Austere Surgery and Anesthesia





Surgery


A significant number of Western physicians and other medical associates develop professional relationships with organizations involved with overseas medical care. The nature and extent of involvement ranges from brief educational or charitable exposures to longer periods of actual practice. This chapter seeks to start a brief preparation for both medical professionals and nonclinical medical planners with respect to the particular surgical management of issues often encountered in austere medical environments. Additionally, we want to highlight some common surgical conditions and pathologies while providing advice on how to triage, evaluate, temporize, stabilize, resuscitate, and refer patients.


From our perspective, austere surgery denotes surgical care in an environment that is infrastructure-, resource-, and/or technology-challenged. Whether or not one is a surgeon, nearly all healthcare professionals will be uncomfortable when faced with the issues encountered in rural or even urban areas in low-income countries (LICs) or low-middle income countries (LMICs). Those designations refer to a World Bank classification of countries with respect to per capita national income, per annum adjusted for purchasing power. The value for the United States in 2018 was about $63,000 and an LIC (many of which are in Africa) has a value of about $2400. Combining LICs and LMICs, that is, less than $10,600, generates a list of about 137 countries accounting for a large portion of the world’s population. Per capita governmental health expenditure of less than $24 per citizen exists in many areas of the world, including in sub-Saharan Africa. The number of operative procedures annually also reflects the drastic differences in access, availability, and affordability between populations: Africa less than 200, United Kingdom 13,600, and United States 21,000 per 100,000 population, respectively. With socioeconomics and infrastructure being so critically important, “the pathology of poverty” derives from economic, political, social, and medical etiologies, with the medical being a function of the other three.


Other than the trained medical workforce crisis per se, there are at least six major “surgical” challenges: (1) safe anesthesia and airway management; (2) trauma: particularly long bone, head and spine, and thermal (burns); (3) women’s health issues: peripartum hemorrhage, obstructed labor; (4) cancer; (5) pediatric surgery; and (6) analgesia—perioperative and palliative ( Box 12.1 ). These six challenges are the focus of joint initiatives by the World Health Organization (WHO), the Lancet Commission on Global Surgery (LCoGS), the G4 Alliance (G4: surgery, trauma, anesthesia, obstetrics-gynecology), the Alliance for Surgical and Anesthesia Presence (ASAP), and similar organizations internationally. The growth of global cell-based and web-based capabilities facilitates access to up-to-date surgical atlases, texts, and information resources. Primary Surgery Non-Trauma and Trauma and Primary Anesthesia by M. King et al. (Oxford Press) and the revised Primary Surgery by Cotton were/are key references for physicians and surgeons providing surgical care in austere environments from the 1980s forward. In 2015, the Global Surgery and Anesthesia Handbook edited by John Meara et al. became available both in a portable paperback and an e-book edition that updates Primary Surgery . Links to free valuable resources, such as the International Committee of the Red Cross’s (ICRC) War Surgery, Volumes 1 and 2, , the Principles of Reconstructive Surgery in Africa, revised edition edited by Louis Carter Jr. and Peter Nthumba, and Paediatric Surgery: A Comprehensive Text for Africa, Volume 1 , address the spectrum of surgical challenges. The number of such resources continues to increase and helps provide needed instructions at the point of contact and in real time for those providing surgical management. Before traveling to an austere locale, one ought to load key texts and atlases onto a laptop or other device and/or carry one or more well-chosen texts, which can then be left behind for the hosts.



Box 12.1

Six Major Surgical Challenges




  • 1.

    Safe anesthesia and airway management


  • 2.

    Trauma: long bone; head and spine; thermal (burns)


  • 3.

    Women’s health issues: peripartum hemorrhage; obstructed labor


  • 4.

    Cancer


  • 5.

    Pediatric surgery


  • 6.

    Analgesia: perioperative and palliative




Prerequisites not always available but required to provide ongoing surgical care if one hopes to go beyond first aid include: water (potable is better); electricity (often inconsistent); a sterilizing capability (even if “homemade”); basic operating room (OR) equipment and supplies (sutures, instruments, lighting, head light, a suction capability); a pharmacy with intravenous (IV) fluids; basic imaging (usually limited to plain films); ultrasonography; and some level of laboratory capability (hopefully to include blood-typing, even if just an Eldon card). Any histopathology capability will likely experience a turnaround time in weeks or even months.


Evaluation of foreign medical facilities and dialogues/interactions with local/host medical providers are almost always more productive if conducted with consideration, circumspection, and respect. If you are visiting an overseas facility, you are likely the guest of someone affiliated with it. Preserving that relationship is critical to long-term success. Hosts are likely sensitive to the fact that their facility/practice is not equivalent to those in more affluent countries. The informed observer must look closely but quietly. Your hosts will likely appreciate any assistance provided but may be sensitive to criticism.


This chapter focuses on several common and a few less common conditions one may be called upon to manage that will likely be outside the usual practice for surgeons based in North America, Western Europe, and the Pacific high-income countries (HICs). By necessity, most comments must be terse.


Pearls, Pitfalls, and Aphorisms





  • Anesthesia: Safe anesthesia is the first requisite, with mandatory use of pulse oximeters.



  • Typhoid perforations lead to secondary, bacterial, suppurative peritonitis in a patient immunologically and nutritionally compromised.



  • Tetanus: Never presume a patient is immunized. No wounds are trivial.



  • Trauma, burns, bites, and stings: Blunt and penetrating trauma, particularly from vehicular crashes, falls, farming, and industrial accidents, consume time, resources, and beds. Fracture and wound care are everyday procedures. Open fires, gasoline-tainted kerosene, and vehicular wrecks cause burns. Animal, human, and insect bites can lead to serious wounds.



  • Osteomyelitis ensues from either open fractures or from hematogenous spread in patients with and without sickle cell disease.



  • Gastrointestinal (GI) surgery and oncology: Sigmoid volvulus and incarcerated/strangulated hernias lead to colon resections. Common cancers include gastric, prostate, hepatocellular, breast, cervical, and lymphoma. Medical or radiation oncology, radiology, and pathology are rarely available.



  • Critical care: An Ambu bag, a clock, and an OR technician may be the ventilator. Pressors and invasive monitoring, found mostly in teaching hospitals or capital cities, are uncommon. Creativity aids coping.



  • Pediatric surgery, urology, and obstetrics: The surgeon must be a specialist in many areas. Neonatal and pediatric presentations include anorectal atresia, Hirschsprung’s disease (HD), GI atresia, and intussusception. Urologic problems involve urinary retention, urethral strictures, torsion, and hypospadias. Obstetric issues include obstructed labor and ruptured ectopic pregnancies.



  • Parasitic and mycobacterial diseases: Chagas disease, hydatid cysts, Buruli ulcer, schistosomiasis, lymphatic filariasis, and helminthoma vary by geographic locale.



  • Surgical colleagues or referral specialists are likely unavailable, with professional isolation a norm, although the rapidly increasing use of wireless phone and Internet availability have improved this situation. Surgical practice is “the skin and its contents.” Currently, telemedicine options are present and increasing in some countries. Listen to your hosts, whatever their specialty.



  • Festina lente ”—make haste slowly.



  • “If you argue for your limitations; they are yours” (Richard Bach); but likewise, “There is no condition that cannot be made worse with an operation” (Art Brooks).



Trauma


About 5 million die annually from injuries (accounting for 9% of all deaths globally), and deaths from trauma account for almost 1.7 times the total fatalities from malaria, tuberculosis, and human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) combined. Some 90% of injury-related deaths occur in LICs and LMICs. Prehospital emergency provider care is virtually nonexistent for managing trauma in resource-poor areas (RPAs). Emergency rooms are underequipped and understaffed, often without basics such as a suction capability. “Essentials” that surgeons in the developed world take for granted (e.g., timely imaging, a robust transfusion capability, and well-equipped/staffed ORs) are most often lacking.



  • A.

    Blunt/Vehicular Trauma


    An “epidemic of trauma” afflicts much of the LICs and LMICs of the world, especially road traffic crashes. The proliferation of inexpensive, sturdy motorcycles, the use of motorcycle “taxis,” and a lack of traffic control have led to a marked increase in motorcycle crashes over the past decade with consequent head and/or spine injuries and long bone fractures.



    • 1.

      The fundamentals apply: that is, protect/immobilize the cervical spine; address the A, B, Cs of advanced trauma life support (ATLS); and complete the primary and secondary surveys. Mass casualty situations requiring triage are common. Establish and/or maintain the airway; ventilate the patient (even if not intubated); and address hypovolemia and optimize the circulation, usually relying on crystalloid rather than blood or blood products. Head, spine, abdominal, thoracic, and vascular injuries must be considered, ruled out, or addressed, often on the basis of clinical examination only. See the Meara and/or ICRC War Injury volumes.


    • 2.

      Extremity long bone fractures: stabilize, immobilize as you assess for pulses and neurologic status, motor and sensory. Options include traction, splinting, casting, external fixation, or open reduction with internal fixation, among others. Is there an open wound? Blood supply is “everything.” The soft tissue envelope of skin and muscle is key to a successful outcome. What was the mechanism of injury? How much energy was applied to the tissues? Consider the “zone of injury” as with a crush injury. How long ago? “A fracture is a soft tissue injury complicated by a break in a bone” (CR Murray).


    • 3.

      Abdominal trauma: Splenic injuries are frequent, perhaps in part because splenomegaly from malaria and other diseases is more prevalent. Management without computed tomography (CT), transfusion-readiness, or an interventional radiology presence dictates that early recognition and decision-making to proceed to the OR/theater are critical. The principles are similar to the practices stateside once the decision to proceed to laparotomy has been made. Various attempts at “galley pot” autotransfusions have been reported but are not clearly beneficial. A prompt decision to operate before irreversible physiologic exhaustion (the “golden hour” for adults or “platinum half hour” for children), judicious source control, packing, and perhaps “returning to fight again another day” are important. Avoid acidosis, hypothermia, and coagulopathy, known as the “lethal triad.”


    • 4.

      Vascular trauma: Patients with significant aortic or major venous injuries do not survive transport to casualty, triage, or the emergency room, not so different from what pertains in developed countries. Falls with fracture dislocations through the knee with popliteal arterial trauma with or without concomitant venous injury occur, notably if the patient was carrying a heavy load on their head. Vascular injuries associated with long bone fractures, notably about the elbow or the lower extremity, are encountered and present often hours postinjury.


    • 5.

      Head and spine trauma: Both vehicular trauma and falls from heights during occupational pursuits are frequent and most unforgiving. Inspection burr holes without the benefit of a head CT can be performed based on the Glasgow Coma Scale and physical exam, but loss of life and function are the rule. Spinal cord patients can be treated with traction in hopes of some return of function, but outcomes are discouraging.



  • B.

    Penetrating Trauma


    The incidence of penetrating trauma depends a great deal on the country and the political situation at any given time. Penetrating trauma from falls with impalement, encounters with wild animals, and machete, knife, and arrow injuries were formerly the rule. Historically, there were fewer gun-owning citizens with many of the guns used in hunting homemade and of low velocity. Yet in certain areas where extremists are active, sophisticated weapons such as high velocity automatic rifles, and bomb-laden suicide-terrorists, often produce mass casualty scenarios. The presence of improvised explosive devices (IEDs) and commercial land mines is now more common and can add “blast injuries” to the burden of penetrating trauma. The two Red Cross War Surgery texts , are useful guides for managing such patients.


  • C.

    Thermal Trauma (Burns)


    Burns are an underappreciated crisis in much of sub-Saharan Africa, especially pediatric burns. Burns can occur from flame or scalding mechanisms and are associated with cooking, use of kerosene, kerosene adulterated with gasoline explosions, vehicular trauma, and even petrol tanker or pipeline disasters. Burn care entails incredible expenditures of time, effort, and supplies, and needs a physiotherapy/rehabilitation capability (often rudimentary or absent). In environments with open fires, without nonflammable garments for children, and with unsafe petrol storage, burn prevention is an inadequately addressed public health challenge.



Wound Care


The Pan-African Academy of Christian Surgeons (PAACS) e-book by Carter and Nthumba, the Principles of Reconstructive Surgery in Africa , and the Gionnou et al. War Surgery volume 2 have key principles on debridement, wound care, and coverage, in addition to management options.




  • Wounds result from many causes: trauma, burn, postsurgical, decubitus, diabetic, pyomyositis/abscess, infections such as Buruli ulcer, vascular, and hemoglobinopathies, etc.



  • Debridement refers to the resection of nonviable tissues back to bleeding, viable tissue and is one hallmark of the care for wounds and ulcers, where an ulcer is defined as “the loss of epithelial continuity.” A thorough history and physical are mandatory. Questions to ask: What was the mechanism of injury? What type of wound? Clean and fresh versus dirty and old (>6 hours)? How did it happen? Is this a bite wound? How long ago did it happen? Does the patient have other medical issues? Ask about tetanus immunization status; “think” tetanus and suspect tetanus-prone wounds.



  • Examine: hemorrhage, viability, foreign bodies, x-rays, motor/sensory function, proximity to vessels, nerves, ducts? Tetanus status? Consider antirabies treatment if an animal is involved.



  • General principles: Most bleeding can be controlled by direct pressure. A tourniquet or blood pressure cuff can help to control bleeding, but be aware—and beware—of how long either has been in place. Consider pressure at adjacent pulse points: femoral artery at the groin, popliteal artery at the knee, or brachial artery in arm or elbow. “Blind” clamping into a wound is never a good idea!! The damage caused is often worse than the initial injury.



  • If local anesthesia is to be used, the maximal dose for lidocaine is 4 mg/kg without epinephrine (epi) or 7 mg/kg with epi. Use diazepam or similar agent in addition. Note that a 50-cc vial of 1% lidocaine with epi has 500 mg of lidocaine, a safe amount for a 70 kg person who receives diazepam.



Obstetrics


An estimated 99% of world maternal deaths occur in Africa, Asia, Latin America, and the Caribbean. In LICs and LMICs, pregnancy-related complications are the leading cause of maternal death and disability for women 15 to 49 years of age. The lifetime risk of death in childbirth varies from 1 in 7 in Angola to 1 in 3500 in Europe to 1 in around 30,000 in Sweden. Annually, 45 million women deliver without a skilled birth attendant. A woman dies every 7 minutes from postpartum hemorrhage, the most common cause of maternal death. Infectious and hypertensive (preeclampsia/eclampsia) emergencies make up the remainder of the common causes of maternal mortality, which constitutes the single most disparate public health measure between rich and poor countries.



  • A.

    Peripartum Hemorrhage


    Pre- and postpartum hemorrhage are ubiquitous obstetrical challenges, especially in areas with deficient antenatal care, instant-donor or nonexistent blood banks, and the absence of safe anesthesia, airway management, and knowledgeable personnel.



    • 1.

      Antepartum


      The three major concerns are placenta previa, placental abruption, and uterine rupture. An ultrasound (U/S) helps locate the placenta and gives some guidance on strategy. If the placenta is not covering the cervix, a vaginal delivery can be attempted if both mother and baby are not in distress. If bleeding is heavy, continual, or with clots, or if either the mother or baby are in distress, then proceed straightaway to a cesarean section (C-section). If there is a history of prior C-section plus a low-lying placenta, consider placenta accreta. Abruptio placenta is separation of the placenta before delivery and can be accompanied by hypertension, preeclampsia, eclampsia with a hard, tender uterus and “pain out of proportion” to contractions. Fetal distress and death often occur. The goal is to save the mother which, if the cervix is not dilated, means resuscitation and an emergent C-section, often attended by coagulation disorders. Uterine rupture is seen primarily in women with prior C-sections or in grand multiparas (>5), those who present with long obstructive labors, or those with malpresentations. The bleeding may be intraabdominal rather than vaginal because the baby’s head obstructs the birth canal. A midline laparotomy is indicated whenever a ruptured uterus is suspected, both for any chance to salvage the baby and to save the mother.


    • 2.

      Postpartum


      Uterine atony with prolonged labor or multiparity, genital tract trauma, retained placental tissue, inversion of the uterus, maternal bleeding disorders, and ruptured uterus produce postpartum bleeding.



      • a.

        Atony


        Options include uterotonics (oxytocin, IV/intramuscular [IM]/intramyometrial and cytotec, methergine, carboprost), bimanual fundal “massage,” removing all products of conception (swiping the uterine cavity with a lap sponge over one’s hand), and uterine artery ligations ± ligation of the ovarian arteries, compressing sutures (B-Lynch suture), and ligation of the hypogastric (internal iliac) arteries. The last resort is hysterectomy.


      • b.

        Genital tract trauma


        Lacerations to the cervix or lateral vaginal walls can occur with cephalopelvic disproportion (CPD)/larger infants, rapid labor, obstructed labor, or instrumented labor. Thorough vaginal examination with good lighting and the patient in the lithotomy position can abet detection of such lacerations. For retained products of conception, evacuate the uterus using a lap sponge over one’s hand. Examine the maternal surface of every placenta to look for missing cotyledons. If uterine inversion is noted, use a closed fist to try and replace the uterus back into the pelvis; once replaced, perform immediate massage, and use oxytocin or other uterotonics. Note: reinversion can occur. If unsuccessful, proceed to laparotomy and “pull” the uterus back up and into the pelvis by pulling on the round ligaments from inside the abdomen. For maternal bleeding disorders, keep the patient warm and use blood products if available. When a ruptured uterus is diagnosed, try to repair it via laparotomy. Failing a successful repair, proceed to hysterectomy. Timely decision making to proceed to hysterectomy is key once you know such is required. The morbidity and mortality of the procedure climb with time and blood loss.




  • B.

    Cesarean Sections


    C-sections are indicated for cephalopelvic disproportion, abnormal fetal presentations, placenta previa, fetal distress with a nondilated cervix, failure to progress (dystocia), abruption of the placenta, a prolapsed cord, etc. (See chapter 22, especially pages 237–238, by Groen and Kushner in Meara et al. ). Young age at conception and undernutrition with a small pelvis are a recipe for trouble, especially when coupled with late presentation, a bias against C-section, and the attendant fears of financial burden. This “perfect storm” combines to yield high fetal loss and obstetric fistula (vesicovaginal fistula [VVF] or vesicorectal fistula) in many RPAs. Timely C-section is the preferred treatment for obstructed labor. In most centers, equipment and expertise for vacuum-assisted deliveries are not available. Symphysiotomy in obstructed labor entails dividing the symphysis pubis sharply to open up the pelvic ring and has a role in the second stage of labor if C-section is not available but with concerns about urethral injury and subsequent gait issues. Stateside symphysiotomy is generally reserved for a shoulder dystocia with the head already out. For the C-section, key areas to address follow.



    • 1.

      Preparation


      Required are good anesthesia, illumination (a headlight helps), suction capability, a circulator, suture and equipment, and someone to focus on and resuscitate the baby once delivered, whether a nurse, midwife, colleague, or informed theater technician.


    • 2.

      Positioning


      Place the mother in slight left lateral decubitus tilt to thwart inferior vena caval compression. Place a urinary catheter (Foley). Prep widely and include the perineum and the vagina.


    • 3.

      Anesthesia


      Most agents cross the placenta and suppress the baby’s subsequent breathing, etc. C-sections can be performed under general, spinal, or local anesthesia. The goals are a healthy mother and a healthy baby.


    • 4.

      Abdominal incision


      For the nonobstetrician and in the emergent/urgent situation, use a lower midline incision, taking care not to enter the coelomic cavity. The uterus is extraperitoneal, below the peritoneal reflection. Try to avoid peritoneal cavity entry; but it is not a deal-breaker, more a style point. Incise the vesicouterine peritoneum and “push” the bladder down. Seek to avoid bladder entry. If you injure the bladder, repair it in two layers with absorbable sutures and keep the Foley in for a week or fortnight.


    • 5.

      Uterine incision


      A horizontal lower uterine segment access is preferred over the “classical” vertical incision, given its lower uterine rupture potential with a subsequent pregnancy. Carefully enter the uterus via a 3 cm or so transverse incision above the bladder reflection, with care not to “stab” and injure the baby. Use digital retraction cephalad and caudally to enlarge the incision; use bandage scissors to extend the incision when needed. Take care: the myometrium may be only a few mm thick, that is, quite thin at this point.


    • 6.

      Delivery


      Engage the presenting part with the palm of your hand, flex the neck of the fetus if possible, and cautiously deliver the baby. If the head is wedged in the pelvis, an assistant with gloved hands can push the fetus’s head cephalad to abet delivery.


    • 7.

      Postdelivery


      Place the baby, stably and securely, on the abdominal wall and clamp the cord. Note: the baby will be quite slippery. Once the cord has been divided, give the baby to the waiting assistant, and only then administer to the mother pharmacologic agents such as muscle relaxants, benzodiazepines, antibiotics, and, especially, oxytocin (5 units IV). Place atraumatic triangular, Babcock, or ring clamps on the lateral edges of the uterine incision to decrease blood loss.


    • 8.

      Placental delivery


      Use slow, steady controlled cord traction to deliver the placenta followed by a sponge-stick or gauze removal of any remaining membranes.


    • 9.

      Closure of the uterus


      Any heavy bleeding will usually abate with uterine closure if one takes care. Close with a careful running closure with 0 absorbable suture (catgut or polyglycolic) in one or two layers.


    • 10.

      Abdominal wall closure


      Use your preferred suture and technique. Absorbable polydioxanone suture (PDS) or nonabsorbable monofilament nylon all work if performed properly. Skin closure is your preference.




Abdomen and Abdominal Wall




  • A.

    Groin Hernias


    Inguinal and femoral hernia, often incarcerated or strangulated. Hernias of the groin in children may present from birth, the first year of life, or childhood and represent a patent processus vaginalis. Hernias in infants are often bilateral and should be addressed with a high ligation of the sac.


    Until recently, adults with inguinal or femoral hernias were treated via an open technique employing autogenous tissues utilizing a Bassini, McVay (Cooper’s ligament), Shouldice, nylon darn, or other repair. Over the past 25 years, with the emergence of prosthetic repairs stateside and minimally invasive repairs, many surgeons have less experience with autogenous repairs. Mosquito net mesh with steam sterilization at 121°C × 15 minutes or 134°C to 137°C × 3.0 to 3.5 minutes has been found to be safe and economical with only 2 of more than 4000 patients requiring mesh excision during the past 6 years by Operation Hernia surgeons. If strangulation, perforation, or contamination are encountered, then an autogenous repair is indicated.


  • B.

    The Acute Abdomen


    Acute abdomen does not equal “operative abdomen.” Acute refers to a recent time since onset (a day or two, not weeks or longer) and not the characteristic of the pain, as with sharp versus dull. The “acute abdomen” bespeaks any of a myriad of disorders, excluding trauma, whose chief manifestation is in or abuts the abdomen and for which urgent operation may be necessary. If one visualizes the abdomen as a cylinder, then extraperitoneal processes such as pleurisy, pneumonia, pancreatitis, pelvic inflammatory disease, prostatitis, nephritis, and rectus muscle hematoma, among others, can cause pain and tenderness, which fall under the term “acute abdomen.” Sir Zachery Cope enumerated a score of “medical conditions,” including lues, diabetes, pancreatitis, sickle cell crisis, etc., that can present with an “acute abdomen” picture, for which operation is not indicated. The usual causes of the acute abdomen in Western practice relate to a perforated viscus, inflammation, obstruction, or ischemia. In the austere environment and in many LICs and LMICs, one must consider diseases such as typhoid with perforation, helminthoma, sigmoid volvulus, and more. For the surgeon, the history and physical examination are key because investigations (imaging and labs) are often unavailable or unaffordable. Whereas minimally invasive procedures (laparoscopy) are frequent in Western locales today, open procedures are the norm in underresourced areas. Open operations for perforated gastric and duodenal ulcers, appendicitis, cholecystitis, and diverticulitis of the colon (rare) will be similar to what pertains stateside and are not discussed here. Amoeba-related pathologies can confront the surgeon but are infrequent. Cholecystitis is quite rare in many parts of Africa, not so in other RPAs. Emergent abdominal operations include the aforementioned diagnoses plus perforated ileal ulcers from typhoid, sigmoid volvulus, bowel obstruction, especially from incarcerated or strangulated hernia, and rarer helminthic causes.



    • 1.

      Perforated typhoid


      The four classic pathological stages of intestinal typhoid, almost always ileal, are hyperplasia of lymphoid follicles, necrosis of mucosa, ulceration ± bleeding, and perforation. Perforated typhoid constitutes a threefold problem: generalized septicemia, generalized peritonitis, and dehydration and electrolyte imbalance. The key points of diagnosis and treatment include recognition, resuscitation, repair, and rehabilitation. Operative options include local drainage, simple closure, ileostomy tube via perforation, wedge resection or segmental small bowel resection, closure and ileotransverse colostomy, and ileoright colectomy. A helpful aphorism at the time of the initial operation is to do “as much as necessary, as little as possible” in these compromised, critically ill patients requiring damage control. Close the fascia, but pack the skin and subcutaneous tissues. There is a role for healing by second intention or perhaps delayed primary closure. In these patients, intraabdominal deep space and interloop abscesses are frequent; second-look procedures and reoperation are common. “Preperforations” encountered at the initial operation should be over sewn and reinforced but may break down subsequently.


    • 2.

      Sigmoid volvulus


      Per Denis Burkitt, sigmoid volvulus may be a downside of the “high fiber diet” and is often seen in many parts of Africa, notably the Horn. Although some advocate resection and primary anastomosis, with or without on-table lavage, most would resect the sigmoid, create an end colostomy and a mucus fistula, or close the rectosigmoid as in a Hartmann’s procedure. At times, some small bowel can be caught up in the twist, the so-called “bowel in a knot” or “complex volvulus.” Resect the compromised small bowel and perform a primary enteroenterostomy, and resect the twisted sigmoid as above. Volvulus of the cecum can occur but is infrequent. A right hemicolectomy is preferred to reduction and pexy procedures utilizing sutures or placement of a cecostomy tube.




Oncology


The WHO Cancer Today reported more than 18 million new cases with 9.5 million cancer-related deaths in 2018. More than 60% of the world’s cancer cases occur in Africa, Asia, and Central and South America, and these regions account for about 70% of the cancer deaths. Chemotherapeutic agents are not usually affordable, even if available. Few radiotherapy centers exist. Thus, for solid neoplasms, it is often the surgeon who is the provider of hope for a cure or, failing that, palliation. Patients often present late. Staging is usually based on a physical examination coupled with imaging via plain x-rays and abdominal U/S. In addition to lymphomas, the frequent solid cancers include breast, prostate, cervix uteri, hepatoma, Kaposi’s, and stomach. Again there is much geographical variation: esophageal cancer in Kenya; oral cancer in Yemen (khat) and India (reverse smoking); and lung cancer anywhere tobacco use is prevalent. Childhood challenges include Wilms’ tumor.


Urology




  • A.

    Acute urinary retention ensues from prostatic hypertrophy or cancer and urethral stricture. The history as always is vital. Ask about hesitancy in initiation of micturition, stream strength, interruption, frequency, terminal dribbling, etc. Percuss the bladder. Palpate the penile urethra and the perineum to assess for fibrosis. Watch the patient void and then attempt to pass a well-lubricated red rubber or urethral catheter. Is passage obstructed before the level of the prostate or at the prostate level? If the obstruction is prostatic, a 20 or 22 Fr catheter can more readily be passed than a smaller one. If the obstruction is from a stricture, use a filiform and follower technique to decompress the bladder. At times, neither a stout Foley nor a filiform can be passed, and a percutaneous (trocar-assisted) cystostomy can be performed to relieve the obstruction acutely before proceeding to further workup with either urethroscopy/cystoscopy or a retrograde urethrogram. Falls involving trauma to the perineum can injure or rupture the membranous urethra, and pelvic fractures with shear can disrupt the urethra at the membranous/prostatic urethral junction. Gonococcal urethritis is on the decline but still a cause of urethral stricture.


  • B.

    Cancers of the prostate and bladder predominate, the latter associated with schistosomiasis in some regions. Most patients with cancer of the prostate present with advanced disease and treatment is hormonal or castration.


  • C.

    Congenital conditions. Hypospadias: do not perform circumcision on any male with abnormalities of the urethra/urethral orifice; preserve the valuable foreskin for later reconstruction via various urethroplasties. Undescended testis or testes: orchiopexy by 12 months of age maximizes the chances for spermatogenesis for boys with undescended testes. Posterior urethral valves in boys may not be diagnosed prenatally or shortly after birth. The child may present months later with chronic urinary difficulties with initiation of micturition and a weak stream. Consider a cystostomy to await expertise to permit valve destruction either endoscopically or via a perineal approach.



Osteomyelitis


Osteomyelitis may be either open (direct inoculation) or hematogenous, the latter at times often associated with hemoglobinopathies such as hemoglobin SS or SC. Presentations vary: acute, subacute, or chronic. View acute osteomyelitis as an abscess that requires incision and drainage (I&D), to not only drain the pus and allow speciation of the bacteria, but also to decompress the “hypertension” within the marrow cavity that causes further progression. Once the process has progressed to the chronic phase with involucrum (reactive cancellous bone formation) and sequestration (infarcted bone), the patient likely will have long-term drainage and intermittent flaring of infection until the sequestrum and any loculated pus are totally removed. Pathological fractures are a concern early on before significant involucrum formation occurs.


Common Neonatal/Pediatric Conditions


At least half of the population in RPAs are 15 years old or younger. African children have an estimated 85% cumulative risk of surgical disease by 15 years of age.



  • A.

    Neonates: Up to 28 days



    • 1.

      Abdominal wall defects: omphalocele or gastroschisis. Membranes cover an omphalocele unless they have ruptured, whereas gastroschisis has no membrane. Children with omphalocele often have associated anomalies (cardiac, neurologic). If the membranes are intact, leave them alone, and do not perform any operation. Do not debride them. If left intact, the wound will eventually close by secondary intention. Omphaloceles with ruptured membranes or gastroschisis bowel must be covered somehow via either primary closure of the skin (make sure you have a ventilator available) or coverage with a silo (make one out of a sterilized IV bag).


    • 2.

      Anorectal malformations (ARMs)


      The most common male anomaly is a rectourethral fistula; the most common female defect is a fistula into the vestibule of the vagina just outside the hymen. Both of these are considered “high” defects and need a colostomy on the first or second day of life. Use a left lower quadrant incision to create a double-barrel, completely diverting colostomy with the distal descending or proximal sigmoid colon. The distal colon/rectum should be irrigated thoroughly at the time of colostomy creation to remove all meconium while it is soft. Definitive repair awaits someone with the expertise along with a safe anesthesia capability. If there is a perineal fistula, perhaps to the scrotal raphe, the fistula is considered “low” and can be repaired in the first day or two of life with a perineal anoplasty without colostomy. An anal cutback is easier for the nonpediatric surgeon and can be converted at a later time to a perineal anoplasty if needed.


    • 3.

      Small bowel atresia


      Atresias can occur anywhere in the intestine and are often multiple. Patients present with vomiting in the newborn period. Duodenal atresia can be treated with a duodenoduodenostomy or duodenojejunostomy. Instill saline via the anastomotic opening of the intestine distal to the atresia to demonstrate and ensure transit to the cecum, because multiple atresias must be ruled out.


    • 4.

      Malrotation with midgut volvulus


      Malrotation is a true emergency, because the torsed bowel, most often of the small bowel, can infarct. Suspect malrotation in any newborn or child with bilious vomiting. The upper gastrointestinal (UGI) series can help locate or identify the ligament of Treitz. When in doubt, explore. Reduce any malrotation found, lyse Ladd’s bands in the right upper quadrant, make radial incisions in the peritoneal covering of the mesentery to widen the base of the mesentery to hopefully decrease repeat midgut volvulus, and then perform an appendectomy.


    • 5.

      Esophageal atresia with or without a fistula


      Diagnosis can be made clinically, incorporating attempted passage of a red rubber catheter orally coupled with a chest/upper abdomen x-ray. Success will depend on surgical, anesthetic, and critical care/pediatric expertise and timeliness. If there is a fistula confirmed by air in the stomach but nonpassage of the catheter, then a thoracotomy is required to ligate the fistula and hopefully perform a definitive primary repair. If there is no fistula, as determined by nonpassage of the catheter without air in the stomach, then a cervical esophagostomy and gastrostomy are performed to await another day for definitive treatment with possibly a colon interposition. This differs from treatment in the United States, where there are intensive care nurseries where a gastrostomy can be performed but an esophagostomy avoided by using suction catheters in the esophageal pouch.


    • 6.

      Congenital diaphragmatic hernia (CDH)


      The outcomes for children with CDH stateside are not outstanding even with critical care expertise and extracorporeal membrane oxygenation (ECMO). The neonate presents with “respiratory distress of the newborn” and has decreased or nil breath sounds on the left, with bowel in the left chest by x-ray and accompanying pulmonary hypoplasia. Pass an orogastric tube and treat expectantly, supportively for the first 5 days. If the child survives, then operation can be undertaken via a left subcostal incision or via the left chest to reduce the viscera and repair the diaphragm, either primarily or with prosthetic material if available.


    • 7.

      Hypospadias—see Urology section previously.


    • 8.

      Pyloric stenosis


      Suspect pyloric stenosis in any child in the first 2 months of life with progressive, projectile, nonbilious vomiting. One may palpate an “olive” in the epigastrium or right upper quadrant. If no “olive” is appreciated, use U/S if available, to confirm the diagnosis. Preoperative volume repletion until the child is voiding well is mandatory. When in doubt and no U/S is available, proceed to pyloroplasty based on clinical impression, via a transverse incision through the right rectus muscle midway between xiphoid and umbilicus. A longitudinal incision is made through the serosa and barely into the muscularis along the whole length of the hypertrophic pylorus. A pyloric spreader or hemostat is used to spread the halves of the pylorus. Great care is taken to avoid entering the mucosa; but if this occurs, carefully repair the defect and keep the child nil per os for 24 hours postoperatively.


    • 9.

      Hirschsprung’s disease


      A newborn with an anus who does not pass meconium in the first 48 hours should be suspected of having HD. Without contrast enemas and suction biopsy to confirm the diagnosis, one must operate based on clinical suspicion. Treatment is an initial colostomy in the distal portion of the grossly dilated colon (usually sigmoid) just above the transition zone funnel. A definitive pull-through procedure can be performed later electively, when expertise and safe anesthesia are available.



  • B.

    Infants


    Intussusception is the leading cause of small bowel obstruction from 1 to 12 months. The child presents with intermittent colicky abdominal pain, perhaps with a “currant jelly stool,” and at times with an empty right lower quadrant on physical exam. Diagnosis is often clinical. Reduction with air-contrast enemas is not the rule in RPAs. If suspected, explore. A key is to “push” the telescoped bowel from distal to proximal, not “pull” it. The bowel must be totally reduced to reveal the ileocecal valve area. The bowel is assessed for viability. If there is concern for infarction or ischemia that does not pinken up, then resection is indicated. A Meckel’s diverticulum can serve as a “lead point,” although usually the lead point is related to hyperplasia of Peyer’s patches.


  • C.

    Children: 1 Year to Adolescence or Adulthood



    • 1.

      Groin hernia; umbilical hernia


      Inguinal hernias should be repaired when diagnosed unless in a neonate with immature lungs or other issues. The concerns are incarceration and strangulation. High ligation of the indirect sac usually without any floor repair is recommended. Consider exploring the contralateral groin in children under 10 years because there is a real possibility of bilaterality. Umbilical hernias are ubiquitous and spontaneous closure can occur until age 14 years. As a rule, there is no rush to repair them; incarceration episodes, with or without strangulation, are rare and the primary reason for repair.


    • 2.

      Appendicitis


      Open appendectomy via a right lower quadrant incision is the norm in RPAs. In advanced perforated appendicitis, conversion to a lower midline incision or a significantly extended right lower quadrant incision may be necessary to adequately perform peritoneal toileting.




Inflammatory/Infectious Conditions




  • A.

    Abscesses of the skin, subcutaneous tissue, muscles (pyomyositis), bones (osteomyelitis), joints (pyarthritis), thorax (empyema), and pericardial sac occur frequently and require drainage. Staphylococcus aureus is the most frequent pathogen. Multiple abscesses are common and may occur synchronously or metachronously. Early and wide drainage with antibiotic administration minimizes hematogenous spread of infection. Hand infections pose a special difficulty because most patients delay seeking medical care; even after drainage, antibiotics, elevation, and physiotherapy, residual hand deformity is frequently the outcome. Neonates may present with multiple metastatic abscesses, perhaps subsequent to the care of the umbilicus or male circumcision.


  • B.

    Inflammatory and mixed-synergistic infections include cancrum oris (noma, gangrenous stomatitis), Ludwig’s angina, Fournier’s gangrene, and necrotizing fasciitis. Cancrum oris, usually seen in malnourished children, is a destructive necrotic process that can produce oronasocutaneous fistulas and ankylosis of the temporomandibular joint. Treatment entails controlling the inflammation/infection, debriding and resecting the infarcted tissue, and restoring nutrition and immunocompetence, followed in time by a staged reconstruction with a vascularized flap. Ludwig’s angina is a severe form of cellulitis of the submaxillary space and secondary involvement of the sublingual and segmental spaces subsequent to infection in the mandibular molar area or at times penetrating trauma to the floor of the mouth. For Ludwig’s patients, maintaining and protecting the airway with adequate incision and drainage coupled with antibiotics are the initial treatments. These patients will need staged trips to the OR and vary in management from vascularized flap reconstruction for closure in the cancrum oris patients, to skin grafting versus healing by second intention via contraction and epithelialization for Fournier’s gangrene patients. “Nec. fasc.” patients warrant early and frequent (qd [daily] vs. qod [every other day] early on) debridement in the OR; some patients may require amputation or fecal diversion depending on location (extremity vs. perineum) and multiple trips to the OR theater. Necrotizing fasciitis can be like a fire and often lethal. Do not underestimate its virulence



Parasitic and Mycobacterial Diseases




  • A.

    Parasitic Diseases


    It is claimed more people in the world have parasites than do not.



    • 1.

      Ascariasis, historically, was ascribed as the leading cause of small bowel obstruction among patients where and when laparotomies were rare. Obstruction from worms seems rare at present, although in patients with a sizable biomass load, anthelmintics can create paralysis of the worms; obstruction can ensue after the initiation of treatment. Most patients can be successfully treated nonoperatively. Amoeba cause more medical problems than surgical as a rule, with either liver abscesses, usually treated with metronidazole rather than operations, or ameboma.


    • 2.

      Other parasitic challenges for the surgeon often have a geographic track record such as the megasyndromes from Chaga’ disease in South America and hydatid disease in the Middle East. A hookworm relative found in Ghana and Uganda, the nematode Oesophagostomum , evokes an intense inflammatory reaction and can present as appendicitis or even cancer. Most subside with medical therapy, but uncertainty as to diagnosis or complications such as abscesses, obstruction, or peritonitis can lead to exploration. Seek to learn and know the parasitic prevalences and patterns in whatever locale you find yourself. Listen to and learn from your hosts and their collective experience.



  • B.

    Mycobacterial Diseases



    • 1.

      Tuberculosis ( Mycobacterium tuberculosis ) can fall into the domain of the surgeon because of pulmonary tuberculosis, empyema, Pott’s disease with paraplegia potential, joint disease, and abdominal issues such as tuberculous peritonitis or ileal narrowing with bowel obstruction. In the present era, if a patient has tuberculosis, one must query if they have HIV infection and vice versa. Many patients are afflicted with the double burden of tuberculosis on top of HIV. A major concern, abetted by partial treatment, is the potential and emergence of multidrug resistant tuberculosis.


    • 2.

      Hansen’s disease ( M. leprae , leprosy) patients present to the surgeon because of foot, finger, hand, and, at times, eye issues. The loss of protective sensation with subsequent neuropathic ulcers of the feet, mal perforans, and so on, are not dissimilar to what one encounters stateside in diabetic patients, albeit there is less associated vascular disease. Margaret Brand cautions us to Mind the Eyes of Hansen’s patients who can proceed to blindness via about six mechanisms. The inability of the patient to completely blink (lagophthalmos) to cover and moisten the cornea can be treated by a lateral tarsorrhaphy.


    • 3.

      Buruli ulcer ( M. ulcerans ) may be consequent to a trivial penetrating injury by a stick or twig, perhaps near a stream or river. The organism prefers a cooler environment and thrives in the subcutaneous tissue plane. Operative debridement and grafting may be required, but more recently, there is a role for antibiotic therapy with rifampicin combined with clarithromycin. The infection may be increased in immunologically compromised patients. Treatment entails debridement of the margins of the ulcer, wound care, elevating the local temperature via a goose-neck lamp or other mechanism, nutritional replenishment if that is a cofactor, and often subsequent skin grafting.




Other Major Important Conditions—Not Addressed




  • A.

    Congenital Heart Disease


    An estimated 40,000 infants per year are born in Nigeria with some form of congenital heart disease, yet perhaps only a few receive corrective operations.


  • B.

    Ophthalmologic Conditions; Blindness


    About 80% of the blindness in RPAs is preventable. The major diagnoses are trachoma, cataract, xerophthalmia, onchocerciasis, and corneal scarring, whereas in the more resourced world the causes are macular degeneration, glaucoma, diabetes, cataracts, and congenital diseases. Most ophthalmologists reside in the resourced world; most folks who proceed to blindness in an RPA never see an ophthalmologist. Leprosy can produce blindness via a variety of mechanisms.



(Acknowledgment: Margaret Tarpley, MLS, Adjunct Lecturer, Department of Medical Education, University of Botswana and Adjunct Instructor, Surgery, Vanderbilt University, for editorial and technical support.)


Anesthesia


The global volume of surgery is estimated to be 313 million operations annually as of 2012. Approximately 29% of this total, 91 million operations, were performed in LICs. , Médecins Sans Frontières (Doctors Without Borders [MSF]) analyzed data over a 6-year period providing a sense of surgery patterns and anesthesia modalities most frequently used. Over the 6-year study, more than 75,000 anesthetics were provided to adult patients as follows: spinal anesthesia (46%); general anesthesia (GA) without intubation and often in conjunction with ketamine (34%); GA with intubation (10%); and regional anesthesia (RA) (7%). Given the inherent logistical challenges in austere and resource-limited environments, it is not surprising that spinal anesthesia was the most frequently used anesthetic in this large study. The most common types of procedures performed were C-sections (35%), followed by wound surgeries (25%), and herniorrhaphies (7%). Overall perioperative mortality was 0.25%, with the lowest rates associated with spinal anesthesia, RA, and GA without intubation. Another retrospective study published by MSF showed that of over 79,000 procedures performed in a 7-year period, 45% were for trauma.


Anesthesia and surgery will continue to play a pivotal role in managing the global burden of disease, especially because trauma remains a significant contributor to surgical volume. In addition, noncommunicable ailments potentially amenable to surgery, such as cardiovascular and pulmonary disease, are projected to surpass infectious diseases as the most important cause of mortality by 2020. As the MSF analysis underscored, LICs and LMICs have underdeveloped and unreliable infrastructure, that is, inadequately maintained anesthesia equipment, unproven medical facilities, and constrained medical supply systems. Therefore, the austere anesthesia team should construct a standardized and streamlined anesthesia care model that can withstand challenging environments and uncertain logistics.


This chapter is intended to underscore the contextual framework for austere missions and identify high-yield considerations for austere anesthesia. This framework may be applied to short-term surgical missions that rely on the mission team’s organic supplies and equipment, in addition to longer-term partner-support missions that may use host nation supplies and equipment. Less focus will be given to specific techniques of anesthesia or medication choices. Assumptions made with these recommendations are that anesthesia delivery will be overseen by a certified anesthesiologist (also recommended by the World Health Organization-World Federation of Societies of Anaesthesiologists [WHO-WFSA]), clinical anesthesia decisions made for individual circumstances will rest on the responsible anesthesia provider, and there may be multiple “right” answers to a given anesthesia scenario. Lastly, this document is not exhaustive and relies upon the anesthesia provider’s appropriate application of anesthesia and creativity therein. Topics to be addressed are:



  • 1.

    Case prioritization in resource-limited environments


  • 2.

    Medical facilities, drugs, and equipment


  • 3.

    Preparation


  • 4.

    Patient safety


  • 5.

    Technology and equipment


  • 6.

    Techniques


  • 7.

    Medications


  • 8.

    Practical pointers and practice pearls



Case Prioritization in Resource-Limited Environments


Providing anesthesia services in the austere environment is highly demanding and can be stressful for the surgical/anesthesia team. Establishing common (team) goals and a common treatment philosophy before undertaking the medical mission is of utmost importance. Additionally, medical ethics, patient safety, and team capabilities and limitations should be considered. For example, should the team invest the most resources into the worst injuries/illnesses, or should the team strategize how to provide the most good for the most people, that is, a single long surgery versus many short surgeries? Should the team complete one complex surgery that requires complex postoperative care or one well-planned surgery that requires little to no postoperative care? These questions are simplified but serve to bring out the philosophical underpinnings of establishing surgical priorities and triage. Methods for selecting surgical candidates should therefore be established a priori, as it may be difficult to reconcile ethical issues in the heat of the moment and unexpected team conflict may result.


Safety standards must be established and agreed upon by the team. In LMICs anesthesia-related mortality can be as high as 1 in 300. Many sources recommend that austere anesthesia providers adhere as closely as possible to HIC anesthesia standards of care. The team should decide beforehand if and how it will deviate from home country safety standards and which host nation safety standards are acceptable. The team should also determine beforehand when to stop providing medical care (e.g., when resources or safety capabilities are exhausted, and despite host nation pleas to continue). It is critical to understand that the team’s capabilities in its home environment do not equal the same team’s capabilities in the austere environment. Surgical team members will not likely be familiar with each other, further affecting patient care. Failure to acknowledge these limitations can be a significant source of team friction and can lead to increased patient harm.


In 2018, the WHO-WFSA jointly published an updated document detailing recommendations for international standards for safe anesthesia. The WHO-WFSA document reconciled recommendations from other entities concerned with the same goal of safe surgery, such as the LCoGS, and illustrates the suggested degrees/capabilities of anesthesia care at three healthcare facility and infrastructure levels (see further in this section). Also included are recommended standards for patient monitoring at each level. It is important to note that the recommended capabilities and standards will be unique to the specific environment and clinical situation. A complete review of this WHO-WFSA document is beyond the scope of this chapter; however, it is highly encouraged that the entire anesthesia team reviews it before undertaking an austere or resource-limited surgical mission.


Considering the WHO-WFSA safety standards document and the preponderance of anesthesia safety literature currently available, it is important to note that wherever and whenever possible anesthesia care should be provided or overseen by a certified anesthesiologist (Highly Recommended, see Patient Safety, Perioperative Care). As such, the ultimate provision of anesthesia, choice of medication and technique, risk assessment, and so on should be decided by the responsible anesthesia provider and even more importantly by a provider who has experience providing anesthesia care in the austere setting. Many recently trained anesthesiologists, for example, may have never used older anesthetics with significant hemodynamic implications such as halothane, which are still in use in other countries. The exact prevalence of worldwide use of halothane for GA is unknown, however, the WHO Model List of Essential Medicines (August 2017) lists halothane as an essential medicine along with isoflurane, nitrous oxide, and oxygen (available at www.who.int.easyaccess2.lib.cuhk.edu.hk/medicines/publications/essentialmedicines/en/ ).


Medical Facilities/Drugs/Equipment


The WHO and the WHO-WFSA safe anesthesia standards documents describe three levels of medical facilities and associated services, capabilities, equipment, and drugs. Tables 12.1 and 12.2 summarize this information. The LCoGS article mentioned previously notes that all Level 2 hospitals should aim to provide Bellwether procedures defined as laparotomy, cesarean delivery, and treatment of an open fracture. These procedures are acute and high value, and the consistent performance of these procedures is suggestive of a capable surgical system with broad service delivery.


Aug 20, 2021 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Austere Surgery and Anesthesia
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