Lymphatic ?lariasis (LF) is a debilitating mosquito-transmitted disease caused by the helminths Wuchereria bancrofti, Brugia malayi,  and  Brugia timori[1]. The disease occurs in individuals of all ages and both sexes but prevails in those of low socioeconomic status [2]. Lymphatic filariasis, commonly-known as elephantiasis is a neglected tropical disease and infection occurs when filarial parasites are transmitted to humans through mosquitoes. Infection is usually acquired in childhood causing hidden damage to the lymphatic system. In 2018, 893 million people in 49 countries were living in areas that require preventive chemotherapy to stop the spread of infection [3]. Lymphatic filariasis infection involves asymptomatic, acute, and chronic conditions. The majority of infections are asymptomatic, showing no external signs of infection while contributing to the transmission of the parasite. These asymptomatic infections still cause damage to the lymphatic system and the kidneys and alter the body's immune system. When lymphatic filariasis develops into chronic conditions, the microfilaria matures into adult worms in lymphatics causing dilatation of the lymphatics and also leakage of lymph out of the lymphatics. This leads to lymphoedema (tissue swelling) or elephantiasis (skin/tissue thickening) of limbs and hydrocele (scrotal swelling) [4, 5]. World Health Assembly resolution WHA50.29 encourages Member States to eliminate lymphatic filariasis as a public health problem. In response, WHO launched its Global Programme to Eliminate Lymphatic Filariasis (GPELF) in 2000, based on 2 key components: mass drug administration and morbidity management and disability prevention.  The latter involves: the treatment for episodes of adenolymphangitis (ADL); guidance in applying simple measures to manage lymphedema and surgery for hydrocele and the treatment of infected people with antifilarial medicines. Hydrocele is defined as fluid accumulation in the layers of the tunica vaginalis [5]. Over the years various techniques existed for the management of hydrocele including aspiration and sclerotherapy, eversion of the tunica vaginalis, and excision of the tunica vaginalis with eversion [6]. All these were associated with complications such as haematoma, infection, and recurrence [7]. The technique of total tunical resection (modified filarial hydrocelectomy technique) has been found to yield good post-operative results with fewer complications [8, 9]. This technique was described in Sri Lanka in 1948 and eventually was modified in Brazil by Prof Noroes and Prof Dreyer. The technique helps minimize complications such as haematoma, infection and recurrence [8, 9]. According to Neglected Tropical Disease Programme, Annual report, 2020, Lymphatic filariasis was mapped in Ghana in 1999 and 114 endemic districts were identified. The implementation of the programme to eliminate the disease was basically a mass drug administration (MDAs) which commenced in 2001 with 10 districts. The gradual upscaling year-by-year led to the full-scale MDA in all 114 districts by 2005. The transmission of LF has been interrupted in 103 out of the 114 districts and have stopped MDA. Currently, and11 hotspot districts remain.  Although, Ghana has made significant achievements in reducing the transmission of the disease, the provision of morbidity management and disability prevention (MMDP) services has not been as successful, even though the LF control programme takes advantage of the annual MDAs to collect information on the number of suspected hydrocele and lymphedema cases in endemic communities and districts. We report on the process and immediate outcomes in the capacity building of medical officers in a modified filarial hydrocelectomy technique in two LF endemic regions in Ghana. The aim of the hydrocelectomy training was to build the capacity of institutions and medical doctors in endemic regions and districts to provide service to patients with hydroceles using the new approach.

Study Area

Medical officers who were interested in surgical practice were recruited from district hospitals in six regions in Ghana. These were Bono, Bono East, Central, Eastern, Western and Western North regions. The population of these regions constitute about 35% of the Ghanaian population.  In the Eastern region, out of the 33 districts and municipalities, 22 have at least one hospital however smaller health facilities abound in all districts in the region. In the western region, there are 614 health facilities with 102 medical officers and 1148 nurses. In all six regions are many community-based health planning and service dotted in both the urban and rural communities. (Annual reports GHS, 2020).

Data Collection Procedure

The Neglected Tropical Disease Programme (NTDP) communicated with the Regional Health Directorates in both Eastern and Western Regions to initiate processes involved in organizing the hydrocele surgery training. The Regional Health Teams communicated with the respective districts to inform communities of the impending exercise and solicited their readiness and support. The District Health Teams informed the sub-districts and community–based health planning and service (CHPs) compounds to also prepare. The Sub-districts Health Teams in turn informed the Community Drug Distributors (CDDs) to announce in the communities for patients to avail themselves for the opportunity. Announcements were made on local radios in the districts and information on the hydrocele surgeries were shared through community information centres (CIC), gong-gong beating and interpersonal communication. A surgery schedule was made, with selected patients from specific districts and communities assigned to specific dates. This schedule was shared with the districts and concerned sub-districts for them to help in the mobilization of the patients to report on the assigned dates. The national and regional teams also made phone calls to the patients to inform them of their dates of reporting and other guidance on how to report at the facility.  The Deputy Director, Clinical Care in both regions in consultation with the Regional Directors of Health Service selected medical doctors from the endemic districts who were interested in the training. All required arrangements were made with the Tarkwa, Koforidua Regional and the other Hospitals for the surgeries. The medical officers were taken through a classroom session before the practical work at the theatres. Areas covered included LF as a disease, its transmission, endemicity in Ghana, and the status of the elimination programme in Ghana. They also accessed the power point presentations of filarial hydrocele, its pathology, and the types of surgical approaches available. Also stressed were the advantages of the resection method over the other methods. Prior to the surgery, the case-patients were assessed at the surgical wards to identify complicated cases and the process to apply was determined before going to the theatre. Demographic features of the patients such as age and gender were recorded. Masses in the groin were differentiated based on whether they were hard such as “testicular cancer or hydrocele/cystocele” or soft or reducible indicating “groin hernia. Standard protocols for surgical operations were followed. The consultant and facilitators reviewed operated cases together with the trainees each day as part of the training. Upon the discharge of the patients, each was assigned to a trainee doctor from a facility closer to the communities of residence of the patients, for post-operation follow-up. Patients were also provided with supplies for dressing at the nearest facility to their communities of residence.

Surgical Procedure

All patients were prescreened with a complete medical history including past history of diabetes, hypertension or any bleeding diathesis, complete physical examination, full blood count and urinalysis and an ultrasound of the scrotum performed. The patients were then made to sign a consent form after careful explanation of the technique and its possible complications on them. All patients were then admitted a day before surgery and made to have a good shower (washing the genitals with soap & water) and also made to take two antibiotics namely metronidazole and amoxsiklav. The surgical technique involved a total tunical resection without drainage.8 After meticulous cleaning and draping a midline scrotal incision was made and the hydrocele was carefully dissected out of the scrotum. The fluid was then aspirated and the tunica vaginalis was totally resected followed by careful continuous interlocking suturing of the edges of the tunica around the testis using 3-0 vicryl sutures. Haemostasis was also secured on the inner aspect of the scrotum using electrocautery. Care was taken not to damage the vas deferens, epididymis, and the testis and its vessels during the procedure. In the event that the testis was found necrotic, orchidectomy was done .The testis was then placed in the scrotum without fixation and the scrotum was closed in two layers using 3-0 vicryl sutures without drainage. The scrotum was then bandaged and suspended using adhesive tape. The average operating time for a unilateral hydrocele was 45 minutes to one hour and for bilateral hydrocelectomy was 1½ h to 2 h depending on the size of the hydrocele.

Data were entered into Epi Info software version 3.3 for data cleaning and analysis. We performed descriptive analysis of the case patients and the participants at the training. Univariate analyses were expressed as frequency distributions, percentages as appropriate.

Community members from six regions were screened. Out of the 883 patients identified with a soft or reducible swelling, 15.4% (136/883) were noted and validated as hydroceles Refer (Table 1).

Table 1: Distribution of hernia and hydrocele cases screened by region and district, 2020.

Out of the 136 hydrocele cases, 15.5% (21/136) failed to avail themselves for the surgery mainly due to the fear of not surviving the operation. Majority, 65% (75/115) of the patients with hydrocele were between the ages of 40-60 years old and 55% (63/115) percent were peasant farmers and the rest mainly fishermen. Majority, 60%, (69/115) had primary level of education, 60% (69/115) were married and 30% (34/115) were divorcees. Forty three medical officers were trained and the majority 42% (18/43) were from the Western and Western North Regions. Among the trainee medical officers was a female. All the medical officers were from the district hospitals and most of them, 80% (34/43), were in the age group 30-45 years old. Sixty percent (26/43) had practiced medicine between 2-3 years.

All the 115 patients with hydroceles who consented for the hydrocelectomy were successfully operated and none of them had a post-surgery complication. Infection rate was zero. Patients and Surgeons were found to be very happy about this observation. Even though the surgeries were offered free of charge, some patients could not raise transportation and had to be assisted by the NTD Programme to access the service.  

To our knowledge, the present report revealed from the case search that more hydrocele cases were found in the western regions than that found in the other regions. Disability due to hydroceles is a concern for both the individual as well as society in general. It affects an individual's ability to work in the community as well as the daily life of a family that experiences a reduction in household income. The higher numbers of hydrocele cases in the Western region could be attributed to the higher endemicity of lymphatic filariasis disease in the Western region than found in the other regions where the active case search for hydroceles were done [8]. The baseline prevalence of the disease in the districts of the Eastern and the other regions were much lower (5% antigenaemia prevalence in the Suhum district) as compared to those in the Western region (41% antigenaemia prevalence in the Ahanta West district.) The districts in the Eastern, Central and Bono northern region have all interrupted transmission of the disease after nine rounds of Mass Drug Administration (MDA) whilst some of those in the Western region remain hotspots after 18 rounds of MDAs. The current situation in the Western region is even better because the NTD Programme has organized similar programs in the region earlier and this must have even reduced the burden of hydroceles in the beneficiary districts. There used to be a lot of hydrocele cases in the coastal districts of the region.The infection rate after surgery was found to be zero among patients identified and operated in all the regions. The technique of total tunical resection has been found to yield good post-operative results with fewer complications [9]. This technique was described in Sri Lanka in 1948 and eventually was modified in Brazil by Prof Noroes and Prof Dreyer. The technique helps minimize complications such as haematoma, infection and recurrence [9]. Most men become sexually inactive with the filarial hydroceles before surgery and eventually become sexually active after surgery [10]. It was noted that some of the patients with hydrocele had been divorced and had unstable marriages, NTDs are a consistent cause of domestic and marital conflict as well as desertion practices, which disproportionately affect women. The disfigurement resulting from the hydrocele may prevent young women from getting married to the affected men or act as grounds for spousal abandonment. Our results were consistent with the observations from Hunt et al.,2007   who established that some end results from neglected tropical diseases such as hydroceles inflict a substantial  social and economic burden to individuals, households, communities, and the society all of which promote poverty and ill health for populations[11]. In conclusion, medical doctors in six LF endemic regions in Ghana had a hands-on coaching under strict supervision on hydrocelectomy which involved a modified total tunical vaginalis resection without drainage, a WHO recommended technique for hydrocelectomy. The patients with hydroceles were successfully operated and none of them had a post-surgery complication. Patients and Surgeons were found satisfied. It is however recommended that, the programme of free- hydrocelectomy is extended to the rest of the endemic and non-endemic regions with the inclusion of hernia repair taking into consideration the huge number of patients with various forms of hernias that were identified  during the case validation in the communities. The patients who had been operated should be supported by an income generation activities and those with broken homes be counseled to return to their marriages. To sum up, surgical services in underdeveloped regions of the world can be improved with continuous and committed collaboration of the workforces.

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