M. G. Katz1, E. Yenli2, D. Bandoh2, F. Gyamfi3, A. Jalali5, R. E. Nelson4, R. R. Price1, S. Tabiri2 1University Of Utah,Department Of Surgery,Salt Lake City, UT, USA 2University For Development Studies,Department Of Surgery,Tamale, NORTHERN REGION, Ghana 3Holy Family Hospital,Department Of Surgery,Berekum, BRONG AHAFO, Ghana 4VA Salt Lake City Healthcare System/University Of Utah,Division Of Epidemiology,Salt Lake City, UT, USA 5University Of Utah,Department Of Economics, Health Economics,Salt Lake City, UT, USA
Introduction: Surgical conditions are a major source of global disease burden, and Africa has the highest rate of Disability-Adjusted Life-Years (DALYs) due to surgical conditions of any global region. Certain surgical procedures, including inguinal hernia repair, have been demonstrated to be cost-effective with DALYs averted rivalling other public health interventions. Ghana has a high prevalence of inguinal hernias (IH) with low repair rates. Untreated IH may present emergently as incarcerated or strangulated, leading to increased morbidity, mortality, and burden on the healthcare system. In a previous study, 65% of IH repaired in Kumasi, Ghana are performed emergently compared to 5-10% reported in high-income countries. When performed electively, suture repair is often used in low and middle-income countries despite multiple randomized controlled trials and meta-analysis demonstrating lower recurrence (2% vs 4.9%) and less pain with mesh repair. Cost of mesh and surgeon education have been identified as barriers in southern Ghana, although little is known for the rest of the country. The purpose of our study was to assess the current state of IH repair in northern Ghana.
Methods: A survey tool was used to capture patient demographics, presentation and characteristics of hernia repair. From January 2013 to January 2017 operative reports from 23 hospitals in northern Ghana were collected. All males above 18 years were included. Data was analyzed using multivariate logistic regression to determine predictors of mesh use.
Results: 4523 patients underwent IH surgery. The average age was 48, and 4522 patients were male. The majority of cases were performed at district hospitals (70%), followed by regional hospitals (25%), then teaching hospitals (3%). Most were repaired electively (95%), but 1.9% were performed due to obstruction, 2.2% for strangulation. Suture repair was most common (94%) while mesh was used 6% of the time. The operation was performed most often by non-surgeon physicians (68%) while the remaining were performed by surgeons (32%). Spinal anesthesia was used 55%, followed by local (42%) and then general anesthesia (3%). The strongest predictor for mesh repair was surgery being performed in a teaching hospital (OR 7.94, p < 0.001), followed by the procedure being performed by a surgeon (OR 4.54, p < 0.001). Hernia repair at a regional hospital was a negative predictor of mesh use (OR 0.22, p < 0.000) as was emergent surgery (OR 0.56, p = 0.047).
Conclusion: Only 5% of patients presented for emergent IH repair, a rate far less than previously reported in Ghana. The 6% rate of mesh repair is similar to previous studies in Africa. Most repairs in northern Ghana are being performed by non-surgeon physicians who were less likely to use mesh. In light of mesh repair’s status as the gold standard for treatment, future investigation should assess and address barriers to mesh placement during IH repair in northern Ghana.