Monday, October 31, 2011

#65 Operative report #2 omphalocele

Omphalocele. Said like ohm-FALL-oh-seal.

An omphalocele is a malformation of a newborn baby. The cute little baby is born with some or all of it’s gut within a thin membrane on his or her abdomen. So if this thin little membrane gets infected or cut, all of the intestines spill out and the baby dies. The cure is to fix it with surgery.

Did I mention that these problems arise in NEWBORNS?! Very small, tiny, itty-bitty babies? Well, actually, they arise in utero while the baby is forming. But, most people here don’t get ultrasounds during their pregnancy.

These are pretty rare. I’ve never seen one here before. I’ve never seen one before here. Samedi and James saw and operated on ONE during all of their time here before.

God forsaw this and James just happened to make a last minute trip here yesterday to get some of his belongings to Moundou.

Then during rounds a lady came in with her baby girl. Malformation. Diagnosis. Omphalocele. At least I knew what it was.

“Hey, James, have you ever done one of these?”

“Yeah, one time with Samedi.”

“Do you mind staying a little longer to help us with this?”


The cute little girl was born the day before. She hadn’t eaten any breastmilk yet, but the family had already given her water. (This problem is SOOOOO getting old!)

We brushed up in the surgery book before starting.

Now comes for the interesting part.

Simeon gave her some IV Diazepam. Maybe the first problem. The O2 sat read 70%. Oh, wow! We haven’t even given ketamine yet. She is only 1 day old. This little girl was perfectly fine before we started. Well, minus the water, but at least breathing well.

We don’t have oxygen here, remember? The O2 sat improved and James, Samedi and I scrubbed.

If we don’t use a spinal, we do everything else here with ketamine. Not INTUBATED! It works surprisingly well actually. Except when they’re not breathing well!

We had barely started the surgery. I tied off the umbilical vessels, then made an incision about 4mm next to the edge of the omphalocele to undermine the skin all the way around. Then the same thing happened again.

James broke scrub and started doing CPR. I broke scrub and helped Simeon with respirations for the baby with the ambubag. I told someone to go get Olen to help with anesthesia. Olen came and helped out.

We re-gloved and continued with the operation. James cut off the small part of skin that was on the omphalocele. I undermined the skin that was left on the abdomen. Next, James pushed the herniated thin sac with intestines back into the abdomen and I closed the skin with mattress stitches. It was too tight to close the fascia. This will have to wait another 9 months or so for a second operation.

Then the baby would NOT wake up. The monitor wasn’t showing a good oxygen saturation. When we used the ambubag, it would improve, some of the time.

It was several hours after the operation was done. I had gone home to be with the kids and feed Zane. Olen called. He needed a break from baby that kept threatening to die. He couldn’t leave Janna and Adam alone with a sick baby. The oxygen saturation kept reading 60-70% for the longest time even with respirations. Should we cut all of the sutures? Maybe there was not enough space inside for the tiny lungs to expand.

So we switched out. I brought over a different oxygen monitor. The new monitor read 90%. Maybe the first two monitors just hadn’t been working. By now the baby looked okay. I put my finger in her mouth and she actually started to suck. I had the mom express some colostrum and used a syringe to put some in her mouth. She did well.

Janna volunteered to stay with the baby during the night to watch and observe. Usually we just leave the patient with the family to guard the patient, but we were sure the family would fall asleep and then the baby would just die if she needed to be stimulated to wake up.

By this time it was dark. I had a GYN patient to see in maternity, then a baby in urgence (the ER) with another malformation.

You will NOT believe this!

Another baby girl with an omphalocele! She had just been born that same day (at home of course, just like the one today). I could not believe it! TWO babies came on the same day with this rare problem.

So today I did the second operation. James wasn’t here. Samedi was out. So it was me and Abre. There were so many problems yesterday with anesthesia that I decided to do it with local anesthesia. I kept Olen in the room with me this time, just in case. It actually went much smoother not having to worry if the child was going to die or not. And no, the child was not suffering. The lidocaine actually worked well surprisingly.

We fixed the immediate problem of the exposed membranes, but the fascia (the thick stuff that causes hernias if it’s broken) was too tight to pull together. It will have to be done at a later time. If someone knows a pediatric surgeon who would like to come fix these two precious girls’ abdominal hernias, they are welcome here in 9 months or so. Otherwise it will be us.


Olen phone: +235 62 16 04 93
Danae phone: +235 62 17 04 80

Olen et Danae Netteburg
Hopital Adventiste de Bere
52 Boite Postale
Kelo, Tchad

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