The operating room can be intimidating.
The first cut, to the last stitching can be unerving. For many years, hospitals have been appreciated as beneficent places of caring and compassion. We are at the Kenyatta National Hospital private wing and this floor has two operating rooms, each with two large steel doors. The floor and surfaces of the theatre are dustless. Clean air blows in this theatre, and you can almost slice the optimism in the entire medical team. The overhead colour corrected lamps do not allow shadows during surgery. These lights have both horizontal and vertical ranges. This is a great view for the operating surgeon to see the internal tissues and organs. At the head of the operating table is a stool that marks where the anaesthetist will sit during today’s surgery.
It is early Thursday morning, 9.00 a.m. and a radical Werheims abdominal hysterectomy is scheduled. The atmosphere becomes more relaxed as the doctors and nurses explain today’s surgery. The patient this morning is a 64 year old woman with stage one cervical cancer. She is brought to the theatre receiving area, a sterile environment, she meets the doctors of the day; Dr Alfred Mokomba, and Dr Ramadhan Muyika. Dr Muyika introduces himself as the anaesthetist and Dr Mokomba as the surgeon. Family bids their loved one ‘goodbye’ and they whisper a short prayer for a successful surgery. The nurses introduce themselves to the patient (name withheld). Dr Muyika jokingly explains that he has the honourable task to put her to sleep until the surgery is over. He promises to look after her (checking all her vital signs like blood pressure) until the end of the surgery.
Dr Alfred Mokomba, obstetrician, gynaecologist and a fellow in gynaecology oncology at the Kenyatta National Hospital explains that this form of surgery is one of the most effective ways of managing the early stages of cervical cancer. I get a feel of a team culture where these theatre colleagues share norms, and a little later, humour during surgery. The task of the day is a hysterectomy which is the removal of the entire uterus, the connective tissue and lymph nodes close to it, fallopian tubes, ovaries, and the upper part of the vagina. This is for the management of cervical cancer stage one. Did you know that surgery is responsible for roughly seven out of every ten of all cancer cure and control? In the next theatre, there is an ongoing head surgery known as craniotomy on a two year old girl with brain tumour. (story for another day)
Preparing for surgery
There are four stages of surgery;
- Pre-operative stage
- Anaesthetic stage- patient put to sleep (general) or numbed under local anaesthetic
- Surgical stage is when the operation is performed in the operating theatre
- Recovery stage- back to ward and later home for recovery.
Strict control is exerted in the theatre. This ensures that everybody in the room has a specific role to reduce the chances of infection for the patient. But even before we establish the actual team in theatre, there are a few checklists and procedures that need to be instituted to ensure that all is well when you go under the knife.
- Getting all your medical records in order.
- Going through the surgical plan with the surgeon.
- List all the medicines you take and state whether you are allergic to any
- Schedule and do all lab tests needed.
- Meet the anaesthesiologist
- Follow specific instructions on lifestyle before surgery
- Sign all consent forms
- Plan payment plan and execute
- Have a discussion with family members, get a second opinion if you want.
- Quit smoking, ladies too.
- Remove all jewellery
- Ladies, no nail polish, acrylic nails on fingers and toes.
- Please avoid false lashes and the make up too. The anaesthesiologist may put tape over your eyes prior to surgery to protect the eyes.
- Remove contact lenses.
The surgery will take about three hours.
Dr Mokomba estimates that the surgery today, known as Werheim’s radical hysterectomy will take about three hours if no complications arise, but he cautions that you are only aware of the task ahead when the abdomen is opened. The patient is connected to monitors that check on vital signs like your blood pressure and heart rate. This is also monitored by the anaesthetist who in most cases is positioned at the head of the patient. The rhythmic beating of the pulse oximeter in the background can be annoying, but it is an indication that you are alive and well.
A breathing machine known as the ventilator serves the purpose of breathing for the patient during the procedure by moving oxygen and air in and out of your lungs if you are under general anaesthesia. A stainless steel table holds the sterile equipment that is carefully sealed in green sterile cotton material and laced with white hospital tape known as ‘strapping’ The strapping is a type of strips of adhesive tape that are usually used to secure the gauze used to cover a wound but in this case, it secures the instruments safely. The instruments are made of stainless steel with a satin finish.As he performs the surgery, he is particularly skilful and dextrous.
The work of the theatre nurse is to pass the instruments to the surgeon. Today the equipment needed for the surgery include forceps that are both curved and straight, needle holders, scissors, scalpels, clamps and retractors. The work of the retractors is to hold the incision or wound open while a surgeon works. In this case, the abdomen stays open as Dr Mokomba makes his way through the abdomen to get to the reproductive organs. Other ways to remove the uterus can be through the vagina, or with laparoscopy, a key-hole surgery. And the operating room is also kinda cold; Dr Mokomba informs me that this is done to ensure that the environment is comfortable enough for the medical team. The conversation gets warmer as Dr Mokomba operates. He describes a hysterectomy as one of the safest surgical procedures.
The resourceful theatre nurses made the experience worthwhile
The surgical space is relaxed and as Dr Mokomba performs the surgery, he is keen to find out whether as women, we have had our annual pap-smear tests that screens for cervical cancer.. He does not let the men off easily as well and asks them too whether the women in their lives have been screened for cervical cancer.
What are the key steps of this surgery?
- Place the patient under general anaesthesia
- Clean abdomen to make a proper cut to access the reproductive health organs.
- Open a midline cut from half of abdomen
- Remove uterus , cervix, upper third vaginal wall
- Remove the ovaries and pelvic lymph nodes.
- Be dexterous as you remove the uterus to avoid injury to intestines, bladder, and ureters.
- Take everything for histology with pathologists.
- Close abdomen through surgery.
- Reverse anaesthesia by weaning the patient from the heart-lung machine and wake them up.
- Take the patient to the post-operation ward.
- If histology shows that all the cancerous cells were removed, them the patient is cured.
- Radiotherapy should be done if there are traces of cancer cells after surgery.Sadly, only one public health facility, Kenyatta National Hospital, does radiotherapy, making the cost prohibitive.
Back to theatre, Dr Mokomba successfully removes the uterus and shows the medical team and I the cancerous cells on the surface of the cervix. The lesions were at the entrance of the uterus and are noticeable after close examination.
The first step in fighting cervical cancer begins with screening.
What is cervical cancer?
Cancer of cervix is caused mainly by Human Papilloma Virus, which is a sexually transmitted infection. Dr Mokomba stressed that initially, cervical cancer starts as a silent and painless disease before the signs are more apparent, advanced and accompanies by the symptoms.
The World Health Organisation cites the signs and symptoms of cervical cancer as;
- Irregular, inter menstrual (between periods)
- Abnormal vaginal bleeding after sexual intercourse
- Back, leg or pelvic pain
- Weight loss,
- Loss of appetite;
- vaginal discomfort
- Smelly discharge
According to Dr Mokomba, the key to prevention of cervical cancer is through regular screening, pap smear test or inspection after applying acetic acid. Vaccines are also available to prevent the disease. Dr Mokomba notes that the treatment for cervical cancer depends on the staging of the cancer.
“The preferred treatment for stages 1 and 2 is surgery, Wertheim’s radical hysterectomy, plus or minus radiotherapy. For stage 3 to 4, we advise radiotherapy and chemotherapy,” Dr Mokomba said. Wertheim’s radical hysterectomy is the removal of the entire uterus, the connective tissue and lymph nodes close to it, fallopian tubes, ovaries, and the upper part of the vagina. This procedure is named after Austrian gynaecologist who first performed this surgery.
When the surgeon and all assisting member of the medical team wash and dress appropriately before surgery, this is known as scrubbing. But for other persons who are not directly participating in the surgery but are in the theatre, like me, you are expected to be suitably dressed in attire that includes;
- Surgical scrubs given by theatre staff
- Theatre hat (hair should be tied especially for ladies or men with long hair)
- Form of identification to establish your role in the theatre
When the surgery ends, the anaesthetist reverses the medicines to awake the patient who seems a bit drowsy and confused. Dr Muyika calls out her name and she responds in the affirmative. He also removes the oxygen mask and the endotracheal tube that was helping her breathe. Later, she is wheeled to the High Dependency Unit before they are moved to the gynaeacological ward before she is discharged to go home. She is urged to walk around from the second day to prevent blood clots in the legs.
Almost immediately after Dr Mokomba confirms that the patient is alive and well, he asks his nursing colleagues, “Have you sent for the next patient from the ward?” This marks another surgery about to be brought to the table. There is only 20 minutes of lunch break for the surgeon and his team due to the demanding theatre schedule. But he takes time to meet the family members to assure them that the surgery was successful. He brings along the sample of the removed uterus and shows them the early stages of the cervical cancer at the entrance of the uterus. The family members exclaim in surprise but they are also grateful that the surgery was a success. They promise to ensure she has follow-up tests to ensure their loved one has a clean bill of health.
I salute the entire surgical teams!! May the long standing hours be opportunities to save lives. And that was my day in theatre with Dr Mokomba, the doctor who looks at his patients from the outside-in. Indeed, successful surgeons have the eyes of a hawk and the heart of a lion.
Where are we going with this story? Get screened for cervical cancer this week. If male, encourage your wife or mother to get the critical test. It’s life-saving.