Memoire Online - Review of groin hernias at Kibogora hospital

A retrospective descriptive study to describe the prevalence, pattern and the immediate outcome of groin hernia surgery in KIBOGORA Hospital, Department of surgery.

DEDICATION

ACKNOWLEDGEMENT

The success of a dissertation is a big endeavour that one never claims to own alone and when it comes to expressing gratitude, it is always hard to find who to thank and who to leave. This is because various people played different roles under different circumstances in their particular capacities through out the period of writing my dissertation. However let me attempt to this great task:

I owe special thanks to my Mum SSONKO Prossy and Dad BIGIRANDE Emile who managed to forego all and made their son an opportunity cost, without forgetting my uncle MUGGAGA, brothers KAAYA, LUYIMA ,KAKANDE, ISHIMWE, SHYAKA and my sisters NAMATOVU, NAKACHWA, UWASEKURU, and UMUBYEYI who were always there for me during my academic struggle. May God bless them abundantly.

I extend my sincere gratitude to my supervisors Prof. Patrick KYAMANYWA and Prof Ignatius KAKANDE, I am grateful for their advice, instructions and time sacrificed towards the success of this work.

My heartfelt thanks go to Dr. George NTAKIYIRUTA for his support towards perfecting my surgical skills during my spell in Kibogora hospital, may GOD bless him endlessly.

I am greatly indebted to my friends more especially Fred, Joseph, Ivan, James for their tireless help towards making this' dream `come true.

There would be nothing unreasonable than not mentioning the personal attention got from my beloved friends Rachael BUSINGYE and Bob KAGORO for both moral and academic support.

Lastly I wish to thank the entire staff of the National University of Rwanda; mostly the Faculty of Medicine may the almighty God award you abundantly.

LIST OF FIGURES

LIST OF TABLES

ACRONYMS, INITIALS AND ABBREVIATIONS

Old Hippocratic Oath 425 BC

I swear by Apollo the physician, and Aesculapius and Health and all-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this oath and stipulation-to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this Art, if they shall wish to learn it, without fee or stipulation, and that by percept, lectures and every other mode of instruction, I will impart a knowledge of the Art to my own sons and those of my teachers, and to disciple bound by a stipulation and oath according to the law of medicine, but to none other.

I will follow that system of regimen, which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.

I will give no deadly medicine to anyone if asked, nor suggest such counsel; and in like manner I will not give to a woman pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art.

I will not cut persons labouring under the stone, but will leave this work to be done by men who are practitioners of this work.

Into whatever houses I enter, I will go into them for the benefit of the sick and will abstain from every voluntary act of mischief and corruption; and further from the seduction of female, or males, of freemen or slaves.

Whatever in connection with my professional practice, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret.

While I continue to keep this oath unviolated, may it be granted to me to enjoy life and practice this Art, respected by all men, in all times. Should I violate this oath may the reverse be my lot.

ABSTRACT

Background: Hernia is defined as the protrusion of an organ or part of an organ or any other structure through the wall of the cavity that normally contains it.

Goal: To determine the prevalence, pattern and the immediate outcome of groin hernia surgery in Kibogora hospital.

Methodology: This was a retrospective descriptive study for all patients treated for groin hernias in the period of 18 months from 01/01/2007 to 30/06 2008 at Kibogora hospital in the western province. Data was collected using a structured data collection form from patients' clinical files, computerized and analyzed using Epidata and SPSS computer soft wares. The text was written using Microsoft word. Graphs, tables and pie charts were drawn with the help of Microsoft excel. Results were cross-tabulated to examine relationships and association between the variables. Statistical analysis was performed using Q² for test of association. P value of less than 0.05 was considered significant in all the statistical tests performed.

Results: The Prevalence of GH in the surgical department of Kibogora Hospital during the period of study was 121 (16%) among the total of 765 cases. The Male: Female ratio occurrence was 6:1. In a total of 121 cases, 105 (87%) were males and only 16 (13%) were females. Modified Bassini was the most commonly applied technique in Groin Hernia repair (68%), with spinal anesthesia being predominant (77%). Post-operative complications occurred in 25% of all the cases and hematoma wound was the predominant (14%), scrotal edema followed (7%) and wound sepsis came last with only a 4%. The majority of patients (78%) were discharged in good condition

Conclusion: GH is a public health hazard at large as revealed by the above results at Kibogora Hospital. Although the majority of patients operated on for groin hernia are discharged in good condition some post-operative complications (25%) were revealed, wound hematoma and scrotal edema at 14% and 7% respectively were the common . Modified Bassini technique and spinal anesthesia are commonly employed, though in our settings local anesthesia is highly recommended.

CHAPTER 1: INTRODUCTION

Hernia is the protrusion of an organ or part of an organ or any other structure through the wall of the cavity that normally contains it.^1,2Hernias (incorrectly known as rupture) are qualified by the name of the part that protrudes or the area through which protrusion occurs. Thus, an inguinal hernia, perhaps the most common form, is one that passes through the abdominal wall in the groin area ^{[1, 2].}

Groin hernia may be either congenital or acquired. Congenital hernias are preformed hernial openings caused by incomplete closure of the abdominal wall (e.g., persistent processus vaginalis), while, in acquired hernias, the cause is increasing dehiscence of fascial structure with accompanying loss of abdominal wall strength. They develop typically in locations where larger blood vessels or the spermatic cord lie, or where previous incisions were made.

Different factors contribute to the etiology of groin hernias such as increased intra-abdominal pressure (in pregnancy, heavy lifting, chronic cough as in COPD, ascites, straining to pass stool, obesity) ^[3] .

Symptoms of inguinal hernia may include a lump in the groin near the thigh; pain in the groin; and, in severe cases, partial or complete blockage of the intestine.

Blood may be unable to enter or leave the organs in a hernia, so that they strangulate. This is more likely to happen in a hernia with a narrow neck. Most strangulated hernias are therefore either inguinal or femoral, because these hernias have narrow necks and they both require immediate surgery. The main treatment for inguinal hernia in adults is surgery to repair the weakness in the posterior wall. This surgery is called herniorrhaphy. Sometimes the weak area is reinforced with prosthetic mesh. This operation is called hernioplasty. In children usually the hernia sac is ligated after reducing the hernia contents. If the protruding intestine becomes twisted or traps stool, part of the intestine might need to be removed if strangulated.

Femoral hernia is a variety of groin hernia. It usually presents as a defect in the fascia transversalis that is exploited by a peritoneal sac similar to the patent processus vaginalis in an indirect inguinal hernia exploiting the deep ring in the fascia transversalis of the posterior wall of the inguinal canal. Femoral hernias are not as common as inguinal hernias. Femoral hernias are more common in women, usually elderly and frail. They typically present as a groin lump. They may or may not be associated with pain. Often, they present with a varying degree of complication ranging from irreducibility through intestinal obstruction to strangulation of contained bowel. The incidence of strangulation in femoral hernias is high. A femoral hernia has often been found to be the cause of unexplained small bowel obstruction ^[4].

CHAPTER 2: PROBLEM STATEMENT

Hernia repair is one of the most common operations performed worldwide. However, the hernia burden in Rwanda remains unknown as does the outcome of hernia repair surgery in our hospitals.

According to the National Centre for Health Statistics, about 700,000 inguinal hernia repairs are performed each year in the United States. Surgery for hernias represents a significant social expenditure, particularly when lost days of work are factored in. Direct annual costs of hernia surgery alone have been estimated at (2.5 billion dollars). The indirect costs of hernia surgery are difficult to determine, but clearly add substantially to the overall costs ^[4].

In 2000 a prospective descriptive study was conducted at Mulago National Referral and Teaching Hospital in Kampala Uganda for 12 months and 208 patients under went surgical repair for groin hernia. There were 195 (93.7%) inguinal hernias of which 159 (81.5%) were indirect inguinal hernias and 34 (17.4%) were of the direct inguinal variety. Busoga hernias were diagnosed in only 4 (2.05%) of inguinal hernias. There were only 13 (6.2%) femoral hernias. The pantaloon hernias were diagnosed in two patients (1.1%).

One hundred and fifty (76.9%) of the inguinal hernia presented as emergencies and 45 (23.1%) as elective. Post-operative complications occurred in 41.8% of the cases. There was one death. (0.48%) ^[5].

Femoral hernias are not as common as inguinal hernias. Femoral hernias account for about 1.2% to 10% of all groin hernias. In British practice 50% of femoral hernias are admitted as emergencies with strangulation². In Nigeria, in a 5-year study done at a teaching hospital, only 5 patients presented with femoral hernias out of a total of 111 groin hernias seen. In a 14-year period Miller, while working in different parts of Kenya, saw only 3 cases of femoral hernias. He further noted that by 1961, no operation for femoral hernia appeared on the operation lists at Kenyatta National Hospital in Nairobi^[4].

A review of intestinal obstruction at Mulago Hospital between 1958 to 1960 showed that femoral hernias accounted for 12% of the strangulated hernias. Whereas in Kampala, for every one man with a femoral hernia there are nine women ^[5] the male to female ratio is 1.2 to 1 in the West African Hausa^[7] .

Untreated or recurrent groin hernias are responsible for an incalculable loss of productivity and revenue. Postoperative convalescence also contributes to absence from the work force.

Currently the epidemiology of groin hernias in Rwanda is not well understood. This study aimed to evaluate the prevalence and possible complications following surgery and gather baseline data for further clinical and basic research on groin hernias in Rwanda. The study was also used to pass on recommendations to different levels of decision making in government like the ministry of health, Non-Government organizations, medical and paramedical staff on better management and possible preventive measures for complications encountered after groin hernia repair.

2.1 RESEARCH QUESTION AND OBJECTIVES

2.1.1. Research question

What is the prevalence and possible complications following groin hernia surgery at Kibogora Hospital?

2.1.2. Objectives

2.1.2.1. General objective

To determine the prevalence, pattern and the immediate outcome of groin hernia surgery in Kibogora hospital.

2.1.2.2. Specific objectives

(a) To determine the demographic characteristics of patients presenting with specific type of groin hernia.

CHAPTER 3: MATERIALS AND METHODS

3.1. MATERIALS

3.1.1 Study design

This was a retrospective descriptive study; the study involved a review of medical records of all patients treated for groin hernias in the period of 18 months from 01/01/2007 to 30/06/ 2008 at Kibogora hospital.

3.1.2. Study Population and Site

The study was carried out in the surgery department of Kibogora Hospital, in the western province.

3.1.3. Inclusion and exclusion criteria

All patients diagnosed and admitted with Groin hernia as (inguinal or femoral) and underwent hernia repair during 01/01/2007 to 30/06 2008 at Kibogora hospital. We exclude all incomplete files not providing the key information.

3.1.4. Data collection

A structured data collection form was used during the review of clinical files of the patients admitted to the hospital during the time interval from 01/01/2007 to 30/06/2008 and this included; the patients' registration data, clinical assessment, type of operation, type of anesthesia, post operative stay in hospital, possible post operative complications and the actual condition on discharge.

3.1.5. Data analysis methods

The text was written using Microsoft word. Graphs, tables and pie charts were drawn with the help of Microsoft excel. The collected data was computerized and analyzed using Epidata and SPSS computer soft wares, Results were cross-tabulated to examine relationships and association between the variables. Statistical analysis was performed using Q² for test of association. P value of less than 0.05 was considered significant in all the statistical tests performed.

3.1.6. Ethical considerations

No patient's name was written on the structured questionnaire during the study and the data collected from patients' clinical files was destroyed immediately after data analysis.

3.1.7. Study limitations

Our study was limited by the remote location of the hospital in question. This had financial implications in terms of transport and maintenance costs.

CHAPTER 4: RESULTS AND DISCUSSIONS

4.1. RESULTS

4.1.1. Prevalence of Groin Hernia

Figure 1 above shows the total of patients who underwent major operations at Kibogora hospital in the period 18 months from 01/01/2007 to 30/06/2008 was 765 patients among them 121 were operated for groin hernias, this made up a local hospital prevalence for groin hernia of 16%.

4.1.2. Socio-demographic aspects

In our study as it is demonstrated by figure 2 above, the majority of patients 42 (35%) was in the group of >47 years, followed by a group of the age range 24-47 years with 39 (32%), < 13 years were 27(22%) and came last the group of 14-23 years with 13 (11%), the extremities were 1 year and 77 years.

Figure 3 shows that the majority of our patients was male sex making up 105 (87%). Only 16 (13%) of patients were female

Figure 4 above shows that the biggest percentage of patients under went elective surgery for hernia repair this making 77 (63%). Only 8 (7%) of all the patients were emergency. 36 (30%) were referred cases.

Figure 5 shows that 99 (81%) of the patients with groin hernia had no remarkable previous medical status, 14 (12%) of the patients had respiratory problems (as chronic cough), 7 (6%) of the patients had GUT problems (as strain on micturation) and came last

4.1.3. Clinical assessment

Figure 6 above demonstrates that most patients had inguinal hernia i.e. 58 (48%) as RIH and 50 (41%) as LIH, 7 (6%) of the patients had bilateral hernia. Femoral hernia was only seen in 5% of the patients (3%) as left femoral hernia and 2 (2% as right femoral hernia)

Figure 7 above demonstrates that the biggest percentage of the patients in our study had reducible type of hernia and this constituted 95 (79%), followed by non reducible hernia with 12 (10%). Incarcerated hernia hernia was 9 (7%), obstructed hernia and strangulated hernias had equal percentages of 2 (2%) each.

Figure 8 above shows Modified Bassini was the most type of hernia repair performed constituting 83 (68%), this was followed by herniotomy with a 24 (20%). Other nonspecified hernia repairs constituted 7%. Figure of eight for femoral hernia repair constituted 3% and came last the simple closure of defect with a 2%.

Figure 9 above shows that spinal anaesthesia was the mostly used type of anaesthesia with 77% i.e. it was used in 93 hernia repairs out of the 121 cases, only 28 (23%) of hernia repair were under general anaesthesia.

Figure 10 above indicates that 50% of the patients spent 4-7 days in the hospital postoperatively after hernia repair and this was the highest percentage, 43% of the patients spent 1-3days post operatively and only 7% spent 8-14 days postoperatively. This indicates that the evolution of patients' status after hernia repair was good.

Figure 11 above demonstrates that most patients had no complications after groin hernia repair and this constituted 91 (75%). Among the complications seen after groin hernia repair in Kibogora hospital, wound hematoma formation was the commonest with 17 cases making up (14%), scrotal edema came second with 8 cases (7%) and wound sepsis was only in 5 cases making only a 5%.

Figure 12 above demonstrates that the majority 94 (78%) of patients were discharged in good condition, this is attributed to the advanced surgical skills applied during hernia repair in Kibogora hospital, 22% of the patients were discharged in fair condition. There was no death reported during the study period.

4.1.4. Analytical results

Table 1: Distribution of patients basing on comparing sex and type of groin hernia

SEX	TYPE OF GROIN HERNIA					TOTAL	P value
	LIH	RIH	Bilateral inguinal hernia	Left femoral hernia	Right femoral hernia
Male	47 (38.8%)	52 (43%)	6 (5.0%)	0 (0%)	0 (0%)	105 (86.8%)
Female	3 (2.5%)	6 (5.0%)	1 (0.8%)	4 (3.3%)	2 (1.7%)	16 (13.2%)
Total	50 (41.3%)	58 (47.9%)	7 (5.8%)	4 (3.3%)	2 (1.7%)	121 (100%)	0.000 S

Table 1 above shows that the majority of Groin hernia was inguinal hernia and predominantly seen in male sex. Femoral hernia was only seen in 6 cases and all cases were females.

Table 2: Distribution of patients on comparing age range and type of Groin hernia

AGE RANGE	TYPE OF GROIN HERNIA					TOTAL	P value
AGE RANGE	LIH	RIH	Bilateral inguinal hernia	Left femoral hernia	Right femoral hernia
<13 years	10 (8.3%)	16 (13.2%)	1 (0.8%)	0 (0%)	0 (0%)	27 (22.3%)
14-23 years	6 (5%)	7 (5.8%0	0 (0%)	0 (0%)	0 (0%)	13 (10.7%)
24-47 years	19 (15.7%)	18 (14.9%)	1 (0.8%)	1 (0.8%)	0 (0%)	39 (32.2%)
> 47 years	15 (12.4%)	17 (14%)	5 (4.1%)	3 (2.5%)	2 (1.7%)	42 (34.7%)
TOTAL	50 (41.3%)	58 (47.9%)	7 (5.8%)	4 (3.3%)	2 (1.7%)	121 (110%)	0.317 NS

Table 2 above demonstrates that Groin hernia was predominantly seen in the age range >

47 years although the difference was not statistically significant (p value= 0.317). Inguinal hernias were the commonest type of groin hernia seen.

Table 3: Distribution of patients basing on comparing mode of consultation and Pre-operative diagnosis

MODE OF CONSU-LTATION

PRE-OPERATIVE DIAGNOSIS

TOTAL

P value

Reducible

hernia

Non reducible hernia

Incarce-rated

hernia

Obstru-cted

hernia

Strang-ulated

hernia

Referral

25 (20.7%)

(5.0%)

(4.1%)

(0%)

36 (29.8%)

Elective

70 (57.9%)

(4.1%)

(1.7%)

(0%)

77 (63.6%)

Emergency

(0%)

(0.8%)

(1.7%)

(2.5%)

(1.7%)

(6.6%)

TOTAL

95 (78.5%)

(9.9%)

(7.4%)

(2.5%)

(1.7%)

121 (100%)

0.000 S

Results in table 3 above: shows that the mode of consultation differed from each type of pre-operative diagnosis, but all obstructed and strangulated hernias were seen as emergency cases.

Table 4: Distribution of patients basing on comparison between previous medical status and post operative stay

PREVIOUS MEDICAL STATUS	POST-OPERATIVE STAY			TOTAL	P value
	1-3 days	4-7 days	8-14 days
Resp. system (chronic cough)	3 (2.5%)	9 (7.4%)	2 (1.7%)	14 (11.6%)
GUT (strain on micturation)	0 (0%)	5 (4.1%)	2 (1.7%)	7 (5.8%)
Others (ascitis)	0 (0%)	0 (0%)	1 (0.8%)	1 (0.8%)
Unremarkable	49 (40.5%)	47 (38.8%)	3 (2.5%)	99 (81%)
TOTAL	52 (43%)	61 (50.4%)	8 (6.6%)	121 (100%)	0.001 S

Table 4 above shows a significant relationship (p=0.001) between the previous medical status and the post-operative stay on the surgical ward.

4.2. DISCUSSION

Here the results obtained in our study at Kibogora hospital are compared with findings from other studies and we draft some conclusions and recommendations.

A. Prevalence of Groin hernia in Kibogora Hospital (Department of surgery)

At the end of our study we found that the total of patients who underwent major surgical interventions in the department of surgery at Kibogora Hospital from 01/01/2007 to 30/06/2008 i.e. (in 18 months) was 765 patients of which 121 patients were operated for groin hernia making a local hospital prevalence for GH 16%. Although the literature does not prevail a reliable regional or international prevalence for GH, a study carried out by Karuranga Ernest in March 2007 in Kanombe Military Hospital came up with a prevalence of 14.7% in 59 cases recorded among a total of 397 cases involved during the period of 12 months ^[8]. The prevalence of Groin hernia is difficult to determine and the possible reasons for this difficulty being; the inconsistency of data sources used and also lack of standard differentiation of Groin hernia studies from abdominal wall hernia in general.

B. Characteristics of patients according to age

In total this study had a male population of 105 (87%) and females at 16 (13%) and M: F ratio of 6.5:1. This shows a clear agreement with the study conducted by Karuranga [8] which came up with a M: F ratio of 6.1:1. Another study done by Kakande I and Odula P.O about Groin hernia in Mulago Hospital Kampala also confirmed a male predominance ^[5]. The female population in both studies was quite low. This may reflect the role of increased abdominal pressure commonly seen in male sex especially with advancing age.

C. Characteristics according to clinical presentation and type/site of hernia

In Kibogora Hospital (Western province in Rwanda), most patients 95/121 (79%) presented with uncomplicated reducible hernias, 2/121 (2%) presented as strangulated or obstructed hernias, others 12/121 (10%) and 9/121 (7%) presented as non reducible and incarcerated hernias. Basing on the type/site of groin hernia our study revealed that most patients had inguinal hernia i.e. 65/121 (54%), femoral hernia was only seen in 5% of all the cases. Ohene-Yeboah ^[9] in Ghana reported that 71% of cases in his study were inguinal hernias, 10% femoral hernias. In yet another study, by McConkey ^[10] from Sierra Leone, had strangulated hernias representing 25% of all emergency operations. Adesunkanmi in Nigeria, ^[11] in his study of 250 consecutive patients, the incarceration rate was 25%, obstructed hernias were said to represent 26% of all abdominal hernias.

D. Characteristics of patients according to type of operation

In our study at Kibogora hospital we revealed a high tendency to practising the Modified Bassini technique during hernia repair making up 68%. Other techniques included Herniotomy 20%, Non specifified repairs 7%, figure of eight for femoral hernia repair at 3%, Simple closure of defect at 2%. Our study findings were very much consistent with various study findings. In Karuranga's study at KMH in Kigali ^[8], Modified Bassini technique took 52% of cases, followed by Herniotomy 15%. Comparatively to another study by Odula and Kakande in Mulago Hospital, Kampala Uganda ^[5], Modified Bassini technique constituted 68.2% of all cases, Herniotomy at 16.9%, Simple closure of defect 1%. In all the above studies Modified Bassini was the mostly employed technique during hernia repair.

E. Anaesthesia

This study at Kibogora Hospital showed a predominance of applying Spinal anaesthesia during hernia repair with 77% of all hernia repairs. The rest of cases were under General anaesthesia, no local anaesthesia application was revealed during the study period. Elsewhere, in a study done in northern Ghana by Wilhelm TJ et al ^[12], equally revealed that spinal anesthesia was predominant with 48% ,followed by general anesthesia on 29.6% whilst local anesthesia on 22.4% which contrasts with our findings in Kibogora hospital as regards the use of local anesthesia. This trend difference can be explained by the fact that merits of local anesthesia use in elective groin hernia repair in our settings are less known.

F. Post-operative complications/ evolution

In our study, significant complications occurred in 30 (25%) cases in a total of 121 cases which underwent groin hernia repair. Hematoma formation was the most common post-operative complication encountered making up 17 (14%), scrotal edema came second with 8 (7%) and Wound sepsis came last with only 5 (4%) cases. The majority of patients 94 (78%) was discharged from the surgical ward in a good condition. Only 27 (22%) of were discharged in a fair condition, no patient died during this study period. In another study by H Lau and F. Lee in Hong Kong ^[14]to audit the outcome of 271 cases who underwent inguinal hernia repair, no patient died, 265 (97%) cases were discharged home on the day of operation and in good condition, wound complication was the common morbidity encountered.

CHAPTER 5. CONCLUSION AND RECOMMENDATIONS

5.1. CONCLUSION

1. The prevalence of GH at Kibogora Hospital was 16% in 121 cases recorded among

3. Modified Bassini technique is the most commonly performed procedure for Groin

6. Spinal anesthesia was mainly used during groin hernia repair, this was followed by

5.2. RECOMMENDATIONS

To the general population

Ø The entire population should all the time seek medical help whenever they notice a swelling in the groin area because this limits chance of developing complications.

To the Physicians

Ø General practitioners should always seek surgical skills from senior surgeons on how to operate on the groin hernia in order to minimise chances of patients developing post-operative complications.

To the hospitals

Ø Elective hernia repair should be encouraged in order to prevent complications

Ø Improve training to enable students have rational surgical knowledge to enable them improve their surgical skills in general but more specifically for the management of hernias.

Ø Encourage more medical students to carry out research on this subject in other hospitals and compare their results with our findings.

Ø The ministry should carry out a larger fully powered study to determine the extent of this problem in all major hospitals in the country and then take appropriate measures.

REFERENCES

1. Mann CV Hernias. Umbilicus. Abdominal wall In: Mann CV; Russell RCG; Williams NS Bailey and Love's Short practice of surgery. 22^nd ed. ELBS with Chapman and Hall, London 1995, Ch.55; 885-903.

2. Wantz GE Abdominal wall hernias In: Schwartz SI; Shires GT; Spencer FC; Fischer JE Principles of surgery 7^th ed. New York, McGraw-Hill 1999, Ch.34; 1585-1612).

3. Zuckschwerdt W. Verlag , GmbH, Surgical treatment. Abdominal wall. Hernias, pathogenesis 2001.

4. David C Brooks: Classification and diagnosis of groin hernias; 16.2 May 27, 2008, www.Update.com.

5. Kakande I, Odula P 0, Groin Hernia in Mulago hospital, Kampala. East and Central African Journal of Surgery Volume 9 Number 2 - December 2004. 2004 - bioline. rg.br

6. Kark AE, Kurzer M, Waters KJ. Accuracy of clinical diagnosis of direct and indirect inguinal hernia. Br J Surg 1994; 81:1081-1082. [ISI] [Medline]

7. Cameron AE. Accuracy of clinical diagnosis of direct and indirect inguinal hernia. Br JSurg 1994; 81: 250. [ISI][Medline.

8. Karuranga E., Prevalence and management of abdominal wall hernia at Kanombe Miltary Hospital. From Jan 2006-jan 2007. A desertation presented in partial fulfilments of the requirements for the award of MB.ChB. of the national university of Rwanda.2007.

9. Ohene Yeboah M. Stangulated external hernias in Kumasi. W. Africa J Med 200 22(4) : 310-31.

10. McConkey S.J. Case series of Acute Abdominal surgery in rural Sierra Leone. World J. Surg 2002 26: 509-513

11. Adesunkanmi A.R Agbakwuru EA, Badmus T.A. Obstructed Abdominal Hernia at the Wesley Guide Hosp, Nigeria. E Afr Med. J.2000 Jan 77(1) : 31-33.

12. Wilhelm TJ, S,Anemana , P. KyamanywA, J. Rennie , S. Post , S.Freudenberg . Anaesthesia for elective inguinal hernia repair in rural Ghana, Appeal for local anaesthesia in resource-poor countries. (2006 The Royal Society of Medicine Press). Tropical Doctor, Volume 36, N° 3, Pp 147-149.

13. Paola Primatesta and Micheal J. Goldacre. Inguinal Hernia Repair: Incidence of Elective and Emergency Surgery, Readmissions and Mortality. International Journal of Epidemiology. Volume 25, Number-4, pp. 835-839. (1996 Oxford University Press).

14. Lau H, Lee H , An audit of the early outcome of ambulatory inguinal hernia at a surgical day-care centre. Day Surgery Centre, Department of Surgery, The University of Hong Kong Medical Centre, Tung Wah Hospital, Sheung Wan, Hong. 218 HKMJ Vol 6, No 2 June 2000.

15. Ramyil V.M, Iya D, Ogbonna B.C, Dakum N.K. Safety day care hernia repair in Jos, Nigeria. East African Medical Journal ISSN 0012-835X. (2000, Vol.77, No 6, pp. 326-328).

APPENDIX

No	Descriptive question	Response	Code
REGISTRATION DATA
1	Age	< 13 years	1
		14-3 years	2
		24-46 years	3
		> 47 years	4
2	Sex	Male	1
2	Sex	Female	2
3	Mode of consultation	Referral	1
		Elective	2
		Emergency	3
4	Previous Medical Status	Resp. system (e.g. Chronic cough)	1
		GIT ( e.g. constipation)	2
		GUT (e.g. strain on micturation)	3
		Obstetrical (pregnancy)	4
		Others ( e.g. ascitis)	5
		Unremarkable	6
CLINICAL ASSESSMENT
5	Site/type of Groin Hernia	LIH	1
		RIH	2
		Bilateral Inguinal Hernia	3
		Left Femoral Hernia	4
		Right Femoral Hernia	5
6	Pre-operative diagnosis	Reducible Hernia	1
		Non reducible	2
		Incarcerated Hernia	3
		Obstructed Hernia	4
		Strangulated Hernia	5
7	Type of operation	Modified Bassini technique	1
		Shouldice	2
		Herniotomy	3
		Figure of eight for Femoral hernia	4
		Simple closure of defect	5
		Others	6
8	Anaesthesia	General anaesthesia	1
		Spinal anaesthesia	2
		Local anaesthesia	3
9	Post-operative stay (in days)	1-3 days	1
		4-7 days	2
		8-14 days	3
		> 2 weeks	4
10	Post-operative complications	Hematoma formation	1
		Retension of urine	2
		Wound sepsis	3
		Wound sinus	4
		Testicular ischemia	5
		Nerve entrapment	6
		Scrotal edema	7
11	Condition on discharge	Good condition	1
		Fair condition	2
		Died	3

Review of groin hernias at Kibogora hospital

DEDICATION

ACKNOWLEDGEMENT

TABLE OF CONTENTS

LIST OF FIGURES

LIST OF TABLES

ACRONYMS, INITIALS AND ABBREVIATIONS

Old Hippocratic Oath 425 BC

ABSTRACT

CHAPTER 1: INTRODUCTION

CHAPTER 2: PROBLEM STATEMENT

2.1 RESEARCH QUESTION AND OBJECTIVES

2.1.1. Research question

2.1.2. Objectives

2.1.2.1. General objective

2.1.2.2. Specific objectives

CHAPTER 3: MATERIALS AND METHODS

3.1. MATERIALS

3.1.1 Study design

3.1.2. Study Population and Site

3.1.3. Inclusion and exclusion criteria

3.1.4. Data collection

3.1.5. Data analysis methods

3.1.6. Ethical considerations

3.1.7. Study limitations

CHAPTER 4: RESULTS AND DISCUSSIONS

4.1. RESULTS

4.1.1. Prevalence of Groin Hernia

4.1.2. Socio-demographic aspects

4.1.3. Clinical assessment

4.1.4. Analytical results

4.2. DISCUSSION

A. Prevalence of Groin hernia in Kibogora Hospital (Department of surgery)

B. Characteristics of patients according to age

C. Characteristics according to clinical presentation and type/site of hernia

D. Characteristics of patients according to type of operation

E. Anaesthesia

F. Post-operative complications/ evolution

CHAPTER 5. CONCLUSION AND RECOMMENDATIONS

5.1. CONCLUSION

5.2. RECOMMENDATIONS

To the general population

To the Physicians

To the hospitals

REFERENCES

APPENDIX