|Year : 2016 | Volume
| Issue : 2 | Page : 116-121
Clinicoepidemiologic profile of inguinal hernia in rural medical college in central India
S Siddharth Rao, Prashant Singh, Dilip Gupta, Ravinder Narang
Department of Surgery, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
|Date of Web Publication||31-Aug-2016|
S Siddharth Rao
Department of Surgery, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha - 442 102, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Inguinal hernias are one most common problem dealt by general surgeons and have significant morbidity and mortality. In the developed countries, almost all of the inguinal hernias are recognized early and present early in the course of disease to the surgeon. However, in developing countries, quite a considerable percentage of it is not repaired leading to a higher incidence of morbidity and mortality. Hence, we planned this study to understand the clinicoepidemiologic profile of inguinal hernia in rural medical college in central India.
Methodology: This is a descriptive epidemiological, prospective study carried out in rural medical college. All patients who presented to the surgical wards and outpatient with a clinical diagnosis of inguinal hernia were included in the study.
Results: Among the 61 patients included in the study, most of them were men (91.8%) with a mean age of 45.02 ± 22.87 years, married (77.05%) and farmer (37.7%) by occupation. All the patients of inguinal hernia presented with the complaints of lump above the inguinal crease and three-fourth of these patients had complaints of pain (73.77%) and had predominantly right-sided hernia. More than half of the patients had one of the signs of obstruction at the time of presentation of which crease in pain was the most common (52.46%). Most of the patients presented late to the hospital due to the lack of awareness of the disease. The most common operative procedure done was open hernioplasty (Lichtenstein's procedure) in 61.67% patients followed by herniotomy (18.33%) and herniorrhaphy (modified Bassini's procedure) in 13.33% patients.
Conclusion: Late presentation of disease is the hallmark of this disease in rural areas due to the lack of awareness. Increasing awareness of the disease among general population will lead to inguinal hernias being detected at earlier stage and will decrease the morbidity due to this disease.
Keywords: Clinical profile, epidemiology, hernia, inguinal hernia
|How to cite this article:|
Rao S S, Singh P, Gupta D, Narang R. Clinicoepidemiologic profile of inguinal hernia in rural medical college in central India. J Mahatma Gandhi Inst Med Sci 2016;21:116-21
|How to cite this URL:|
Rao S S, Singh P, Gupta D, Narang R. Clinicoepidemiologic profile of inguinal hernia in rural medical college in central India. J Mahatma Gandhi Inst Med Sci [serial online] 2016 [cited 2019 Dec 11];21:116-21. Available from: http://www.jmgims.co.in/text.asp?2016/21/2/116/189543
| Introduction|| |
Inguinal hernias are one most common problem dealt by general surgeons and have statistically significant morbidity and mortality. Globally, inguinal hernias comprise 75% of all abdominal wall hernias. Inguinal hernia repair is one of the most common general surgical operations worldwide accounting for about 10–15% of all surgical procedures second only to appendectomy. It has been estimated that worldwide over 20 million repairs of inguinal hernia are carried out each year, the specific operation rates varying between countries from around 100 to 300/100,000 population/year. In the United Kingdom, some 100,000 inguinal hernias are repaired each year and approximately 750,000 inguinal hernias are repaired each year in the United States. In India, the estimated annual incidence of inguinal hernias is 1,957,850.
Inguinal hernias have varied presentation, and treatment of hernia depends upon the duration of presentation and the type of presentation. In the developed countries, almost all of the inguinal hernias are recognized early and present early in the course of disease to the surgeon.
However, in developing countries, quite a considerable percentage of it is not repaired leading to a higher incidence of morbidity and mortality. The management of inguinal hernia poses therapeutic challenges to general surgeons practicing in resource limited countries. Late presentation of the disease coupled with the lack of modern therapeutic facilities such as laparoscopy and mesh are among the hallmarks of the disease in developing countries. In India, there is a paucity of published data on the clinicoepidemiological profile of patients presenting with inguinal hernia and data on their surgical management and outcomes.
Hence, we planned this study to understand the clinicoepidemiologic profile of inguinal hernia in rural medical college in central India. We describe our experience of the various presentations, epidemiological profile, and treatment outcome of patients with inguinal hernia.
| Methodology|| |
Study design and setting
This is a descriptive epidemiological, prospective study which was carried out in Mahatma Gandhi Institute of Medical Sciences, which is a 920 bedded medical college located in rural central India. The hospital caters to more than 45,000 in-patients annually, out of which a tenth are admitted in surgical wards. Inguinal hernias comprise of about 8–10% of these surgical admissions. The study was conducted in the months of July and August 2013.
Subjects and methods
All patients (adults and pediatric age) who presented to the surgical wards and outpatient with a clinical diagnosis of inguinal hernia were included in the study. Patients those who refused to give consent were excluded from the study. The clinical diagnosis of inguinal hernia was made by detailed history and clinical examination. All patients being admitted/or managed in outpatients are seen by a surgical attending/consultant to confirm diagnosis of hernia. Those patients who are willing for surgical intervention are then admitted to the surgical wards. Patients with complications of inguinal hernias are directly admitted from emergency ward. All patients have a detailed preoperative assessment by a team of attending surgeons and attending anesthetists before operative procedure.
At the time of diagnosis of the patient with inguinal hernia, the study investigator completed the detailed pretested, coded questionnaire of the patient, which included sociodemographic details (age, sex and occupation), clinical presentation (duration of hernia, side affected, extent, reasons for late presentation, type of hernia, whether primary or recurrence), past medical and surgical history, American Society of Anesthesiologists (ASA) class, type of surgical procedure, postoperative complications, the duration of hospital stay, and mortality. Data were then abstracted from the medical records regarding the complications and hospital stay.
Ethical approval to conduct the study was obtained from the Institutional Ethic Review Committee before the commencement of the study. Informed consent was sought from each patient before being enrolled into the study.
Statistical data analysis
All the variables from questionnaire were entered into Microsoft Excel sheet and electronically transferred. Statistical data analysis was done using SPSS software version 17.0 (SPSS Inc., Chicago, IL, USA). Data were summarized in the form of proportions and frequent tables for categorical variables. Continuous variables were summarized using means, median, mode, and standard deviation.
| Results|| |
A total of 65 patients were enrolled in the study. However, four patients were excluded as they refused to give consent. These patients were mostly men (91.8%) with a mean age of 45.02 ± 22.87 years, married (77.05%), laborer (19.67%), or farmer (37.7%) by occupation mostly and educated up to primary (31.43%) or secondary (31.43%). The demographic characteristics of the study population are given in [Table 1].
Most of the patients of inguinal hernia were admitted from Surgical Outpatient Department (85.25%) and none were managed on outpatient or day care basis. All the patients of inguinal hernia presented with complaints of lump above the inguinal increase and three-fourth of these patients had complaints of pain (73.77%). The duration of hernia was a median of 180 days (14–3650 days). Eighty percent of the patients complained of change in lump with coughing or straining. More than half of the patients had one of the signs of obstruction at the time of presentation; of which increase in pain was the most common (52.46%). History of benign prostatic hyperplasia was one of the most common risk factor for the occurrence of inguinal hernia in the study population and was seen in 16.39% patients. History of strenuous activity of lifting heavy weights was seen in 59.02% of cases of inguinal hernia. Almost 60% patients had a history of tobacco use/smoking [Table 2].
Most of the patients presented late to the hospital due to lack of awareness of the disease [Table 3]. About 20% patients felt that hernia is not a dangerous disease and hence did not seek medical advice early and 8% patients had financial constraints.
Most of our study patients had normal built and presented with predominantly right-sided hernia [Table 4]. Bilateral hernia was seen only in 6.56% patients. Eighty percent of the hernias were acquired, approximately 74% were incomplete, about 84% were indirect and all were primary in occurrence. Cough impulse and reducibility were seen in about 85% of the patients with hernias. [Table 5] shows the operative details of the patients.
Most of the hernia surgeries were done electively (86.89%) and under spinal anesthesia (83.61%). The most common operative procedure done was open hernioplasty (Lichtenstein's procedure) in 61.67% patients followed by herniotomy (18.33%) and herniorrhaphy (modified Bassini's procedure) in 13.33% patients. Laparoscopic hernia repairs were done only in four patients. During surgery, indirect hernial sacs were most commonly encountered (90.16%). About 85% of patients did not show any complications of hernia intraoperative and only eight patients (13.11%) had adherent omentum and one patient (1.64%) had ischemic bowel. Postoperative only three patients (4.92%) had fever. There were no other postoperative complications or death seen. The mean duration of hospital stay was 2.05 ± 0.79 days.
| Discussion|| |
This study was done to understand the demographics, clinical presentation, and treatment outcomes of patients with inguinal hernia. In our study, we found that inguinal hernia affected mostly men with a mean age of 45.02 ± 22.87 years. However, studying the distribution of age, we found that there were maximum numbers of patient in the age group of 40–60 years followed by 0–10 years. It has been said that inguinal hernia is a disease of infants due to defect in inguinal canal  by some, whereas others have found higher incidence of inguinal hernia in higher age groups. Our study demonstrated that though inguinal hernia was seen with increase in age but there are many pediatric patients with congenital inguinal hernia as well. The mean age of presentation was comparative with other studies in literature. Increased incidence of inguinal hernia in the productive age group of 40–60 years causes a burden on the economy of the country by increasing the morbidity in its working population.
Literature suggests that inguinal hernias are more common in males than in females (20:1). In our study also, we found that there were more males with inguinal hernias than females. The exact mechanism for this is not known but it postulated that it is probably because males are involved in more strenuous activities than females. However, in our study, the females were very less which may be due to the cultural dynamics of the society where females tend to seek medical care quite late. Some studies have shown a higher incidence in females and the factors that were independently associated with a higher incidence of inguinal hernia among women were middle or older age, rural residence, height in the upper two-third, chronic cough, and umbilical hernia.
Inguinal hernias are reported to be more common in low socioeconomic strata. This is very well reflected in our study where in most of the patients had a median income of rupees 6500 only and were educated only up to primary or secondary level and this is comparative to other studies.,
In our study, most of the patients of inguinal hernias presented late to health care provider which is similar to the scenario in other developing countries. This leads to the presentation of long standing inguinal hernias. Lump and pain were the most common presenting symptoms with increase in pain as a sign of obstruction. Most of our patients presented late to health care provider because of the lack of awareness, fear of surgery, and financial constraints, which is comparable to other developing countries.,, Inguinal hernias have a predilection for right side, and this was demonstrated in our study and was in agreement with existing literature. It has been postulated that the reason for this is as the right testis descents later and this leads to the higher incidence of failure of closure of processus vaginalis.,
Strenuous activity such as lifting weights and coexisting benign prostatic hyperplasia and smoking were the common risk factors for the development of inguinal hernia in our study. Increased intraabdominal pressure has long been suspected in the pathogenesis of inguinal hernia, though with little quantitative evidence. Constance et al. did not find an association with factors that might exert an effect through such a mechanism, including physical activity, constipation, chronic cough, and chronic obstructive pulmonary disease. An increased risk of inguinal hernia with greater physical exertion was found in two Spanish hospital-based case–control studies investigating occupational activity  or both work and recreational activity, while greater current sports activity was found to decrease the risk among Dutch women. There was no relation with work-related physical activity among Israeli men. Other factors that might increase intraabdominal pressure were not associated with inguinal hernia in previous studies, with the exception of an increased risk with constipation in the Dutch study.,
Increased body mass index was not seen in our patients. It has been demonstrated that overweight and obese tend to have higher incidence of inguinal hernia both primary and recurrence. Obesity (Quetelet index >30) was found protective for inguinal hernia (OR = 0.2, 95% confidence interval 0.04–1.0) in the case–control study done in women by Liem et al.
Open hernioplasty (Lichtenstein's procedure) under spinal anesthesia was the most common surgical procedure performed and there was rarely any postoperative complication. Lichtenstein's procedure is an open, tension-free, mesh repair popularly used because of the ease of procedure and low recurrence rates. Due to the cost of the mesh, the procedure has not gained popularity in many developing countries were open herniorrhaphy (modified Bassini's repair) is the method of choice in majority of cases.,, Laproscopic hernia repairs in our study were done hardly on four patients. Laparoscopic hernia repairs have gained immense popularity due to the fact that they involve lesser morbidity, shorter hospital stay, faster recovery, and earlier return to employment. However, the obvious lesser use of this procedure at our center may be due to increase in the cost involved as compared to open repair.
In our study, spinal anesthesia was most commonly used for hernia repairs. The choice of anesthesia depends on ASA class of the patient, the size of hernia and the anticipation of operative difficulties. Our study is in comparison to the study done by Mabula and Chalya  in Tanzania where spinal anesthesia is most commonly used. However, in the study done by McFarlane, local anesthesia was used more commonly as hernia repairs were done on day-care basis. In our study, no repair was done on day care basis.
The postoperative complication rate in our study was only 4.92%, which is less than many studies in the literature wherein it varies from 4.2% to as high as 12.4%. This may be attributed to the fact that most of the hernia repairs done were elective (86.89%) and uncomplicated hernias. All the emergency surgeries were done on complicated hernias and had mostly adherent omentum and ischemic bowel was seen only in one case. There was no mortality in our study population.
The mean duration of hospital stay was 2.05 ± 0.79 days which is quite good as compared to other studies from developing countries where it varied from 5 to 9 days. In a metaanalysis by Goodney et al. and other systemic reviews comparing laparoscopic and open mesh repair, the average hospital stay in open repair cases was 4 days and laparoscopic cases was 2 days. Moreover, in our experience, we have not had patients seeking medical care again for any late postoperative complication.
One of the major strengths of our study is that it is one of its kinds of study done in Indian subcontinent which looks at the demographics, clinical presentation, and treatment outcomes of patients with inguinal hernia in rural India. There are a few limitations of this study as well. As this study was done in a short period of 2 months, only 61 patients could be included in the study and no follow-up of the patients could be done. Perhaps, a study of longer duration with a follow-up would be able to generate richer information about inguinal hernias.
| Conclusion|| |
Inguinal hernias continue to be a source of morbidity and mortality in our center and globally. The data regarding the presentation and epidemiologically profile of patients with inguinal hernia is lacking from Indian subcontinent. Late presentation of disease is the hallmark of this disease in rural areas due to the lack of awareness. Increasing awareness of the disease among general population will lead to inguinal hernias being detected at earlier stage and will decrease the morbidity due to this disease. This study highlights this data which is of paramount importance in order to eliminate the morbidity and mortality associated with this common problem.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mabula JB, Chalya PL. Surgical management of inguinal hernias at Bugando Medical Centre in Northwestern Tanzania: Our experiences in a resource-limited setting. BMC Res Notes 2012;5:585.
Kingsnorth AN, LeBlanc KA. Management of Abdominal Hernias. 3rd
ed. London, New York: Edward Arnold; 2003. p. 40-7.
Primatesta P, Goldacre MJ. Inguinal hernia repair: Incidence of elective and emergency surgery, readmission and mortality. Int J Epidemiol 1996;25:835-9.
Williams NS, Bulstrode CJ, O'Connell PR. Bailey and Love's Short Practice of Surgery. 25th
ed. London: Hodder Arnold; 2008.
Wolters U, Wolf T, Stützer H, Schröder T. ASA classification and perioperative variables as predictors of postoperative outcome. Br J Anaesth 1996;77:217-22.
Constance E, James E. Risk Factors for Inguinal Hernia among Adults in the US Population Am J Epidemiol 2007;165:1154-1161. doi: 10.1093/aje/kwm011.
Ruhl CE, Everhart JE. Risk factors for inguinal hernia among adults in the US population. Am J Epidemiol 2007;165:1154-61.
Osifo O, Amusan TI. Outcomes of giant inguinoscrotal hernia repair with local lidocaine anesthesia. Saudi Med J 2010;31:53-8.
Garba ES. The patterns of adult external abdominal hernias in Zaria. Niger J Surg Res 2000;2:12-5.
Ohene-Yeboah M. Strangulated external hernias in Kumasi. West Afr J Med 2003;22:310-3.
Nesterenko IV, Shovskii OL. Outcome of treatment of incarcerated hernia. Khirurgiia (Mosk) 1993;9:26-30.
Mbah N. Morbidity and mortality associated with inguinal hernia in Northwestern Nigeria. West Afr J Med 2007;26:288-92.
Flich J, Alfonso JL, Delgado F, Prado MJ, Cortina P. Inguinal hernia and certain risk factors. Eur J Epidemiol 1992;8:277-82.
Carbonell JF, Sanchez JL, Peris RT, Ivorra JC, Del Baño MJ, Sanchez CS, et al.
Risk factors associated with inguinal hernias: A case control study. Eur J Surg 1993;159:481-6.
Liem MS, van der Graaf Y, Zwart RC, Geurts I, van Vroonhoven TJ. Risk factors for inguinal hernia in women: A case-control study. The Coala Trial Group. Am J Epidemiol 1997;146:721-6.
McFarlane ME. Analgesia-sedation for day-case inguinal hernia repair. A review of patient acceptance and morbidity. West Indian Med J 2000;49:158-60.
McCormack K, Scott NW, Go PM, Ross S, Grant AM; EU Hernia Trialists Collaboration. Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev 2003:CD001785.
Goodney PP, Birkmeyer CM, Birkmeyer JD. Short-term outcomes of laparoscopic and open ventral hernia repair: A meta-analysis. Arch Surg 2002;137:1161-5.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]