Small bowel obstruction following perforation of the uterus at induced abortion.

BACKGROUND: Unsafe abortion is an important contributor to maternal morbidity and mortality. OBJECTIVE: To present a case of small bowel obstruction following perforation of the uterus at induced abortion. METHODS: A 36-year-old woman, presented at a private hospital, with abdominal pain and weight loss. She had full clinical assessment and laboratory investigations which indicated small bowel obstruction following perforation of the uterus at induced abortion, and was commenced on treatment. RESULTS: She was para 5+0. Her main complaints were abdominal and weight loss following induced abortion of a 12- week pregnancy, four months prior to presentation. At presentation the tools (ultrasound scan, plain abdominal radiograph and barium enema) used for diagnoses only suggested some form of intestinal obstruction and were unremarkable. Correct diagnoses indicating small bowel obstruction was only made at laparotomy. An exploratory laparotomy, adhesiolysis, small bowel resection, end to end anastomosis and bowel decompression was done after bowel preparation. CONCLUSION: Laparotomy has an enviable place in bowel injuries secondary to uterine perforation especially when there is a diagnostic dilemma. Nigerian female population requires continuous health education on widespread and effective use of contraception. Physicians need training and retraining on abortion techniques and management of abortion complications.

Prospective randomized comparison of two preoperative skin preparation techniques in a developing world country.

Povidone-iodine (PI) is a scarce and expensive item for some hospitals in developing countries. This prospective, randomized study was performed at Baptist Medical Centre (BMCO) in Ogbomoso, Nigeria to determine if the use of PI for preoperative skin preparation would result in a lower postoperative wound infection rate and to identify other factors influencing the infection rate. Two hundred patients undergoing inguinal hernia repair were randomized to receive skin preparation with either: (1) locally available, inexpensive market soap and methylated spirit or (2) imported PI. The two groups were equally stratified. The overall postoperative wound infection rate was 5.5%, and there was no significant difference between the groups (5.1% vs. 5.9%). Factors that did not affect the infection rate included gender, age, type of anesthesia, type or duration of the operative procedure, and number of breaks in optimal technique. There were eight abscesses and three cases of cellulitis without suppuration diagnosed an average of 10 days postoperatively. Staphylococcus was the only bacterium identified on Gram stain or culture. The expense of procuring PI is not justified at BMCO. Available funds may better be used for preoperative antibiotics or for improvement in hospital infrastructure, which should result in fewer breaks in optimal operating room technique.

Incidence of umbilical hernia in African children: redefinition of "normal" and reevaluation of indications for repair.

This study was undertaken to assess the degree of ubiquity of umbilical hernias (UHs) in Nigerians and to determine if a laissez faire approach to the presence of UHs is justified. A prospective evaluation was conducted of the umbilical area of 4052 Nigerians living in the vicinity of the Baptist Medical Centre (BMCO) in Ogbomoso, Nigeria. The diameter of the fascial defect was measured with the subject supine and the protrusion of the umbilical skin with the subject erect. Subjects were divided into three groups: group 1 (1 month to 18 years old); group 2 (older than 18 years); and group 3 (pregnant women in an antenatal clinic). "Outies" (defined as any protrusion of the umbilical tip past the periumbilical skin) were present in 92% of group 1, 49% of group 2, and 90% of group 3 subjects. UHs (defined as protrusion of at least 5 mm and diameter of at least 10 mm) were present in 23% of group 1, 8% of group 2, and 15% of group 3 subjects. Spontaneous closure of UHs seems to occur until age 14. A retrospective analysis identified 11 patients undergoing emergency operations for UH-related problems during the past 15 years. With a low incidence and 0% mortality rate associated with management of these emergencies, a policy of prophylactic repair is not justified at BMCO. Because most of the children we examined had outies, repair for cosmetic reasons is rarely requested. The only logical indication for repair of UHs at BMCO is incarceration, and this rarely occurs.

Ketamine : A safe and effective anesthetic agent for children in the developing world.

Ketamine is used extensively in the developing world (DW) because of its effectiveness, availability, relatively low cost, and presumed safety. This report is a prospective, objective assessment of the efficacy and safety of ketamine when used as the sole anesthetic agent in a general medical practice hospital in the DW in children less than 16 years of age undergoing nonemergent operative procedures. Children undergoing laparotomy, thoracotomy, or craniotomy were excluded. Data analysis included serial arterial hemoglobin saturation (SpO2) and pulse rate, amount of ketamine utilized, adequacy of anesthesia, and perioperative complications. One hundred thirty-one children undergoing a total of 210 anesthetics were studied. The level of anesthesia was adequate in all cases. The SpO2 dropped below 90% in 40 (19%) children, below 85% in 25 (12%), and below 80% in 13 (6%). SpO2 drops occurred significantly (P = 0.004) more often after IM than after IV injection. All drops in SpO2 were abrupt without premonitory signs. Thirty-three (82.5%) of these 40 children responded readily to airway manipulation with a jaw thrust, and only 7 (3.3% of the total series) required face-mask O2. None required intubation or positive-pressure ventilation. Transient laryngospasm occurred in 1 child, but there were no other complications. In particular, there was no mortality, apnea, emesis, excessive salivation, or significant early or delayed emergence phenomena. Ketamine is quite effective when used as the sole anesthetic agent in DW children. It is relatively safe, but hypoxemia may go undetected unless technologically sophisticated monitoring equipment is available. Proper suction and ventilatory support equipment should be readily available prior to ketamine injection. The first step when hypoxemia is detected is simple airway manipulation, followed by oxygen administration by face mask if needed. Rarely will intubation be indicated. Ketamine is also a good drug for the management of pediatric emergency department procedures in the United States, but all children in these more developed centers should be monitored with a pulse oximeter, since a significant number of children have a precipitous drop in SpO2.

The outcome of suprapubic prostatectomy: a contemporary series in the developing world.

OBJECTIVES: To assess the appropriateness of the technique of suprapubic prostatectomy using a removable bladder neck partition suture for use in a developing world hospital and to provide contemporary open prostatectomy outcome data currently lacking in the world's literature. METHODS: From 1984 to 1994, 240 consecutive patients presenting to a developing world hospital with acute urinary retention underwent suprapubic prostatectomy using a removable bladder neck partition suture. The average length of time from bladder decompression until operation was 2.5 months. The outcome of these cases was retrospectively analyzed. RESULTS: The overall early complication rate was 19.6%. There were no deaths. The transfusion rate was 4.6%. Clot retention occurred in 6.7%, and 2.9% required return to the operating room for evaluation. For the second half of the series, the early complication rate decreased to 8.3%, the clot retention rate to 0.8%, and the transfusion rate to 1.7%. Other early and late complications were minimal. The length of delay from decompression until operation did not affect outcome. CONCLUSIONS: The technique of suprapubic prostatectomy using a removable bladder neck partition suture is appropriate for use in developing world hospitals because of its low morbidity and mortality rates. The outcome in this contemporary series of open prostatectomy cases compares favorably with the outcome from reported contemporary transurethral resection of the prostate (TURP) series. These data demonstrate that suprapubic prostatectomy is an acceptable option when the patient's anatomy or the state of local medical facilities precludes TURP.