In this study, the objectives were to determine patterns and predictors of adverse postoperative outcomes among emergency groin hernia patients. Simple irreducible and obstructed hernias accounted for 29.9% each, 26.9% had strangulation alone, while 13.4% had both strangulation and obstruction. The proportion of patients that had strangulation in total was 40.3%. These results are comparable to a study done by Gouws et al (13) in South Africa about hernia repair, which observed that 37.5% of the patients operated on as emergency cases had a strangulated hernia. Another study from Saudi Arabia done by Altaf & Algethmi (14) about the risk of bowel resection in emergency hernia reported that the proportion of strangulation was 36.1%, while obstruction and irreducible hernia were 37% and 19.3% respectively.
Contrary to our findings, Hariprasad & Sriniva (15) from India, reported that the proportion of strangulated hernias was 30% and that of incarcerated hernia was 70%. The difference could be due to the difference in study setting and patient characteristics. A five years retrospective study from Italy done by Compagna (16) about emergency hernia repair in elderly patients, reported that 52.1% of the hernias were strangulated while 47.9% were incarcerated, The higher proportion of incarceration could be due to the fact that majority of the patients were elderly with comorbidities.
In Uganda, Odula & Kakande (17) observed that of all patients that presented to Mulago national referral hospital with Groin hernias, 55.8% had strangulation. The fact that Mulago is the national referral hospital where the referral cases could take some time to reach the facility could explain the high rates of strangulation. More so, this study was done more than 20 years ago, and so, this difference could be reflecting the gaps in health care that existed in Uganda 20 years ago.
In this study, 29.9% of the participants had adverse outcomes. The commonest complication was surgical site infection accounting for 11.9% of the study participants. In line with our study, Rayamajhi (13) did a retrospective review of patients that had emergency hernia surgery in South Africa, in which he noted that the proportion that got complications was 32%, and surgical site infection was the most common complication. Also, in a study conducted at Mulago national referral hospital in Uganda, among patients with femoral hernias, wound complications were seen in 30.8% of the participants and respiratory complications in 7.7% (18). Dissanayake (19) reported that complications were seen in 34% of the study participants in Australia with surgical site infection being the commonest while Mabula & Chalya (20) observed that the overall complication rate was 34.6% with surgical site infection being the commonest in Tanzania (20). All the above had findings comparable to our study findings.
The mean length of hospital stay was 5.97 (SD = 3.289) days in our study. Comparable to our study, Lebeau (21) from Ivory coast reported that the average days that patients spend in hospital were 4 (1–28) days. A study in China by Dai (22), also reported 5 days as the mean length of hospital stay in patients operated for an emergency hernia. Contrary to our findings, Urquijo (23) in Mexico while evaluating patients with femoral hernias, observed that the average length of hospital stays for patients that had intestinal obstruction was 11.1 days with a standard deviation of 21.1 days. Which was higher than our findings. This is possibly because this study was about patients with femoral hernias which carry a high complication rate and are therefore more likely to have increased length of hospital stay (24).
We lost one patient representing a mortality rate of 1.5%. This was an elderly patient who presented with strangulated femoral hernia, resection and end to end anastomosis was done, but later she developed anastomotic leak and intra-abdominal sepsis. Contrary to our study, a retrospective review of patients that had emergency hernia surgery in South Africa noted that 5.2% of the patients died following surgery (13). When Gouws et al (13) reviewed the hernia registry of South Africa, they observed that all the mortalities that were seen in hernia patients occurred among patients that had an emergency hernia surgery, with 5.7% of the patients that had emergency surgeries reported to have died. The mortalities in both studies were much higher than our study possibly because these studies included all types of emergency abdominal hernia, and had a longer follow-up duration.
At multivariate analysis, a patient who had gut resection was 10.250 times more likely to have adverse outcomes compared to one that had no gut resection. Our findings were in agreement with what was reported by Dissanayake (19) in Australia, where the need for bowel resection was associated with the occurrence of postoperative complications following emergency hernia surgery. Also in agreement with a study done in Egypt, which revealed that diabetes mellitus and bowel resection were significantly associated with adverse outcomes (25). However, in our study, diabetes mellitus was only significant at bivariate level of analysis.
Strength of the study
To the best of the author’s knowledge, this was the first study that evaluated emergency hernias and predictors of early post-operative adverse outcomes in our setting. This was a prospective cohort done at two centres which makes the findings generalizable.
Study Limitations
The follow-up was limited to recording the outcomes that occurred before discharge, therefore adverse outcomes occurring after discharge were not captured.