Addressing Unmet Surgical Needs in an Underserved Nigerian Community: Report of a 'Town and Gown' Initiative.

BACKGROUND: Access to quality and timely care prevents unnecessary deaths and morbidity from potentially curable surgical diseases. This study describes the magnitude of unmet surgical needs in a Nigerian community and describes the experiences garnered during a surgical outreach organized by a tertiary institution in an underserved community. METHODS: This is a descriptive study highlighting details of a surgical outreach to a community in south-Western part of Nigeria. The project was based on a collaboration between a University Teaching Hospital (gown) and the community (town). Details of the patients' demographic and disease characteristics as well as barriers to seeking medical care were obtained. The operational workflow, treatment offered, and outcomes are highlighted. Results are presented as descriptive statistics. RESULTS: Over a two-day period, 83 out of 3,056 patients who were screened had surgically treatable conditions (2.7%), predominantly hernias (37, 46.6%), goitres (13, 15.7%) and soft tissue swellings (9, 10.8%). The majority were adults (56, 67.5%) while 27 (32.5%) were in the paediatric age group. The mean duration of symptoms was 8.64 months ± 9.5 months. About half of the patients (46.9%) had never visited a medical facility on account of their index illnesses. Lack of funds was cited by many patients as the main reason for having not presented at a hospital. Sixty-three surgical operations were performed with no peri-operative adverse events. CONCLUSION: Lack of financial access was the major barrier to surgical care in the sampled community. Moving from 'gown to town' helped address a significant proportion of the unmet needs over a relatively short period. Tertiary hospitals can provide surgical oversight to communities within their jurisdiction using this approach.

CONTEXTE: L'accès à des soins de qualité et en temps opportun permet d'éiter les décès et la morbidité inutiles dus à des maladies chirurgicales potentiellement curables. Cette étude décrit l'ampleur des besoins chirurgicaux non satisfaits dans une communauté nigériane et décrit les expériences recueillies au cours d'une action chirurgicale organisée par une institution tertiaire dans une communauté mal desservie. MÉTHODES: Il s'agit d'une étude descriptive mettant en évidence les détails d'une action chirurgicale dans une communauté du sud-ouest du Nigeria. Le projet était basé sur une collaboration entre un hôpital universitaire (ville) et la communauté (ville). Les détails des caractéristiques démographiques et pathologiques des patients ainsi que les obstacles à la recherche de soins médicaux ont été obtenus. Le déroulement des opérations, le traitement proposé et les résultats sont mis en évidence. Les résultats sont présentés sous forme de statistiques descriptives. RÉSULTATS: Sur une période de deux jours, 83 des 3056 patients examinés présentaient des affections pouvant être traitées chirurgicalement (2,7 %), principalement des hernies (37, 46,6 %), des goitres (13, 15,7 %) et des tuméfactions des tissus mous (9, 10,8 %). La majorité des patients étaient des adultes (56, 67,5 %), tandis que 27 (32,5 %) appartenaient au groupe d'âge pédiatrique. La durée moyenne des symptômes était de 8,64 mois ±9,5 mois. Environ la moitié des patients (46,9 %) ne s'étaient jamais rendus dans un établissement médical en raison de leurs maladies index. Le manque de moyens financiers a été cité par de nombreux patients comme la principale raison pour laquelle ils ne s'étaient pas présentés à l'hôpital. Soixante-trois opérations chirurgicales ont été réalisées sans aucun événement indésirable périopératoire. CONCLUSION: Le manque d'accès financier était le principal obstacle aux soins chirurgicaux dans la communauté échantillonnée. Le passage de la ville à l'hôpital a permis de répondre à une proportion importante des besoins non satisfaits sur une période relativement courte. Les hôpitaux tertiaires peuvent fournir une supervision chirurgicale aux communautés de leur juridiction en utilisant cette approche. Mots clés: Chirurgie, Besoins non satisfaits, Nigeria, Communauté mal desservie.

Polyp prevalence at colonoscopy among Nigerians: A prospective observational study.

BACKGROUND: This study was aimed at identifying the prevalence, distribution, and clinicopathologic characteristic of colonic polyps among Nigerians undergoing colonoscopy at the Obafemi Awolowo University Teaching Hospitals complex, Ile-Ife, Nigeria. We also determined the polyp detection rate (PDR), polyps per colonoscopy (PPC) and adenoma detection rate (ADR). MATERIALS AND METHODS: This is a prospective study of all colonoscopy examinations performed at the endoscopy unit of our hospital from January, 2007 to December 2013. The patient demographics, indications for colonoscopy, colonoscopic findings, number of the polyps, their sizes, possible risk factors in the individual case histories, and histopathological characteristics of the polyps. RESULTS: During the study period, a total of 415 patients met the inclusion criteria and only 67 out of these had colonic polyps. The overall PDR was 16.1%. The age ranged was 2-87 years with a median of 57 years. Forty-three (64.2%) patients were 50 years or above and there were 40 (59.7%) males. Thirty-three (49.3%) patients were referred as a result of lower gastrointestinal bleeding, 14 (20.9%) for colorectal cancer (CRC) and 13 (19.4%) for routine screening. Thirty-nine (58.2%) patients had the polyps at the rectosigmoid region of the colon, 17 (25.4%) had the polyps located proximal to sigmoid colon and 11 (16.4%) patients had multiple polyps involving both segments. Adenomatous polyps was the most common (28 [47.5%]) histopathological finding of which two patients had adenomatous polyposis. Other findings include inflammatory polyps in 17 (18.8%) patients, 5 (8.5%) patients each had hyperplastic and malignant polyps, while 4 (6.8%) patients had juvenile polyps. The ADR was 6.8 and the PPC was 0.2. Statistically, patients 50 years and older were more likely to have adenomatous and hyperplastic polyps than those younger than this age (P = 0.010). CONCLUSION: We conclude that polyps are probably not as rare among black Africans especially when they are above 50 years. Our histopathological finding of adenomatous change in a good proportion of the detected polyps show that they are likely to be associated with CRCs in our compatriots and as such we would recommend a routine screening colonoscopy for Nigerians aged 50 and above.

Adulthood hirschprung's disease: a report of 4 cases in Ile-Ife. Nigeria.

BACKGROUND: Hirschsprung's disease in adulthood is very rare and is often misdiagnosed. We present four cases of adulthood Hirschsprung's disease seen in the last two decades to illustrate challenges accompanying its diagnosis and management. METHOD: This descriptive case series included cases of histologically proven Hirschsprung's seen in adulthood at the Obafemi Awolowo University Teaching Hospitals Complex in the last two decades (1991-2011). The clinical data, radiological investigations, details of surgical treatment, histological diagnosis, outcomes and complications were analyzed. RESULT: There were 4 adult patients, 3 males and 1 female with age ranging from 17 to 74 years (mean 23 years). Each patient presented with sub acute intestinal obstruction needing two staged procedures of initial colostomy followed by definitive procedure of low anterior resection (State procedure) in 3 patients and Swenson-Bill procedure in one. There was one mortality and good long term outcome in the remaining three. CONCLUSION: This review presented the oldest patient presenting with adult Hirschsprung's and the highest mean age of any case series. Four patients with adulthood Hirschsprung's disease managed by two operative procedures enabled comparison of operative outcome with respect to complications and functional outcomes. Mortality seems to correlate with presentation at old age, which is usually due to life long self-management of chronic constipation. Though very rare, a high index of suspicion of adulthood Hirschprung's disease should be maintained in adult patients with recurrent chronic constipation needing lifelong laxative, enema or mechanical wash-out.

Using methylene blue for perioperative localization of the hydrocele sac in boys.

BACKGROUND: Ligation of a patent processus vaginalis via the inguinal approach is the standard operative technique for the treatment of hydroceles in infants and children. Although a simple technique, identification of the processus vaginalis can be difficult even for the experienced surgeon. AIMS: To investigate the use of methylene blue in the perioperative identification of the patent processus vaginalis in a group of children presenting with hydrocele. MATERIALS AND METHODS: Twenty consecutive patients with hydrocele between the ages of 1 and 9 years were recruited for the study. Methylene blue 0.3-0.5 ml was injected slowly into the hydrocele fluid through the scrotal wall after aspiration, followed by routine ligation of the hydrocele track. RESULTS: The track of the processus vaginalis was clearly visualized in 17 (85%) of the patients, while in 3 (15%) patients no track could be seen, the hydrocele being localized to the tunica vaginalis. There were no cases of inadvertent testicular injury and there was no intraoperative complication. No patient reacted in any abnormal way to the methylene blue. CONCLUSION: The technique helps in the identification of a patent processus vaginalis when it is present. It may be useful in cases where difficulty in identification of the hydrocele tract is anticipated in a child.

Pentalogy of cantrell: a report of three cases.

Pentalogy of Cantrell is a rare upper midline syndrome that may present in association with anomalies outside the torso. The pentad - the supraumbilical body wall defect, sternal defect, deficiency of the anterior diaphragm, defect of the diaphragmatic pericardium, and the intracardiac anomalies - was first described by Cantrell et al., in 1958. The defect is said to be more common in males, and survival is dependent on the cardiac malformations and on the degree of completeness of the syndrome. We report three cases of Cantrell's pentalogy managed in our unit. Two of the patients were females and one a male. All were seen at peripheral health centers before being referred to us. Age at presentation for the girls was 18 hours and 36 hours, respectively, the boy presented at the age of six weeks. All of their parents were unschooled manual workers. All patients presented with a defect in the supraumbilical body wall, bifid sternum, and a visible cardiac impulse. We were unable to do echocardiography to rule out intracardiac anomalies in the three patients. The thin membranous covering of the epigastrium in the female patients was managed conservatively. Both female patients were discharged against medical advice as requested by their parents, due to financial constraints. The male patient was lost to follow up after two clinic visits. A multidisciplinary approach to the management of this syndrome is recommended.

Day case surgery in Nigerian children: influence of social circumstances of patients.

BACKGROUND: In order to achieve good results in day surgery and avoid pitfalls, selection of appropriate procedures and patients is required with attention given to the social circumstances among other considerations. The aim of this prospective study therefore was to evaluate the influence of the social circumstances of the patients on the performance of day surgery practice in our environment. METHOD: This was a prospective study carried out between April, 2004 and December, 2004, during which time 88 children aged 15 years and below with uncomplicated inguinal hernias were treated at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC). The parents of the patients were interviewed about their social circumstances to determine the possibility of compliance with postoperative instructions. The data generated were then analyzed. RESULTS: More than half (54.6%) of the patients were from Ile-Ife. A few came from towns varying in distances from 65 to 80 km and spent an average time of 75 to 90 minutes to reach the hospital. Majority of the patients used public vehicles as a means of transport to and from the hospital in escort of their mothers. Despite the long distances and difficult traveling conditions, the parents still preferred day case surgery and were willing to obey postoperative instructions. CONCLUSION: From the findings in this study, day case surgery in children in our environment is feasible, despite the poor social circumstances of most of them. There is, however a compelling need to raise the standard of living of the people to enable them benefit maximally from day case surgery.

Epidemiology of external birth defects in neonates in Southwestern Nigeria.

BACKGROUND: There is paucity of information on the prevalence of birth defects in Nigeria, particularly in our setting. This study determined the epidemiology of external congenital anomalies in Southwest Nigerian children. PATIENTS AND METHODS: This was a stratified, randomized study of neonates presenting with external birth defects in Ife-Ijesha in Southwestern Nigeria, from August 2003 to July 2004. The neonates were screened for obvious congenital malformations by thorough physical examination. RESULTS: A total of 624 neonates were screened, 43 (6.9%) of whom had external birth defects (prevalence: 3.7 +/- 0.8% SD). There was a slight male preponderance (M: F= 1.4: 0.9). The overall prevalence rates of external congenital and major anomalies in Ife-Ijesa are 6.9 and 3.7% respectively. A higher prevalence for major malformations, 6.3%, was also found within the minority ethnic groups in these communities compared to the native majority. Musculoskeletal abnormalities are the most common anomaly, followed by those of abnormal external genitalia and head defects. CONCLUSION: Major malformations are more common amongst the minority settlers in this study, and musculoskeletal abnormalities were the most prevalent.

Outcome of primary closure of abdominal wounds following typhoid perforation in children in Ile-Ife, Nigeria.

BACKGROUND: Abdominal wounds following surgery for typhoid perforation are classified as dirty, with an infection rate of over 40%. To date, the optimal method for closure of these wounds remains controversial. Delayed primary closure which was conventionally recommended as standard practice, is now considered to be of no value in preventing surgical site infection (SSI). This study evaluates the outcome of primary closure of this class of wounds in children in Ile-Ife, Nigeria, and advocates a multidisciplinary wound management protocol. PATIENTS AND METHODS: This is a retrospective study of children aged < 1-15 years who had had surgery for typhoid perforation in a teaching hospital in south western Nigeria, over a period of ten years. RESULTS: Thirty-two patients, 18 males and 14 females, in the ratio of 1.3:1 were managed for typhoid perforation during the ten year period. All 32 patients had primary closure of their abdominal wounds. There was primary wound healing in six (18.8%) patients, while 19 (59.4%) patients had surgical site infections. Wound dehiscence, intraabdominal abscess, and faecal fistulas were the other complications documented in the study. CONCLUSION: Abdominal wounds of typhoid perforation, though classified as being dirty, can be closed primarily with good healing outcomes. A multidisciplinary approach to wound management will reduce the incidence of wound sepsis and its associated morbidity and costs.

Determinants of mortality in neonatal intestinal obstruction in Ile Ife, Nigeria.

BACKGROUND: Neonatal intestinal obstruction (NIO) is a common cause of mortality. This study determined the causes of mortality in patients with NIO at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile Ife. PATIENTS AND METHODS: Records of all cases of NIO managed at OAUTHC between January 1996 and December 2005 were retrospectively reviewed and the possible factors that may result in mortality were analysed. RESULTS: Sixty-three neonates with intestinal obstruction were managed, representing 24.3% of the neonatal admissions during the study period. Forty-two were males and 21 were females (M:F = 2:1). The majority (71.4%) of the patients presented within the first week of life. Anorectal malformation constituted 57.1% of the causes of NIO. Other causes included Hirschsprung's disease, duodenal atresia, intestinal malrotation with midgut volvulus and jejunal atresia. There were 18 deaths, with a mortality rate of 28.6%. Reoperation, postoperative bleeding and peroperative sepsis were significant determinants of mortality. CONCLUSION: NIO is associated with significant mortality in our centre. Repeat surgery, postoperative bleeding and sepsis were the significant factors that contributed to mortality in NIO.

Evaluation of cosmetic appearance of herniotomy wound scars in African children: Comparison of tissue glue and subcuticular suturing.

AIM: To evaluate the cosmetic appearance of herniotomy wound scars closed using either the tissue glue or subcuticular suturing technique. MATERIALS AND METHODS: Prospective randomised control study; randomisation into tissue glue and suturing groups. Ethical clearance obtained. Cosmetic outcome were based on visual analogue scale by parents and Hollander wound evaluation scale by a Plastic Surgeon blinded to the wound closure method. RESULTS: Fifty one wounds were evaluated, 26 in the tissue glue group and 25 in the suturing group. Parents' evaluation using Visual Analogue scale (VAS) showed that in the suturing group, 17 parents (68%) gave a VAS of 8cm while six parents (24%) gave a score of 7cm. Two parents (8%) gave a score of 9cm. In the tissue glue group, 22 parents (84.6%) scored the scar of their children as 8 or 9cm on the VAS while four parents (15.4%) gave a score of 7cm. The median VAS was 8cm for both groups with a range of 7 to 9cm. The Chi- square test showed that the parents preferred tissue glue compared with subcuticular suturing (X2 = 7.90, P < 0.05). The Hollander Wound Evaluation Scale (HWES) used by Plastic Surgeon showed 21 herniotomy wounds (84%) had a score of 6 in the suturing group while four wounds (16%) had a score of 5. In the tissue glue group, 19 wounds (73%) had a score of 6, six wounds (23.1%) had a score of 5 and a patient (3.8%) had a score of 4. The median score is 6 for both groups. There was no statistically significant difference between both groups (X(2) = 1.481, P = 0.393). CONCLUSION: This study has shown that the cosmetic outcome of wound closure using the tissue glue technique and subcuticular suturing technique are similar.

Day Case Surgery in Nigerian Children: Influence of Social Circumstances of Patients

Background: In order to achieve good results in day surgery and avoid pitfalls; selection of appropriate procedures and patients is required with attention given to the social circumstances among other considerations. The aim of this prospective study therefore was to evaluate the influence of the social circumstances of the patients on the performance of day surgery practice in our environment. Method: This was a prospective study carried out between April; 2004 and December; 2004; during which time 88 children aged 15 years and below with uncomplicated inguinal hernias were treated at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC). The parents of the patients were interviewed about their social circumstances to determine the possibility of compliance with postoperative instructions. The data generated were then analyzed. Results: More than half (54.6) of the patients were from Ile-Ife. A few came from towns varying in distances from 65 to 80 km and spent an average time of 75 to 90 minutes to reach the hospital. Majority of the patients used public vehicles as a means of transport to and from the hospital in escort of their mothers. Despite the long distances and difficult traveling conditions; the parents still preferred day case surgery and were willing to obey postoperative instructions. Conclusion: From the findings in this study; day case surgery in children in our environment is feasible; despite the poor social circumstances of most of them. There is; however a compelling need to raise the standard of living of the people to enable them benefit maximally from day case surgery

Typhoid Perforation: Determinants of Outcome in Children in Ile-Ife; Nigeria

Background: Ileal perforation can be a fatal complication of typhoid fever in children as its clinical presentation is often atypical. The risk of death from intestinal perforation in typhoid fever is more than four times when compared with patients without perforation. A high index of suspicion therefore; and early intervention are mandatory to reduce morbidities and deaths due to this disease in children. Aim: To highlight the factors that adversely influence treatment outcome following typhoid ileal perforation in a paediatric population and how they could be modified to reduce morbidity and mortality. Methods: This was a retrospective study whereby medical records of children aged 1 to 15 years with typhoid fever admitted to OAUTHC; Ile-Ife; over a 10-year period; 1994-2004. Results: A total of 38 patients; 20 males and 18 females in the ratio 1.1:1; were managed for typhoid perforation during the 10-year study period. Twenty-nine patients (76.3) survived while 9 (23.7) died. Of the many factors evaluated; only the duration of time before operation was found to significantly influence treatment outcome adversely (P=0.009); while large single or large multiple perforations (P=0.256); severe peritoneal contamination (P=0.291) and extensive surgery (P=0.089) did not. Conclusion: Typhoid ileal perforation has a poor treatment outcome in children in Ile-Ife; Nigeria. The duration of time before operation was the single most important factor that adversely affected treatment outcome. Therefore; swift preoperative resuscitation and early surgical intervention will enhance overall outcome irrespective of the number of perforations; severity of faecal contamination and extent of surgery

Determinants of mortality in neonatal intestinal obstruction in Ile Ife, Nigeria

Background: Neonatal intestinal obstruction (NIO) is a common cause of mortality. This study determined the causes of mortality in patients with NIO at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC); Ile Ife. Patients and Methods: Records of all cases of NIO managed at OAUTHC between January 1996 and December 2005 were retrospectively reviewed and the possible factors that may result in mortality were analysed. Results: Sixty-three neonates with intestinal obstruction were managed; representing 24.3of the neonatal admissions during the study period. Forty-two were males and 21 were females (M:F = 2:1). The majority (71.4) of the patients presented within the first week of life. Anorectal malformation constituted 57.1of the causes of NIO. Other causes included Hirschsprung's disease; duodenal atresia; intestinal malrotation with midgut volvulus and jejunal atresia. There were 18 deaths; with a mortality rate of 28.6. Reoperation; postoperative bleeding and peroperative sepsis were significant determinants of mortality. Conclusion: NIO is associated with significant mortality in our centre. Repeat surgery; postoperative bleeding and sepsis were the significant factors that contributed to mortality in NIO

Outcome of primary closure of abdominal wounds following typhoid perforation in children in Ile-Ife, Nigeria

Background: Abdominal wounds following surgery for typhoid perforation are classified as dirty; with an infection rate of over 40. To date; the optimal method for closure of these wounds remains controversial. Delayed primary closure which was conventionally recommended as standard practice; is now considered to be of no value in preventing surgical site infection (SSI). This study evaluates the outcome of primary closure of this class of wounds in children in Ile-Ife; Nigeria; and advocates a multidisciplinary wound management protocol. Patients and Methods: This is a retrospective study of children aged 1-15 years who had had surgery for typhoid perforation in a teaching hospital in south western Nigeria; over a period of ten years. Results: Thirty-two patients; 18 males and 14 females; in the ratio of 1.3:1 were managed for typhoid perforation during the ten year period. All 32 patients had primary closure of their abdominal wounds. There was primary wound healing in six (18.8) patients; while 19 (59.4) patients had surgical site infections. Wound dehiscence; intraabdominal abscess; and faecal fistulas were the other complications documented in the study. Conclusion: Abdominal wounds of typhoid perforation; though classified as being dirty; can be closed primarily with good healing outcomes. A multidisciplinary approach to wound management will reduce the incidence of wound sepsis and its associated morbidity and costs

Circumcision Mishaps: A Continuing Challenge In The Developing Countries

Objective: Circumcision has been described as the most commonly performed surgical operation in the boys and is probably the oldest surgical procedure in man. This prospective study was aimed at establishing the pattern; treatment outcome and cost of major complications of neonatal circumcision seen in a tertiary center in Nigeria. Methods: Consecutive cases of complications of circumcision presenting at the Paediatric Outpatient Department in a tertiary centre in Nigeria were prospectively studied over a period of 3 and half years from July 2003 to December 2006. Information regarding the age of the patient; time of circumcision; the surgeon; place of circumcision was recorded as well as the type of mishap; outcome and cost of management were noted. Results: Forty five patients with major complications of circumcision representing 6.2of the patients. Their age at presentation ranged between 2 weeks to 10 years (Median = 3months). All the patients were circumcised during the neonatal period. The commonest complication reported is urethro-cutaneous fistula in 25 (56); Meatal Stenosis in 4(8.9); Severe bleeding in 4(8.9); Epidermoid cyst in 3 (6.7); and 2 (4.4) cases each of Buried penis; penile amputation; penile degloving with glans amputation; glanular adhesions and redundant prepuce respectively. The cost of treatment for the repairs varies from 4500 -35;000NGN (40-305 Dollars) Conclusion: The prevalence of complications of circumcision is high in our environment

The role of preoperative antibiotics in the prevention of wound infection after day case surgery for inguinal hernia in children in Ile Ife, Nigeria.

PURPOSE: Day case surgery for inguinal hernia had been an established practice of the Paediatric Surgery Unit, OAUTHC, Ile Ife for about two decades. In a retrospective review of the practice from the same center, a high incidence of postoperative wound infection was noted, which was attributed to the poor personal hygiene of the patients. This prospective study, therefore, was performed to evaluate the role of a single dose of preoperative antibiotic (using gentamicin) in the prevention of these wound infections after day case surgery for inguinal hernia in children. METHODS: This was a prospective study carried out over a period of 8 months from 11 April 2004 to 20 December 2004. During this period, 88 children aged from birth to 15 years were randomized into two groups of equal numbers to undergo elective inguinal herniotomy. The children in the test group received prophylactic intravenous gentamicin, 30 min before a groin crease incision was made, while those in the control group did not. All patients were subsequently followed up for 32 days for any evidence of a wound infection. RESULTS: There were 104 wounds in the ratio of 50:54 in the control and test groups, respectively. All 54 wounds of the children who received prophylactic gentamicin healed primarily and without complication. Five cases of wound infections occurred in the control group, giving an infection rate of 4.8% (P < 0.041). Staphylococcus aureus was the single pathogen isolated from the infected postherniotomy wounds and this organism was wholly sensitive to gentamicin. CONCLUSION: From the findings in this study, administration of preoperative gentamicin has a role in the prevention of wound infection after day case surgery for inguinal hernias in susceptible children. Preoperative intravenous gentamicin is therefore recommended as a prophylactic measure against wound infection after day case surgery for inguinal hernias in those children at risk of wound infection.

Day case inguinal hernia surgery in Nigerian children: prospective study.

BACKGROUND: There has been an increase in day case surgery for children worldwide, but there have been few reports of the practice (most of them being retrospective) by many of the surgical sub-specialties in the sub-region. The aim of this study was to document our experience with day case inguinal hernia surgery in a developing economy. MATERIALS AND METHODS: This was a prospective study of uncomplicated inguinal hernias treated as day case at OAUTHC between April 2004 and December 2004. Data were collected and analysed. RESULTS: Eighty-eight patients were recruited into the study and none defaulted. There were 88 patients, (M:F = 16.6:1). A majority (n = 54) of the hernias occurred on the right side, while just a few (n = 18) occurred on the left. There were 5 cases of wound infections giving an infection rate of 4.8%. In all, the morbidity following day case inguinal hernia surgery was slight and no patient required readmission into the hospital. CONCLUSION: Day case inguinal hernia surgery in children is safe and well accepted by patients and parents alike. Health institutions in which children with inguinal hernias still queue for long periods for space on the operation list need to adopt day case surgery for inguinal hernia in order to forestall the risk of their obstruction.

Posterior sagittal approach in complicated Swenson's pull-through.

CONTEXT: Swenson's pull-through is one of the standard operations for the treatment of children with Hirschsprung's disease. Complications arising from the operation are difficult to treat because of fibrosis in the pelvis. The posterior sagittal approach may be a safer alternative. AIMS: The aim of this paper is to highlight our experience with the use of the posterior sagittal trans-sphincteric approach to treat unusual complications of Swenson's pull-through. SETTINGS AND DESIGN: A retrospective study of four patients who had posterior sagittal repair of their complications of Swenson pull-through at the Obafemi Awolowo University Teaching Hospital, Ile Ife, Nigeria. MATERIALS AND METHODS: Four cases of Hirschsprung's disease that developed post-Swenson pull-through complications are presented. There were three males and one female. Their age ranged between 10 months and 15 years. The patients had rectovaginal fistula, rectourethral fistula, high trans-sphincteric fistula-in-ano and complete anastomotic disruption. RESULT: All the patients were successfully treated using the posterior sagittal approach. The approach was used twice in one patient without significant sequelae. The three patients were old enough to be assessed and had a Kelly score of 4-6 at follow-up. CONCLUSION: The posterior sagittal technique offers a safe approach to treat the complications of Swenson pull-through.

Day case inguinal hernia surgery in Nigerian children: prospective study

Background: There has been an increase in day case surgery for children worldwide; but there have been few reports of the practice (most of them being retrospec-tive) by many of the surgical sub-specialties in the sub-region. The aim of this study was to document our experience with day case inguinal hernia surgery in a developing economy. Materials and Methods: This was a prospective study of uncomplicated inguinal hernias treated as day case at OAUTHC between April 2004 and December 2004. Data were collected and analysed. Results: Eighty-eight patients were recruited into the study and none defaulted. There were 88 patients; (M:F = 16.6:1). A majority (n = 54) of the hernias occurred on the right side; while just a few (n = 18) occurred on the left. There were 5 cases of wound infections giving an infection rate of 4.8. In all; the morbidity following day case inguinal hernia surgery was slight and no patient required readmission into the hospital. Conclusion: Day case inguinal hernia surgery in children is safe and well accepted by patients and parents alike. Health institutions in which children with inguinal hernias still queue for long periods for space on the operation list need to adopt day case surgery for inguinal hernia in order to forestall the risk of their obstruction