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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 21  |  Issue : 2  |  Page : 140-145  

Anesthesia for inguinal hernia repair: Experience with a tertiary hospital-based surgical outreach in a developing world


1 Division of Plastic Surgery, Department of Surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
2 Department of Surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, India
3 Department of Anaesthesia, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, India
4 Surgery Unit, NLNG Industrial Hospital, Bonny, Port Harcourt, Nigeria
5 Plastic Surgery Unit, Department of Surgery, Federal Medical Center, Yenagoa, Bayelsa State, Nigeria
6 Department of Morbid Anatomy, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, India

Date of Submission13-Oct-2020
Date of Decision21-Feb-2021
Date of Acceptance24-Mar-2021
Date of Web Publication6-Jul-2022

Correspondence Address:
Ugochukwu Uzodimma Nnadozie
Division of Plastic Surgery, Department of Surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aam.aam_95_20

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   Abstract 


Background: The dearth of adequate facilities and anesthetists limits the number and extent of surgical cases that can be attended to in surgical outreach programs. Inguinal hernia remains a common health burden in the developing world. Tertiary hospitals provide good anesthetic complements to safe surgeries and will be a veritable tool in surgical outreaches. Objectives: The objective of the study is to assess the types/techniques of anesthesia used in uncomplicated open inguinal hernia repair in a tertiary hospital-based surgical outreach program. Materials and Methods: This study was a prospective analysis of anesthetic techniques used in all uncomplicated inguinal hernia repairs performed in outreach program over 1 week in May 2018. Data were collected with a pro forma, analyzed with SPSS, and presented in tables and figures. Results: One hundred and ninety-five patients with uncomplicated inguinal hernias were recruited for the study. The patients' age ranged from 0 to 89 years, with a mean age of 33.62 ± 22.75 years. Most cases occurred in children. The male-to-female ratio was 7:1, and the majority were primary hernia repairs. Eighty-seven (44.6%) patients had local anesthesia (LA), 65 (33.3%) had general anesthesia (GA), while 43 (22.1%) had spinal anesthesia (SA). One hundred and sixty-two (83.1%) patients needed intraoperative analgesic augmentation. One hundred and sixty-nine (86.7%) patients were operated as day-case surgeries, while 26 (13.3%) patients were discharged the day after surgery. The failure rate of LA and SA put together was 74.6%, but there was no conversion to GA. Anesthetic complication was observed in 3.4% of cases. Conclusion: Organizing inguinal hernia repair outreach in a tertiary hospital offers the benefit of a full complement of anesthesia, which ensures safe and smooth surgery with low anesthetic complications. Most cases were done as daycare surgeries despite the high failure rate of LA and SA.
Résumé
Contexte: Le manque d'installations adéquates et d'anesthésistes limite le nombre et l'étendue des cas chirurgicaux qui peuvent être traités dans les programmes de proximité chirurgicale. La hernie inguinale reste un fardeau de santé courant dans les pays en développement. Les hôpitaux tertiaires fournissent de bons compléments anesthésiques aux chirurgies sûres et seront un véritable outil dans les interventions chirurgicales. Objectifs: Évaluer les types / techniques d'anesthésie utilisés dans la réparation de hernie inguinale ouverte non compliquée dans un programme de proximité chirurgicale en milieu hospitalier tertiaire. Méthode: Une analyse prospective des techniques d'anesthésie utilisées dans toutes les réparations de hernie inguinale non compliquées effectuées dans le cadre d'un programme de sensibilisation sur une semaine en mai 2018. Les données ont été recueillies à l'aide d'un formulaire, analysées avec SPSS et présentées sous forme de tableaux et de figures. Résultats: Cent quatre-vingt-quinze patients atteints de hernies inguinales non compliquées ont été recrutés pour l'étude. L'âge des patients variait de 0 à 89 ans avec un âge moyen de 33,62 + 22,75 ans. La plupart des cas sont survenus chez des enfants. Le ratio homme / femme était de 7: 1 et la majorité était des réparations primaires de hernie. Quatre-vingt-sept (44,6%) des patients ont eu une anesthésie locale (LA), 65 (33,3%) une anesthésie générale (AG), tandis que 43 (22,1%) une anesthésie rachidienne (SA). Cent soixante-deux (83,1%) patients ont eu besoin d'une augmentation analgésique peropératoire. Cent soixante-neuf (86,7%) patients ont été opérés en garderie tandis que 26 (13,3%) patients ont obtenu leur congé le lendemain de la chirurgie. Le taux d'échec de LA et SA réunis était de 74,6%, mais il n'y a pas eu de conversion en GA. Une complication anesthésique a été observée dans 3,4% des cas. Conclusion: l'organisation de soins de proximité pour la réparation de la hernie inguinale dans un hôpital tertiaire offre l'avantage d'un complément complet d'anesthésie qui garantit une chirurgie sûre et en douceur avec de faibles complications anesthésiques. La plupart des cas ont été pratiqués en garderie malgré le taux d'échec élevé de l'anesthésie locale et rachidienne.
Mots-clés: Réparation de hernie inguinale, chirurgie de jour, anesthésie générale, anesthésie locale, anesthésie rachidienne

Keywords: Day-case surgery, general anesthesia, inguinal hernia repair, local anesthesia, rural surgical outreach, spinal anesthesia


How to cite this article:
Nnadozie UU, Sunday-Nweke NA, Maduba CC, Madu CI, Nnamonu MI, Akunekwe MI, Igboanugo AA, Okeke VU. Anesthesia for inguinal hernia repair: Experience with a tertiary hospital-based surgical outreach in a developing world. Ann Afr Med 2022;21:140-5

How to cite this URL:
Nnadozie UU, Sunday-Nweke NA, Maduba CC, Madu CI, Nnamonu MI, Akunekwe MI, Igboanugo AA, Okeke VU. Anesthesia for inguinal hernia repair: Experience with a tertiary hospital-based surgical outreach in a developing world. Ann Afr Med [serial online] 2022 [cited 2022 Aug 18];21:140-5. Available from: https://www.annalsafrmed.org/text.asp?2022/21/2/140/349973




   Introduction Top


The treatment plan for hernia presents with some challenges such as anesthesia for the procedure, postoperative analgesic therapy, and convalescence.[1] Local, general, and spinal anesthetic (LA, GA, and SA) techniques are all used for open inguinal hernia repair.[1],[2] The choice of technique will be influenced by local resources, skills, and patients' factors.[2] There is no consensus on the best form of anesthesia in hernia repairs. This is attributed to low rate of serious complications in hernia repair with most anesthetic techniques.[3] However, several studies have shown that LA provides the best clinical and economic benefits to patients.[1],[3],[4],[5],[6]

LA has been shown to be the preferred choice in adult reducible inguinal hernia repair as it is simple, safe, effective, and economical with a low rate of serious complications.[1],[6],[7] LA has also been shown to be feasible in emergency hernia repairs.[8]

The possibility of failure of SA and LA has long been recognized and can be as a result of one of several factors or a combination of factors.[9],[10] Definition of failure has to do with the extent, quality, and duration of LA action. It occurs in 1%–17% of cases.[9] Common causes of failure to achieve anesthesia following infiltration of LA include technical failure, infection, defective medications, and resistance to LA agents, while the causes of inadequate SA may be due to problems with a lumbar puncture, the inadequate spread of drug in the cerebrospinal fluid, or failure of drug action on the nervous tissue. Failure usually disrupts the intraoperative process and could be a source of stress to the anesthetist, patients, and the surgeon. The presence of the anesthetist leads to early recognition and containment of failure in LA and RA. Dealing with inadequate SA can be very challenging.[9],[10] Options for managing an inadequate block include repeating the injection, manipulation of the patient's posture, supplementation of SA with LA infiltration, use of systemic sedation, systemic analgesia, or conversion to GA.[9]

In LA and SA, the patient's conscious awareness of the clinical setting may, in some cases, be a setback to anesthesia and surgery. Lying supine on the operating table and being wide awake while undergoing surgery are not always a pleasant experience. It can increase patients' anxiety. The more anxious the patient is, the more likely he/she reports minor discomfort as pain. The presence of the anesthetist is therefore needed during LA and SA to manage these situations. GA is commonly used for giant, recurrent, and complicated hernia or hernia repairs in children.[11]

In adult patients, the feasibility of LA is high, as judged by the low rate of conversion to GA (<1%).[1]

In children, the choice of anesthetic agent and technique must be informed by both the patient's and surgeon's factors. General inhalational anesthesia with shorter-acting agents such as sevoflurane, supplemented with the caudal or ilioinguinal blockade, is widely utilized for open inguinal hernia repair.[12]

In Africa, surgeons choose LA far less frequently than visiting overseas surgeons (15.6% vs. 27.7%, respectively). Wilhelm et al. reviewed operation theater notes in all seven hospitals in the Northern Region in Ghana over a period of 1 year and found that only 22.4% out of 1038 repairs were performed under LA while SA and GA were predominantly used for the rest of the repairs.[7] However, the failure rate or adequacy of anesthesia was not referenced in the study.

In Nigeria, reviewed studies showed that LA is still the anesthesia of choice in the repair of uncomplicated groin hernias.[11],[13],[14]

Anesthetic support is indispensable if surgery has to be smooth for the patient and the surgeon.

An outreach program is a veritable tool for handling topical health issues where healthcare is provided for the poor and the unreached. Conventionally, in outreaches, the care is taken to the patient in their locality which is usually rural areas in low- and middle-income countries. This study tends to highlight the place of full anesthetic complements in an uncommon hernia outreach setting, where the program is organized in a tertiary healthcare facility rather than in the rural setting.


   Materials and Methods Top


A prospective analytic study of the types of anesthesia used in surgical outreach for inguinal hernia repairs performed in Alex Ekwueme Federal University Teaching Hospital Abakaliki (AEFUTHA) over 1 week in May 2018 was hereby analyzed. The outreach was sponsored by the TY Danjuma Foundation in collaboration with the management of AEFUTHA. Ethical clearance for the study was obtained from the hospital's research and ethics committee.

Study area

The study site is AEFUTHA which is a 720-bed university teaching hospital located in Abakaliki, the capital of Ebonyi state, Southeast Nigeria. AEFUTHA is the only tertiary hospital in Ebonyi state providing tertiary care to Ebonyi state with a population of about 3 million inhabitants and her neighboring states. The inhabitants are predominantly peasant farmers.

Patient selection

The social welfare department of the hospital mobilized patients from all the local government areas of Ebonyi state. Announcement for the program was made via radio jingles, via town criers, and in the places of worship throughout the state. Patients with accompanying relatives were brought to a predetermined/announced location in their locality. They were screened by a team of doctors and nurses from AEFUTHA to select those to be operated on and educated on the surgery and anesthesia, especially on fasting guidelines.

On the day of surgery, most of the selected patients were transported to the AEFUTHA. They were clinically assessed by a team of surgeons and anesthetists to confirm the diagnoses and determine their fitness for anesthesia and surgery. Observation of the fasting guidelines was also confirmed. Patients who were of American Society of Anesthesiologists category 1 and 11, with uncomplicated inguinal hernia who gave consent for anesthesia and surgeries, were recruited into the program.

Team organization and protocol

Workforce mobilized for the program were hospital staff and comprised consultant and resident surgeons, consultant and resident physician anesthetists, perioperative nurses, nurse anesthetists, anesthesia technicians, and porters. Five theater suites and a 6-bed recovery room were dedicated to the program. In each of the theater suite, essential surgical and anesthetic equipment were made available. The recovery room was equipped with pulse oximeters, suction machines, oxygen cylinders, a defibrillator, and an emergency drug tray. The recovery room was manned by nurse anesthetists under physician anesthetists' supervision. They monitored the vital signs of postoperative patients for not <2 h before discharge. Discharge of the patients was made by the anesthetists after full recovery.

Anesthesia and surgery

Patients enrolled for the program had a thorough preanesthesia review. The choice of anesthesia technique was determined by the anesthetist and the surgeon based on clinical findings. On the table, patients were connected to a multi-parameter monitor, and baseline vital signs which consist of heart rate, blood pressure, and SpO2 were recorded.

A start dose of prophylactic intravenous antibiotics was given at induction of anesthesia. Materials were made available for GA, SA, and LA.

Pediatric patients who received GA had it with a face mask. They were premedicated with intravenous atropine and dexamethasone, induced with intravenous ketamine, and maintained with halothane in oxygen. Adult patients who received GA had GA with endotracheal intubation. They were premedicated with intravenous atropine and dexamethasone, induced with intravenous ketamine and propofol with intubation facilitated by intravenous suxamethonium. Anesthesia was maintained with isoflurane in oxygen, while analgesia was maintained with intravenous pentazocine. Those who received SA were premedicated with intravenous metoclopramide and preloaded with 1 L of normal saline.

Anesthesia was induced with 15 mg of 0.5% heavy bupivacaine under aseptic conditions, while those who had LA infiltration received about 5 mg/kg of 2% lidocaine with adrenaline. Those who complained of pain intraoperatively had analgesia augmented with intravenous pentazocine. This was mainly among the LA infiltration and SA group.

The type of hernia repair was based on the age of the patient, integrity of the posterior wall, skills, and preference of the surgeon. Monofilament sutures were used to repair the posterior wall, especially in adults and few grown-up children with weak posterior walls. Vicry 2/0 was used for ligation of the sac during herniotomy in children. The wound was cleaned with povidone iodine and dressed. Patients were discharged the same day to continue oral medications (Vitamin C and analgesics) and antibiotics in a few selected cases for 5 days postoperatively. Follow-up was done on day 3, 1 week, and 6 weeks postoperatively for wound inspections, stitch removal, and complete discharge.

Data collection and analysis

Information on sociodemographic factors, anesthetic techniques, anesthetic complications, duration of hospital stay, and other independent variables was collated using a pro forma. Results were analyzed with Statistical Package for the Social Sciences (SPSS) IBM SPSS Statistics for Windows, Version 20.0. IBM Corp. Armonk, NY, USA and presented in tables and figures.


   Results Top


Two hundred and six patients were enrolled and operated during the program. One hundred and ninety-five had hernia surgeries while 11 had open hemorrhoidectomy. 195 patients with hernia were recruited for the study. The patients' age ranged from 0 to 89 years, with a mean age of 33.62 ± 22.75 years [Table 1]. Most of the operated hernias occurred in children [Table 1]. The male-to-female ratio was 7:1, and the majority were primary hernia repairs [Table 2]. Out of all hernia patients, 87 (44.6%) had LA, 65 (33.3%) had GA, while 43 (22.1%) had SA [Figure 1]. One hundred and sixty-two (83.1%) patients needed intraoperative analgesia, while 33 (16.9%) patients did not require extra analgesia following induction of anesthesia [Table 2]. The mean baseline vital signs were grossly normal (temperature 36.6°C ± 0.51°C, respiratory rate 25.30 ± 5.21 cycles per minute, and pulse rate 89.80 ± 13.30).
Table 1: Age group distribution of patients with inguinal hernia that had different forms of anesthesia

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Table 2: Independent variables

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Figure 1: Anesthetic technique

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The anesthesia failure rate of the LA and RA put together was 74.6%. ([SA + LA = 130]: SA + LA that had analgesia is 97 [i.e., 162 − 65] [analgesia is part of GA]). All patients received a start dose of prophylactic antibiotics at induction of anesthesia. One hundred and sixty-nine (86.7%) patients were discharged on the day of surgery (daycare). Twenty-six patients (13.3%) were admitted for a day before discharge. These were patients who were either operated late and could not go back home or had GA/SA and needed enough time for full recovery [Table 2]. All the patients had postoperative analgesia and Vitamin C for 5 days. Ten patients were given oral antibiotics for 5 days. Anesthetic complications observed in the patients were minimal (scrotal edema in 6 [2.9%] and postdural puncture headache in one patient [0.5%]). No mortality was recorded.


   Discussion Top


Daycare anesthesia is commonly employed in hernia surgical outreach programs because of its numerous benefits, which include increased patient turnover rates, reduced hospital cost, and minimal disruption to family and social settings. To achieve this, there has to be proper patient selection, efficient team organization, and a specialized anesthetic team observing safe anesthesia care.[15] In hernia repair, surgical safety is paramount, and anesthetic support is an important aspect toward its achievement.

The age range of the study population was 1 month to 89 years, with a mean age of 33.62 ± 22.75 years. The sociodemographic features and hernia characteristics such as male preponderance, age involved, and farmers being predisposed, as seen in our study group, are in keeping with those in other reports.[16],[17],[18]

In the program, five operating suites were used. This enhanced our turnover rate and ensured that there was no backlog of cases. We also did not have any difficulties with the mobilization of workforce and transportation of equipment which is usually encountered when surgical outreach programs are conducted in remote areas.[19] Our patients had preanesthetic review by the anesthetist after surgical review the same day just like in other studies.[19] Emphases of the preanesthetic review were to assess general well-being, assess their airways for ease of intubation, and ensure that they had no allergies and upper respiratory tract infections. In all the theater suites, equipment for GA and endotracheal intubation were made available, in case there was a need for conversion to GA or to manage any critical incident in which securing the airway will be necessary. The use of prophylactic antiemetics (intravenous dexamethasone and metoclopramide) was beneficial as it enhanced the reduction in the incidence of nausea and vomiting. Our pediatric patients were spontaneously ventilated with face mask and maintained with halothane in oxygen. This technique has been reported to be good for day-case anesthesia by Imarengiaye et al.[20] Halothane is sweet-smelling and can be safely administered by face mask without bucking, coughing, or breath-holding.

In our region, where the population with hernias are mainly farmers and may need to return to the farm as soon as possible to maintain a livelihood, the decision to return them to active state early will be necessary and the best, cheap, safe, and feasible repair method is chosen. LA has been shown to be a suitable anesthetic technique for the majority of patients presenting for elective hernia surgeries.[11] In our study, the use of LA by infiltration with 2% lidocaine accounted for the majority (44.6%) of the anesthesia given. The advantages of LAs include availability, they are cheap and needs little anesthetists'/specialists supervision, they also allow for hernia demonstration intraoperatively, early mobilization of patients, and they are ideal for daycare surgeries.[1],[6],[7],[9],[21]

Failure of anesthesia has been known to occur with both LA and SA. In our study, failure was noticed in some cases, as a limitation in the extent, quality, and duration of LA/SA. A failure rate of about 74.6% was observed in our study. This is much higher than the rate of 1%–17% which has been reported in previous studies.[9],[10] This maybe because our assessment of pain was not objective as we did not use any pain scoring system. We only relied on intraoperative complaints of pain by the patient before the expiration of the duration of action of the drug used. Further studies will be needed to find out the reason for this high rate of LA and SA failure. Pentazocine proved to be an effective agent to augment analgesia in our patients with failure. We used pentazocine because it is cheap and readily available in our setting.

SA and GA are also good options for hernia surgeries. Their choice is usually a decision of the surgeon and anesthetist, putting patients' medical condition, and choice in perspective. Mostly, they were used for complicated giant hernia, recurrent hernia, and hernia repairs in children as also reported in other studies.[11],[12],[22]

Complications peculiar to SA include urinary retention, postdural puncture headache, scrotal edema, and total SA. The complications noticed in some of our patients were scrotal edema and postdural puncture headache in 2.9% and 0.5% of our patients, respectively. The use of antiemetics may have contributed to zero incidence of nausea and/or vomiting noted in our study.

O'Dwyer et al. compared LA and GA in open hernia repair and concluded that there was no statistically significant difference between the groups in any of the recovery parameters measured and also in terms of cost on the patients.[23]

Some studies have reported the conversion of LA to GA.[24],[25],[26] However, no such conversion was noted in this study and this could be explained by the presence of anesthetists in all the cases who offered adequate anesthesia through supplementation with intraoperative analgesia. The potency of the drugs used may also have contributed as a high-quality tertiary hospital is expected to use only certified drugs. Even if the need for conversion arose, the anesthetists were on the ground with what it takes to do the conversion safely.

Bonnet and Marret in their work on “anesthetic and analgesic techniques can influence the outcome of surgery” stated that intraoperative analgesia helps reduce the intensity of pain and improves patient's comfort during surgery as adequate pain control is a prerequisite to recovery after surgery.[27] In our study, all patients benefitted from the services of anesthetists and 83.1% received intraoperative analgesia which facilitated a smooth procedure for the surgeon through the operation.

Postoperative recovery was assessed by stable postoperative vital signs, the ability to tolerate oral intake without significant nausea/vomiting, and the patient's ability to ambulate.[11] In our study, this was achieved in 86.7% of patients.

Limitations

This is a single-center study. A multicenter study or systematic review is needed to make a more valid inference. Our study did not use any pain scoring method to assess the adequacy of intraoperative analgesia; this if used will have given a more objective pain assessment.


   Conclusion Top


A hernia repair outreach in a tertiary hospital has the advantage of the presence of anesthetists who offered adequate intraoperative analgesia for safe, effective, and adequate anesthesia. Most cases done using LA and SA needed supplementation with analgesia. There was no incidence of conversion from LA or RA to GA. LA remains a safe option in adults for uncomplicated inguinal hernia repair.

Recommendation

We recommend that in the developing world, surgical outreach programs should be based in a tertiary hospital where there is full anesthetic complement when and where such hospitals are available.

Acknowledgment

We acknowledge the TY Danjuma Foundation that sponsored the operations. We also acknowledge the Heads of Surgery, Anaesthesia, and Medical Social Welfare Departments and management of Alex Ekwueme Federal University Teaching Hospital for their roles during the surgical outreach.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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