November 2012 - Week 7 - William Schecter

Lawrence and I had a fantastic week.  The list of cases does not really do them justice.  The retroperitoneal tumor cases had the portal vein and SMV splayed over it.  I originally thought it was unresectable but the poor girl was only 17 so I tried.  I ended up debulking it and hope it was a neuroendocrine tumor.  We introduced the concept of “Damage Control Elective Surgery in a Resource Constrained Environment”.  We had only one unit of blood (we were called to the OR to help others who started the case and first met the patient on the OR table).  I packed the patient and took her back to the OR the next day for definitive closure after resuscitating her in the ICU.  She is now fine.  The next day we did a gigantic spleen with a splenic artery aneurysm.  The spleen was the most difficult I have ever done with extensive adhesions and I originally thought the splenic artery aneurysm was a tumor in the tail of the pancreas as it was rock hard until I realized it was pulsatile and expansile.  The incarcerated scrotal hernia case had a liter of intestinal contents in the tunica vaginalis.  We opened the abdomen and controlled the blood supply of the incarcerated viscera before opening the rectus for about 2 cm to permit reduction of the hernia—another great case.

On Thursday I drove 12 hours to a Mission Hospital at Haidom, a place in the middle of nowhere, two hours by dirt road from the nearest town on a maintained road.  One of the Tanzanian residents invited me to visit his home hospital.  Most of the surgery there is done by assistant medical officers—non MDs who are trained to do surgery.  One I met there is about my age and a reasonably skilled orthopedist who was also doing burr holes and prostatectomies.  While there, I did a suprapubic prostatectomy and helped an assistant medical officer re-explore an abdomen two weeks after a hysterectomy—she began to discharge blood from the vaginal cuff.  The abdomen was filled with old clot and the intestines had multiple points of obstruction but we found no definite source of bleeding.  The burden of disease there was immense.  The wards were filled with patients, literally about six inches between the beds so that you could hardly move between the beds.  I saw a 25-year-old man with a large untreated malignant melanoma of the foot, a groin full of nodes and the largest liver I have seen in quite some time obviously filled with tumor.  They next presented a 30-year-old very wasted man with a huge retroperitoneal tumor that looked like it was going to necessitate out of the abdomen.  Finally, I saw a poor woman with a fungating carcinoma of the breast who unfortunately also had a malignant pericardial effusion with tamponade physiology.   There was a five-year-old boy who had been bitten by a snake and had had a fasciotomy.  He had a large granulating wound of the leg.  I was going to cover it with a skin graft but the anesthetist and the nurses decided he was not ready for a graft!!  There were no trained surgeons in the entire hospital.  Those are the patients I saw, and there were many more.

Lawrence and Jessica are leaving tomorrow to attend the annual meeting of the Congress of Surgeons of Eastern, Central and Southern Africa in Addis Ababa, Ethiopia.  This is a wonderful opportunity.  Jessica is presenting data on the epidemiology of inguinal hernia in Tanzania.  We listened to her presentation this morning and it is excellent.  I will continue to work here clinically with the Tanzanian faculty and staff for the week they are away.

Cases

S/P Hartman resection                                 Colostomy take down
Retroperitoneal Tumor                                 Resection retroperitoneal tumor
Hypersplenism/splenic A. aneurysm           Splenectomy
Strangulated Hernia                                     R hemicolectomy, hernia repair
Incisional Hernia                                            Incisional hernia repair
Obstructing rectal tumor                              Transverse Colostomy
Male Breast Cancer                                        L Mastectomy