In Low Resource Settings, Task Sharing for Mesh Hernia Repair Seems Safe, Effective

By Carolyn Crist

February 02, 2021

NEW YORK (Reuters Health) - Patient outcomes for elective mesh hernia repair were similar for medical doctors and associate clinicians in Sierra Leone, a new randomized controlled trial shows.

Surgical task sharing could be safe, effective and beneficial in low-resource countries, and surgical training program for non-surgeons could build the capacity for elective surgeries in these countries, researchers write in JAMA Network Open.

"Task sharing is widely implemented in most low-resource settings but to different extents," said senior author Dr. Jenny Loefgren of the Karolinska Institutet in Stockholm.

In some countries, surgeries and obstetric procedures are performed by surgery specialists and medical doctors without specific surgery training. In others, associate clinicians (ACs), that is, healthcare workers with an educational level between that of a nurse and an MD, also perform surgical procedures after receiving surgical training.

"The discussion is very much centered around if task sharing should be practiced or not, while in reality it already is," Dr. Loefgren told Reuters Health by email. "We designed this study to investigate what the consequences of task sharing for a common surgical procedure are."

She and her colleagues conducted a noninferiority trial that included 229 adult men with primary inguinal hernia at Kamakwie Wesleyan Hospital, a first-level hospital in rural Sierra Leone. The patients were randomized to receive surgery from an associate clinician or from a medical doctor who completed two years of internship with rotations in surgery but no formal surgical training.

In Sierra Leone, associate clinicians practicing surgery have received two years of surgical training and completed a one-year internship. Before the study, the doctors and clinicians routinely performed hernia repair using tissue techniques and received hands-on training in inguinal hernia mesh repair.

Blinded observers assessed patient outcomes two weeks after surgery and looked for hernia recurrence one year after surgery. Five medical doctors operated on 114 patients, and six associated clinicians operated on 115 patients.

During a two-week follow-up, 37 patients developed a hematoma or seroma on the side of the operation, and 10 patients developed infections that required antibiotics. Overall, all patients reported fewer symptoms in the groin than before the operation, and 99% of patients were satisfied with the results of the operation.

Postoperative complications and chronic pain were similar for both groups.

After one year, hernia recurrence happened in seven patients operated on by medical doctors and one patient operated on by associate clinicians. The recurrence rate was 6.9% for medical doctors and 0.9% for associate clinicians (P<0.001). The research team has planned a three-year follow-up to monitor hernia recurrence in both groups.

"This result was very surprising to us and has not been well-received by some reviewers," Dr. Loefgren said. "During the process of publication of this paper, we have discovered that the results are very controversial."

Task-sharing debates should focus on optimizing surgical training in low-resource countries rather than whether it should be done in the first place, the authors argue. Medical doctors could receive more surgical training during medical school and internships, and associate clinicians could receive more specialized training to build the capacity for more people to receive elective surgeries in low- and middle-income countries.

"It is not the title of the surgical provider that is key, it is the training that she or he has received that is most important," Dr. Loefgren said.

Future studies should look at the best practices in surgical task sharing for emergency hernia repair, as well as for women and children, the authors write.

"An AC surgeon is (in nearly all cases) better than no surgeon, and this is, in many low-resource settings, what we should be comparing," said Dr. Frederik Federspiel of the London School of Hygiene and Tropical Medicine in the U.K. Dr. Federspiel, who wasn't involved in this study, has written about surgical, anesthetic and obstetric task sharing globally.

"A growing body of evidence is demonstrating their non-inferiority to MD surgeons, and in this case, even superiority to junior MD surgeons," he told Reuters Health by email. "This is profound, and we need to move away from the notion of unconditional doctor superiority and start training and supporting more ACs to meet the vast, global unmet need for surgical care."

SOURCE: JAMA Network Open, online January 11, 2021.