Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Guide to the Operating Theater on $25 a Patient
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Figure 2. Placement of the Malement purse-string suture. After removal of the prostate
adenoma by the supra-public technique, and after placement of figure of 8 sutures at
4:30 and 7:30 (staying away from ureteral orifices), a purse-string suture is made in the
bladder neck, brought out through the abdominal wall and tied over gauze or large
buttons, thereby tightening the neck over a Foley catheter. The suture is removed after
48 hours. (With permission of Lippincott-Williams Wilkins. Glenn JF, ed. Urologic Surgery.)
Typhoid Enteritis and Perforation
Typhoid fever is a devastating illness when untreated. Often patients do not
present until the most serious complication, enteral perforation, has occurred. Most
reported studies in the developing world still describe a 10-25% mortality. Early
surgical therapy has far better survival rates than medical therapy alone. The addition
of total parenteral nutrition has improved survival considerably but is prohibitively
expensive for many hospitals. Though an ileostomy might allow earlier feeding,
most surgeons prefer closure, resection or bypass. If more than one perforation is
present or imminent, bypass or resection of ileum 10 cm proximal and distal to the
involved area is recommended. If there is recurrent perforation as evidenced by fecal
drainage, reoperation and ileostomy offers the only hope of salvage, albeit slim. For
all cases of typhoid perforation, broad spectrum antibiotics covering anaerobes and
specific anti-Salmonella therapy, e.g., chloramphenicol, trimethoprim sulfa or, in
adults, quinolones, are needed, and there is really no economical substitute. Public
health efforts to improve the water supply and sewage disposal are the long-term
solution, albeit a logistically difficult one.
Urology-Suprapubic Prostatectomy
Readers are referred to a urology text for the many urologic conditions one encounters
worldwide in every hospital. One cost-saving technique that is very useful
for the surgeon who must do prostate surgery but lacks the equipment or training
for trasurethral surgery is the routine of the Malement suture (Fig. 2). This consists
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