Twice

I somehow feel like I'm missing something but I don't know what. The old man's belly sure gave me reason to think I needed to operate. He had a hernia and talked about it coming out and hurting a lot before he finally stuffed it back in. I thought maybe he had some necrotic bowel or something. His belly was certainly swollen and tender and he'd had no stool for 6 days and no gas for one day.

But now I've opened up a small hole in his abdomen big enough to both get a good look and fit my hand inside to explore with tactile sensation. There's no fluid, no pus, no stool no blood. All the intestines look pink, healthy and clean. The appendix is normal. I run the small bowel which is slightly distended distally but peters off to normal proximally with no twisted areas, no masses, no holes, nothing. The large bowel is quite distended but soft with no lesions or masses that I can see or feel. Maybe it's just constipation after all. It won't be the first time I've operated on severe constipation. But something just doesn't feel right. Against my nagging feelings I close up and then proceed to fix his hernia.

At the end, I clear out his rectum and give him several liters of enema which washes out some hard stool but not much. I hope that will stimulate things. He had a fever so maybe it's just an ileus from malaria.

Everyday for three days I keep hoping I'm right, but he still has no stool or gas and vomits frequently. I can't get the idea out of my head that I've missed an obstructing colon cancer. I hadn't thought of it at the time, until afterwards. I'm wishy washy and don't want to take an old man back to surgery so soon. He looks so frail. I go home. Maybe tomorrow he'll have regained bowel function. My hopes don't comfort me much.

At midnight, Faka, one of the nurses is at the door.



"His belly is really tense, he's vomiting," he says. "I think you should come see him."

"No, just call the OR team," I reply. "We have to take him back to surgery.

I reopen the lower abdominal wound and swollen small bowel spills out. I enlarge the midline incision all the way up to his chest and really explore as Samedi holds the eviscerated bowel covered with lap sponges to keep it from falling off. Abel retracts the lower abdominal muscles away so can get a good look. Still nothing is obvious, but this time I'm a little more thorough and since I'm looking for cancer now, I find it. His sigmoid colon has a small hard mass right in the center of it that is obstructing the flow of stool and gas.

I clamp off the bowel, clamp and tie off the blood vessels and remove the mass. I painstakingly sew the two sections of colon together with two layers of sutures and release the bowel clamps. No leakage. I realize I'll have a hard time closing the abdomen with the swollen small intestine and it would speed recovery of function if I emptied them. It seems like a good idea at the time.

I tie a purse string around where I want to make the hole and get the suction catheter ready. I incise the bowel wall but the suction gets plugged up with a hard chunk and stool starts to spill out everywhere contaminating everything. I quickly try to block the flow with my fingers and get Samedi to hold it while I clear off the suction. It keeps getting blocked so I call for a basin. We don't have any sterile ones, but then we are no longer in a sterile field anyway. I grab the basin and just let the stool pour into it instead of the abdomen. Samedi and I milk the still down from both sides of the hole until the intestines are relatively empty and we have a couple of liters of stool in the basin. I hand it off, wash off my gloves in bleach water and then suture up the hole in the intestine with the previously placed purse string followed by another layer over it. We copiously irrigate the intestines and the entire abdomen with sterile saline until everything looks really clean and we've diluted the pollution.

I insert two drains in the deepest portions of the abdomen to drain off any excess contamination and close up. We then dilate his anus and evacuate much more green liquid badness into the plastic basin until his belly is actually flat and matches the rest of his lean body. I place him on antibiotics and IV fluids and with a final prayer go home 4 hours later.

Arriving home, the adrenaline starts to wear off and I notice my ankle is swollen, red and hot around the rope burn I got 3 days ago. I take some antibiotics myself, soak and elevate it but can't go in to work the next day. Today I hobble out a little and go to see my old man. He's lying in bed asleep. He looks kind of bad but when I shake him awake, his eyes alertly open and he shakes my hand in a firm grip.



"Can I have some tea?" He asks.

His family laughs and says that since yesterday that's all he's wanted. He's a big tea drinker at home, apparently.

"Ok, you can have tea," I reply through the interpretation of the nurse from French into Ngambai. "But only if you sit up."

Despite no pain meds except Tylenol and Ibuprofen on a huge abdominal incision, he lifts himself up with only a little help and looks at me defiantly as I ask the family to bring him porridge and tea.

I examine the wound which is clean. The drains have only clear fluid in them and he has had regular bowel movements 3 times since surgery. As the family hands him the porridge he slurps it up hungrily before spitting out the chunks of rice he doesn't like.




I think he's going to be ok.