PATTERN oF ABdoMINAl WAll HERNIA ATTENdEd IN FISHTAIl HoSPITAl, PoKHARA, NEPAl

Introduction: All hernias are caused by a combination of pressure and an opening or weakness of muscle or fascia. The pressures push an organ or tissue through the opening or weak spot. Sometimes muscle weakness is present at birth; more often it occurs later in life. Abdominal wall hernias occur only at sites at which the aponeurosis and fascia are not covered by striated muscle. The aim of the study was to know different pattern of abdominal hernias, to analyze various clonal and demographic profiles of various abdominal wall hernias presenting to the mid-western part of Nepal and to evaluate different types of operation and complication performed in hernias patients. Methods: Hospital based retrospective descriptive study performed in Fishtail Hospital and Research Centre, Pokhara Nepal in october 2012 to July 2017. Ethical clearance was taken from institute and written consent was taken from all the patients who are involved in the study. All sociodemographic data were collected and analyzed by using SPSS 20 statistical software. Results: In this study period, 492 patients of various types of hernias were operated by various methods. Most common type of hernia is indirect inguinal hernia (94.39%) and one rare spigelian hernia was also there. Right inguinal hernia was more common (58.42%). Conclusion: Inguinal Hernia was the commonest type of hernia (394, 90.3%). Among inguinal hernia right side was more common (58.42%). Among inguinal hernias, most of the hernias were found in 0-9 years (38.21%). In this study we found recurrence rate 1.4%.


INTRoduCTIoN
A hernia is the bulging of part of the contents of the abdominal cavity through a weakness in the abdominal wall. Various factors are contributing to cause the different types of hernia. Among them basic design weakness, weakness due to structures entering and leaving the abdomen, developmental failures, genetic weakness of collagen, sharp and blunt trauma, weakness due to aging and pregnancy, primary neurological and muscle diseases and excessive intra-abdominal pressure. 1 The classic reasons for repair of hernia includes, relief of symptoms, prevention of progression, with further weakening of the interior abdominal wall, preventions of complications such as acute incarceration and strangulation, addressing economic/employment/workers compensation issues and treatment of incarceration and strangulation. Contraindications of repair of hernia includes presence of ascites, skin sepsis or other active infections, pregnancy and reversible causes of increased intra-abdominal pressure (eg: prostatism, acute respiratory exacerbation and severe constipation). 2 It is estimated that 5% of the population will develop an abdominal wall hernia. About 75% of all hernias occur in the inguinal region, 2/3 of these are indirect inguinal hernias. Femoral hernias comprise only 3% of all groin hernias. Men are 25 times more likely to have groin hernias than women. Indirect inguinal hernia and femoral hernia occur more commonly on the right side. Hernia recurrence are usually caused by technical factors such as excessive tension on the repair, missed hernias, failure to include an adequate musculo-aponeurotic margin in the repair, improper mesh size and placement. Other factor includes patulous internal ring, chronically elevated intra-abdominal pressure, chronic cough, deep incisional infections and poor collagen formation in the wound. 3

Inguinal Hernia:
Inguinal hernia repair is the most frequently performed operation by the general surgeons. The recurrence rate is relatively low but difficult to pin down because it is nearly impossible to truly follow these patients long term. The true lifetime recurrence rate is probably around 5%, but may be higher. There are many large series of inguinal hernia repair patients with recurrence rates of 1%-3%. The rate of recurrence after a second repair is definitely higher and may approach 10% in growing hernia.
Basic principles for surgical repair are reduction of the hernia content into the abdominal cavity with removal of any non-viable tissue and bowel repair if necessary, excision and closer of a peritoneal sac if present or replacing it deep to the muscles, reapproximation of the walls of the neck of the hernia if possible and permanent re-enforcement of the abdominal wall defect with suture or mesh.
Among all groin hernias, 10% will present with bilateral inguinal hernias and up-to 20% or more will have an occult contralateral hernia on laparoscopic evaluation. A patient with single hernia has a lifetime 33% risk of developing a hernia on the other side. All hernias are caused by a combination of pressure and an opening or a weakness of muscle or fascia; the pressure pushes an organ or tissue through the opening or weak spot. Sometimes the muscle weakness is present at birth; more often; it occurs later in life.

Inguinal Hernia:
A ventral hernia is defined by a protrusion through the anterior abdominal wall fascia. It includes epigastric, umbilical, hypogastric, and incisional hernia. Incisional hernias account for 15-20% of all abdominal wall hernias; umbilical and epigastric hernias constitute 10% of hernias. Incisional hernias are twice as common in women as in men. Umbilical hernia close spontaneously in most cases by the age of 2 years, those that persist after the age of 5 years are frequently repaired. Approximately 3-5% of the population has epigastric hernias. Epigastric hernias are 2-3 times more common in men. These are located between xiphoid process and umbilical. Of all hernias encountered, incisional hernias can be the most frustrating and difficult to treat.

METHodS
A retrospective study was conducted in between October 2012 and July 2017, including all cases of various abdominal wall hernias performed in Fishtail Hospital and research center, Pokhara, Nepal with an objective to analyze various clonal and demographic profile of various abdominal wall hernia presenting to the mid-western part of Nepal. All the cases were noted from operation register of the hospital and data were retrieved from the medical records department. All ages and both sex were included in the study. Various sociodemographic, clinical and operative data were entered in a preformed chart and were analysed using SPSS 20 statistical software.

RESulTS
In between October 2012 to July 2017, a total of 492 cases were operated for various abdominal wall hernias. Out of these 58 cases were excluded as the records could not be retrieved for 17 cases and the rest 41 cases comprised of congenital hydrocele for which herniotomy had been performed. Thus 475 cases of various abdominal wall hernias were included in this study. There were 87.79% males and 12.21% females (figure 1) and there age distributions are shown in figure 2. Inguinal hernia (90.3%) consisted of majority of the series followed by incisional hernia (4.8%), epigastric (1.4%), umbilical (2.1%), femoral (0.9%) and lumbar and spigelian (0.2% each) ( Table 2). Hypertension 96.7%) and Chronic Obstructive Airway Disease (4.6%) consisted of the commonest comorbidities associated with abdominal wall hernias in our series (Table 3). Table 4 depicts various surgical procedures performed in this series. Herniotomy (44.7%), hernioplasty (43.8%) and herniorrhaphy (1.6%) were done for various inguinal hernias whereas only mesh repair (9%) was performed for epigastric, lumbar, umbilical, spigelian and incisional hernia. All 4 cases of femoral hernia in our series were approached via Lockwood inferior approach. Overall 6 cases (1.4%) in our series had recurrences and all of these cases consisted of inguinal hernias. Most of the inguinal hernia in our series were indirect inguinal hernia (370, 94.39%). Out of the 392 cases of inguinal hernia, 22 (6.2%) presented with strangulation and 6 (1.4%) presented with features of obstruction and were thus tackled as emergency. Amongst the inguinal hernias 58.42% were right sided, 37.2% were left and 4.34% were bilateral; whereas 50% each of femoral hernia were left and right sided and the only spigelian hernia in our series was left sided (Table5). Amongst the incisional hernias 28.57% had previous history of hysterectomy, 19.05% had cholecystectomies, 14.29% each had intestinal obstruction and exploratory laparotomy for various other reasons and 23.80% had history of perforation peritonitis in the past.      The incisional of hernia recurrence was up-to 60% in the long term before routine use of mesh prostheses. 10 Another milestone in abdominal wall surgery was the concept of tension free repair which is associated with less postoperative pain and faster recovery, especially after inguinal hernia surgery. 11 Also tension free repair has been associated with a reduction of recurrence rates. 12

CoNCluSIoN
Abdominal wall hernia is a common surgical problem among our population. There is a high incidence of right sided inguinal hernia in male population. Inguinal hernia is a considerable cause of morbidity thus requiring the repair. Lichtenstein tension free repair is the best among the open method of repair which has low recurrence.