Page 112 - International guidelines for groin hernia management

Hernia

approach, the IH prevalence in the Ghanaian general resource environments are laparoscopy and day-case
population was 3.15% (range 2.79–3.5%). The number of surgery. 216, 217
symptomatic hernias was estimated at 530,082 (range In LRSs, where out-of-pocket expenditures are signifi-
469,501–588,980). The annual incidence of symptomatic cant and families often cope by borrowing money or selling
hernias was 210 per 100,000 individuals (range assets to pay for surgery, mesh is often either unavailable
186/100,000–233/100,000). It was concluded that at the or unaffordable. Most IHs in these settings are still repaired
estimated Ghanaian IH repair rate of 30 per 100,000, a with the Bassini method (and many modifications) because
backlog of one million hernias needing repair develops of the high cost of mesh and the lack of training in mesh
each decade. The cost of repairing all symptomatic hernias repair. 200, 218–220
in Ghana was estimated to be 53 million USD. Hernia Occasional exceptions have been reported. A study from
elimination over a 10-year period would cost 106 million Nigeria found that mesh repair was well accepted with few
USD. Nearly five million disability-adjust life years complications at 1-year follow-up. 221 Similarly, in rural
(DALYs) would be saved by the repair of prevalent cases Ghana and Uganda, mesh repair has been successfully used
of symptomatic hernia in Ghana. These findings are sup- without significant complications. 222, 223 In India, mesh
ported by another study which estimated the unmet burden repair seems to be more common (or perhaps more com-
of IHs in sub-Saharan Africa. 212 This study reported that monly written about) than in other LRSs. 224 Laparoscopy
the average district hospital performs 30 hernia repairs per has been introduced in India as well. 225 Nevertheless, mesh
100,000 individuals per year (95% CI 18–41), leaving an cost remains prohibitive in most LRSs.
unmet need of 175 per 100,000 annually. KQ28.c What is the recommended operation for an ingu-
The same model was used to estimate Tanzanian IH inal hernia in low resource settings?
198
prevalence. The prevalence of IH in Tanzanian adults Most people with IHs live in LRSs. Many operative
was 5.36% while an estimated 12% of men had hernias. innovations such as laparo-endoscopic and mesh repair
This equates to 683,904 Tanzanian adults with symp- methods cannot be widely used in LRSs due to cost.
tomatic IH. The annual incidence of IH in Tanzanian adults Solutions that provide cheaper alternatives and do not
was 163 per 100,000 people. At Tanzania’s current hernia- compromise the safety and effectiveness of mesh repair are
repair rate, nearly one million hernia-in-need-of-repair needed. One alternative to expensive synthetic mesh is
backlog will develop over 10 years. Repair of the prevalent sterilized low-cost ‘‘mosquito mesh’’. It too is a similar
symptomatic hernias in Tanzania would save 4.4 million synthetic product originally intended for another purpose
DALYs. but is in use for hernia surgery in several loca-
224, 226–228
A 2012 study using data from the 2010 Global Burden tions. Several studies of ‘‘mosquito mesh’’ have
of Disease (GBD) database quantified the burden of shown promising results in terms of tissue reaction, out-
digestive diseases avertable by surgical care at first-level comes, and cost-effectiveness. 222, 223, 229, 230
hospitals in low- and middle-income countries (LMICs). 202 One animal study concluded that ‘‘mosquito mesh’’
The study calculated the potential decrease in digestive might serve as a cheap substitute to other forms of mesh
disease burden if quality surgical services were universally when the latter is unaffordable or unavailable. 231 Two
available and accessible at first-level hospitals. It con- randomized trials have compared ‘‘mosquito mesh’’ with
cluded that 74% of the burden of inguinal/femoral hernias commercial mesh. One involved 40 patients from Burkina
in East Europe and Central Asia was avertable. Faso and found no differences in outcomes at 30-day fol-
These disparities in surgical coverage highlight issues low-up. 232 One recent trial with 302 patients from eastern
possibly amenable to rapid improvement. In East Europe Uganda had a follow-up of 12–35 months. All patients
and Central Asia, for example, the excess hernia burden included were operated on with the anterior mesh tech-
can likely be addressed with few additional resources. nique according to Lichtenstein, under local anesthesia,
Other regions may require a comprehensive reordering of and the vast majority as day cases. Recurrence rate and
priorities and resources to address their IH burden. postoperative complications did not differ significantly
KQ28.b Which types of inguinal hernia repairs are between low-cost mesh and those undergoing hernia repair
currently performed in LRSs? with commercial mesh. 223
Groin hernia repair techniques have evolved over Hernia repair with ‘‘mosquito mesh’’ has also been
time. 213 During the last 25 years, techniques with synthetic found to be highly cost effective in both Ghana and
mesh have become the norm and are now the preferred Ecuador. 197, 233
technique in high-resource settings. They have demon- KQ28.d What are the logistical challenges for safe groin
strated superiority over conventional non-mesh procedures, hernia repair in low resource settings?
particularly because of their lower recurrence inci- The challenge for hernia surgery in LRSs is to integrate
dence. 50, 214, 215 Additional practice changes in high- the organizational structure of surgical care into the larger

123