Photos

FOR MEDICAL PROFESSIONALS

 

This section contains a captioned slide presentation displaying the spectrum of pathology encountered on the border along with Dr. Mueller’s insights and solutions for successful surgical treatment. 

The descriptions are in professional jargon and the clinical images
are graphic and may be offensive to lay viewers.


Thank you for your interest in my book. This section of the website is intended for medical professionals interested in the realities of successful remote Third World surgery. The patients and their operations depicted over several images are discussed at length in the book itself. The text is clinical and many of the photos are graphic. Lay readers may find the images disturbing and possibly offensive, but such is the reality of surgical mission work.

The Karen's only hospital, located in Htoo Wah Loo, served two million people, until destroyed by the Burmese Army in 1995.

The nurses were uniformed, clean and professional, with access to a limited selection of medicines and supplies. They excelled at their specialty of compassionate care.

Note the view out the OR windows. I'm harvesting a split-thickness skin graft (STSG) with a Humby knife, assisted by Karen medic Mahn Mahn.

After the loss of the Htoo Wah Loo Hospital, many patients still developed problems that required life-saving surgery, like this nine-year-old boy left with a gangrenous left leg following a poisonous snakebite.

Despite the lack of an adequate operating room, the Karen medics performed a successful above-knee amputation on the floor of a village hut. This photo convinced me of the need to develop a new proper surgery program for the Karens. Lives could be saved and suffering alleviated.

Entrance to the Mae Tao Clinic (MTC), on a Thai highway 2 km from the Burma border, the site of the new Surgery Department in 2003.

All patients were housed in a single open ward. Families slept on the floor under the "beds."

Due to the success of the surgery program, a new ward and operating room was built by donors in 2005.

The remodel included a tile floor, 25 beds, and a new operating room. During my annual missions, I performed 20 - 30 major operations, while in my absence, my trained medics performed hundreds of less complex procedures.

Eventually, a dropped ceiling was added as the Surgery Department's evolution continued.

Gauze dressings were handmade by nurses from meter-wide gauze rolls.

Families of patients also helped. All dressings were tied in small bundles, then sterilized in the autoclave.

Anesthesia options were local, spinal and ketamine only for general. Since I had no trained anesthesia support and virtually no diagnostic imaging, procedures in the abdominal cavity were rarely preformed.

Karen medic Eh Tah Mwee quickly became an expert in spinal anesthesia.

The autoclave provided dry sterile gowns, drapes, towels, and washed, recycled lap sponges.

This 70 y/o refugee presented with a forty-year history of an enlarging mass on the back of his head.

Since my patient reported no history of trauma, and the mass did not first appear until he was a young adult, I reasoned that the underlying skull bone should be intact, without herniation of any intracranial contents. The tumor was too large for local anesthesia.

He accepted the risks, and I chose ketamine and a prone position, allowing airway access between shoulder and forehead pillows.

The lipoma shelled out nicely.

Post op day (PO) #5 - no seromas and excellent flap healing.

With a grateful patient on his day of discharge.

58 y/o male with a sacrococcygeal teratoma, enlarging since birth. He had no chance of ever affording an operation in Burma, even if he could find a properly-trained surgeon.

My main concern was preserving his still-continent anal sphincter function, as his anal orifice was two inches down the stalk. He willingly accepted the risks.

After a successful spinal was placed by Chief Medic Lo Kwa, my patient is prepped and the team ready to go. Time for a short prayer requesting favorable anatomy and successful healing.

The dissection is underway, heading down to the pelvic muscles.

Further dissection with Lo Kwa retracting. So far, so good.

Success! This teratoma was filled with egg-shaped sacs, some solid and some with fluid. No hair or teeth, as seen in many teratomas.

PO#4 appearance. A small seroma was drained on PO#2, no new reaccumulation, tight sphincter tone and no pain.

Happy postop patient, now free from his affliction, and surgeon.

80 y/o grandma, six weeks since a right forearm snakebite that caused gangrene and severe pain.

Successful above elbow amputation. My patient reported that her pain was gone the evening of surgery.

Her granddaughter was always there for her.

She reminded me of my four daughters, and was as cute as they come. The sand colored paste on her face is actually ground bark, used both as a sunscreen and cosmetic statement.

This 40 y/o woman had an enlarging tumor over her lower back for 25 years.

As with all of my patients, surgery had never been an available option, until we met.

After a successful ketamine induction, our patient was positioned and ready for a Betadine prep and sterile draping.

Just as I had hoped and prayed for, her tumor could be mostly finger-dissected from the surrounding normal tissue. Its few feeding blood vessels were readily seen and ligated.

Steristrips will reinforce the incision for the first postop week.

Tint Tint proudly displays the tumor after a successful operation.

Our most common major operation was repair of indirect inguinal hernias in males, from young boys to old men.

After hernia sac dissection, reduction of the contents, and distal sac excision, I utilized a modified traditional floor repair with running 3-0 Prolene and, when needed, a superior relaxing incision to eliminate tension.

I avoided mesh since no surgeon would be available to remove it if problems developed. Overweight Burmese refugee patients were quite rare.

Like inguinal hernias, the natural history of many hydroceles is continued enlargement.

A gallon of water weighs over eight pounds, and these two patient's hydroceles had at least that much content. Both had good results with drainage, partial wall resection and eversion about the testicle of the remaining sac wall.

This patient's lipoma had been growing since childhood.


My first choice for skin closure was always 3-0 subcuticular Vicryl and Steristrips. I always brought plenty with me.

The mass was easily removed with a combination of local lidocaine and ketamine.

A buttock lipoma in a six-year-old boy. Again, ketamine made this operation possible.

Problem solved forever with a clean dissection of the encapsulated mass.

I removed many jumbo flank and abdominal wall benign masses.

Once again, a happy and grateful patient.

This nine-year-old boy has a subcutaneous posterior thoracic lipoma.

Without removal, this benign tumor would probably continue to enlarge, at least to softball size. In American, his tumor would already have been removed at a much younger age.

The natural history of basal cell cancer. The ulcer was mobile and without gross evidence of invasion into underlying structures after more than ten years.

PO#7 Excellent growth of new granulation tissue. Ready for skin grafting.

One week following placement of a STSG, with 100% take and a happy patient.

Another clinical basal cell cancer, slowly enlarging over many years.

PO#7 and ready for grafting. I always delayed STSG placement for a week following any elective wide surgical excision, allowing for an adequate bed of granulation tissue to develop, insuring success.

The graft is trimmed and sewn into place.

The graft is stented for 5 days with a paraffin-soaked cotton ball (glycerine is used in the States), to maintain continuous contoured contact between the graft and the recipient bed.

Karen village medics were skilled at open wound care, including debridements, but without access to skin grafting. The procedure requires a manual or electric dermatome, with sharp blades, to harvest the skin graft, and proper training. Without skin grafting, this unfortunate woman, recovering from a cooking oil burn for several months, would probably heal with thick scars and keloids, along with a frozen ankle and partially contracted knee. A skin graft will prevent these healing complications.

Teaching Tint Tint the correct technique for our new Swiss electric dermatome, replacing the manual Humby knife.

The STSG is meshed with small slits to increase its coverage area and allow for drainage of fluid from the recipient site during the early postop course. We used an autoclaved teakwood cutting board and a #15 scalpel blade for meshing.

That's the new dermatome. The harvested graft pieces are trimmed to fit, then sutured to each other and the skin border.

The puzzle is nearly complete. Note the minimal donor site bleeding - the gauze was soaked with 1% lidocaine with epi.

Here is another lower leg with two chronic ulcers and mature granulation tissue treated with a similar procedure.

PO#7 with 100% graft take.

I treated many patients with excessive scarring following trauma, burns and infections that resulted in severe joint contractures. An ankle flexion contracture like this one made walking up and down muddy trails during the six-month rainy season quite a challenge.

Fortunately, after excising the scar contracture, I was pleased to see that her ankle joint had not yet froze and was able to obtain ninety degrees of extension.

A meshed STSG is in place, ready for trimming and placement of final lateral sutures.

Acid was thrown at this poor man's face several years earlier.

After scar release and excision, the good news for my patient was that her ankle joint had not yet froze.

Excision of the keloid left only a remaining thirty-degree contracture, from muscle shortening and joint capsule fibrosis.

A STSG was harvested, meshed and sutured in place.

One year later, physical therapy found in a refugee's day-to-day life restored complete range of motion to his left elbow.

I am examining this unfortunate fresh landmine victim with Eliya, Chief Medic of the Free Burma Rangers, and Lo Kwa, then Chief Medic of the MTC Surgery Department.

Leg amputations were a common operation at the MTC.

This older patient presented with a two year history of right foot gangrene, diabetes, and no pedal pulses. He needed a below knee amputation (BKA).

Anything less would not be expected to heal, and I would not be available for another operation.

Many older male Karens were cheroot smokers and tobacco chewers, leading to significant peripherial arterial disease.

Obviously, this pathology was years in the making.

This patient had no place to go for a simple BKA.

Chronic osteomyletitis after a misguided procedure performed in Burma. An above knee amputation (AKA) solved his problem.

Transecting the fibula in a BKA. All were done under spinal anesthesia, with ketamine backup available if needed.

Ligating the last bleeders during a BKA. Note the elongated posterior skin and muscle flap.

PO#7. Skin flaps viable with no sign of infection. Proper technique requires the incision scar to be on the anterior wall of the stump, well away from the weight-bearing cut end of the tibia.

Another BKA on PO#10 with a subcuticular skin closure.

For years, I averaged five limb amputations per trip. My team performed many more during my absence.

First dressing change on PO#4 following an above knee amputation.

My patients were delighted to be rid of their longstanding maladies.

On most trips, I saw usually five unfortunate women with unmistakable breast cancer.

A biopsy one year ago confirmed breast cancer, but this lady could not afford any more surgery. The mass extended down to the areola, but remained mobile.

If not surgically removed, and metastatic disease is not yet lethal, primary breast cancers eventually will ulcerate.

No need for a pathology diagnosis here, especially with a rock-hard large underlying mass.

Unfortunately, the primary tumor had already invaded the poor woman's rib cage, making her a nonoperative candidate. Note the axillary metastasis.

The sad and painful natural history of breast cancer, with ascites from probable liver mets.

Dissection of superior, medial and inferior skin flaps away from the breast to be excised.

The initial dissection of medial skin flaps away from the breast to be removed.

Completed and dressed modified radical mastectomy. Along with dozens of donated boxes of suture, I brought Hemovac and bulb suction drains on each trip.

Not all breast masses were cancer. Here is a somewhat large, but otherwise typical, well-encapsulated benign fibroadenoma.

Benign masses merited cosmetic incisions.

At the MTC, I even treated one of the rarest breast neoplasms, a cystosarcoma phyllodes, clinically evident in this 30 y/o woman. Her left breast felt rubbery, not hard, and no axillary adenopathy was palpable.

I performed a simple mastectomy. Despite the tumor's size, I encountered no gross pathology during the dissection that would suggest a malignant component.

Note the large solid component of this tumor, resembling a fibroadenoma.

PO#7 With drains three days ago, excellent healing, and no sign of infection, my patient is ready to return to her village.

Not before a final hug from her surgeon. Without the operation, her breast could have enlarged to a massive size and possibly develop cancer. I felt bad about the disfiguring result in such a young woman.

Most of my breast cancer patients knew of the slow and painful death associated with their affliction, and were deeply appreciative of my help.

What could this mass possibly be, slowly growing over several years and now tender and uncomfortable due to its size? It felt firm and rubbery, and no cervical adenopathy was palpable.

The mass was well encapsulated, deep to her mylohyoid muscle and the size of a golf ball.

The well encapsulated cyst contained a gray pasty filling, like found in a sebaceous cyst. I was able to completely excise the intact cyst, resulting in a cure for this patient of whatever it was. Medical mission surgery offered many surprises.

Through short cosmetic incisions, I removed one or two thyroglossal duct cysts on each trip.

Early on, I performed several subtotal thyroidectomies for huge goiters without any problems and good results. I discontinued offering the operation over concern for laryngeal spasm, since I would be the surgeon and the only one at the MTC who knew how to place an endotracheal tube. The potential risk/benefit ratio forced me to tell patients with large goiters, "I'm sorry, but I cannot help you."

I felt compassion for this 24 y/o young lady with a rock-hard sarcoma in her medial lower thigh. The obvious inguinal nodal metastases eliminated any chance for a cure with surgery.

I had no idea what this poor monk had. Not being a urologist, any attempt at a surgical treatment was beyond my skill set.

No amount of surgery could help this unfortunate keloid-producing patient.

The following photos show the basic equipment and tools necessary for safe and effective major surgery. This complete instrument set for a modified radical mastectomy has been washed and is ready to be wrapped and autoclaved. Note the reuseable electrocautery pencil, good for hundreds of operations. Grounding pads were also extensively recycled.

Steel instruments can be sterilized in a pressure cooker, but sterile dry linen drapes, gowns, towels and dressings require an autoclave.

Dry, dust-free storage kept sterilized surgery packs ready.

Electricity, from either a municipal power grid or a generator, is mandatory to power the autoclave, lights and electrocautery.

Multiple lights eliminated shadows. An OR table with armboards allows for ready IV access, and one with adjustable height is kind on the visiting surgeon's back.

Donated electrocautery units are sometimes available, or a refurbished unit can be bought for $1500. I will not perform a major operation without one.

Our MTC OR unit was part of the history of pulse oximeters, c. late 1990's. A modern oximeter is a small, battery-operated clothespin-like device costing $30. I believe that this is the single most useful monitoring device for safe surgery.

My complete sterile backtable for a modified radical mastectomy.

A washing machine is well worth the investment, especially if running water is available.

My MTC medic team: Eliya, on loan from the Free Burma Rangers, Chief Surgical Medic, Lo Kwa, and Tint Tint.

After Lo Kwa emigrated to the States, Eh Tah Mwee succeeded him as Chief Medic of the MTC Surgery Department.

This 50 y/o woman suffered from these painful nodules on her upper lateral thigh since she was a little girl. She never knew life without pain. Her problem was not described in any textbook that I was familiar with.

Inside her thigh I found marbles resembling calcified pieces of cauliflower, with extensive surrounding scar tissue. I excised the rocks and every bit of abnormal tissue through a four-inch incision. My Karen team explained that when she was a small child, she must have been sick with a high fever, and a village witch doctor injected her thigh with coconut milk, then took credit for her survival.

The night of her operation was the first night that this lady slept without pain. The gratitude that she displayed with this hug sums up the rewards that one receives when serving the poorest of the poor. I hope that you found this slide show interesting, informative and perhaps even inspiring. If so, you will enjoy the book even more.