Sunday, April 01, 2007
Stones and Knives
No chemist I, unable to explain solubility constants or crystal formation, I can only note and admire: gallstones come in all sizes, shapes, and textures. Hard and shiny like agates, faceted like emeralds, crumbly like clay. Mulberry-shaped, round, uniform or uneven; surfaces determined by their neighbor, or identically shaped as if manufactured. Green, black, bright yellow, fecaloid. They can occur by the hundreds in a single gallbladder, or fill up an entire bag in the form of one gigantic rock. Feeling like a magician, I liked to save a few from the lab and present them to their owners, more amazed than if I'd pulled a quarter from behind their ear. I always enjoyed looking at gallstones. Unless they were oozing out of a gooey gallbladder in the middle of an operation, like cockroaches from a garbage bin.
Learning surgical technique is an incremental process. The student may be allowed to cut some sutures, maybe even tie a few. Simple as that is, it allows a sense of tissue tension, unlearns the old way of holding scissors, teaches the new. Taking up a knife and cutting through the skin requires overcoming practically everything you ever knew. I was eventually allowed to "do" a hernia as a student (a rarity indeed), although I really had no idea what was happening, anatomically speaking. The resident held something in such a way that I had no question of what I was to do, and I did it. As an intern, I did more of them, getting better at maneuvering instruments, placing sutures where I aimed them, cutting without shaking so hard it was visible across the room. Taking out a gallbladder was, where I trained, too big a deal for an intern. It was real surgery, inside the abdomen, close enough to structures of significance, demanding enough of dissecting skills that we waited a year before getting the chance. So it always held special significance: like passing through a portal, like being taught the secret handshake. Tourists in fancy eateries are shown to the main dining area; locals get invited to the wood-paneled special rooms upstairs.
You can do some operations without knowing how to operate. In my book I wrote "with enough bananas, you could teach a monkey to take out an ovary." Some gallbladders are so easy to remove, hanging loosely under the liver like a pluckable plum, that I refer to them as "gynecologic gallbladders." If your first couple of gallbladders are like that, you can get lulled into thinking you know what you're doing. (Way back in my early practice days, when our community allowed more or less unfettered surgery privileges, more than once I was urgently invited in to bail out a family doc who discovered dramatically the mysteries held in the right upper quadrant, and who'd been epiphanized into the realization that knowing how to hold a scissors in one's hand does not a surgeon make.) In those same ancient times, it was believed that operating when the gallbladder was actively inflamed was to be avoided at almost all costs. Whereas it's true that most attacks of acute cholecystitis simmer down without the need for emergency intervention, they don't always. Gallbladders can get severely infected and can rupture (especially in diabetics); acute attacks can flare up again during a cooling off period. More recent studies tend to show that early intervention isn't associated with more problems than waiting. But it sure as hell requires knowing how to operate.
While serving in Vietnam, I "flew" EC-47s. The pilot would arrange power settings and trim, giving over to me the stick and rudder. I "did" takeoffs and landings, accomplished some cool maneuvers over the China Sea. Shit hot, as we pilots liked to say. On final approach, if the crosswinds were a little too harsh and I was coming in crabwise, at the last minute he'd say "I got it" and keep us alive. Under tight tutelage I removed a few gallbladders early in training, and came to feel I could do it. When I first encountered the real thing while helping a young 'un -- a red, swollen, pus-filled gallbladder, speckled with the black spots of gangrene and stuck tightly to the colon and liver -- I squealed for help like a kid who'd wandered out of the shallow end. Throughout my career, when I'd be working my way through such a mess with confidence, at some point I'd always remind myself of that first really scary one, and allow myself a smile. Behind the mask.
In the illustration above, you can see how the colon makes a sharp left turn (the "hepatic flexure" -- "left," by the way, orients vis a vis the patient). In life, it's immediately below the gallbladder, very often touching it. Same with the duodenum, which isn't marked but is the C-shaped tube at the bottom of the stomach. Uninflamed, those structures easily peel away from the gallbladder. There's a thin covering of the gallbladder which holds it to the undersurface of the liver, filmy, as if it were sprayed on, easy to navigate, buzzing a few small bleeders on the way. Down at the business end, the tube that connects the gallbladder to the main bile duct, and the artery that feeds the gallbladder (cystic duct and cystic artery) are usually not to hard to identify and divide: in most cases it takes a little dissection through a layer of fat to find them, typically not a great challenge. Ironically, though, some studies show that it's when things are "easy" that injury is most likely to occur: when your guard is down, you feel relaxed and floaty, recreational, and you might not attend as intently to the anatomy. So they say. Subtle anatomic variations occur here, and they can fool you. Still, with care, it's fun and safe.
Oh man! Not when the gallbladder is acutely inflamed or infected or both. That sprayed-on film is now thick as a the peel of a grapefruit. The colon -- duodenum, also, maybe -- is plastered to the mess and has become inflamed, too, such that where one ends and the other begins is anyone's guess. The adjacent surface of the liver, caught up in the raging redness, is gooified and extra bloody. And the little duct and artery? Good luck! Encased in dense edematous tissue and often indecipherable. This is where everything you've ever learned about handling tissues, every trick you were taught and every wrinkle you've come up with yourself needs to come front and center. When nothing is normal, no move has a predictable outcome.
How can I describe a combination of caution and boldness, of confidence and trepidation? What does it take to enter such a zone recognizing the danger but believing you can do it? (Not as much as entering a burning building or a free-fire zone.) In "Cutting Remarks," I came up with the term "delicate brutality." I like it (in fact, I've since thought that would have been a better title for the book.) You can't blunder into the foray swinging sledgehammers like an orthopedist. But if you diddle around forever, nibbling at the edges, afraid of the water, you'll drag the operation out too long: the sicker you are, the less you need a long anesthetic. So you resort to techniques that can move along briskly but respectfully. Blunt baby steps. A careful cudgel. Delicate brutality.