Fieldset
Day 4: Liver on the Menu

Tomas blogs about coplicated abdominal surgery on a patient and his evening in Afghanistan.

I am opening up the abdomen. From the emergency room to the operating theatre it took about seven minutes, including X-ray, ultrasound, taking samples and connecting the drip-feed. I have never seen anything like this before. I’m into the abdomen in one minute. When there is nowhere for it to bleed from, it just does not bleed. Globs of dark blood are oozing into my shoes. Nothing but blood. Apparently all the blood that this thirty-year-old guy now has left is between his intestinal loops. In addition to this there are adhesions (scar tissue that binds organs together) everywhere from a previous laparotomy. It will be the liver that’s bleeding, I think. And then it will take me at least another 10 minutes before I get through these endless adhesions...

A liver almost torn in half

A year ago he had been operated on for the same thing. He hurtled off his motorbike, bruising his stomach and chest. That time they removed his spleen. A great surgeon had done the cutting – precisely from the metasternum to the symphysis. He had to disembowel him, that is why there were so many adhesions. Now he has been brought to us with an injury caused in the same manner – a fall from a motorbike. Abdomen like a board, a quick ultrasound and I could tell that everywhere in the abdomen was just blood; it is not worth it to even investigate it further ‘remotely’. When I finally get through the adhesions to where the liver used to be, I marvel. Floating amidst the dark blood there are two large chunks of an originally solid liver. The right lobe is nearly torn in half... Simply speaking – a disaster. I have never seen anything like this in my life and I have certainly never operated on it. I definitely do not dare to perform a resection and I am not trying the Pringle manoeuvre, this is mainly about veins. Before I finish my deliberations I am already sewing it. We do not have a parenchymal needle here so I must manage with one for closing up the skin after surgery, which is quite small. Stitch-by-stitch I am closing-up that scary entity. I tighten them patiently as every stitch has a tendency to tear. When, after half an hour, I have closed the convexity, I still do not have any idea of what to do with what rests beneath the liver. I am stuffing gauze on top and I am pulling it at the bottom. I would never have thought that I would undertake classic gallbladder surgery in Afghanistan. To get to the torn alveolus beneath it, I have to remove the gallbladder. Everything somehow goes faster when there’s reason for it. Then, including the entire alveolus, I can sew a little bit into the hepatic hilum where, with relief, after the evacuation of the last blood cell, I find that the crack does not continue. So it is luck again, so far mainly for me; this young man has not won yet. He has lost over two litres of blood. I am watching the anaesthetist as he struggles. He is literally squeezing the third package of blood into the patient and sweat is pouring from his forehead, as it is from mine...

Afghan Street

By around seven in the evening I am already sitting peacefully at reception and kidding around with the radio operators, the drivers and the security guys. “Hey Tom, dude, how was your day?” I feel ashamed again – so far I have not managed to remember more than a few names from the whole hospital. There are about 60 employees in total. I Definitely do not catch the names of those people outside the core group of the hospital. They have me on the name list and they also constantly monitor the newcomers.  “It went OK, gentlemen, how about you?” The first tells me about his university studies. Here in Kunduz they have a private university for 1,000 students where he studies law. Another person talks about his home... While we are chatting here, we are sitting opposite the gate and staring directly at a big local intersection. There, on the corner, something like a newsagent’s shop is illuminated; people are strolling hither and thither, cars are passing, dusk is coming. It's as if I were sitting by the fountain on the square during the holidays. Everyone is friendly, they laugh, they chat; the day is ending. I half close my eyes. I recall again that this is the same everywhere: the people, the problems, the fun. A car is arriving for me, I bid farewell and get a ride to the base.