Many who are following this story are far removed from neck surgeries, and even those of us that have been through them really are not versed on what actually happens as we experience them under the dream state of anesthesia. While I explain neck dissections to patients several times a week along with bone grafting, flaps, harvesting bone from secondary sites to rebuild anatomical structures lost to cancers and so much more in minute detail, I’ve never actually been part of it all. My knowledge about trauma is certainly real world, but about surgery it’s totally didactic. Lectures, scientific papers, and more sources have left me more than literate in it all. I know what/where/why of all the internal structures, and I completely understand the process technically; but actually being there is a whole “nuther” thing. I think most of us think of surgery the way it has been produced for us on TV. Well news flash…especially in an environment without modern equipment that works right, with a shortage of supplies from hemostats to the right suture material, to power going off in the middle of a complex procedure with routine, and beginning the process without scans and x-rays to prep you for what’s there… it’s wildly different. And the blood is not neat and tidy, but occasionally pooled in pockets you formed on each side of the patients neck when you draped them.

I really don’t want to make this post about science so much, but someone did ask about these huge growths we are removing, and I will just quickly tell you what these are. These are thyroid goiters. We don’t see this stuff in the states, because when it happens (as very small nodules and growths) it gets dealt with early, not after ten years of growth, and it just isn’t as common an occurrence. In the third world such as where we operated, one absent of much available medicine, a population that makes 2 dollars a day if anything; in this environment people will live with a growing mass for a decade or more allowing it to become these giant things you are seeing in the images. Ironically, some of this could be circumvented if BASIC things were available to them. One of the most common cause is a lack of iodine in the diet of these people. We in the first world / western, learned the consequences resulting from a lack of it, and we routinely buy items that have had it added, such as table salt and other common foods that are artificially iodized – without even thinking about it – because we need this in our diets and have found simple mechanisms around the issue to obtain it. Unlike vitamin D which our bodies can make from just sunshine, this necessary nutrient is not made by our bodies. In Africa a small source of it is a common banana, but one of those little yellow bits of delight in the great natural packaging has only about 2% of the daily recommended intake. In first world eastern cultures, the eating of seaweed in salads, and as a ubiquitous sushi component, eating just a quarter ounce will give you 3000 times the required daily value. These enlarged thyroids can be benign or malignant, but even if benign, when of the sizes you see in my posts, they compress the trachea compromising breathing, compress the esophagus, compromising the ability to swallow, and when a goiter extends down into the chest, blood returning from the neck and head can be partially obstructed, causing neck veins to bulge, causing a cascade of additional problems. So they compromise life in serious ways. OK so much for the lesson part of all this.

While we all think in terms of scalpels and the sharp blades on them as being the primary tool of surgery, there is a completely different approach, which has significant advantages in certain environments. It is electro surgery, a tool commonly known as a “bovie.” You can Google it if you want to know the details, but in some of the images you will see it in one of its applications, the cutting of tissue. The advantage is that while cutting, it is also cauterizing the cut as it goes… meaning not so much bleeding. Pretty cool. Mark is clearly the master of the bovie, though I suspect a scalpel is an equally routine part of his world as well. With our first anesthetized patient on the table, having skillfully been pre sedated by our volunteer nurse anesthetists, and now in the hands of another stationed at the head of our table; who with outdated monitors and equipment is regulating and responding to every change in the patient’s breathing, heart rate and more, making the necessary adjustments controlling their sedation; Mark draws a clean line across the center of the growth. Imagine the equator on the earth…through this demarcation we will enter the patient’s neck, right above the center of the mass and gradually begin separating the surrounding tissues away from it. With the six inch plus incision made using the bovie, and not a drop of blood on the the patients neck yet, I’m kinda amazed. Suction in hand ready to follow his cut, I realize I’m holding a device that at this juncture is completely unnecessary. I mean this is surgery right?….I’m ready for blood!

Mark places a pair of small retractors (they get really big as we progress) under the edge of the freshly incised skin, and passing them off to me I use them to pull the superficial tissues directly upward. Like he is using a small paint brush, he begins to separate the underlying mass and surrounding structures from the superficial tissues above and around it. His motions are more like