Baby Hernia

Friday. The end of a long week. I'm set to travel Sunday to N'Djamena to pick up some volunteers. The day is almost over. It's been pretty quiet...

"Docteur, you should see this case." Jacob pokes his head in my office at around noon.

A talk, lean father with his young wife wrapped in a bright blue, and yellow patterned body wrap walks in carrying a chubby little three month old. He's sleeping quietly. The mom sits on the exam table and unwraps the baby exposing the obvious problem.

His left groin and scrotum is swollen to 10 times the normal size.

I palpate it and with gentle pressure the "mass" slithers back into the belly causing the child to wake up and cry. My finger is in a hole in the inguinal canal. When I release, the cries cause the baby's intestines to pouch right back out.

If I wait, the intestines could get trapped outside, and since I'm leaving Sunday, I should operate today even though I'm tired.

Samedi, Abel and Simeon all try tirelessly to find an IV without success. Finally, we are forced to use intramuscular Ketamine for the anesthesia.

The tiny is strapped onto a "papoose board" so he can't move and Betadine applied generously to his abdomen, groin, scrotum, penis and upper legs.

I open the hernia pack, scrub, pull on sterile gown and gloves and pick up the scalpel.

It seems so big compared to the little body now draped in sterile towels.

I carefully, gently slice a two centimenter incision over the still bulging hernia.

The sac is so thin I can see the intestines inside. It reaches all the way down to the testicule. It is a delicate thing to dissect off the spermatic cord from the thin sac and it tears in a couple places but finally is free.

I push in the intestines and clamp off the sac. I tie it closed and cut off the rest of the sac. This is where I briefly think of doing something I regret not doing later. Everything I've just read says that tying off the sac in infants is almost always enough with just a 1% chance of recurrence. So, I decide not to close the hernia defect but just close the fascia over the spermatic cord. I attach the testicle to the scrotum with a button on the outside and close up the skin.

He did well under anesthesia and I go home.

The next day is Saturday so I don't do rounds until the afternoon.

I come up to see the nurse and he says that I need to see the baby I operated on yesterday, his scrotum is swollen up.

I have a sinking feeling in my stomach as I walk down the dimly lit corrider to the bare bones hospital ward packed with visitors.

The baby looks sick. He is somewhat lethargic and has a rapid heartbeat and is a little pale. His scrotum is swollen and edematous. It's not readily obvious if it's the hernia come back or a hematoma. I ask the father and he says the swelling started on the inferior part of the scrotum and worked it's way up.

Sounds like a hematoma, but I'm not sure. I feel a sense of helplessness. If it's the hernia he'll die without an operation, but he's so sick he won't survive another operation. And I'm leaving tomorrow morning early.

I make a tough decision to not operate. I suspect he has malaria as well, so I treat his malaria and hope it's just a hematoma that will resolve itself. I don't feel good about my decision, but go home with a heavy heart. I'm sure I'll never see him again.

The next day is an early day. I get on the motorcycle and as I pull away from the hospital I can't help but wondering if the baby's not already dead.

I get back to Béré after midnight Wednesday after getting stuck in the mud just right before the barge crossing...just a few kilometers from Béré.

By the time I eat and hit the sack it's 1:30am. I sleep till almost 10:00 the next morning before going up to the hospital.

To my surprise, the baby is still alive and looking a lot better. He is alert and bright eyed, but his belly is very swollen and he's still pale. He now has an IV that has given him some much needed IV fluids. I order a hemoglobin...it's barely over 6, about a third of normal. We give him a blood transfusion.

The testicle is still swollen and it's obvious now that it's the hernia that's come back. I take him to surgery as the blood transfusion runs in.

Odei assists me as I incise larger and perpindicular to the old incision. A mass of swollen, dark red intestines pop into the field. I try to push them back in but without muscle relaxation and an already swollen abdomen, it's all but impossible.

It seems like most of the intestine is still viable. I push and push but can't get it all inside. It starts to get darker. The blood supply is being cut off before my very eyes. I'm feeling desperate and am sweating and swearing under my breath.

Finally, part of the intestine tears partway through. Thankfully, the inner part doesn't tear but now I have to take out part of the intestine. I open the appropriate instrument pack, put bowel clamps over where the intestine looks nice and pink. Then I clamp off the blood vessels supplying the dying part and cut it out.

Now, I'm stuck trying to suture the tiniest of small intestines in a field only about 3cm big. I make a ton of tiny interrupted stitches through the inner lining and then run a second layer through the tougher muscle layer. I release the bowel clamps. Air and stool inflates the newly sewn intestine without leakage.

Now, I'm able to push the rest of the intestine inside. I take out the testicle and cut and tie the cord pushing the stump inside. Then I close the fascia and all the the rest in three layers.

The I close my cross shaped incision. The kid's still alive though his belly is tense and he's not breathing that well.

I put him on IV fluids and antibiotics and tell his parents to not let him breastfeed or take anything to drink.

He's still alive the next few days but his belly is still very swollen.

Three days later, I come in and his belly is flat and soft, he's been farting and pooping and looks wide-eyed and has normal vital signs. The wound is healing well and he starts breast-feeding.

We'll send him home tomorrow.