VOLUMETRIC CLASSIFICATION OF INGUINOSCROTAL SWELLINGS

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S.S. Dumbuya¹, O.O. Ayandipo², I.O. Smalle¹, J.C. Boima¹, M.A. Dawo¹, O.A. Ajagbe³, T.O. Ogundiran²

1. Department of Surgery, College of Medicine and Allied Health Sciences (COMAHS), University of Sierra Leone, and Connaught Hospital, University of Sierra Leone Teaching Hospitals Complex, Freetown, Sierra Leone.
2. Department of Surgery, College of Medicine, University of Ibadan, and University College Hospital, Ibadan, Nigeria.
3. Department of Surgery, University College Hospital, Ibadan, Nigeria

Abstract

Background: External hernias and scrotal swellings are diverse in presentation and are described in many subjective ways.

Aim: To create an objective classification of inguinoscrotal swellings in the rural setting.

Patients and methods: It was a prospective study on the measurement of inguinoscrotal swellings volume/contents in a cohort of surgical patients in a provincial general hospital in the north of Sierra Leone over a three-year period. For inguinal hernias and other scrotal swellings, the volume ranges of 0- 500ml were used in the classification; for femoral and other external hernias which generally do not reach ‘huge” sizes, the volume ranges of 0-100 ml were used.

Results: A total of 962 external hernias and hydroceles were classified over a 3- year period. Most, 610 (63.4%) were inguino-scrotal hernias, others were hydroceles, 303 (31.0%) and femoral hernias, 42 (4.3%). The remaining small number consisted of umbilical (4) and epigastric (3) hernias. For the common conditions of hydroceles, inguinal and femoral hernias, about 50% were ‘small’, more than 40% were ‘large’, the rest were giant. The same findings were true for
epigastric and umbilical hernias.

Conclusion: Using the scale that we adopted, majority of the groin hernias and hydroceles were in the small and large categories with a few giant varieties. Volumetric-based classification of hernias and hydroceles can help surgeons
communicate more clearly based on standard rather than arbitrary ascription of descriptive terminologies to these very common surgical entities.

Keywords: Volumetric classification, External Hernias, Scrotal swellings

Introduction

Inguinal hernia is a common surgical disease that is often ignored by patients in most of Africa. Many avoidable deaths occur almost daily in remote rural communities across Africa due to lack of adequate surgical care for complications arising from inguinal hernia disease.¹ Adult hydroceles are also quite common with an incidence of up to 28% in some populations and the associated economic burden involved with their treatment can be significant in these mostly poor resource economies.² A study compared inguinal hernias in a West African population with those in a developed country and found that 67% and 6% of the hernias were inguinoscrotal respectively.³

More than 20 million inguinal hernias are repaired every year around the world and specific rates by country vary from 100 to 300 per 100 000 population per year⁴. The hernia surgery output from Africa unknown but estimates indicate an average need of 175 inguinal hernia repairs per 100 000 population per year out of which only 25 are actually performed⁵. Therefore, many hernias end up not repaired or if repaired, repair is done under emergency conditions^1,5. It has also been noted that many men die fromcomplicated hernias, something that should be unheard of in the 21st century.¹

A nationwide surgical survey in Sierra Leone indicates that groin masses present a major burden of disease in the male population with an estimated prevalence of 7.01% for groin hernias¹⁹, which corresponds to a rate of 7,010 per 100,000 men and extrapolates to over 200,000 males with hernia in the country. Most of these were found in patients with jobs involving manual labour and strenuous lifting. Up to 70% of employed individuals in Sierra Leone work in agricultural setting and engage in lifting of heavy weights, which may explain the high burden of the disease and this is also true of other West African countries.^6,7

External hernias in general and inguino-scrotal swellings in particular, in developing countries, reach ‘huge’ dimensions before the patient seeks surgical treatment. Although, swellings bigger than the human head have been designated ‘giant’ yet the adjectives used to describe the intermediate sizes are not standardized.²⁰ As such, someone’s idea of ‘large’ might be completely different from another’s.⁸ Several hernia classification systems have been developed to guide the surgeon in hernia repair and to ease comparison between the different techniques of hernia repair. Halverson and McVay grouped groin hernias in four classes: small indirect inguinal hernia, medium indirect inguinal hernia, large indirect and direct inguinal hernia, femoral hernia.⁹ Gilbert classified hernias based on anatomic and functional aspects according to intraoperative findings, like presence or absence of the peritoneal sac, the size of the internal ring, and the status of the posterior wall.¹⁰ Nyhus classification emphasizes the anatomic criteria including the size of the internal ring and status of the posterior wall.¹¹ Others include the Aachen and the Zollinger’s classifications. Common to all classifications is the fact that they use the size of the hernia and the status of the posterior floor and/or the internal ring to describe the hernia.¹² However, these classifications are all subjective. Larger hernias are generally assumed to be more severe.

It may be useful to classify hernias by volume as it is frequent to see patients with large inguinoscrotal swellings in West Africa. Certain factors such as incidence of post-operative morbidity, length of stay in hospital, and even management, bear some relationship to the size of the lesion.²¹ Therefore, we embarked upon a volumetric classification of inguinoscrotal swellings to confer quantitative values to the descriptive terms commonly ascribed to them, in order to minimize ambiguity and to establish a common ground of understanding when referring to their sizes.