Typhoid ileal perforation in children: does clinical diagnosis alone justify laparotomy?

Introduction: Typhoid ileal perforation is one of the most common surgical complications of typhoid fever, with high morbidity and mortality in resource poor tropical areas in Africa and other developing countries. Objective: The aim of this study was to evaluate clinical diagnosis of typhoid ileal perforation as justification for laparotomy. Method: A retrospective study from January 2008 to December 2011 in the Paediatric Surgery Division of the University of Abuja Teaching Hospital. Results: The age group most commonly affected was aged 6-9 years (43.5%); there were 20 (43.5%) males and 26 (56.5%) females. The commonest clinical features were fever, vomiting, abdominal pain, tenderness and distension (52.3%). Thirty one (67.4%) of the patients did not have any diagnostic radiological investigations. Fifteen (32.6%) patients had superficial wound infection, ten (21.7%) died, eleven (23.9%) had no complications. Conclusion: We advocate that under circumstances where urgent diagnostic radiological and laboratory investigations are not available promptly, clinical diagnosis of typhoid ileal perforation, especially signs of peritonitis should justify an emergency laparotomy

Is direct consultant supervision of all trauma laparotomies necessary?

Introduction: This study examines the nature of trauma laparotomies performed primarily by trainees and those performed under the direct supervision of a consultant. Materials and Methods: A retrospective review was undertaken at the Pietermaritzburg Metropolitan Trauma Service (PMTS), South Africa. All patients who underwent a trauma laparotomy were included. Admission physiology, organ injury and outcome were assessed. Statistical comparison using STATA was performed. Chi-squared analysis was used for categorical variables and unpaired T-test for physiology. Results: A total of 562 patients for trauma laparotomy were identified. Ninety percent (506/562) were male and the mean age was 30 years. The in hospital mortality was 7% (40/562). A consultant was present at 35% of cases (197/562). Consultant-lead operations were found to have a higher rate of mortality 16% vs 2% (32/197 vs 8/365: p < 0.001) and ICU 45% vs 25% (89/197 vs 91/365: p < 0.001) than trainee only.Significant differences in many parameters of admission physiology were identified. Consultant-lead procedures had a higher lactate (3.7 vs 2.9: p 0.0043), respiratory rate (RR) (22 vs 20: p 0.0005), heart rate (HR) (102 vs 96: p 0.0035) and a lower systolic blood pressure (SBP) (115 vs 122: p 0.0001) diastolic blood pressure (DBP) (69 vs 73: p 0.0350) pH (7.34 vs 7.36: p 0.0216) base excess (BE, mEq/L) (-4.1 vs -2.5: p 0.0036) and bicarbonate (HCO3, mEq/L) (21.3 vs 22.5: p 0.0043) than trainee only procedures. Consultants were more likely to be called in for a gunshot than a stab wound (p < 0.001).Of the solid organ injuries, consultants are more likely to be called in for cases with liver injury 23% vs 16% (45/197 vs 58/365: p 0.005) and pancreatic injury 15% vs 3% (30/197 vs 11/365: p < 0.001). Conclusion: Trainees can safely undertake a subset of trauma laparotomies. However, patients with deranged physiology and complex hepatobiliary injuries should be operated on directly by a consultant

A selective vacuum assisted mesh mediated fascial traction approach following temporary abdominal containment for trauma laparotomy is effective in achieving closure

Background: Definitive primary abdominal closure is often not possible nor desirable following trauma laparotomy. In such situations, temporary abdominal containment (TAC) is necessary. This audit reviews our experience with TAC and interrogates our use of the Vacuum Assisted Mesh Mediated Fascial Traction approach (VAMMFT) to achieve delayed closure of the Open Abdomen (OA). Methods: We conducted a retrospective study over a 4-year period of trauma patients who underwent a trauma laparotomy and who required a TAC. Results: Over the four-year period, 596 patients underwent a laparotomy for trauma. Of these trauma laparotomies, 463 (78%) underwent primary closure and 133 (22%) required a TAC. Of these 133 patients who required a TAC, 37 died, 41 underwent delayed primary fascial closure at repeat laparotomy and 55 were left with an OA. Of this cohort of 55 patients, 15 underwent a VAMMFT procedure. The VAMMFT procedure yielded a 60% closure rate, with failure to close being due to late mesh insertion and sepsis. Conclusion: Our initial results with VAMMFT are encouraging. The technique appears to be effective and safe. Ongoing audit will allow us to accrue more patients and to better refine our algorithms and strategies

A randomised trial comparing laparoscopy with laparotomy in the management of women with ruptured ectopic pregnancy

Background. Ruptured ectopic pregnancy (REP) is a common gynaecological emergency in resource-poor settings, where laparotomy is the standard treatment despite laparoscopic surgery being regarded as the optimal treatment. There is a lack of prospective randomised data comparing laparoscopic surgery with laparotomy in the surgical management of women with REP.Objective. To compare operative laparoscopy with laparotomy in women with REP.Methods. This was a randomised parallel study. One hundred and forty women with suspected REP were randomised to undergo operative laparoscopy or laparotomy. The outcome measures were operating time, hospital stay, pain scores and analgesic requirements, blood transfusion, time to return to work, and time to full recovery.Results. Operating time was significantly longer in the laparoscopy group (67.3 v. 30.5 minutes, p<0.001). Duration of hospital stay, pain scores and need for analgesia were significantly less in the laparoscopy group. Women in this group returned to work 8 days earlier and their time to full recovery was significantly shorter compared with those in the laparotomy group. Significantly more women undergoing laparotomy required blood transfusion than women in the laparoscopy group. In the latter group, 14.5% of women required blood transfusion compared with 26.5% in the laparotomy group (p=0.01). Conclusion. Operative laparoscopy in women treated for REP is feasible in a resource-poor setting and is associated with significantly less morbidity and a quicker return to economic activity

Cas rare de prolapsus rectal dû à une invagination intestinale aiguë de diagnostic tardif

Le prolapsus rectal est l'issue par l'anus de la paroi rectale évaginée. L'Invagination Intestinale Aiguë (IIA) réalise un télescopage d'un segment intestinal d'aval par le segment intestinal d'amont pour former le "boudin". Vue tardivement l'évolution se fait vers une occlusion intestinale aiguë sévère, et à l'extrême un prolapsus rectal avec nécrose d'anses intestinales. Dans la littérature les cas de prolapsus rectal dû à une IIA sont rares, du fait de diagnostic précoce. Nous rapportons le cas d'un nourrisson de sexe masculin âgé de 11 mois qui a présenté un prolapsus rectal dû à une IIA, ceci dans le but de souligner les particularités diagnostiques et thérapeutiques de cette présentation clinique et éviter les retards diagnostiques. La prise en charge s'est faite en urgence. Après une courte réanimation, une laparotomie a permis de retrouver une IIA dans sa forme iléo-cæco-colique et de nombreuses adénopathies mésentériques. La désinvagination n'a pas été complète et la décision d'une résection intestinale emportant l'iléon terminal, le cæcum, le côlon ascendant a été prise. L'anastomose était iléo-colique, termino-terminale. Le transit a repris au 3e jour post-opératoire autorisant une alimentation parentérale. Le diagnostic de prolapsus rectal compliquant une IIA est clinique, et le toucher rectal en est l'élément fondamental. L'imagerie ne permet pas de confirmer le diagnostic. En contexte de plateau technique limité, la chirurgie ne doit pas être retardée. Seule la clinique permet de poser un diagnostic précoce et l'indication opératoire

A ten year review of female sterilization at the university of Maiduguri teaching hospital, Maiduguri, Nigeria

Background: In most developing countries like Nigeria, female sterilization is not a popular method of contraception. Objective: The objective of this study was to determine the prevalence of female sterilization and socio-demographic characteristics of women who had sterilization in our setting.Methodology: This was a retrospective study carried out between 1st January 1997 and 31 December 2006.A total of two hundred and one female sterilisation operations were performed but ten case notes were incomplete and therefore, one hundred and ninety one 191 were analyzed. Information retrieved from the case notes included the age, parity, religion, literacy, and type of bilateral tubal ligation. The data collected were analyzed using SPSS Version 16.0 statistical package and the results represented in simple tables and percentages.Results: There were 16,319 deliveries during the study period and 201women had bilateral tubal ligation (BTL), giving a prevalence of 1.2%. The mean age at BTL was 30.18, while the mean parity was 4±0.6. Women between the ages of 30-39 constituted majority of the patients. In most of the women 138 (72.3%) bilateral tubal ligation was performed during caesarean section, while few women 16 (8.4%) had the procedure at laparotomy. The rest, 37(19.4%) women opted for interval BTL. Significantly more literate women (73%) sought for interval tubal ligation compared to non literate (23%) ones. A large number of the Muslims (87.5%) had BTL at laparotomy compared to the Christians (12.5%). P=0.002.Conclusion: The prevalence of bilateral tubal ligation in this study is low. There is need to encourage the uptake of female sterilization in our environment

Epidemiology of pediatric surgery in Rwanda: A one year review

Introduction: In Rwanda, as in other Sub-Saharan Africa countries, there is insufficient data on pediatric surgical conditions. Despite the lack of Pediatric Surgeons and Pediatric Anesthesiologists, Kigali and Butare University Teaching Hospitals receive and manage children with surgical conditions. Some of these patients could benefit from the expertise of specialists trained in Pediatric surgical conditions. Purpose: The aim of this study is to describe the pattern of pediatric surgery in Rwanda and to determine the prevalence of pediatric surgical conditions that require the expertise of a Pediatric Surgeon. Methods: This is a retrospective study carried out between August, 2013 and July, 2014. Data were obtained from theater books and operative database. Data analysis was done by SPSS 16 and MS Excel. Results: From August, 2013 to July, 2014, a total number of 1274 children were operated at Butare and Kigali University Teaching Hospitals. 391 (30.7) were female and 883 (69.3) were male, with a male to female ratio of 2.2:1. The age ranged between 1 day and 16 years, Mean age was 6.4 ± 4.9 years. Children under fie were 45.1%. 857 (67%) children needed the Pediatric Surgery specialty expertise. 369 (29%) patients were operated at Butare University Teaching Hospital, while 905 (71%) were operated from Kigali University Teaching Hospital. Trauma and burn: 466 (36.58%), congenital anomaly: 298 (23.39%) and Surgical infections: 188 (14.76%) were the three common diagnoses in pediatric surgery.Conclusion: Training of Pediatric Surgery sub-specialists, Anesthesiologists and Nurses will provide improved care in Rwanda. Education in trauma prevention, early screening and management of congenital anomalies, will improve service delivery to children with surgical conditions in Rwanda

Grossesse abdominale. A propos d'un cas observé à l'hôpital de zone de Dassa (Bénin)

Les auteurs rapportent un cas de grossesse abdominale à 31 semaines d'aménorrhée chez une patiente de 32 ans à l'hôpital de zone de Dassa. Diagnostic fait, la patiente refuse l'hospitalisation et sort contre avis médical. Revue deux semaines plus tard pour douleurs abdominales, l'échographie de contrôle révèle une mort fœtale à 33 semaines d'aménorrhée + 3 jours. Une laparotomie a été réalisée suivie d'une extraction de la cavité abdominale d'un fœtus mort-né macéré 3ème degré. L'évolution post-opératoire était simple et la patiente était sortie au 6ème jour post-opératoire

Peri-mortem laparotomy in a patient with a ruptured intra-abdominal pregnancy

Introduction :Intra-abdominal pregnancies can present at an advanced stage of pregnancy and can have the potential for life-threatening rupture and haemorrhage. The purpose of this case report was to discuss the early recognition and prompt management options of a patient with a life threatening ruptured intra-abdominal pregnancy.Case report:We report what we believe to be the first case of a patient who presented with an intra-abdominal pregnancy who underwent a peri-mortem laparotomy in the Emergency Centre following a cardiac arrest; and who exhibited a return to spontaneous circulation (ROSC).Conclusion: Peri-mortem laparotomy/thoracotomy coupled with high quality CPR and resuscitation may be lifesaving in a patient with a life threatening ruptured intra-abdominal pregnancy

The Postoperative Complications Prediction in Mulago Hospital using POSSUM Scoring System

Introduction: Prediction of complications is an essential part of risk management in surgery. Knowing which patient to operate and those at high risk of developing complications contributes significantly to the quality of surgical care and cost reduction. The postoperative complications of patients who underwent Laparotomy in Mulago hospital were studied using POSSUM scoring system. The main objective of this study was to determine the postoperative complications of Laparotomy in Mulago Hospital; between September 2003 and February 2004. Methods: consecutive patients; who underwent Laparotomy in Mulago; were studied using POSSUM system for development of complications. For each patient operated; they were followed up in wards until discharge. When the postoperative complications were reported; they were reexamined by the surgeons; treated and followed up for 30 days postoperatively. Phone contacts were used for the follow up. Surgical reviews were conducted once a week in Mulago Hospital and the data obtained recorded in the data sheet for the patients. Results: Seventy-six patients were studied. The observed post operative complications were as follows: Respiratory tract infection (28.2); wound haemmorrhage (18.2); anaemia (15.5); hypotension (14.1); UTI (2.2); Anastomotic leak (1.4); Wound sepsis (9.9); wound dehiscence (4.2); Thromboembolism (1.4). The postoperative nursing care significantly determined the outcomes. Conclusion: Postoperative complications can be predicted in the modern management of surgery especially while using a scoring system

Peritonite primitive chez l'adulte: une realite

Nous rapportons un cas de peritonite primitive; initialement prise pour une infection abdominale secondaire; observe chez un adulte sans antecedents medicaux ou chirurgicaux; porteur de foyer infectieux respiratoire. Ce patient age de 45 ans avait beneficie en urgence d'une laparotomie devant un syndrome pseudo-peritoneal. Dans la litterature; cette affection est peu frequente chez l'adulte. Elle necessite une surveillance clinique et paraclinique pour eviter une insuffisance respiratoire aigue

Un nouveau cas d'endometriose sur cicatrice de laparotomie

L'endometriose cutanee cicatricielle est rare. Les auteurs en rapportent un cas chez une femme de 31 ans qui; apres une laparotomie pour grossesse extra uterine rompue trois ans auparavant; presentait une tumefaction cicatricielle d'evolution catameniale. Cette tumefaction bleue noiratre; mal limitee; etait douloureuse; augmentait de volume et se fistulisait en periode menstruelle. Une exerese large etait pratiquee suivie d'un traitement medical a base d'ostroprogestatifs en prise continue pendant six mois. Aucune recidive n'est a deplorer apres un recul de trois ans. Les particularites de cette localisation rare sont discutees a travers une revue de la litterature

Experience with Acute Perforated Duodenal Ulcer in a West African Population

Background: The advent of proton pump inhibitors and helicobacter pylori eradication in the management of chronic peptic ulcer disease has reduced the operative treatment of this condition to its complications. Perforated duodenal ulcer remains a major life threatening complication of chronic peptic ulcer disease. This retrospective study reviews our experience at the Royal Victoria Teaching Hospital . Methods: All patients with clinical diagnosis of perforated duodenal ulcer seen in this hospital between June 2003 and October 2005 were included in this study. Data extracted from their hospital records were analyzed for age; sex; duration of symptoms; previous history of peptic ulcer disease; use of NSAIDS; main presenting features; investigations; resuscitative measures; time of surgery; operative findings; and type of surgery offered; complications and mortality. After resuscitation; laparotomy followed by simple closure or definitive ulcer surgery and helicobacter pylori eradication therapy was given to all the patients. Duration of follow up ranged 8 to 12 months with endoscopy in some patients. Results: There were 41 patients with intraoperative diagnosis of acute perforated duodenal ulcer seen over the study period; comprising 34 males (82.9) and 7 females (17.1); a male female ratio of 4.8:1; age range of 18-77 years and a mean age of 45.49+/-14.46 years. Previous history of peptic ulcer disease was found in 32 (78.6) of the patient and the main presenting features were sudden onset of severe abdominal pain in 95.1of cases and fever in 65.8. Features of frank peritonitis were demonstrable in all the patients and 11(26.8) presented in shock. Plain chest x-rays demonstrated gas under the diaphragm in 21(65.6) of the patients. After adequate resuscitation; all the patients underwent laparotomy where the abdomen was explored; the diagnosis of perforated duodenal ulcer was confirmed and 29(70.7) had simple closure of the perforation with omentum (after Graham). The average time between presentation and surgery was 9 hours (range 6-11hours). The mean size of perforation was 10.5mm (range 5- 15mm). Definitive peptic ulcer surgery was done in 12 (29.3) patients. 8 had truncal vagotomy and pyloroplasty. The major complications included wound infection in 14 (34.1); postoperative fever in 16 (39.0) and prolonged ileus in 15 (36.6) There were 7 deaths; mortality rate of 17.1and the causes of death included severe electrolyte imbalance in 1 and gram negative septicaemia and shock in 6. The average duration of hospital stay was 10 days (range 8 36). Conclusion: Perforated duodenal ulcer is a major complication of chronic peptic ulcer disease. Simple omental patch by open method and helicobacter pylori eradication therapy is sufficient to prevent reperforation

Avantages de la voie vaginale coelio-assistee

Introduction : Apres l'enjeu carcinologique et de survie de la chirurgie des cancers de l'endometre; les auteurs de cette etude se proposent d'evaluer l'impact reel de la voie coelio-vaginale dans la chirurgie des cancers de l'endometre. Patientes et methodes : Entre le 1er Juin 2002 et le 31 Mai 2005; nous avons effectue une etude retrospective; comparative portant sur 36 interventions par voie colio-vaginale et 20 laparotomies realisees chez 56 patientes. Resultats : Dans les stades precoces (I et II de la FIGO); la voie coelio-vaginale est aussi performante que la laparotomie (p =0;07) alors que dans les stades plus avances la laparotomie etait plus complete et efficace. Le cas de conversion observe (soit 2;8) etait du a une des adherences complexes dans un contexte de carcinose peritoneale chez une patiente au stade IIIc. Il n'y avait pas de difference significative dans les complications (p=0;51). Le confort post operatoire etait; par contre; de loin meilleur dans le groupe de coelio-vaginale (p=0;0002). Le delai moyen de suivi sans recidive etait de 22;3 mois dans le groupe de coelio-vaginale versus 23 mois dans le groupe de laparotomie (p = 0;51). Conclusion : Devant ces resultats; les auteurs retiennent que dans les stades precoces (I- II de la FIGO); la voie coelio-vaginale constitue une reelle option dans la chirurgie des cancers de l'endometre par contre les stades avances devraient etre reserves a la laparotomie

Abdominal injuries in olabisi onabanjo university teaching Hospital Sagamu, Nigeria: Pattern and outcome

Objective: The aim was to study the pattern and outcome of abdominal trauma managed by Laparotomy in Olabisi Onabanjo University teaching Hospital Sagamu (OOUTH), South Western Nigeria.Method: This is a retrospective study. The records of the patients were retrieved and relevant data extracted such as age, sex, occupation, address, cause of injury, vital signs on admission, abdominal signs, other injuries, number of units of blood transfused, investigations, indications for surgery, operative findings, procedure carried out, complications and outcome.Results: Seventy seven subjects were reviewed. There were 23 females (29.9%), and 54 males (70.1%). The age range was 3years to 68years, 32 patients (41.6%) were in 20-30 years age group. The mechanism of injury was blunt trauma in 61 (79.2%) and penetrating injury in 16 patients (20.8%). Road traffic accident was the commonest cause of injury, in 53 patients (68.8%). 42 patients (54.5%) had extra abdominal injuries. Positive paracentesis abdominis was the commonest indication for surgery, in 53 patients (68.8%). The spleen was the most commonly injured organ, in 31 patients (40.2%) while the organs were normal in 4 patients (5.2%). The complication observed includes acute renal failure, in 5 patients (6.5%), multiple organ failure in 5 patients, and wound infection in 8 patients (10.4%). Ten patients died. (13%)Conclusion: Splenic rupture is the most common abdominal injury treated by Laparotomy in OOUTH Sagamu and the commonest cause is road traffic accident. Mortality was due mainly to acute renal failure and multiple organ failure

Case Report - Heterotopic Pregnancy with Spontaneous Vaginal Delivery at 36 Weeks and Laparotomy at Term - A Case Report

Heterotopic pregnancy; although rare; is occurring more frequently because of an increase in genital infection and the escalating use of new reproductive technologies in infertility patients. The case of a 30-year-old para 2+1 prophetess is presented. She had a spontaneous vaginal delivery at term. Persistent abdominal pain and distension led to suspicion of heterotopic pregnancy. This was confirmed by ultrasonography. Laparotomy revealed a macerated fetus in the peritoneal cavity. The purpose of this report is to sensitise practitioners about the reality and existence of the condition

Pronostic des peritonites post-abortum : a propos de 34 cas colliges aux urgences de gynecologie et obstetrique du CHU de Treichville

INTRODUCTION : Les avortements provoques clandestins ont de nombreuses complications. La peritonite est l'une des plus preoccupantes ; leur mortalite est comprise entre 8;3 et 69;9pour cent. OBJECTIFS: Ce travail avait pour objectif : d'evaluer la prise en charge des peritonites post abortum ; De determiner les criteres sociodemographiques des patientes; De degager les difficultes du diagnostic precoce ; Identifier les dysfonctionnements ; Reduire la morbidite et la mortalite. MATERIELS ET METHODES : Il s'agissait d'une etude transversale descriptive a double composante retrospective et prospective. Nous avons retenus 34 patientes soit 18 patientes dans le volet retrospectif et 16 patientes dans le volet prospectif. Et nous avons etudies chez chacune des patientes les caracteristiques sociodemographiques; l'aspect diagnostic et therapeutique; et enfin l'evaluation de la qualite de la prise en charge. RESULTATS : L'age moyen de nos patientes etait de 20;79pour cent ans; la tranche d'age de 18 a 20 ans etait la plus touche 47;05pour cent. Les patientes etaient nullipares (44;1pour cent); menageres (52;94pour cent) et celibataires (82;35pour cent). L'acte abortif avait ete realise dans 79;59pour cent des cas apres 12 semaines d'amenorrhee par un personnel de sante (n= 22). Le delai moyen de consultation a ete de 6;5 jours. La symptomatologie peritoneale peu marquee etait a l'origine de difficulte diagnostic. 32 patientes ont ete operees. Le traitement a ete conservateur le plus souvent (n= 20 soit 62;5pour cent). 3 patientes sont decedees dans un tableau de choc septique. La morbidite post operatoire etait dominee par les sepsi parietaux (n= 12). Des dysfonctionnements ont ete identifies au cours de la prise en charge ; les causes de ses dysfonctionnements sont attribuables : -Au personnel soignant ; A la structure d'accueil ; -A la patiente et sa famille. CONCLUSION: L'amelioration de la prise en charge des peritonites post abortum impose une amelioration de l'accessibilite aux soins obstetricaux d'urgences et une formation medicale continue du personnel