TRANSCRIPT of JHF JOURNAL

GRACELANDGRACELAND
Hernia Foundation
…taking surgery to the grassroots….
GRACELAND HERNIA FOUNDATION.

The Graceland hernia
foundation is a zero
overhead, Non Profit
humanitarian Organization. We
presently operate from an office
located at First Graceland Hospitals,
Km 43lekki/Epe Express Way,
Opposite Corona School Abijo,
Ibeju-lekki,LagosNigeria.
Graceland Hernia Foundation was
established in 2010 in response to
the pervasive poverty in the land
especially as it affect the rural
farmers, urban slum dwellers and
the financially challenged in our society. It was John F Kennedy, the late American
President that said ' Ask not what your country can do for you, but what you can do
for your country. Sickness has no respect for one's social status. Thewell to do is
however, able to take care for themselves and their own leaving the poor at the
mercyofhisownpoverty.
This is why we at Graceland Hernia Foundation took the initiative to come to the aid
ofthisgroupofpeoplethroughawellthought-outplatformtoassistthem,especially
byalleviatingtheirsurgicalburdensandoratleastmakingiteasierforthemtoaccess
quality medical care [surgery inclusive]. Since inception in 2010 and so far, about 3
surgical mission/ outreaches has been conducted with over 500 free surgeries
carried out at little or no cost to the patients. The 2edition of “Ilutitun Free Surgical
Workshop & Seminar” has just been concluded with about 78 surgeries carried out
with zero mortality. About 25 eminent surgeons and surgical practitioners took part.
About equal number of nurses and other paramedical personnel and technical crew
also participated.Ilutitun is in Ondo South SenatorialDistrictof Ondo State and in the
OKITIPUPALGA.Wehopethatthemissioncontinuestobesustained.
The foundation provides free consultation and surgeries and also organizes
MedicalOutreaches, sourced for funds and contacting participating doctors. Our
Primarymotivesaretoreducetheriskofdeathoccasionedbytheirinabilitytoaccess
First Graceland Hospital Premises
quality surgical care, by helping them take care of the surgical burden while they
regaintheirhopesandtobeabletoliveandachievestheirdreams.
Inaddition,GHFalsoorganizesfree“CervicalscreeningCampaigns”tosensitize our
clients on the need to screen themselves against cervical cancer where Nigeria is
among the 5 nations of the world with highest mortality rate from cervical cancer.
The worst part is that Nigeria, in spite of our resources have no action plan to reduce
theprevalenceofcervicalcancer.
As stated earlier on, The Graceland Hernia Foundation is a Non-Governmental
Organization established essentially to promote the welfare activities aimed at the
alleviation of human suffering and overall amelioration and reductionof the menace
of hernia other surgical pathology in our society especially for the poor, helpless and
the hopeless. Hernia is a disease that goes with severe incapacitation and social
stigma.
In local communities, friends and families including wife and children usually
abandon sufferers. It constitutes such a great psychological burden that victims
usually give to hunger and deprivation far easily than the disease itself. Yet this is a
diseasethateasilytreatable.
THEHERNIABURDEN
vAnybodycangetahernia–one-in-tenofuswillgetoneinhisorherlifetime.
vMillions of hernia operations are performed each year, making hernia the
worlds most common of all surgical operations. Well over 100,000 of them are
performedinNigeria.
vHernia affects men and women, boys and girls, and many babies are born with
them.
vAuseful'GoldenRule'isthatonceyouareawareofthesymptomsandahernia
has been diagnosed, it is in your interests to have it fixed as soonand as well as
possible,
vAbout 27% of males and 3% of females develop a groin hernia at some time in
theirlife.[1]Groinherniasoccurmostoftenbeforetheageofoneandafterthe
age of fifty.[2]Inguinal, femoral and abdominal hernias resulted in 51,000
deathsin2013and55,000in1990.
FIRST GRACELAND HOSPITAL PREMISES FIRST GRACELAND HOSPITAL PREMISES
2 3

Our objective is to develop better
coordination, collaboration, joint
participation, relations and
understanding amongst various
stakeholders which includes the people
of low-socio-economic group both
rural/urban, the surgeons and surgical
practitioners and funding
agencies/groups both local and
multinational thus enhancing
andpromoting the welfare of the rural
masses, eradicating Hernia, Hydrocele
and other surgical diseases and
generally making surgical service
accessible and affordable to them.
Bishop Ogunele[The Bishop of the
Anglican Diocese of the Coast] & The
Care Coordinator at the 2ndIlutitun
free surgical workshop & Seminar.
OUR OBJECTIVE
Our aim is to eradicate
hernia among the people
and help them get rid of the
disease by education,
surgeries and creating
awareness and reducing
mortality and morbidity.
AIMS OF GHF
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Iwas and still the Medical Director and the CEO of First Graceland Hospitals since
its establishment in 1992 and up till now. I see to the day to day running of the
hospital. With over 25years surgical experience I knew I needed to do something
to give back to the society. So when God spoke to me in 2010 I knew the hour has come
to fulfill this aspiration. But how was I to achieve this? It was such a big question and
anevenbiggerburdenbutIwas determinedtoseeitthrough.
I consulted a number of people such as DR. Charles AgbamuSagua: a consultant
General Surgeon based in Igboora. I also brought in a young computer guru Mr.
Andrew Love John who helped tremendously to draw up the initial MOU. He was also
instrumental to the CAC registration of the foundation. The first surgical workshop
was carried out aroundApril 2011 at the premises of First Graceland Hospitals, a sister
facility.
About 27surgeries was done with about 16 surgeon on ground to assist us but the total
number of surgeries carried out was a far cry from the huge number that showed up.
Majority of people that heard about us and came were so huge that by the time we were
rounding up we could not even part ourselves in the back for a job well done. In this
regard, it was more of a huge embarrassment. That same year, we organized 2 free
surgical workshop with a total of about 50free surgeries done.Yet the number of those
inneedkepton growing.
It bears restating here that all effort to raise fund proved impossible.All the mails send
out were not even been acknowledged let alone getting financial support. We had
written to all the mega Churches but none responded. The only Church that sent some
patients and funded us was one REAPERS MINISTRY at Adeba road. We least
expected them. All the bigwigs, the notable politicians, community leaders and
associationswereneverforthcoming.
It did not appear as if we were doing it right and we were getting tired and the only
sources of fund: First Graceland Hospitals was having serious financial challenge.
Paying salary became a huge burden. Moral was so low among workers that they
began to leave in droves. We had to call a meeting of all stakeholders to see what we
werenotdoingwell.
It was obvious that something needed to be done and fast too.We realized that we were
not getting any financial support anywhere contrary to the original expectation. Then
we came up with another idea: To make all our beneficiaries our partners by
encouraging them to contribute a flat rate of N10,000 to a revolving SEED FUND.
From this pool, we be able to raise some percentage of our much needed financial
succor.
It turned out to be the most brilliant idea we can ever come with. Now I should also
hastened to add that the cost implication of bringing so many people together to work
under one roof was the single most challenging obstacle that confronted us. All
participating surgical practitioners needed to given a honorarium to at least to fuel
their cars on their way back. We would have to accommodate them in a standard hotel.
There was also the issue of logistics of conveying them to and from hospital every day:
feeding and working equipment and drugs was another issue.And patients would have
tobetreatedafterthesurgery.
This is irrespective of whether the patient has money or not. We also came up with the
idea never to pool patients together at it was presenting a different logistic problem to
us. Once we eliminate this step we may not need to invite as many practitioners as have
been doing. This will greatly reduced the cost of running our workshops. That was
exactlywhatwedid.
From early 2012, we put the new approach into practice and it the worked. I now had to
do most of the surgeries personally and on day-to-day basis.Beneficiaries would now
beattendedtoasanoutpatientthus eliminatingincurringextra-costforthepatients.
All those by reasons of the complexities of their cases needed admission would ask to
pay a small token for in-patient services. The pressure on me was considerable more
earlier on because of the backlog from 2011 but after a while we were able to clear this
backlog completely. Today beneficiaries are attended to whenever they are ready.
Nobody hastowaitfor aparticulartimetohavehis/hersurgerydone.
BACKGROUND
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Through to our mission statement, we have made significant
impart on hernia statistic in Nigeria. From inception in 2010 to
now [2015], over 2000 surgeries have been successfully carried
out. In all these, only one mortality has been recorded so far.
Today, as we eagerly look forward for the much-needed
financial support from well-meaning individual and corporate
organization, we remained undaunted in our resolve to sustain
the present tempo. We also realize the need for a key secretariat
staff to respond to queries, keep vital records and be able track
donors and donor agencies. The staff should also be able attract
and track funds and prepare budgets for specific projections and
projects. The need to sustain the quantum of success recorded in
Ilutitun Surgical Mission Project will see us opening a
communication channel with our traditional partners in the next
few months. We would like to have a better-coordinated support
base. We also need more funds if we are to archive more this
timearound.
THE JOURNEY SO FAR
FIRST GRACELAND HOSPITALS
The GRACELAND HERNIA FOUNDATION, the Nigeria first
and only Specialized Hernia foundationis perhaps the first of its
kind in Nigeria and probably in Africa. In collaboration with
FIRST GRACELAND HOSPITALS, a sister facility, situated at Km 43,
Lekki-Epe Expressway,oppositeThe New Corona School, Lekki, adjacent
Beto Mall,Abijo. Lagos is our Lagos operational base at the moment. Most
of our surgeries in Lagos are done here at the moment. Anyone around
Lagos who wishes to benefit from our activities should endeavor to visit us
during the weekdays. We are hoping to establish a dedicated hernia center,
to be known as GRACELAND HERNIA CENTER in a not too distant
future where apart from surgical treatment that the center will be offering
to clients,would also provides an enabling environment for the study and
other research activities on hernia.For this purpose, we have acquired a
vast expanse of land in a very strategic location of the State. We should be
abletostartconstructionassoon aswecanfindsponsors.
All this fluid [about 10 Liters shown in this pic] was drained out of this
complex mass of Hernia and Hydrocele. No man should be allowed to
suffer this way in silence and all alone for ailment that has a permanent
solution. Let us start byhelping one person at a time and Nigeria and the
World would be a better place. You may not be able to feed a million, but
you can start by feeding just one person at a time. You may not have the
capacity to help one hundred people, why don't you start by assisting just
one person per time? Be reminded that, true happiness comes by making
othersexperiencethefullnessof joy...PaulPrince.
98

WHAT IS A
HERNIA?
Ahernia occurs when an organ or fatty
tissue squeezes through a weak spot in a
surrounding muscle or connective
tissue called fascia. The most common types of
hernia are inguinal (inner groin), incisional
(resulting from an incision), femoral (outer
groin), umbilical (belly button), and hiatal
(upperstomach).
In an inguinal hernia, the intestine or the
bladder protrudes through the abdominal wall
or into the inguinal canal in the groin. About
96% of all groin hernias are inguinal, and most
occur in men because of a natural weakness in
thisarea.
In an incisional hernia, the intestine pushes
through the abdominal wall at the site of
previous abdominal surgery. This type is most
common in elderly or overweight people who
areinactiveafterabdominalsurgery.
A femoral hernia occurs when the intestine
enters the canal carrying the femoral artery into
the upper thigh. Femoral hernias are most
common in women, especially those who are
pregnantorobese.
In an umbilical hernia, part of the small
intestine passes through the abdominal wall near
the navel. Common in newborn, it also
commonly afflicts obese women or those who
havehadmanychildren.
A hiatal herniahappens when the upper
stomach squeezes through the hiatus, an
opening in the diaphragm through which the
esophaguspasses.
What Causes Hernias?
Ultimately, all hernias are caused by a
combination of pressure and an opening or
weakness of muscle or fascia; the pressure
pushes an organ or tissue through the opening or
weak spot. Sometimes the muscle weakness is
presentatbirth;moreoften,itoccurslaterinlife.
Anything that causes an increase in pressure in
theabdomencancauseahernia,including:
vLifting heavy objects without stabilizing the
abdominalmuscles
vDiarrhoeaorconstipation
vPersistentcoughingor sneezing
vIn addition, obesity, poor nutrition, and
smoking, can all weaken muscles and make
herniasmorelikely.
Irrespective of the cause, age and sex of the
sufferers, the definitive treatment of hernia is
surgery. Fortunately, the surgery is affordable,
available, adaptable, accessible and acceptable
to the generality of the people. It requires no
serious gadgets and no special skills nor an
exotic surgical theatre to operate hernia
successfully. With all these understanding and
coupled with the fact that hernia constitute more
than 65% of all surgical burden especially in
blackAfrica, you should then be wandering why
hernia is still such a menace in Nigeria and in
manyAfricancountries.
WHATARETHESIGNS OFHERNIA?
The most common symptom of a hernia is a
bulge or lump in the affected area. In the case of
an inguinal hernia, you may notice a lump on
either side of your pubic bone where your groin
and thigh meet. You're more likely to feel your
herniathroughtouchwhen you're standingup.
If your baby has a hernia, you may only be able
to feel the bulge when he or she is crying. A
bulge is typically the only symptom of an
umbilicalhernia.
Other common symptoms of an inguinal hernia
include:
vPain or discomfort in the affected area
(usually the lower abdomen), especially
when bendingover, coughing,orlifting
vWeakness, pressure, or a feeling of heaviness
intheabdomen
vA burning, gurgling, or aching sensation at
thesiteof thebulge
vOthersymptomsofahiatalherniainclude:
vAcid reflux, which is when stomach acid
moves backward into the Esophagus causing
aburningsensation
vChestpain
vDifficultyswallowing
In some cases, hernias have no symptoms. You
may not know you have a hernia unless it shows
up during a routine physical or a medical exam
for anunrelatedproblem.
TREATMENT
The universally accepted treatment modality for
herniaisSURGERY
1110

HERNIA&
PAINMost hernias do not hurt.
Paradoxically, the larger ones
often hurt less, the reason
being that a large 'window' in the
abdominal wall that allows the intestine
to slide in and out easily is not usually the
cause of pain. Pain tends to occur when
something is getting 'squeezed'. That is
often (although not exclusively)
associatedwithsmallerhernias.
It is a shame, in a way, that the larger
hernias tend not to hurt because that often
leads the patient to think it is not urgent or
important.Itis!
Pain is a very serious warning indeed.
The hernias that DO hurt are also the ones
more likely to strangulate (more on
strangulated hernias later) which is as bad
news asitcouldbe.
One more fact is that the hernias that are
left until they hurt tend to cause the
longestpost-operativepain.
Most hernias do not hurt. Paradoxically,
the larger ones often hurt less, the reason
being that a large 'window' in the
abdominal wall that allows the intestine
to slide in and out easily is not usually the
cause of pain. Pain tends to occur when
something is getting 'squeezed'. That is
often (although not exclusively)
associatedwithsmallerhernias.
It is a shame, in a way, that the larger
hernias tend not to hurt because that often
leads the patient to think it is not urgent or
important.Itis!
Pain is a very serious warning indeed.
The hernias that DO hurt are also the ones
more likely to strangulate (more on
strangulated hernias later) which is as bad
news asitcouldbe.
One more fact is that the hernias that are
left until they hurt tend to cause the
longestpost-operativepain.
But I had a better idea and I would not
have no for an answer. We went to meet
the Late Chief Aduwo of Moribodo chief
Olu Adeboye and intimated him. He it
was who return us back to Kabiyesi, the
Mojuwa of Moribodo Kingdom who
ultimately pray for us and granted us his
blessing.
It was not until then that we went to the
Bishop of the Anglican Diocese of the
Coast Bishop Ogunele who was full of
praises for our endeavors. We also visited
HRH The Rebuja of Osoro Oba Gbadebo
at his Palace at Igbotako. He also
welcomes us and also gave us the much-
neededroyalblessing.
The Ojomo of Osoro Land, Chief
Shehindemi was always on hand to
personally pilot our team wherever we
needed to visit and whomever we may
need to consult. He it was who linked
with the Late Olusegun Agagu who was
the only person who contributed
N100,000 cash towards the first mission.
The entire project was funded by me
while the and 2 hotels Sarajoe and Salem
Guest House, both in Ilutitun, also
supported by providing complimentary
hotel accommodation for all our
participants.
All efforts to bring in the then Council
Chairman yielded no positive result. I
was made to understand that the
youndman, who I briefly met only once,
was from Ode-Aye, a neighboring
community to the North of Okitipupa.
Many things may have militated against
us at the time. Foremost, there was the
politics of Ilutitun/Igbotako dichotomy.
Secondly, many who could have
supported us financially were not so sure
of my intentions. I was practically a
greenhorn here. I had no antecedent that
anybody could relate to. Many felt it was
an attempt ingenious attempt to make the
people buy into my soon-to-be-declared
politicalambition.
For these totally baseless reason many
would-be financiers were not ready to
wastetheirpreciousresources.
1. VENUE;
Right from the word go, the chosen venue
for this workshop/seminar was the
Comprehensive Health Center, Ilutitun
[CHCI]. Our decision was without
prejudice to the prevailing politics of the
local community. As the privileged
Coordinator of Graceland Hernia
Foundation and the Chief convener of the
Workshop, it was entirely my decision to
THECHALLENGES:
SURGICAL MISSION TO ILUTITUN.
[The challenges of taking free surgical Care to Osoroland]
1312

make this call but because I hadn't been
here in almost 30 years, I hadn't the
faintest idea about the state of disrepair in
CHCI. The last time I was here in the
early 80s, the hospital was under
construction. I was also aware that the
construction has since been completed
and the edifice was successfully
commissioned. That was the best I had. I
was totally un-aware that successive
government after the Late Adekunle
Ajasin of UPN has allowed politics to
destroy what was supposed to be
monumenttoposterity.
So, you can imagine how shock we were
to see the state of neglect the facility was
in when we arrived in 2012 for the first
visittoaccessthefacilityonground.
The facility, for no cogent reason, had not
only been abandoned, the state of neglect
was so total that even the few scanty ill-
motivated local security men who were
on duty when we arrived could not
understand what on earth we could be
looking for there. It was a benumbing
sight.
Wild Elephant grass had completely
taking over what used to a beautifully
landscaped areas while dangerous
reptiles had taken possession of whatever
was left. Rodents and other pests made a
nest of the beds and beddings.We did find
it difficult to make a U-turn to attempt to
scout for an alternative. This one was
totally out of the loop. Straight away,
we visited the Ojomo who was my uncle
to brief him and perhaps suggested any
other facility that would hopefully meet
our aspirations. It was his turn now to be
surprice at my rather monumental
ignorance. How on earth would I not
know thestateofthingsinICHC?
How was I supposed to know? Though, I
had been in this town a few times in the
last 30years or so but my sate is usually so
brief that I usually get insulated from such
political issues. It wasn't until after we
were duly entertained that he took us to
the Iju-Ode Health Center. This facility
was either constructed or refurbished by
the immediate past government of Dr.
Olusegun Agagu. This was his ancestral
home after all. The facility was in far
betterstatethanICHC, nodoubt.
I had no hesitation in deciding in favor of
Iju-Odo.The facility was well located and
accessible from all sides. There was a
handful of medical and paramedical staff
on ground that would be of invaluable
assistancetous.
If the undercurrent of the local politics
was anything to go by, then this facility
was our best choice. Coincidentally, it
was located in a community that was
supposed to be politically neutral. That
should be a plus factor for Iju-Odo health
Center.
Having made up our mind on this
location, the High Chief Ojomo took us
to the Palance of The Paramount Ruler of
Osoroland, Oba Gbadebo Bajowa at
Igbotako. The Kabiyesi was happy at
seen us. He prayed for and also gave us
his Royal blessing. We had a chance
meeting at the Rebuja's with some top
officials of Igbotako Descendant Union
[IDU].
They were all full of encomium for this
laudable project and they pledged their
The opening ceremony at the 2nd Ilutitun Free Surgical Workshop and Seminars.
1514

support and promised to liaise with their
President to support us morally and
financially. I felt so bolstered
emotionally. This was a departure from
the negative emotions we had been
strugglingwithallthiswhile.
As we made out of the Kabiyesi's Palace,
he asked me what look like an innocuous
question. Was I from this place[ he must
have sensed that from the passion I put
into my discussion or perhaps my accent.
Whatever it is I did not hesitate to let him
know that I was one of his children from
Ilutitun. Now I could really sense a
sudden disappointment. It was like…”ah
Ishould haveknown”.
As we stood there what the matter was he
broke the house again…”If you will use
our facility here, we will provide all that
you may need including fund and
accommodations”. Because I didn't quite
understand the import of what Kabyesi
was saying, I greeted him and bid him
goodnight. I also left words that we
would want him to be the Royal father of
the day at the Opening Ceremony. He
again waved the Royal Tassel/Horse Tail
in our direction as we excused ourselves
ndmadeintoour carattheparkinglot.
As we sped into the night, my Uncle
wanted to know my opinion
concerning the Alayeluwa's last
request. But he was totally mistaken.
Of course I could not say that I did
not know that the Eminent Royal
Father was trying to pass a message
across to me but I was completely in
the dark as to what he might be
referringto.
What I did not know was that
Igbotako town now has their own
General Hospital. For those who
may not be familiar with local
politics here, Ilutitun, Iju-Odo and
Igbotako were a contiguous communities
separated by brooks. The founders of
these 3 towns were practically siblings
with parentage traceable to one single
mother.
I n t e r m a r r i a g e s a n d p h y s i c a l
development has overtaken all known
physical boundaries so much whatever
boundary we have now would only be in
our consciousness. Yet we find it easy to
promote our differences rather than our
commonheritage.
Going back to my uncle's question, you
could imagine my total surprise to think
that the revered Kabiyesi was implying
what my Uncle was hinting at. I thought
wewerefarbeyondthisdivisivepolitics.
For the rest of the journey home that night
I was very uncomfortable and unhappy.
All the decisions that we had made earlier
on were coming back to me now. I was
more confused that we started out.All the
issues I thought we had settled may not
have been settled afterall. Meanwhile, I
should tell you that on our back home that
night, mu Uncle pointed a barely
perceptible structures he claimed was the
new Igbitako general Hospital. Though,
we could not see well because it was dark
and perhaps there was no Electricity that
night and may be their generator had been
switched off but he promised to bring us
back in the day time to inspect the facility,
ifweevercare.Weneverhaveto.
As soon as the full import of what the
Royal Father said hit home to me, I knew I
had to return back to ICHC. I do not want
to be sucked in by these political
tendencies that I think may do more harm
than good to our people. This program is
for the suffering masses irrespective of
political affiliations, creed, tribe or
religious inclinations. It is not about
which town or community hosting us but
about the health of the people. It is really
irrelevant whether you are Ikale, Ibo,
Housa or Urobo. We are primarily here
for all that may be in serious need. I am
persuaded that God has sent me here for
this purpose and I do not want to miss this
opportunity to be a useful tool in God's
hand. Instantly, I knew I must revisit the
ICHC the following day in company of
my elderly Erudite companion Prof. H.
Adeyemi-doro. Prof. Adeyemi-doro died
early this year [2015] in Otan Ayegbaju,
his hometown in Osun State. May his rest
inperfectpeace.Amen.
With all these at the back of my mind, I
went back to the ICHC early the
following day to re-assessed the
magnitude of work to be done to bring the
hospitaltopar.
We got in touch with some of the nursing
and other paramedical worker who
fortunately were not staying not too far
away from the hospital premises. We
gave out some fund to the gardener to
immediately commence the clearing of
theovergrown weed.
We also encourage the nursing and
paramedical staff to begin the cleaning,
dusting and fixing of damaged and
dilapidated fixtures while we sought out a
furniture man to help provide 10
temporary theatre beds and overhead
tables for our instrument during surgery.
As the Lord would have it, these workers
perhaps were our greatest assets. They
were very resourceful and highly
motivated.
They were more than eager to see the
hospital becoming functional again.
Right there and then calls were placed to
there friends across the entire local
government inviting all to come and be
part of this entirely private initiative to
bring succor and smiles to the faces of all
thosewho wereburdenedbyhernia.
I was emboldened and happy. We visited
all hospitals, private and public, across
the 5 South Senatorial district of the State.
From Big Road to Ore and to Okitipupa
and to Igbokoda in riverine area of the
state. We went from Ikonya to Ilutitun,
Igbotako, Iju-Odo and to as far as
Akinfosilejunction.
Though the people were happy about it,
but many remained patently skeptical for
1716

number of reasons. Some felt we might be
using this opportunity to collect money
for personal gains. Some others were of
the opinion that were people of white
skin, we cannot be trusted to fulfill our
promise to them. For many others, we
were perhaps politician try to hoodwink
them for a hideous political end. The
challenges were seemingly endless but I
was determined and refused to be
discouraged.
Originally, the idea to establish the
foundation came in 2010 in Gboko,
Benue State. The idea was to source for
fund to from well meaning Nigerian and
non-Nigerian including Multilateral
donor agencies across the word to
prosecute this project but the support had
been few and far between. Not until the
second edition in 2014 that the Okitipupa
Local government during the tenure of
the Immediate past Sole Administrator
Mr Niyi pirisola that we were able to get
something from the State. For this we
would always be eternally grateful to
him.
During the first edition in 2012, nothing
was given and nothing was received from
anybody. Of course, we cannot but
commend the efforts of the Anglican
Diocese of the Coast, Bishop and Mrs
Ogunele who through the Church fed and
accommodatedus all.
He remained the only consistent
supporter that over the years has
remained consistent on our side. In 2012,
when the Chiefs mention his name, it was
in the negative. We were asked never to
border to see the bishop as a section of the
community especially the Chiefs has a
contrary view of him but we were
undaunted.
FUNDING
The church is about the only place where
the common man has hope. This is about
the quickest way to easily reach the
people. More over, the Church remained
invaluable partners in Lagos where we
have done several similar workshops
successfully. We were undaunted. By the
time we the highly Revered Man of God,
it was obvious that he turned out to be the
first real supporter we had. He was very
for us all the way. He promised to
accommodate and as to feed our entire
contingent. He made good his promise.
By 2014 when we returned again to
Ilutitun, he also fed and accommodated
morethanhalfof our expanded.
He was personally on ground to received
and welcomes us to his domain. We were
also received and had the royal Blessing
of HRH Oba Mojuwa of Moribodoland.
During the 2014 edition as mentioned
earlier on, Mr Niyi Pirisola, the
Okitipupa local Council contributed
immenselytothesuccessof theprogram.
During our maiden visit in 2012, about 47
surgeries were done and we expended
about N1.2million. Out of which only
N100,000 cash donation came in through
Dr. OlusegunAgagu.This amount did not
factored in the contribution in kind by the
Church and the 2 hotels that gave us 4
complimentary hotel accommodation for
some of our delegates. In that meeting,
we had about 23 doctors and about 30
nurse and paramedical staff in
attendance. And about 200 patients were
screenedaltogether.
Two years later, in 2014, by the time we
returned back, over 2thousand
respondent were waiting for us. Our
budget had jumped to N2million
excluding the fund expended by the
Church and complimentary hotel
accommodations.
There were over 25 eminent surgical
practitioners and 60 nurses and
paramedical staff as well as 3dedicated
technical crew who were engaged to
record our activities for posterity. In just
2days about 78surgeries were
successfully carried out and just like
during our maiden visit, not a single
mortality was recorded. To God be the
glory.
STATISTICAL ILUSTRATIONS OF THE FIRST FREE SURGICAL MISSION TO ILUTITUN
1918

CIRCUMCISION USING
PAULINE'S
The procedure is preferable for
babies under 3 months of age
but it can be used for babies of
up to 2years of age. In my practice I
prefer my circumcisions done about
2weeks after birth. When started
initially, we were doing our
circumcisions along with Ear Piercing
within the first 3days as part of the
freebies to encourage our ANC patients
to encourage them to come for
deliveries rather than ending up at
TBA's of worse still have their babies
even on the road, at home or in the
farms.
But we had to stop because it was not
having the desired result. Some may
have been discouraged because they felt
it was not in keeping with the local
culture.
vThe procedure is best in a naturally
well-illuminated and cozy
environment.
vThe baby needed not to be
completely exposed: We preferred
the top retained to minimize baby's
discomfort.
vIdeally, a strip of sterilized gauze
about 6cm soaked in Olive Oil
should have been prepared before
hand.
INSTRUMENTS:
METHOD
By Paul Jesuyajolu
1. AsmallinstrumentTray.
2. Agalleypot
3. Amediumsizekidneydish.
4. AbottleofOliveOil
5. 3 nos artery forceps preferably
number3mosquito.
6. AboneCrushingforceps
7. Asmallsterilepack.
8. A tongue depressor or a wooding
spatula.
9. AtigerBlade.
10.A pair of sterile glove [Over the
years we have been using Latex
glove the same outcome. There may
not be any real need for a pair sterile
glove which will only add to the cost
un-necessarily]
The procedure can only be performed
with an experienced assistant. The
assistant would place the baby tummy-
up position, on a sterile Mackintosh,
with both legs held firmly in a well-
flexed and externally rotated position.
This gives ample room for the surgeon
to maneuver while the baby is well
restrained. In this position, the elbows
of the assistant would have been used to
pin down, at the same time, the baby's
arms and also supporting the baby's
headfrommovingsidetoside.
vThe baby's top is rolled up to expose
the genitalia and up to the level of the
navel.
vThe skin is scrubbed with Savlon and
thereaftermopeddry
vAt rest, a mark is made on the Phallus
skin just below the impressions of
the gland. This can be done by
simply picking up the skin with one
of the artery forceps and apply
sufficient pressure with aim of
leaving a mark on the Phallus skin.
The baby usually yells in response in
response.
vThe foreskin is now picked up again
with 2 artery forceps exposing the
PROCEDURE:
tiny orifice. The third artery forceps
is then introduced gently at an angle
to avoid traumatizing the urethra.
The introduced forceps is now used
to free the glans from the fore skin.
Once done, the introduced forceps is
now withdrawn halfway before
being opened wide to further
widenedtheusuallytinyorifice.This
step is necessary to allow the glans to
be expose through the hitherto very
tinyorifice.
vThe redundant skin is now milked
down exposingtheglans
vThe exposed glans is now cleaned
free of Smegma and other secretions
especially around the sulcus. It is
very important that the glans is well
exposed including the grove at the
sulcusforagoodoutcome.
vThe glans is now released and
worked on to retract back into the
redundantskinagain.
vThe glans is now milked down while
holding the foreskin is been held
between the thumb and the left index
finger. The glans is pushed down
way below the mark made on the
skin earlier on at the beginning. The
is to create enough clearance for the
foreskin to be sectioned without risk
to the glans using the Bone crushing
forceps.
vWith the foreskin held up the bone
crushing forceps is carefully
introduced just above the mark
initially made on the skin in such a
way that the flat part is adjacent to
the left fingers still holding tightly to
the redundant skin while the un-even
part is towards the glans at the other
side.
vThe bone crushing forceps is now
clamped firmly over the firmly held
2120

redundant skin just above the
original skin mark. The bone
crushing forceps can be place below
or above the skin mark depending on
the position of the skin mark. The
most important thing here is to be
sure that whatever you do the
foreskin taken out should be enough
and should not be excessive…just
enoughtogivegoodexposureatrest.
vOnce the Bone Crushing forceps is
appropriately positioned free of the
glans, then it is then clamped down
and a good measure of force applied
for between 3minutes and then the
foreskin thereafter sectioned using a
new Tiger brand blade. The pressure
should still be maintained for
another 2minutes after before being
releasedfinally.
vIf due process is followed, the
prepuce should still rap around the
glans completely even after the BCF
is taken off and there should be no
bleedingwhatsoever.
vThe stump is now held firmly with
the left thumb and index finger while
an artery forceps is now used to price
open a pin-hole through the sealed
foreskin and the pressed glans is
allowed to squeeze through exposing
the glans. A tiny strip of raw skin
must clearly separate the glans from
theskincoveringtheshaft.
vFinally, the wound is covered with
the gauze preparation soaked in
Olive Oil. This is to remain in place
for just 2day and it is taken off by the
third day and thereafter dressing is
sustained using olive Oil. Our
wound usually heals within a week
andatmostunder10days.
vThis is an absolutely bloodless
procedure. It is simple, affordable
and easy to master after a few
attempts.
vAdult circumcision in a 25year old
Nigerian. This is perhaps the first
time in over 25years that the writer is
coming across something like this.
The youngman was probably
compelled and usually by his fiance,
to have the circumcision done else
therewouldbenomarriage.
vThis is very significant in many
African nations where it may not be
within the individual men to make a
c h o i c e b e t w e e n h a v i n g a
circumcisionandnothavingitdone.
vThe default position in most
Nigerian communities is that every
rationalmanmustbecircumcised.
A poorly done circumcision being
brought to us for correction. We do see
quite a lot of these type of shoddy job in
my practice. Most of the victims are
usually from TBAs or healthworkers
who practices at home or those who
practicesquackeryathome.
Introduction
Male circumcision is the surgical
removal of the foreskin. The foreskin is
LITERATURE REVIEW:
the hood of skin covering the end of the
penis,whichcanbegentlypulledback.
Circumcisionmaybeperformedfor:
· Religious reasons – circumcision
is a common practice in the Jewish and
Islamic faiths, and is also practised by
manyAfricancommunitiesasatr
· ibalorethnictradition.
· Medical reasons, although
alternative treatments are usually
preferredtocircumcision.
· Globally, 30% of men are
circumcised, mostly for religious
reasons. In many African societies,
male circumcision is carried out for
cultural reasons, particularly as an
initiation ritual and a rite of passage into
manhood
The origin of male circumcision is not
known with certainty. It has been
variously proposed that it began as a
religious sacrifice, as a rite of passage
marking a boy's entrance into
adulthood, as a form of sympathetic
magic to ensure virility or fertility, as a
means of reducing sexual pleasure, as
an aid to hygiene where regular bathing
was impractical, as a means of marking
those of higher social status, as a means
of humiliating enemies and slaves by
symbolic castration, as a means of
differentiating a circumcising group
from their non-circumcising neighbors,
as a means of discouraging mastubation
or other socially proscribed sexual
behaviors, as a means of removing
"excess" pleasure, as a means of
increasing a man's attractiveness to
women, as a demonstration of one's
ability to endure pain, or as a male
counterpart to menstruationor the
breaking of the hymen, or to copy the
HISTORYOFCERCUMCISION:
rare natural occurrence of a missing
foreskin of an important leader a way to
repel demonesses and as a display of
disgust of the smegma produced by
theforeskin. Removing the foreskin can
prevent or treat a medical condition
known asphimosis.
It has been suggested that the custom of
circumcision gave advantages to tribes
that practiced it and thus led to its
spread.
The oldest documentary evidence of loil
circumcision comes from Ancient
Egypt . Circumcision was common,
although not universal, among ancient
Semintic people. In the aftermath of the
conquests of Alexander the Great,
however, Greek dislike of circumcision
(they regarded a man as truly "naked"
only if his prepuce was retracted) led to
a decline in its incidence among many
peoplesthathadpreviouslypractices.
Circumcision has ancient roots among
several ethnic groups in sub-equatorial
Africa, and is still performed on
adolescent boys to symbolize their
transitiontowarriorstatusoradulthood.
The young men in the eastern Cape
belong to the Xhosa ethnic group for
whom circumcision is considered part
of the passage into manhood. ... A law
was recently introduced requiring
initiation schools to be licensed and
only allowing circumcisions to be
performedonyouthsaged18andolder.
After circumcision, young men became
members of the warrior class, and were
free to date and marry. The graduants
became a fraternity which served
2322

together, and continued to have mutual
obligationtoeachotherforlife.
In the modern context in EastAfrica, the
physical element of male circumcision
remains (in the societies that have
historically practiced it) but without
most of the other accompanying rites,
context and programs. For many, the
operation is now performed in private
on one individual, in a hospital or
doctor's office. Anesthesia is often used
in such settings. There are tribes
however, that do not accept this
modernized practice. They insist on
circumcision in a group ceremony, and a
test of courage at the banks of a river.
This more traditional approach is
common amongst the Meru and the
KisiitribesofKenya.
African cultural history is conveniently
spoken of in terms of language group.
The Niger–Congo speakers of today
extend from Senegal to Kenya to South
Africa and all points between. In the
historic period, the Niger–Congo
speaking peoples predominantly have
and have had male circumcision which
occurred in young warrior initiation
schools, the schools of Senegal and
Gambia being not so very different from
those of the Kenyan Gikuyu and South
African Zulu. Their common ancestor
was a horticultural group five, perhaps
seven, thousand years ago from an area
oftheCross RiverinmodernNigeria.
A variety of studies confirm that new-
born infant responses to pain are similar
to and greater than those in adult
subjects. Robert Van Howe, M.D., a
Michigan paediatrician who has
FINALLY A WORD OR TWO ON
PAINS:
authored numerous studies about
circumcision, describes the infant's
response. "Circumcision results in not
only severe pain but also an increased
risk of choking and difficulty breathing.
Medical studies show significant
increases in heart rate and level of blood
stress hormone. Some infants do not cry
because they go into shock from the
overwhelming pain of the surgery."
According to clinical definitions and
researchers' reports, circumcision is
traumatic. Even when pain medication
is used (local injection, the best option
tested), it relieves only some of the pain,
the effect is inconsistent, and it wanes
before the post-operative pain does.
General anaesthesia is not considered
safefornewborninfants.
Increased awareness of extreme
circumcision pain by Jewish mothers
has contributed to growing questioning
and forgoing of circumcision by some
Jews, as reported in dozens of articles
appearing in mainstream Jewish
publications on the topic in recent years.
Five rabbis endorse a book that
questionsJewish circumcision.
1. Wkipedia.
2. Sorrells, M. et al., "Fine-Touch Pressure
Thresholds in the Adult Penis," BJU
International99(2007):864-869.
3. How MaleCircumcisionHarmsWomenBy
RonaldGoldman,Ph.D.
4. Magoha GAO. Circumcision in various
Nigerian and Kenyan hospitals. East Afr
MedJ 1999;76:583-6 pmid:10734511.
5. Jump up^ Encyclopædia Britannica, 10th
Edition(1902),ArticleaboutCircumcision.
successful in preventing recurrences
when combined with excision. Dosing is
15-20 mg given in a single dose every 4
days, starting a week before surgery and
continuingfor3months.
Pentoxifylline (Trental) 400 mg 3 times a
day has had some impact on decreasing
recurrence. The mechanism is not fully
known.
Colchicine inhibits collagen synthesis,
microtubular disruption, and
collagenase stimulation, and is thus used
inthetreatmentofkeloids.
Other medical therapies used with
limited success include topical zinc,
interlesional verapamil, cyclosporine, D-
penicillamine, relaxin, and topical
mitomycinC.
Because of the high recurrence rate of
keloidscars,afollow-upperiodofatleast
1 year is required to enable the start of
treatment of recurrences as expediently
as possible and to evaluate long-term
success.
Our Contact:
C/o
FIRST GRACELAND HOSPITALS
Km 43, LekkiEpe Expressway Abijo, IbejuLekki, Lagos State, Nigeria.
Opp. Corona School, Lekki and by Beto Mall
Phone: 0706 552 2167; 0802 372 4546
E-mails: pauljesuyajolu@yahoo.com
firstgracelandhospital@yahoo.com
pauljesuyajolu2@gmail.com
Website: www.gracelandherniafoundation.org
www.gracelandhernia.com.ng
4324

2625

CASE PRESENTATION 1.
By Dr. Adetoki Olukunle
PAROTID GLANDPAROTID GLAND
TUMOURBIODATATUMOURBIODATA
B.J
16years
Male
Student
Ikorodu,Lagos.
Religion:Christian.
LeftjawswellingX5yearsduration.
Apparently well until about 5years ago
when he started having left jaw swelling.
Initially the mass was small but has been
progressively increasing in size over the last
5years.
PRESENTINGCOMPLAINTS
HISTORYOFPRESENTINGCOMPLAINTS
There was history of associated pain
especially while chewing food. The pain has
nobearingwhatsoeverwithswallowing.No
associated history of drooling of saliva and
no history of similar swelling in any other
partofthebodyorinthepast.
Nil history of contacts with anyone with
similar swelling or history of swelling in his
other siblings. Nil history of abdominal pain
orscrotalpain.
Patient presented at sister private hospital
where some drugs where administered
withoutanysignificantimprovement.
He also presented at trado-medical Centre
where scarification marks was made on the
swelling, which according to the patient,
made the swelling to subside for a while
only to progressively increases again but
withlittleornopainthistimearound.
Patient presented at this Centre after
hearing about GRACELAND HERNIA
FOUNDATIONONradio.
vNil history of surgery or hospital
admission,
vNil blood transfusion, not a known
asthmatic,
vNotaknownPUDpatient
vNilhistoryofdrugsallergy,genotypenot
known.
vHedoesnotsmokeortakealcohol.
A young boy, afebrile, not pale, anicteric,
notcyanosed,wellhydrated.
HeadandNeck-
vA dimorphic facie with left jaw swelling
about12cmX10cm.
OBJECTIVEFINDINGS
vNottender,Nodifferentialwarmth
vNot movable, attached to overlying
structure.
vDoesnottrans-illuminate.
CNS-Nosignificantfindings.
CVS/ABD-NAD
INVESTIGATIONS.
FBC: PCV-37%,WBC:5000/mm
HBV,HBC: NEGATIVE
HIVI&II: NEGATIVE
X-RAY:
ULTRASOUNDSCANREVEAL:
DIAGNOSIS- ?PAROTIDGLANDTUMOUR
Counsel patient and relative on nature of
illness
Counselforsurgery:–ExcisionalBiopsy.
Obtaininformconsent
ForsurgeryASAP
A multi-cystic mass containing fluids and
blood,whichwasremoved
Leftparotidisintact
PLAN:–
INTRAOPERATIVEFINDINGS
2827

The cystic mass is directly overlying the
parotidgland.
HISTOPATHOLOGYRESULT(MECURE)
Microscopy Specimen consists of 3 soft and
rough surfaced greyish brown 2X2X1cm to
3x2x1.5cm
INTRAOPERATIVE DIAGNOSIS: CYSTIC
MASS OVERLYING A NORMAL PAROTID
GLAND.
Microscopy Histologic sections show dense
inflammatory exudate comprises of
granulation tissue reaction and
lymphocytic aggregates. The inflammatory
exudate is disposed on fibrous stroma with
adjoining skeletal muscles. No parotid
glandisseen.
DIAGNOSIS:Organizingabscess.
SALIVARYGLANDTUMOUR
Salivary gland cancer is a cancer that forms
in tissues of a salivary gland. The salivary
glands are classified as major and minor.
The major salivary glands consist of the
parotid, submandibular, and sublingual
glands. The minor glands include small
mucus-secretingglandslocatedthroughout
the palate, nasal and oral cavity.[1] Salivary
gland cancer is rare, with 2% of head and
neck tumors forming in the salivary glands,
themajorityintheparotid.[2]
Due to diverse nature of salivary gland
neoplasms, many different terms and
classification systems have been used.
Perhaps the most widely used currently is
that system proposed by the World Health
Organization in 2004, which classifies
salivary neoplasms as primary or
secondary, benign or malignant, and also by
tissue of origin. This system defines five
broad categories of salivary gland
neoplasms:[3][4]
vMalignantepithelialtumors
vAciniccellcarcinoma
vMucoepidermoidcarcinoma
vAdenoidcysticcarcinoma
vP o l y m o r p h o u s l o w - g r a d e
adenocarcinoma
vEpithelial-myoepithelialcarcinoma
LITERATURE
Classification
vClear cell carcinoma, not otherwise
specified
vBasalcelladenocarcinoma
vSebaceouscarcinoma
vSebaceouslymphadenocarcinoma
vCystadenocarcinoma
vL o w - g r a d e c r i b r i f o r m
cystadenocarcinoma
vMucinousadenocarcinoma
vOncocyticcarcinoma
vSalivaryductcarcinoma
vSalivary duct carcinoma, not otherwise
specified
vAdenocarcinoma, not otherwise
specified
vMyoepithelialcarcinoma
vCarcinomaexpleomorphicadenoma
vCarcinosarcoma
vMetastasizingpleomorphicadenoma
vSquamouscellcarcinoma
vLargecellcarcinoma
vLymphoepithelialcarcinoma
vSialoblastoma
vBenignepithelialtumors
vPleomorphicadenoma
vMyoepithelioma
vBasalcelladenoma
vWarthin'stumor
vOncocytoma
vCanalicularadenoma
vLymphadenoma
vSebaceouslymphadenoma
vNonsebaceouslymphadenoma
vDuctalpapilloma
vInvertedductalpapilloma
vIntraductalpapilloma
vSialadenomapapilliferum
vCystadenoma
vSofttissuetumors
vHemangioma
vHematolymphoidtumors
vHodgkinlymphoma
vDiffuselargeB-celllymphoma
vExtranodal marginal zone B cell
lymphoma
Secondary tumors (i.e. a tumor which has
metastasized to the salivary gland from a
distantlocation)
Others, not included in the WHO
classificationabove,include:[3]
Intraosseous (central) salivary gland
tumors
Hybrid tumors (i.e. a tumor displaying
combinedformsofhistologictumortypes)
vHybridcarcinoma
vOthers
vOthers
vKeratocystoma
vSialolipoma
Benign tumor of the submandibular gland,
also known as pleomorphic adenoma,
presented as a painless neck mass in a 40-
year-old man. At the left of the image is the
white tumor with its characteristic
cartilaginous cut surface. To the right is the
normally lobated submandibular salivary
gland.
Signs include fluid draining from the ear,
pain, numbness, weakness, trouble
swallowing, and a lump. The most common
symptom of major salivary gland cancer is a
painless lump in the affected gland,
sometimesaccompanied byparalysis of the
facialnerve.
The chief risk factor is chewing tobacco,
followed by smoking. Other risk factors
include older age, radiation therapy
treatment to head or neck, and being
exposed to certain carcinogenic substances
SYMPTOMS
SIGNS
CAUSES
PIX. 3
3029

atwork.
Exams and Tests(Diagnosis)? An
examination by a health care provider or
dentist shows a larger than normal salivary
gland, usually one of the parotid
glands.??Testsmayinclude:
vX-rays of the salivary gland (called a
ptyalogram or sialogram) to look for a
tumor
vUltrasound, CT scan or MRI to confirm
that there is a growth, and to see if the
cancerhasspreadtolymphnodesinthe
neck
vSalivary gland biopsy or fine needle
aspiration to determine whether the
tumor is benign or malignant. Enlarged
cervical lymph nodes in association
with a salivary gland tumor are
considered a manifestation of cancer
until proved otherwise. In the parotid
region, the presence of pain, recent
rapid enlargement of a preexisting
nodule, skin involvement, or facial
nerve paralysis suggests cancer. Fine-
needle aspiration is indicated if
accurate diagnosis will allow for better
treatmentplanning.
Abstainingfromsmoking,chewingtobacco.
Maintaining a diet high in fiber and green
leafy vegetables. Change your toothbrush
atregularintervals(weekly)
Treatmentmayincludethefollowing:
Surgerywithorwithoutradiation
Radiotherapy
Fast neutron therapy has been used
successfully to treat salivary gland
tumors,[5] and has shown to be
significantly more effective than photons in
PREVENTION
TREATMENT
studies treating un-resettable salivary
glandtumors.[6][7]*Chemotherapy.
Outlook(Prognosis)
Most salivary gland tumors are
noncancerous and slow growing. Removing
the tumor with surgery usually cures the
condition. In rare cases, the tumor is
cancerousandfurthertreatmentisneeded.
vCancerous tumors may cause further
complications,includingspreadtoother
organs(metastasis).
vIn rare cases, surgery to remove the
tumor can injure the nerve that controls
movementoftheface.
1. Shah JP; Patel SG (2001). Cancer of the Head and Neck.
PMPH-USA.p.240.ISBN978-1-55009-084-0.
2. Harari PM; Connor NP; CaiGrau (12 June 2009).
Functional Preservation and Quality of Life in Head
and Neck Radiotherapy. Springer Science & Business
Media.p.89.ISBN978-3-540-73232-7.
3. Barnes L (23 December 2008). Surgical Pathology of
the Head and Neck 1 (3rd ed.).Taylor & Francis. p.
511. ISBN 978-0-8493-9023-4.Barnes L (2005).
"Chapter 5: Tumors of the salivary glands (chapter
authors: Eveson JW, Auclair P, Gnepp DR, El-Naggar
AK)". Pathology and Genetics of Head and Neck
Tumours (PDF). International Agency for Research
on Cancer, World Health Organization. p. 210. ISBN
978-92-832-2417-4.
4. Douglas JD, KohWJ , Austin-Seymour, M, Laramore GE.
Treatment of Salivary Gland Neoplasms with fast
neutron Radiotherapy. Arch Otolaryngol Head Neck
SurgVol129944-948Sep2003
5. Laramore GE, Krall JM, Griffin TW, Duncan W, Richter
MP, Saroja KR, Maor MH, Davis LW. Neutron versus
photon irradiation for unresectable salivary gland
tumors: final report of an RTOG-MRC randomized
clinical trial. Int J RadiatOncolBiol Phys. 1993 Sep
30;27(2):235-40.
6. Krüll A, Schwarz R, Engenhart R, et al.: European
results in neutron therapy of malignant salivary
gland tumors. Bull Cancer Radiother 83 (Suppl): 125-
9s,1996
Chemotherapy
PossibleComplications
References
CASE STUDY 2.
By Dr. Awujoola Abayomi Oyekunle
PAROTID GLANDPAROTID GLAND
TUMOURBIODATATUMOURBIODATA
Miss I.C. a 35 Year oldself employed, Christian and of the Igbo tribe presented at the facility
on the 28th of august 2015 with a 24 year history of abnormal tissue scar formation.
She noticed the abnormal scar tissue
formation about 24yrs ago following the
healingofaboil.Theboilbecomesbigger
(grows) underneath the left breast, two
other spots were noticed after a chicken
pot was heat at the lateral part of the left
breast. The scar grew bigger over years
migrating towards the areolar of the left
breast.
There is neither associated itching nor
abnormal sensation on theskinoverlying
theabnormalscartissue.
She does not have any other post
injurious scar or any other similar scar
tissue formation on any other part of her
body.
There is family history of hypertrophic
scar formation in the father and
grandmother.
She had an ophthalmological procedure
carried out last year, a growth suspected
to be pterygium was removed from both
eyes.
No prior hospital admissions or blood
transfusion.
No known medical conditions, blood
3231

groupisA+:genotypeisAA.
She couldn't as certain when she
attained menache. She bleeds for 5 days
inaregular28daysmenstrualcycle.
Shehasneverbeenpregnant.
She is the second child of a four siblings
born to parents married in a
monogamous setting. She is not married
and stays with her family. She drinks
alcoholsocially.Shedoesnotsmoke.
A 35 year old self-employed woman,
presenting with a 24 year history of
abnormal scar tissue formation affecting
the underlying portion and areolar of the
left breast following the healing of a boil
in the same region. There is familial
history of keloid formation in the father
andgrandmother.
PreProcedure
Procedure.
Miss I.C was worked up for excisional
surgeryofthekeloidsfor10days.
SerologytestsFORHEPATITISBandHIV1
AND2cameoutnon-reactive.
PCVwas38%.
She was counseled accordingly and the
procedure was explained extensively,
after which an informed consent was
obtained.
Surgical excision of the keloid scar of the
leftbreast.O7/09/2015.
Procedurewascommencedat10.32am.
In the supine anatomical position, she
wascleanedandroutinelydraped.
Strict aseptic protocols were observed
byalltheaterpersonnel.
Patient's fears allayed as procedure was
commenced with the initiation of local
anaesthesia over and around the flap of
hypertrophic scar tissue on the left
breastandareolar.
The scar tissue was then systematically
excised; haemostasis was secured all
throughouttheprocedure.
Minimal handling of the subcutaneous
tissue was paramount to limiting the
collection of blood in the potential
space.
The surgical incision was closed
interruptedly with chromic catgut
suturesundernotensionatall.
Procedure was well tolerated and was
concludedat12.47pm.
1. She was commenced on oral intake as
tolerated immediately after the
procedure.
2. I.V Ceftriazone 2g stat then 1g 12hrly
for48hours.
3. I.V Metronidazole 500mg 8hrly for 48
hours.
4. I.V Gentamicin 80mg 8hrly for 48
hours.
5. I.VPentazocine30mg8hrlyfor24hrs.
6. I.MDiclofenac75mg8hrlyfor24hrs.
7. DailyDrycompressiondressing.
POD108/09/2015.
Nilcomplaints.
Wounddressingwascleananddry.
Postoporderwascontinued.
POSTOPORDER.
3433

POD209/09/2015.
Nilcomplaints.
Wounddressingwascleananddry.
Patient was subsequently discharged on
oral medications: tablet augmentin
625mg b.d for 5 days, tablet
metronidazole 400mg t.d.s for 5 days,
tablet diclofenac 50mg t.d.s for 3 days,
tabletastyfer1b.dfor1week.Shewasto
continue I.M Gentamicin 160mg for 5
days.
POD3 10/09/2015.-POD13
20/09/2015.
Nil adverse sequelae post operation.
Patient came in on alternate days for
woundinspection.Pictures….
POD14.21/09/2015.
· Patient was placed on the first
doseoftriamcinolone.
· Nextdosetobegivenin2weeks.
Woundgranulatingnormally.
DefinitionandHistoricalBackground
Keloids were described by Egyptian
surgeonsaround1700BC.
Baron Jean-Louis Alibert (1768–1837)
identified the keloid as an entity in 1806.
He called them cancroïde, later changing
the name to chéloïde to avoid confusion
withcancer.Thewordisderivedfromthe
Greek ÷çëﬁ, chele, meaning "hoof", here
in the sense of "crab pincers", and the
suffix -oid, meaning "like". For many
years, Alibert's clinic at Hôpital Saint-
LITERATUREREVIEW
Louiswastheworld'scenterfor.
A keloid is an abnormal proliferation of
scar tissue that forms at the site of
cutaneous injury (eg, on the site of a
surgical incision or trauma); it does not
regress and grows beyond the original
marginsofthescar.
Keloids should not be confused with
hypertrophic scars, which are raised
scars that do not grow beyond the
boundaries of the original wound and
mayreduceovertime.[1]
K e l o i d s a r e b e n i g n d e r m a l
fibroproliferative tumors with no
malignantpotential.
Keloids are found only in humans and
occur in 5-15% of wounds. They tend to
affect both sexes equally, although a
higher incidence exists of women
presenting with keloids, possibly
secondary to the cosmetic implications
associated with the disfigurement. The
frequency of keloid occurrence in
persons with highly pigmented skin is 15
times higher than in persons with less
pigmented skin.[5] The average age at
onset is 10-30 years. Persons at the
extremesofagerarelydevelopkeloids.
Individuals with darker pigmentation,
black persons, and Asian persons are
more likely to develop keloids. In a
random sampling of black individuals, as
many as 16% have reported developing
keloid scars, with an incidence rate of
4.5-16% in the black and Hispanic
Epidemiology
Race
populations. White persons and albinos
are least affected. Alhady's 1969 study
found that Chinese individuals were
more likely to develop keloids than
IndianorMalaysianindividuals.
Some evidence supports a relationship
between genetic predisposition and an
individual's propensity to form keloid
scars. Genetic associations for the
development of abnormal scars have
been found for HLA-B14, HLA-B21, HLA-
BW16, HLA-BW35, HLA-DR5, HLA-
DQW3,andbloodgroupA.
Keloids are dermal fibrotic lesions that
are a variation of the normal wound
healing process. They usually occur
during the healing of a deep skin wound.
Hypertrophic scars and keloids are both
Genetics
Pathophysiology
included in the spectrum of
fibroproliferative disorders. These
abnormal scars result from the loss of
the control mechanisms that normally
regulate the fine balance of tissue repair
andregeneration.
The excessive proliferation of normal
tissue healing processes results in both
hypertrophic scars and keloids. The
production of extracellular matrix
proteins, collagen, elastin, and
proteoglycans presumably is due to a
prolonged inflammatory process in the
wound. Hypertrophic scars are raised,
erythematous, fibrotic lesions that
usually remain confined within the
borders of the original wound. These
scars occur within months of the initial
trauma and have a tendency to remain
stableorregresswithtime.
3635

Keloid formation can occur within a year
after injury, and keloids enlarge well
beyond the original scar margin. The
most frequently involved sites of keloids
are areas of the body that are constantly
subjected to high skin tension. Wounds
on the anterior chest, shoulders, flexor
surfaces of the extremities (eg, deltoid
region), and anterior neck and wounds
that cross skin tension lines are more
susceptibletoabnormalscarformation.
The most important risk factor for the
development of abnormal scars such as
keloids is a wound healing by secondary
intention, especially if healing time is
greater than 3 weeks. Wounds subjected
to a prolonged inflammation, whether
due to a foreign body, infection, burn, or
inadequate wound closure, are at risk of
abnormal scar formation. Areas of
chronic inflammation, such as an earring
site or a site of repeated trauma, are also
more likely to develop keloids.
Occasionally, spontaneous keloids occur
withoutahistoryoftrauma.
After the initial insult to the skin and the
formation of a wound clot, the balance
between granulation tissue degradation
and biosynthesis becomes essential to
adequate healing. Extensive studies of
the biochemical and cellular
composition of keloids compared to
mature scar tissue demonstrate
significant differences. Keloids have an
increased blood vessel density, higher
mesenchymal cell density, a thickened
epidermal layer, and increased mucinous
ground substance. The alpha–smooth
muscle actin fibroblasts, myofibroblasts
important for contractile situations, are
few,ifpresentatall.
The collagen fibrils in keloids are more
irregular, abnormally thick, and have
unidirectional fibers arranged in a highly
stressed orientation.Biochemical
differences in collagen content in normal
hypertrophicscarsandkeloidshavebeen
examined in numerous studies.
Collagenase activity, ie, prolyl
hydroxylase, has been found to be 14
times greater in keloids than in both
hypertrophic scars and normal scars.
Collagen synthesis in keloids is 3 times
greater than in hypertrophic scars and 20
times greater than in normal scars. Type
III collagen, chondroitin 4-sulfate, and
glycosaminoglycan content are higher in
keloids than in both hypertrophic and
normal scars. Collagen cross-linking is
greater in normal scars, while keloids
have immature cross-links that do not
formnormalscarstability.
The increased numbers of fibroblasts,
recruited to the site of tissue damage,
synthesize an overabundance of
fibronectin, and receptor expression is
increased in keloids. Mast cell
population within keloid scars is also
increased, and, subsequently, histamine
productionincreases.
Growth factors and cytokines are
intimately involved in the cycle of wound
healing. Immunohistochemical studies
of keloids demonstrate an amplified
production of tumor necrosis factor
(TNF)–alpha, interferon (INF)–beta, and
interleukin-6. Production of INF-alpha,
INF-gamma, and TNF-beta is diminished.
INF-alpha, INF-beta, and INF-gamma
reduce fibroblast synthesis of collagen
types I, III, and, possibly, VI. A
relationship appears to exist between
immunoglobulins and keloid formation;
while levels of immunoglobulin G and
immunoglobulin M are normal in the
serum of patients with keloids, the
concentration of immunoglobulin G in
the scar tissue is elevated when
compared to hypertrophic and normal
scar tissue. Note that no animal model
exists for experimental investigation of
keloids.
When a patient presents with an
abnormal scar, differentiating a keloid
from a hypertrophic scar is necessary.
Mostpatientswhopresentfortreatment
are concerned about cosmesis, although
some present with complaints of pruritic
pain or a burning sensation around the
scar. Keloids initially manifest as
erythematous lesions devoid of hair
follicles and other normal glandular
tissue. The consistency can range from
soft and doughy to rubbery and hard.
Most keloids tend to grow slowly over
months to a year, extending past the
initial area of injury but rarely into the
subcutaneous tissue. Most keloids
eventually stop growing and remain
stableoreveninvoluteslightly.
Keloids have a normal epidermal layer;
abundant vasculature; increased
mesenchymaldensity,asmanifestedbya
thickened dermis; and increased
inflammatory-cell infiltrate when
compared with normal scar tissue. The
PhysicalExamination
Histology
reticular layer of the dermis consists
mainly of collagen and fibroblasts, and
injury to this layer is thought to
contribute to formation of keloids.
Collagenbundlesinthedermisofnormal
skin appear relaxed and in an unordered
arrangement; collagen bundles are
thicker and more abundant in keloids,
yielding acellular, nodelike structures in
the deep dermal region. The most
consistent histologic distinguishing
characteristic of keloids is the presence
oflarge,broad,closelyarrangedcollagen
fibers composed of numerous fibrils. In
addition to collagen, proteoglycans are
another major extracellular matrix
(ECM) component deposited in excess
amountsinkeloidscars.
There are four histologic features that
are consistently found in keloid
s p e c i m e n s t h a t a r e d e e m e d
pathognomonic for their diagnosis.[4]
They are 1) the presence of
keloidalhyalinized collagen, 2) a
tonguelike advancing edge underneath
normal-appearing epidermis and
papillary dermis, 3) horizontal cellular
fibrous bands in the upper reticular
dermis, and 4) prominent fascialike
fibrousbands.[4]
No single therapeutic modality has been
determined experimentally to be most
effective for treating keloid scars. The
most important thing to consider in the
management of keloid scar formation is
prevention. Prior to all surgical
procedures, thoroughly discuss a history
of abnormal scar formation or a family
Therapy
3837

history of keloid scar formation with the
patient. In a patient with a history of
keloid scars, all nonessential surgery
should be avoided, especially at sites of
predilection. Persons with only earlobe
keloids should not be considered keloid
formers. In situations in which surgery
cannot be avoided, make all attempts to
minimize skin tension and secondary
infection. When possible, preoperative
radiation therapy to the wound is a
useful form of prevention. Also,
antibiotics should be given to cover local
flora, and sterile technique should be
maximized.
Silicone gel sheets and silicone occlusive
dressings have been used with varied
success in the treatment of keloids. The
sheets can be worn for as long as 24 h/d
Occlusivedressings
for up to 1 year, with care to avoid
contact dermatitis and skin breakdown.
The silicone does not appear to enter the
skin; therefore, the antikeloid effects
appear to be secondary to both
occlusion and hydration. Studies have
demonstrated that silicone gel increases
the temperature of the scar, possibly
increasing collagenase activity.
Increased pressure, hydration of the
stratum corneum, and direct pressure on
the wound also may be modes of action.
In some studies, the response rate has
been as high as 79%, showing substantial
reduction in erythema, scar elevation,
and pruritus.[8] However, complete
resolutionhasnotbeennoted.
Mechanical compression dressings have
long been known to be effective forms of
Compression
treatment of keloid scars, especially with
ear lobe keloids. Compression devices
are usually custom-made for the patient
and are most effective if worn 24 h/d.
Pressure devices include garments made
of Dacron spandex bobbinet fabric,
shaped Tubigrip support bandages, or
zinc oxide adhesive plaster. The patient
should start wearing the pressure
garment as soon as re-epithelization
occurs and continue wearing it until scar
m a t u r a t i o n i s e v i d e n t . T h e
recommendedlevelofpressureis25mm
Hg, but good results have been observed
withpressuresaslowas5-15mmHg.
The mechanism of action is unknown;
however, by reducing the oxygen tension
in the wound through occlusion of small
vessels, subsequent reductions in tissue
metabolism, fibroblast proliferation, and
collagen synthesis result. Studies have
demonstrated that with button
compression devices on the earlobe, no
recurrence was noted from 8 months to
4years.
Pharmacological therapyhas long been a
mainstay and relatively effective first-
line therapy of treatment of keloids,
either as sole treatment or in
combination with other therapies.[9]
Intralesional steroid injections
apparently act by diminishing collagen
synthesis, decreasing mucinous ground
substance, and inhibiting collagenase
inhibitors that prevent the degradation
of collagen, thus significantly decreasing
dermal thickening. This is accomplished
by uniform injection of 10-40 mg/mL of
triamcinolone acetonide (Kenalog) into
Corticosteroids
thefreshsiteofscarexcisionwitha25-to
27-gaugeneedleat4-to6-weekintervals
until the scar flattens and discomfort is
controlled. The steroid should be
injected into the papillary dermis (where
collagenase is produced). Avoid injection
into the subcutaneous tissues, which
causes fat atrophy and undercuts the
intendedpurpose.
Studies examining the effects of
corticosteroid injections alone show a 5-
year response rate of 50-100% and
recurrenceratesof9-50%.Whensurgical
excision is combined with steroid
injection, the response rate increases to
85-100%. A typical treatment program of
surgery combined with steroids involves
injecting Kenalog into the wound edges
after excision and repeating injections
into the scar at 6-week intervals for a
totalof6months.
Adverse effects of corticosteroid
injections include atrophy of the skin or
s u b c u t a n e o u s t i s s u e ,
hypopigmentation, telangiectasia,
necrosis ulceration, visible deposition of
steroid in the form of white flecks in the
scar, and systemic effects resulting in
cushingoid habitus. Most of these
adverse effects can be avoided by
confining injections of the lowest
possible dose of steroid to the dermal
layer.
Simple excisional surgery should involve
the least amount of soft tissue handling
to minimize trauma; also, plan the
closure with minimal skin tension along
relaxed skin tension lines. In an effort to
Excisionalsurgery
4039

reduce wound tension, both full- and
split-thickness skin grafts have been
used, but these have been only partially
successful. Make all attempts to remove
a ny s o u rc e o f p o sto p e rat i ve
inflammation, such as trapped hair
follicles, foreign material, hematomas,
orinfectiousareas.
Recurrence rates with surgery alone
range from 45-100%. The combination
of surgical excision with other
modalities, such as corticosteroid
injection, steroid injection with pressure
dressing, x-ray therapy, interstitial
radiation, single fraction radiation,
t e l e t h e r a p y r a d i a t i o n , a n d
brachytherapy have revealed relatively
good results, with 5-year recurrence
ratesreportedfrom8-50%
.
Radiation can be used as monotherapy
or in combination with surgical excision
in order to prevent recurrence. Success
with monotherapy has not been
acceptable, with recurrence rates
reaching 100%. Some success has been
shownwithlargedosesofmonotherapy;
however, this may lead to malignant
transformation 15-30 years later. Thus,
large-dose monotherapy has fallen out
offavor.
The most effective time to give radiation
therapy is during the first 2 weeks after
excision, while fibroblasts are
proliferating. A typical regimen is 300 Gy
every other day for 4 days or 500 Gy
every day for 3 days, starting the day of
surgery. Postoperative radiation is just as
Radiation
effective as combination preoperative
andpostoperativeradiation.
Children should not be irradiated unless
this is the only viable option. If so, the
metaphyses should be shielded. A case
of medullary carcinoma of the thyroid
was reported in an 8-year-old boy after
excisionandpostoperativeradiation.
Some studies have shownthat high-dose
brachytherapy combined with surgical
excision can achieve good to excellent
cosmetic results with an 80-94%
prevention of recurrence. However,
some residual hyperpigmentation (5%)
andtelangiectasias(7%)canoccur.
Cryotherapy uses liquid nitrogen to
cause cell damage and to affect the
microvasculature, causing subsequent
stasis, thrombosis, and transudation of
fluid, which result in cell anoxia. Studies
that have evaluated cryotherapy used a
protocol of 1-3 freeze cycles lasting from
10-30 seconds, repeating the therapy
every 20-30 days. The most common
adverse effects of treatment are pain
and depigmentation. The therapy was
quite effective, as the rate of no
recurrence with significant flattening of
the scar ranges from 51-74%.
Cryotherapy used in combination with
intralesionalsteroidshasanevengreater
response rate, with objective success
reportedin84%ofpatients.
Theadvantageoflasertherapyisthatitis
a precise, hemostatic excision with
Cryosurgery
Lasertherapy
minimal tissue trauma, thereby
eliminating an excessive inflammatory
reaction. The different modes of laser
therapy are flash lamp pulse-dyed laser,
carbon dioxide laser, argon laser, and the
Nd:YAG laser. The carbon dioxide laser
and argon laser work by similar
mechanisms (ie, by inducing collagen
shrinkage through the laser heat). The
pulse-dyed laser induces microvascular
thrombosis, and the Nd:YAG laser
appears to selectively inhibit collagen
metabolismandproduction.
One of the newest therapeutic
modalities is intralesional injection of
INF-alpha, INF-beta, and INF-gamma.
Numerous studies have demonstrated
that these interferons reduce fibroblast
synthesis of collagen types I, III, and,
possibly, VI; reduce mucinous ground
substance production; and increase
collagenase activity. These mechanisms
act by reducing the steady-state levels of
mRNA. Studies examining the effects of
intralesional injections of INF-alpha 2b
and INF-gamma found them effective if
injected immediately postoperatively
into the excision site. INF-alpha 2b
appears to normalize the increased
c o l l a g e n s y n t h e s i s a n d
glycosaminoglycan production by keloid
fibroblasts, resulting in a reduction in the
sizeofthekeloidbyapproximately50%.
This is performed immediately after
surgery by injecting 1 million U to each
linearcentimeterof theskinsurrounding
the postoperative site. Another injection
should be done 1-2 weeks later. INF-
gamma injected weekly reduces the size
Interferontherapy
and elevation of keloids, but the highest
reduction obtained was 50% at 18
weeks.
5-fluorouracil (5-FU) injected
intralesionally has been successfully
usedtotreatsmallkeloids..
Imiquimod induces local production of
interferons at the site of application. It
comes as a 5% cream and is started
immediatelyaftersurgeryandcontinued
daily for 8 weeks. Patients with large
surgical sites, flaps, grafts, or wounds
closed with tension should not start
imiquimod therapy for 4-6 weeks. The
major side effect is mild-to-marked
irritation at the site of application. Often,
therapymustbestoppedforseveraldays
then restarted. Hyperpigmentation
developsin50%oftreatedwounds.
Flurandrenolide tape (Cordran) used on
aformedkeloidwillcauseittosoftenand
flatten over time. This is placed on the
keloid for 12-20 hours a day. It is also
good at eliminating pruritus. Prolonged
usewillcausecutaneousatrophy.
Bleomycin (1 mg/mL) is used with
successtotreatsmallkeloids.
Tacrolimus is a new treatment for keloids
given twice a day. This is based on the
data that it may mute the gil- 1
oncogene.
Methotrexate has proven quite
5-Fluoruracil
Imiquimodtherapy
Othermedicaltherapies
4241

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