One cannot put a figure to the average age of those that he has had to perform surgery on. But what definitely one can remember are the ages of the youngest and the oldest surgical patients that one has had. The youngest was just a few hours old that had a condition known as OMPHALOCOELE. This condition could be detected while the baby is still in-utero or in the womb and at birth. It’s an uncommon abdominal wall defect in which the contents of the abdomen remain outside. These may include the liver and bowel loops. In omphalocoele the herniation is usually through the umbilical opening.
In other instances there may be splitting of the muscles around the umbilicus with resultant protrusion of abdominal contents. This phenomenon known as EXOMPMHALOUS and also GASTROSCHISIS is by and large a muscle developmental defect that is genetically determined. In majority of cases, this condition is associated with other birth defects or congenital anomalies. These anomalies in extreme cases affect almost all the organ systems in the body especially the heart, the brain and spinal cord, the genitourinary system and so on. The variations in this condition have been variously described by different care givers depending on the location in the chromosome chain where the challenge is situated. These include Edwards Syndrome with abnormality of chromosome 18, Patau Syndrome chromosome 13 and Beckith-Wiedemann syndrome, chromosome 11. This variant has the worst clinical outlook with enlarged organs and childhood cancers.
As a rule it is expedient to close the defect as soon as possible to prevent infections especially peritonitis which could be fatal. In mild cases where the contents of the abdomen can be pushed back into the abdominal cavity, the surgical closure is usually simple and easy. On occasions when this is not achievable, a silicone pouch may be used to cover for a couple of days before surgical intervention. In our environment this has not been met with much success as most time the patient succumbs from infection during the waiting period and as a result of co-existing malformations. There is usually a need to do a final repair at about five years later when the fascia of the anterior abdominal wall muscles must have strengthened. That was how our index case was finally rested. I have digressed.
The oldest patient this surgeon encountered was aged 93 years! When I was invited, I just couldn’t figure out the need for a woman that old needing to have a Hernia repaired. To the surgeon it didn’t make sense as she was in no form of discomfort. But her children and grandchildren would have none of that. It was all too sentimental; they didn’t want Mama to go incomplete! Whatever was the meaning of that? I guess it was a kind of appreciation and payback time. You can’t beat that attitude in terms of caring. God help you if anything goes wrong in the process of performing surgery on a person you’d rather leave alone. Thank God it all went well with Mama’s wound healing well. Six months later Mama passed on in her sleep.
One of the characteristics of our women folk is that they love having children. It is not unusual that to find a mother with ten siblings. Same thing goes for the male folks who love having children but are clueless on how to raise them. Having many children has its own price. With multiple child births the supporting structures of the pelvic organs become
weakened and this could lead to a condition in which the bladder ‘drops’ or rather prolapses into the vagina causing a bulge. This is often referred to as a CYSTOCOELE. In the event of this and depending on its severity, there could be all sorts of urinary challenges. The most embarrassing of these challenges is stress incontinence in which the individual voids urine with as simple an act as coughing or any action that raises intra abdominal pressure.
Others symptoms include difficulty starting a urine stream, frequent and urgent urination and the sensation of heaviness or something falling out from the vagina. It is pertinent at this point to state some of the conditions that can trigger the occurrence of cystocoele in those that are predispose to it. They include chronic constipation and repetitive straining during bowel movements, long standing and violent coughing, heavy lifting especially during subsistent tool farming and obesity. In some instances other pelvic structures like the urethra and bowel loops may join in the prolapse. If that be the case, it is known as RECTOCOELE.
The diagnosis of cystocoele in most cases is based on history and physical examination. Ironically in the experience of this writer a lot of patients do not even know that they have prolapsed bladder. They are informed of this during routine examination or minor procedures in the genital tract. Having said this much, X-rays taken during urination could be done. This procedure is often referred to micturating or voiding cystourethrogram. The added advantage of this is that it helps to elicit the shape of the bladder and any other lesion that may cause urinary outflow obstruction. Ultrasonography can be handy to complete the picture just in case there are other associated lesions like tumour of the uterus and the ovaries.
The treatment of cystocoele in this environment depends on the degree of prolapsed and the severity of urinary symptoms. Commonly the type of cystocoele we have here are those due to the damage to the central portion of the pubocervical fascia. This is common with multiple child births and it’s referred to as central defect cystocoele. This is seen as a bulge on the vaginal wall with variable loss of the vaginal mucosa fold or rugae. There could also be defects on the sides; the so called lateral defect cystocoele.
Whatever be the type of the cystocoele the repair procedure is basically the same with slight variations between surgeons depending on other co-existing pelvic and vaginal lesions. The widely accepted is bladder wall plication popularly referred to as ANTERIOR COLPORRHAPHY via the vaginal route. This basically involves freeing the bladder from the vaginal mucosa and approximating the edges of the pubocervical fascia while taking bites from the bladder wall. A little bit confusing? Don’t bother. Repairing the anomaly through intra abdominal route is no longer an acceptable practice. Post operative period is usually uneventful and in twenty four hours the patient is home. In mild case pelvic exercises and pessaries can be recommended.
So when next you hear that grandma is going for surgery, don’t ask what for? You just might be the cause.