Beware…

This is a medical post. The above is an elaborate scheme for a designed new hospital to replace the one built initially as a mission hospital by the Norwegian Lutherans. The design had  many basic faults.  Hopefully they listened and incorporated some changes. It should be opening soon and I trust it will work well. You may note the expected completion date (in our calendar 2017) it was hardly started by then!

You may not want to read beyond the ‘more’ line as there are some very interesting but a bit gory photographs. You can see worse on TV.

I almost  always lived and worked in the southern part of the country, between  250 and 500 km from the capital. I had taught briefly in the capital, but that was where the vast majority of the nationals sought to be, so I usually worked down country.

Interestingly I had a postgraduate surgical trainee come down from the capital, as a patient,  where he was working in a major teaching hospital for surgery on himself. He brought his own anaesthetist with him. The anaesthetist went to church and prayed while I operated on his colon cancer and my guy gave the anaesthetic. Follow up on Mesfin of the ‘3 Teenagers’

Another man come from the capital of a neighbouring country. He had drunk lye and had a very narrowed scarred oesophagus. He had an oesophagectomy performed and his oesophagus replaced with a piece of colon. We didn’t have a physiotherapist, so essential in the postoperative care of such patients, and I gave a crash course to the servant (slave) he had brought with him. The patient and the servant did well and the patient wrote to me yearly for several years.

But the case I wish to write about today is a man whom I met on arrival as a new professor at a down country University Hospital. He was a poor man with a huge scrotum. When he stood up his scrotum nearly touched the ground. When weighed, after excision, it was 30 kg. There were 2 trained surgeons there but they weren’t prepared to operate on him, even though they were quite senior.

• It looked gross.
• He was hardly able to walk.
• His penis was buried inside the mass, so that when he urinated it was a mess.
• Although married sex was not possible.

The cause was tuberculosis of his groin lymph glands and if you look at the photo later, you will see that his left leg had begun to swell as well.

The condition is called lymphedema and occurs because the lymph cannot drain back through the diseased nodes which are blocked by the disease. In his case they were affected by TB. Lymph is part of the blood carried out by the arteries which is filtered through the tissues and returned through the lymph channels  higher up back into the veins. It has no blood cells in it but is a second return system running parallel in function to the veins. The volume drained as lymph is much less than is returned through the veins. In other words the volume carried out by the arteries equals the volume returned by the veins and the lymph.

Of interest are the following….

• The shaft of the penis is not involved in the swollen diseased state, although its skin is.
• If the patient hasn’t been circumcised the skin on the inside of the foreskin is not affected in the disease and can be used to help cover the penile shaft when closing the defect after excision. This man had been circumcised.
• The testicles also are not involved in the disease but the spermatic cord is often very elongated, as the weight of the scrotum pulls the testes down.

So the aim of the surgery is to dissect out the penis and testicles without damaging them; excise the abnormal tissue; cover the defect – creating a new scrotum and covering the penis with skin, often using skin grafts.

Photo 1 shows the patient lying on the operating table prepared for surgery. As he had to be prep’d from the umbilicus down to his feet on the front and back, it was done with him awake and standing up. You will perhaps note the left leg has begun to swell.

Photo 2 shows the penis dissected out before the mass is excised.

Photo 3 shows the dissection complete and awaiting repair.

Photo 4 shows the excised scrotum, which weighed 30 kg.

Several days after surgery I asked him if he had had an erection. With the broadest of smiles – the frustrated young husband said “yes”.

Looking through my photos preparing for this I noted that my first assistant was a postgrad student, who is now working with the Red Cross in South Sudan. He’s a very good young surgeon. After his grandfather died he appointed me as his new g’father replacement.

The photos are below the line.

Dominic Cartier