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A serendipitous surgical story by anDrew Huang
WARNING: This newsletter contains a graphic surgical photo

The Huang family newsletter


december 2019
A few months ago, I arrived in Liberia for a week-long cleft lip & palate surgical mission trip (sponsored by Samaritan’s Purse). It was a trip I looked forward to, not only because it meant doing selfishly fun and gratifying operations on cute children with an easily fixable congenital deformity, but because ELWA Hospital outside of Monrovia happened to be the place where our recently graduated Bongolo surgery resident Dieudonné had just started his first job. We greeted each other warmly; in fact, he and his family had only left Bongolo several weeks prior, so it seemed quite normal and familiar to work with him again.
Dieudonné, the 2019 graduate of the general surgery residency program with the Pan-African Academy of Christian Surgeons and Bongolo Hospital.
This is perhaps why I didn’t bat an eye when Dieudonné called me at 11 p.m. on my first night at the hospital guesthouse, asking for my assistance in the operating room. A young university student had fallen awkwardly on some broken glass and suffered a deep gash over her elbow joint. Three young African surgeons, including Dieudonné, were already in the room, pondering their next operative steps.

I put on my loupes and headlamp and scrubbed in. The woman had transected the blood supply to the forearm and hand, as well as one of the major nerves controlling the hand and fingers. Not only that, but there was a large gap between the flailing, cut ends of the artery and nerve.  It was not an easily fixable problem in the middle of the night in an African setting.

“Do you have a pediatric feeding tube?” I asked in my best possible Liberian accent. None of the nurses understood me. Dieudonné translated my English into Liberian English, and a nurse eventually produced a small, flexible, sterile, plastic tube.

We spent some time inserting the feeding tube into the brachial artery to create an emergency temporary vascular shunt. It was tricky; the feeding tube was small, but the artery was even smaller. Eventually we succeeded, and I sighed.
“Well, the hand has blood flow now. We’ll see if this actually works and if her hand will survive the next couple days,” I remarked rather pessimistically, as Dieudonné and his surgical colleague Juvenal proceeded with the necessary forearm fasciotomies.
The next couple days were filled with cleft lip and cleft palate operations. I spent the days at the operating room table with my friendly, talented, American scrub nurse Alison.
Multiple cleft lip & palate operating teams in one operating room.
Each morning, Dieudonné and Juvenal would greet me with a smile, and they would happily report that the temporary shunt was functioning, and that the hand had not yet died from lack of blood flow.
I began to worry. I had half-believed that the forearm and hand would have been unsalvageable after such an overwhelming injury, and that she would have required a devastating but simple forearm amputation. Now, it seemed like the temporary shunt had worked, but it meant that she would need a second, more complicated, and more definitive reconstructive operation – and soon.
The small plastic tube (arrow) is the only thing keeping the hand alive at this point.
The needed operation was fairly straightforward to describe: brachial artery reconstruction with reversed interposition saphenous vein graft and cable grafting to the median nerve. However, performing the operation would be an entirely different story.

Did we even have vascular clamps? Appropriate sized suture? An operating microscope?

One by one, by some miracle, things appeared. Six-zero Prolene on a tapered vascular needle. Castroviejo needle drivers. Satinsky and bulldog atraumatic vascular clamps.

And it just so happened that I had recently acquired some 5x loupes for low-level microsurgery.

“You want to stay late for some vascular surgery?” I asked Alison. “I could really use your help.”
The arm salvage team, which included (from right) Alison, Dieudonné, myself, and Juvenal, along with hospital Liberian staff.
We started at 5 p.m., after a full day’s load of cleft surgery. Juvenal, Alison, and I worked on the arm while Dieudonné harvested saphenous vein and sural nerve from the leg.

“Can you do this, Dieudonné?” I queried, knowing full well that Dieudonné had never harvested saphenous vein or sural nerve grafts before.

“No problem!” he answered confidently before making a long incision on the women’s leg.

We worked quietly and, thanks to Alison, efficiently. The branchial artery was diminutive, only about 3 mm in diameter. I had worked to establish proximal and distal control of the artery when Dieudonné produced a beautifully long saphenous vein graft. Amazingly, there were no leaks: the graft was perfect.

Dieudonné worked on nerve graft harvest while we completed a distal thrombectomy and then the two vascular anastomoses. We then completed the nerve reconstruction with five cable grafts.

We stepped back and took a big, collective sigh. Before us was a 12 cm brachial artery gap beautifully reconstructed with a pulsating vein graft. Immediately adjacent, a 7 cm cable graft median nerve reconstruction. Our ischemia time was under an hour. The hand was still alive.
The postoperative course was rocky. I left Liberia a few days later with the rest of the cleft lip & palate team. Dieudonné and Juvenal had to perform a number of subsequent operations until the arm incisions healed completely. But eventually, more than a month after she first arrived, the patient was discharged – with both hands intact.
The ELWA Hospital Cleft Lip & Palate Team of 2019.
It was fortunate that I happened to be in Liberia at just the right time when this patient injured herself. It was fortunate that I had just bought some new loupes that were up for the job. It was fortunate that we found the proper suture and instruments just hours before we planned the definitive reconstruction. It was fortunate that Dieudonné and Juvenal (some of the best surgeons that Liberia boasts) were present to take care of the patient and the complications postoperatively. It was fortunate.

Or maybe it was more than fortunate. Maybe it was foreordained. Maybe it was miraculous.

And now...for some family pictures!

anDrew's parents came to visit for two weeks at the beginning of October. We had a great time showing them our life at Bongolo, and also spending a beach holiday with them in São Tomé.
Between visitors to Bongolo and travel for work and conferences in the past three months, we've been happy to see dozens of friends and family from around the world, including those from French language school, from the US, Canada, Australia, Taiwan, Hong Kong, Singapore, Indonesia, and many others. For all of you, we thank you for taking the time and effort to meet up with us!
     
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anDrew: docdrew@gmail.com

Kimberley: kimboley@gmail.com
Copyright © 2019 The Huang Dynasty, All rights reserved.

This newsletter is about Andrew, Kimberley, Nolan and Solène Huang: their journey from the US to Canada to France and, ultimately, to Bongolo Hospital in Gabon, West Africa, with the Post-Residency Program of Samaritan's Purse (World Medical Mission).

The views and opinions expressed here are solely ours, and they do not necessarily represent those of Samaritan's Purse or World Medical Mission.

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