RCS visiting fellow: Ethiopian plastic and reconstructive surgeon Bereket Atnafu at UCLH

I visited University College London Hospital (UCLH) from May 8 to May 21 2017. The objective of my visit was to observe and learn advanced head and neck reconstructive surgery in a modern setup. This included:

• observing and learning the basic skills of microsurgery;
• the system needed to run it;
• understanding the level of advanced head and neck reconstructive surgery in the contemporary world;
• understanding how the health system generally works in a developed setup;
• and establishing links with doctors and surgeons and other health professionals in the UK to acquire and internalize those modern skills and technologies in Ethiopia. 

In the operating room activities, I was able to see three cases of free flap microvascular reconstruction after excision and lymph node dissection for intra oral squamous cell carcinomas. Two of them were free radial forearm flap reconstruction and the third case was LD osseomusculocutaneous flap for reconstruction of the mandible and associated soft tissue/inner linening after failed free fibula flap. Other OR cases I saw included lipotransfer for post radiotherapy facial fibrosis, sentinel lymph node biopsy with gamma camera, fluorescent, and blue dye, parotidectomies with nerve stimulators, maxillary fracture fixations with mini plates and laser biopsy of supraglottic mass.

I attended two multidisciplinary team meetings and gave a 40-minute talk on Ethiopian reconstructive surgery, focusing on head and neck reconstructive surgery. My presentation was focused on pedicled flaps we do for various head and neck reconstructive needs including reverse radial forearm flap and deltopectoral flap which were unusual to most of the audience. I also discussed some of the reconstructive challenges we face in need of sophisticated reconstruction.

I have gained a lot of knowledge and insights on how head and neck cancer reconstructive surgery in particular and the health system in general differs significantly in developed nations and underdeveloped or developing nations. It was very valuable for me and helped me to have a vision of what the best setup looks like, what to aim for and what is possible in our setup with basic reconstructive armaments.

From the clinics, I saw how effectively the GP referral system works and how efficient the communication between specialists and GPs is. The daily morning sessions were very informative of the daily progress of patients and were also very educational as teaching points were raised on cases. Daily rounds were also beneficial for the whole team including the patients as the plan and possible complications were discussed in depth with the patient and all of their inquiries answered.

In the OR, I saw how modern the operating rooms are, how efficiently the OR runs including all the OR teams including surgeons, nurses, and anesthetists - even in the very long cases of tumour surgeries with microvascular reconstruction that took more than 12 hours. All team members were motivated, even out of work hours as was the case in the prolonged free flap surgeries I saw. The technological inputs in the ORs were amazing including modern operating microscope with a monitor, anesthesia machines and monitors, different disposable vessel sealing apparatuses like Liga clip, Liga suture and harmony, gamma camera and fluorescent camera for sentinel lymph node biopsy and many more.

I found the MDTs extremely valuable for the holistic approach to the patient's condition with really important teams like oncologists, radiologists, pathologists and even prior teaching physicians from other hospitals participating in teleconferencing.

Future actions

Free flap microsurgery is quite possible in Ethiopia if we can get proper operating microscopes and functioning micro instruments. I learned that skill and knowledge-wise, free flap microsurgery is not difficult to learn in our setup, considering the already practiced nerve and vesseles microsurgery with loop magnification other than the financial restraints to get the micro gadgets in the first place and to keep them running and the expansion of ORs and hospitals which is already going on in the capital and elsewhere.

I have learned the necessity to interact with different government branches to increase the funding to our health system to acquire important technological inputs like operating microscopes to give standard care to our patients. I have also learned the necessity to interact with different companies for local capacity building with regard to technological inputs to the reconstructive surgery or to the health system in general. Above all, I think working with international partners like the RCS and NGOs who have experience with the proper set up is indispensable to build the setup and to keep it running.

I presented my experience at UCLH in my hospital morning meeting and explained how far developed the western setup is and what we should do to stretch our unit in terms of surgical care, system development, staff motivation and team work among different specialties and technology companies. I think this is possible if we continue to fight in terms of increased finance to reconstructive surgery in particular and to the health system in general and the already OR and hospitals expansion and general industrialization and development. Working with international partners like the RCS and others and NGOs is also very essential for capacity building.

I am extremely grateful to the Royal College of Surgeons for giving me this opportunity to travel and observe modern reconstructive surgeries and developed health system in UK. I am also very thankful of Professor Mark McGurk for inviting me to the UCLH and showing me head and neck cancer reconstructive surgeries and for being very kind to me. I would also like to thank the UK Project Harar team for having me in London and make my stay pleasurable.

In the future, I look forward to continued links between me, my colleagues and my institution and the RCS and Professor McGurk and UCLH and other UK hospitals for further motivation and development of reconstructive surgery and health system in Ethiopia. I also recommend longer practical and hands-on training grants for young surgeons in Ethiopia to advance their ambition into practical intervention.