Thursday, August 15, 2013

Lap Choley

Should a laparoscopic cholecystectomy be attempted in eastern Congo?  That is a question that I am still asking myself.  It can be done.  We did one yesterday, but it nearly killed me.  There are a lot of machines to coordinate.  The patient has to be under general anesthesia, a challenge in itself.  There are video monitors on either side of the table.  You need an insufflator, a light source, a camera module, suction, cautery, trocars, specialized instruments, a gas source, clip appliers, endo-loops, etc.    In short, there are lots of moving parts, and whatever can go wrong, will go wrong.  I couldn't find the special cautery cord and I had to make one with a wire.  Burned/shocked myself in the process.  Most of the equipment runs off of 110V and our transformer can't quite handle the load.  What usually happens is that the ladies in the sterilization room turn on the washing machine and then the whole system shuts off.  It is unsettling to have instruments inside the patient and have no idea where they might be.  In the US we use carbon dioxide to blow the abdomen up with air.  No CO2 available around here, so I use a medical air compressor, which seems to work...except when it doesn't.  

I am the only one around who actually knows how to manipulate laparoscopic instruments, and I'm not all that good at it.  It's kind of like operating with chopsticks and doing it in a mirror, as all the directions are reversed.  I selected the person who I thought would make the best assistant.  It didn't work out so well.  I asked him to grab the top of the gallbladder.  He could see it, know what he wanted to do, but simply could not make it happen.  Every time I needed him to do something, I had to reach across the table, put the instruments where I needed them, and then return to my instruments.  I also had to hold the camera, as no one else could manage to show me what I needed to see.  

Anyway, we struggled and sweated through it, and finally managed to get the gallbladder out.  We lost power a couple of times.  I poked a hole in the gallbladder and spilled some bile.  Not such a big deal.  The clip applier did not function well and I had to get a tie around the cystic duct.  I finished the case with a splitting headache.  It left me wondering if it was worth all the effort.  On one level it was.  The patient left the hospital the following day.  I know we'll get better at it.  I'll teach someone to assist me.  We'll work through the technical challenges.  This is not a new operation, and I believe with all my heart that I should do the very best I can for the people I treat.  The young doctors working here deserve to learn about laparoscopic surgery.  In the meantime, however, it is so, so, so hard!

Most of what we do is really, really hard.  It demands a lot from me and I leave the hospital feeling spent.  We are pushing the envelope here.  Nearly every day I end up doing something and wondering if I should.  I am also finding that it becomes a vicious circle.  The more you do, the more you have to do.  Yesterday we did a laparoscopic cholecystectomy, and today another one showed up to be scheduled.  We have started doing more ortho cases.  The more we do, the more patients are referred to us.  We have started doing procedures such as cystoscopy and endoscopic banding of esophageal varices here.  No one else around here is doing this stuff, so we get more and more referrals.  The more you do, the more you do.  Eventually you arrive at a balance, I suppose.  We have yet to do so.  At some point I will need help.  Maybe even (dare I say it?) another surgeon!  I'm doing what I can to train the folks here, but it is a process and they simply aren't there yet.  Last I checked there wasn't a backlog of trained surgeons wanting to go to Congo...  Who knows.  God might have someone in mind.  It would be wonderful to share the burden.  

In the meantime, we do what we can.

Warren Cooper

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