Amarachukwu Chiduziem Etonyeaku

Violence in the emergency department: a multicentre survey of nurses’ perceptions in Nigeria

Background Emergency department (ED) violence is common and widespread. ED staff receive both verbal and physical abuse, with ED nurses bearing the brunt of this violence. The violence is becoming increasingly common and lethal and many institutions are still improperly prepared to deal with it. Methods A questionnaire based survey of the perception of violence among nurses working in six tertiary hospitals’ EDs across five states in Nigeria was conducted. Results 81 nurses were interviewed with a male to female ratio of 1:4. Most were right about the definition of violence. About 88.6% of respondents have witnessed ED violence while 65.0% had been direct victims before. Nurses followed by doctors were the usual victims. The acts were carried out mostly by visitors to the ED. Men were usually responsible for the violence, which usually occurred in the evenings. Weapons were not commonly utilised: only 15.8% of the nurses had been threatened with a weapon over a 1-year period. The main perceived reasons for violence were overcrowded emergency rooms, long waiting time and inadequate system of security. All the institutions were lacking in basic strategies for prevention. While most of the nurses were not satisfied with the EDs that were considered not safe, few would wish for redeployment to other departments/units. Conclusions There is a need to make the EDs safer for all users. This can be achieved by a deliberate management policy of ‘zero’ tolerance to workplace violence, effective reporting systems, adequate security and staff training on prevention of violence.

A 5‑year Review of Darning Technique of Inguinal Hernia Repair

Context: The Darning technique of inguinal hernia repair is a tissue-based technique with documented low recurrence rate in some parts of the world. Though practiced in our setting, little is documented on its outcome. Aims: The aim was to review the outcome of Darning technique of inguinal hernia repair in our setting. Study Design: A descriptive retrospective study. Patients and Methods: Clinical records of all patients who had inguinal hernia repair using the Darning technique between January 2007 and December 2011 in our institution were obtained. Details of sociodemographic data, intraoperative findings and postoperative complications were reviewed. Statistical Analysis Used: simple frequencies, proportions and cross-tabulations. Results: A total of 132 patients whose ages ranged from 15 to 84 years (mean = 49.4 years) with a male: female ratio of 12:1 were studied. Majority of the hernias were right sided (68.9%), mostly indirect (81.8%). The procedures were for emergencies in 17 (12.9%) cases whereas the rest (87.1%) were done electively. Most procedures, 110 (83.3%) were performed under local anesthesia. Surgical site infection was the most common complication occurring in six patients (4.5%), while four patients (3%) had chronic groin pain. At a mean follow-up period of 15 months there were two recurrences (1.5%) both occurring in patients with bilateral hernias (P = 0.001). Conclusions: The Darning technique of inguinal hernia repair is a safe and effective method for inguinal hernia repair in our setting.

Groin Hernias at the Wesley Guild Hospital Ilesa, Nigeria: Characteristics and emerging patterns of repair

Objectives: We sought to determine the current trends in groin hernia characteristics and surgical care in our hospital. Materials and Methods: A prospective descriptive study from Wesley Guild Hospital Ilesa Nigeria: A tertiary hospital unit in a semi-urban community. All adults who had groin hernia repair between September 2008 and August 2013 were reviewed for age, gender, occupation, hernia type, repair technique and anaesthesia, complications of surgery and duration of hospital stay were analyzed for descriptive and inferential statistics. The main outcome measures were post-operative complications and recurrence. Results: Totally, 270 patients with 296 hernias were treated. Majority were males (256; 94.8%). The modal age group was 51-60 years (20.4%). Hernias were unilateral in most patients (251; 93%) with the majority of them right-sided (162/270; 60%). There were 295 inguinal hernias and one femoral hernia. Indirect inguinal hernia was most common (205 patients; 73.3%); while 79 (27.7%) were direct and 11 (4%) pantaloon hernias. Repairs were for recurrent hernias in 17 cases (3.8%) while 64 patients (23.7%) presented with complications requiring emergency operation. Local anesthesia (LA) was most commonly used (80.7%), and day-case surgery was common (206, 76.3%). Nylon darn (155; 52.4%), mesh hernioplasty (94, 31.8%) and Bassini (43; 14.5%) techniques were commonly used. Morbidity (17, 6.3%) was mainly from the surgical site infection (6, 2.2%). Mortality rate was 0.7%. Follow-up ranged from 3 to 30 months (mean = 9.8 months); no recurrence was recorded. Conclusion: Most repairs are now done using LA as day-case procedures. Mesh hernioplasty is becoming popular.

Posterior Urethral Valves in Children: Pattern of Presentation and Outcome of Initial Treatment in Ile-Ife, Nigeria.

Background: The management of posterior urethral valves (PUV) and its sequelae is still a challenge to most pediatric surgeons in our environment due to late presentation and inadequate facilities for long-term evaluation and treatment. Despite initial successful treatment about 40% would develop chronic renal failure. The aim is to describe the presentation, management and outcome of the initial treatment in boys with PUV. Materials and Methods: It is a retrospective analysis of PUV in boys 8 years and below over a 17 years period. Demographic characteristics, clinical features, investigations, and treatment outcome were reviewed. Results: Thirty-seven cases were analyzed. The median age was 5 months (range from birth to 8 years). Three (8.1%) patients had prenatal ultrasound diagnosis. The most common presentation was voiding dysfunction 37 (100%). Part of the preoperative investigation included micturating cystourethrogram (n = 31: 83.8%) and abdomino-pelvic ultrasonography (n = 37:(100%). The mean serum creatinine value of those who presented within thefirst 30 days of life and those who presented afterwards were 325 (±251) µmol/L and 141 (±100) µmol/L respectively, P = 0.003. Surgical interventions included trans-vesical excision of valves (n = 9: 28.1%), valvotomy (n = 10: 31.3%), balloon avulsion (n = 8: 25.0%), vesicostomy (n = 4: 12.5%) and endoscopic valve avulsion (n = 1: 3.1%). Seventeen (56.7%) patients had serum creatinine >70.4 µmol/L after 1-month of valve excision. Five (13.5%) patients had postrelief complications and 5 (13.5%) died on admission. Ninety percentage (27/30) of patients had poor prognostic indices. Conclusions: The initial treatment outcome was good but most had poor prognostic factors.

Groin exploration for the nonpalpable testes: A single center experience

Background: Management of non-palpable testes in Nigeria can be difficult due to late presentation and poor resources. Surgical exploration is often required for diagnosis and treatment. Aim: This study reviews the management outcome of clinically non-palpable testeis in a tertiary center in Nigeria. Materials and Methods: Ten years retrospective review of all clinically non-palpable testes in children aged 2-15years managed at the Obafemi Awolowo University Teaching Hospitals Complex Ile-Ife Nigeria. Results: Thirty two children with 44 testicular units were managed. The right side was involved in 12 (37.5%); left in 8 (25.0%) and bilateral in 12 (37.5%) patients. Pre-operative ultrasound was done in 12 patients with localization in just 4 patients (33.3% success rate).At groin exploration, 34 (77.32%) testicular units were located in the inguinal canal. Eight patients with 10 The remaining 10 (22.7%) testicular units required additional mini-laparotomy for which six (13.6%) and 4 (9.1%) testicular units respectively were either in the retroperitoneum or not found. Of the testes in the groin, twenty two (64.7%) testicular units were normal while 12 (35.3%) were atrophic. Four of the retroperitoneal testes were normal while 2 were atrophic. Eight (22.5%) testicular units among the inguinal group had multi-staged orchidopexy; while 2 each of the retroperitoneal group had orchidectomy,one stage orchidopexy, two staged Fowler Stephens (F-S) procedure or lost to follow up after first stage of F-S procedure. Mean follow up period was 2 months. 2 testicular units each had retracted or vanished respectively during follow up. Conclusion: Groin exploration still offers a viable approach Surgical exploration is still useful in to the management of non-palpable testes in low resource environment despite the lack of laparoscopy.

Pattern of abdominal wall herniae in females: a retrospective analysis

BACKGROUND Gender differences are expected to influence the pattern and outcome of management of abdominal wall hernias. Some of these are left to speculations with few published articles on hernias in females. OBJECTIVES To describe the clinical pattern of abdominal wall hernias in females. METHOD A 5 year retrospective review. RESULT There were 181 female patients with 184 hernias representing 27.9% of the total number of hernia patients operated. Mean age was 41.66±24.46 years with a bimodal peak in the 1(st) and 7(th) decades. Inguinal hernia accounted for majority (50.5%) but incisional hernia predominated in the 30-49 age group, while only inguinal and umbilical hernias were seen in the first two decades (p=0.04). There was no side predilection in the cases of inguinal hernia. There were 12 (6.6%) emergency presentations, most of which occurred in the 6th decade and above and none below 30 years (p=0.02). Umbilical (4 cases) and femoral hernias (3cases) accounted for most of these cases. Incisional hernia was the commonest cause of recurrent hernias. CONCLUSION Inguinal hernia is the commonest hernia type in females followed by incisional hernias which also accounteds for most recurrent cases. Age appears to be a risk factor for developing complications.

Early experience with laparoscopic surgery in children in Ile-Ife, Nigeria

Background: Laparoscopy is not yet routinely employed in many Paediatric Surgical Units in Nigeria despite the advantages it offers. This study describes the preliminary experience with laparoscopic procedures in a single centre. Patients and Methods: A retrospective analysis of all children who had laparoscopic surgery between January 2009 and December 2013 at the Paediatric Surgical Unit of Obafemi Awolowo University Teaching Hospitals Complex Ile-Ife was carried out. Their sociodemographic, preoperative and intraoperative data along with postoperative records were subjected to descriptive analysis. Results: Eleven (44%) diagnostic and 14 (56%) therapeutic procedures were performed on 25 children whose age ranged from 5 months to 15 years (Median: 84 months, Mean: 103 ± 64.1 months), including eight (32%) females and 17 (68%) males. Indications included acute appendicitis in 12 (48%), intra-abdominal masses in six (24%), three (12%) disorders of sexual differentiation, two (8%) ventriculoperitoneal shunt malfunctions and impalpable undescended testes in two (8%) children. The procedures lasted 15-90 minutes (Mean = 54 (±21.6) minutes). Conversion rate was 17% for two patients who had ruptured retrocaecal appendices. No intra operative complications were recorded while three (12%) patients had superficial port site infections post-operatively. All diagnostic (11) and two therapeutic procedures were done as day case surgery. The mean duration of hospital stay was 3.1 (±3.3) days for those who had appendectomies. Conclusion: Laparoscopic surgery in children is safe and feasible in our hospital. We advocate increased use of laparoscopy in paediatric surgical practice in Nigeria and similar developing settings.

Emerging pattern of emergency abdominal surgeries in Ile-ife Nigeria

Background: The pattern of abdominal surgical emergency may not be the same in different settings because of changes in demography, diet, socioeconomic or geographical factors. We present the pattern, management and outcome of such emergencies in Ile Ife, South Western Nigeria. Aim: To document the pattern of abdominal surgical emergency in our environment with a view to highlighting the management and outcome. Because, superstitiously our people mostly think toward poison as the cause of abdominal pain, it is justified to do this study. The societal meaning of poison refers to a situation whereby someone′s friend or relative introduces a deadly substance or material into his drink or food which will eventually lead to morbidity or mortality. It is thought that the introduction of deadly poison could be physically done or diabolically in form of spiritual attack. Materials and Methods: This was a retrospective review of data collected in Obafemi Awolowo University Teaching Hospital Ile Ife, Osun State, Nigeria between June 2006 and June 2012. Patients with abdominal surgical emergencies exclusive of gynecological cases were consecutively entered into the study at the time of presentation and followed-up. The frequencies of different diagnosis and age distribution were recorded. The indications for operative intervention, management and outcome were also highlighted. Results: Of the 8001 cases presenting with abdominal pain in our hospital, 2408 (28.8%) required surgery. Males were 1445 (60.1%), while 963 (39.9%) were female patients with a mean age of 35.9 years. Uncomplicated appendicitis was the most common indication for surgery (61.3%), obstructed hernias constituted the most common etiological factor in intestinal obstruction (51.2%), while postoperative bands and adhesions accounted for 14.6%. Ruptured appendix and typhoid perforation accounted for 32.4% and 18.9% of peritonitis, respectively. The spleen was the most affected intra-abdominal organ in cases of abdominal trauma. Three patients had repair of the spleen. 16 (0.7%) had emergency surgery for complicated duodenal ulcer, repair of burst abdomen accounted for 48 (2.1%) cases of emergency abdominal surgery. Postoperative death was 1.1%. Delayed presentation increased mortality. Conclusions: Surgery for appendicitis is the commonest emergency abdominal surgery. Others include operations for peritonitis, trauma and strangulated inguinal hernia. Delayed presentation contributed to delayed intervention in some cases which impact negatively on treatment outcome. No single case of abdominal pain secondary to ingestion of the so called poison was seen during the study period

Herniorrhaphy: an unusual cause of ureteral injury in Nigeria

Herniorrhaphy is a common surgery worldwide. Common complications include hemorrhage, infection, chronic pain, and recurrence. Ureteric injury from herniorrhaphy is unusual. We present a case of ureteric injury complicating an inguinal herniorrhaphy for a huge right inguino‐scrotal hernia. Patient had primary uretero‐neocystostomy but died from septicemia in the postoperative period.