Where There Is No Paediatric Surgeon!

Case 1: A female baby weighing 3 kg referred from a small town near Afghanistan border, after providing initial surgical care for gastroschisis. In privately owned vehicle it takes more than 36 hours to reach our facility from the hospital, where patient was managed initially. The baby was delivered with no antenatal workup. Following birth the patient was immediately transferred to the military hospital in the town where a general surgeon recognized the condition correctly. The referral notes provided details of the condition with clarity. According to the notes impending gangrene of gut protruding out of defect was managed by increasing the defect both in midline and laterally (though incision was too large) with manual stretching of abdominal cavity. The surgeon then applied latex surgical glove after trimming it according to the size of the defect. Neonatal care was provided and the family advised to seek paediatric surgical opinion. On arrival at our hospital the baby was in poor general condition with signs of sepsis. Following resuscitation the baby was reexplored. On removal of silo the color of almost whole of the small bowel was found dusky with doubtful viability patches over the oedematous wall. It was non rotated with jejunal atresia. A large necrotic patch was present near the atretic end (Fig. 1). The terminal part of the atretic gut was resected including necrotic area and end stoma in the left flank made. A silo bag was applied to main defect. The general condition of the baby did not improve and she died on day 5 of admission.