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South African Journal of Surgery

versão On-line ISSN 2078-5151
versão impressa ISSN 0038-2361

S. Afr. j. surg. vol.53 no.2 Cape Town Jul. 2015 



Hernia surgery, South Africa 2015



Dr Ravi Oodit

MB ChB, FCS (SA); Chair of South African Hernia Interest Group.



Abdominal hernia repair is one of the most common operations in general surgery. Abdominal wall hernias include inguinal, incisional, ventral and femoral hernias. The repair rate ranges from 10 per 100 000 population in the UK to 28 per 100 000 in the US.[1, 2] More than one million hernia repairs are performed each year in the US. No published hernia repair rate is available for South Africa.

Inguinal hernias account for 75% of all abdominal wall hernias, presenting a lifetime risk of 27% in men and 3% in women. Incisional hernias will develop in 10 - 15% of patients who have abdominal incisions, increasing to 23% in those who develop postoperative wound infection. [3-5]

The practice of hernia surgery has changed significantly over the last decade. There still remain unresolved issues related to new and evolving open and laparoscopic surgical techniques, different types of meshes and their fixation and advances in abdominal wall imaging. The recent trend is toward the use of biological meshes, which hold promise, but are expensive and outcomes are inconclusive. Advances in radiological imaging have assisted with preoperative planning, but it is unclear if this approach is cost-effective. As yet there is no gold standard operative technique for abdominal wall hernia repair.

This period has also seen a drive to practising patient-centered, evidence-based medicine and the realisation of the importance of compliance and outcomes data and adequate training. The success of evidence-based medicine allows for individualised evidence, expert judgment, relies on local feasibility and requires all stakeholders to work together.

In the absence of local data and strong leadership in hernia surgery in South Africa, there have been attempts to adopt European or American guidelines, with little success and much frustration. In South Africa, there is no profession-driven, formal, national training programme for hernia repair or prevention. Much of the existing training is industry driven. Several research gaps exist, from basic science to patient outcomes, and there is a dearth of locally relevant data.

In response to this, the South African Society for Endoscopic Surgery (SASES) and Association of Surgeons of South Africa (ASSA) have initiated the formation of the Hernia Interest Group (HIG). This was established in August 2013 with the aim to improve the quality of care for patients with hernias.

To achieve this, HIG is collaborating with key role players viz. the academic sector, public healthcare managers and providers, private practitioners, corporate sector and healthcare funders.

In establishing these management guidelines for inguinal hernias (see supplement), the HIG have highlighted the important, locally relevant issues and have presented objective, evidence-based guidelines that will be useful to surgeons, trainees, referring doctors and the healthcare industry.

For these guidelines to have an impact a framework for good data collection on outcome needs to be coupled to a standardised national training programme with adequate proctoring and mentorship programmes, and with regular evaluation and monitoring.

Guidelines on the management of ventral hernias are to follow, together with coordinated attempts to develop and roll out skills training nationally. Guidelines on the development in monitoring and evaluation will also be developed. These data will provide all stakeholders with an indispensable tool to assess the efficacy and impact of the programme, to identify weaknesses and to provide a platform to address these deficiencies to ensure that high-quality, cost-effective patient-centered care is delivered.



1. Kingsnorth A, LeBlanc K. Hernias: Inguinal and incisional. Lancet 2003;362(9395):1561-1571.         [ Links ]

2. Rutkow IM. Demographic and socioeconomic aspects of hernia repair in the United States in 2003. Surg Clin North Am 2003;83(5):1045-1051.         [ Links ]

3. Jenkins JT, O'Dwyer PJ. Inguinal hernias. BMJ 2008;336(7638):269-272. []        [ Links ]

4. Matthews RD, Neumayer L. Inguinal hernia in the 21st century: An evidence- based review. Curr Probl Surg 2008;45(4):261-312. []        [ Links ]

5. Bernhardt GA , Komprat P, Cerwenka H, El-Shabrawi A, Mischinger HJ. Do we follow evidence-based medicine recommendations during inguinal hernia surgery? Results of a survey covering 2441 hernia repairs in 2007. World J Surg 2009;33(10):2050-2055. []        [ Links ]

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