Scielo RSS <![CDATA[South African Journal of Surgery]]> vol. 52 num. 4 lang. en <![CDATA[SciELO Logo]]> <![CDATA[<b>Developing a clinical model to predict the need for relaparotomy in severe intra-abdominal sepsis secondary to complicated appendicitis</b>]]> INTRODUCTION: Complex intra-abdominal sepsis secondary to acute appendicitis is common in South Africa, and management frequently involves relaparotomy. The decision to perform relaparotomy is often difficult, and this study aimed to develop a clinical model to aid the decision-making process. METHODS: The study was conducted from January 2008 to December 2012 at Edendale Hospital, Pietermaritzburg. All patients with intraoperatively confirmed acute appendicitis and all patients in this group who subsequently underwent relaparotomy were included. The clinical course, intraoperative findings and outcome of all patients were recorded until discharge (or death). Using a combination of preoperative and intraoperative parameters, a clinical model was developed to predict the need for relaparotomy. RESULTS: Of the total of 1 000 patients identified, 54.1% were males. The median age for all patients was 21 years. Of 406 relaparotomies, 227 (55.9%) were planned and 179 (44.1%) on demand (expectant treatment). In the relaparotomy group, 367 patients (90.4%) had positive findings. Logistic regression analysis showed that the following four factors accurately predicted the need for subsequent relaparotomy: patients referred from any rural centre, duration of illness >5 days, heart rate >120 bpm, and perforation associated with generalised intra-abdominal sepsis. This model had a predictive value of >90%. CONCLUSIONS: We have constructed a model that uses clinical data available at initial laparotomy to predict the need for subsequent relaparotomy in patients with complicated acute appendicitis. It is hoped that this model can be integrated into routine clinical practice, but further study is first needed to validate this model. <![CDATA[<b>Exposure to key surgical procedures during specialist general surgical training in South Africa</b>]]> BACKGROUND: The logged experience of specialist general surgical trainees has made it possible to analyse their surgical procedural exposure. OBJECTIVE: To evaluate the exposure to key surgical procedures of South African (SA) trainees in general surgery from logbooks submitted to the Colleges of Medicine of South Africa (CMSA). METHODS: Logbooks submitted and meeting the minimum requirements for the six final examinations for the fellowship of the College of Surgeons of the CMSA between August 2010 and March 2013 were selected. Consolidated surgical procedural experience was analysed according to procedural category, extent of supervision, procedure complexity and university at which the trainee performed the procedures. RESULTS: The 95 logbooks entered into the study recorded 144 499 procedures, 60.6% of which were unsupervised, 18.5% supervised and 20.9% assisting another surgeon. Major and minor procedures made up 40.4% and 54.6%, respectively, with the remaining 5% categorised as 'other'. A breakdown of procedural exposure per category, including the main contributing or key procedure for each category, is presented. CONCLUSION: Large numbers of procedures are logged by trainees during their surgical training. Inter-university and trainee key procedural exposure in SA differ to a small degree but are striking in some categories. Exposure to key procedures is insufficient in some categories. We are currently unable to assess the quality of training and quality of surgical skills from such logbooks. A standardised electronic logbook will facilitate future analyses of trainee procedural exposure, but other tools will be required to assess the quality of surgical skills training. <![CDATA[<b>An audit of trauma-related mortality in a provincial capital in South Africa</b>]]> INTRODUCTION: It has been shown repeatedly that hospital-based mortality data do not capture the actual mortality rate in South Africa, as many corpses are taken directly to the state mortuary. OBJECTIVE: To present a comprehensive overview of the forensic mortality data for trauma in an urban metropolitan complex METHODS: A retrospective audit was conducted by reviewing all mortuary reports for the period 1 January 2010 - 31 December 2011. The data recorded included demographics, mechanism of trauma, and cause and site of death. RESULTS: A total of 1 105 trauma victims died. There were 930 males (84.2%) and 175 females (15.8%), of whom 615 were victims of blunt trauma (55.7%) and 490 victims of penetrating trauma (44.3%). The scenes of death were: on scene 584 (52.9%), Edendale Hospital 259 (23.4%), Grey's Hospital 144 (13.0%), Northdale Hospital 68 (6.2%), and 'other' 50 (4.5%). The 'other' group comprised nine deaths at primary healthcare clinics and 41 at private hospitals in Pietermaritzburg. Of deaths related to blunt trauma, 153 (24.9%) were secondary to assault and 462 (75.1%) to a road traffic collision. Of the victims of penetrating trauma, 81 (36.9%) had sustained gunshot wounds and 309 (63.1%) stab wounds. The three leading causes of trauma-related deaths were head injuries (32.6%), polytrauma (29.7%) and chest injuries (27.4%). CONCLUSIONS: Pietermaritzburg has both a high rate of trauma-related mortality and an immature trauma system, resulting in a significant number of preventable deaths. <![CDATA[<b>Propeller flaps for lower-limb trauma</b>]]> The propeller flap has become a versatile and important component in our reconstructive algorithm following complex lower limb trauma. First described by Hyakusoku in 1991, it has since been adapted and modified by Hallock and Teo. This article outlines our experience specifically with perforator pedicled propeller flaps (as per the Tokyo consensus) for traumatic defects of the leg. In this procedure, the reconstructive surgeon skeletonises a single perforator and rotates the skin island on its axis between 90º and 180º to close the defect. The minor blade of the propeller may be designed to close the donor defect completely for the 180º version. The propeller flap has the advantages of local flaps (reliability, contour, texture, 'like-with-like') with additional versatility of design and donor site management, and requires minimal expertise and operative time. <![CDATA[<b>Regional anaesthesia for cleft lip surgery in a developing world setting</b>]]> BACKGROUND: The role of regional anaesthesia in cleft lip surgery in the developing world is not well documented OBJECTIVE: To report on the use of regional anaesthesia in cleft lip surgery in adults and adolescents in a developing world setting. METHOD: A retrospective chart review of 100 patients aged >14 years who had cleft lip surgery during an Operation Smile South Africa (OSSA) volunteer surgical programme in Madagascar during 2007 and 2008. The nerve blocks used included a bilateral infraorbital nerve block, a dorsal-nasal nerve block and a septal block supplemented with peri-incisional local infiltration. Appropriateness of the regional anaesthesia alone for cleft lip surgery was determined by absence of any intraoperative complications, postoperative complications or conversions to general anaesthesia. RESULTS: Seventy-four patients commenced their operation under regional anaesthesia. There were no intraoperative or postoperative complications documented, and no patient required conversion to general anaesthesia. Two patients required additional analgesia in the immediate postoperative period. CONCLUSION: Regional anaesthesia for cleft lip surgery in patients >14 years of age was well tolerated and associated with few complications. It is a safe and effective option when used as the sole anaesthetic modality for cheiloplasty in the developing world. <![CDATA[<b>Haemangiopericytoma/solitary fibrous tumour of the greater omentum</b>]]> We report a rare case of haemangiopericytoma/solitary fibrous tumour of the greater omentum in a 41-year-old woman. It presented as a large mobile abdominal mass measuring 30 χ 24 χ 8 cm. A computed tomography scan confirmed the presence of a large vascular tumour, and biochemical tumour markers were non-contributory. The tumour was removed through a conventional laparotomy incision with the aid of a Ligasure dissector. There were no macroscopic metastases, and histologically it was benign. The size of >5 cm, however, suggests that it may have been malignant. In the absence of visible metastases and in view of the favourable histological features, it was decided to follow up the patient very closely and give further treatment if necessary. <![CDATA[<b>Largest recorded non-invasive true intrathoracic desmoid tumour</b>]]> Intrathoracic desmoid tumours are rare soft-tissue neoplasms arising from fascial or musculo-aponeurotic structures, accounting for less than 0.03% of all neoplasms. Most cases in fact represent intrathoracic extension of chest wall tumours. This case report describes the largest recorded true intrathoracic desmoid tumour without mediastinal or chest wall invasion. The tumour was completely excised through a left thoracotomy with negative tumour margins. Management of the patient will involve radiological surveillance. Desmoids are benign tumours that do not metastasise but have a high rate of recurrence, especially if tumour margins are positive after surgical resection. Complete surgical resection is the treatment of choice. Other treatment options include radiotherapy; non-steroidal inflammatory drugs or antioestrogen therapy (tamoxifen) or a combination thereof; and chemotherapy or targeted drug therapy. <![CDATA[<b>The mystical foot with pink mushrooms: Imaging of maduromycosis - a rarity in southern Africa</b>]]> Maduromycoses (Madura foot) are chronic granulomatous subcutaneous infections endemic to certain regions, but not southern Africa. The infection is caused by both pure fungi and bacteria. Imaging plays an important role in assessing the severity of disease and the direction of its spread, assisting in treatment planning and in the monitoring of treatment response. The typical 'dot-in-circle' sign on magnetic resonance imaging is diagnostic of Madura foot. We present the case of an adolescent South African boy who presented with fungoid growths on his foot, typical of this disease. <![CDATA[<b>Isolated gallbladder perforation following blunt abdominal trauma</b>]]> A 32-year-old man sustained an isolated perforation of the gallbladder following blunt abdominal trauma. A preoperative diagnosis was made on an ultrasound scan, which showed a pericholecystic fluid collection only. At laparotomy, a gallbladder perforation at the infundibulum was identified with a localised bile collection, warranting a cholecystectomy. Isolated gallbladder injury from blunt abdominal trauma is rare, and a high index of suspicion is required to establish the diagnosis. Cholecystectomy is the treatment of choice. <![CDATA[<b>Hamid Ismail Yakoob</b>]]> A 32-year-old man sustained an isolated perforation of the gallbladder following blunt abdominal trauma. A preoperative diagnosis was made on an ultrasound scan, which showed a pericholecystic fluid collection only. At laparotomy, a gallbladder perforation at the infundibulum was identified with a localised bile collection, warranting a cholecystectomy. Isolated gallbladder injury from blunt abdominal trauma is rare, and a high index of suspicion is required to establish the diagnosis. Cholecystectomy is the treatment of choice.