Classification, Management and Prognosis of Giant Inguinoscrotal Hernia in Rural Cameroon

Abstract

Introduction : Giant inguinoscrotal hernias (GISH) have been defined as hernias that extend below the midpoint of the inner thigh when the patient is in the standing position. Its management represents a challenge due to the risk of developing abdominal compartment syndrome (ACS) or difficulties during the surgery. The large size and chronicity of the hernia, associated with modified properties of the abdominal wall, makes the management of these cases unique and interesting. There is no standard procedure for treatment of this condition as literature describes several treatment strategies. This study is set out to provide an efficient tool based on clinical assessment, for management of GISH in the rural areas of Cameroon. Materials and methods : We conducted a descriptive cross-sectional study in the ten regions of Cameroon within 13 years. Sampling included patients operated for GISH. The patients were recruited during ASCOVIME health campaigns and operated free in charge in a local health centre/district hospital. Postoperative follow up was done by the local team. Patients were followed up for at least 3 years following the surgery. Patients were classified such that: Type I had their sac reaching the mid-inner thigh; Type II with sac reaching a midline between the mid-thigh and the supra-patellar line; Type III with sac reaching the supra-patella; and Type IV with sac extending below the supra-patella or if associated to other hernias. Results : We included n = 93 cases with a male predominance; sex ratio 11: 1. The average age was 54.7 ± 1.1 (34 - 79) years. Majority of the participants were farmers 66% (n = 61). Those with Type II were the most frequent 48.3% (n = 45). The average length of evolution was 30.8 ± 0.7 years (14 - 50). More than half of the participants 88.7% (n = 82) had reducible hernia predominantly Type I and II. Lichtenstein was the most practised technique 56.5% (n = 53). Bowel resection in 22.6% (n = 21) concerning all Type III and IV, who also all required blood transfusion. The main per operative complications were bowel injury in 9.7% (n = 9). We recorded a case fatality rate of 3.2% (n = 3) from ACS (Type IV) and perioperative bleeding (Type III). Scrotoplasty, when necessary, was postponed. Conclusion : GISH is a reality in our community. Treatment and prognosis greatly rely on the reducibility, and the dissection which can help prevent deadly complications associated to Type III and IV, as the chronicity and visceromegaly characterises them. This should enhance their reference to centres of higher categories for appropriate management.