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Groin hernia repair constitute one of the most
common practiced surgery in general surgery nowadays. Post-operative
complications constitute a major problem in the management process of this
pathology. The objective of this study was to determine and assess the
complications related to the different surgical techniques of herniorrhaphy. As
such, a retrospective study of 10 years has been carried out at the regional
hospital of Ngaoundéré, whereby 286 cases of groin hernia were recorded.
Results reveal that, the most used surgical technique was that of Bassini with
46.20% and 11.45% recurrence. The least recurrence complication recorded was
that of Shouldice with 1.21%. It is concluded that, post-operative
complications of herniorrhaphy is related to the surgical technique used.
Hence, Shouldice surgical technique is the best mean for hernia repair in
developing countries as a result of its reduced complication rate and
cheapness.
Keywords: Herniorrhaphy, Complications,
Ngaoundéré
INTRODUCTION
Herniorrhaphy is the surgical repair of
hernia, with suture of the abdominal wall. But when the weakened area is very
large, strong synthetic material is sewn over the defect to reinforce the area
and this procedure is called hernioplasty. It is the surgical technique that
assures an efficient and durable treatment of groin hernias. In the world,
hernia is a frequent benign pathology and more than 20 million patients are
operated every year [1]. In Africa, hernia affects about 4.6% of the population
[2,3] and mostly youths. In Cameroon, hernia is also a public health problem
regarding the circumstances of appearance and its management not so easy. The
most frequent groin hernia is inguinal hernia followed by inguino-scrotal
hernia [4]. Several techniques of groin hernia repairs are known amongst which
are the techniques of Bassini, Shouldice, Mac Vay, Lichtenstein, etc. The goal
of the modern surgical treatment is to favor techniques that decrease
postoperative pain and faster recovery along with low recurrence rates. The
first etiologic factor of recurrence resulting from these hernias is suture
under tension of structures which are not normally in apposition [5]. A global
rate of about 10% of complications is recorded every year in patients
undergoing groin hernia repairs in the USA; and the complications are probably
related to the surgical technique used [6]. We noticed another complication
related to post-operative chronic pain (1-63%) which last 3-6 months after
surgery. Several reasons may explain the importance of this study as the
outcome of recurrences and post-operative infections which are a real fact to
be considered in the process of hernia repair [7]. As a result, the general
objective of this study was to make a census of complications related to the
technique of herniorrhaphy used at the regional hospital of Ngaoundéré so as to
establish strategies for prevention of these complications. As such specific
objectives were:
i.
Enumerate the different techniques of
herniorrhaphy practiced at the regional hospital of Ngaoundéré.
ii.
Establish the link of association
between the technique used and the outcome of complications.
i.
Identify techniques with less post-operative complications.
METHODOLOGY
Study design and
setting
This was a descriptive retrospective study
carried out at the regional hospital of Ngaoundéré from January 1st 2005
to January 31st 2015.
Study subjects and
population
All patients’ files that presented to the
surgical department with a clinical diagnosis of groins hernias and
subsequently underwent surgery at the regional hospital of Ngaoundéré were
included in the study. Patients’ files presenting with strangulated hernia,
voluminous obstructive hernia were excluded from the study. The recruitment of
patients was based on the documented available files in the hospital and
included as such: registers of hospitalization, registers of surgical report
and a pre-established data collection file. Data collected included
socio-demographic data (age, sex and occupation), clinical presentation (side
affected, type of hernia, notion of primary or recurrence hernia), type of
surgical procedure, postoperative complications, the duration of hospital stay
and mortality.
STATISTICAL DATA
ANALYSIS
Statistical data analysis was done using SPSS
software version 20.0 and the rest by the software Microsoft office Word and
Excel version 2010. Chi-square (χ2) test was used to study
associations between certain qualitative variables. Data was summarized in form
of figures and frequent tables for categorical variables and results presented
in the form of proportions, percentages, tables and graphs.
ETHICAL
CONSIDERATIONS
Ethical approval to conduct the study was
obtained from the university department of biomedical sciences, the ethical
committee of the regional hospital of Ngaoundéré and regional delegation of
public health for the Adamawa region before the commencement of the study.
RESULTS
Type of surgical
technique/procedure
The most used surgical procedure is that of
Bassini with 132 appearances for a general percentage of 46.2%. The least used
surgical technique is that of Lichtenstein with 15 appearances for a percentage
of 5.2% (Figure 1).
Duration of surgery
by surgical procedure
Figure 2 below reveals that, two cases of
herniorrhaphy using the Bassini technique took more than 2 h of surgery with a
rate of 1.54%. Whereas, for the other known techniques, the average duration is
generally less than 1 h and rarely between 1-2 h.
Duration of surgery
by surgical procedure
Figure 2 below reveals that, two cases of
herniorrhaphy using the Bassini technique took more than 2 h of surgery with a
rate of 1.54%. Whereas, for the other known techniques, the average duration is
generally less than 1 h and rarely between 1-2 h.
Types of hernias
We have for the most right inguinal hernia
represented in 138 cases with a percentage of 48%, followed by the left inguinal
hernia represented in 120 cases with a percentage of 42% and lastly bilateral
inguinal hernia with 28 cases and a percentage of 9.8% (Figure 4).
Association
relations
For association relations between our
different variables, we used a confidence interval of 95% for Chi-Square values
(Table 1).
We
used for this purpose a Chi-Square value χ2=9 and a p-value 0.001.
P-value p=0.001 is less than 0.05 as a result statistically significant.
Consequently, there exist a relation of significance between the surgical
technique used and post-operative complications.
DISCUSSION
Every surgical procedure has judgment
criteria that serve as an evaluation guide of efficiency for the techniques
used in the repair process of groin hernia. We talk here of secondary judgments
which are the rate of post-operative complications, post-operative pain intensity,
the cost of the surgical procedure, duration of hospitalization and work
stoppage. The most of part of these criteria are subjective and or liable to
external factors. Nevertheless, the principal judgment criteria remain the rate
of recurrence which is an objective criterion for the evaluation of efficiency
of groin hernia repair.
Cases of recurrences
of groin hernia
In the course of this study, we recorded one
case of recurrence by the technique of Shouldice with a percentage of 1.21%.
This rate is comparable to those of Warssern et al. [8]; in Pakistan who
obtained 1.28%, Harouna [9] in Niger with 2%, Drew et al. [10] in England with
0.99% and Paul et al. [11] who obtained 1%. This small recurrence rate may be
explained by the fact that the Shouldice technique for hernia repair has been
proven by the Toronto team in Canada. Elsewhere, the rate of recurrence of
primary hernia after surgery by the technique of Lichtenstein varies between 0%
to 4% [8]. In this study the percentage obtained from the technique is 0%.
The choice of
surgical procedure
The repair of groin hernia today faces the
problem of choice regarding the technique to be used among the several
techniques known with relatively comparable clinical results [12]. The most
practiced technique is that of Bassini whereby the cases were 132 followed by
the Shouldice technique with 120 cases and lastly the Lichtenstein technique 15
cases. Obtained results are comparable to those of Halidou A. with 51.5% for
Bassini technique [13] and Miyazaki [14] with 51.08%. Studies carried out by
Harouna and Varshney [15] used instead the technique of Shouldice and obtained
each 45.79% and 48.27%, respectively. In this design study, we obtained 28.67%
for the Shouldice technique. This difference may be as a result of the
difference in practice of every surgeon that considers one technique more
appropriate for him than the other [16].
Presence of hematoma
after surgery
Post-operative sub-cutaneous hematoma
represented 8.52% of the sample of patients operated by the Shouldice
technique. The result of this study is similar to that of Drissa et al. [17] in
2015 who obtained a rate of inguinal hematoma of 8%. Post-operative
sub-cutaneous hematoma represented 7.14% regarding Mac Vay technique. This
result is greatly above that of Flemming et al. [18] in 2001 who obtained 3% of
sub-cutaneous hematoma. This other difference may be explained by the absence
of electrosurgical knife which is and indispensable instrument for hemostasis.
Types of
anesthesiology used
Herniorrhaphy with spinal anesthesiology was
mainly the anesthetic procedure used with 242 cases and a percentage of 84.61%.
On the other hand, herniorrhaphy with general anesthesiology represented 15.38%
of the cases. Our results obtained are similar to that of Dieng and al in 2012
who obtained 86.2% spinal anesthesiology and 13.8% general anesthesiology [19].
Equally, Desarda [20] in 2006 practiced most of his hernia repairs using either
local or loco-regional anesthesiology in 98.95% of all his cases.
CONCLUSION
The complications resulting from hernia
repair depends on the surgical technique used which equally depends on the
pathway approach. Certain complications are it benign or severe may breakout
despite the attention and care brought by surgical team, as such creating
generally real deontological and medico-legal problems. Among the surgical
procedures used to repair hernia, the technique of Shouldice seems to be the
best for repairs of groin hernia in developing countries because of the limited
post-operative complications related to its procedure and yet equally cheap
compared to others techniques that need prosthesis.
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