Surgery and Healing in the Developing World - Dartmouth-Hitchcock

CHAPTER 1
CHAPTER 26
Reconstructive Surgery in the Tropics
Harold P. Adolph
Useful and practical flaps must be:
1. Simple
2. Quick
3. Dependable
4. Easily raised and applied
5. Able to solve a difficult problem with only one major operation
6. Easily learned and taught
7. No inconvenience for the patient
These requirements are necessary because the number of patients requiring help
is always greater than the number of helpers available to help them. The supplies are
usually limited. The procurement of staff and drugs are frequently problematic. The
economic feasibility of each treatment must be constantly reviewed.
In some locations only 15% of hernia patients will ever have operative repair
during their lifetime. In many locations only 1 in 20 women with obstructing labor
can receive the C-section she needs. The large number of patients needing help
dictates the operative choices. In these pages we want to promote only one operating
room visit per patient to maximize the number of patients that can be helped.
The choice of operative technique chosen will be affected by the postoperative
care available in hospital. Usually limited intensive care is available because of the
ratio.
Of nurses, nurses aids and physician assistants to the number of patients being
compassionately cared for.
The surgeon will want to incorporate many technical safeguards against the most
common complications. This will maximize favorable outcomes:
In a step by step process these surgical points will be emphasized and illustrated.
Surgeries where the expected blood loss will exceed 1000 cc must usually be
refused.
It is important to use all the preoperative, intraoperative, and postoperative autologous
blood transfusion techniques available. These techniques have allowed coronary
bypass surgery to be carried out without a single homologous blood transfusion.
This surgery formerly required an average of 16 units.
This change was necessitated because of the significant risks of infectious disease
transmission.
500 cc of blood is taken from the patient weekly two or three times before surgery.
Iron supplements and vitamins are given. The hematocrit should be kept above
20.
At the time of surgery and just after anesthesia is administered two more units
are removed and replaced rapidly with normal saline with 5% glucose in a ratio of 3
Surgery and Healing in the Developing World, edited by Glenn Geelhoed.