Today was a “normal” day. It rained heavily last night and it is finally cooler and I slept finally after about 3 days of minimal sleep. I get up about 7:30 and realize Ive already missed worship. I have my own usual morning worship- consisting of reading from the Bible, praying to God. I head in to see what’s happening and if any patients are ready to have their operation done. I know there are at least two hysterectomies on the schedule and the others on the list didn’t register so I guess they weren’t worrisome to me. The first lady is older and has a painful mass in her lower abdomen. I examine her belly as shes on the operating table, IV in place. Her head is covered over the top and her abdomen and chest are exposed and she has some shorts on. So she feels not well covered but acceptably covered considering shes here. Womens chest and abdomens aren’t usually terribly private. A child will pull a breast out of their moms shirt and start sucking. So i palpate and Im told shes here for a hysterectomy. She doesn’t want any more children. I look at her book and it says she would like to keep her uterus if possible but wants the mass gone. As it is almost up to her umbilicus I know Ill do a vertical incision.
At her operation in a few minutes after seeing some consults outside, I incise her abdomen up and down. Then into the abdomen we see the uterus is huge. I feel around and cant feel any uterine fibroids. So I guess I cant do a fibroidectomy, so a hysterectomy it is. Dr Steven and I are working together. So he works down one side and I work down the other. We get into some bleeding that we are able to control and we get down to the cervix and then take out the uterus. It looks about the size of a small bowling ball. Im sure she will feel better with this out. There is definitely more space in her abdomen!
Next is a younger woman in her 30s who has an ovarian tumor. She definitely wants more children. She has had 4 and and only 2 are living, and hasn’t had any for the last 4 years. Womens value in the local cultures are very tied to how many children they have. So i want to take the ovary, both to help her live longer and so that she still has a chance to have children like she wants. I palpate her abdomen and then get my butterfly to see it for myself. Apparently there was some confusion wether the mass was in the ovary or uterus. I see a large mass and then a small uterus behind. I open her thin abdomen and start exploring with my fingers. It seems the intestines are stuck to the mass all over. This is a bad sign, more likely to be cancerous. I slowly dissect some off an Dr Steven dissects other parts off. Then we get into a cystic area somewhere deep inside. A dark bloody fluid comes out. We dissect more and find that we end up getting two large cysts. Then there is a large mass below that is really stuck to the rectum and bladder and i feel we cannot get down to the uterus. We are bleeding and leaving cyst wall stuck to intestine. So if this is cancer, there is definitely not a cure here. And with us dissecting the bladder and rectum the chance of injuring these and blood vessels is very high. So i tell Dr Steven i think its time to stop and get out, that we are not helping any more. After assessing it again he agrees and we drain and start closing. We are both bummed that we couldn’t get it out safely. But Im also glad to not be threatening her lift TODAY.
I go out and see some more surgical consults as they get the next US proportioned guy ready. Everyone here is very thin, and this guy isn’t. He has a mass on the back of his leg, and it is likely a sarcoma. These need to be removed with a good margin of normal tissue around them. The anesthetist Phillipe, puts in the spinal and after a number of minutes have past we get 8 people around him to turn him on his side. His big belly starts to drape off the side of the narrow OR table, so we reposition and prop him so that he is safely on his side and then we are able to work on the back of his lower leg. I want a centimeter of normal tissue around the tumor. Now this sounds easy, just measure and cut 1cm further. Yes that is easy at the skin, once you are deeper it’s harder to be certain that your are one cm away. To be certain you’d have to cut down to it and then go back a cm to make sure you have it. But that violates the purpose of staying away that far in being beyond tumor that is microscopic spread. So it ends up being a feel of how much tissue is between my finger and the cancer. So i end up cutting a large hole out of the back of his leg down into the muscle. So after removing it, the spot is about the size of half an orange. There is not near enough laxity of the surrounding skin to get it any where near back together. So I can skin graft it or leave it open. Skin grafting covers this large divot with skin and it will forever look like a large divot. Or I can leave it open and in about 3 months it will be flat and covered with skin. So I leave a large hole in the back of his leg for Gods design to take over and heal it.
The next guy I operate on is the guy I referenced a couple days ago that has epilepsy and fell in the fire and burned his toes on his left foot, well the three middle ones, and also burned the top/side of his head. He has exposed skull that will not heal and cannot be skin grafted, and three toes that are floppy and have bone sticking out of one. So in the operating room I slowly remove the three toes that need to come off and then I get to the interesting part, the skull. There is a patch of about 3x5inches that is exposed. Since this won’t heal the solution is to remove the outer table of the skull and leave the marrow to granulate. So after prepping the head I get the drill and drill multiple small holes in the outer skull. Then I use a rongour to nibble off the bone between the holes. One hole drills quickly and a get a constant squirt of dark blood coming out about 5 inches. Oh no, did I hit the cavernous sinus, a large vein just above the brain? I hold pressure for a few minutes and every time i let go the same stream is there. Dr. Steven has the idea of taking the bone shavings and shove them into the hole, so I do that and we hold pressure and continue work. This eventually works and we finish up removing the outer skull. Later that night I check on him before going to bed and and he is not bleeding and he is laying flat and i get him with head up like I want and head to bed.
It’s been a good interesting day.
