Inguinal hernia repair in Nigeria: a survey of surgical trainees.

PURPOSE: Africa's inguinal hernia burden is high with large numbers of untreated hernias. Mesh repair is recommended in developed countries, but the best repair in developing countries is unknown. Little is known about knowledge and practice of surgeons in Nigeria performing inguinal hernia repair. Surgical trainees can provide this information. METHODS: A questionnaire-based survey was administered to surgical trainees from all over Nigeria who had attended the West African College of Surgeons' integrated revision course in Jos, on their practice and recommendations concerning elective inguinal hernia repair. RESULTS: One hundred and nine surgical trainees (90.8%) consisting of 78 (71.6%) registrars and 30 (27.5%) senior registrars responded. Thirty-two (29.4%) used antibiotics routinely for inguinal hernia surgery. Ceftriaxone was the most widely used antibiotic (45%). Ninety-two (84.4%) respondents will perform this surgery as day case. Forty (36.7%) respondents stated modified Bassini repair as their preferred method of repair. Mesh repair was recommended by 93 (85.3%) respondents while 65 of 100 respondents (65%) recommended laparoscopic surgery. Of 103 respondents, 93 (90.3%) had performed inguinal hernia repair and 34 (33%), mesh repair. For 56 (51.4%) respondents, the most difficult part of open hernia surgery was sac dissection. CONCLUSIONS: Surgical trainees in Nigeria perform more tissue-based inguinal hernia repair than mesh but majority would recommend both mesh repair and laparoscopic surgery. Majority found sac dissection as the most difficult part of open hernia surgery.

COMPLETE OESOPHAGEAL STRICTURE FOLLOWING THYROIDECTOMY FOR BENIGN GOITRE: A CASE REPORT.

Oesophageal injury leading to stricture is a dreaded disease with clinical course and prognosis that are dependent on the etiology, early recognition, and prompt and effective treatment. Commonly, iatrogenic oesophageal injury occurs during endoscopic procedures, and often in a diseased oesophagus. Though uncommon, injury can occur during thyroidectomy. We therefore present the case of a Nigerian woman with complete oesophageal stricture resulting from oesophageal injury sustained during thyroidectomy.

Management of the mass casualty from the 2001 Jos crisis.

BACKGROUND: We report our experience in the hospital management of mass casualty following the Jos civil crisis of 2001. MATERIALS AND METHODS: A retrospective analysis of the records of patients managed in the Jos civil crisis of September 2001, in Plateau State, Nigeria. Information extracted included demographic data of patients, mechanisms of injury, nature and site of injury, treatment modalities and outcome of care. RESULTS: A total of 463 crisis victims presented over a 5 day period. Out of these, the records of 389 (84.0%) were available and analyzed. There were 348 (89.5%) males and 41 females (10.5%) aged between 3 weeks and 70 years, with a median age of 26 years. Most common mechanisms of injury were gunshot in 176 patients (45.2%) and blunt injuries from clubs and sticks in 140 patients (36.0%). Debridement with or without suturing was the most common surgical procedure, performed in 128 patients (33%) followed by exploratory laparotomy in 27 (6.9%) patients. Complications were documented in 55 patients (14.1%) and there were 16 hospital deaths (4.1% mortality). Challenges included exhaustion of supplies, poor communication and security threats both within the hospital and outside. CONCLUSION: Most patients reaching the hospital alive had injuries that did not require lifesaving interventions. Institutional preparedness plan would enable the hospital to have an organized approach to care, with better chances of success. More effective means of containing crises should be employed to reduce the attendant casualty rate.

The conundrum of polytrauma on the jos plateau.

BACKGROUND: The leading cause of morbidity and mortality from the end of the first year of life to the forty fifth is trauma. This is true worldwide but especially so in our environment. In no other situation are the complexities of the management of trauma more manifest than in the context of polytrauma. For this we undertake to study the problem of polytrauma in Jos. AIMS AND OBJECTIVES: To determine the frequency and pattern of occurrence of poly trauma in Jos university teaching hospital. PATIENTS AND METHODS: Consecutive patients presenting with polytrauma to the casualty department were prospectively studied. Data regarding demographics and a detailed description of injuries were entered into a proforma and collated over a one-year period. RESULTS: A total of 131 patients were studied. There were 103 males and 28 females giving a male to female ratio of 3.7:1. The ages ranged from 2 to 61 years with a mean of 28.4 ± 12.4 years. Road traffic accident was the most common aetiology in 113 (86.3%) patients, while falls 7 (5.3%), gunshots 5 (3.8%) and assaults 2 (1.6%) were observed. The most frequently encountered injuries were head, extremity and chest in 71.8%, 68.5% and 29.2% respectively. The combinations most frequently observed were head\extremity (43.5%), head\chest (17.6%) and chest\extremity (10.7%) injuries. Complications were observed in 20.6% while death occurred in 7.6%. CONCLUSION: Polytrauma occurs with sufficient frequency to warrant serious attention. As majority follow RTA, there is a need to intensify measures aimed at improving road safety. There is also a need to establish pre-hospital care\ambulance services. It is suggested that improved orthopaedic and neurosurgical care will lead to improved polytrauma care and most importantly, the establishment of dedicated trauma teams in tertiary institutions is proposed as a prelude to the establishment of regional trauma centers.

Adult large bowel obstruction: a review of clinical experience.

BACKGROUND: Adult large bowel obstruction is an infrequent cause of acute obstruction in Africa and India. The cause of obstruction varies between regions of the world. Current controversy concerns the surgical management of the acutely obstructed left colon. MATERIALS AND METHODS: This is a prospective study of adult patients with acute large bowel obstruction over a 6-year period. The diagnosis of adult obstruction was made from a history of constipation, abdominal distension, abdominal pain, nausea, and radiographic features of large bowel obstruction. Laparotomy was performed on all patients after resuscitation. If the obstruction involved the right colon resection and primary ileo-colic anastomosis was performed, while for a lesion in the left colon a resection and primary colocolic anastomosis was performed after intraoperative antegrade colonic irrigation. If the obstructing lesions were thought to be malignant and too advanced to merit any excisional or the patient's general condition was too poor to withstand resection, a biopsy was taken and a decompressive bypass procedure given pending the confirmation of the diagnosis. The clinical course and postoperative outcome were carefully documented. RESULTS: A total of 50 patients aged 20-80 years, with a median age of 49 years, presented with features consistent with large bowel obstruction. Of these, 32 had simple sigmoid volvulus and were offered sigmoid colectomy and primary colorectal anastomosis, while 3 further patients with compound sigmoid volvulus had double resection with primary ileo-ileal and colorectal anastomosis. A patient with sigmoid volvulus had a Hartmann's procedure. Twelve patients had colon cancer, four had left hemicolectomy and primary colocolic anastomosis; three, sigmoid colectomy and primary colorectal anastomosis; three, low anterior resection and primary colorectal anastomosis; one decompressive colostomy and one, a right hemicolectomy and primary ileocolic anastomosis. The two patients with functional obstruction (Ogilvie syndrome) had tube caecostomy. All resections and primary anastomosis involving the right colon were preceded by antegrade on-table colonic lavage. One clinical anastomotic leak occurred in a low rectal anastomosis and minor wound infection in 10 patients. Operative mortality occurred in three patients with sigmoid volvulus. CONCLUSION: Adult large bowel obstruction is infrequent in our community and is caused commonly by sigmoid volvulus. Resection and primary anastomosis of the acute left-sided large bowel obstruction seems safe after antegrade on-table colonic lavage, provided bowel gangrene with peritonitis or any additional risk factor for anastomotic breakdown is not present.

Exsanguinating blunt breast trauma: a report of a rare injury.

We report a rare case of blunt trauma in a non-augmented multiparous breast of a young Nigeria woman with exsanguinating haemorrhage who had no clotting disorder. She had no seatbelt on at the time of injury and the car was not fitted with air bag device. Prompt surgical intervention to control haemorrhage from the breast was essential in saving her life. Reasons are advanced why this injury is uncommon.

The use of cyanoacrylate in surgical anastomosis: an alternative to microsurgery.

To present anastomosis with cyanoacrylate as a cheap, simple, fast, and available technique for anastomosis in urological, vascular, gynecological, and general surgical procedures. This method may in the future be a good alternative to microsurgery, particularly in centers where facilities are unavailable and the financial implication is unbearable for the patient. Cyanoacrylate is an adhesive or glue that is available in different chemical forms ranging from ethylcyanoacrylate (superglue) to Isobutylcyanoacrylate and octylcyanoacrylate (dermerbond), which is in clinical use. Anastomosis with cyanoacrylate requires the application of stay sutures, a luminal stent and the subsequent application of the adhesive. The adhesives with lower molecular weights produce a rigid and patent region of anastomosis, while the higher molecular compounds produce a consistency close to the normal tissue. This technique presents a surgical method that is socially, culturally, and ethically acceptable, which is affordable to a larger majority of patients in our subregion. Cyanoacrylate anastomosis may in the future present a fast, convenient, simple, and affordable option in the treatment of patients requiring anastomosis. In our subregion where the socio-cultural, psychological, and economic burden of failed anastomosis is high, associated with the low per capital income, this may be a novel option for the management of urogynecological, vascular, neurosurgical, and general surgical procedures requiring either microscopic or macroscopic anastomosis.

Pattern of duplex doppler ultrasound scans in Jos University Teaching Hospital.

INTRODUCTION: Doppler ultrasound scan is a non invasive diagnostic tool used in the evaluation of vascular and perivascular lesions. It is gaining a wider acceptance over other methods of vascular evaluation which are expensive and invasive. We aimed at evaluating the indications and findings of duplex doppler ultrasound scans performed in this centre. METHODOLOGY: This was a retrospective study of all consecutive patients that had doppler ultrasound scans from January 2000 to December 2004. RESULTS: One Hundred and sixty five (165) Doppler ultra sound scans were performed on 115 patients. Thirty nine patients had a double scan while 19 had repeated scans. The study population was aged between 2-90 years with a mean age of 44.5 +/- 17.5 years. There were 86 (52.1%) males and 79 (47.9%) females giving a male to female ratio of 1:1.67 (41%) of the doppler scans were for deep vein thrombosis while peripheral vascular disease and vascular aneurysm accounted for 24 (14.5%) and 23 (13.9%) respectively, see Table 1. Reduction in vascular blood flow was the most common doppler finding seen in 34 (20.6%) patients followed by visible thrombi in 14 (8.5%) patients. CONCLUSION: Deep vein thrombosis is the most common indication for doppler ultrasound scan in our practice.

Breast tuberculosis: a case report.

Primary tuberculosis of the breast unlike carcinoma is rare, but secondary lesions from cervical and axillary tuberculous lymphadenitis are not uncommon. In this case, a 60-year-old woman presented with ulcerated axillary lymph node swelling and breast lump. Biopsy of the breast lump and lymph node confirmed tuberculous granuloma. She was commenced on anti-tuberculous chemotherapy and wound dressing. Her wounds and sinuses healed satisfactorily before being discharged to continue her treatment at home. She was however lost to followup.

Postoperative non-adhesive mechanical intestinal obstruction: a review of seven cases.

BACKGROUND: Postoperative mechanical intestinal obstruction results commonly from adhesions and less often from other pathologies. Establishing the cause of obstruction in the latter category is usually delayed as attention is often focused on the former. Delayed diagnosis and expedient surgical treatment may lead to bowel infarction. METHODOLOGY: Consecutive patients presenting with features of postoperative mechanical intestinal obstruction seen at Jos University Teaching Hospital over a 2 year period between February 2000 and December 2002 were the subject of the study. RESULTS: Seven (20.6 percent) of 34 patients presenting with postoperative mechanical bowel obstruction had pathologies other than adhesions as the underlying cause of obstruction. There were three females and four males with age ranging from 17 to 45 years. All patients presented with features consistent with bowel obstruction. There were no features at the initial setting to suggest non-adhesions as the underlying cause of obstruction. However, three patients had clues that suggested non-adhesions were responsible for the postoperative obstruction. These patients had diagnoses of recurrent sigmoid volvulus, anastomotic colon cancer and a large bowel cancer. They had early surgery and definitive treatment. CONCLUSION: Non-adhesive postoperative mechanical bowel obstruction is a rare life-threatening surgical emergency. A high index of suspicion based on the patient's history and response to conservative management is required to achieve early diagnosis so that surgical treatment can be rapidly instituted.

Thyroidectomy under local anaesthesia: how safe?

BACKGROUND: In order to compliment the inadequate health facilities in the rural areas in Nigeria, nongovernmental organisations provide adhoc outreach health camps that offer treatment in various medical specialties including surgery. SETTING: Rural outreach health camps. OBJECTIVE: To evaluate the safety of thyroidectomy under local anaesthesia at rural outreach setting with inadequate facilities for general anaesthesia. PATIENTS AND METHODS: This was a prospective descriptive study of 33 consecutive cases of thyroidectomy performed using field block with 1% lignocaine and adrenaline 1: 200,000 dilution during two free medical outreaches that held at Jos, Nigeria in March and October 2005 respectively, lasting two weeks each. RESULTS: A total of 33 primary thyroid operations were performed consisting of 30 subtotal thyroidectomies (91%), 2 lobectomies (6%) and one total thyroidectomy (3%), The patients were aged between 23 and 62 years with a mean age of 45.8 years. There were 3 males and 30 females with a male: female ratio of 1:10. There was no mortality but morbidity was 2/33 (6%) Two complications were recorded in 2 patients and were superficial surgical site infection (3%) and reactionary haemorrhage (3%). CONCLUSION: We conclude that thyroidectomy under local anaesthesia is a safe procedure in experienced hands at rural settings with inadequate facilities for general anaesthesia.

One-stage treatment of left-sided large bowel emergencies.

OBJECTIVE: To evaluate the safety and benefits of left-sided colectomy and primary anastomosis without intraoperative colonic irrigation in the management of patients with colorectal emergencies. DESIGN: Prospective descriptive analysis of patients with emergency left-sided colonic and rectal lesions requiring resection and primary anastomosis. Setting A hospital based cohort over a five and a half year period at Jos University Teaching Hospital, Jos, Nigeria. SUBJECTS: A total of 42 patients with left sided and rectal emergency lesions. Their ages ranged from 9-65 years with a mean of 43.1 years. INTERVENTION: Twenty patients had sigmoid colectomy and primary colorectal anastomosis for sigmoid volvulus. Two patients with compound sigmoid volvulus had sigmoid colectomy as well as ileal resection and primary colorectal and ileoileal anastomosis. Transverse colectomy and primary colocolic anastomosis was carried out in six patients who had transverse colon tumour from gastric neoplasia. These six patients had in addition distal partial gastrectomy and gastrojejunal anastomosis to remove the primary gastric neoplasia. One patient had transverse colectomy and another four left hemicolectomy and primary colocolic anastomosis for trauma. Left colectomy and colocolic anastomosis was performed in three patients with left colon tumour while anterior resection and colorectal anastomosis for rectosigmoid cancer was carried out in six patients. MAIN OUTCOME MEASURES: Manual decompression of the colon is as good as antegrade colonic irrigation in the management of left-sided large bowel emergency conditions in selected patients when undertaken by dedicated experienced surgeons. RESULTS: There was one clinical anastomostic leak presenting as enteric fistula on the sixth postoperative day. The discharge was bilious and occurred in a patient with gastric mesenchymal stromal tumour who had distal partial gastrectomy and gastrojejunal anastomosis. He had no features of generalised peritonitis nor residual intra-abdominal abscesses. The fistula was managed non-operatively. A 12% wound infection rate was recorded. All infections were superficial and healed with conservative measures. We had no mortality in our series. The hospital stay ranged from 6 to 21 days with a mean of 7.5 days. CONCLUSION: Manual decompression of the colon alone is as good as colonic irrigation in the management of left-sided large bowel emergencies. However, on-table antegrade colonic irrigation should be reserved for the loaded colon that may interfere with the use of a stapling instrument, when the resection margins are limited as in low anterior resections and when left-side colonic emergencies are undertaken by non-dedicated, less experienced surgeons.

Gastrointestinal perforation following blunt abdominal trauma.

OBJECTIVE: To highlight the pertinent management problems of bowel perforation following blunt abdominal trauma. DESIGN: A prospective descriptive study. SETTING: Hospital-based cohort over a nine year period in Jos University Teaching Hospital, Jos, Nigeria. SUBJECTS: A total of 23 patients with bowel perforation out of 8,970 trauma victims with a mean age of 28.5 years. INTERVENTION: Exploratory laparotomy, drainage of septic peritoneal fluid and wound saline lavage and closure of perforations were performed in all the 23 patients with clinical features and imaging signs suggestive of bowel perforation following blunt abdominal trauma. Femoral fractures were splinted and tube thoracostomy were carried out in four and two patients respectively. MAIN OUTCOME MEASURES: There is an apparent delay in presentation and diagnosis of traumatic bowel perforation following blunt abdominal trauma. Signs of peritoneal sepsis remain the most consistent findings in our environment. The morbidity and mortality following blunt abdominal trauma and bowel perforation are high because of established peritonitis. Delayed presentation or large leakage of bowel content into the peritoneal cavity and the attendant ease with which peritonitis develops in the latter are factors responsible. RESULTS: Delayed presentation (mean 3.05 days) was observed in seven of 23 patients. Eight patients had concomitant injuries; two to the head, four had right femoral fracture and two blunt chest injury. Features of peritonitis were present at initial evaluation in 19 patients. Seventeen patients were victims of motor vehicle accident. Radiological evidence of perforation (pneumoperitoneum) was present in only two of four patients with difficult diagnosis. Free peritoneal fluid without solid organ injury was detected in two patients with ultrasound. Diagnostic peritoneal lavage was, therefore, not used in any of our patients. The mean time from admission to laparotomy was six hours. Sites of perforations were: stomach (2), jejunum (9), ileum (8), jejunum/ileum (2) and colon (2). Sepsis originating from the perforated bowel was responsible for mortality in our patients who died in the perioperative period with concomitant injury playing significant role in three of 11 patients with such injuries. CONCLUSION: Peritonitis following a bowel perforation after blunt abdominal trauma is often present at the time of presentation and diagnosis is usually made. In the few doubtful cases, often in patients presenting soon after trauma, X-ray and trans-abdominal ultrasonography will assist in making a diagnosis. Delayed presentation still accounts for a high mortality in bowel perforation following blunt abdominal trauma.

One stage procedure in the management of acute sigmoid volvulus without colonic lavage.

BACKGROUND: There is a growing acceptance of one-stage primary resection and anastomosis of left-sided colon obstruction with on-table antegrade colonic lavage to reduce the risk of post-operative infectious complications and anastomotic dehiscence. The purpose of this study was to evaluate the safety of single-stage resection and anastomosis for acute left-sided colonic obstruction due to acute sigmoid volvulus, without intraoperative colonic lavage, in a consecutive series of patients admitted to our department. METHODS: Emergency resection of acute sigmoid volvulus was performed by an experienced senior surgeon (consultant grade). This was followed by primary anastomosis without on-table colonic lavage after a manual decompression. RESULTS: A total of 21 patients underwent bowel decompression, resection and primary colorectal anastomosis. Two of the patients who had ileosigmoid knotting and gangrenous bowel had double resection with primary ileoileal and colorectal anastomosis. There were two superficial wound infections. No death or clinical anastomotic failure were recorded in this series. The mean hospital stay was 10.3 days. CONCLUSION: Our results suggest that resection of acute sigmoid volvulus and primary anastomosis after decompression alone can be carried out safely in reasonably fit patients.

The scope and utilisation of day case surgery in a developing country.

BACKGROUND: The practice of day case surgery is today an attractive and an appealing one with increase spread to many specialties and many regions of the world. However, there is a great variability in its use and application. OBJECTIVE: To determine the scope and degree of utilisation of day case surgery in a developing country. DESIGN: A prospective study. SETTING: Jos University Teaching Hospital, Jos, Nigeria between January and December 2004. SUBJECTS: One thousand and twenty four patients had elective surgical procedures carried out during the study period out of which, three hundred and twenty procedures were done as day cases. MAIN OUTCOME MEASURES: There is a changing trend with a great prospect for the practice of day case surgery in the developing world. CONCLUSION: There is the need to harness all resources and keep abreast with relevant technological drive to realise the full potentials of this practice in this part of the world.

A review of the radiological diagnosis of small bowel obstruction using various imaging modalities.

Radiological investigation is an important tool in the diagnosis of small bowel obstruction (SBO). While plain abdominal radiograph remains the commonest investigation done in SBO, contrast gastrointestinal radiography, ultrasonography (US), computerised tomography (CT) scan -- with or without contrast enhancement are increasingly being advocated particularly in equivocal cases of SBO. We conducted manual, medicine and internet search for relevant literature on diagnosis of SBO using radiological investigations. Plain abdominal radiograph has a diagnostic accuracy for SBO that varies widely from 50 - 92% . Contrast gastrointestinal radiograph in equivocal cases of adhesive SBO can readily differentiate between complete and partial obstruction. Abdominal ultrasound is cheap and readily available. Accuracy of as high as 89% has been reported in experienced hands. CT scan has an added advantage of predicting the site and cause of obstruction. In developing countries like ours, plain abdominal radiography still remains an important diagnostic tool. The role of abdominal ultrasonography needs further evaluation since it is safe, readily available and affordable.

Acalculous cholecystitis in Nigerian children.

Sixteen children with acalculous cholecystitis (AC) were treated over a 9-year period (13 male and 3 female). Their ages ranged from 8 to 18 years (median 11). Eight (50%) presented with complications (perforation 4, gangrene 2, empyema 2); 13 (80%) presented with acute AC with a duration of symptoms of 2 weeks or less while 3 (20%) presented with chronic AC with symptoms present for more than 3 months. The diagnosis was made by ultrasound except in the patients with complications, who were diagnosed at laparotomy. Salmonella typhi was cultured in the bile and blood in 2 cases and the Widal titre was significantly elevated in 4 others. One child had chronic blockage of the cystic duct by a lymph node; in 9 there was no identifiable cause. Open cholecystectomy was successfully performed in 15 cases, while 1 child was managed non-operatively. The need for early diagnosis of cholecystitis in children is obvious if the potentially life-threatening complications of perforation and gangrene are to be avoided.

Acute colonic pseudo-obstruction (Ogilvie's syndrome). A case presentation and review of literature.

The syndrome of acute colonic pseudo-obstruction popularly known as Ogilvie's syndrome is an infrequent pathology and has been the subject of numerous medical communications in the past two decades. Its aetiology and pathophysiology remains poorly understood and patients are still treated inappropriately. In this report, a patient with acute colonic pseudo-obstruction managed surgically is presented. The pathogenesis and surgical management of this condition is also reviewed.

Undiagnosed renal abscess presenting as acute bacterial peritonitis: case report.

A case of undiagnosed renal abscess complicated by intraperitoneal rupture with generalised bacterial peritonitis is presented. Prompt surgical intervention was essential for saving the patient's life. Early imaging of the kidney in unresolved renal infection is essential if renal abscess, its delayed presentation and complications are to be avoided. Most patients will be cured without operation by antibiotics and if necessary, by additional percutaneous drainage where an abscess has formed.