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28 How toDiagnose andManage Anorectal Disorders inLow- andMiddle-Income Countries
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carcinoma. It is uncertain whether these lesions
are causative for squamous cell carcinoma and
therefore some advocate destruction of these precursor lesions with serial high resolution anoscopy
exams and cauterization to prevent progression to
cancer. Others argue that there is a low risk of
developing anal cancer and do not support serial
exams and ablation of these lesions. When available, the HPV vaccine should be administered to
everyone prior to the initiation of sexual activity. A
study performed in female sex workers in Ibadan,
Nigeria, found the prevalence of HPV infection to
be as high as 88% in the vulva, 84% in the cervix,
and 75% in the anus. Development of cervical cancer is also known to be associated with HPV infections and patients should have annual Papanicolaou
smears. There is little doubt that all high-risk populations should urgently be vaccinated against
HPV to at least prevent continued transmission
[6]. There are bivalent vaccines that focus on
oncogenic subtypes and there are quadrivalent
vaccines whose major protection is against HPV 6,
11, 16, and 18. These vaccines could probably
reduce signicantly the risk of anal cancers.
Unfortunately, the vaccines are still not readily
available worldwide and especially in LMICs.
HIV/AIDS may present initially with anorectal issues such as a ssure; therefore suspicion
should be high dependent on patient risk factors
and presentation. Another manifestation of HIV/
AIDS could be an anal ulcer, abscess, or stula.
Ulcers are often more proximal than the common
ssures. Fissures infected with HIV/AIDS may
present in an atypical position and may therefore
be difcult to locate and track.
Molluscum contagiosum can also present
initially in the perianal region. Diagnosis is often
made by visual conrmation as molluscum have
characteristic features. These include papules
that have waxy domes with an umbilication centrally. If there is uncertainty and a PCR test is
available, it should be done (it may not be available on site). The disease is persistent in immunocompromised patients and treatment is similar
to genital warts. Imiquimod can be applied topically, or these lesions can be removed surgically
by excision, cautery, or cryotherapy.
Pubic lice is caused by the parasite Pthirus
pubis. Transmission is usually from a close con-
tact which may be sexual or just from sheets or
mattresses as it jumps from one patient to the
next one. Recommended treatment is permethrin
1% cream or pyrethrins 0.3%/piperonyl butoxide
4% cream. Sheets/linens/clothing must also be
treated in hot water.
Scabies is caused by the mite Sarcoptes
scabiei. Skin contact is required for transmis-
sion as mites do not jump. Mites burrow in
folds/webs/creases and burrow into skin. They
can mimic a pruritic rash in the groin or buttock region. Diagnosis is often by visualization
and can be conrmed by skin scrapings.
Treatment is with topical permethrin 5%
cream. Oral regimen with ivermectin can be
used as either rst or second line of treatment.
Like with lice, sheets/linens/clothing must be
treated in hot water and heat dried to eradicate
the mites [3].
Tuberculosis, among its many presentations,
can also initially present as an anal lesion. It is rare
that it is conned to the anus and therefore full
systemic workup needs to be initiated. The initial
presentation of anal TB can vary from ulceration
to ssures, to stulas. High suspicion for tuberculosis should be considered if anorectal treatment of
a lesion is refractory to standard treatments. To
conrm the diagnosis of anal TB, a scraping of the
lesion should be examined with acid-fast stain of a
smear and/or biopsy of the lesion or PCR.Anal TB
can also often mimic anal malignancies by not
responding to treatment. While it has been reported
that anal TB is rare and accounts for only 1% of all
GI-related TB cases [7], a recent study which evaluated pus/samples taken from anorectal abscess/
stulas revealed that TB was found in 13.7% of
patients’ samples by GeneXpert testing [8].
Treatment of anorectal TB includes standard antiTB therapy. In cases of anorectal obstruction by
inammation and stenosis, a temporary diverting
stoma should be created and reversed after remission of TB and of obstruction.
Anal Cancer
Workup of anal cancer consists of diagnosis,
staging, and then treatment planning. The etiology of anal cancer appears to be due to HPV
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C. H.-H. Keung
infection. The progression is thought to be
HPV infection (subtypes 16 and 18) leading to
dysplasia resulting in anal intraepithelial neoplasia (AIN). AIN then progresses to anal
squamous cell carcinoma. This pathway from
virus leading to neoplasia is especially concerning in immunocompromised individuals.
These and high-risk patients (men who have
sex with men, MSM) should be monitored
more carefully for anal cancer. With the prevalence of HIV/AIDS in some LMICs, specically in sub-Saharan Africa, this specic
population should be counseled and monitored
for these issues.
Squamous cell carcinoma (SCC) is the most
common malignancy of the anal canal and anal
region while adenocarcinoma is very rare. The
incidence of anal carcinoma was relatively rare in
LMICs at approximately 3% of malignancies in
the past, but it has increased signicantly with the
increased incidence of HIV/AIDS as outlined
above. The symptoms can mimic many of the
conditions that have been described above and
include pain, anal mass, bleeding, change in
bowel habits and narrow stools, and sometimes a
feeling of fullness in the rectum. The diagnosis
starts with DRE and progresses to anoscopy and
colonoscopy with biopsies of the lesion. Blood
tests and total body CT scan should be performed
to rule out metastases. In the past, treatment of
anal SCC consisted of surgical resection, sometimes abdominoperineal resections, or for smaller
tumors of 1cm or less wide local excision. There
is now a debate as to the correct course of action
for anal intraepithelial neoplasia. While some
advocate for no intervention and simply observation for mild dysplasia, others advocate for treatment of even mild dysplasia with surgical
excision and/or cautery. Effective treatment of
AIN includes ablation with electrocautery; this
can be aided with high resolution anoscopy to
specically target areas of dysplasia. This should
be done for moderate- and high-grade dysplasia.
It is important to be mindful of not excising and
cauterizing too much anal tissue as this may lead
to anal stricture and stenosis. Serial exams and
observations are required every 3–6 months of
serial evaluations [3].
If left untreated, moderate- and high-grade
dysplasia can progress to anal cancer. Presentation
is often anal pain and bleeding. Examination will
reveal a mass which should be biopsied. Initial
workup should also include a careful physical
examination with abdominal examination inclusive of inguinal node examination. Anoscopy can
sometimes be limited due to pain from the malignant lesion. Therefore, examination under anesthesia may be warranted to fully appreciate the
extent of the tumor and permit a biopsy. It is
important to document the size of the lesion prior
to biopsy and the location in relation to anal verge
(distance), presence within the anal canal, and/or
location in the anal margin.
Biopsy is important as even unsightly masses
may not be cancer. Buschke-Lowenstein tumors
are such an example. Similar in etiology from
anal carcinoma, the pathogen is HPV virus and
progression is from small condylomata acuminata to a large cauliower like lesion. As opposed
to anal carcinoma, treatment management is surgical excision alone [9].
Anal squamous cell carcinoma, after diagnosis, needs appropriate staging with CT of the
chest/abdomen/pelvis to rule out its extent and
any metastasis. HIV testing and cervical evaluation (pap smear) should be pursued to perform a
comprehensive workup. Case discussion regarding treatment plan should be done in conjunction
with oncology and radiation oncology. For small
select cases of anal margin cancers (tumor size
less than 1cm and no involvement of sphincter
musculature), surgical excision alone can be
curative.
Most recent approach to the treatment of large
tumors with local invasion has focused on the use
of chemoradiation which has revolutionized the
treatment of SCC as it has improved local recurrence rates as well as survival. It rarely requires
colostomy which is frequently not accepted by
patients in LMICs. Since the number of cases of
anal cancer is on the rise in Africa, especially in
HIV infected women where it is 3.9 to 30 per
million, as well as men, greater attention than
ever should be focused on early diagnosis of any
anal complaints and on prevention by vaccination
against HPV.
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351
Anal melanoma is another neoplasia within
the anorectal region that has poor prognosis. It
represents 1–4% of all anorectal malignancies,
and therefore it should be included in the differential diagnosis. Lesions are often pigmented or
present as an ulceration. There is often distant
metastatic disease at the time of diagnosis so the
discussion is usually geared towards palliation
rather than cure [3].
Anal adenocarcinoma accounts for 3% of anal
cancers. These are treated like rectal
adenocarcinoma and should be staged similarly.
Like rectal cancers, treatment discussion and
plan should be done in a multi-disciplinary fashion with oncology and radiation oncology [3].
Especially in late presentation of anorectal
malignancies, it is important to address the urgent
issues of prognosis and complications of treatment prior to discussion of cure or therapy. Anal
neoplasia can potentially stulize leading to
infections (GU/GYN), obstruct, or bleed causing
severe anemia. These acute issues must be
addressed initially while the oncologic workup
proceeds simultaneously. These problems may
imply diversion with an ostomy for obstructions
or stulas that cause sepsis. Transfusions may be
needed to replete blood loss for anemia. It is most
important that at these late stages, the futility of
cure and discussions of palliative goals should be
discussed with patient and their family.
Since anal cancer does not require emergency
treatment, patients who are discovered to have it
should be promptly transferred to tertiary centers
where surgical and medical oncology teams may
apply the latest modalities of treatment.
Conclusion
This chapter offers a brief review of the urgent
surgical anal problems that a general surgeon is
likely to face in LMICs, both in the clinic and in
the emergency room. Most of these conditions
are not life threatening and can be treated successfully, once properly diagnosed. The diagnosis can be sometimes confusing and the surgeon
must be very aware that benign diagnoses such as
hemorrhoids may be masking a more dangerous
diagnosis such as a malignancy. Most of the
infectious problems can be treated successfully if
the infectious agent is properly identied. The
discomfort of pain, disturbed bowel movements,
and occasional anal bleeding can be frequently
relieved by ofce or outpatient procedures performed under local anesthesia. Other problems,
like abscesses, may require hospital admissions,
drainage, and intense course of antibiotics to
avoid occasional death from septicemia. The high
frequency of anal pathology makes this type of
surgical care urgently needed in LMICs as it is in
HICs. Although the incidence of anal malignancies is much lower in LMICs than in HICs, it is
on the rise and is frequently associated with HPV
and HIV. The modern treatment of these malignancies is still best practiced in tertiary centers in
LMICs and it is strongly recommended that once
diagnosed, patients be referred there where
chemoradiation therapy can be applied and selective surgical procedures can be performed by
experts.
References
1. Wexner, S.a.B., D, Fundamentals of Anorectal
Surgery. 1998. https://www.amazon.com/
Fundamentals-Anorectal-Surgery-David-Beck/
dp/0702023663.
2. Kibret AA, Oumer M, Moges AM. Prevalence and
associated factors of hemorrhoids among adult
patients visiting the surgical outpatient department in the University of Gondar Comprehensive
Specialized Hospital, Northwest Ethiopia. PLoS One.
2021;16(4):e0249736.
3. Steele S.The ASCRS manual of colon rectal surgery.
2019. https://www.amazon.com/ASCRS-Manual-
Colon-Rectal-Surgery/dp/303001164X/ref=asc_
df_303001164X/?tag=hyprod-20&linkCode=df0&hv
adid=333072128347&hvpos=&hvnetw=g&hvrand=4
52502010252282729&hvpone=&hvptwo=&hvqmt=
&hvdev=c&hvdvcmdl=&hvlocint=&hvlocphy=9021
556&hvtargid=pla-649739926449&psc=1.
4. Alatise OI, etal. Health-seeking behavior and barriers
to Care in Patients with Rectal Bleeding in Nigeria. J
Glob Oncol. 2017;3(6):749–56.
5. Ashebir DZ, Gebreselassie HA. Pattern and outcome of colorectal and perianal surgery in a Referral
Hospital, Addis Ababa, Ethiopia. Ethiop J Health Sci.
2021;31(5):985–92.
6. Morhason-Bello IO, et al. Oral, genital and anal
human papillomavirus infections among female
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sex workers in Ibadan, Nigeria. PLoS One.
2022;17(3):e0265269.
7. Malikowski T, etal. Tuberculosis of the gastrointestinal tract and associated viscera. J Clin Tuberc Other
Mycobact Dis. 2018;12:1–8.
8. Garg P, et al. Diagnosis of anorectal tuberculosis by polymerase chain reaction, GeneXpert
and histopathology in 1336 samples in 776
anal fistula patients. World J Gastrointest Surg.
2021;13(4):355–65.
9. Kadouri Y, Nouini Y.Buschke-Lowenstein tumor. Pan
Afr Med J. 2020;36:359.
How toManage Hernias
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inLimited-Resource Settings
ImadAljabban andZacharyGleit
Success is not the key to happiness. Happiness is the key to success. If you love what you
are doing, you will be successful.
– Albert Schweitzer
Abbreviations
CT Computed tomography
LMICs Low- and middle-income countries
MRI Magnetic resonance imagining
US Ultrasonography
WHO World Health Organization
Introduction
The anterolateral abdominal wall is a complex
structure involved in a myriad of functions,
including protecting the abdominal viscera from
injury, trunk mobility, ventilation, and regulation
of intra-abdominal pressure. Abdominal wall
hernias are protrusions of abdominal contents
I. Aljabban
Post-Graduate Residency Fellow, Department of
Surgery, NY Presbyterian Hospital,
New York, NY, USA
e-mail: ia2444@cumc.columbia.edu
Z. Gleit (*)
Department of Surgery, Columbia University Vagelos
College of Physicians & Surgeons,
New York, NY, USA
e-mail: zlg1@columbia.edu
29
through the musculofascial layers of the abdominal wall and represent one of the most common
problems encountered by the general surgeon. In
this chapter, we will limit our discussion to the
most common kinds of groin (inguinal and femoral) and ventral abdominal (primary and incisional) hernias. Diaphragmatic, lumbar, spigelian,
obturator, and other rare abdominal wall hernias
are beyond the scope of this discussion.
Hernias are often diagnosed by physical exam,
but in some instances ultrasonography (US) or
computed tomography (CT) may be useful in further characterizing anatomy and hernia contents,
presence of bowel obstruction, and potential
bowel compromise. Indications for repair of hernias include pain or discomfort, and the treatment
or prevention of conditions associated with acute
incarceration—namely, strangulation and
obstruction. Techniques for repair are varied,
including open and laparoscopic approaches,
with or without mesh prostheses.
Availability of hospital resources has the
potential to impact modalities of diagnosis and
treatment signicantly. Surgeons in some lowand middle-income countries (LMICs) often lack
the equipment necessary to adequately diagnose
and provide a durable repair of abdominal wall
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_29
353
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I. Aljabban and Z. Gleit
hernias. Here we will discuss the barriers providers face in LMICs and methods that may be
employed for optimal repair. Some of the limitations that the surgeon faces in LMICs when it
comes to the diagnosis and repair of abdominal
wall hernias include availability of diagnostic
imaging, laparoscopic equipment, and prosthetic
mesh.
Imaging
The rst-line modality for the diagnosis of
abdominal wall hernias is careful physical examination, which is sufcient in most cases. The
patient should be evaluated while supine and
standing. A Valsalva maneuver may be useful in
demonstrating the hernia. Physical exam may
need to be supplemented if the hernia is small or
subtle, or if the exam is limited by the patient’s
body habitus (obesity) or difculty in cooperating with the physical exam. In these cases, US is
a sensitive diagnostic tool in identifying the hernia defect [1]. When US is non-diagnostic, crosssectional imaging (CT) can be used.
Lack of imaging availability in LMICs may be
due to the cost of equipment, lack of resources
for maintenance, and limited availability of
trained technicians to perform imaging studies.
However, compared to CT and magnetic resonance imaging (MRI), US is safe, inexpensive,
and mobile. In a study conducted in Rwanda,
Noble et al. demonstrated that a short training
program led to the successful uptake of US by
hospital clinicians in limited-resource environments, with acceptable accuracy and a signicant
impact on clinical decision-making [2]. The
World Health Organization (WHO) estimated
that nearly 50% of LMICs did not have access to
US in 1997, but evidence suggests that US availability and usage has increased signicantly in
the last decade [3]. Although US has become
increasingly less expensive, lack of sonography
training continues to be a major reason for underutilization [4].
When US is non-diagnostic, CT may be useful
for diagnosis and operative planning for abdominal wall hernias. Indeed, in high-income coun-
tries (HIC), CT is often the imaging modality of
choice for investigation of ventral hernias, but CT
is much less available in LMICs: there is one CT
scanner per 25,000 people in HIC, but only one
per 1.7 million people in LMICs [5].
Laparoscopy
Modern surgical techniques for ventral and groin
hernia repair include robotic and laparoscopic
(“minimally invasive”) approaches in addition to
open approaches. In ideal circumstances, the surgical approach is individualized to each patient.
Laparoscopic and robotic repairs have advantages that potentially include easier recovery,
lower risks of chronic pain, better visualization
of abdominal wall and hernia anatomy, and lower
risks of wound complications related to large
open wounds. However, robotic and laparoscopic
repairs require surgical expertise, and equipment
and instruments that may not be available in
limited- resource environments. In addition, laparoscopic and robotic hernia repairs typically
require general anesthesia, which can often be
avoided for the repair of groin hernias and small
ventral hernias. General anesthesia itself is associated with signicant resource demands and
expense. Because of the resource requirements of
minimally invasive surgery, minimally invasive
techniques are beyond the scope of this chapter.
Availability ofMesh
Over the last four decades, hernia repairs involving the use of synthetic mesh have largely supplanted non-mesh repairs, except for small
primary ventral hernias. In multiple contexts,
mesh has been shown to decrease recurrence
rates substantially, and some data suggest that
mesh repairs are associated with more-rapid
recovery. Although simple polypropylene mesh
implants are fairly inexpensive by the standards
of HIC, with estimates ranging as low as $40–50
for typical implants [6], healthcare expenses are
frequently paid out-of-pocket in LIC, where
many live on less than $2 per day [7]. For this
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reason, cheaper alternatives to commercial mesh
have been investigated and will be discussed later
in his chapter.
Historically and prior to the availability of
synthetic mesh, complex procedures involving
muscle and fascial aps were advocated for hernia repair. We do not advocate these repairs in
limited-resource settings, since we think that surgical expertise for these unusual procedures is
likely less available than mesh. In emergency settings, the use of temporizing procedures (such as
primary repair or soft-tissue closure, with the
expectation of a hernia recurrence) until adequate
resources are available is more prudent than
attempting a complex repair with a high failure
rate and a signicant likelihood of making subsequent repair more complicated.
Less expensive alternatives to commercially
produced mesh have been studied, mainly in the
setting of inguinal hernia repair. The use of mosquito netting, discussed below, has been especially
well-investigated, but there are very limited data
regarding its use other than for inguinal hernias.
Observation Vs Repair
Estimates of the risk of acute incarceration for
ventral and inguinal hernias vary, but this risk is
likely to be low, less than 3% at 5years for incisional hernias [8] and less than 3% at 7years for
small inguinal hernias [9]. Risk of hernia-related
emergency is related to the site and size of the
hernia, so it is difcult to generalize, and clinical
judgment is appropriate.
Though several studies have supported the
idea that observation of small, asymptomatic or
minimally symptomatic inguinal hernias is a safe
strategy, there are also abundant data suggesting
that the crossover rate from observation to operative repair is high. Fitzgibbons etal. reported that
nearly a third of men initially pursuing a strategy
of watchful waiting with regard to their minimally symptomatic inguinal hernias crossed over
to the repair group within 2 years, generally
because of an increase in pain [10]. With longer
follow-up, the authors reported a nearly 70%
crossover rate after 7years [9]. Thus, although
repair of small inguinal hernias is rarely urgent, a
planned repair is generally appropriate.
Similar outcomes have been demonstrated with
regard to minimally symptomatic ventral hernias.
In a retrospective study with more than a thousand
patients, 19% and 16% of patients with incisional
and umbilical/epigastric hernias (respectively)
who were initially asymptomatic elected to have
surgery over a period of 5years. However, when
comparing readmission, reoperation, and overall
mortality, there was no difference between the
cross-over group and those who elected to have
surgery initially [11], again suggesting that there is
generally little urgency to repair.
In non-urgent settings, abdominal binders are
simple and inexpensive and can offer palliation of
reducible ventral hernias by reducing the discomfort associated with visceral bulging and by providing stability to the abdominal wall. They may
be especially useful when temporizing is desirable – for instance, if timing is inconvenient or
suitable resources are temporarily unavailable.
Their efcacy is dependent on the ability to nd a
binder that provides suitable support to the area of
herniation without migrating on the abdominal
wall. They are mainly helpful when the patient is
active, and they need not be worn during times of
rest or recumbency. Binders are likely to be of less
use in chronically incarcerated ventral hernias.
Similarly, a hernia belt or truss may be helpful
to treat the symptoms of inguinal hernia when
surgery is to be deferred, though some evidence
suggests that only a minority of patients will
achieve symptom control [12]. Attention to t is
important, and patients should be instructed on
how to wear them; in particular, a truss should be
donned when the hernia has been reduced, and
the part of the truss that supports the hernia must
be accurately located near the external inguinal
ring in order to provide appropriately localized
pressure.
Groin Hernias
Inguinal hernia repairs are among the most common surgical procedures performed worldwide.
It has been estimated that more than 25% of men
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I. Aljabban and Z. Gleit
will undergo inguinal hernia repair during their
lifetimes [13], and inguinal hernia repair is
thought to be the most common surgical procedure worldwide. Femoral hernias are far less
common than inguinal hernias, and they are more
common in women than in men. Numerous techniques for inguinal hernia repair have been developed, and these can generally be performed under
local anesthesia in outpatient settings. Of note,
most modern guidelines recommend mesh techniques [14]. Especially in non-specialist hands,
mesh repairs have been shown to have lower
recurrence rates with at least comparable risks of
chronic pain and very low risks of other complications. However, commercially produced mesh
may not be readily available in LIC, and, as mentioned above, it can be expensive (in excess of
$100 according to one report) [7].
The Shouldice repair is the best-studied modern non-mesh technique for inguinal hernia
repairs. It involves a multi-layer repair of the
inguinal oor, starting with incision of the inguinal oor and release of the cribriform fascia inferior to the inguinal ligament, providing mobility
to the external oblique aponeurosis. The inguinal
oor is repaired in two overlapping layers, by
sewing the two divided aps of the inguinal oor/
transversalis fascia to the conjoined tendon/internal oblique aponeurosis and to the shelving edge
of the inguinal ligament respectively. This repair
of the oor is then imbricated by approximating
the external oblique aponeurosis to the conjoined
tendon/internal oblique aponeurosis, again in two
overlapping layers. In experienced hands and
appropriately selected patients (generally excluding recurrent hernias or scrotal hernias), some
studies have reported recurrence rates comparable to those associated with open mesh repairs.
However, other studies have failed to conrm
these results, and meta-analyses suggest that
recurrence rates are worse with the Shouldice
repair than with mesh repairs, though better than
with traditional non-mesh repairs [15].
In 2001, Dr. Mohan Desarda published a technique for non-mesh inguinal hernia repair that
seems to be simpler than the Shouldice repair
[16]. It involves creating a pedicle of external
oblique aponeurosis that is then sutured to the
inguinal ligament inferolaterally and to the conjoined tendon/internal oblique aponeurosis
superomedially. The external oblique pedicle is
sewn in a similar fashion to that in which mesh is
sutured over the inguinal oor in a Lichtenstein
repair. Although data are more limited than for
the Shouldice repair, studies have reported recurrence rates that are similar to those following a
Lichtenstein mesh repair, even with long-term
follow-up [17]. As with the Shouldice repair,
however, patient selection may be important; in
particular the external oblique aponeurosis has to
be intact and strong enough to permit a durable
reinforcement of the inguinal oor. To date, there
are no studies that directly compare the Desarda
and Shouldice techniques.
The Lichtenstein mesh inguinal hernia repair
is generally regarded as the standard against
which other open inguinal hernia repairs are
measured. It is a straightforward procedure, in
which a synthetic mesh bridge is placed across
the inguinal oor and sewn to the shelving edge
of the inguinal ligament inferolaterally and to the
conjoined tendon/internal oblique aponeurosis
superomedially. Mosquito netting has been studied as a replacement for commercially produced
mesh for this procedure. It is cheap and widely
available, and it is similar to commercially produced mesh in construction and makeup. It is
often made of polymers (especially nylon, polyester, and polyethylene) that are used in surgical
implants. Several studies over the last 25 years
have investigated the use of mosquito netting in
place of commercially available mesh for groin
hernia repair, without evidence of worse outcome
in short-term or even long-term follow-up [18];
however long-term data are limited. Of note,
however, different mosquito netting products are
made of different materials and are not subject to
the same quality-control and reporting regimens
associated with commercially available hernia
mesh. Attention must be paid to adequate sterilization and, of course, only mosquito netting that
is not impregnated with insecticide should be
used.
Femoral hernias are much rarer than inguinal
hernias and hence are less well-studied. Both
mesh and non-mesh repairs have been described.
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A modication of the Shouldice repair incorporating Cooper’s ligament into the inguinal oor
reconstruction addresses both inguinal and femoral hernias. Similarly, the Lichtenstein repair can
be modied to include Cooper’s ligament rather
than the inguinal ligament inferomedial to the
femoral vein, thereby closing the femoral canal.
Ventral Hernias
Ventral hernias are hernias that occur on the anterior or ventral surface of the abdomen. They may
be further subdivided into primary and incisional
hernias. Primary ventral hernias occur spontaneously without prior surgical trauma to the abdominal wall in their vicinity, and they may be either
congenital or acquired. The most common primary ventral hernias are umbilical and epigastric
hernias; they have a high prevalence in the population (in excess of 20% of the population in one
screening study [19]). Incisional hernias are
related to the failure and breakdown of abdominal wall closure following abdominal surgical
incisions and have been estimated to occur in
about 10% of patients following midline laparotomy [20].
Primary ventral hernias are almost always in
the midline (spigelian hernias, which are rare and
will not be discussed here, are a notable exception). Incisional hernias can occur at any site of
incision but are also most common in the midline. Perhaps the most effective intervention to
decrease the health-care burden of incisional hernias is proper surgical technique to prevent their
occurrence to begin with. Minimizing the use of
midline incisions when feasible is one way to
accomplish this: the risk of incisional hernia after
midline laparotomy has been estimated to be
11%, and less than half that if a transverse incision is used [21]. Similarly, the use of nonabsorbable or slowly absorbable suture instead of
rapidly absorbable suture has been shown to
decrease the risk of subsequent incisional hernia
[21]. Finally, when midline incisions are used, a
small-bite closure technique has been shown to
decrease the rate of hernia formation signicantly
(from 21% to 13% in one randomized trial [22]);
with this technique, a relatively ne (2-0) suture
is used to take fascial bites of 5mm every 5mm,
rather than taking larger bites with more travel
and a larger-caliber suture.
For epigastric and umbilical hernias up to
2 cm in diameter, primary repair is associated
with a relatively low recurrence rate (8% in one
study of small umbilical hernias [23]), though
even for these small hernias, this risk of recurrence is more than twice the recurrence risk when
mesh is used. Small, primary hernias can generally be repaired under local anesthesia. For larger
hernias and for almost all incisional hernias, the
recurrence risk for non-mesh repairs is unacceptably high (22% for umbilical hernias larger than
2cm in the afore-mentioned study [23], and 33%
for incisional hernias according to a Cochrane
review [24]). Multiple techniques for mesh
repairs of ventral hernias have been described,
including inlay (within the peritoneal cavity),
preperitoneal, retromuscular, and onlay
techniques.
Unlike for inguinal hernias, mosquito netting
in place of commercially produced mesh has not
been well studied in the setting of ventral hernias,
perhaps because incisional and large primary
ventral hernias are much less common than
inguinal hernias. We are aware of one case series
describing the use of mosquito netting in this setting, but follow-up was short [25]. In principle,
the experience in the setting of ventral hernias
might not be expected to be signicantly different than that for inguinal hernias. However, ventral hernia repair may require a signicantly
larger mesh patch than is necessary for inguinal
hernias, and the risk of surgical-site complications (seromas and infections, in particular) is
signicantly higher for large ventral hernias.
Thus, the experience with ventral hernias might
differ from that noted with inguinal hernias.
Different forms of myofascial release have
been described to provide increased mobility to
the abdominal wall to permit primary repair for
midline hernias and theoretically avoid the use
of mesh. The underlying principle is that if the
fascia and muscle layers are separated from each
other, the rectus muscles can be advanced to
midline, allowing restoration of the midline and
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I. Aljabban and Z. Gleit
linea alba. This can be done with an anterior or
posterior/transversus abdominis component
release. Anterior component separation has been
particularly described as a technique to avoid the
use of mesh and may be useful when mesh is
unavailable or the surgeon chooses to avoid it.
Anterior component separation can result in
20cm of mobilization of the rectus muscles. The
procedure involves creating a subcutaneous ap
over the external oblique past the linea semilunaris. An incision is made in the external oblique
aponeurosis just lateral to the linea semilunaris,
and the external oblique aponeurosis is separated
from the underlying internal oblique muscle.
Incising the posterior rectus sheaths medially, at
the margins of the hernia on each side, creates
additional mobility, allowing for midline approximation with reduction in tension [26]. However,
this technique and posterior component separation (involving division of the transversus
abdominis muscle and dissection between this
divided muscle and the more-supercial muscle
layers) are generally combined with mesh reinforcement when possible. Recurrences following myofascial release procedures are difcult to
repair, and we therefore do not advocate these
non-mesh approaches except in extenuating circumstances. Again, in urgent circumstances, it is
often preferable to perform a simpler temporizing procedure (such as primary closure or softtissue closure) with a plan to x a likely
recurrence under optimal circumstances in the
future.
Conclusion
Hernias are the most common healthcare challenge requiring surgical expertise worldwide.
Most hernias can be repaired with minimal
demands for extensive surgical or anesthetic
resources or need for advanced expertise. Mesh
repairs have revolutionized the surgical approach
to hernia repair and are widely advocated for
most hernia repairs. Though commercially produced mesh is comparatively expensive, cheap
replacements for mesh (namely, mosquito netting) have been extensively used and studied. For
uncomplicated groin hernias and small ventral
hernias, non-mesh techniques exist, with acceptable reported outcomes.
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