A dedicated quality improvement programme can increase access to paediatric minimal access surgery in South Africa

BACKGROUND

In this project, we reviewed our experience in minimal access paediatric surgery (MAPS) at Greys Hospital over the last decade. This information would provide an overview of our experience and would enable us to identify areas where we can strengthen our surgical service and our training programme.

METHODS

All surgical patients are captured in the hybrid electronic medical registry (HEMR). All patients aged 18 years or less who underwent a MAPS procedure between 2012 and 2021 were reviewed. Data collected included demographic information, type of surgery, nature of the surgery (elective or emergency), organ system operated on, whether trainees or consultants performed the surgeries and the morbidities and mortalities experienced. Statistical analysis included linear regression and ANOVA, which was performed using Jamovi software.

RESULTS

A total of 1 328 MAPS procedures were performed on 994 patients over nine years. There were 359 female and 635 male patients. There was a steady increase in the number of cases performed per year. The age of the patients ranged from one day of life to 18 years, with a median of 8 years. The multiple linear regression results indicated a very strong collective significant effect between the courses performed, the number of consultants, and the MAPS cases performed. The ANOVA test for the individual factors was not statistically significant, but there was a very strong combined correlation with an r-value of 0.87 and a p-value of 0.014 using the overall model test. The consultants' training also directly impacted on the teaching and training of registrars, with progressively more cases being performed by trainees over the years. Postoperative morbidity was reported in 40 patients. The morbidity rate was three per cent. There were no mortalities.

CONCLUSION

It is feasible to deliver MAPS to children in our environment. A comprehensive quality improvement strategy has yielded satisfying results. The increased use of MAPS has resulted in a general transfer of skills to junior staff. Ongoing efforts to support the rollout of MAPS in children are warranted.

A case of bowel perforation secondary to burn conversion

SUMMARY

Burn conversion is a process by which superficial partial-thickness burns spontaneously progress into deep partialthickness or full-thickness wounds. Factors that influence this process centre around poor perfusion which can be related to either too much or too little fluid resuscitation, infection, free radical damage, and metabolic or nutritional derangements. Therein lies the role of preventative strategies, i.e., adequate fluid resuscitation, prompt identification and management of sepsis, correction of electrolyte derangements and early institution of feeds. Prevention of burn conversion could prevent the need for surgical intervention and improve the morbidity and mortality of burns patients.

Laparoscopic percutaneous internal ring suturing for paediatric inguinal hernias: a South African tertiary centre experience

BACKGROUND

Laparoscopic inguinal hernia repair is routine in many paediatric centres. One of several techniques described in 2006 is the laparoscopic percutaneous internal ring suturing (PIRS) technique. This technique which is not widely used in South Africa has been adopted for paediatric inguinal hernias at our institution, and this is a review of the experience.

METHOD

The study is a retrospective review of the patients who underwent PIRS (a single port combined percutaneous procedure used to close the internal ring) at our hospital from October 2018 until March 2020. We describe the technique in our setting and review our cohort of patients, demographics, clinical presentation, operative duration and complications.

RESULTS

One hundred and ten laparoscopic PIRS procedures were performed on 94 patients; 15 had bilateral inguinal hernias. Polydioxanone and Prolene were the sutures used for the procedures. Average operative time was 12 minutes for unilateral hernias and 33 minutes for bilateral hernias. All operations were completed laparoscopically. Follow-up was for a minimum of three months, but up to 21 months. Complications included three intraoperative haematomas, three hydrocoeles and two umbilical granulomas postoperatively. There were two recurrent hernias of which one was managed with redo PIRS; the other required open herniotomy for an irreducible obstructed hernia.

CONCLUSION

This review is supportive evidence that the PIRS technique for managing paediatric inguinal hernias in a tertiary institution in South Africa can be performed safely with few complications.

Laparoscopic percutaneous internal ring suturing for paediatric inguinal hernias: a South African tertiary centre experience

ABSTRACT BACKGROUND: Laparoscopic inguinal hernia repair is routine in many paediatric centres. One of several techniques described in 2006 is the laparoscopic percutaneous internal ring suturing (PIRS) technique. This technique which is not widely used in South Africa has been adopted for paediatric inguinal hernias at our institution, and this is a review of the experience METHOD: The study is a retrospective review of the patients who underwent PIRS (a single port combined percutaneous procedure used to close the internal ring) at our hospital from October 2018 until March 2020. We describe the technique in our setting and review our cohort of patients, demographics, clinical presentation, operative duration and complications RESULTS: One hundred and ten laparoscopic PIRS procedures were performed on 94 patients; 15 had bilateral inguinal hernias. Polydioxanone and Prolene were the sutures used for the procedures. Average operative time was 12 minutes for unilateral hernias and 33 minutes for bilateral hernias. All operations were completed laparoscopically. Follow-up was for a minimum of three months, but up to 21 months. Complications included three intraoperative haematomas, three hydrocoeles and two umbilical granulomas postoperatively. There were two recurrent hernias of which one was managed with redo PIRS; the other required open herniotomy for an irreducible obstructed hernia CONCLUSION: This review is supportive evidence that the PIRS technique for managing paediatric inguinal hernias in a tertiary institution in South Africa can be performed safely with few complications Supplementary video available online: http://sajs.redbricklibrary.com/index.php/sajs/article/view/3498 Keywords: inguinal hernia, paediatric, laparoscopy, percutaneous internal ring suturing