EVALUATION OF THE CLINICAL, EPIDEMIOLOGICAL PROFILE AND ASSOCIATED RISK FACTORS OF INGUINAL HERNIA

Abdominal wall hernias are frequently encountered in surgical practice accounting for 15% - 18% of all surgical procedures. Worldwide, more than 20 million hernias are operated per year. Lifetime risk of developing inguinal hernia is 15% - 27% in men and 3% in women. Itscommonly performed general surgical procedure that constitute more than 95% of all groin hernia repairs. However, in developing countries, quite a considerable percentage of it is not repaired or delayed repaired and that lead to a higher incidence of morbidity and mortality. Objective: To evaluate the clinical, epidemiological profile and associated risk factors for inguinal hernia. Methodology: This observational study was conducted among 100 patients during March 2019 to March 2020 who admitted in the surgery department of a General Surgeryfor inguinal hernia surgery. All the study subjects were examined and their clinical and epidemiological profiles studied, tabulated and analyzed. Results: Among the 100 patients, most of them (94%) were men with an age of 57.02 Â± 12.87, farmer (36%) by occupation.61% patients were in low sacio-ecenomic status. Most of the patients (60%) were in the age group of 40-60 years followed by less than 30 years (21%). on query regarding symptoms of inguinal hernia, all of them (100%) complaints of groin swelling. more than half of the patients complaints of groin pain and sensation of heaviness in groin. On clinical examination, right sided, left sided, bilateral hernias were found in 49%, 45% and 6% study patients respectively. Direct hernias, indirect, pantaloons hernias were seen in57%, 30%, 7% study patient respectly. Most of hernias (81%) were reducible and were incomplete (88%). Most of the patients (75%) presented late to the health care center due to the lack of awareness of the disease and were initially treated by homeopath medicine. During query about risk factors for inguinal hernia, 46% patients were more than 50 years of age and 26% patients were smoker. Total open procedure was 93% and laparoscopic hernia repairs were done only in 7% patients. Conclusion: In this study, we found that male are more affected than male. Right sided and direct hernia is more common. Most of the patients from low socio-ecenomic condition and main risk factors are old age, smoking, lifting heavy objects prostatism and constipation. Most common hernia repair procedure were Lichtensteinsprocedure.

Hernia as defined by Astley Cooper in 1804 is "A protrusion of any viscus from its proper cavity.The protruded parts are generally contained in a sac like structure, formed by the membrane with which the cavity is naturally lined." The word hernia is derived from the Latin word for "Rupture". Hippocrates used theGreekword"Hernios"forabudorbulgetode-scribe abdominal hernias. Statues of this era portray this condition [1]. Abdominal wall hernias are frequently encountered in surgical practice accounting for 15% -18% of all surgical procedures [2,3]. There are about 500,000 cases of abdominal hernia that are reported every year [4]. Lifetime risk of developing inguinal hernia is 15% -27% in men and 3% in women [5]. Although males are affected more commonly (7:1), the incidence of femoral hernia is four times higher in females [6]. Still now nguinal hernia repair is second most common general surgical operations worldwide that account for about 10-15% of all surgical procedures [7,8]. It is very common in men with lifetime risk of 27% and 3% for women, thus 1 in 4 men has the risk of developing the condition and incidence increase with increase of age in man [9] Though exact data of hernia surgery in Bangladesh is unavailable, but with the average global incidence of hernia surgery being 3 per 1000 population yearly [10], Bangladesh with a population of 180 million where more than half million hernia surgeries performed every year. Very often hernia as a disease is ignored specially underdeveloped and developing countries as they may remain asymptomatic for prolonged periods, the severity of the condition is often overlooked and ultimately it results higher mortalityashighas7%inemergencysurgeries [10]World health organization (2002) reported that inguinal hernias are sources of social stigma [11].It lower the chances for employment, create sexual problems, physical deformation, loss of work, low self-esteem or confidence [12] People who are living with victims of inguinal hernia were reported to have not only poor health-seeking behavior but also they were negligent about their conditions, ignorant about the life threatening side effects or complications associated with their conditions. Sometimes cultural, educational factors and economic constraints may prevent the realization of illness and suppress proper utilization of available health services. So, in developing countries, quite a considerable percentage of inguinal hernia is not repaired that leads to a higher incidence of morbidity andmortality.However, symptoms may not appear in some people and they will only realize that they have this condition during medical checkups [13]. The time a hernia takes to develop depends on its causes, which relate to muscle weaknessandstrain.Commoncausesincludechronic coughing, damage from an injury or through surgery, and the inability of the wall of the abdomen to close properly [14]. Inguinal hernias may be congenital or acquired [7]. Several hypotheses regarding the etiology of inguinal hernia have been proposed. In male increased abdominal pressure, preexisting abdominal muscles weakness, constipation, prostatism, chronic cough, heavy weight lifting,obesity, smoking, aging, pelvic fractures and trauma, connective tissue diseases, and systemic illnesses and in females, obesity, pregnancy, and operative procedures have been proposed and well-known risk factors that commonly contribute to the formation of inguinal hernia.In Bangladesh, there is insufficient published data on the clinical and epidemiologicalprofile of patients presenting with inguinal hernia and this study may provide further understanding to the pathophysiology of inguinal hernia development and may estimate the prevalence, age and gender differences, risk factors associated with the inguinal hernia development. This study was conducted with the intention of identifying evaluation of the clinical, epidemiological profile and associated risk factors of inguinal hernia.

Material And Methods:-
During March 2019 to March 2020, this prospective study was conducted among 100 patients who were clinically diagnosed asprimary inguinal hernia and admitted in the surgery department ofGeneral Surgery. Necessary particulars regarding relevant history, demographic facts, risk factors, clinical data and examination findings, operation theatre logs data were recorded in a questionnaire, then, tabulated. Outcome of surgery was not a parameter of assessment.

Statistical analysis:
The data collected was entered into Microsoft excel and analysed using SPSS 19 software, Chi square test for the proportion and other appropriate statistical tests were applied.

Results:-
Total 100 patients were enrolled in this study, mean age was 57.5±11.26 years and the majority (60%) patients belonged to the 40-60 years. Increasing incidence noted in early age and in old age ( Figure 1). Among 100 patients, 94 were male and only 6 patient were female (Figure2). Leading profession was cultivation (36%), while 23% the patients were servicemen. Business was profession forabout 13% patients. Labor and student were other notable profession ( Figure 3). Among 100 study patients in 41 patients duration of symptoms were more than 12 months. Mean duration 8.03±8.15 months (Table 1).   In this study, 61% patients were in low saocio-ecenomic status, 24% and 15% were in middle and higher socioecenomiccategories respectively (figure 4). Most of the patients (41%) presented late to the hospital due to lack of awareness of the disease. 24% patients had financial constraints. 34%,19% reated by treated by homeopath medicine and traditional healer respectively.23% relactant to treatment due to fear of surgery (Table 2). On clinical examination, right sided, left sided, bilateral hernias were found in 49%, 45% and 6% study patients respectively. Direct hernias, indirect pantaloons hernias seen were in 57%, 30%, 7% study patient respectly.81% hernia was reducible and 88% was incomplete (Table 3). During query about risk factors for inguinal hernia,46% patients were more than 50 years. 26% patients were smoker. History of prostatism, lifting heavy weights lifting, constipation, obesity, chronic cough were seen in 19%, 21%, 17%, 7%, 7% studypatients respectively ( Figure 6).

Discussion:-
Among the 100 patients, most of them (94%) were men with a mean age of 57.02 ± 12.87 years that coincides with other studies [15,16,17] Being a commonly performed general surgical operation, abdominal wall hernia comprises a significant proportion of total surgical work load in most of the centers. Al-though it has been reported to constitute 15% -18% of total surgical operations but a slightly higher prevalence in present study area may be due to rural population having agriculture as main profession. Lifting heavy weights, old age may be the other contributory factors. Inguinal hernia constituted 78% of total abdominal wall hernias which is in accordance with literature [10][11][12]. However, studying the distribution of age, most of the patients(60%) in this study were in the age group of 40-60 years followed by less than 30 years (21%).This type of bimodal peaking was found among the elderly and the young in some other studies also [15,17] Due to increased incidence of inguinal hernia in this productive age group of 40-60 years, it becomes a burden on the economy of the country by increasing the morbidity.Inguinal hernias are reported to be more common in low socioeconomic strata [18][19][20][21][22]. It is reflectedverywell inthis study where most of the patients (61%) were in low saocio-ecenomic status, 24% and 15% were in middle and higher socioecenomiccatagoriesrespectively.In this study, right inguinal hernias were more common than left, ratio 1.08:1 and only 6% cases were bilateral which correlates with study done by Mukeshsangwan [20] et al. showed 1.45:1 and with also some other studies [20] In our study, direct hernias, indirect pantaloons hernias seen were in 57%, 30%, 7% study patient respectly and the present study correlated well with Burcharth et al. [10]In our study population, older age (50%) and smoking (39%) were the most common risk factors present. History of prostatism (19%), heavy weightlifting (21%), constipation (17%) were the other common risk factors for the development of inguinalherniainourstudy (Figure5)thatcorrelateswithstudyof RobinderaKour et al. [21] and some other studies [12,22] .Smoking was established as an independent risk factor for hernia development with Malviya et al. [11] reporting 30.6%10 of their study. Family history however appears to be an independent risk factor in the etiopathogenesis [16,23] but in this study only 5% study population had positive family history.A study in USA conducted by Constance et al. [13] found that the inguinal hernia was associated with older age, chronic cough, obesity, greater heigh, rural residence and it was supported by many other studies like Lau H et al. [24] and Junge K et al. [22], which showed that family history is an important predictor for development of inguinal hernias and as well as recurrent hernia. The other risk factors suggested were chronic cough, Prostatic hypertrophy,chronicconstipation,ChronicDiabetes [7,14,18] In this study, Lump (100%) and pain (64%) were the most common presenting symptoms that correlates with some other studies [2-3, 6-7, 10]. Duration of symptoms at presentation in our study was 5.02±8.19 months and 59% study patients presented to hospital after 6 months of their developing symptoms. In our study, most of the patients of inguinal hernia presented late to health care provider which is similar to the scenario in other developing countries [8,11,12]. Most of the patients (41%) presented late to the hospital due to lack of awareness of the disease, 24% patients had financial constraints. 34%,19% reated by treated by homeopath medicine and traditional healer respectively.23% patient relactant to treatment due to fear of surgery. During searching of operation theatre logs we recorded that openprocedure were done in 93% patients and laparoscopic hernia repairs were done only in 7 patients among total 100 study patients. Among open procedure most common hernia repair procedure was Lichtenstein's procedure in 63% patients followed by modified Bassini's procedure in 11% patients compared to laparoscopic repair (7%). It suggest that still Lichtenstein`s repair is till surgeon`s first choice in developing countries may be due to financial contrains. These factors increase the abdominal pressure during cough or straining, which further increase the risk of inguinal hernia. A study in USA reported that inguinal hernia was associated with older age, obesity, greater height, chronic cough or rural residence. [25] Conclusion:-In this study, we found that male is more affected than male. Right sided and direct hernia is more common. Most of the patients from low socio-ecenomic condition and main risk factors are old age, smoking, lifting heavy objects prostatismand constipation. Lack of awareness of the disease, financial constraints, fear of surgery, treatment by homeopath medicine and traditional healer are common causes for late presentation to health care proiders that increase morbidity and mortality. Most common hernia repair procedure were Lichtenstein'sprocedure.