Odysseys of George

Case Two - all on the same day

This lady was admitted 8 weeks ago for what appeared to my MO as acute appendicitis. However, in the morning as we were doing ward rounds, she claimed the pain felt better. Upon examining and questioning her, I felt a mass on the right side of the lower abdomen. I was sure it was her right ovary that was giving her the pain but.. all the investigations were coming back normal. The gynaecology team also insisted that all was normal. Dumbfounded, I explained to her the findings. I had no real reason to operate her. Then the break came, she was admitted for severe pain and I proceeded for a diagnostic laparoscopic procedure. This was the positive finding: A ruptured polycystic right ovary


The red inflamed looking organ is the uterus and beside it on the left of the picture is the enlarged right ovary. It was 3 times larger than the left. There was blood stained fluid within the abdominal cavity in the pelvis.

The enlarged right ovary which has ruptured. The gynae was called in and they performed a laparoscopic cystectomy! Retrospectively, the gynae agreed that it was larger than the left but felt that it was still normal!

Moral: Always trust your clinical findings and there is a reason why God gave a pair for many things in our body.

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Case Three - the last on the same day!

She came in via emergency for painful abdomen. She has been having this pain for the last three or four days and it was getting worse. She was in her 50s and had previous surgery for some gynaecological procedure many years ago. She was getting deteriorating and again referrals to the gynae was negative. So I booked her for surgery. Upon opening her abdomen, there was 3 litres of pus within the abdominal cavity. She had a large uterine fibroid and both her tubes were inflammed and dilated. She also had a large cystic swelling of her left ovary. Her left fallopian tube had perforated and frank pus was exudating from it. Again, we called the gynae team to continue management. Diagnosis:Perforated Left tubo-ovarian abscess

So, isn’t surgery interesting!?

Story One - all on the same day!

Well it was few days ago, I was asked to assist in an interesting case, a lady with a abnormal tract connecting her uterus to her previous surgical scar over the lower abdomen. This is what we call as utero-cutaneous fistula. Now how did that come about? Well, a year ago she presented herself to the emergency department in severe abdominal pain. She was taken immediately to surgery and was found to have more than a litre of pus within the abdomen. Her uterus had ruptured - from what we call pyometra (pus within the uterus). This is rare in humans. She developed the fistula thereafter. As the gynae, investigated her despite the intraoperative findings, she was diagnosed to have uterine didelphy. This is a congenital anomaly where there are a pair of uterus, a pair of cervix and also a pair of vagina! Hmmm..!

I showed her Xrays a few days ago and Dr Vijay answered the quiz correctly.
We took her into surgery again hoping to revise her fistula and we managed to do so. I always enjoyed working with the Gynae chaps. A few hours later, I was back in to the operating theatre for Case 2

She was discharged home well 3 days later.

##Anomalies of fusion of the paramesonephric duct are completed by the 18th week of fetal life. The overall incidence is 0.1-3%. UTERINE anomalies are found in 9% women with infertility and/or repeated spontaneous abortions. 25% of women with UTERINE abnormalities have fertility problems. Associated urinary tract anomalies occur in 20-50% of the cases. There is also a possible increased familial occurrence of limb reduction.##

I thought I would put this up just to kindle your tummy, sorry, your interest.

This is a lady who presented with recurrent right sided upper abdominal pain. It was getting more frequent and was increasing in intensity. She was admitted three times for the pain which spontaneously resolved with analgesics. Her ultrasound just reported as gallstones present.

We operated on her and this is what we found.

Single stone impacted at the neck of the gallbladder. Mucous like fluid within the gallbladder with multiple small black pigment stones within it. There is evidence of chronicity with central fibrosis causing the gallbladder to have an contracted hour-glass shape and also the thickened wall.

A mucocoele is a mucus-filled gallbladder, which arises when the neck of the gallbladder becomes obstructed, normally by impaction of a stone. The bile is absorbed and replaced by mucus secreted by the gallbladder inner wall.

Management : Surgery to remove the gallbladder - Cholecystectomy

I just received a call from my very hard working medical officer, who is doing his ENT masters training, who has just completed his surgical rotations with me.

“Mr. George, are you free to talk?”

“Yes”

“I just witnessed a very bad accident, head on collision, one died on the spot. The was another four. One had difficulty breathing and was bleeding profusely, another has serious limb injuries. The other two was ok.”

“You were there at the scene”

“Yes, the ambulance that arrived did not have a doctor. So, I introduced myself. I had to do CPR in the ambulance. We reached the Hospital but the ED doctor was not around, so I intubated the patient and continued CPR. She lost a lot of blood. The ED doctor came and took over. I am very happy I was able to save two lives today. I managed to use my surgical training and the CPR course I recently attended fully. Thank you!.”

“Good! Excellent! Not many will have this opportunity and many will refrain from getting involved. Good!”

“Will there be any problems?”

“No, don’t worry!”

“I will call Serdang tomorrow to see how the patient is getting along!”

“I am happy for you! Good job! Good!”

“Thanks, Mr George. Bye”

Bravo, Soma. I am so proud of you!

Wah! This is so difficult. Then I thought of the shashimi served with a condiment of wasabi mixed with soy sauce, my Divemaster in Sipadan prepared for us. It was delicious. It was one of these fishes that was caught and cooked for us — I think! I am not sure.

A group of Japanese restaurent chefs cooking away!

Eel flesh, with eggs from I don’t know where(the small orange pearl-like) was quite tasteful with the soysauce and wasabe(not in picture)

And to end this post, like all meals we have at the end are desserts, a cake cooked by my sister, Susan last year for Christmas

And a piece for all my blogger friends as I unshamefully remind all my blogger friends who had links to my old addrress to change it to the new one. Thank you! And Enjoy the dessert!

A young lady in her 30s was referred to me for having serous mixed with blood(haemoserous) discharge from her previous abdominal incision. This discharge increased during her menses and with the same consistency. She had an emergency surgery a year ago for a ruptured uterus from pyometra (pus within the uterus) She was found to have a congenital (from birth) anomaly. This is her hysterogram

and fistulogram from the skin discharge.

Any guesses?

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