Page 113 - International guidelines for groin hernia management

Hernia

healthcare system. 203 The healthcare systems in LRSs have should particularly be evaluated in respect to the retention
variations in the range of services offered between hospi- of surgical skills of the newly trained staff, to improve-
tals in the same country. 234 Studies have shown that ments in outcomes, and to the retention, in-country, of
properly functioning small hospitals and health centers in local healthcare providers. 243, 244
rural areas can deliver effective basic low-cost surgical A sustainable model to improve hernia surgery in LRS
services. 187, 235 However, many of them suffer from a lack requires a national commitment to providing access to
of trained staff, equipment and integration of services surgical services, especially in rural areas, and to ade-
236
delivery. A well-functioning hospital offering a narrow quately training practitioners. Safe, effective, accessible
range of vital surgical services can be part of an integrated and cost-effective surgical services must be available to
245
model of healthcare delivery. Integration aims to improve meet needs in LRSs.
the service in relation to efficiency and quality, thereby KQ28.e Should any special precautions be taken?
maximizing use of resources and opportunities. 237 The Only a few studies exist on interventions like antibiotics
benefit of integration has been demonstrated in several or nutritional supplementation pre- or postsurgery in
settings. 238 LRSs. 197, 208, 246–248 One additional study analyzed IH
Health practitioners should have appropriate surgical patients in Ghana, Nigeria and the Ivory Coast operated on
and anesthetic equipment and supplies. It is important for between 2005 and 2010. Mesh—either a standard brand
hospitals to be able to administer appropriate anesthesia, polypropylene mesh or sterilized mosquito net—was used.
whether local (LA), spinal, general (GA) or with tracheal Antibiotics were administered at the surgeon’s discretion,
235 249
intubation. with most patients receiving them.
A meta-analysis demonstrated a striking disparity Summary statements from the studies cited above
between anesthesia-related mortality in LRSs when com- include:
pared with high income countries. 239 Factors contributing • Antibiotics are recommended, particularly when mesh
to this disparity included: few qualified anesthetists, lack of
is implanted.
appropriate training, limited supplies for safe patient • For incarcerated hernias without bowel necrosis, a
monitoring, and limited supplies for the safe administration mesh repair with antibiotic coverage might be
of anesthesia. 240
recommended.
Adequate surgical training of practitioners and the use of
• Antibiotics are recommended in all strangulated hernia
LA permit the vast majority of IH repairs to be done in
repairs with or without bowel necrosis.
LRSs. Studies have shown that IH repairs with LA allow
• Antibiotic administration was not standardized across
return to normal activity a day earlier than GA, important
in LRSs. 241 Local anesthesia costs significantly less than • the studies.
No recommendations about nutritional supplementation
spinal anesthesia and GA, another advantage in LRSs. 234
were made.
Given these limitations and the inherently higher risk of
GA, it is recommended that groin hernia repairs in LRSs be Clearly, multi-centered RCTs in LRSs are needed to
performed under LA. guide decision making about antibiotic use and nutritional
Several strategies can be used to overcome the logistical supplementation.
challenge of cost. Surgical instrument packs and other KQ28.f Which mesh is most suitable for IH repair in
materials can be bought at a discount from non-profit LRSs?
organizations. Healthcare facilities and manufacturers can In most resource-poor countries, sutured repair—with
donate these materials close to their expiration dates. 242 If significantly inferior results compared with mesh—is
medical personnel and equipment are in short supply, common, since commercial mesh is either unavailable or
short-term surgical missions by charitable organization can unaffordable. 184, 250
help reinforce the existing infrastructure. Sanitary mobile The hernia healthcare industry has developed over 200
surgical platforms can be used in environments lacking mesh types with costs ranging from 40 to 6000 USD per
modern sterile facilities. 243 While short-term surgical piece. 251 The most commonly used macro-porous polymers
missions have been promoted as a method of alleviating are polypropylene and polyester. Meshes differ marginally
disease burden, the best way for charitable organizations to in their ultrastructure, filament type/construction, pore size,
support surgical care in LRSs is through partnerships with weight/density, tensile strength and elasticity. 251 Com-
local hernia societies and health practitioners. 243, 244 mercial hernia meshes are class II medical devices and are
Teaching and training local teams should be performed required to undergo the Food and Drug Administration
next to alleviate the waiting list. A partnership of this type (FDA) pre-market notification process in the United States
is occurring presently in Ghana with Operation Hernia or the Medicines and Healthcare products Regulatory
http://www.operationhernia.org.uk/. 234 The effectiveness Agency (MHRA) or other authority approval in the UK and

123