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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 12  |  Page : 1728-1735

Elective Incisional Hernia Repair: Risk Factors and Evolution of Treatment in a Low-Income Setting


1 Department of Surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA); Department of Surgery, Ebonyi State University, Abakaliki (EBSU), Ebonyi State, Nigeria
2 Department of Obstetric and Gynaecology, Enugu State University Teaching Hospital, Enugu, Nigeria

Date of Submission29-May-2020
Date of Acceptance02-Aug-2020
Date of Web Publication23-Dec-2020

Correspondence Address:
Dr. A U Ogbuanya
Department of Surgery, Alex Ekwueme Federal University Teaching Hospital, PMB 102, Abakaliki, Ebonyi State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_309_20

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   Abstract 


Background: The steady rise in laparotomy rates, particularly resulting from gynecologic and obstetric procedures in our environment has given rise to corresponding increase in the proportions of incisional hernias (IH). Over the years, discussion on the appropriate repair technique for IH has continued, nevertheless, with advances in laparo-endoscopy and introduction of prosthetic meshes, the surgical treatment has been revolutionized. Aims: The aim of this study is to examine the risk factors and the evolutionary trend in surgical repair in our center. Methodology: This is a descriptive prospective study of adult patients with incisional hernias. The study was carried out in a tertiary health institution from January 2011 to December 2017. Results: A total of 177 patients were recruited, 147 (83.1%) females and 30 (16.9%) males. Nearly two-thirds, 115 patients (65.0%) received prosthetic mesh repair, the rest, 62 patients (35.0%) were fixed using suture-based techniques. Among the 115 mesh repairs, 110 (995.7%) were in females and the remaining five (4.3%) were in males. The most frequent precipitating surgery was caesarean section in 72 patients (40.7%), followed by gynecology operations, 45 patients (25.4%), none-obstetrics and gynecology laparotomies, 50 patients (28.2%) and others, 10 patients (5.7%). Of the 177 patients evaluated, in 99 patients (55.9%) there was history of wound infection in the previous surgery while 24.9%, 5.1%, 4.5% and 1.1% reported that they had prolonged cough, diabetes, jaundice, and urinary obstruction in the peri-operative period of the initiating operations. The rate of recurrence was 17.7% in the non-mesh repairs and 0.0% in the group that had mesh repair. Conclusion: In our locality, the trend over time shows a shift from predominantly anatomic suture-based repair to a tensionless mesh implant with far lower recurrent rates. Laparotomy incisions for obstetric and gynecologic procedures are the most common precipitating incisions.

Keywords: Incisional, laparotomy, mesh, morbidity, wound


How to cite this article:
Ogbuanya A U, Onah L N. Elective Incisional Hernia Repair: Risk Factors and Evolution of Treatment in a Low-Income Setting. Niger J Clin Pract 2020;23:1728-35

How to cite this URL:
Ogbuanya A U, Onah L N. Elective Incisional Hernia Repair: Risk Factors and Evolution of Treatment in a Low-Income Setting. Niger J Clin Pract [serial online] 2020 [cited 2022 Nov 30];23:1728-35. Available from: https://www.njcponline.com/text.asp?2020/23/12/1728/304422




   Introduction Top


The surgical repair of incisional hernia (IH) has witnessed tremendous evolution, ranging from suture-based method through a versatile autologous tissue advancement approach to laparo-endoscopic repair techniques.[1],[2] Incisional hernia represents any abdominal wall defect with or without bulge in the area of a post-operative scar, perceptible or palpable by clinical examination or imaging technique.[1] These hernias, also known as post-operative ventral hernias, occur in 10–20% of laparotomies, and are common with midline incisions and rarely laparoscopic port sites or ambulatory peritoneal dialysis cannula sites.[2],[3],[4],[5] The figure rises to 26% in the context of post-operative wound infection, though disturbing rates of 2–91% have been quoted elsewhere.[6],[7] The wide variability of these rates has been ascribed to heterogeneity in study design, patient population, and length of follow up in the various series.[7] The annual incidence is projected at 90,000 in USA, 41,000 in Germany and 2,150 in Korea with 50% of the hernias developing within two years and 74% within 3 years of abdominal operations, respectively.[2]

The development of incisional hernia after abdominal operations follows a risk stratification index, with some procedures being more susceptible to post-operative incisional hernia development than others.[3],[4],[8],[9],[10] In Enugu, Nigeria, Ezeome and Nwajiobi determined that gynecologic procedures, especially caesarean section accounted for the greatest proportions (66.7%) of surgical procedures that initiated development of IH in their series.[8] This was followed by laparotomy for other conditions, representing 23.8%.[8] Apart from surgery, other associated predisposing factors were ascites, chronic cough, steroid abuse, and child birth.[8] Published data from Italy,[7] Nigeria,[9],[10] Yemen,[11] India[12] and Denmark[13] support the above findings. Although incisional hernia may remain silent and asymptomatic for years, it may enlarge over time and lead to complications like pain, bowel obstruction, and strangulation.[2] Indeed, 17.0% will lead to strangulation with mortality rate of about 0.3%.[2]

Over the years, discussion on the appropriate technique for IH repair has continued, with a plethora of tissue-based techniques described in the surgical literatures.[2],[3],[7],[14],[15] Nevertheless, with advances in surgical services, repair of incisional hernias has been revolutionized by the introduction of prosthetic meshes and advent of laparo-endoscopy.[2],[14] In the industrialized economy, the era of laparoscopic IH repair with mesh has witnessed an explosion of published scientific reports validating superior outcome measures compared to the tissue-based, open techniques.[2],[14],[16] Published clinical data indicate that open suture-based repair of IH is significantly associated with short-term complications (infection, hematoma, stitch sinus, and flap necrosis) occurring at the rate of 10–44% and recurrence rate of 11–52%.[2]

In 1990, Ramirez and coworkers popularized the novel tissue-based, open technique namely “component separation technique”, but in its later modifications, prosthetic meshes were routinely added for reinforcement.[15],[17] The technique was originally intended to manage large, complex, and recurrent midline abdominal wall defects, but over the years, it became adapted for repair of incisional hernias.[14],[15]

Despite the verifiable benefits recorded with prosthetic implants for repair of IH (lower recurrence, manageable short-term complication rates), anatomic, suture- based techniques have continued to thrive in many parts of Sub-Saharan Africa.[3],[10],[18],[19],[20],[21] Interestingly, there are some published reports across Africa that cited increasing application of mesh for repair of these hernias, akin to the practice in the western world.[4],[8] The inconsistent, slow shift from tissue-based to mesh-based repairs seen in many parts of Africa has been suggested to stern from poverty, ignorance, unavailability of meshes and limited surgical expertise for mesh placement.[3],[18],[22]

In Nigeria, IH is assuming an emerging epidemic due to increased rates of laparotomies and gynecologic procedures, especially those performed by poorly trained surgeons and general duty doctors,[3],[10] yet data on this subject have been very scanty and poorly documented in our center. This study therefore, aimed to document the risk factors and the trend in surgical repair and outcomes of incisional hernia in our environment.


   Patients and Methods Top


Design and setting

All consecutive patients with incisional hernias that fulfilled the inclusion criteria were prospectively recruited from January 2011 to December 2017. These patients were seen and managed at a tertiary health institution in southeast Nigeria.

Study population

Initially, all adult patients aged 18 years and above who presented with IHs were seen and counselled for mesh repair. However, in our local practice, many patients with small- and medium-sized IHs decline commercial mesh implantation mostly due to ignorance, additional cost and socio-cultural reasons. Patients with small IHs less than 3 cm were equally counselled for operative repair, but all defaulted and only those with sizes 3 cm and above, small multiple IHs or those with recurrent incisional hernias of any sizes were available and included in this study. The use of tissue-based anatomic method to repair some IHs in this series was born out of necessity, mostly as a result of inability of this category of patients to accept mesh implants. Patients whose hernias manifested features of obstruction or strangulation and those with metastatic intra-abdominal tumors or severe debilitation were excluded from the study. Informed consent for mesh was sought from all the included patients, but those who declined consent for mesh were managed with tissue-based, suture repairs, but this did not affect the quality of care given to such patients.

Procedure

At the time of first clinic visit, all the patients presenting with external abdominal wall hernias were noted. However, of those with IH, only 177 patients gave consent to participate in the study. Each of these patients was interviewed and examined at the specialist hernia clinic of our center. The socio-demographic data and other relevant clinical details were extracted and entered into a proforma. Of particular interest, the presenting complaint, duration of illness, number and type of previous repairs, reason for the previous initiating surgery, occupation, and presence of other predisposing factors were noted. Each patient was examined comprehensively taking particular note on number, site, and size of the hernia. The laxity of anterior abdominal wall was assessed to inform decision on how best to approach management.

Full blood count, abdominal ultrasound, urinalysis, serum electrolytes, creatinine, and urea were routinely done while other special investigations like Electrocardiography, computed tomography, chest X-ray and blood sugar were reserved for older patients and those with comorbidities. “Body Mass Index” (BMI) of the patients were assessed routinely and patients classified accordingly. Pre-operatively, all active infections were treated, anemia corrected and deep vein thrombosis (DVT) prophylaxis commenced (if applicable). Those billed for prosthetic repair using polypropylene mesh (PROLENE mesh, Braun Inc) were specially counseled with regards to possible post-operative complications. At the time of induction of anesthesia, intravenous cephalosporin, and metronidazole were administered. Following elliptical skin incision that encompassed the old scar, dissection was carried down to the fascial plane through combined instrument and diathermy dissection. The sac was isolated and opened; the size of the fascial defect and contents of the sac were noted. Adhesions were lysed and adherent gut or omentum released and returned into abdominal cavity. Any redundant peritoneum interfacing between anterior abdominal wall and intra-abdominal viscera was excised under direct vision. The rectus sheath was routinely closed with nylon 2 to prevent potential space that may lead to communication between polypropylene mesh and intra-abdominal viscera (polypropylene mesh is a non-composite mesh). For the onlay mesh placement, further dissection along the subcutaneous-fascial plane, ensuring at least 6 cm dissection margin from the medial side of the rectus sheath was done. Subsequently, prolene meshes with size range of 7.5 cm x 15 cm to 30 cm x 30 cm were anchored using nylon 2/0. For the suture repair, the guiding principle still remains avoidance of tension at the surure line. Tube drain was inserted superficial to the mesh in all cases, followed by wound closure in layers. The drain was left in situ for a variable period of 2-7 days and skin sutures were removed after 10th to 12th postoperative day. Available patients were followed up for 24 months. During the follow-up period, presence of complications like wound infection, hematoma, seroma, recurrences, and respiratory disturbances were noted. Those that defaulted from appointment and still fail to attend the next clinic day were interviewed via a telephone line and new arrangements made.

Data analysis

This was done using Statistical Package for Social Sciences (SPSS) software, version 22.0, 2015 model (IBM, Chicago IL, USA) and presented as mean, standard deviation, percentages, and tables. Confidence interval was calculated at 95% level and significance at 5% probability level (p < 0.05).

Ethical Approval: The proposal for the study was approved by the research and ethical committee of our hospital before commencement of the study. All ethical principles relating to studies involving human subjects were observed during the study period.


   Results Top


Socio-demographic characteristics

During the seven years under review, 1,802 patients with uncomplicated external hernias were treated surgically. Over a tenth, 206 (11.4%) of the patients harbored incisional hernias. The vast majority, 177 (85.9%) of the patients with IH had hernias that were either large, multiple, or recurrent and these group formed our study cohorts. Of the remaining 29 (14.1%) patients, 16 harbored small hernias less than 3 cm and defaulted following counselling for operative repair while 13 did not meet the inclusion criteria. Overall, there were 147 females and 30 males, giving a female to male ratio of 5:1. Among the 115 patients repaired with mesh, 110, (95.7%) were females and the remaining five (4.3%) were males. Similarly, of the 62 patients that had suture-based repair, 25 (40.3%) were males while 37 (59.7%) were females. Approximately half (89, 50.3%) of the patients had normal BMI (18.5-24.9 kg/M2). Nearly a third (58, 32.8%) were overweight (BMI = 25.0-29.9 kg/M2). Twenty-four (13.6%) patients were obese (BMI equal to or greater than 30.0 kg/M2) and the rest (6,3.4%) were underweight (BMI less than 18.5 kg/M2). The ages of the patients ranged from 18 to 78 years with a mean of 42.01 +/- SD 15.57 [Table 1]. Majority (66, 37.3%) of the patients were farmers, followed by traders (52, 29.4%); others were professionals (22, 12.4%), artisans (19, 10.9%), laborers (14, 7.9%) and others (4, 2.3%). Of the 62 patients that had suture repair, majority (40, 64.5%) were farmers, followed by laborers (11, 17.8%), then artisans (9, 14.5%) and traders (2, 3.2%). Nearly two-third (40, 64.5%) of the patients who had suture repair were farmers; 11 (17.8%), nine (14.55) and two (3.2%) were laborers, artisans, and traders, respectively.
Table 1: Age Distribution and repair techniques

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Clinical presentation

The duration between onset of IH and presentation ranged from one month to 21 years. Less than a tenth (15, 8.5%) of the patients presented within six months of noticing the hernias while a negligible 2.3% (four patients) presented within the first three months. However, about 12.4% (22 patients) presented between 6 and 12 months, more than half (96,54.2%) between one to five years and the rest (44, 24.9%) waited beyond five years before presentation. Caesarean section and gynecologic operations were the most frequent predisposing operations for development of incisional hernia in this study, both accounting for approximately two-third (117,66.1%) of the entire initiating operations [Table 2]. Majority of the initiating surgeries were done in private (54.2%, 96) and general (39.5%, 70) hospitals; only a negligible 6.3% (11 patients) were carried out at tertiary health institutions. Of the 177 patients evaluated, 99 (55.9%) gave positive history of wound infection in the previous surgery, while 44 (24.9%), eight (4.5%), nine (5.1%) and two (1.1%) patients reported that they had prolonged cough, jaundice, diabetes and obstructive lower urinary tract symptoms respectively in the peri-operative period of the initiating operations. In the remaining 15 (8.5%) patients, no known precipitating factors were identified. Over a quarter (61, 34.5%) of the patients harbored one comorbid condition or the other. Twenty-one (11.9%) were hypertensive while nine (5.1%) were diabetic. Other comorbidities were chronic obstructive pulmonary disease (3, 1.7%), benign prostatic hyperplasia (4, 2.3%) and obesity (24, 13.6%). Of the 24 obese patients, 14 (58.4%) were class I, eight (33.3%) were class II while two (8.3%) were severely obese (class III).
Table 2: Precipitating surgeries for development of incisional hernia

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Surgical treatment and anesthetic assessment

Nearly two-thirds (65.0%, 115) of the recruited patients received prosthetic mesh repair, the rest, (35%, 62) were fixed using anatomic, suture-based techniques. Reported reasons for non-mesh repairs included financial constraint (42, 67.7%), unavailability of mesh (4, 6.5%), fear of effect of mesh on subsequent pregnancy (10, 16.1%) and fear of effect of mesh on general health (6,9.7%). The annual incidence of IH showed a progressive rise on the annual rates, with corresponding increase on the rates of utilization of prosthetic implants for IH repairs [Table 3]. Among the 115 patients treated with mesh implants, panniculectomy of the excess abdominal wall subcutaneous fats was added to the formal mesh repair in 44 (38.3%) patients (all were females). Mayo's technique was used to repair all the non-mesh cases (62, 35.0%). The remaining 71 patients (26 males and 45 females) received mesh implants alone. Majority (145, 81.2%) of the hernias were fixed under general anesthesia and the most frequent hernia sac content was “omentum” (106, 59.9%), followed by “empty sac” (31, 17.5%), then intestine (29, 16.4%) and others (11, 6.2%) as shown below [Table 4].
Table 3: Annual frequency and mesh repair rate

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Table 4: Anaesthetic and intra-operative findings

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Outcomes of surgical treatment

The post-operative complication profile of the mesh and non-mesh repairs were comparable except the high recurrence rate observed in the non-mesh group (11,17.7%) compared with 0.0% rate in the mesh repair group. Four (36.4%) recurrences were in farmers, six (54.5%) were in obese patients and one (9.1%) occurred in a patient with bladder outlet obstruction who also had protracted wound infection. More so, hematomas were slightly higher in the mesh group (2.6%) compared to 1.6% recorded in the non-mesh group [Table 5]. There was one mortality (0.6%) recorded in this study. At one and two years postoperative period, 138 (78.4%), and 111 (63.1%) of the surviving patients were available for follow up.
Table 5: Post-operative outcomes

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   Discussion Top


Incisional hernia is common in our environment as we determined that elective IH represented nearly a tenth (9.8%) of all uncomplicated abdominal wall hernias in our institution during the period under review. This figure is comparable with values quoted in other parts of Nigeria; 9.1% in Ibadan and 8.6% in Maiduguri.[10],[18]

A recent publication from our center indicated that emergency laparotomy output has been rising steadily from 115 (16.8%) in 2009 to 194 (28.4%) in 2013.[23] This upsurge probably mirrors increased frequency of laparotomies (both elective and emergency) and other abdominal operations in the authors' environment. In our previous report,[23] we observed, over the years, that majority of the general surgical patients we managed in our center were referred from private, mission or general hospitals due to complexities of the diseases or comorbidities. This observation was corroborated by the finding that 93.7% of the incisional hernias managed in this series were referred from outside our facility. Arguably, the steady rise in the laparotomy, caesarean, and gynecologic operation rates within our center and neighboring private, mission, and general hospitals probably explains the corresponding rise in the annual rates of IH recorded in this series.

The elective IH rate of 9.8% approaches a USA rate of 10.0% and has taken over the UK value of 6.5% despite the fact that up to 10,000 IH repairs are performed in United Kingdom and 100,000 in USA yearly.[24],[25] The explanation for this high figure in our series may be related to the fact that the rate of elective repair of abdominal wall hernias in our setting is generally low, leading to a pool of longstanding, neglected hernias that swell up the unmet needs for hernia disease in Nigeria.

Also, the high proportion of patients that reported post-operative wound infection in the initiating (precipitating) operations is a pointer to the fact that majority of the obstetric (especially those performed for obstructed labor), gynecologic, and other laparotomy incisions performed in our environment develop significant infections post-operatively.[3],[10] This common event may predispose a large proportion of the wounds to subsequent IH formation, similar to reports from India[12] and Nigeria[10]. Indeed, comparing African and western figures may be misleading, because it has been cited elsewhere, that data on African abdominal wall hernia output are incomplete and patients' health seeking behaviors are unpredictable, late, and often in emergency compared to the western series.[1],[3],[9],[18],[22]

Overall, we used Mayo's technique to repair more than a third (62, 35.0%) of the hernias, although we counseled all participants for prosthetic mesh repair. The use of mesh implants for repair of IH increased from 4.5% (1 case) in 2011 to 100.0% (all 38 cases) in 2017. We considered this impressive output to be a product of new surgical era in our institution characterized by elaborate and dedicated enlightenments during discussions on diagnosis and treatment options and occasional mesh donations by us (current authors). Curiously, over a decade ago, published data from Zaria and Maiduguri both in Nigeria indicated that all 30 and 38 incisional hernias, respectively repaired in those centers were carried out without mesh.[9],[10] Agbakwuru and colleagues in Ile-Ife, Nigeria shared similar experience and repaired 32 (72.7%) of their 44 selected female cohorts using Mayo's technique and the remainder (12, 27.3%), with Keel's method.[3] Indeed, anatomic repair of IH has a long history and hitherto, numerous techniques like Keel, Mayo, parietorrhaphy, and component separation technique of Ramirez have been described and extensively used globally, but unfortunately, they have continued to be indispensable in many parts of sub-Saharan Africa.[3],[5],[12],[17],[26]

Beyond the borders of Africa, the tissue-based techniques were also in vogue in Italy[5] and Netherland,[26] but the advent of laparoscopic or open mesh repair has largely supplanted the less efficient anatomic, suture-based methods in those nations.[5],[26] In summary, globally, anatomic, tissue-based repair for IH enjoyed a good surgical standing in the pre-mesh era, but the gains of the tensionless prosthetic mesh repairs remain superior. In many communities across Africa, the crux of the matter with hernia repair is late presentation in addition to insufficient resources to afford prosthetic implants. Our local experience in southeast Nigeria, like other researchers in Nigeria[3],[18] and Africa[22] shows that surgeons in this part of the world are facing surgical challenges different from their colleagues in the industrialized nations. Despite the painstaking efforts by the authors to repair all the IHs with prosthetic meshes, it was not feasible and the prize for these inadequate surgical services became glaring when 17.7% (11 patients) of the 62 non-mesh repairs developed recurrence within 24 months of follow-up compared with the zero recurrence in the mesh-treated arm.

The size of the defect was the most important clinical predictor of mesh utilization in this study (P = 0.000). For instance, 64.1% of patients with hernia defect ranging from 3 to 6 cm received tissue-based repair compared to 92.1% mesh repair rate among patients with defects sizes greater 14 cm. The reason for higher utilization of mesh implants in larger IHs may be related to higher acceptance of mesh by patients with voluminous hernias considering the cosmetic disadvantage conferred by huge IH and fear of a recurrent disease. Overall, there was no statistically significant difference (P = 0.291) between the two repair groups with respect to use of general or spinal anesthesia. This may be explained by the fact that most of the hernias in both group were large (7 cm or more) and necessitated general or spinal anesthesia for adequate relaxation. More so, it has been observed that African surgeons and anesthetists have predilection for general and regional anesthesia for hernia repairs[22] and this may be the reason why most of the hernias in both groups were predominantly fixed under general and spinal anesthesia

The challenges of IH in our environment are not likely to be short-lived, because the factors that precipitate it are multifactorial and rapidly evolving. When we evaluated the precipitating surgical operations, cesarean section and gynecologic operations accounted for approximately two-third (66.1%) of all cases followed by laparotomies (28.2%%). But none of the indications for these major surgical procedures is decreasing in frequency in our environment as previously highlighted by a recent work done in our unit.[23] This probably explained why far more females than males were evaluated. Perhaps, this similar observation prompted Udo and colleagues to suggest that IH is a disease of the female in Nigeria.[4]

Another factor perpetrating IH in our locality is poor surgical technique. We documented that an overwhelming 93.7% of patients with IH managed in this series were from previous operations performed in private, mission and general hospitals where the rank of the surgeon is often below par. A recent publication from southeast, Nigeria indicated that nearly three-fifth (59.1%) of 1,268 women seeking obstetric care in a rural mission hospital were initially managed either by traditional birth attendant or at maternity homes.[27] This is the state of the art in many parts of Nigeria and those that will require caesarean section will most likely be sectioned by trainee gynecologists or general duty doctors without supervision.[27]

In the current report, the intra-operative findings showed that absorbable sutures were used for fascial closure in approximately two-thirds of the cases referred from private, mission, and general hospitals and a further 16 (16.8%) patients from these facilities had their fascia closure done with a diminutive size 2/0 or 0 nylon sutures. Similar to observations made in Uyo[4] and Ile-Ife,[3] both in Nigeria, midline incisional scars produced the highest incidence (162, 91.5%) of IH in this study. Agbakwuru and coworkers, therefore recommended the use of transverse incisions rather than midline incisions whenever practicable.[3] Previous investigators shared similar view and emphasized the need for re-training the general duty doctors on basic surgical principles and abdominal wound closure techniques.[3],[9],[10] Even in the teaching hospitals, there is need to appraise our surgical skill training program and learning curve and come up with requisite benchmarks that qualify a trainee surgeon/gynecologist to perform abdominal operations without supervision. In support of the role of poor surgical skill in IH development was the finding that nearly three-fourth of the previous initiating operations in the teaching hospital were performed by trainee surgeons compared to those done by certified general surgeons. Moreover, factors related to common comorbid states in our environment (chronic bronchitis, obesity, and bladder outlet obstruction in males) were prominent in our patients. Worse still, many of the patients were unaware of their medical conditions and never sought orthodox medical services for their problems. Elsewhere, these factors have been implicated as contributing to the development of incisional hernia after abdominal incisions.[3],[10],[25]

In the current report, general anesthesia was the most commonly utilized method in both the mesh and non-mesh repairs. The fact that most of the IHs and previous scars were above the umbilicus limited the number that would have been adequately fixed under spinal anesthesia. Because of extensive dissection needed for mesh placement and relaxation needed for adequate repair, local infiltrative anesthesia was strictly reserved for smaller hernias and in those with severe comorbidities that were deemed to preclude use of general or spinal anesthesia. For similar reason, only a single IH was repaired under local anesthesia in Enugu, Nigeria.[8]

The complication profile after repair of IH was similar in both groups except for high recurrence rates in the suture-repaired group; hence there was a statistically significant difference (p = 0.002) in postoperative complication rates between mesh and suture-based repair groups. Importantly, hernia recurrence is the most important parameter against which hernia surgeons judge the effectiveness of a repair technique.[2],[4],[12],[20] The high recurrence rate in the suture repair patients may be partly predicated on their socio-demographic characteristics as 64.5% of the farmers did not receive mesh implants and over a third (4, 36.4%) of the recurrences occurred in farmers. More so, over half (6, 54.5%) of the recurrences were in obese patients. The remaining patient with recurrence was diabetic and had protracted wound infection, and the infection, perhaps contributed to the development of recurrence. Seroma was prominent in a series of 19 females treated with mesh repair in Uyo, Nigeria where intense tissue reaction to mesh and extensive subcutaneous tissue dissection were implicated.[4] We did not notice any significant increase in rate of seroma in our mesh repair group, probably because we used diathermy for dissection and inserted drains in all the cases. All the wound infections were superficial and together with other complications, were managed conservatively. In our unit, it is a common practice to administer parenteral antibiotics for a variable period of two to four days after mesh implants. This probably, accounted for higher proportion (74.0%) of patients that stayed beyond 72 hrs after operation compared to 24.2% in the non-mesh repair group.

The relatively short duration of follow up and the high attrition rate of follow-up patients may have constituted limitations in the observations on outcomes. A large, multicenter, or population-based prospective study is needed to evaluate other aspects like causes of barrier to use of mesh implants, possible genetic or hormonal risk factors and the influence of other socio-demographic factors yet to be identified.


   Conclusion Top


Over the years, the trend in surgical management of patients with IH in our center has shifted from a predominantly tissue-based, suture repair technique to a tensionless prosthetic mesh implantation. Unfortunately, the sub-optimal surgical option of suture-based repair led to many recurrences. The risk of developing IH in our setting is multi-faceted and is more common with laparotomy incisions particularly obstetric and gynecologic procedures, but to a lesser extent, other abdominal procedures.

Recommendation

A change in government policies that will provide more robust national insurance coverage for all is most salutary. Re-appraisal of surgical training for both general duty doctors and trainee surgeons/gynecologists is a requisite need for more effective surgical services in our environment.

Acknowledgement

We are grateful to the board of consultants and resident doctors, general surgery section of our institution for their understanding and cooperation throughout the period of this study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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