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| ORIGINAL ARTICLES |
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| Year : 2023 | Volume
: 6
| Issue : 1 | Page : 23-29 |
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Epidemiology and treatment of groin and ventral hernias in the Zinder region, Niger Republic
Harissou Adamou1, Ibrahim Amadou Magagi1, Oumarou Habou1, Amadou Magagi2, Rachid Sani3
1 Department of Surgery and Surgical Specialties, Zinder National Hospital, Faculty of Health Sciences, André Salifou University, Zinder, Niger
2 Department of Anesthesia and Intensive Care, Zinder National Hospital, Faculty of Health Sciences, André Salifou University, Zinder, Niger
3 Department of Surgery and Surgical Specialties, Faculty of Health Sciences, Abdou Moumouni University, Niamey, Niger
| Date of Submission | 06-Dec-2022 |
| Date of Decision | 23-Jan-2023 |
| Date of Acceptance | 02-Feb-2023 |
| Date of Web Publication | 30-Mar-2023 |
Correspondence Address:
Harissou Adamou
Department of Surgery and Surgical Specialties, Zinder National Hospital, Faculty of Health Sciences, André Salifou University, Zinder
Niger
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijawhs.ijawhs_66_22
OBJECTIVE: To describe epidemiological, therapeutic, and prognostic aspects of groin and ventral hernia in adults at Zinder National Hospital. MATERIALS AND METHODS: This was a retrospective data collected over a period of 10 years (January 2012–December 2021). All patients aged at least 18 years operated for abdominal wall hernia were included. A value of P < 0.05 was considered significant. RESULTS: A total of 921 patients were included. In these patients, groin hernia was present in 78.8% (n = 726), umbilical hernia in 13.25% (n = 122), linea alba hernia in 7.3% (n = 67), and Spiegel’s hernia in 6 cases (0.65%). The mean age was 48 ± 17.2 years. Men accounted for 80.9% (n = 745). Rural origin was 67% (n = 623) and poor 63.8% (n = 588). The stage of hernia strangulation represents 32% (n = 295). The median time to surgical consultation was 8 years. This delay was associated with rural origin (odds ratio [OR] = 1.42; P = 0.0142), poverty status (OR = 1.67; P = 0.0001), and inguinal location (OR = 1.75; 0.0371). General anesthesia was used in 58.7% (n = 541). Bowel necrosis was seen in 9.33% (n = 86). For all groin hernias (n = 783), 96.2% (n = 753) underwent herniorrhaphy and 3.8% (n = 30) underwent a Lichtenstein procedure. For all ventral hernias herniorrhaphy was performed in 95% (n = 245) and mesh repair in 5% (n = 13). Morbidity was 15.4% (n = 142) and mortality 1.74% (n = 16). This was associated with age over 60 years (OR = 3.06; P = 0.0341), ASAIII and ASAIV classes (OR = 5.21; P = 0.015), complicated clinical forms (OR = 4.87; P = 0.023), emergency surgery (OR = 4.51; P = 0.003), and the occurrence of bowel necrosis (OR = 4.11; P = 0.001). The median follow-up was 6 months (range: 3–36 months). Overall, hernia recurrence was recorded in 69 cases or 7.6%. This was associated with emergency surgery (OR = 6.26; P = 0.000) and age over 60 years (OR = 3.02; P = 0.000). CONCLUSION: In our context, the management of groin and ventral hernias is an important activity for the surgeon. Inguinal hernias predominate and hernia strangulation is an element of poor prognosis. Keywords: Groin, hernias, inguinal, linea alba, Niger, prognosis, surgery, umbilical
How to cite this article:
Adamou H, Amadou Magagi I, Habou O, Magagi A, Sani R. Epidemiology and treatment of groin and ventral hernias in the Zinder region, Niger Republic. Int J Abdom Wall Hernia Surg 2023;6:23-9 |
How to cite this URL:
Adamou H, Amadou Magagi I, Habou O, Magagi A, Sani R. Epidemiology and treatment of groin and ventral hernias in the Zinder region, Niger Republic. Int J Abdom Wall Hernia Surg [serial online] 2023 [cited 2023 Jun 4];6:23-9. Available from: http://www.herniasurgeryjournal.org/text.asp?2023/6/1/23/372940 |
| Introduction | |  |
Worldwide, groin and abdominal hernias affect a large proportion of the population.[1],[2],[3] Surgical repair of these hernias represents an important part of the surgeon’s workload, ranging from 7.7% to 30% of all surgical procedures.[2],[3],[4],[5],[6] Inguinal hernias are the most common, occurring in 7/10 of cases.[1],[2],[5],[7] Hernias have a good prognosis when diagnosed and treated early.[8],[9],[10],[11] Delayed treatment due to a variety of factors is leading to significant morbidity and mortality in many countries in sub-Saharan Africa, particularly in rural communities.[3],[5],[10-12] This unacceptable prognosis would be linked to the unbearable financial cost for these populations, who often live below the poverty line. On the other hand, sociocultural barriers in the perception of the disease and the difficulty of access to qualified care structures are as many challenges to early consultation.[3],[11],[13] However, the number of complicated or historical forms in Africa has been reduced by resilience measures, with the promotion of rural and outpatient surgery.[3],[14] There is a lack of documented data on the epidemiology and management of abdominal wall hernias, despite their importance in surgical activity in our context. In light of these considerations, this study was designed, whose aim was to describe the epidemiological, therapeutic, and prognostic aspects of groin and ventral hernias in adults at Zinder National Hospital, Niger Republic.
| Materials and Methods | | |
Study design, setting, and participants
This was a retrospective data collection over a 10-year period (January 2012–December 2021) at the Zinder National Hospital, Niger Republic. All adult patients aged 18 years and above who were diagnosed with and operated on for groin and ventral hernias, whether simple or complicated, were included. Cases of associated incisional hernia, other laparotomies, those who did not undergo surgery for other medical reasons were excluded.
Variables
The following variables were collected: age, sex, origin, occupation, socioeconomic status (indigent or nonindigent), admission type, comorbidities, general condition (according to ASA score),[15] presentation type (simple or complicated), groin hernia location, anesthesia type, surgical technique used, length of hospital stay, treatment costs, morbidity, and mortality. Complications were classified according to the Clavien and Dindo classification.[16] Postoperative follow-up data were collected. Complicated hernias included strangulation/incarceration and giant hernias. Complicated cases underwent urgent preoperative assessment and resuscitation. Scheduled patients underwent outpatient assessment and were admitted the day before surgery.
Statistical methods and analysis
Data were recorded in Excel and exported to Epi-Info 7-(CDC) software for analysis. Continuous variables were expressed as median with interquartile range (IQ) or mean ± standard deviation (if the distribution was Gaussian). Nonparametric Mann–Whitney W or Kruskal–Walis tests were used. Categorical variables were expressed as numbers or percentages (%), and Pearson’s chi-squared and Fisher’s chi-squared tests were used for associations. Univariate and multivariate analyses were performed by crossing mortality with the independent variables. Tests were performed with a 95% confidence interval (CI: 95%). A P-value <0.05 was considered significant.
Ethical approval
This study is in compliance with the ethical standards of the institutional or regional human experimentation committee and the Helsinki Declaration of 1975 (2013 revision). Ethical approval was obtained from the relevant hospital and university.
Limitations
This study is limited by the retrospective nature of the data. There is insufficient information on follow-up. Consequently, this study cannot provide data on the long-term evolution of these operated hernias. A prospective study would be more interesting, but more difficult to carry out in our context.
| Results | | |
During the 10-year study period, 4,119 gastrointestinal surgeries were performed, of which 921 patients underwent groin and ventral hernia surgery, that is, 22.35% of the surgical procedures.
The mean age was 48 ± 17.2 years (extremes: 18–90 years). The age group 40–59 years accounted for 34.64% (n = 319). Men accounted for 80.9% (n = 745), with a sex ratio of 4.23. More than 67% (n = 623) of the respondents were from rural areas. Farmers and housewives constituted 66.77% (n = 615). Our patients were poor in 63.8% (n = 588). [Table 1] summarizes the sociodemographic characteristics of the patients.
In 35.07% of cases (n = 323), patients were admitted as emergencies, including 295 cases of hernial strangulation. Obstructive and irritative signs of the lower urinary tract were found in 14.9% (n = 137). These included prostatic hypertrophy in 102 cases and urethral stricture in 35 cases.
Median delay in consultation between hernia presentation and surgical consultation was 8 years (extremes: 6 months and 46 years). This delay in consultation was associated with rural origin (odds ratio [OR] = 1.42 [1.07–1.90]; P = 0.0142), poverty status (OR = 1.67 [1.27–2.19]; P = 0.0001), and location of the hernia in the groin considered as a shameful area (OR = 1.75 [1.27–2.42]; 0.0371).
ASAI and ASAII patients accounted for 55.27% (n = 509). Groin hernias were the most common with 78.8% (n = 726), including 662 inguinal hernias (71.9%) and 64 crural hernias (6.9%). Ventral hernias accounted for 21.2% (n = 195), including 122 umbilical hernias (13.25%), 67 linea alba or epigastric hernias (7.3%), and Spiegel’s hernia in 6 cases (0.65%). More than 25% (n = 235) of patients had at least 2 hernias. A total of 1,041 hernias were recorded in the 921 patients. [Table 2] shows the clinical characteristics of the patients.
In patients with inguinal hernia (n = 726), 34.71% (n = 252) underwent emergency treatment. The location was right in 59.92% (n = 435), left in 32.23% (n = 234) and bilateral in 6.19% (n = 57). This bilaterality explains the total number of 783 cases of inguinal hernia. According to the anatomical extension, at the inguinal level (662), inguinal-scrotal hernias accounted for 51.51% (n = 341) and inguinal hernias for 48.49% (n = 321). Indirect hernias accounted for 48.03% (n = 318). [Table 3] summarizes the anatomical locations and types of groin hernias.
Of all patients, 67.97% (n = 626) underwent planned surgery and 32.03% (n = 295) underwent emergency surgery. Emergency surgery was performed in 34.71% (n = 252) for groin hernia and in 22.05% (n = 43) for ventral hernia.
General anesthesia was used in 58.7% (n = 541), spinal anesthesia in 33.6% (n = 309), and local anesthesia in 7.7% (n = 71). Bowel necrosis was found in 9.33% of cases (n = 86). Intestinal resection was performed in 93 cases, that is, 10.1% (86 cases of necrosis and 7 cases of hernia with loss of right passage). Digestive stoma was performed in 1.84% (n = 17).
Simple herniorrhaphy (Bassini (n = 686), Mc Vay (n = 67), umbilical herniorrhaphy, and/or linea alba (n = 245)) were performed in 95.9% (n = 998) of cases. Hernioplasty was performed in 4.1% (n = 43). [Table 4] shows the different therapeutic issues. | Table 4: Hernia repair therapeutic aspects (number of patients = 921, number of hernias = 1,041)
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Urologically, transvesical prostatic adenectomy, urethral dilatation, endoscopic resection of the prostate, and internal urethrotomy were associated with herniorrhaphy in 7.7% (n = 71), 1.62% (n = 15), 0.86% (n = 8), and 0.76% (n = 7), respectively.
The median length of stay was 3 days (range: 12 h to 22 days). The overall morbidity (Grade I–IV complications) was 15.4% (n = 142). Surgical site infections predominated with 9.44% (n = 87). All-cause mortality (Grade V) was 1.74% (n = 16). [Table 5] shows the distribution of patients according to complications. Mortality was statistically associated with age over 60 years (P = 0.0341), ASAIII and ASAIV classes (P = 0.015), complicated clinical presentation (P = 0.023), emergency surgery (P = 0.003), and the occurrence of intestinal necrosis (P = 0.001). [Table 6] shows the association between mortality and prognostic factors. | Table 5: Distribution of patients according to the clavien-dindo classification
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 | Table 6: Association between mortality with prognostic factors in univariate and multivariate analysis
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The median postoperative follow-up of the 905 patients who were discharged alive was 6 months (range: 3–36 months). 75.9% (n = 687) of patients were lost to follow-up at 12 months. The median recurrence time was 4 months (range: 3–24 months). A total of 7.6% (n = 69) had a recurrence of the hernia. All recurrences were simple herniorrhaphies. This recurrence was higher (OR = 6.26 [3.64–10.76]; P = 0.000) if the hernia was operated on as an emergency (49/284) than if the operation was planned (20/601). Age over 60 years was also associated with recurrence (39/290; OR = 3.02 [1.84–4.98]; P = 0.000).
| Discussion | | |
Abdominal wall hernias are a major public health problem and the most common surgical procedure performed worldwide.[2],[3],[8],[17],[18] This study also shows that the proportion of hernia repairs in our context is significant, accounting for more than 22% of the operative acts in general surgery. The predominance of young male adults (mean age 48 years) has been reported in several studies in Africa and the rest of the world.[3],[5],[10],[19],[20] The rural origin of almost 70% found in this study is consistent with previous analyses in sub-Saharan Africa, where the majority of patients live far from urban centers, have low incomes, and have sociocultural constraints to express their suffering located in the “private parts.”[3],[5],[11] These evoked aspects were statistically associated (P < 0.01) with delay in surgical consultation. In this study, the time varied from 6 months to 46 years. As a consequence of this delay, we can partly consider the type of emergency admission, which is more than 35%. In several African studies, the number of patients treated in emergency surgery is high, ranging from 19.3% to 34.6%.[3],[5],[11],[13]
In this study, inguinal hernias accounted for almost 72% of cases, followed by ventral hernias (21.2%) and crural hernias (6.9%). The situation is similar in most sub-Saharan African countries with a predominance of groin hernias followed by umbilical hernias.[1],[3],[4],[6],[19] The rarity of Spiegel’s hernias found in this study (0.65%) is consistent with previous data.[3],[7],[21],[22] The prevalence of comorbidities (urinary dysfunction, chronic cough, obesity, and diabetes) responsible for abdominal hypertension and/or wall weakness would explain the high incidence of acquired hernias in the elderly.[1],[3],[5] In our series, comorbidities were recorded in 38.11% of patients.
General anesthesia was used in more than 58.7% of cases in this study. This may be due to the large number of patients admitted with complications and the significant number of patients with comorbidities in this study. These data confirm the study by Ogbuanya and Ugwu,[3] the rate of use of local anesthesia of 7.7% should be increased by planning mobile surgery sessions in rural areas. This would reduce the cost of care, which is too high for patients in our context.[11],[14],[23]
There are many surgical techniques used in the management of abdominal wall hernias. Increasing knowledge of the anatomy and physiology of the anterolateral wall has allowed significant advances in the management of hernias.[7],[9],[17],[18] Today, the minimally invasive surgical approach is replacing conventional surgery in the treatment of hernias.[2],[7],[17],[24],[25] Of the many techniques, herniorrhaphy and hernioplasty (mesh repair and autoplasty) are classically opposed.[1],[2],[8],[9] The latter has the advantage that the hernia can be repaired without causing tension.[1],[2],[9],[25] In Africa and other developing countries, optimal repair techniques are not always consistent. It depends on the technical platform, the surgeon’s habits, the patient’s clinical condition, and the mode of clinical presentation.[3],[10],[13],[21],[26] More than 1/3 of our patients required emergency surgery. In this context, hernioplasty cannot be considered. In more than 95% of cases, we performed herniorrhaphy, including the Bassini technique for the majority of groin hernias. In fact, the low rate of use of mesh repair was related to the absence of this material. This corroborates previous studies in Africa, where most studies reported that the modified Bassini technique was the most commonly used in inguinal hernia repair, followed by other techniques such as Mac-Vay and more recently Desarda autoplasty, with the use of mesh repair being uncommon.[6],[10],[13],[23],[26] This is in contrast to European and American data, but also to South Africa, where the majority of hernias are increasingly treated with mesh repair, sometimes mini-invasive, laparoscopic, or robotic.[12],[18],[27] At present, laparoendoscopic hernia repair is not performed in Niger. General laparoscopy (cholecystectomy, diagnostic laparoscopy, etc.) can be found in some centers in Niamey. Digestive and urological diagnostic endoscopy is also performed in some hospitals like ours. Endoscopic hernia surgery equipment does not exist and surgeons are not trained in this technique, which requires equipment and a long learning curve. It is necessary to invest in equipment and set up a training system for surgeons for these minimally invasive hernia procedures.
The overall morbidity in this study was 15.4%, dominated by surgical site infections. The morbidity varied from 12.1% to 37.8% depending on the series.[3],[5],[19],[26] In this study, mortality was 1.74% and was statistically associated with complicated hernias (P = 0.023), the presence of comorbidities (P = 0.015), age over 60 years at emergency surgery (P = 0.003), and the occurrence of bowel necrosis (P = 0.001). Ogbuanya and Ugwu[3] reported 2.9% mortality associated with prolonged admission time (P = 0.003), advanced patient age (P = 0.020), and the presence of comorbidities (P = 0.002).[3] Our overall hernia recurrence rate of 7.6% is higher than that reported by Ogbuanya and Ugwu,[3] who reported 2.4% recurrence, with almost 2/3 occurring in the emergency group.
Several authors agree that the morbidity and mortality of abdominal hernias are higher in emergency cases than in planned surgery.[3],[8],[11],[13],[26] They, therefore, argue that hernias should be diagnosed and operated on to prevent problems, especially in the elderly.[8] Emergency surgery campaigns are a good alternative to manage the flow of patients. Hernia surgery is an integral part of essential surgery and has been a concern of healthcare providers and policy makers in Niger for several years. The development of decentralized hernia management strategies through the training of district surgeons has increased the number of hernia cases treated in rural areas and reduced the number of complications.[14]
| Conclusion | | |
The management of abdominal wall hernias is one of the most common conditions in general surgery in our areas. The high frequency of complications is explained by the long delay before surgical consultation. Groin hernias predominate. Herniorrhaphy was the most common surgical procedure, and mesh implantation was used to a lesser extent. Factors associated with a poor prognosis include poor general condition, the presence of comorbidities, and hernia strangulation, which is the source of necrosis. To reduce the burden of complications and management of these hernias, we strongly recommend a mass surgery campaign to provide outreach care to rural populations. This would have the potential to reduce the number of hernia cases in the complicated stage.
Author contribution
HA, IAM: conception and design of the study, acquisition of data, analysis and interpretation of data; drafting of the article.
OH, AM: critical revision for important intellectual content.
RS: final approval of the version to be published.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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