congenital Medical penile Social Surgical

Just looking at a picture…

Early morning driving from Addis to Arba Minch

I decided today that, as I’m about a month ahead in the daily devotional articles As I read it (plainly understanding the Bible) that I produce, it is time to do a medical article. So I decided to open my photo gallery and just write about a picture. I love kids so I’ll go to the paediatric section and I’ll choose a not very gory picture and see what memories it brings back. Gory is a relative word and so I’ll put the picture at the end, so that unless you choose to see it and press the ‘more’ line you can just consider what I write. And I guess that I am using this example to show you the number of issues that lie behind almost all patients whom you see as a practicing surgeon.

In the Ethiopian Orthodox church circumcision is practiced according to the law as laid down in the Old Testament for the Jews. They go further in that they do it for both boys and girls. Usually it is performed by a neighbour who may have experience but is not qualified. The Muslim population do it in on much older boys and in some of the animistic areas they even delay until they are of marriageable age.

I refused to be involved in female circumcision as a prime agent but sometimes was drawn in later on. I remember a family bringing their twins a boy and a girl. They were maybe 4 0r 5 years old. I made a booking to operate on the son but after explaining why I thought girls should not be operated upon, I refused to do the daughter. The boy’s procedure went well. That evening I was called back to the hospital urgently. A neighbour had ‘operated’ on the daughter. She was brought in shock and still bleeding. Question – should I have been involved primarily? She survived and I hope that the community learnt a lesson. Note please almost all girls are circumcised and this sort of complication is rare.

Most have learned not to perform the procedure if there is some anatomical abnormality, which occurs with a 1/1500 live births. The prepuce is frequently used in repair of an abnormal situation. Fortunately the young teenager I am about to describe had not been circumcised. This boy had 2 problems a) he had hypospadias and was urinating from a hole about half way along the shaft of his penis, and b) he had a moderate chordee – that means that when erect his penis was curved, in his case downwards and through about 45 degrees. As a little boy this created few if any problems but when he urinated standing up he had to be careful not to urinate onto his own legs or clothes. Obviously it later would cause problems with intercourse. So he needed surgery, which in a well doctored country would be done by a paediatric urologist. At the time there was such a specialist in the capital. As about 90% of people are rural and in the capital there are about 8 million people at any rate, it is not possible to refer every case! When I operated on my first such case I had never even seen a case like this operated upon. Most people consider that area of their body ‘private’, but are still very conscious of it!

Surgical trauma Uncategorized

Diaphragm Injuries

Over the years I have seen a number of diaphragm injuries. Four come to mind as very interestingly different.

  1. While I was doing a lot of chest surgery, I received an urgent call to come to the OR, where a an obstetrician friend was doing a Caesarian Section. The patient had been in a car accident a couple of years before, and had gone through pregnancy well until when on the operating table, having been given a dose of scoline her left chest became dull and the anaesthetist had to struggle to keep her oxygenated. She had a rapid LSCS making it much easier for the anaesthetist. You could hear bowel sounds in the chest, so with her accident story, we diagnosed delayed rupture of the diaphragm, probably by the rupture of her incomplete tear with the twitches caused by the scoline. She was repositioned and her diaphragm repaired. She and her baby did well.
  2. A man had been caught between a backing utility and a bench several years before. He was referred to me with a large AAA and a ruptured diaphragm. At the time he had been investigated and no problems found. After work up, and postulating that his prior accident had probably damaged his aortic wall allowing his aneurysm to develop, and that its size had caused an incompletely ruptured diaphragm to completely tear, he was operated on. We repaired both problems at the same time. Obviously this time the diaphragm was repaired from below.
  3. A grossly obese woman unwisely sat on a glass table. She had a stab wound in her right back,  and was operated on by a general surgeon who at laparotomy found a little blood but no other problem and closed the abdomen. She survived but was not well. They did a chest X-ray and found a mass in her right lower chest. I was asked to see her and after investigation explored her right chest finding a complete cut across her diaphragm with the liver totally in the chest. With it repaired she made a rapid recovery.
  4. The fourth case was seen when one day I made one of my weekly trips to Nazret Hospital when living in Addis Ababa. There was a man who had been stabbed in the back of his right chest. There was an UWSD in place to treat the pneumothorax. He had no abdominal signs or symptoms. But no one had noticed that there was bile coming out the drain! I explored his chest and found about a 5cm laceration in his diaphragm and a considerable laceration into the bare area on the top of his liver. I repaired both liver and diaphragm through the chest. He did well.

Being a surgeon is interesting!

Barry Hicks