Welcome to Hernia society of Kenya.

Our guest of honour, guest speaker, regional representatives, my fellow colleagues, and our industry partners

It is a great honour for me personally and as the founding and current chairman of the Hernia Society of Kenya to welcome you to this Hernia symposium; the first of its kind in the surgical history of this country.

It is said that progress is not one big change but a series of small but significant changes. Today, I wish to illustrate this in two to three ways.

One; the history of the disease subject of this symposium;

two, the hernia society and

lastly, the programme of the day.

The history of hernia repair is the history of surgery itself, and has undergone numerous, enormous, progress throughout the ages. The main reasons for intervention has however remained the same: continuous growth of the inguinal and/or scrotal swelling, the risk of incarceration of the hernia content and the bad results of conservative methods like truss placement.

From the early Greeks who coined the term hernia (Hernios = bud), through the ages of hernia treatment by cautery and castration, we have come a long way. Here, the word “treatment” needs clarification. This is best illustrated by a description of a hernia operative procedure detailed by Demetrius de Cantemir, prince of Moldavia that

“the inhabitants of Albania and Epirus, otherwise called by the Turks Arnaut, excelled in the cure of ruptures; and after he (Cantemir) has spoken of their skill in many respects, he related a process which he observed himself.”

When he was at Constantinople he had the operation performed upon his secretary, who was an elderly man. They tied the patient down upon a broad plank, and secured him from his breast to his feet with proper bandages: the operator made an incision in the inferior part of the abdomen with a kind of razor or bistoury. The peritoneum being opened, he pulled and drew up the intestines, which was fallen into the scrotum, into its proper place. Afterward he sewed up the peritoneum with strong thread, and a knot at the end of it to hinder it from slipping; and the lips which hung over were cut off with the same razor. Then the wound was cauterized with a red hot-iron.

Before the dressing was applied, they lifted up a little of the legs of the patient, who was almost dead, and poured the whites of nine new-laid eggs into the wound; and if that liquor fermented and bubbled within the space of an hour or two, it was certain sign of a cure; on the contrary, if there was no appearance of that kind in three hours, they made no favourable prognostic.

They attribute ill success to the age or weakness of the patient, which obstructs the cure, for they never doubt of the efficacy of their method: and indeed there seldom die two out an hundred of those whom they undertake.

Convalescence was prolonged, as it lasted from 20 to 40 days, this being the time needed for the separation of the thread.

 

 

Logical treatment for hernia commenced with an understanding of the anatomy and the establishment of sound surgical principles, a surgical treatment best described by Eduardo Bassini in 1888 by his concept of tissue repair or rather tissue approximation. Bassini brought down the recurrence rate of hernia from 100 to 2.7%. Though surgeons were aware of the problems of tissue repair, the Bassini procedure with several modifications was the mainstay of hernia repair for nine decades and for millions of patients till tension-free onlay mesh hernioplasty. Introduced by D.E. Aquaviva & Bouret in France(1948) and standardized by Lichtenstein, this ushered an era of less pain, shorter hospitalization, lower recurrence and early return to work after hernia surgery.

With the advent of laparoscopy entering every field of surgery, laparoscopic hernia repair was the obvious next step. For several reasons, unlike laparoscopic cholecystectomy, which had a market penetration of 93% within 3 years, laparoscopic hernia repair after 25years has enjoyed or rather suffered, a market penetration of 5–15% in the developed worl and ofcourse less than 0.5% in our setting.

Hitherto, in spite of or perhaps because of its common occurrence, hernia repair was relegated to a minor, almost step-child, position in surgery.

Laparoscopic hernia repair has focused world surgical attention on the treatment of hernia and elevated it to its current status of study, controversy, evaluation and treatment.

Papers at conferences and articles in journals on hernia repair are by and large contributed by “Herniologists” who work and practice in ideal conditions as they apply in developed countries or in urban centers of excellence in developing countries. However, the vast mass of patients in Kenya and Africa in general does not come under the gambit of “centers of excellence”.

If it is our intent to go beyond mere lip-service to the vast population of hernia patients, we need to rethink our strategies in terms of economics and management to enable surgeons, offer the best possible treatment to all patients in all places, irrespective of regional or economic barriers.

 

 

Scientific vigour in Hernia Surgery /Hernia Societies

In the 19th century British surgeons, such as Sir Astley Cooper, made outstanding contributions to herniology, both in terms of understanding the functional anatomy of the groin and in developing sound surgical techniques.

In the 20th century the initiative was taken by North Americans and Europeans such as Earl Shouldice, Lloyd Nyhus, Irving Lichtenstein

The only African in this picture is the late Rene Stoppa who had migrated and practiced in Amhiens, France

GREPA/EHS was founded 1979 by JP Chevrel and a group of 8 friends sharing the desire to promote and improve abdominal wall surgery. The group consisted of surgeons, intensive care specialists, anatomists, radiologists and physiologists whose aims were:

“The promotion of abdominal wall surgery, the study of anatomic, physiologic and therapeutic problems related to the pathology of the abdominal wall, the creation of associated groups which will promote research and teaching in this field, and the development of interdisciplinary realations”.

Other Hernia Societies with similar missions followed suit; Thus

AHS             -1994

APHS           -Lomanto, Chobey et.al 1997

AMEHS was found in September 2009 by a group of surgeons and doctors in general from North Africa and from the Middle East, a part of the world where the pathologies of Abdominal Wall are very frequent and where there is a real need of information, of modernization, of culturisation in this surgical field.

After the first ‘World hernia congress’ in Berlin in 2009, I mooted the idea of a National hernia society and went ahead and drafted bylaws for the same. However the idea had to wait for two years until June 2011 when Johnson & Johnson invited a group of 16 surgeons to Naivasha; and there, the dream was actualized. The bylaws/constitution were ratified and  HSK   was born with the mission of

‘Provision of professional forum for the exchange of information and education regarding historical, current and future methods of diagnosis and treatment and basic science of abdominal and pelvic floor abdomalities’

This encompasses

Periodic meetings

Collaboration with other similar societies

Joint meetings

Training

The society was officially registered last year and has a program of events, a logo, a website in construction and has commenced collaboration having been recognized as a local chapter by the AMEHS. Further collaborations with other regional societies is in progress.

The society has been involved in one major training event on Laparoscopic Hernia repair in which 12 patients were operated on in Kijabe Mission Hospital and KNH.

Today marks the first meeting hosted by Johnson & Johnson and looking at the program, the contents are similar to what is expected of any hernia meeting; ranging from Anatomy, practice in varying resource environments, innovations including advanced laparoscopic surgeries and hernia education including hernia registries. The only challenge is the order in which it has been done but as I said earlier,this brings me to the last illustration of the fact that ‘Rome was not built in a day’

Our Chief Guest, despite our slow pace I believe, Surgeons in Kenya have a forum which places them ahead regionally in the direction of developing an orderly, scientific based, hernia management protocols,guidelines and research all aimed at improving patients outcome and reaching hernia to the subspeciality it is in the rest of the world.

The society have some few teething problems which are inevitable with any change. As Nicollo Machiavelli puts it

“ And it ought to be remembered that there is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success,nor more dangerous to administer than to take lead in the introduction of a new order of things. Because the innovator has for enemies all those who have done well under the old conditions and Lukewarm defenders in those who may do well under the new”

Our Chief guest, ladies and gentlemen, In this chamber today is a subset of healthcare personel and allied industry players with an interest in hernia surgery, and who will be involved with  teaching, training and clinical guideline development.  We also envisage to develop authoritative unbiased resource of hernia information for other healthcare professionals and patients.

It is my great pleasure to invite you to pamper this gathering with words of wisdom which you have accumulated from your long experience with modern affairs and continous study of antiquity and to declare this symposium officially open.

Thank You