Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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172 Surgery and Healing in the Developing World
Figure 1A. The Weck dermatome is a very useful tool as a back-up to more expensive
dermatomes and blades. A width of 5.5 cm is possible and various thicknesses are possible
by selecting the appropriate depth guard. It is especially useful for small grafts, but
very large areas can be covered at minimal cost, especially with meshing or “pie-crusting”,
by taking repeated strips.
second degree burns can be treated by gentle washing with water three times a day,
leaving the burns open under a mosquito net.
Hepatoma
Few cases are sadder to see than the many younger patients who present with
hepatocellular carcinoma generally associated with chronic hepatitis B infection. An
attempt at resection generally taxes scarce resources and is rarely curative. Palliation
almost equal to surgery can be achieved by ethanol injection. Generally at least a
50% concentration is used and injected under direct vision or ultrasound guidance
if available. One large study averaged 49 cc per case. Recent studies have shown that
hepatomas in females are often estrogen-receptor positive. Qualitative assay for receptors
can be done if available and empiric treatment with tamoxifen is used.
Hernias
Hernias usually can be repaired with fairly inexpensive techniques assuming mesh
is not used. Generally mesh should be reserved for recurrences with major fascial
weakness. With regional or local anesthesia, standard repairs of the Bassini type
work for most indirect inguinal hernias and a running 12-pound test fish line works
well. The Shouldice repair with similar suture works well for direct hernias but
unfortunately has a higher incidence of pain post repair. Marlex or Prolene mesh
work very well but add markedly to the cost. Giant hernias are becoming less com-