Thursday September 15

.  This was our final full day of operating, and as usual, several interesting surprises. First we brought back the 12 year old boy we had circumcised earlier. He needed to be cleaned up, but that could best be done under sedation. Then we went over to the Maternity Hospital to operate on a woman we saw yesterday who had a vaginal delivery about 2 weeks ago but was not recovering as expected, and she had in fact necrosed the skin of her belly button. I have never seen that before. We thought this might be a small operation to fix an umbilical hernia, but it turned into a full laparotomy and washout. As often happens here, decisions must be made on less than complete information.she had a lot of necrotic debris in her abdominal cavity, but no frank purulence. Her small bowel was matted under a thin  omentum, and there was a dense adhesion of something to the dome of her uterus. I was concerned that if we tried to free everything up, we would likely cause damage. So after discussing it with Dr. Louise Kpoto, a senior Ob-Gyn resident, we decided that since we saw nothing green or brown which might be indicative of a bowel perforation, we should leave well enough alone. Our hypothesis is that she ruptured her uterus during labor ( she had had a previous C-section), and it was now sealed off, but that would account for all of the debris and inflammation. After finishing there, we stopped by to see Leela, the now 11 day old with jejunal atresia that Deidre and Jonathan operated on; she is doing well and will start feeds today.
      We went back to JFK Hospital and did a debridement, a hernia, and an arm mass/tumor, and we saw some potential operative candidates. One was a woman with a locally advanced breast cancer who would benefit from a toilet mastectomy. We made arrangements to admit her today for surgery tomorrow, but later on in the day she back out because she was scared. That is a major problem here, and I wish I knew how to solve it. I also saw a lady with a goiter who will come back in March, and a 5 day old infant with what is reported as a congenital rectovesical fistula. I told the mother that it was too soon to operate, and she should bring the child back in March also.
      Then Dr Utam brought up a mother with her 2 week old baby who has a large cyst below his right eye which is forcing the eye closed and pushing his nose to the left. It is soft and non- tender, and it transilluminates, but I have no idea what it is. We sent text messages containing pictures of it to
Connecticut, Arkansas, Liberia, and Ghana asking if anyone could help us figure out what it is. Several voiced the desire for advanced imaging studies( x-rays) but this is Liberia. Eventually we decided that we could aspirate it to see the quality of the fluid; we emptied it of 15cc of clean fluid. We will bring the fluid back for examination, and then we will see how fast it reaccumulates.
        After changing we went to the Mamba Point Hotel for a delightful and delicious dinner with Masmina Sirleaf, her brother, and a business associate. They are currently renovating the Sirleaf Clinic in downtown Monrovia, planning to turn it into an outpatient center. I think they have the vision to make it happen. After dinner we went to Angler's, a new nightclub Karaoke bar in the Capitol Hill neighborhood where we met Precillar and some of the OR staff. It was good fun, and a great way to celebrate the last night of this trip.