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A Randomized Trial of Low-Cost Mesh in Groin Hernia Repair
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.ORCID iD: 0000-0001-5884-0369
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
Makerere University.
Makerere University.
Show others and affiliations
2016 (English)In: New England Journal of Medicine, ISSN 0028-4793, E-ISSN 1533-4406, Vol. 374, no 2, 146-153 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The most effective method for repair of a groin hernia involves the use of a syn-thetic mesh, but this type of mesh is unaffordable for many patients in low- and middle-income countries. Sterilized mosquito meshes have been used as a lower-cost alternative but have not been rigorously studied.METHODS: We performed a double-blind, randomized, controlled trial comparing low-cost mesh with commercial mesh (both lightweight) for the repair of a groin hernia in adult men in eastern Uganda who had primary, unilateral, reducible groin hernias. Surgery was performed by four qualified surgeons. The primary outcomes were hernia recurrence at 1 year and postoperative complications.RESULTS: A total of 302 patients were included in the study. The follow-up rate was 97.3% after 2 weeks and 95.6% after 1 year. Hernia recurred in 1 patient (0.7%) assigned to the low-cost mesh and in no patients assigned to the commercial mesh (abso-lute risk difference, 0.7 percentage points; 95% confidence interval [CI], −1.2 to 2.6; P = 1.0). Postoperative complications occurred in 44 patients (30.8%) assigned to the low-cost mesh and in 44 patients (29.7%) assigned to the commercial mesh (absolute risk difference, 1.0 percentage point; 95% CI, −9.5 to 11.6; P = 1.0).CONCLUSIONS: Rates of hernia recurrence and postoperative complications did not differ signifi-cantly between men undergoing hernia repair with low-cost mesh and those un-dergoing hernia repair with commercial mesh.

Place, publisher, year, edition, pages
2016. Vol. 374, no 2, 146-153 p.
National Category
Research subject
URN: urn:nbn:se:umu:diva-107657DOI: 10.1056/NEJMoa1505126ISI: 000367996700009PubMedID: 26760085OAI: diva2:848685

Originally published in manuscript form with title "Low cost mesh in groin hernia repair - A double-blinded, randomized trial"

Available from: 2015-08-25 Created: 2015-08-25 Last updated: 2017-12-04Bibliographically approved
In thesis
1. Groin hernias and unmet need for surgery in Uganda: Epidemiology, mosquito nets and cost-effectiveness
Open this publication in new window or tab >>Groin hernias and unmet need for surgery in Uganda: Epidemiology, mosquito nets and cost-effectiveness
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background Surgery has traditionally been considered more expensive than many other health care interventions and with little impact on the burden of disease in a global perspective. One of the reasons behind this misconception is that the effects of surgical conditions and their treatment have not been factored into the equation. Cost-effectiveness analyses of surgical interventions have largely been missing.

An estimated 20 million herniorrhaphies are carried out annually but over 200 million people suffer from groin hernias. Herniorrhaphy is one of the most commonly performed surgical procedures also in Low and Middle Income Countries (LMIC). However, the surgical repair method is not the same due to financial constraints. In high income countries a synthetic mesh is used and has reduced the risk of recurrence. This 125 USD mesh is too costly for the majority in LMIC. Mosquito mesh, which is cheaper but very similar to commercial meshes, is used in several settings but outcomes need to be investigated more extensively before this practice can be recommended in routine surgical service.

The Aims of this thesis were to define the prevalence of groin hernia, to relate it to the surgical capacity, outcomes and costs of surgery in eastern Uganda and to investigate the feasibility and difference in cost and cost-effectiveness of replacing a commercial mesh with a mosquito mesh in groin hernia surgery.

Methods Three studies (1-3) were carried out in eastern Uganda. 1: A cross sectional study investigating the prevalence of groin hernia in adult males in the Health and Demographic Surveillance Site (HDSS) in Iganga and Mayuge districts. 2: A facility based study with prospective data collection of all surgeries undertaken in the two hospitals providing surgery for the HDSS population. 3: A double blinded, randomised controlled trial comparing the outcomes of using a mosquito mesh relative using a commercial mesh in groin hernia surgery.

Results 1: the prevalence of untreated groin hernia among the study participants was 6.6%. 2: the rate of groin hernia surgery was 17 per 100 000 population. Thus, less than 1% of the estimated number of cases of groin hernia in the catchment area of the two hospitals are operated per year. A herniorrhaphy costs around 60 USD to perform. This corresponds to a third of the cost of TB treatment and a 15th of the cost of HIV/AIDS treatment per year in Uganda. 3: No significant differences in terms of recurrence rates, post operative and chronic complications and patient satisfaction were demonstrated between the patients operated using the mosquito mesh and the commercial mesh. Cost-effectiveness was very high for both materials but total cost in the mosquito mesh group was 124 USD lower per surgery than in the commercial mesh group.

Conclusion There is a vast unmet need for groin hernia surgery. Cost of surgery compares favourably with other health care interventions prioritised by the international organisations and funders. A superior technique can be used in groin hernia surgery at low cost, with high cost-effectiveness in a Low Income Country. 

Place, publisher, year, edition, pages
Umeå: Umeå Universitet, 2015. 78 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 1740
Global surgery, groin hernia, groin hernia surgery, hernia epidemiology, low cost surgery, cost-effectiveness
National Category
Research subject
urn:nbn:se:umu:diva-107659 (URN)978-91-7601-316-8 (ISBN)
Public defence
2015-09-17, Hörsalen, Östersunds Sjukhus, Kyrkgatan 16, Östersund, 09:00 (English)
Available from: 2015-08-27 Created: 2015-08-25 Last updated: 2015-08-26Bibliographically approved

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