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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 11  |  Issue : 1  |  Page : 30-35

Feasibility of elective mass hernia repair in Kano State, Northwestern Nigeria


Department of Surgery, Aminu Kano Teaching Hospital/Bayero University, Kano, Nigeria

Date of Web Publication7-Apr-2014

Correspondence Address:
Abdurrahman Abba Sheshe
Department of Surgery, Bayero University/Aminu Kano Teaching Hospital, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0331-8540.130169

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  Abstract 

Background: Hernia is a common surgical condition in our environment and constitutes a serious problem in male farmers in northern Nigeria. Complications are frequently seen, especially during the rainy season, due to increased physical activity as a result of farm work; many of these are Life threatening. Elective repair is often delayed due to long waiting time and the cost of operation is not readily affordable to many in the general public. Approach: The government of Kano State decided to embark upon a free campaign to electively treat 1000 patients with hernia across the state in order to decrease the morbidity and mortality associated with its complications and also to increase the capacity of the hospitals by retaining procured equipments used for the campaign for further use. Following public enlightenment, the campaign was carried out over a period of 3 weeks between 4 and 25 December 2006 in six selected hospitals using mobile surgical teams. A protocol and a questionnaire were designed for use during the campaign. Achievements: A total of 2824 patients with hernia and/or hydrocoele were screened during the campaign, out of which 1155 stable patients were successfully operated at no cost. Equipment, surgical outfits, patient drapes including remaining drugs and consumables were left for use in the centers. No untoward event was reported. Conclusion: It is feasible to conduct a mass hernia campaign to decrease the morbidity and mortality associated with its complications and emergency repair. Mass hernia campaigns require adequate organization, trained staff, necessary equipments and enough supply of consumables. The mass turnout of patients demands a regular/scheduled campaign to further alleviate this problem. There is need for participation of non-governmental organizations, professional associations and corporate bodies to be more involved in health care delivery in our society.

Keywords: Feasibility, free mass hernia repair, Kano, Northwestern Nigeria


How to cite this article:
Sheshe AA. Feasibility of elective mass hernia repair in Kano State, Northwestern Nigeria. Niger J Basic Clin Sci 2014;11:30-5

How to cite this URL:
Sheshe AA. Feasibility of elective mass hernia repair in Kano State, Northwestern Nigeria. Niger J Basic Clin Sci [serial online] 2014 [cited 2019 Mar 20];11:30-5. Available from: http://www.njbcs.net/text.asp?2014/11/1/30/130169


  Introduction Top


Hernia is common surgical condition prevalent all over the world and afflicts both sexes. [1],[2],[3] However, it is a more serious problem among males due to their higher physical activity. [2],[4],[5],[6],[7] Complications are common and could be life-threatening if not treated on time. [3],[8],[9],[10] In northern Nigeria, the farming season is a period when many patients with groin hernia present with complications, and these have to be managed with all the attendant consequences of emergency care. [2],[3],[8],[10],[11] Elective repair of hernia is the best approach for preventing complications; however, this is often delayed due to limited hospital facilities, trained staff, long waiting time and the unaffordable cost to many. In order to address this public health problem affecting our society, the government of Kano State embarked upon a free campaign for the mass repair of hernia. The aim of this article is to describe the feasibility of conducting a free mass repair of hernia in six hospitals in Kano State, Northwestern Nigeria.


  Approach Top


The goal of the campaign was to reduce the morbidity and mortality arising from strangulation/obstruction of hernia through mass elective repair in 1000 patients with hernia. This was in addition to poverty alleviation by the provision of free care, and improvement of economic output and outgrowth through the enhancement of the quality of health of the natives. It was also aimed to strengthen the capacity of the selected hospitals by retaining all surgical items bought for the exercise. The campaign was funded in part by the state government with contribution by all the local governments in the state carried out through the Ministry of Health, Kano State, Nigeria.

Strategy

A situation analysis was first conducted in the six selected hospitals for the campaign, namely Wudil, Bichi, Gwarzo, Danbatta, Rano, and Tudun Wada general hospitals. The aim was to assess the available facilities for sterilization of equipment, operation, recovery, trained staff, accommodation and alternative electric power supply. The arrangement made for feeding the surgical mobile teams was also verified.

A 1-day pre-campaign meeting was conducted. The objective was to update and discuss the operative modality of the campaign with the participants. Selected topics were presented. Three committees were formed to ease and streamline the campaign. These were monitoring and logistics, purchasing and distribution, and data collection and processing. A protocol and a questionnaire were designed and a time table for the campaign was outlined. Consumables and instruments were purchased and distributed to the various centers to ensure smooth running of the programme.

Courtesy calls were made to the local government secretariat and the offices of the district heads in order to establish rapport in mobilizing support for the success of the programme.

Public enlightenment was carried out through the local government's offices, the representatives of the Kano Emirate council in the district, and the various state-owned and freelance media houses. The campaign was also launched in Bichi General Hospital to further mobilize all patients with hernia across the state to present in the various centers for the exercise.

Trained staffs were recruited from Aminu Kano Teaching Hospital, Murtala Mohammed and Abdullahi Wase specialist hospitals to complement the local available staff in the centers. These consisted of six consultants, four senior residents, eight medical officers and six anaesthetic nurses. All the doctors have vast experience in the management of hernia. The services of pharmaceutical and laboratory staff were also sought locally. Mobile surgical teams were used, with each consisting of a consultant surgeon, two medical officers, one theatre nurse, one anaesthetic nurse and two auxiliary staffs.

Screening and operation were done either simultaneously or separately, at the convenience of the surgical team. A questionnaire was used to elicit information from each patient.

Protocol

All patients presenting for the exercise with groin or scrotal swelling were clinically assessed by the team doctors to make diagnosis and determine the risk of anaesthesia and surgery. High-risk patients with uncontrolled hypertension and or diabetes, heart failure, significant symptoms of bladder outflow obstruction, and chronic airway diseases were excluded. Patients that constitute a risk for day care surgery were prescribed medications and advised to present after the campaign for further evaluation. The site of the operation was shaved and cleaned with antiseptic before the patients entered the operating room.

Prophylactic intravenous Ampiclox 1 g stat was given to adults and 50 mg/kg stat to children at the time of anaesthesia. The choice of anaesthesia was determined by the surgeon, anesthetic nurse and the patient based on the clinical findings. Materials were made available for general and spinal anesthesia while including 2% lignocaine for local anaesthesia. The type of hernia repair was based on the skill and familiarity of the surgeon. Monofilament nylon was used for repair of posterior wall, fascia and skin, while chromic catgut was used for subcutaneous tissue, haemostasis and in herniotomy. Patients with hernia associated with hydrocoele on the same side were treated through groin incision; otherwise hydroceles were treated via scrotal incision, except in children. Corrugated rubber drains were used as appropriate in giant hernia and or hydrocoele. Wounds were cleaned with povidone-iodine solution and dressed normally. Tight under-wears were used as appropriate. Patients were discharged on the same day to continue oral medication (Ampiclox capsules and Paracetamol tablets at normal doses) for 5 days postoperatively. Follow-up was done on the 3 rd and 7 th days post-op to inspect the wound for any complication and to remove the stitches.

The collected data were entered into Microsoft Excel 2007 for statistical analysis.


  Achievements Top


The campaign was conducted simultaneously in all the centres during 3 weeks, i.e. from 4 to 25 December 2006. The turnout during the period was overwhelming. Subsequently, the crowd was difficult to control and some members of Hizbah corps and volunteers joined in order to streamline the processes.

A total of 2824 patients were screened during the 3-week period of the campaign. About 1669 (59.1%) were not operated either due to unsuitability for the exercise or time constrains. Each team operated about 10-15 patients per day. A total of 1155 (40.9%) patients with hernia, hydrocoele or both were successfully operated in the six designated centres.

The patients ranged in age from 9 months to 87 years, with a mean of 49.5 years. Majority 951 (82.3%) of the patients operated were above the age of 15 years. There were 1128 (97.7%) males and 27 (23.3%) females, giving a M:F ratio of 42:1. About 682 (59.0%) patients who were operated were in the age group of 30-50 years.

Farming was the predominant occupation constituting 752 (79.1%) of the adult patients. The rest of the patients were constituted by various cadres of government civil service and self-employed entrepreneurs.

Among the adult patients, the hernia was inguinal and right sided in 514 (54.0%), while it was left sided in 257 (27.0%) patients. There were 173 (18.2%) patients with hydrocoele alone. Both hernia and hydrocoele were present in 110 patients. Other hernias repaired were epigastric and femoral hernias in two and five patients, respectively [Table 1].
Table 1: Types of hernia/hydrocoele in 951 adults treated during the campaign

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Both hernia and hydrocoele were present in 110 patients.

A total of 204 patients below the age of 15 years were operated. Groin hernia repair was done in 199 (97.5%), umbilical hernia repair in 3 and right-sided orchidopexy was done in 2 patients.

A total of 1263 operations were carried out in 1155 patients, among which 980 (77.6%) were hernia repair and 280 (22.2%) were repair of hydrocoele; 2 had orchidopexy and 1 had laparotomy, these together constituted 0.2%.

Local anaesthesia using plain lignocaine or with adrenaline was successfully used in 940 (81.4%) patients. Spinal and general anaesthesia were used in 98 (8.4%) and 122 (10.6%) patients, respectively; these patients had mostly giant, recurrent, and complex hernias or were children. A total of 884 patients were discharged on the same day after the operation. However, 271 (23.5%) patients were inadvertently admitted due to complications, long distance and difficult operations due to giant hernia.

Postoperative complications occurred in 132 (11.4%) patients in the limited period of follow-up during the campaign. This may probably be more in the long term. Massive scrotal haematoma was seen in 78 (6.7%) patients; these were admitted and drained. Wound infection occurred in 38 (3.3%) patients; they were also admitted for removal of stitches and drainage of abscesses. Urethral catheters were inserted in 8 (0.7%) patients who had acute urinary retention. There were 8 (0.7%) patients with postoperative pyrexia who responded to empirical antimalarial treatment. A single mortality was recorded of a 45-year-old farmer who presented with obstructed right inguinal hernia. He had resection of gangrenous segment and repair. He died of sepsis 3 days later.

A decision was made to purchase additional consumables on the 8 th day of the campaign. These were catheters, urine bags, antimalarials and paediatric saline bags.

The equipments, materials and remaining consumables were left in each of the centres at the end of the campaign for further free services. These consisted of 10 herniorrhaphy packs, 6 surgical outfits, 10 surgical gowns, 30 pieces of small and large patient reusable drapes, and remaining drugs and consumables.


  Discussion Top


External abdominal hernias are a common surgical ailment affecting both males and females worldwide. [5],[11],[12],[13] It is the commonest condition encountered in surgical practice. [1],[2],[11] The high incidence of this disease makes inguinal hernia repair the most frequently performed procedure in general surgery. [13],[14],[15] Hernia operation constitutes a significant proportion of the surgical workload of doctors practicing in Nigeria. [1],[2],[12] In more developed countries, hernia accounts for 10-15% of all operations, reflecting its impact on health care expenditure and working disability. [15] Complications are common and account for 32-75% of cases of intestinal obstruction in developing countries. [3],[9],[10],[16]

Elective repair of hernia is the best approach for preventing its complications. Recommendation for mass elective repair of hernia was made in several reports. [6],[8] Similarly, in order to address this paramount issue, the government of Kano State, Nigeria embarked upon a free campaign to electively treat 1000 patients with hernia.

In this campaign, over 2824 patients presented for the screening exercise from within and the neighboring states. Half of the screened patients (50.1%) were not operated due to unsuitability for discharge on the same day or due to limitation of time and resources allocated to the campaign.

A total of 1155 patients were operated within the three-week period of the campaign.. This is more than the total number of patients operated with hernia in one teaching hospital over a period of 12 years. [1]

In this report, 682 (59.0%) of the patients operated were in the age group of 30-50 years, with a mean of 45 years, comparable with the average age of hernia presentation in various reports of 32 and 49 years, respectively. [12],[13]

The male to female ratio of 42:1 contrasted with other reports that gave a ratio of 20:1. [6],[7],[15] The high number of males could be attributed to the failure of women to present for the campaign due to the socio-cultural practice restricting females at home. However, hernia is more common in males, perhaps due to their higher physical activity. [2],[3],[6],[11] Previous studies have reported that about 80-90% [7],[17],[18],[19],[20] of hernia repairs were done in the males, which is similar to our finding of 97.7% repair done in males observed during the campaign.

The major occupation of the patients was farming 752 (79.1%). This correlates with other studies from northern Nigeria which reported that the majority of the patients who presented with intestinal obstruction were young peasant farmers undertaking active manual work in the farm. [1],[2],[3] Farmers are significantly predisposed to the development of hernia, either due to recurrent raised intra-abdominal pressure or groin trauma. However, individual predisposition may be a more significant risk factor than otherwise assumed. [6],[11] Right indirect inguinal hernia was found to be more frequent than the left hernia, similar to other reports. [7],[11],[12] This could be due to late descent of the testis on the right side with a resultant increase in congenital abnormalities.

Hydrocoeles were encountered during the campaign and were treated accordingly. These are common in Africans and occur in all age groups, especially in those between 30 and 60 years of age. [7] It is difficult to establish a cause-effect relationship in those with longstanding hernia and ipsilateral hydrocoele. Such hernia/hydrocoele was recorded in 110 (14.3%) patients.

Hernia/hydrocoeles are a common problem in children and are mostly congenital. [5],[21] The incidence of inguinal hernia in children is reported to be about 4.5%. [22],[23],[24] In this study, 204 (17.6%) patients were below the age of 15 years.

Reports have shown that the vast majority of patients presenting for elective hernia repair were suitable for local anaesthesia. [1],[11],[22] Similarly, the choice of general anaesthesia or otherwise is a combined decision of the operating surgeon, anaesthetistand the patient, based on the presumed difficulty of the repair. Use of local infiltration with lignocaine of 1-2% strength with or without adrenaline accounted for 81.4% of anaesthesia given during the campaign period. Local anaesthesia allows demonstration of the hernia and testing of the repair, and early mobilisation, and is therefore suitable for use in day case surgery. It also circumvents cardiopulmonary disease in the elderly and gives a better postoperative analgesia. [1],[20],[23],[24],[25],[26] This campaign further demonstrates the feasibility of mass hernia repair using local anaesthesia in terms of cost and patients' turnaround time.

The importance of the postoperative complications of hernia repair is not so much due to their frequency or severity as to the very large number of these operations performed. [17] The frequency of 3.3% wound infection recorded during the campaign is acceptable and comparable to 1-2% reported from developed countries [17] and 4.7% recorded in this environment. [11] The use of prophylactic antibiotics was deemed paramount because of the large number of patients and the possible breakdown in observance of strict asepsis. Scrotal haematoma was seen in 6.7% patients. Haematoma formation following hernia repair usually depends on the difficulty of the repair and the surgeon's skill, rather than the type of repair effected. [11],[17]

It was difficult for the teams to return to the site at the conclusion of the campaign. The follow-up period was therefore limited and negates proper conclusions made out of the present figures of complications.

Reports have shown a mortality risk of less than 0.01% in elective hernia as compared to 5% following emergency operations. [1],[3],[4],[6] The patient who died following emergency operation was not part of the protocol; however, the surgical team had to make the difficult decision to operate based on the circumstances. No mortality was recorded in the remaining 1154 elective patients operated during the campaign. This is achievable by proper selection of patient and taking necessary precautions to turnaround any risks involved.

A number of challenges were faced during the campaign. Early assessment on the 8 th day of the campaign enabled proper measures to be taken on many. The decision was made to refer children due to lack of proper paediatric instruments and breathing system. The turnout of women was less than expected, as evidenced by the large disproportionate ratio. A designated centre for women may probably improve their chances in the future. A number of patients did not receive or were given inadequate instructions at the time of discharge which further contributed to the lack of follow-up. Many of the patients screened and not operated due to time constraints were not happy about the lack of services. These patients were not informed earlier for the fear of chaos and corrupt practices. Some of the records were inconsistent and many were lost due to manhandling in the hands of junior staff. Unplanned admission posed a challenge, but luckily there were enough beds to accommodate them in the centres despite the short notice. A future campaign should consider provision of separate centres for women and children to join freely in the exercise, in addition to making funds available for follow-up. Strict adherence to the protocol, including keeping proper records, must also be emphasised in subsequent programmes.


  Conclusion Top


Abdominal hernia is a common affliction in the people of Kano State, especially among low-income rural farmers. Mass hernia repair is a safe, feasible and worthwhile effort to alleviate suffering, and improve the health and productivity of our people. There is need for regular campaigning and the participation of non-governmental organisations, professional associations and corporate bodies to contribute in providing surgical care to the less privileged. A similar programme in the future may need to consider some of the challenges encountered to ensure greater success.


  Acknowdgements Top


I wish to express my profound gratitude to the former commissioner of health, Dr. Sanda Mohammed, for the confidence reposed on the author to conduct the first ever hernia campaign in Kano State. Dr. Habeeb Sadauki, who initiated the programme, and the entire staff of the ministry are also acknowledged for their advice and assistance in running the programme. Other individuals contributed especially the Director of Clinical Services Dr. Amiru Imam and his deputy Dr. Aminu Da'u. My gratitude also goes to the consultants, staff and numerous volunteers who participated in the campaign and made it a huge success.

 
  References Top

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