contrary, the lowest pooled prevalence emanated from America, 4.73%. The pooled prevalence of inguinal hernia in males is far higher than females. It was, respectively, 9.61% (95% confidence interval: 6.46-12.76) and 1.31% (95% confidence interval: 0.36-2.26) for males and females. The current meta-analysis revealed a higher burden of inguinal hernia. This finding glares the light that giving greater attention to inguinal hernia is required. It is recommended to identify the significant causes of inguinal hernia and design appropriate prevention as well as management strategies.

Living with a giant inguinoscrotal hernia for 35 years-a case report

In this modern era, giant inguinoscrotal hernias are very rare to experience in a medical career. We discuss a case of a 65-year-old man with a history of an inguinoscrotal hernia with progressive growth for the past 35 years. On examination, he had a 20 cm × 15 cm non-reducible swelling with multiple ulcers over the skin surface extending to the mid-thigh with otherwise no other bladder and bowel complications. These large hernias pose a different set of surgical problems. Open surgery was performed, hernial sac opened, contents reverted and left orchidectomy were done with scrotal reconstruction. The defect was closed with Vicryl 1-0 over the muscle layer and the skin was stapled. Daily wound care was provided. Besides, this case also compels us to explore possible reasons for the occurrence of such potentially dangerous surgical problems in low-to-middle income countries (LMIC).

Population-based rates of hernia surgery in Ghana

PURPOSE

To estimate the population-based annual rate of hernia surgery in Ghana, so as to better define the met and unmet need and to identify opportunities to decrease the unmet need.

METHODS

Data on operations performed from June 2014 to May 2015 were obtained from representative samples of 48 of 124 district (first-level) hospitals, 9 of 11 regional (referral) hospitals, and 3 of 5 tertiary hospitals, and scaled-up to nationwide estimates. Rates of hernia surgery were compared to previously published annual incidence of symptomatic hernia in Ghana (210/100,000 population) and to published annual rates of hernia surgery in high-income countries (120-275/100,000).

RESULTS

Estimated 17,418 [95% uncertainty interval (UI) 8154-26,683] hernia operations were performed nationally. The annual rate of hernia operations was 65 operations/100,000 population (95% UI 30.2-99.0). The rate was considerably less than the annual incidence of new symptomatic hernia or rates of hernia surgery in high-income countries. Hernia operations represented 7.5% of all operations. Most hernia operations (74%) were performed at district hospitals. Most district hospitals (54%) did not have fully trained surgeons, but nonetheless performed 38% of district-level hernia operations.

CONCLUSIONS

The rate of hernia operations fell short of estimated need. Most hernia repairs were performed at district hospitals, many without fully trained surgeons. Future global surgery benchmarking needs to address both overall surgical rates as well as rates for specific highly important operations. Countries can strengthen their planning for surgical care by defining their total, met, and unmet need for hernia surgery.

Antibiotics for Groin Hernia Repair According to Evidence-Based Guidelines: Time for Action in Ghana

BACKGROUD

Groin hernia repairs (GHR), though classified as clean surgeries, are associated with varying rates of surgical site infections. We assessed the practices of surgeons in Ghana regarding antibiotic use for GHR in comparison to evidence-based international guidelines (EBIG).

METHODS

We interviewed surgeons trained by the Ghana College of Physicians and Surgeons (GCPS), from inception (2003) through 2016, about their use of antibiotics for GHR. We defined the outcome variable of consistently following EBIG in antibiotics use for GHR. Logistic regression was used to examine how a priori selected covariates contributed to the outcome.

RESULTS

Eighty-two of 117 surgeons reported performing/supervising at least one GHR per week. They performed/supervised a mean of five GHR per week. Thirty-two (40%) reported using mesh for at least 50% of GHR. For primary GHR, 75% of surgeons administered antibiotics according to EBIG, whereas for GHR with mesh only, 45% did so. Predictors of consistently following EBIG were increasing number of GHR performed per week (adjusted odds ratio 1.44, 95% CI 1.07-1.96) and increasing time spent for clinical work (adjusted odds ratio 0.95, 95% CI 0.91-0.99). Years of practice since GCPS graduation, total operations performed per week, and hospital level of practice were not predictive of the outcome variable.

CONCLUSIONS

Two-thirds of Ghanaian surgeons interviewed do not consistently administer antibiotics for GHR per EBIG, raising the need to improve access to evidence-based medical information overall to guide practice. Determining local surgical site infections rates to guide antibiotic use in GHR will be useful in Ghana and other LMICs.

Backlog and burden of fractures in Sierra Leone and Nepal: Results from nationwide cluster randomized, population-based surveys

BACKGROUND

The burden of injury is increasing worldwide; planning for its impact on population health and health systems is urgently needed, particularly in low- and middle-income countries (LMICs). This study aimed to model the burden of fractures and project costs to eliminate avertable fracture-related disability-adjusted life-years (i.e., a measure of overall disease burden, expressed as the number of years lost due to ill-health, disability or premature death; DALYs) in Sierra Leone and Nepal.

METHODS

Data from nationwide, cluster-randomized, community-based surveys of surgical need in Sierra Leone and Nepal were used to model the incidence and prevalence of fractures stratified by met and unmet needs. DALYs incurred from treated and untreated fractures were estimated. Additionally, the investment necessary to eliminate avertable incident fracture DALYs was modeled through 2025 using published cost per DALY averted estimates.

RESULTS

The incidence of treated and untreated fractures in Sierra Leone was 570 and 1004 fractures per 100,000 persons, respectively. There could be more than 2 million avertable fracture DALYs by 2025 in Sierra Leone and 2.5 million in Nepal requiring an estimated US$ 4,049,932 (range US$ 2,011,500-6,088,364) and US$ 4,962,402 (range US$ 2,464,701-7,460,103) to address this excess burden, respectively.

CONCLUSION

This study identified a significant burden of untreated fractures in both countries, and an opportunity to avert more than 4.5 million DALYs in 10 years in a cost-effective manner. Prioritizing funding mechanisms for orthopaedic care and implants should be considered given the large burden of untreated fractures found in both countries and the long-term savings and functional benefit from properly treated fractures.

Barriers to essential surgical care experienced by women in the two northernmost regions of Ghana: a cross-sectional survey

BACKGROUND

Women in developing countries might experience certain barriers to care more frequently than men. We aimed to describe barriers to essential surgical care that women face in five communities in Ghana.

METHODS

Questions regarding potential barriers were asked during surgical outreaches to five communities in the northernmost regions of Ghana. Responses were scored in three dimensions from 0 to 18 (i.e., 'acceptability,' 'affordability,' and 'accessibility'; 18 implied no barriers). A barrier to care index out of 10 was derived (10 implied no barriers). An open-ended question to elicit gender-specific barriers was also asked.

RESULTS

Of the 320 participants approached, 315 responded (response rate 98 %); 149 were women (47 %). Women had a slightly lower barriers to surgical care index (median index 7.4; IQR 3.9-9.1) than men (7.9; IQR 3.9-9.4; p = 0.002). Compared with men, women had lower accessibility and acceptability dimension scores (14.4/18 vs 14.4/18; p = 0.001 and 13.5/18 vs 14/18; p = 0.05, respectively), but similar affordability scores (13.5/18 vs 13.5/18; p = 0.13). Factors contributing to low dimension scores among women included fear of anesthesia, lack of social support, and difficulty navigating healthcare, as well as lack of hospital privacy and confidentiality.

CONCLUSION

Women had a slightly lower barriers to surgical care index than men, which may indicate greater barriers to surgical care. However, the actual significance of this difference is not yet known. Community-level education regarding the safety and benefits of essential surgical care is needed. Additionally, healthcare facilities must ensure a private and confidential care environment. These interventions might ameliorate some barriers to essential surgical care for women in Ghana, as well as other LMICs more broadly.

Barriers to Essential Surgical Care in Low- and Middle-Income Countries: A Pilot Study of a Comprehensive Assessment Tool in Ghana

BACKGROUND

Beyond resource deficiencies, other barriers to care prevent patients from receiving surgery in low- and middle-income countries (LMICs). This study aimed to develop and pilot a comprehensive, generalizable tool for assessing the barriers to surgical care.

METHODS

Sociodemographic, clinical and 38 questions regarding potential barriers to surgical care were asked during a surgical outreach to two district and one regional hospital in Upper East Region, Ghana. Sites were selected to capture individuals with prolonged unmet surgical needs and represent geographic, socioeconomic, and healthcare development differences. Results were indexed into three dimensions of barriers to care (i.e., 'acceptability,' 'affordability,' and 'accessibility') so that communities could be compared and targeted interventions developed.

RESULTS

The tool was administered to 148 participants (98 % response rate): Bolgatanga 54 (37 %); Amiah 16 (11 %); and Sandema 78 (52 %). Amiah had the fewest barriers to surgical care (median index 8.3; IQR 7.6-9.3), followed by Sandema (8.2; IQR 5.3-9.2) and Bolgatanga (6.7; IQR 3.9-9.5). Individual dimension scores (i.e., acceptability, affordability, accessibility) ranged from 10.8 to 18 out of 18 possible points. Main factors contributing to low dimension scores were different between communities: Bolgatanga-cost and healthcare navigation; Amiah-social marginalization and poor medical understanding; Sandema-distance to surgically capable facility.

CONCLUSION

This study identified a number of significant barriers, as well as successes for patients' ability and willingness to access surgical care that differed between communities. The tool itself was well accepted, easy to administer and provided valuable data from which targeted interventions can be developed.

Changing Epidemiology of Intestinal Obstruction in Ghana: Signs of Increasing Surgical Capacity and an Aging Population

INTRODUCTION

This study aimed to describe the epidemiology and outcomes of intestinal obstruction at a tertiary hospital in Ghana over time.

METHODS

Records of all patients admitted to a tertiary hospital from 2007 to 2011 with intestinal obstruction were identified using ICD-9 codes. Sociodemographic and clinical data were compared to a previously published series of intestinal obstructions from 1998 to 2003. Factors contributing to longer than expected hospital stays and death were further examined.

RESULTS

Of the 230 records reviewed, 108 patients (47%) had obstructions due to adhesions, 50 (21%) had volvulus, 22 (7%) had an ileus from perforation and 14 (6%) had intussusception. Hernia fell from the 1st to the 8th most common cause of obstruction. Patients with intestinal obstruction were older in 2007-2011 compared to those presenting between 1998 and 2003 (p < 0.001); conditions associated with older age (e.g., volvulus and neoplasia) were more frequently encountered (p < 0.001). Age over 50 years was strong factor of in-hospital death (adjusted OR 14.2, 95% CI 1.41-142.95).

CONCLUSION

Efforts to reduce hernia backlog and expand the surgical workforce may have had an effect on intestinal obstruction epidemiology in Ghana. Increasing aging-related pathology and a higher risk of death in elderly patients suggest that improvement in geriatric surgical care is urgently needed.