To do? Or, not to do? That has been my question.

Rightly or wrongly, today I did.

It would be fair to say that today has been a day of two halves. The ‘quick’ trip to Tanga early this morning to ‘just’ get our visas stamped, turned into a very unsettling process. Many things were explained to us, which in short were quite alarming. Essentially, it seems that we were issued with the wrong type of visa when we arrived at the airport (in good faith by both the immigration team and by us). Certainly, at the airport we reviewed in detail the large stack of documents we had brought to support and explain our visit. However, the bottom line is that the type of visa we have is not easy to extend. We have been granted a month to get matters in hand, but it is going to take quite a lot more effort on the part of many people to enable us to stay. I am very tired by this process and so will leave further details at that. It will either get sorted or it won’t. Everyone seems to want to help us to stay, acknowledging the work we are doing, but you have to have the right papers and THAT is the challenge. 

Improvised tourniquet.

It worked very well!

This afternoon however, represented the culmination of much thought and consideration. You may recall the young boy whose predicament I described in my blog post ‘Dilemmas’ (11^th December) with the large tumour on his foot. I had used whatsapp to ‘phone a few friends’ (well message actually) for advice about what to do and had a mixed response. Some encouraging, some very cautioning (the most frightening being that if it was a vascular malformation he could bleed to death). I was left with much still to consider. The local team remained very encouraging (I don’t want to call it pressure) but I was still unsure. There were some important unknowns remaining and I have used the time since December to try and fill the gaps as much as possible. For example, ‘Blue Peter skills’ have once again come into play, with a creative but effective (and reliable) solution for a tourniquet (to make surgery easier and minimise the risk of death by exsanguination).

However, the final catalyst in my decision making was seeing another patient with an advanced, obviously malignant tumour that I am sure could have been excised long before it had become cancerous. The reality hit me that if I did not operate, it is most likely that no-one would. On my departure, this young boy would be left with a disabling growth that would almost invariably develop into cancer in the future (although possibly malignant already, more likely not to be). So my decision was made and today was the day.

Now as surgeons, when presented with the prospect of a difficult case, we usually try to make our other activities leading up to the time of surgery as easy as possible. So, it was an ideal morning’s preparation then, I can hear you thinking. Hmmmm.

However, perhaps because of the ‘laws’ of ying and yang, pleasure and pain, his surgery couldn’t have gone any better. The tourniquet worked brilliantly (the cuff holding its pressure for the 25 minutes it was up without any mischief) and the tumour shelled out beautifully. This means that once the dissection was started, the planes between the tumour and the ‘normal’ tissue were very well defined. An excellent prognostic indicator (much less likely to be something nasty) and made the surgery a real pleasure. It was actually very straight forward in the end. Deflation of the cuff revealed a healthy skin flap (the danger is that you can devascularise such tissue during the dissection). Then, my only remaining challenge was how to cobble it all back together giving him the best possible reconstruction and wound (the sole of the foot is a functionally a very important structure and wounds on the surface are far from ideal). The problem I faced was a large excess of skin – imagine a deflated football when all I wanted was the semicircle itself and not the wrinkly dome. I toyed with many ideas, including trying to work out some complex flap that would keep all the wound off the sole, but in the end, decided that a small wound off the pressure area would give the best possible outcome. I hope I am right.

Dressed with extra padding for

protection / fill the redundant space

Technically, I am delighted and really hope that it will heal well. The chances of keeping a 6 year old off the wound is difficult at the best of times. Here there are no such things as crutches! It is all wrapped up and I am hopeful it will heal. We will resist the urge to look at it for at least 5 days (and as I will be away, these instructions will hopefully be followed). Fingers and toes crossed again please.

(Once again I have many fantastic 'gory' photos which I will resist posting. All clinical photographs that I do post are with the explicit consent of the patients / families for such purpose).

We've still got some learning to do with histology!

At least we have formalin.