Outcomes After Inguinal Hernia Repair With Mesh Performed by Medical Doctors and Surgeons in Ghana

JAMA Surg. 2019 Sep 1;154(9):853-859. doi: 10.1001/jamasurg.2019.1744.


Importance: Inguinal hernia is the most common general surgical condition in the world. Although task sharing of surgical care with nonsurgeons represents one method to increase access to essential surgery, the safety and outcomes of this strategy are not well described for hernia repair.

Objective: To compare outcomes after inguinal hernia repair with mesh performed by medical doctors and surgeons in Ghana.

Design, setting, and participants: This prospective cohort study was conducted from February 15, 2017, to September 17, 2018, at the Volta Regional Hospital in Ho, Ghana. Following successful completion of a training course, 3 medical doctors and 2 surgeons performed inguinal hernia repair with mesh according to the Lichtenstein technique on 242 men with primary, reducible inguinal hernia.

Main outcomes and measures: The primary end point was hernia recurrence at 1 year. The noninferiority limit was set at 5 percentage points. Secondary end points included postoperative complications at 2 weeks and patient satisfaction, pain, and self-assessed health status at 1 year.

Results: Two-hundred forty-two patients were included; 119 men underwent operations performed by medical doctors and 123 men underwent operations performed by surgeons. Preoperative patient characteristics were similar in both groups. Two-hundred thirty-seven patients (97.9%) were seen at follow-up at 2 weeks, and 223 patients (92.1%) were seen at follow-up at 1 year. The absolute difference in recurrence rate between the medical doctor group (1 [0.9%]) and the surgeon group (3 [2.8%]) was -1.9 (1-tailed 95% CI, -4.8; P < .001), demonstrating noninferiority of the medical doctors. There were no statistically significant differences in postoperative complications (34 [29.1%] vs 29 [24.2%]), patient satisfaction (112 [98.2%] vs 108 [99.1%]), severe chronic pain (1 [0.9%] vs 4 [3.7%]), or self-assessed health (85.9 vs 83.7 of 100) for medical doctors and surgeons.

Conclusions and relevance: This study shows that medical doctors can be trained to perform elective inguinal hernia repair with mesh in men with good results and high patient satisfaction in a low-resource setting. This finding supports surgical task sharing to combat the global burden of hernia disease.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Clinical Competence
  • Cohort Studies
  • Developing Countries
  • Elective Surgical Procedures / methods
  • General Practitioners / education*
  • Ghana
  • Hernia, Inguinal / diagnosis
  • Hernia, Inguinal / mortality
  • Hernia, Inguinal / surgery*
  • Herniorrhaphy / adverse effects
  • Herniorrhaphy / methods*
  • Humans
  • Middle Aged
  • Postoperative Complications / epidemiology
  • Postoperative Complications / physiopathology
  • Prospective Studies
  • Recurrence
  • Risk Assessment
  • Surgeons / education*
  • Surgical Mesh*
  • Survival Rate
  • Treatment Outcome