Key findings:

Key findings from the study on socio-clinical characteristics of patients with inguinal hernia include: Most patients were male (98%), farmers (52%), with right-sided, funicular, reducible swellings and cough impulse. Direct reducible inguinal hernia (46%) was the most common diagnosis. Lichtenstein tension-free mesh hernioplasty (98%) was the predominant surgical technique used.

What is known and what is new?

The known aspect in this abstract is the prevalence of inguinal hernias as a common surgical issue, often repaired using techniques like Lichtenstein hernioplasty. The new contribution is the detailed evaluation of the socio-clinical characteristics of patients with inguinal hernias, shedding light on demographics, hernia types, and surgical approaches in a specific hospital setting.

What is the implication, and what should change now?

The implication of this study on inguinal hernia patients is the need for targeted preventive measures and early intervention, especially in high-risk groups like male farmers. Changes needed include promoting awareness about hernia risk factors, encouraging early medical consultation, and ensuring access to advanced surgical techniques for optimal outcomes in inguinal hernia management.

INTRODUCTION

A hernia is defined as a protrusion, bulge or projection of an organ or a part of an organ through the body wall that normally contains it. In an inguinal hernia the protrusion occurs through the inguinal canal. Groin hernias are the most common conditions for which primary care physicians refer patients for surgical management. Approximately 96% of groin hernias are inguinal and 4% are femoral. [1,2]

In spite of its great incidence, hernias can pose a surgical dilemma, even for the skilled surgeon, because many pathologic entities can masquerade as inguinal hernia. The unexpected hernia content and pseudo hernias constitute some of these cases. The incidence of inguinal hernia is unknown, but about 500,000 cases come to medical attention each year. [3,4]

Although inguinal hernias occur in both sexes, they are more common in men compared with women. In general, inguinal hernia affects all ages, but the incidence increases with age. With respect to gender, women manifest inguinal hernia at a later age, their peak age range at presentation being 40 to 60 years of age, with median age of 60 to 79 years, unlike that of men, which is 10 years earlier. Inguinal hernia is bilateral in up to 20% of affected adults. It is more common on the right than on the left, the ratio being 2:1.5 

Although the incidence and prevalence of inguinal hernias worldwide is unknown, it is estimated, that in the United States, approximately 4.5 million people have inguinal hernia while in Jerusalem, it was documented as 18 per 100 men aged 25 and over. [5]

High morbidity and recurrence rates as well as prolonged recovery have led to a gradual evolution in inguinal hernia repair. Bassini began the era of modern hernia repair more than 100 years ago by proposing an anatomical approach to inguinal hernia repair, which radically reduced recurrence rates. McVay and later Shouldice introduced further modifications of the anatomical approach to improve on Bassini’s technique. Next, mesh-reinforced repairs were introduced to further decrease the incidence of failure. Lichtenstein et al.,8 championed an anterior approach that incorporated a tension-free repair with mesh. In 1990, laparoscopic surgeons took the posterior mesh repair one step further, utilizing modern laparoscopic instrumentation to reduce morbidity and recurrence rates seen with conventional open hernia repairs. At first, surgeons tried simple approaches like Ger’s closure of the internal ring and Shultz’s plug and patch, but these failed to improve on the results of open repairs. When surgeons realized that laparoscopic repairs had to mimic the open posterior repairs of Nyhus and Stoppa, results dramatically improved. [6,7]

Against this background, a present study was done to evaluate the Socio-Clinical Characteristics of Patients admitted with Inguinal Hernia in a Tertiary care Hospital.

Aim & Objectives:

To evaluate the Socio-Clinical Characteristics of Patients admitted with Inguinal Hernia in a Tertiary care Hospital

• Place of Study: Department of General Surgery, Dr. RPGMC Kangra at Tanda, H.P.

   

• Study Design: Prospective observational study

   

• Study Duration:

The study was conducted over the period of 12 months including data collection, data organization, data organization, presentation, analysis, and interpretation.

• Sample Size: 

All the patients who fulfilled the criteria in the study period. In our Study 50 patients were included, who underwent open inguinal hernia repair. No cases of laparoscopic hernia repair were included due to COVID-19 pandemic limitations.

• Inclusion Criteria:

Patients more than 18 years of age with clinical and radiological diagnosis of direct and indirect inguinal hernias, with unilateral or bilateral inguinal hernias and the patients fit for surgery for inguinal hernia were included in the study.

• Exclusion criteria:

• Patients not fit for surgery.

• Not willing to participate in the study.

• Patients < 18 y of age.

Cases with diagnosis of inguinal hernia were included in study admitted under the department of general surgery.

• Methodology:

All patients diagnosed with inguinal hernia who satisfied the inclusion criteria were included in the study. All the included patients underwent general and clinical history examination as per case Performa.

• Ethical Considerations:

The study was initiated following approval from institutional ethics committee (IEC) at Dr. RPGMC Kangra at Tanda. Consent form was collected from each enrolled study subject.

• Statistical Analysis:

The data were recorded in a predesigned Performa. Data entry and analysis were done in Microsoft Office Excel and Epi-Info Software respectively. Descriptive analysis was done using frequency, percentages and mean ±SD. Other statistical analysis was utilized as per requirement.

The present study evaluated the Socio-Clinical Characteristics of Patients admitted with Inguinal Hernia in a Tertiary care Hospital A total of 50 patients were included in this study at the Department Of Surgery, Dr. Rajendra Prasad Government Medical College, Kangra at Tanda, who were fit for surgery.

Table 1: Socio-demographic characteristics of study participants

In our study population the mean age group of the patient was 50+13.5 years. 98% of them were male patients and 2% were female. 12% of the patients were in 18-30 years’ age group range, 12% of them between were in the range of 31-40 years, 24% of the patients were in the range of 41-50 years, 30% of them between 51-60 years range, 18% of our study population were in the range of 61-70 years and the rest 4% were above 70 years. 52% of participants were farmers, 16% were laborers, 10% were students, 6% were shopkeepers, 6% were teachers, 4% drivers, 4% were ex-servicemen and 2% were homemakers. Mean BMI of study participants was 23.4+2 Kg/m2. (Table 1)

Table 2: Frequency of co-morbidities

12% participants had diabetes mellitus, 10% had hypertension and 12% had COPD. In the study 76% participants had no Comorbidities. (Table 2)

Table 3: Hernia examination findings

In our study the most common site of hernia was the right side which constituted 76% and the rest i.e., 24% were on the left side. The shape of the swelling on examination were funicular in 52% of the cases and Globular in 48% of them. In 90% of the patients examined cough impulse was present and, in the rest, i.e., 10% of them had no or absent cough impulse. All the patients in our study group had normal skin appearance over the swelling. On clinical examination tenderness was present over the swelling in 8% of the cases and the rest 92% had normal findings. 90% of the patients had reducible swelling and the rest 10% had irreducible swelling on clinical assessment. On the examination with special tests for hernia like Zeiman’s test, Invagination test and deep ring occlusion test it was noted that 36% of the study population had Indirect Hernia, 48% of them had direct hernia, 6% of them had both while the rest 10% were unclassified. (Table 3)

Table 4: Clinical findings and management procedure

Digital rectal examination Finding was normal in 82% of cases, BPH Grade I was found in 12% patients while BPH Grade II was found in 6% of patients. In 46% of patient’s final diagnosis of direct reducible inguinal hernia was made while 34% had indirect reducible inguinal hernia, 10% had indirect irreducible inguinal hernia and 10% had Reducible pantaloon hernia. According to Nyhus classification Type, 44% patients were in Type 2, 46% were in Type 3a and 10% were in Type 3b. In our study all the patients were subjected to open inguinal hernia repair. 98% of the patients underwent lichtenstein tension free mesh hernioplasty, 2% of them underwent Bassini’s repair. (Table 4) 

Hernias are a common problem; however, their true incidence is unknown. It is estimated that 5% of the population will develop an abdominal wall hernia, but the prevalence may be even higher. In our study population the median age group of the patient was 50+13.5. 98% of them were male patients and 2% were female. 12% of the patients were in 18-30 years’ age group range, 12% of them between were in the range of 31-40 years, 24 % of the patients were in the range of 41-50 years, 30% of them between 51-60 years range, 18% of our study population were in the range of 61-70 years and the rest 4% were above 70 years.

Zahid Mahmood et al.,[8] (2006) conducted a descriptive study conducted over a period of three years from July 2006 to June 2009 in surgical dept.  GTTH, Lahore on a total of 120   patients with diagnosis of inguinal hernia. Mean age of patients was 52.2±15.1 years, which were similar to our data regarding median age group of study population.

Nadim khan et al.,[9] (2008) conducted a descriptive study conducted over a period of twelve months from 1st July 2007 to 30th June 2008 in Surgical 'B' unit, Lady Reading Hospital, Peshawar. Of a total of 112 patients. Mean age of patients was 48.78 +/- 14.41 years, which was similar to our study.

Ragesh et al.,[10] (2016) conducted a prospective study conducted in 100 patients admitted in the emergency Department of Surgery in Govt. Medical College, Kozhikode. To study the early postoperative complications of emergency Lichtenstein hernioplasty and the risk factors and comorbidities that predisposes to these complications. All patients included in this are males and the mean age group is found to be between 53-63 years. Among this, complicated hernias are distributed widely from 30-70 years with maximum incidence in age group of 51-70 years, which were in coherence with our study.

Anwarul Kabir et al.,[11] (2019) conducted a prospective study on 30 inguinal hernia repairs were performed by Lichtenstein technique between January 2015 and December 2017 in surgery department of Holy Family Red Crescent Medical College Hospital., The mean age was 51.93 (±SD 10.12) years, which were in coherence with our study.

Jan et al.,[12] (2021) conducted a study to compare common postoperative complications in Lichtenstein mesh repair and laparoscopic TAPP repair for unilateral inguinal hernia. The mean age was 39.40+/-16.184 years, ranging from 18 to 70 years, which were similar to our study pattern.

P vasu et al.,[13] (2015) who conducted a prospective clinical study conducted at Sapthagiri Institute of Medical Science and Research Centre, Bangalore during the period from May 2015 to April 2016 had a mean age of 49.3±13.7 years with Male preponderance was observed in the study (n=48; 96%), which were similar to our study profile

The mean BMI in our study population was 23.4+2 which was in coherence with a study conducted by Jan et al.,12 (2021) to compare common postoperative complications in Lichtenstein mesh repair and laparoscopic TAPP repair for unilateral inguinal hernia. The mean body mass index (BMI) in their study was 25.61+/-3.803 kg/m2.

The main occupational group in our study population were farmers which constituted 52%, 16% of the study population were laborers, 10% of them were students, shopkeeper and teachers constituted 6% each, while the rest of them belonged to different other professions.

In the present study all the study population was thoroughly examined for hernia and the findings were tabulated in the pre designed performa and the diagnosis was made on the basis of the findings. In our study the most common site of hernia was the right side which constituted 76% and the rest i.e. 24% were on the left side. The shape of the swelling on examination were funicular in 52 % of the cases and Globular in 48% of them. In 90% of the patients examined cough impulse was present and, in the rest, i.e. 10 % of them had no or absent cough impulse. All the patients in our study group had normal skin appearance over the swelling. On clinical examination tenderness was present over the swelling in 8% of the cases and the rest 92% had normal findings. 90% of the patients had reducible swelling and the rest 10 % had irreducible swelling on clinical assessment. On the examination with special tests for hernia like Zeiman’s test, Invagination test and deep ring occlusion test it was noted that 36% of the study population had Indirect Hernia, 48% of them had direct hernia,6% of them had both while the rest 10% were unclassified.

Zahid Mahmood et al.,[8] (2006) conducted a descriptive study in which 64 patients (53.3%) had right sided inguinal hernia while 56 patients (46.7%) had a left sided hernia which correlated with our study. However, in their study 68 patients (56.7%) had indirect hernia and 52 (43.3%) cases had direct hernia, which differed from our study. This may be attributed to the fact that most of the study population in our study belonged to elderly population in whom direct hernias are common.

In a descriptive study conducted by Nadim khan et al.,[9] (2008), a total of 112 patients were subjected to inguinal mesh repair using the Lichtenstein technique with polypropylene mesh. Mean age of patients was 48.78 +/- 14.41 years. Sixty patients (53.6%) had right sided inguinal hernia while 46 patients (41.1%) had a left sided hernia and 6 patients (5.4%) had bilateral hernia which were in coherence with the study. Sixty-two patients (55.4%) had indirect hernia and 43 (38.4%) cases had direct hernia in their study, the discrepancy regarding the most common type of study can be due to a predominance of elderly population in our study.

P vasu et al.,[13] (2015) conducted a prospective clinical study in which all the patients underwent Lichtenstein’s hernioplasty. They found that 36 (72%) patients presented with right sided inguinal hernia, 10 (20%) patients had left sided inguinal hernia and 4 patients i.e. 8% had bilateral inguinal hernia. 39 (78%) patients had indirect hernia and 11 (22%) patients had direct hernia, which were similar to our study on certain parameters.

In a prospective study conducted by Anwarul Kabir et al.,[11] (2019) they found that most of the hernias were of indirect type (18/30) followed by direct type (9/30). In indirect type 55.6% of the hernias were in the right side and the rest were in the left side, which correlated to our study in terms of the predominant side of hernia found.

Our study concluded that most of patients of inguinal hernia were male, between 51-60 years range, farmer had hernia of right side, funicular shaped swelling, had cough impulse, reducible swelling and direct reducible inguinal hernia on final diagnosis and majority of patients underwent lichtenstein tension free mesh hernioplasty.

Funding: No funding sources.

Conflict of interest: None declared.

Ethical approval: The study was approved by the Institutional Ethics Committee of Civil Hospital, Rajgarh, Sirmour.

1. Chawla, Subhash. "Recent Concepts in Inguinal Hernia Repair." Medical Journal of Dr. DY Patil University, vol. 6, no. 4, 2013, p. 381. https://go.gale.com/ps/i.do?id=GALE%7CA344972259&sid=googleScholar&v=2.1&it=r&linkaccess=abs&issn=09752870&p=AONE&sw=w.

2. Bax, Tim, Brett C. Sheppard, and Richard A. Crass. "Surgical Options in the Management of Groin Hernias." American Family Physician, vol. 59, no. 1, 1999, pp. 143-156. https://www.aafp.org/pubs/afp/issues/1999/0101/p143.html/1000.

3. Everhart, James E. "Abdominal Wall Hernia." Digestive Diseases in the United States: Epidemiology and Impact. National Institute of Diabetes and Digestive and Kidney Diseases, 1994, pp. 471-507.

4. Je, Everhart. "The Burden of Digestive Diseases in the United States." US Department of Health and Human Services NIoH, National Institute of Diabetes and Digestive and Kidney Diseases, 2008.

5. Onuigbo, W. I. B., and G. E. Njeze. "Inguinal Hernia: A Review." J Surg Oper Care, vol. 1, no. 2, 2016, p. 202. https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=336676c6a2da0e232c3cdff5af09b05b43894146.

6. McVay, C. B. "The Anatomic Basis for Inguinal and Femoral Hernioplasty." Surgery, Gynecology & Obstetrics, vol. 139, no. 6, 1974, pp. 931-945. https://pubmed.ncbi.nlm.nih.gov/4278445/.

7. Shouldice, E. E. "The Treatment of Hernia." Ontario Medical Review, vol. 20, 1953, pp. 670-684.

8. Mahmood, Z. A. H. I. D., M. Imiran, and T. A. Shah. "Results of Open Mesh Hernioplasty (Lichtenstein) for Inguinal Hernia: A Study of 120 Cases at Ghurki Trust Teaching Hospital Lahore." East & Central African Journal of Surgery, vol. 11, no. 2, 2006, pp. 28-34. https://pjmhsonline.com/2010/july_sep/pdf/nn%20%20%20Results%20of%20Open%20Mesh%20Hernioplasty%20for%20Inguinal%20Herniaat%20Ghurki%20Trust%20Teaching%20Hospital,.pdf.

9. Khan, Nadim, et al. "Early Outcome of Lichtenstein Technique of Tension-Free Open Mesh Repair for Inguinal Hernia." Journal of Ayub Medical College, Abbottabad: JAMC, vol. 20, no. 4, 2008, pp. 29-33. https://europepmc.org/article/med/19999198.

10. Gulino, Gaetano, et al. "Urological Complications Following Inguinal Hernioplasty." Archivio Italiano di Urologia, Andrologia, vol. 84, no. 3, 2012, pp. 105-110. https://europepmc.org/article/med/23210400.

11. Kabir, A. S. M. A., et al. "Early Outcome of Lichtenstein Technique for Inguinal Hernia Repair in Tertiary Care Hospital." Anwer Khan Modern Medical College Journal, vol. 10, no. 1, 2019, pp. 62-69. https://www.researchgate.net/profile/Mahbuba-Sharmin-2/publication/336681258_Early_Outcome_of_Lichtenstein_Technique_for_Inguinal_Hernia_Repair_in_Tertiary_Care_Hospital/links/5ecb8a4192851c11a8880176/Early-Outcome-of-Lichtenstein-Technique-for-Inguinal-Hernia-Repair-in-Tertiary-Care-Hospital.pdf.

12. Jan, ZakaUllah, et al. "Comparison of Common Postoperative Complications Between Lichtenstein Open Repair and Laparoscopic Transabdominal Pre-Peritoneal (TAPP) Repair for Unilateral Inguinal Hernia." Cureus, vol. 13, no. 9, 2021. https://doi.org/10.7759/cureus.17863.

13. Vasu, S., and Kshir Sagar. "A Clinical Study of Postoperative Complications of Lichtenstein’s Hernioplasty for Inguinal Hernia." International Surgery Journal, vol. 6, no. 1, 2019, pp. 13-16. https://doi.org/10.18203/2349-2902.isj20185457.