Background: Remarkable gains have been made in global health with respect to provision of essential and emergency surgical and anesthesia care. At the same time, little has been written about the state of surgical care, or the potential strategies for scale-up of surgical services in sub-Saharan Africa, southeast Nigeria inclusive. Objective:The aim was to document the state of surgical care at district hospitals in southeast Nigeria. Methods:We surveyed 13 district hospitals using the World Health Organization (WHO) tool for situational analysis developed by the "Lancet Commission on Global Surgery" initiative to assess surgical care in rural Southeast Nigeria. A systematic literature review of scientific literatures and policy documents was performed. Extraction was performed for all articles relating to the five National Surgical, Obstetric and Anesthesia Plans (NSOAPs) domains: infrastructure, service delivery, workforce, information management and financing.Findings: Of the 13 facilities investigated, there were six private, four mission and three public hospitals. Though all the facilities were connected to the national power grid, all equally suffered electricity interruption ranging from 10-22 hours daily. Only 15.4% and 38.5% of the 13 hospitals had running water and blood bank services, respectively. Only two general surgeon and two orthopedic surgeons covered all the facilities. Though most of the general surgical procedures were performed in private and mission hospitals, the majority of the public hospitals had limited ability to do the same. Orthopedic procedures were practically non-existent in public hospitals. None of the facilities offered inhalational anesthetic technique. There was no designated record unit in 53.8% of facilities and 69.2% had no trained health record officer. Conclusion:Important deficits were observed in infrastructure, service delivery, workforce and information management. There were indirect indices of gross inadequacies in financing as well.

Objective: Recently, emergency and essential surgical and anesthesia care at district hospitals is increasingly gaining recognition as a critical, though neglected element of health care system in Africa and other developing nations. Emergency laparotomy is a versatile procedure that can cure a great deal of acute abdominal conditions. The aim of this study was to document the indications and outcomes of laparotomy for emergency abdominal surgical conditions in our district hospitals. Methods: This retrospective study was undertaken in district hospitals from January 2009 to December 2018. Associations between different variables were measured and compared using statistical tests of significance. Results: Of the 879 patients evaluated, appendicitis (n=361, 41.1%) was the most frequent indication for emergency laparotomy followed by complicated external hernias (n=120, 13.7%). Other indications were adhesive intestinal obstruction (n=111, 12.6%), typhoid perforation (n=98, 11.1%), perforated peptic ulcer (n=89, 10.1%), trauma (n=58, 6.6%), colorectal cancer (CRC) (n=18, 2.0%) and others (n=24, 2.8%). The vast majority of patients (n=726, 82.6%) were presented after 24 hours of the onset of disease. Approximately, one-third of patients (n=278, 31.6%) had comorbidities, 867 (98.6%) had high ASA scores (III and IV) and 105 (11.9%) received intestinal resection with or without stoma. The main independent predictors of mortality were late presentation (P=0.003), generalized peritonitis (P=0.001), bowel resection (P=0.000) and high ASA (III and IV) scores (P=.000). Overall, the mortality rate was 10.6%. The commonest complication was wound infection (39.7%), followed by intra-abdominal collection (10.0%). Conclusion: The most common indication for emergency laparotomy was appendicitis followed by complicated hernias. The major independent predictors of mortality included bowel resection, high ASA score, late presentation and generalized peritonitis.

Background: Femoral hernia is peculiar due to its high propensity towards strangulation, high rates of diagnostic pitfalls and occurrence in older patients with multiple comorbidities. Therefore, an updated record of the clinical characteristics and burden of the disease in our locality should be established. Aims and Objectives: This study aimed to document the challenges of diagnosis and outcome of repair of femoral hernia in southeast Nigeria. Materials and Methods: This was a multi-centre retrospective study of adult patients with femoral hernias repaired surgically over twelveyears period. Tests of statistical significances were done. Results: A total of 128 patients were studied and they represented 3.4% and 2.6% of all patients with groin and abdominal wall hernias respectively. There were 116 females and 12 males. The overall rate of missed diagnosis was 14.8%; majority (84.2%) were in the emergency arm. Eighty-one (63.4%) patients presented emergently while 47 (36.7%) were managed electively. In the emergency group, the vast majority (72, 88.9%) presented beyond 24hours from onset of complications. Still on the emergency group, 72 (88.9%) were strangulated, seven (8.6%) were obstructed and 2 (2.5%) were incarcerated at presentation. Overall resection rate was 39.8%, but in the emergency group, it was 63.0%. Prosthetic meshes were used in only 4 (8.5%) of the 47 elective cases. Recurrence rate was Overall morbidity and mortality rates were 43.0% and 10.9% respectively. Late presentation was an independent predictor of mortality (p=0.000). Conclusion: Thoughfemoral hernias are relatively uncommon, the rate of missed diagnosis is high, majority of which occur in the emergency group. Majority presented in emergency and have high propensity towards strangulation with attendant high morbidity and mortality.

Background: In recent time, incidence of abdominal injuries continues to increase steadily in most major regions of West Africa due to emergence of various religious, social and political conflicts. Indeed, violence and social conflicts constitute major global public health challenges that commonly lead to injuries and long-term physical and mental health problems. In our setting, increasing cases of abdominal trauma resulting from civilian violence led to additional workload in the general surgery unit and the audit of our experiences is presented in this paper. Objective:To analyze the etiological spectrum, trend and management outcome of abdominal injuries from civilian violence in our setting. Methods:This was a multicenter prospective study of adult patients with abdominal injuries from civilian conflicts managed at three selected district hospitals in Southeast Nigeria between January 2013 to December 2020. Findings:Of 398 patients evaluated, 359 (90.2%) sustained penetrating while 39 (9.8%) had blunt abdominal injuries. Gunshot was the most common mechanism, accounting for 248 (62.3%) cases, followed by stab wound (95, 23.9%). Armed robbery attack (68, 27.4%) was the main source of gunshot wounds. Overall, annual rates showed a fourfold rise over an eight-year period from 24 cases (6.0%) in 2013 to 96 (24.1%) in 2020. Majority (365, 91.7%) had operative management (OM); the rest (33, 8.3%) were treated non-operatively. Morbidity and mortality rates for operative cases were 29.6% and 12.1% respectively. The main factors associated with increased mortality rates were delayed presentation (p = 0.002), bowel resection (p = 0.006), gunshot wounds (p = 0.013), *Author affiliations can be found in the back matter of this article 2 Ogbuanya et al.

Background: Worldwide, inguinal hernia repair is the commonest surgical procedure in general surgery, but the optimal repair technique for inguinal hernia has not been defined and accepted in most parts of Africa and other developing nations. The aim of this study was to determine the epidemiology of inguinal hernias and feasibility of mesh implants in our centre. Methodology: This was a descriptive cross-sectional study of consecutive adult patients with uncomplicated inguinal hernias who received polypropylene mesh for repair of their inguinal hernias. Selection criteria included inguinoscrotal/inguinolabial hernia, recurrent or bilateral hernia or bubunoceles with wide defects. Descriptive statistics and tests of significance were done. Results: Inguinal hernia represented 77.3% of all abdominal wall hernias encountered during the study. However, only 27.8% (100 patients) of the 360 patients that satisfied the inclusion criteria received mesh implants. Of the 100 patients studied, 31% had recurrent hernias, 48% harbored complete inguinoscrotal/inguinolabial hernia while 13% had incomplete inguinoscrotal hernia. Majority (86%) had unilateral hernia.The annual repair rates using mesh implants increased progressively from 4% in 2013 to 40% in 2017. A quarter (25%) had comorbidities. Majority (60%) of repairs were under general anesthesia. The overall postoperative complication rate was 14%. Wound infection rate was 3.5%. There was statistically significant difference in the rates of wound-related events between recurrent and primary inguinal hernias (p=0.000).  There was no mortality or recurrence recorded in this study. Conclusion: The uptake of mesh implants for inguinal hernia repair in our environment is low, though the trend is changing with higher proportions of patients accepting mesh implants in recent time. Elective inguinal hernia surgery with polypropylene mesh is feasible, safe, effective and reproducible in our setting.