Abdominal hernia repair is the commonest operation in general surgery. The repair rate ranges from 10 per 100000 population in the United Kingdom to 28 per 100000 in the United States.1, 2 More than one million hernia repairs are performed each year in the U.S. No published hernia repair rate is available for South Africa. Abdominal wall hernias include inguinal, incisional, ventral and femoral hernias. The prevalence is also very high. It is 1.7% for all ages, rising to 4% for those over 45 years. 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 to 15 percent of patients who have abdominal incisions, increasing to 23% in those who develop postoperative wound infection.3,4,5 The terrain of hernia surgery has changed significantly over the last decade. This has included new and evolving operative techniques, increase in the types of mesh and fixation devices used and advances in abdominal wall imaging. This period has also seen a significant increase in hernia related publications and a drive to evidence based medicine. This has resulted in an insurmountable amount of evidence and management that is protocol driven rather than patient centered. The success of real evidence based medicine allows for individualized evidence and expert judgment, relies on local feasibility, and requires all stakeholders to work together. In the absence of local data and leadership there has been attempts to adopt European or American guidelines with little success and much frustration. Currently there is no gold-standard operative technique for abdominal wall hernia repair.

An increased drive towards laparoscopic repair is evident; however patient selection criteria and outcomes remain unclear. Several types of mesh and fixation devices exist and there are many unresolved issues related to the type of mesh for a given situation. 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. In South Africa there is no profession-driven formal training program for hernia repair or prevention. Much of the existing training is industry driven. Several research gaps exist from basic science to patient outcomes and a dearth of locally relevant data. Profession, locally relevant evidence-based guidelines are needed. In response to this, SASES has initiated the formation of the Hernia Interest Group (HIG) with a vision of this being the lead voice on hernia care in South Africa.

The aim of HIG is to improve the quality of care for patients with hernias.

1. Develop evidence- or consensus-based management guidelines
2. Improve hernia repair training and practice
3. Identify research gaps and facilitate relevant research projects related to the gaps
4. Develop systems to monitor and evaluate hernia repair outcomes

To achieve the objectives HIG will collaborate with key role players viz. academic sector, public health care managers and providers, private practitioners, corporate sector and health care funders.  Five task teams have been set-up to develop activities related to each of the objectives. In establishing these management guidelines (see supplement) the HIG have highlighted the important, locally relevant issues to be addressed in groin hernia management, and have presented objective, evidence-based guidelines that will be useful to surgeons, trainees, referring doctors and the healthcare industry. Guidelines on the management of ventral hernias are to follow, together with coordinated attempts to develop and rollout skills training nationally. Guidelines on the development on monitoring and evaluation will also be developed. This data will provide all stakeholders an indispensable tool to assess the efficacy and impact of the program, to identify weaknesses and provide a platform to address these deficiencies to ensure that high quality, cost effective patient-centered care is delivered.

Authors: Ravi Oodit, Dino Sofianos, Heather Bougard

1. Kingsnorth A, LeBlanc K Hernias: inguinal and incisional. Lancet 2003;362(9395):1561.
2. Devlin HB. Trends in hernia surgery in the land of Astley Cooper. In: Soper NJ, ed. Problems in general surgery Vol 12. Philadelphia, PA: Lippincott-Raven, 1995:85-92
3. Rutkow IM (2003) Demographic and socioeconomic aspects of hernia repair in the United States in 2003. Surg Clin North Am 83:1045–1051
4. Jenkins JT, O'Dwyer PJ; Inguinal hernias. BMJ. 2008 Feb 2;336(7638):269-72.
5. Matthews RD, Neumayer L. Inguinal hernia in the 21st century: an evidence-based review. Curr Probl Surg. Apr 2008;45(4):261-312