Hernia repair as a tracer for elective surgical care
Authors: Rovine Naluyimbazi, Tamara N Fitzgerald
Journal: The Lancet Global Health (2024)

Inguinal hernias are common in both the paediatric and adult population worldwide. When repaired electively, there are minimal complications and the recurrence rate can be decreased with the use of mesh. Emergency repair is more often associated with bowel and spermatic cord injury, as well as other complications. However, there is a large discrepancy in access to surgical repair and availability of mesh between low-income and middle-income countries (LMICs) and high-income countries.1Estridge P Sanders DL Kingsnorth AN Worldwide hernia repair: variations in the treatment of primary unilateral inguinal hernias in adults in the United Kingdom and in low- and middle-income countries.Hernia. 2019; 23: 503-507Crossref PubMed Scopus (10) Google Scholar In The Lancet Global Health, the NIHR Global Health Research Unit on Global Surgery have reported on hernia repair outcomes from 83 countries.2NIHR Global Health Research Unit on Global SurgeryAccess to and quality of elective care: a prospective cohort study using hernia surgery as a tracer condition in 83 countries.Lancet Glob Health. 2024; (published online May 23.)https://doi.org/10.1016/S2214-109X(24)00142-6Google Scholar They found that, from higher-income to lower-income settings, rates of emergency surgery and bowel resection increased and rates of mesh use decreased. Consequently, they propose that hernia surgery could serve as a tracer condition for the provision of elective surgical care. Our experience in Uganda is consistent with these findings, as the national referral hospital receives a large volume of patients, leading to a backlog of elective cases that compete with emergencies. Some patients have their first-time encounter with health-care personnel after the inguinal hernia has already become complicated, including incarceration, bowel obstruction, or bowel perforation. Notably, some children are diagnosed at birth but are lost to follow-up, presenting later in life with complications due to a lack of proper community-based care. Whereas all children in Uganda undergo general anaesthesia with or without a caudal block for inguinal hernia repair, adults usually receive local or regional anaesthesia for non-complicated cases and general anaesthesia for complications. Most surgeries are performed as day procedures, except for complicated cases or those under 60 weeks post-conception. In adults, repairs are done using either mesh or suture techniques (Desarda, Bassini, Shouldice, etc). Mesh repair is rarely used in LMICs due to the cost,3Matovu A Nordin P Wladis A Ajiko MM Löfgren J Groin hernia surgery in Uganda: caseloads and practices at hospitals operating within the publicly funded healthcare sector.World J Surg. 2020; 44: 3277-3283Crossref PubMed Scopus (2) Google Scholar and children rarely require mesh repair. Patients with bowel perforation secondary to a hernia might require bowel resection with anastomosis or ostomy creation. Most patients have an uneventful recovery, but some might have complications including testicular atrophy, surgical site infection, recurrence, transection of the vas deferens, or even death. Some of the complications are attributed to unqualified medical personnel who might not be competent in performing the procedure,4Löfgren J Makumbi F Galiwango E et al.Prevalence of treated and untreated groin hernia in eastern Uganda.Br J Surg. 2014; 101: 728-734Crossref PubMed Scopus (37) Google Scholar and complications can be averted by preventing delays.5Eeson G Birabwa-Male D Pennington M Blair GK Costs and cost-effectiveness of pediatric inguinal hernia repair in Uganda.World J Surg. 2015; 39: 343-349Crossref PubMed Google Scholar The NIHR Global Health Research Unit on Global Surgery present evidence that hernia repair surgery can serve as a tracer condition to evaluate access to surgical care across countries of varying economic status.2NIHR Global Health Research Unit on Global SurgeryAccess to and quality of elective care: a prospective cohort study using hernia surgery as a tracer condition in 83 countries.Lancet Glob Health. 2024; (published online May 23.)https://doi.org/10.1016/S2214-109X(24)00142-6Google Scholar Previous investigators have proposed "bellwether procedures" as a group of surgical procedures that can define the level of accessibility and safety of surgical care in a given region. Using data from the WHO Emergency and Essential Surgical Care Global database, caesarean section, laparotomy, and treatment of open fractures were shown to be significantly associated with the ability to perform other general surgery, emergency, gynaecological, and orthopaedic procedures.6O'Neill KM Greenberg SL Cherian M et al.Bellwether procedures for monitoring and planning essential surgical care in low- and middle-income countries: caesarean delivery, laparotomy, and treatment of open fractures.World J Surg. 2016; 40: 2611-2619Crossref PubMed Scopus (86) Google Scholar However, during the COVID-19 pandemic it was shown that these three bellwether procedures did not decrease in certain countries, while there was a dramatic decrease in the number of elective surgeries performed.7Chan SL Zhang AY Lam SSW et al.The impact of elective surgery postponement during COVID-19 on emergency bellwether procedures in a large tertiary centre in Singapore.Int J Qual Health Care. 2024; 36mzae022Crossref PubMed Scopus (0) Google Scholar Therefore, these three bellwether procedures might be a good marker for emergency surgical capacity, while not capturing elective surgical capacity effectively. The paediatric surgical literature has also proposed other procedures that could be used to evaluate paediatric surgical capacity, such as care for gastroschisis.8Ford K Poenaru D Moulot O et al.Gastroschisis: bellwether for neonatal surgery capacity in low resource settings?.J Pediatr Surg. 2016; 51: 1262-1267Summary Full Text Full Text PDF PubMed Google Scholar Therefore, hernia repair will likely serve as an important bellwether for both elective and paediatric surgery. Although not stated in their article, perhaps an additional finding of this study is that the availability of hernia mesh could be used a tracer for consumable supply availability. Consumables such as suture material, catheters, drains, and other supplies are often difficult to obtain in LMICs and are necessary for successful surgical care. The field of frugal innovation is rapidly expanding and seeks to provide resource-appropriate medical supplies. One such example is use of mosquito nets in locations where commercial hernia mesh is not available.9Udwadia TE Commercial mesh versus nylon mosquito net for hernia repair. A randomized double-blind study in Burkina Faso.World J Surg. 2007; 31: 858Crossref PubMed Google Scholar In conclusion, elective hernia repair is facilitated by robust health systems that allow for prompt diagnosis and surgical access, preventing complications that result from delays. Follow-up mechanisms for children diagnosed with inguinal hernias at birth should be strengthened, especially considering that children usually do not require mesh repair. Hernia surgeries should be performed by adequately trained personnel to minimise complications. Hernia repair is an important surgical intervention that can be used as a tracer to assess surgical care across economically diverse settings, and perhaps mesh availability could be used as a marker for the availability of other needed consumable supplies. We declare no competing interests. Access to and quality of elective care: a prospective cohort study using hernia surgery as a tracer condition in 83 countriesThis study demonstrates that elective health care is essential to preventing over-reliance on emergency systems. We identified actionable targets for system strengthening: clear referral pathways and increasing mesh repair in lower-income settings, and boosting day-case surgery in all income settings. These measures might strengthen non-surgical pathways too, reducing the burden on society and health services. Full-Text PDF Open Access