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144
A. D. Schroeder and C. J. Filipi
– Oral antibiotics for routine hydroceles may
be initiated at the discretion of the surgeon,
and if lariasis is suspected, treatment
should be initiated.
– If a drain is left, the surgeon should change
the dressing on the rst postoperative day
and decide about removing it. If the drain is
not removed, the patient should be followed daily until it is. After drain removal
the patient should be seen by an in-country
surgeon.
15.3.3 Adult Giant Scrotal Hernias
andLarge Inguinal Scrotal
Hernias
Giant inguinal scrotal hernias are highly morbid
and are dened as hernias extending below the
midpoint of the inner thigh with the patient standing [20] and an anteroposterior diameter of at
least 30cm and a laterolateral diameter of 50cm
or more [21] (Fig.15.11). They are more common in developing countries because pediatric
hernia repair is dangerous or unavailable, and a
safe adult repair is almost impossible without an
effective intensive care unit. Campanelli et al.
describe a successful but sophisticated operative
approach that necessitates HIC resources [20].
Alarge lower pararectus incision extending into
the groin is made; full reduction of the hernia sac
contents into the abdominal cavity using the “hug
technique” is used; resection of bowel may be
necessary; and a 30×30cm piece of retroperitoneal mesh is xed with brin glue. The patient is
ventilated for 1day and then extubated and supported by intensive respiratory therapy. Giant
scrotal hernias are highly morbid and are currently out of the HRFU purview.
Large inguinal scrotal hernias also are morbid
and cause sexual dysfunction, chronic pain and
present a higher risk of incarceration and strangulation. These hernias can be repaired in an austere environment, but a thorough preoperative
medical evaluation, an experienced anesthesiologist, and careful dissection and hemostasis are
necessary. An overnight stay may be appropriate,
and surgeon postoperative follow-up is necessary. A scrotal support during the rst postoperative week is advisable.
Fig. 15.11 Giant scrotal hernia
15.3.4 Pediatric Hernia Repair
andUndescended Testicle
Dr. Robert Cusick, an Omaha-based pediatric surgeon (Fig.15.12), established a level of excellence
within our organization, and other pediatric surgeons including Dr. David Partrick (Fig. 15.13)
have sustained that expectation. Dr. Cusick is an
ofcer in the American Pediatric Surgical
Association, and through his network of colleagues, we have been able to reliably recruit
excellent pediatric surgeons. We have had to avoid
hernia repair on children under the age of 6months
because hospitalization is not possible in most of
our sites. All hernia repairs are done on an outpatient basis, and therefore, one child with a large
omphalocele-related fascial defect and hernia was
referred to an in-country pediatric surgeon.
Patients with congenital undescended testicles that
are intracanalicular or supra-scrotal are operated
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145
Fig. 15.12 A Dominican Republic patient with Dr.
Cusick
upon, and there have been no related complications. A pediatrician’s preoperative examination
and early postoperative support and a pediatric
anesthesiologist are other important elements to a
successful children’s program, and in most circumstances, we were able to provide that support.
15.3.5 Incisional Hernias
Incisional hernias are a common complication
after abdominal surgery with the incidence after
laparotomy estimated at 10–15% [22]. In LMICs,
gynecologic procedures are frequently performed
Fig. 15.13 An Ecuadorian patient with Dr. Partrick
23], and large incisional hernias will result.
[
Surgical repair can be complex with prolonged
postoperative in-hospital care, and complications
can be catastrophic requiring multiple operations, mechanical ventilation, and a prolonged
ICU stay. Even in HIC hernia centers of excellence, postoperative complications range from 10
to 48% [
24]. In a retrospective analysis from
Nigeria, large ventral hernia repair was associated with 25.6% morbidity rate and a 4.9% mortality rate [25]. Another report from Nigeria
recorded a wound infection rate of 31.6%, wound
dehiscence rate of 21.1%, and overall mortality
of 4.8% [23]. Even clinically small incisional
hernias can intraoperatively reveal multiple
fascial defects [26], necessitating a large incision,
signicant surgical expertise, and extended postoperative care. Previously at all facilities partnering with HRFU, high-quality postoperative care
was not available. A new hospital in Port-auPrince, Haiti, is now, however, making it possible
146
A. D. Schroeder and C. J. Filipi
to safely perform incisional herniorrhaphy on
select patients.
15.3.6 Anesthesia Care
There is a dramatic disparity in anesthesia-related
complications and deaths when comparing outcomes in HICs with those in LMICs. Anesthesia
care has signicantly improved in HICs since
1970 with an estimated 40-fold decrease in overall mortality to approximately one death in
200,000 anesthetics [27]. Similarly, the rate of
anesthesia-related cardiac arrests decreased
threefold within the last 30years [28]. Data from
LMICs is limited, but anesthesia-related mortality rates are estimated to be vefold higher [29]
and in individual reports up to 60-fold higher
than in HICs [27]. High anesthesia-related mortality rates in LMICs are especially prevalent in
the pediatric population. A recent systematic
review by Gonzalez et al. found signicantly
lower anesthesia-related mortality rates in HICs
(0.0–0.69 per 10,000) than in low-income countries (2.4–3.3 per 10,000) [30]. However, there is
considerable variability in quality of anesthesia
at different LIC sites. One report from West
Africa reported a pediatric anesthesia-related
mortality rate of 97 per 10,000 anesthetics [31]. It
is apparent that surgical outreach missions have
to pay special attention to the availability of welltrained anesthesia staff, adequate equipment,
medications/anesthetic agents, hemodynamic
monitoring, and pulse oximetry. An experienced
pediatric anesthesiologist is vital to the success
of any mission that operates upon children.
documentation methods, and costs associated
with cell phones and absence of internet service.
Torchia et al. report a follow-up concept for
orthopedic surgery missions which involves a
Peruvian physician, who performs four follow-up
consultations within 12 months postoperatively
[33]. An incentive structure with a graduated
payment plan was created for the physician. With
this method, consistent follow-up was achieved
in 82% of patients. Lati etal. described utilization of an online database for preoperative assessments prior to surgical mission trips to the
Philippines [34]. Preoperative consultations can
be documented by a mission team member or
local physician and uploaded to an online server
allowing for remote clinical decision-making.
This concept could also be applied to postoperative evaluations.
Hernia Repair for the Underserved trained 120
health-care promoters to provide hernia patient
follow-up in the Dominican Republic. Healthcare promoters are volunteers that are elected by
their local community and are educated on basic
health-care issues at the ILAC center. The program is 35 years old and highly respected by
patients and the Ministry of Health. The volunteers see patients independently, consult with
their coordinator who may take a cell phone picture of the incision and send it to Dr. Filipi. If
necessary a local surgeon, trained by HRFU, then
sees the patient. In other countries pictures are
sent to Dr. Filipi, and a referral is arranged with a
pre-identied local surgeon. Our organization
has not had sufcient funding to pay local providers for systematic follow-up as mentioned
above, although it is one of HRFU’s goals.
15.3.7 Patient Follow-Up
A common pitfall of surgical outreach missions
is lack of systematic follow-up. Shrime et al.
identied temporary short-term platforms as
being prone to inconsistent follow-up [32]. Other
reasons for low follow-up rates include lack of
local medical staff involvement, patient transportation costs, local staff and patient misunderstanding about the value of follow-up, unreliable
15.4 Training Missions
15.4.1 Capacity Building
Capacity building is dened by the United
Nations as developing a “country’s human, scientic, technological, organizational, institutional and resource capabilities … based on an
understanding of environmental potentials, limits and of needs perceived by the people of the
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country concerned” [35, 36]. For global surgery,
education is a recognized priority for capacity
building. Beard etal. mention that a systematic
teaching program for mesh hernia repair techniques would add greater sustainability to surgical outreach programs [11]. Hernia Repair for
the Underserved developed a surgical training
program for tension-free mesh repair with the
goal of local community self-sustainability
within 5years.
147
15.4.2 Training Method
Fully trained surgeons are chosen for training,
on condition that they use donated mesh for
poor patients only and that a mesh patient
spreadsheet is sent to the HRFU education coordinator before more mesh is provided. Six to
seven nonrecurrent, non-scrotal inguinal hernias
are chosen for training purposes during the
1-day course. The trainer uses a validated surgical technique rating form (the Operative
Performance Rating Scale (OPRS)) designed by
the University of Southern Illinois surgical
department education division with the help of
Dr. John Mellinger and input from Dr. Parviz
Amid, Dr. David Chen of the UCLA department
of surgery, and Dr. Filipi of Creighton University.
The OPRS basic method is approved by the
American Board of Surgeons for resident
training.
Before the rst operation, the rating form is
reviewed with the trainee, and then the trainer
performs the rst operation, and the trainee rst
assists. The trainee (Fig. 15.14) and trainer
reverse their roles with the following 4–6 operations. After each operation the trainer lls out the
rating form in privacy (Fig. 15.15) and then
immediately reviews it with the trainee giving
him a numerical score and explanation for all of
the operative step ratings (Fig.15.16). All training operations are performed the same day, and
the OPRS feedback is completed after each operation. If the trainee achieves satisfactory scores,
they are given a certicate of participation and 20
pieces of donated mesh. Photographs 15.14,
15.15, 15.16 show the process.
Fig. 15.14 The trainee giving local anesthesia
Fig. 15.15 The trainer lling out the form
15.4.3 Hernia Mesh inDeveloping
Countries
Since HRFU started hernia trips in 2004, we have
always had an abundance of high-quality polypropylene mesh. C.R. Bard, Ethicon, Covidien, and
Winer from Columbia have been most generous.
There is now more red tape with some manufacturers, but the supply continues. We have always
148
A. D. Schroeder and C. J. Filipi
coordinator that understands the requirements for
effective education and cultural barriers is essential, but even with that, there is the unexpected.
The trained surgeon has to continue performing
elective hernia surgery, but doctor strikes, natural
disasters, government dysfunction, and many
other barriers abound. The trained surgeon has to
be motivated to keep learning, but in austere circumstances, their family may not have enough
food, so despite a passion for learning, economic
necessities pervade, and rather than perform
charity hernia operations, the surgeon has to promote a private pay practice and take emergency
room call. The list of barriers is endless, but most
important are the trainees ability, their previous
training, and their loyalty to the in-country coordinator. Good trainee support and selection can
with time allow trainees to become a trainer—
which provides overall sustainability of the education initiative.
Fig. 15.16 Discussing the OPRS form after an
operation
been able to supply mesh when the surgeon
requests it. Unexpired mesh is used, although at
the beginning we did on occasion use mesh that
was within 2years of expiration if the packaging
was intact. Now we have more mesh, and companies are beginning to locate manufacturing sites in
HMICs with the intent to provide more affordable
mesh. As the companies see the market expand
due to surgeon and hospital request, and increased
competition occurs from in-country companies
using well-regulated manufacturing and sterilization standards, the Lichtenstein repair and other
mesh operations, including ventral hernia operations, will eventually become commonplace.
Well-conceived training is necessary, however,
for tissue repair surgeons to make the transition to
mesh.
15.4.4 Surgeon Trainee Selection
Trainee selection is critical to the success of any
educational program. A trusted in-country
15.4.5 Additional Barriers
toEducation Assessment
andSustainability
In our experience surgeon trainee follow-up has
been plagued by communication difculties and
cultural/economic disparities. Although most
trainee surgeons have cell phones and an e-mail
address, many do not have affordable internet,
consistent internet, and or a working computer.
Surgeon annual incomes are such that computer
repair or a new purchase is often not possible.
Cell phone communication may be difcult
because there can be a more pronounced language barrier on the phone. Some surgeons do
not fully understand the reason for follow-up and
the information we are seeking. Additionally, the
problem is conceptual. In Haiti, for instance, it is
extremely difcult to obtain reports especially
from the public sector. Surgeons follow this trend
and do not feel compelled by education or instinct
to ll out a spreadsheet, especially if it is for a
foreign program. The other developing country
vagaries of life notwithstanding, postgraduate
education, and the added responsibilities are a
professional luxury that is rarely experienced and
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149
unfamiliar, plus the program is relatively new,
and some surgeons do not feel adherent. We are
trying to better understand the individual followup issues and improve trainee follow-up by
reminders and in person visits. To do so, we now
have a multilingual United States-based surgeon
education coordinator.
Trainee follow-up is more likely but there are
still issues; the language barrier is lower but not
always conquered, and the culture of accountability is often foreign in LICs and LMICs.
Corruption and the spoils system is alive and well
in many developing countries, and honest interchanges, especially when money is involved, are
only possible if the in-country organizational
infrastructure is reliable. We provide mesh to the
trainee surgeon for use in poor patients only, but
follow-up communication and mesh use has
occurred with only 50% of our trainees. This is
not because the trainees are disingenuous but
because we, as an organization, after 5years of
training, need to understand how best to select,
monitor, and help our trainees to perform elective
hernia operations on a regular basis.
Therefore, periodic coordinator assessments of
the surgeons’ ability to perform elective surgery
are necessary. An in-person visit is, however,
expensive. Nonprots often live on the ragged
edge of solvency, and balancing nancial priorities is always a challenge. If there is to be dedication to in-country training and capacity building,
the best method appears to be that implemented
by Torchia et al. [34]. In addition to paying the
United States coordinator expenses, improving
the surgeon’s capacity to perform elective surgery
by paying for or obtaining needed new equipment, and possibly supplementing the surgeon’s
salary, with accountability systems in place may
help the surgeon, his prospective patients, and the
country at large. It is our organizational goal to
mature this approach and learn further lessons to
enable our trainee surgeon partners.
Conclusion
Lessons learned for service missions:
1. Without compromise adhere to the preferential option for the poor.
2. Have an organizational zero tolerance for
patient mortality.
3. Recruit and screen true expert hernia
surgeons.
4. Use pediatric surgeons for children under
16.
5. Recruit expert anesthesiologists.
6. Use pediatric anesthesiologists for
children.
7. Recruit experienced dedicated nurses and
sterilization staff.
8. Team leaders should be experienced hernia surgeons with leadership skills.
9. Utilize proven surgical techniques and
high-quality equipment.
10. Operate selectively on large hydroceles
and giant scrotal hernias.
11. Avoid incisional hernias when starting.
12. Avoid large or complicated incisional
hernias.
13. Utilize well-trained local staff for
follow-up.
Lessons learned for training missions:
1. Recruit a multilingual surgeon education
coordinator.
2. Determine if potential surgeon trainees perform >20 elective operations a month.
3. Train surgeons utilizing OPRS and lectures
for 2days rather than 1.
4. Establish systematized patient and surgeon
follow-up.
5. Train candidates to train other local
surgeons.
The HRFU elective morbidity and mortality rates are consistent with outcomes from
HICs and conrm the feasibility of a public
health initiative based on the principles of the
preferential option for the poor. The model is
reproducible and can benet many.
Acknowledgment Disclosures: ADS has nothing to dis-
close. CJF declares conict of interest related to the submitted work (equipment and/or monetary donations to
501(c)3 non-prot organization Hernia Repair for the
Underserved (HRFU) by Covidien, C.R. Bard, Ethicon,
Cook, and Winer. CJF is the HRFU founder and board
member.
150
A. D. Schroeder and C. J. Filipi
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The Most Important Clinical Trial
intheLast 10 Years inInguinal
andIncisional Hernia Surgery
LarsNannestadJorgensen andThueBisgaard
16
Accumulation of scientic evidence is fast, and
the number of publications within hernia-related
topics increases exponentially. A simple search on
PubMed reveals that the number of publications
applying the search time hernia increased by
100% comparing two 4-year periods (2000–2003,
n=1590, and 2013–2016, n=3228). In addition,
there is an explosion of alternative non-indexed
publications appearing in electronic journals, congress abstracts, search machines, and social
media. Therefore, it is challenging for the scientically active surgeons to keep up with the rapid
stream of new data and to implement evidencebased changes into surgical practice. Apart from a
long time lap between initiation of a randomized
controlled trial and nal publication, considerable
time is associated with implementation of the
study results into clinical practice. While some
promising study conclusions based on rm methodology may remain clinically unnoticed, others
are simply ignored due to conservatism. Therefore,
only a minority of studies lead to signicant
breakthroughs and change of clinical practice.
Given these conditions, it is challenging—if
not impossible—to identify the most important
L. N. Jorgensen (*)
Digestive Disease Center, Bispebjerg Hospital,
University of Copenhagen, Copenhagen, Denmark
T. Bisgaard
Gastrounit, Surgical Division, Centre of Surgical
Research, Hvidovre Hospital, University of
Copenhagen, Copenhagen, Denmark
clinical studies on inguinal and incisional hernia
repair. We were assigned to point out two of the
most important clinical trials in groin and incisional hernia surgery during the recent 10years.
In our search, we aimed to identify papers of
exceptional originality and creativity. The study
results should have outstanding clinical implications for a large group of patients and the potential to signicantly improve surgical practice.
Finally, adoption of the study conclusions should
signicantly impact positively on cost-effectiveness. Our selection criteria were not restricted to
papers, which were published in high-impact scientic journals or had an optimal scientic study
design. Each of us independently selected ve
potential papers from each of the two categories.
Selection of the nal two papers was obtained
after consensus.
Groin Hernia Surgery: Löfgren J, Nordin P,
Ibingira C, Matovu A, Galiwango E, Wladis A.A
randomized trial of low-cost mesh in groin hernia
repair. N Engl J Med 2016;374:146–53.
There is an annual number of approximately
20million groin hernia repairs. Even though they
are considered safe and cost-effective in the
industrialized world, there are limiting factors for
groin hernia surgery in the third world including
restricted health economy, relatively high procedural costs, limited access to hospital facilities,
and low availability of surgeons. Moreover,
patients are often expected to pay for their own
medical care. These resource constraints result in
a considerable rate of nonoperated patients with
© Springer International Publishing AG, part of Springer Nature 2018
G. Campanelli (ed.), The Art of Hernia Surgery, https://doi.org/10.1007/978-3-319-72626-7_16
153
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L. N. Jorgensen and T. Bisgaard
irreducible large inguinoscrotal hernias and ultimately fatal cases due to hernia strangulation. In
this setting, there is a great need to dene and
evaluate a safe low-cost procedure for groin hernia repair.
The use of inexpensive mosquito net made of
high-porosity polyethylene as an alternative to
commercially available mesh materials has
reduced costs associated with groin hernia repair
in some places outside the industrialized world
[1, 2]. However, no randomized comparison
against conventional mesh products had been
undertaken until a group consisting of surgeons
from Sweden and Uganda recently published the
results from a double-blind randomized controlled trial conducted in Uganda [3]. Patients
with a primary unilateral inguinal groin were
recruited in several villages. Following informed
consent, 302 patients underwent Lichtenstein
repair under local inltration analgesia by one of
four surgeons. Patients were evenly randomly
allocated under surgery to receive either a mosquito mesh made of polyethylene (38g/m2, pore
size 1.5mm, prize US$ 1) or a commercial polypropylene mesh (Parietene Light, Covidien,
53.7 g/m2, pore size 1.9 mm, price US$ 125).
Scrub nurses performed the preparation and sterilization of the mosquito mesh material following
a simple guideline.
Astonishing high rates of clinical follow-up
were achieved at 14 days (97%) and 1 year
(94%). The 14-day incidence of all postoperative
complications was 30% with no signicant differences between the allocation arms. Most common were wound complications, none of which
required removal of the mesh. There was only
one patient (0.7%) with a hernia recurrence at
1year postoperative in the low-cost mesh group.
All patients reported signicant improvement of
groin symptoms (Inguinal Pain Questionnaire),
self-assessed health and satisfaction at 1 year
compared to the preoperative assessment,
whereas these parameters did not signicantly
depend on the mesh randomization.
The authors are to be congratulated for performing this extremely relevant study and obtain
high follow-up rates under relatively challenging
East African rural conditions. This study has high
potential impact on health services in areas where
the cost of a commercially available mesh is prohibitive for groin hernia repair. The RCT demonstrated the safety of implanting mosquito net as a
synthetic prosthesis in Lichtenstein repair given
that skilled staff is present to conduct the preparation, packing, and sterilization of the material.
Incisional Hernia Surgery: Millbourn D,
Cengiz Y, Israelsson LA. Effect of stitch length
on wound complications after closure of midline
incisions: a randomized controlled trial. Arch
Surg 2009;144:1056–9.
Incisional hernia develops in up to 29% of
patients undergoing a laparotomy [4]. Surgical
site infection (SSI) occurs in nearly one of ve
laparotomies and increases the risk of incisional
hernia formation [5, 6]. The annual number of
incisional hernia repairs is 300,000in Europe [7],
and the associated cost per patient is between
9000 and 12,000 € [8] leading to an approximate
three billion € in total costs. Incisional hernias
are associated with discomfort, pain, risk of
strangulation, increased sick leave, and reduced
quality of life including impaired cosmesis.
Moreover, incisional hernia repair is often complex with a considerable risk of postoperative
complications and repetitive surgery because of
hernia recurrence. There is thus a great need for
effective and easily applied preventive measures
to reduce the hernia rate, as even minor rate
reductions are accompanied by health-care cost
benets [8]. Lately, prophylactic meshes for
abdominal wound closure have proven effective
for the prevention of incisional hernia in highrisk patients [9]. However, there are more simple
measures to reduce the risk of hernia formation
such as adopting a ratio of at least 4 to 1 for the
length of used suture relative to the length of the
wound [10]. Importantly, a 4 to 1 ratio could be
obtained in different ways: large suture bites and
gaps between each stich or small suture bites in
combination with small inter-stich gaps.
Dr. Israelsson’s group from Sweden that originally proposed the 4 to 1 ratio for abdominal
wound closure sets out to investigate how to obtain
this ratio in the most efcient manner. Impressively,
they conducted such a study in their own center
during a 5-year period randomizing 737 patients
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