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Original Investigation
June 26, 2019

Outcomes After Inguinal Hernia Repair With Mesh Performed by Medical Doctors and Surgeons in Ghana

Author Affiliations
  • 1Lewis Katz School of Medicine, Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, Temple University, Philadelphia, Pennsylvania
  • 2Department of Surgery, School of Medicine and Dentistry, University of Ghana, Accra
  • 3Department of Surgery, School of Medicine and Health Sciences, University for Development Studies, Tamale, Ghana
  • 4Trauma Center at Penn, Department of Surgery, University of Pennsylvania, Philadelphia
  • 5Department of Surgery and Perioperative Sciences, Umeå University, Umeå, Sweden
  • 6Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
  • 7Department of Surgery, University of California, San Francisco
  • 8Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
JAMA Surg. Published online June 26, 2019. doi:10.1001/jamasurg.2019.1744
Key Points

Question  What are the outcomes after mesh inguinal hernia repair performed by medical doctors compared with surgeons in Ghana?

Findings  In this cohort study of 242 men with primary reducible inguinal hernia, there was no significant difference in hernia recurrence at 1 year after inguinal hernia repair with mesh performed by medical doctors compared with surgeons (0.9% vs 2.8%).

Meaning  This study shows that medical doctors can be trained to perform inguinal hernia repair with mesh in men with good results in a low-resource setting and appears to support surgical task sharing to combat the global burden of hernia disease.

Abstract

Importance  Inguinal hernia is the most common general surgical condition in the world. Although task sharing of surgical care with nonsurgeons represents one method to increase access to essential surgery, the safety and outcomes of this strategy are not well described for hernia repair.

Objective  To compare outcomes after inguinal hernia repair with mesh performed by medical doctors and surgeons in Ghana.

Design, Setting, and Participants  This prospective cohort study was conducted from February 15, 2017, to September 17, 2018, at the Volta Regional Hospital in Ho, Ghana. Following successful completion of a training course, 3 medical doctors and 2 surgeons performed inguinal hernia repair with mesh according to the Lichtenstein technique on 242 men with primary, reducible inguinal hernia.

Main Outcomes and Measures  The primary end point was hernia recurrence at 1 year. The noninferiority limit was set at 5 percentage points. Secondary end points included postoperative complications at 2 weeks and patient satisfaction, pain, and self-assessed health status at 1 year.

Results  Two-hundred forty-two patients were included; 119 men underwent operations performed by medical doctors and 123 men underwent operations performed by surgeons. Preoperative patient characteristics were similar in both groups. Two-hundred thirty-seven patients (97.9%) were seen at follow-up at 2 weeks, and 223 patients (92.1%) were seen at follow-up at 1 year. The absolute difference in recurrence rate between the medical doctor group (1 [0.9%]) and the surgeon group (3 [2.8%]) was −1.9 (1-tailed 95% CI, −4.8; P < .001), demonstrating noninferiority of the medical doctors. There were no statistically significant differences in postoperative complications (34 [29.1%] vs 29 [24.2%]), patient satisfaction (112 [98.2%] vs 108 [99.1%]), severe chronic pain (1 [0.9%] vs 4 [3.7%]), or self-assessed health (85.9 vs 83.7 of 100) for medical doctors and surgeons.

Conclusions and Relevance  This study shows that medical doctors can be trained to perform elective inguinal hernia repair with mesh in men with good results and high patient satisfaction in a low-resource setting. This finding supports surgical task sharing to combat the global burden of hernia disease.

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