Dataset Information

Outcomes After Inguinal Hernia Repair With Mesh Performed by Medical Doctors and Surgeons in Ghana.

ABSTRACT:

Importance

Inguinal hernia is the most common general surgical condition in the world. Although task sharing of surgical care with nonsurgeons represents one method to increase access to essential surgery, the safety and outcomes of this strategy are not well described for hernia repair.

Objective

To compare outcomes after inguinal hernia repair with mesh performed by medical doctors and surgeons in Ghana.

Design, setting, and participants

This prospective cohort study was conducted from February 15, 2017, to September 17, 2018, at the Volta Regional Hospital in Ho, Ghana. Following successful completion of a training course, 3 medical doctors and 2 surgeons performed inguinal hernia repair with mesh according to the Lichtenstein technique on 242 men with primary, reducible inguinal hernia.

Main outcomes and measures

The primary end point was hernia recurrence at 1 year. The noninferiority limit was set at 5 percentage points. Secondary end points included postoperative complications at 2 weeks and patient satisfaction, pain, and self-assessed health status at 1 year.

Results

Two-hundred forty-two patients were included; 119 men underwent operations performed by medical doctors and 123 men underwent operations performed by surgeons. Preoperative patient characteristics were similar in both groups. Two-hundred thirty-seven patients (97.9%) were seen at follow-up at 2 weeks, and 223 patients (92.1%) were seen at follow-up at 1 year. The absolute difference in recurrence rate between the medical doctor group (1 [0.9%]) and the surgeon group (3 [2.8%]) was -1.9 (1-tailed 95% CI, -4.8; P < .001), demonstrating noninferiority of the medical doctors. There were no statistically significant differences in postoperative complications (34 [29.1%] vs 29 [24.2%]), patient satisfaction (112 [98.2%] vs 108 [99.1%]), severe chronic pain (1 [0.9%] vs 4 [3.7%]), or self-assessed health (85.9 vs 83.7 of 100) for medical doctors and surgeons.

Conclusions and relevance

This study shows that medical doctors can be trained to perform elective inguinal hernia repair with mesh in men with good results and high patient satisfaction in a low-resource setting. This finding supports surgical task sharing to combat the global burden of hernia disease.

SUBMITTER: Beard JH

PROVIDER: S-EPMC6596328 | biostudies-literature |

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description:ImportanceTask sharing of surgical duties with medical doctors (MDs) without formal surgical training and associate clinicians (ACs; health care workers corresponding to an educational level between that of a nurse and an MD) is practiced to provide surgical services to people in low-resource settings. The safety and effectiveness of this has not been fully evaluated through a randomized clinical trial.ObjectiveTo determine whether task sharing with MDs and ACs is safe and effective in mesh hernia repair in Sierra Leone.Design, setting, and participantsThis single-blind, noninferiority randomized clinical trial included adult, healthy men with primary inguinal hernia randomized to receiving surgical treatment from an MD or an AC. In Sierra Leone, ACs practicing surgery have received 2 years of surgical training and completed a 1-year internship. The study was conducted between October 2017 and February 2019. Patients were followed up at 2 weeks and 1 year after operations. Observers were blinded to the study arm of the patients. The study was carried out in a first-level hospital in rural Sierra Leone. Data were analyzed from March to June 2019.InterventionsAll patients received an open mesh inguinal hernia repair under local anesthesia. The control group underwent operations performed by MDs, and the intervention group underwent operations performed by ACs.Main outcomes and measuresThe primary end point was hernia recurrence at 1 year. Outcomes were assessed by blinded observers at 2 weeks and 1 year after operations.ResultsA total of 230 patients were recruited (mean [SD] age, 43.0 [13.5] years), and all but 1 patient underwent inguinal hernia repair between October 23, 2017, and February 2, 2018, performed by 5 MDs and 6 ACs. A total of 114 patients were operated on by MDs, and 115 patients were operated on by ACs. There were no crossovers between the study arms. The follow-up rate was 100% at 2 weeks and 94.1% at 1 year. At 1 year, hernia recurrence occurred in 7 patients (6.9%) operated on by MDs and 1 patient (0.9%) operated on by ACs (absolute difference, -6.0 [95% CI, -11.2 to 0.7] percentage points; P < .001).Conclusions and relevanceThese findings demonstrate that task sharing of elective mesh inguinal hernia repair with ACs was safe and effective. The task sharing debate should progress to focus on optimizing surgical training programs for nonsurgeons and building capacity for elective surgical care in low- and middle-income countries.Trial registrationisrctn.org Identifier: ISRCTN63478884.

Project description:IntroductionInguinal hernia repair is a common procedure and a priority for public health efforts in Ghana. It is essential that inguinal hernia repair be performed in a safe, efficient manner to justify its widespread use. Local anesthesia has many favorable properties and has been shown to be superior, compared to regional or general anesthesia, in terms of pain control, safety profile, cost-effectiveness, resources required, and time to discharge. Local anesthesia is recommended for open repair of reducible hernias, provided clinician experience, by multiple international guidelines. Regional anesthesia is associated with myocardial infarction and other complications, and its use is discouraged by multiple guidelines, especially in older patients. This study aims to assess the current state of anesthesia for inguinal hernia repair in the northern and transitional zone of Ghana. In addition we will assess the perceptions of different types of anesthesia along with understanding of evidence-based guidelines among clinicians participating in inguinal hernia repair.MethodsWe performed a retrospective review of all inguinal hernia repairs for male patients, 18 and older, in over 90% of hospitals in northern Ghana. All 41 hospitals were visited and caselogs and patient charts were manually reviewed to extract data. Multivariate logistic regression was used to determine predictors of local anesthesia use. We designed a survey instrument to assess the perceptions of physicians and anesthetists regarding different types of anesthesia for inguinal hernia repair. The survey was designed by a Ghanaian surgeon, reviewed by all co-authors, and tested prior to implementation using a sample (n = 8) of clinicians having similar practices to those of the survey population. Of 70 clinicians, 66 responded, yielding a response rate of 94%.Results8080 patients underwent hernia repair of which 37% were performed under local anesthesia, while the majority, 60%, were performed under regional anesthesia. Negative predictors of local anesthesia were emergent repair (OR = 0.258, p < 0.001), surgery performed at a teaching hospital (OR = 0.105, p < 0.001), and bilateral hernia repair (OR = 0.374, p < 0.001). 1,839 (22.8%) of IH repairs were done on patients age 65 or older and RA was most frequently used among the elderly population (57.8%), while local anesthesia was used 39.5% of the time. Sixty-six clinicians participated in the survey with the majority reporting that local anesthesia requires fewer staff, less equipment, has a shorter recovery, is more cost-effective, and might be safer for patients. However 66% were unfamiliar with or incorrectly perceived international guidelines.ConclusionTo our knowledge, this study is the largest assessment of anesthesia use for inguinal hernia repair in an LMIC. Although the selection of anesthetic technique should be guided by a patient's general health, the anatomy of the hernia, and clinician judgment, local anesthesia appears to be underutilized in northern Ghana. Survey responses demonstrate high rates of unfamiliarity or incorrectly perceived evidence-based guidelines. Future research should assess how education on the benefits and technique of local anesthesia administration may further increase rates for inguinal hernia repair, especially for older patients.