Rare abdominal wall hernias in South Sudan
This article is dedicated to the memory of Professor Giuseppe Meo who died in January and who initiated, and devoted many years to, the surgical missions in South Sudan.
The repair of abdominal wall hernias (AWH’s) is the most common surgical procedure in the world. In
Figure 1. A Spigelian hernia can become very large
Figure 2. Left Spigelian hernia
Figures 4 and 5. Particular aspects of a large umbilical hernia
The Busoga hernia[b] (BH)
A clear description of the BH is contained in ‘Primary Surgery’ by M. King et al. . The BH is a variety of direct inguinal hernia common in the Busoga area of
Direct inguinal hernias are of two kinds:
- Ordinary direct inguinal hernias which are less frequent in
and seldom strangulate (as one has in Figure 6). They may cause no symptoms, remain the same size for long periods and may not need surgery. Africa
Figure 6. Strangulated hernia
- The BH which is caused by a narrow defect in the conjoint tendon or transversalis fascia and consequently there is a risk of strangulation. The neck of the sac is small, so that when strangulation occurs, often only part of the circumference of the gut is involved causing what is known as a Richter's hernia (Figure7).
Figure 7. Intestinal resection for Richter hernia (arrowed)
Direct hernias can usually be repaired using the same technique as for indirect ones, unless they are very large. However there are differences and a direct hernia may present problems:
- The sac may have no obvious neck so it cannot be excised. The posterior wall of the inguinal canal should be sutured thereby imbricating (overlapping) or over-sewing the excess transversalis fascia. If no prosthesis is used, then the posterior wall of the inguinal canal should be repaired either with the classical Bassini’s or the Shouldice technique, both which incise the traversalis fascia and then resuture accordingly to the method used.
- The weak area in a direct hernia is ill-defined, and tends to involve all or most of the posterior wall of the inguinal canal. In a BH, the opening, often quite narrow, is in the transversalis fascia or the conjoint tendon. Once the sac has been adequately exposed it can be opened, the contents reduced, the redundant part excised and its neck closed with a purse-string suture.
Our rural surgical experience in
- inguinal (including BH and congenital hernias) 481 (68%),
- Spigelian 84 (12%),
- lumbar 64 (9%),
- femoral 43 (6%),
- umbilical in adults 20 (3%),
- epigastric 16 (2%).
In 2011 we reported a retrospective analysis of a surgical service care and ‘on-the-job’ training through mobile surgical missions in South Sudan during the post conflict period 2005 and 2009 . Three surgical teams conducted 23 missions in five primary health care centres in remote areas. A total of 1,543 patients were operated upon: 648 operations (42%) were hernia repairs.
The differential diagnoses of a possible hernia must always be considered and an inexperienced health worker may confuse a lumbar hernia with a subcutaneous lipoma. A BH may confuse the unwary: the herniated loop of the bowel may migrate under the skin and simulate other conditions. For example it may simulate a gynaecological condition when it extends into the labia majora mimicking a tumour or infection (e.g. abscess) (Figure 8). A lumbar hernia may be suspected when a Spigelian hernia loop moves to the lumbar region or to the lateral side of the abdominal wall. It is imperative to identify the true type of a hernia by reducing if possible the intestinal loop into the abdominal cavity.
The repair of the opening in the fascia wall is normally quite easy. Hernia repair with prosthetic meshes should be reserved for recurrences and for huge hernias because of the high risk of infection in rural hospitals and high cost. Cheap mosquito-netting for tension free hernia repair have been proposed [6,7] (Figure 9). Since 2008, we have performed 58 hernia repairs using pieces of mosquito nets as prosthetic material . Follow up is very difficult so a clear description of long term outcomes is not available. However to date no problems have presented.
Figure 9. Mesh for hernia repair (credit Alberto Kiss)
Reporting of the ‘rare’ abdominal hernias is important as they are ‘more common’ in certain geographical areas. Further studies are needed to clarify the occurrence of these hernias. This would highlight the need for health practitioners to be alert to aware of their existence and acquire appropriate surgical training. A study is needed to follow-up patients to define outcomes especially where innovative techniques are used (e.g. the use of mosquito netting as a mesh).
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6.Tongoonkar R, Reeddy B. Preliminary multicentre trial of cheap indigenous mosquito-net clothes for tension free hernia repair. Indian J Surg 2003; 65(1):8295.
7. Clarke MG, Kingsorth AN et al. The use of sterilized polyester mosquito net mesh for inguinal hernia repair in
8. Kiss A,