For his surgeries, my patient had his family vote yes or no

In surgical jargon, the abdomen is known as Pandora’s Box because it is full of surprises and the surgeon often does not know what he will find when he opens it up, all the more applicable in surgical emergencies.

In my long surgical career, I found either something different from what I had diagnosed clinically, or something in addition to what I was expecting.

The classic example of the former is, one goes in with a clinical diagnosis of acute cholecystitis — acute inflammation of the gall bladder — and finds perforation of a duodenal ulcer or, worse still, acute pancreatitis.

I say worse because, in perforation, emergency surgery is indicated to seal the leak and carry out peritoneal toileting, which is badly soiled, while in acute pancreatitis, once the diagnosis is made, the surgeon is advised not to be knife-happy but, on the contrary, to withhold his knife.

As an eminent surgeon said, using the surgical scalpel is easier than having the courage to withhold it and decide to use it at the right time.

A good example of finding additional pathology is to remove an acutely inflamed appendix and find an ovarian cyst on routine exploration of the pelvis.

With a slight modification, this was the problem in the case of Bishop Jeremy Kageka, referred to me by a surgeon in Nyeri, with a detailed note which said: “This venerable gentleman who hails from the slopes of Mount Kenya came to see me, complaining of bleeding per rectum.” He was referring to blood in the stool. “I have done a colonoscopy which shows polyps in the descending colon. I took a biopsy from one of them and it has been reported malignant. I told him that the treatment is removal of the descending colon and he expressed a desire that he wants the surgery done by you in Nairobi.”

The priest proved to be an interesting character, as I took his medical history in the “outpatient” at the only teaching hospital in Kenya at the time, where I did three sessions a week in an honorary capacity and taught undergraduate and postgraduate students until I retired.

Since Dr Muyemba, the surgeon in Nyeri, had taken a full history and sent a copy of his file with the patient, I restricted my questions to details about the family.

“How many children?” I asked.

“Many,” the Reverend replied.

CHANGED MY TACK

I changed my tack in search of a more specific reply. “How many wives?” In my experience, when I received an answer like that, the man had more than one wife and could not truly remember how many children he had sired!

“One,” he replied and, looking at my puzzled expression, added.” I took God’s instruction ‘to go forth and multiply’ with the seriousness it deserved.”

I told him the treatment which was identical with what Dr Muyemba had proposed and asked: “Would you like to think about it and consult your family?”

He replied. “I know my diagnosis and I’m ready for surgery.” His reply took the wind off my sails but also relieved me of giving a dismal diagnosis to him and persuading him to undergo surgery. As I was gloating on my relief, the old man added. “Being a big household, I have tried to establish some democracy.” As I was pondering on the old man’s mixed issues, mzee added. “When the surgeon in Nyeri advised on an operation, I assembled all my family members to a baraza and gave them ballot papers to say ‘operation’ or ‘No operation’ on it. “As I showed amusement on my face, he said. “As a surgeon, you will be glad to know that those in favour of operation won hands down.”

Impressed by his idiomatic language, I remarked to distract his mind from cancer and surgery.” You speak very good English. Where did you learn it?”

“From the missionaries,” he replied and went on. “Until the Bible was translated into the local lingo, we had to learn English to understand the Holy Book.”

Scratching his fast growing bald patch, he made a profound statement: “Seems strange, that God spoke only English and yet He sent the Koran in Arabic, the Geeta in Sanskrit and the Bible in yet another language!”

The colon operation on the bishop was uneventful but he was not picking up after the surgery and he shot up low-grade fever on the tenth day.

My main concern was whether the new connection I had established after removing part of the colon was leaking but in that case the temperature would be very high, the operation wound would look angry and eventually faeces would leak from the wound.

Not sure of what was happening, I asked for a scan of his abdomen. The radiologist called me after doing the scan and set my mind to rest.

LOOKED NICELY HEALED

“The anastomosis looks nicely healed and there is no leak but I see an odd shadow in the left kidney next door. I think an IVP would throw more light on the matter and I would like to know if I can proceed.”

She was seeking my permission to inject a dye which would visualise the kidneys better.

“You are the boss,” I replied.” Please go ahead.”

The IVP confirmed what I dreaded most; Mzee had a second cancer in his left kidney. Low-grade fever was an unusual presentation and surfacing after a colon operation was equally unusual. For the information of my readers, kidney cancer commonly presents with haemeturea, which means frank blood in the urine. I was now faced with the problem of disclosing to the old man that he had another cancer in his kidney and prevailing upon him to let me operate on him again so soon after the first operation. When I gathered enough courage to tell him all this, he replied. “I can only say aye or nay after I have put the matter to vote in the family.”

The family proved very understanding and gave me a green signal to remove the kidney riddled with malignancy.

The operation on the kidney was difficult, mainly because the left kidney, especially the tumour, was adherent to my anastomosis, involving patient dissection. Another impediment was the tumour extending into the renal vein, which it often does, and I had to dissect the vein till it was clear of malignant cells and tie it, a highly perilous manoeuvre.

I did not expect two easy operations on the same patient within a fortnight and was prepared for a difficult nephrectomy. All went well after the second operation and Bishop Kageka picked up fast and was ready to go home.

On the day of his discharge, he dropped a few more pearls of wisdom and I was glad that I had reserved adequate time to discharge him.

When I went to the ward, I found him all ready to go. He was sitting on a chair next to his bed, dressed in his regalia of a bishop. The old Bible was on the bedside locker as it had always been during his stay in the hospital.

Lying on top of the Bible was his ornate rosary. His whole clan was with him to take him home — wife, daughters, sons, daughters-in-law and grand-children. He bid me to sit beside him and I sat on the arm of his easy chair. “Sorry, you came for one operation and ended up with two,” I said to shed my guilty conscience.

MYSTERIOUS WAYS

He spoke like an oracle in reply. “God has His mysterious ways to show the light. If I had not developed fever after my colon surgery, you would not have stumbled onto my kidney cancer in time. I am glad that I am leaving both my cancerous, descending colon and left kidney with your pathologist.”

As the Sister handed him his discharge drugs, just arrived from the pharmacy, he got up from the chair, shook hands with the Sister, waved at the nurses and patients gathered behind him to say kwaheri, took a few steps after shaking hands with me and giving me an emotional hug, and turned back, nudged by his one and only wife.

Picking the Bible and rosary from the top of the bedside locker, he said: “Almost forgot”.

Handing me both items, he added: “Didn’t know how to thank a person who has all worldly things, so I thought it appropriate to give my Bible and rosary, which I have used since I was ordained. They have served me well and I hope they will serve you well, too.” Then, looking at the peeling paint on the walls and two patients in one bed, and patients lying on the floor on thin worn-out blankets, he continued: “Looking around during my prolonged stay here, I have realised that things can go wrong easily due to overcrowding and lack of resources.”

As he walked out of the ward with his retinue behind him, one of his sons handed him a new maridadi walking stick with an ornate handle, which the old man handed to me, saying: “I hope you live to be a hundred and live long to serve your patients. And if the Good Lord accepts my prayers, you might need a walking stick like mine. Mine is old, so I asked my son to buy a new one for you.”

Saying so, he left me in a daze, listening to ululations and cheers from the patients who were waving from behind.