Abdominal Wall Hernias in Adults: Comparative Study of Anatomo-Clinical, Therapeutic and Progressive Aspects between Two Hospitals in the South of Togo ()
1. Introduction
Abdominal wall hernias include anatomo-clinical forms, inguinal hernias, white line hernias, umbilical hernias, Spiegel hernias, lumbar hernias, obturator and ischial hernias [1]. These are common surgical pathologies. In adults, hernias may be caused by weakness of the abdominal wall and/or increased intra-abdominal pressure. It may also be the persistence of a congenital hernia discovered in adulthood [2]-[3]. It is estimated that more than 20 million hernias are repaired each year all over the world [4]. In Ghana, the repair of abdominal hernias represents 7.5% of the whole operations [5]. From a clinical diagnosis, hernia is a benign ailment besides cases of strangulation that can turn into something worse like necrosis of the herniated viscera [1]. The treatment of hernia is surgical, and it aims to repair and/or reinforce the abdominal wall after the reintegration of the viscera [6]. Surgical techniques vary in accordance with the type of hernia, the surgeon’s experience and the technical platform. Surgical techniques in hernia repair involve open-route or laparoscopic procedures. This comparative study, the first in a national series, was therefore initiated between two hospital centers in the south of Togo in order to identify the anatomo-clinical forms, analyze the surgical technique(s) and their results in abdominal wall hernial treatment in adults.
2. Materials and Methods
It was a retrospective, descriptive and comparative study carried out at the Regional Hospital Center of Tsévié (RHC-T) and the Prefectural Hospital Center of Kpalimé (PHC-K), which are the reference centers for these two towns, south Togo, from January 2018 to December 2022 (five years). There is no ethics committee in these hospitals to give ethical approval, but authorization from each hospital manager was obtained for the study. The study material consisted of the medical records of patients aged 18 and over, operated on for an abdominal wall hernia and followed up for a minimum period of three months. The parameters studied were: the frequency of hernias, the anatomo-clinical forms of hernias, the type of anesthesia, the hernia repair technique and the postoperative evolution. Data entry and analysis were done using Microsoft Word, Excel 2013 and Epi Info 7.2.5 software. Comparison of qualitative variables was done by the exact chi2 test. The statistical test was considered significant for a value of p < 0.05. The results are presented in the form of proportion for qualitative variables of average and standard deviation for quantitative variables.
3. Results
We recorded 308 patients at RHC-T and 387 patients at PHC-K with abdominal wall hernia during the study period with an annual average of 61.6 ± 11.93 (extremes: 44 to 76) patients at RHC-T and 77.4 ± 13.79 (extremes: 60 to 95) patients at PHP-K (p = 0.045). There were 1022 surgical interventions at RHC-T versus 1026 at PHC-K, including 312 and 423 hernial repairs, respectively. Hernial repair therefore represented 30.5% of surgical operations at RHC-T and 41.2% at PHC-K with a statistically significant difference; p = 0.001. Clinically, inguinal hernia was the most common in both centers in 83.7% (n = 261) of cases at RHC-T versus 76.6% (n = 324) of cases at PHC-K. Table 1 puts hernias into categories according to their type. Inguinal hernia was most often found on the right in both centers (63.2% at RHC-T and 58.6% at PHC-K) with a prevalence of the inguinoscrotal form at RHC-T in 52.9% of cases (n = 138) and the inguinal form at PHC-K in 53.7% of cases (n = 174); The distribution of inguinal hernias according to the anatomo-clinical form and laterality is summarized in Table 2. Hernias were strangulated in 23.1% of cases (n = 72) versus 16.3% of cases (n = 69) at RHC-T and PHC-K respectively. They were engorged in 9.6% of cases (n = 30) at RHC-T and 8.5% of cases (n = 36) at PHC-K. In terms of treatment, caudal anesthesia was performed in 288 patients (93.5%) at RHC-T and in 377 patients (97.4%) at PHC-K. The other patients had benefited from general anesthesia. Herniorrhaphy was performed for 292 patients (94.8%) at RHC-T and for 376 patients (97.1%) at
Table 1. Displaying the distribution of hernias according to type.
|
CHR Tsévié |
CHP Kpalimé |
n |
% |
n |
% |
Inguinal hernia |
261 |
83.7 |
324 |
76.6 |
Umbilical hernia |
36 |
11.5 |
55 |
13 |
Epigastric hernia |
15 |
4.8 |
44 |
10.4 |
Total |
312 |
100 |
423 |
100 |
Table 2. Displaying the distribution of inguinal hernias in accordance with the anatomo-clinical form and laterality.
|
CHR Tsévié |
CHP Kpalimé |
n |
Laterality |
n |
Laterality |
L |
R |
B |
L |
R |
B |
Inguino-scrotal hernia |
138 |
37 |
90 |
0 |
145 |
41 |
104 |
0 |
Inguinal hernia |
123 |
31 |
75 |
28 |
174 |
56 |
82 |
36 |
Femoral hernia |
0 |
0 |
0 |
0 |
5 |
1 |
4 |
0 |
Total |
261 |
68 |
165 |
28 |
324 |
98 |
190 |
36 |
L: left; R: right; B: bilateral.
PHC-K, with a p = 0.11; not significant. The other cases were taken care of, using hernia repair plates. For inguinal hernias, the Bassini technique was the most frequently used in RHC-T in 83.5% of cases, while in PHC-K it was the Shouldice technique that predominated in 69.1% of cases. Figure 1 shows the percentages of the different techniques for repairing inguinal hernias. Sutures with “X” stitches were the most commonly used technique for repairing umbilical and epigastric hernias in both centers (Table 3 and Table 4). The surgical course were simple in 93.8% (n = 289) of patients at RHC-T and in 95.9% (n = 371) at PHC-K. Postoperative complications were noted in 4.9% of patients (n = 15) at RHC-T and 3.3% of patients (n = 13) at PHC-K with p = 0.31, non-significant. It was a question of scrotal hematomas, surgical areas infections and orchitis. We recorded 1.3% of cases (n = 4) and 0.8% of cases (n = 3) of deaths respectively at the RHC-T and
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAAEAAAABCAYAAAAfFcSJAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsQAAA7EAZUrDhsAAAANSURBVBhXYzh8+PB/AAffA0nNPuCLAAAAAElFTkSuQmCC)
Figure 1. Displaying the distribution of inguinal hernias in accordance with the treatment technique.
Table 3. Displaying the distribution of umbilical hernias in accordance with the treatment technique.
|
CHR Tsévié |
CHP Kpalimé |
n |
% |
n |
% |
Herniorrhaphy |
X stitches |
30 |
83.3 |
50 |
90.9 |
Continuous stitch |
3 |
8.3 |
2 |
3.6 |
Hernioplasty |
3 |
8.3 |
3 |
5.5 |
Total |
36 |
100 |
55 |
100 |
Table 4. Displaying the distribution of epigastric hernias in accordance with the treatment technique.
|
CHR Tsévié |
CHP Kpalimé |
n |
% |
n |
% |
Herniorrhaphy |
X stitches |
12 |
80 |
38 |
86.4 |
Continuous stitch |
2 |
13.3 |
3 |
6.8 |
Hernioplasty |
1 |
6.7 |
3 |
6.8 |
Total |
15 |
100 |
44 |
100 |
PHC-K with p = 0.5 non-significant. The deceased patients had intestinal loop necrosis. They had undergone an anastomosis resection or a stomia. Their evolution was marked by a fistula with malnutrition or deep suppuration leading to death. The average period of hospitalisation of the patients was 3.5 ± 6.3 days (extremes 2 to 60 days) at the RHC-T and 3.1 ± 1.2 days (extremes 2 to 20 days) at the PHC-K.
4. Discussions
Abdominal wall hernia is a benign and very common pathology in our environments. Male prevalence is the norm in keeping with strength labour. It mainly affects subjects around the 4th and 5th decades. We considered it necessary to analyze the data of the surgical nursery in the two towns with similarities on the technical platform and, the homogeneity of the populations facilitated this approach. Of course, this work enriches our data on the treatment of the hernia and highlights the surgical practice as carried out in the field, but it presents biases linked to a retrospective collection. Clinically, inguinal hernia, umbilical hernia and epigastric hernia were the forms found in the two centers. Adabra et al. [7] also observed only these three forms in their study on abdominal hernias in 2021 at Aného Hospital (Togo). These results point out once again the rarity of other forms of hernia, namely Spiegel’s hernia, ischial, lumbar and obturator hernias; already established in the literature [8]-[11]. Hernia repair represented 30.5% and 41.2% of surgical activities at RHC-T and PHC-K, respectively (p = 0.001). This difference may be in connection with data from national health statistics, which shows that the hospital attendance rate at RHC-T (39%) is lower than 58% at PHC-K [12]. The town of Tsévié being the nearest to the togolese capital, a part of its inhabitants would find it easier to get treatment in the hospitals of Lomé. From a point of view relating to surgical techniques, there was no statistically significant difference between the two centers. Herniorrhaphy was indeed the most practiced in 94.8% of patients at the RHC-T and in 97.1% at the PHC-K, with p = 0.11. Mehinto et al. [13] made the same observation by reporting the preponderance of herniorrhaphy (98.4%) in their practices in Benin. The use of plates for hernia repair is, therefore rarely adopted in the two study centers and can be explained by a number of factors: the hernial repair plate alone costs 59.09 US dollars not forgetting the costs of surgical and anesthesia consumables in addition to the surgical procedure, all of which are the responsibility of the majority of patients themselves. The hernia repair in these hospitals without plates costs around 248.83 US dollars. Indeed, the coverage rate by national health insurance was 3.5% and 4.5% respectively in the Tsévié and Kpalimé regions [14]. In the rare cases of hernioplasty by hernial repair plates, they were performed by laparotomy due to the lack of laparoscopic surgical equipment in both hospitals. In accordance with the type of hernia, epigastric and umbilical hernias were mostly treated with “X” stitches, in keeping with the prevalence of small-necked forms of these hernias. Concerning the repair of inguinal hernias, the Bassini technique was widely adopted at the RHC-T versus that of Shouldice at the PHC-K. The choice of the inguinal herniorrhaphy technique depends on the surgeon’s habits, and it is difficult to obtain a consensus in the absence of the undeniable superiority of one technique over the other. However, according to Pélissier et al., the recurrence rate is 6.1% for the Shouldice; 8.6% for the Bassini and 11.2% for the McVay [15]. In the postoperative course, without however observing a statistically significant difference between the two centers, there were more complications (5.3%) and deaths (1.3%) at the RHC-T compared to the PHC-K where they were 3.5% and 0.8%, respectively. In 2021, Adabra et al. [7] reported in their study a complication rate of 3.7% and 0.2% of deaths. The difference observed between the two study centers in the postoperative period can be explained by the fact that there were more cases of strangulated hernias (23.1%) and engorged hernias (9.6%) at the RHC-T compared to 16.3% and 8.5% at the PHC-K. Otherwise, in inguinal hernia repair, inguinal neuritis occurs either in primary inguinal hernias or recurrent hernias, respectively 34% and 66% [16] [17]. These complications had not been mentioned because of their absence in the medical record used for these retrospective studies. Among the factors that significantly have an impact on postoperative morbi-mortality of hernias, we can note the ASA (American Society of Anesthesiology) score equal to or greater than three, strangulated forms, the presence of necrosis of intestinal loops, the performance of intestinal resection and anastomosis and the operative duration [18] [19]. Indeed, all the cases of deaths recorded occurred in the postoperative evolution of strangulated hernias. And out of the total of seven deaths in the two centers, six had got necrosis of intestinal loops.
5. Conclusion
This comparative study between these two hospitals located in two different environments with homogeneous populations has made it possible to note a similarity between the two hospitals with a few variations. The differences observed in the nursery of hernial pathology between these two hospitals were not statistically conclusive. The precept idea of carrying out a comparative study on a national scale on hernial pathology is then more than justified in order to confirm or deny the trend observed through this first work.