A surgical life by Adesoji Ademuyima

I am Adesoji Ademuyiwa, a paediatric surgeon at the Lagos University Teaching Hospital (LUTH), and professor of surgery at the University of Lagos, Nigeria. I am also privileged to be the Director of the National Institute of Health Research, Global Surgery Unit, Nigeria Hub, editor of the African Journal Paediatric Surgery (AJPS) and the Journal of Clinical Sciences (JCS). My main area of clinical interest is paediatric surgery, but I am also involved in surgical epidemiology, medical education and large, crowd-sourcing collaborative studies.

What made you decide to become a surgeon?

I decided to be a surgeon, specifically a paediatric surgeon, while a medical student at the University of Ibadan. One of my mentors, Professor Temitayo Shokunbi, a neurosurgeon, was the inspiration behind this decision. I loved the dexterity with which he operated, and the almost immediate outcome (within a few days) of surgery. I found this much more appealing than some other aspects of medicine, where reaching a diagnosis could be a conundrum, or when treatment was long-term but without cure. I chose paediatric surgery because I knew I wanted to work with my hands and loved my teachers in paediatrics who taught me not only the art of medicine, but also its social aspects. I also loved the fact that children don’t pretend and do well when operated on.

Who were your influences?

Professor Temitayo Shokunbi, who was my neuroanatomy and neurosurgery teacher, encouraged me to become an anatomy demonstrator at the University of Ibadan. He was good and on top of his game as a neurosurgeon. I should also mention my Professors in paediatrics, the late Vidar Agono Nottidge, Professors Shodehinde and Omokhodion.  These were teachers who were passionate about their patients, and encouraged their students to see themselves as being responsible for life and survival of their patients. The impressions created by this trio are still with me to this day.

What were your training highlights?

I had my undergraduate training at the University of Ibadan (UI), widely regarded as the leading university in Nigeria. I then proceeded to the Obafemi Awolowo University Teaching Hospital Complex (OAUTHC), where I met my teachers in paediatric surgery. I am indebted to Professors Olusanya Adejuyigbe and Dayo Sowande, who devoted their time to teaching me the art and science of surgery. I then moved to Lagos University Teaching Hospital (LUTH), where I still work, having been mentored by Professor Chris Bode. I have had multiple opportunities to undergo clinical training abroad, including the Red Cross War Memorial Children Hospital in Cape Town. I   was privileged to be a Hugh Greenwood scholar of the British Association of Paediatric Surgeons (BAPS), with visits to Kings College Hospital and Great Ormond Street Hospital in London, as well as   Leeds General Infirmary. I also had the privilege of visiting the Nationwide Children Hospital in Ohio, US after being invited by Professor Benedict Nwomeh.

These collective influences led me to become a general paediatric surgeon with a sub-specialist interest in colorectal surgery.

Tell me about a surgical triumph

One patient that I would like to share was an adult, not a child. A 31-year-old man was emaciated with a bloated and distended abdomen was investigated and diagnosed with Hirschsprung’s disease. I was invited to lead the Swenson’s pull through operation. a colostomy seemed mandatory, considering the marked discrepancy between the mega-colon and the lower part of the anus. However, my teacher was one of the first in our country to do primary pull through in infants and the marked difference in outcome was irrefutable as it removed the morbidity of stoma creation. Having learnt the technique well, we decided to offer it to this adult patient and avoid the morbidity of a colostomy.  I realised we would need to excise some part of the colon to get to a more moderate sized large bowel.  The procedure was completed successfully and published. It remains one of the few descriptions of primary  coloanal anastomosis for Hirschsprung’s disease in adults.

The second one is quite an interesting case. I was called to a facility to review a child who was born preterm with low birth weight (<2kg), intestinal atresia and a cardiac anomaly. This child was the fourth in the family but the first boy, so the baby was very precious. I was due to travel and informed the mother of my willingness to operate, but my inability to provide personal follow up beyond the first few days. After discussing the risks involved, the parents, who were committed Christians and encouraged through their faith to proceed, consented to surgery. We were able to correct the intestinal atresia and associated malrotation and the child did well. The child was eventually flown out of Nigeria to fix his cardiac anomaly. He is currently in secondary school.

These are things that make one grateful for the opportunity to be in this profession, and to put smiles on the faces of others.

Tell me what you learned from a surgical disaster

One of the first lessons I learned is that you must know your limits and be ready to call for help. While operating on a   patient with a stage 4 Wilm’s tumour encasing the inferior vena cava, we were attempting to strip the tumour away when there was a tear in the cava. As the team had training in vascular surgery we repaired it ourselves. The patient did well and went back to the ward.  There was no evidence of bleeding at the end of the surgery, but we lost the patient overnight and post-mortem showed intra-abdominal bleeding.  I did not know what we had done wrong as a team or as the leader of the team, but since then, we have insisted on vascular surgeons being present when the great vessels are involved in oncology cases.

The second one is the fact that when a mishap occur, try to think logically and accept that natural healing – a slow process – may be needed. While trying to separate a rectal pouch from the urethra, my assistant transected the posterior urethra. I wasn’t sure what to do, as I had not even seen a similar thing in the books before that. We followed simple principles of re-catheterization and repair of the posterior urethra and decided that it was then safe to continue with the procedure. We gave it time, with the catheter in for 14 days. With trepidation, we removed it on the 14th day and were wondering if the child would be able to urinate on his own. It is difficult to quantify the relief when he did. The urethra healed well confirmed by cystourethrogram and the child has done well ever since. Sometimes when there are mishaps, the body is its own best healer.

What was your proudest achievement?

My proudest achievement was the day a medical student came to me and said “why should I, the head of the unit, be holding the camera for a minimal access procedure being conducted by my former student, former trainee, and now certified minimal access surgeon”. I told the student that it was one of the happiest days of my life, that I was able to train someone who had chosen an aspect of our specialty that I am not very good at, who has now turned out to be far better than me.

What are your hobbies outside surgery?

I try to exercise, take walks, play table tennis when I can. I read books, but  could read more. I also like watching movies and sports.

What advice would you give a young surgeon?

Let me offer just three things. Most importantly, be focused. Don’t get distracted by the many things that can distract a surgeon, like private practice or trying to make ends meet.

Learn to be empathetic.  Don’t take patients for granted, make sure you  communicate adequately with them and don’t assume what you think they might  know

Finally encourage and be prepared to mentor others who are in training or thinking of joining our profession. 

In Nigeria, I would tell them not to ‘japa’. We still need surgeons. The National Surgical Obstetric Anesthesia and Nursing plan document shows that the SAO density in Nigeria is less than 2, compared to the target of 20 per 100,000. In many parts of the world, we cannot have the few people who are training to be surgeons, leaving the health care system that has trained them. Some sense of loyalty, if not patriotism, is needed. This is particularly the case, here in Nigeria

What would you be, if you had not been a surgeon?

An engineer.

Any regrets?

No regrets at all and certainly not the decision to be a paediatric surgeon. I love it and I am passionate about it.  I am constantly sustained by my Christian faith.