July 2013 - Week One - Benjamin Howard

Dear colleagues and professors,

“Habari” from Dar es Salaam, Tanzania; as some of you know, I am spending the month of July here with Dr. Schecter, working with the Department of Surgery at Muhimbili University National Hospital. I’ve been here one week now, and wanted to give a quick update.

First, I must acknowledge those who have come before me – Jessica Beard, Evelyn Shue, and Lawrence Oresanya have all spent time on service here at Muhimbili, and they prepared me very well for my time in Africa. They are also remembered fondly by much of the hospital staff!

Since last Monday, Dr. Schecter and I have scrubbed in a number of cases, elective and emergent, a selected list of which may give a taste of the general pathology seen in what was once called “tropical surgery”:

- Exploratory laparotomy and Graham patch repair of a perforated prepyloric ulcer in a 22 year old man with diffuse peritonitis and sub-diaphragmatic free air.

- Gastrojejunostomy and cholecystojejunostomy for palliation in a 38 year old woman with pancreatic cancer, obstructive jaundice, and gastric outlet obstruction.

- Ex lap and diverting sigmoid colostomy on a 21 year old girl struck by a motorcycle with a pelvic fracture and a massive tear in her perineum.

- Modified radical mastectomy on a 43 year old woman with locally advanced breast cancer. (we’ve actually been involved in at least four similar cases – let’s just say the Z11 trial would be difficult to conduct here!)

- Ex lap, hysterectomy with resection of a 40cm mass (!) arising from the uterus in a 36 year old woman with a 3 year history of “enlarging abdomen.”

- Takeback laparotomy, resection of the transverse colon, diverting ileostomy on a 66 year old woman one-week post-repair of gastric perforation, found to have multiple colonic perforations and feculent peritonitis.

- Thyroidectomy and excisional biopsy of clavicular lesion in a 50 year old woman with likely metastatic follicular thyroid cancer, primary lesion 10cm.

- Appendicectomy (that’s how they say it) on a 50 year old man, found to have a 20cm long, 2cm diameter appendix (pathology pending).

- Partial gastrectomy with Billroth II reconstruction for palliation in a 71 year old man with metastatic gastric cancer and persistent bleeding from the primary tumor.

- Open Heller myotomy with Dor fundoplication in a 16 year old girl with achalasia.

- Ex lap, lysis of adhesions, small bowel resection in a 25 year old man with small bowel obstruction and history of laparotomy as a small child.

Needless to say, the differences between surgery here and in San Francisco are vast. Even though it’s a national referral center, the resource limitations are staggering. In the OR, we wear cloth gowns, use a lot of 0-vicryl, hand-sew all anastomoses, and continually battle for effective electrocautery. On the wards, and even in the ICU, the basics we take for granted are just not there. Lab results come back the next day, maybe. The wards are shared, open air, with rows of closely-placed beds and respective mosquito nets over each patient.

Perhaps equally remarkable are the similarities; the attending surgeons, residents, and staff here are dedicated and caring, they do a great job running overwhelmingly busy services, and they have a outstanding ability to adapt to often less-than-optimal conditions. I’ve been taking call with the residents, and the entire department has made me feel very welcome; they have taught me a great deal already. The operating room – I mean theatre – runs basically the same as it does at home. And of course, even in a place where everything else is so foreign, the inside of the abdomen is reliably familiar – an odd comfort!

If you’d like to get in touch with me while I’m here, please use my gmail account, benjaminhoward@gmail.com, as UCSF email is somehow not compatible with my current internet connection.


Benjamin Howard, MD, MPH
UCSF Department of Surgery