84. OP #9: Riobamba II

Day 6

Carmita, a 39 year old primigravid, presented with 2 months of progressive left abdominal pain. An exam confirmed the ultrasound diagnosis of a 7cm simple cyst. No worry about cancer here, but a cyst that size can twist and pull and be the source of significant pain. At home, a laparoscopic approach would have meant a faster recovery (because of a smaller incision), but she did well and the operative findings confirmed a benign cyst. The tube was wrapped around the cyst and had to be carefully dissected away from the cyst, which was removed intact after about 180mL (about 3/4 a cup) of clear fluid had been aspirated. A damaged tube can increase risk of an ectopic pregnancy (a pregnancy fatally stuck in the fallopian tube), but though removing the tube (to eliminate this risk), it also decreases chances of conception. The ovary without a fallopian tube would still takes turns ovulating, but the egg would have to travel to the other fallopian tube. Possible, but unlikely.

The other post-op patients have done well, more pain than expected, partly because it is hard for a surgically naive patient to anticipate the extent of postop pain, and partly because the patients receive significantly less narcotics than they would in the EE.UU.

23 outpatients seen, two surgical candidates, but today was the last day of surgery, so they couldn't be scheduled. The others were mostly a mix of chronic pelvic pain and patients seeking reassurance about treatment programs from local doc's.

At night a closing party; using a non-commissioned officers club with a military band. Too loud and food that looked liked it was catered by Safeway, so I left early, caught a cab home, and packed. My roomate for the week didn't go at all: "I'm 11 years AA and plan to keep it that way."

83. OP#9: Riobamba II

Day 5

Peak day: three major cases.

Two vaginal hysterectomies for complete uterine prolapse (the uterus literally descending beyond the vaginal introitus).  Marie, in her 80´s, has high blood pressure (non-compliant with recommeznded meds) but otherwise a good surgical candidate.  A combination of age, life-long straining (heavy lifting, multiple and difficult deliveries), malnutrition, and perhaps genetic factors combine to cause the prolapse. Marie Dina (on the left with her husband and my ever faithful translator Sarah) is only 51 but with 8 vaginal deliveries...

In her early menopause, Judith received "injeciones," presumably estrogen, not uncommon anywhere in the world at that time.  She does not remember taking progesterone which protects the uterus from uterine cancer, a standard approach in the past 30+ years.  At sixty she experienced an episode of bleeding but was told not to worry about it. Now 62 she presented with persistent bleeding and in our clinic a markedly abnormal ultrasound. Surgical findings showed multiple fibroids (the white mass at top and the egg-shaped mass that was removed early in the case to make it easier o access critical ligaments) and malignant tissue extruding through the uterine wall, making her a candidate for chemotherapy without need for staging.  I did not do a omentectomy (removal of a layer of intraabdominal adipose tissue) which is usually performed since the omentum frequently is an early locus of metastasis.  But her omentum was normal by palpation and wanting to keep the operation as simple as possible, I left the omentum in place.  A difficult decision.

My translator Sarah noted her carrying a set of car keys with an electronic opener, so it is reasonable to assume that she can afford chemotherapy.... (more to follow)