Wednesday, May 30, 2007

Operation, Deconstructed. Eight: coming together

Scenario one:

"Hi Sid, this is Dave, calling about Patient Blahblah, pelvic sidewall. Is it OK to talk?" (Wondering if the patient is awake.)

"Fire away."

"Can you send me any more tissue?"

"If I had to. Why, what's up?"

"Well, I think it's just inflammation. Probably nothing, but I don't want to commit....yak yak yak..."

"OK, OK, OK. I'll send you some more..."
(Useless sonofabitch. I'da known he was there, I'da never sent a frozen...)

Scenario two:

"Room two? Dr. Schwab?"


"Hi Sid. It's Ernie. Can I talk?... Patient Blahblah, date of birth yadayada, sigmoid resection, specimen pelvic sidewall?"


"Nothing here but inflammatory cells. Histiocytes, neutrophils, fibroblasts, few eosinophils. Were you worried about something?"

"Not really. Little more indurated than usual. I'm sure she has diverticulitis. Just giving you something to do."
(Got some bloggers looking over my shoulder, making it real for them.)

"Will you be sending anything else? You'll be orienting the sigmoid for me?"

"Anything for you, Ernie. Nothing more coming. Thank you."

"OK. Have a nice day."

"Same to you...
(click)... I love Ernie."

Joanie brings the bowel clamps to within a couple of inches of each other and rotates them a few degrees in opposite directions to expose the backside of the colon ends. Using the classic 4-0 silk sutures, I place a stitch through the bowel that's at the very end of the clamp, and carry it through the same place on the other piece of bowel. Then I pop the needle off, grasp both ends of the suture in a roach clip and lay it down. Repeat at the other end of the jaws of the clamp: now I have the ends of the anastomosis controlled and marked. Next I place a series of individual silk stitches, filling in the space between the two ends, a few millimeters apart, in the backside of each bowel end. These I lay down as I place them, ends stretched out and unclamped.

There's something about a needle-holder that's very pleasing, particularly the ones with gold handles. Receiving it from the scrub nurse with the needle perfectly placed, the middle of the curve right at the tip of the jaws, suture held back so it doesn't drape across my palm (if it does, it can get pulled out when I re-grab it after the first pass), I slide my index finger down the shaft of the instrument for precise control, and it fits just right in my hand. I leave my fingers out of the finger-holes, preferring to latch and unlatch by pressing them against my palm with my fourth and fifth fingers. The tip of the needle starts perpendicular to the bowel wall, and as I drive it in (just right: not too deep -- the idea is to penetrate the muscular layer but not all the way into the lumen) I rotate my hand, shooting for a perfectly circular motion. As it emerges, I grab the tip of the needle with the forceps in my left hand and pull it the rest of the way out. My left hand is steadied by resting it on the edge of the wound, which allows me briskly and accurately to present the needle to the needle-holder back end first, re-grab it in the jaws in a burst of crunchy clicks, and stitch the other end of the bowel, symmetrically with respect to the placement of the first bite.

As the needle reappears, I let go with the needle-holder, re-grasp it on the other side of the bowel, and draw it out, grabbing the string with my forceps (or keeping the forceps in my hand and using my fingers) and then pulling on the needle-holder. The needle pops off (an innovation that occurred in my surgical lifetime: time was we threaded our own needles, and the first "swaged on" ones didn't pop off) and I hand the instrument back to the scrub, needle in its jaws. She gives me another. (Among the great ((yet small)) frustrations is getting handed a needle-holder of a size differing from the first one. The motions of laying down that series of sutures is repetitive, and the muscle-memory likes it to be consistent: having to adjust to a long instrument then a short one feels like walking with one foot on the curb and the other in the street.)

Sewing bowel is a circus of sensory feedback: the clicks, the pops, the vibrations in my hand as the instruments ratchet open or closed. The steely and dry hardness of the clamps against the living and wet softness of the bowel; the ever-present musty odor of an open belly, above which the air is noticeably humid. The small arteries in the mesentery -- confirming I've left the edges alive -- dancing in time to the heartbeat monitor, their steps delayed a split second from the sound. I can't help but drink it in, always, no matter what else might be going on. Not many people get to do this: I savor it while I can.

Up to a point (maybe five or ten in a row), tying knots is fun. It's one exercise wherein speed and flash are useful -- if not indispensable. Since early in med school, prospective physicians test their worthiness by learning various tying techniques, the acquiring of which is, in some measure, a palpable sign of progress, a talisman against ever-present self-doubt. If a cowboy validates his claim on the title by twirling a rope, a surgeon does the same in a blur of flying fingers. Surely the scrub, my assistant, even the anesthesiologist have expressions of admiration hidden behind their masks as they witness my underhand, overhand, left hand, right hand, my double-handed single-motion surgeon's knot. Admittedly knot the fastest, I can hold up my ends of a suture.

Having placed this entire back row of silk sutures, I pick them all up and hand them to my assistant. If it's Joanie, she knows how to select each proper pair by sliding a deBakey forceps across the bottom of the pair and bringing it up to present them to me (if it's a less skillful assistant, I use the forceps myself and keep it in my hand while I tie. More clumsy, but quicker than laying it down and picking it back up each time): I grab an end in each hand and work my magic, pulling the ends perpendicular to the bowel so the knot lies down in the groove between the ends of bowel, making the tension just right. ("Just right" is completely subjective, but I think it's another area of divergence among surgeons: if too tight you risk affecting circulation and therefore healing. Too loose, leaks are possible. I suppose we need the equivalent of a torque-wrench; as it is, we hope for having developed the right feel.) The reason I keep using silk for this layer is that it ties so, well, silkily; and having imbued the knot with that just-right tension, it holds it perfectly while awaiting the next loop. If surgery is, at times, art, it's like having a favorite brush.

Once all the knots are tied (three throws for silk, four for vicryl, hundred fifty for nylon), it's time to remove the bowel clamps. For colon surgery, for which there's usually been some sort of prep to empty the bowel, and which is unlikely to spill anything when unclamped, I don't place any upstream clamps. I do for small bowel surgery. Still, when opening the clamp, I have the suction ready; I give the opening a swipe with a betadine-soaked sponge. Theoretically dirty, the clamps go off the field. Now I tie the corner stitches, having waited until the clamps were off to avoid too much tension while tying. At this point, it's as if we have two hoses lying side-by-side, like a double-barreled shotgun, with only the touching edges attached. In placing an inner row of continuous sutures, we bring the hoses end-to-end, sealed. It's the most fun stitching, because it's the trickiest; rounding the "corners," switching from inside the bowel to outside, and from a simple right to left through and through, to left to right, inside/outside, outside/inside. [I know I'm not giving you a perfect picture. And believe me, I searched for some diagrams. But the point is there's some technique involved, the doing properly of which ends up with a very happy sense of satisfaction, perfectly inverted bowel edges around the whole circumference.] "Is that pretty, or what?" I say when it's done. "Yes, Dr. Schwab, you're a goddamn genius," says the nurse, mentally twirling her finger and saying whoop de frickin' do.

There's a final row of interrupted silk sutures to place on the anterior surface of the anastomosis. Finished, I cut them one at a time, aiming for equal length, Goldilocksianlly not too long, not too short. With thumb on one side, middle finger on the other, I pinch across the anastomosis to confirm patency. "Drive a damn truck through it..." My thumb and finger squish against each other, padded by the spongy walls of bowel, gliding between the rubbery ring of the anastomosis. "Be closing in a couple of minutes," I add, to the anesthesiologist, so he can begin his chemical resurrection.

If you don't close the mesentery, small bowel could slip through the hole and cause an obstruction. "Three-oh vicryl on a long needle-holder." Whap. Reaching in with my left hand and bringing the edges together with my fingers, I place a stitch at the apex of the rent with my right. Joanie ties the knot since my hands are engaged; I'm re-grabbing the needle with the needle holder, having pushed it through as far as possible, twirling the instrument over in my hand to re-align it for the next stitch. I run the suture line out to the edge of the bowel, while Joanie "follows" (grabbing the suture after I've placed a stitch, applying a little tension, barely tenting it up to ease the next placement.) Nailing a blood vessel at this point is hazardous, in that the need to clamp it off could jeopardize circulation to the anastomosis; so I pass the needle just under the peritoneal surface with each bite. Breaking a cardinal rule of safety, sometimes I grab the needle with my left fingers, steading my hand against the bowel, and hold it while I re-click it into the needle holder.

"Here's your sponges," I say as I hand them all back to the scrub. Or, if she prefers, I arc them one at a time into a pan next to the table, letting the ones that hit the target speak for themselves; saying "somebody moved it" when I miss. I remove the retractor, lift the wound edges to let the small bowel slush into the pelvis. "Irrigation." A critical intervention: I use sterile water, not saline, because it osmotically explodes single cells, like bugs or loose cancer cells. Mixed with betadine, light brown and heated, it floats some of the bowel. The final internal sensation is my hand in the warm water, gently stirring the gutty soup, then inserting the sucker over my hand and vacuuming it all out.

And now, boys and girls who've waded through this with me, we're ready to close...


Unknown said...

An amazing series thus far, you have done a great job at explaining each and every nuance of the surgery at hand. Thank you for showing us the man behind the curtain and for bringing us with you.

Miranda5 said...

I was never interested in surgery before. Now I am. I have a greater appreciation for the ins and outs of your specialty.

Anonymous said...

Oooh, the 2 handed surgeon's knot. When I was in med school the surgery chief resident showed us that and called it the "kung fu" knot. He said he would automatically write a letter of recommendation to the first student who could demonstrate that they could do one. That was me - he wanted me to do surgery but I knew I wasn't meant for it. He went off to do a fellowship in laparoscopy. He used to have me pass him the instruments in his lap surgeries cause I knew them better than the nurses and could load the sutures faster.


Savoy 6 said...

I really enjoy the play-by-plays during these surgical procedures, but being the electrical engineering geek that I am, and being a fan of the anesthesia discipline, I have to know: What's going on with the patient in terms of sedation? What do you do when the arrythmias come along? How often have you seen malignant hyperhtermia from the Halothane? What is your relationship with the Gas-Passer in the room? How much do you get involved with the anesthesia process? Please fill us in with the details of your interaction with your anesthesia colleagues.

Unknown said...

Well told story Dr. Schwab. Maybe at the very end you could post your dictation/post op note to accentuate the difference between what you've blogged and what might go into the medical file. As a medical student, I have to admit watching a surgeon give dictation is almost as impressive as watching the surgery itself. You can see the surgeon mentally reperforming every aspect of the procedure in maybe 30 seconds. "The patient was supine and draped in the usual fashion...

Savoy 6 said...

One other question I have from the electrical engineering world: How much has electrocautery gear improved over the years?

You mentioned in a previous post about getting burned through your gloves from your cautery equipment. Being a radio hobbyist, I have had similar experiences with RF burns from high power radio transmitters, so I know the feeling.

Unknown said...

both pathologists conveyed the same information to you. It all depends on what you wrote on the request form.
For example, if you wrote 'Clinically sigmoid cancer, pelvic side wall 'irregularity' intra op', the pathologist understandably will not be satisfied with seeing inflammation only and either process the whole piece or ask you to send him more tissue.
However if you write 'Diverticulitis, colectomy, pelvic side wall 'irregularity', please rule out cancer', the pathologist can live with a diagnosis of inflammation.
Oh, orienting is always good. We love you when you do that... for certain things. But in the case of a short piece of colon, if one of the resection margins was involved by cancer/ necrotic, because the whole anastomosis has to come out anyway, regardless of whether its proximal or distal.
Anyway, we can usually orient sigmoid colons due to
A) the peritoneal reflection, and the rough perirectal fat distal to it.
B) the lesion is usually closer to the distal margin,because the surgeon would like to preserve sphincter function in the patient.

Jeffrey Parks MD FACS said...

Hand sew all your anastomoses?

Sid Schwab said...

ming: I agree. However, some pathologists seem always unable to say anything useful about a frozen, and others have no problem with it. Like surgeons, there's a spectrum...

buck: not every. I staple low pelvics, some gastrics, esophageal. Meckel's. Hand sewn is more fun (I wrote about it here), is equally if not more safe, and saves several hundred bucks in equipment (not to mention landfill). Done right, the OR time is about the same. And there's nothing like hearing a GI guy say he scoped your patient and couldn't even tell where the anastomosis was.... Young guys haven't really been shown how to do it well. The ones I know, anyway...

Jeffrey Parks MD FACS said...

I agree hand sewing the bowel is becoming a lost art. Luckily we had a few attendings who made us learn hand sewn anastomoses during residency. I usually run 3-0 PDS in one layer. If the bowel is edematous (like in a SB resection secondary to obstruction), I'll do an outer layer of seromuscular 3-0 silk in addition to the running PDS.

Anonymous said...

Interesting to read an account of "old school" resection and anastomosis. I've only seen staple jobs in my work.

Anonymous said...

This is fascinating! I am an artist and I'm surprised to find so many parallels between what I do all day and surgery. It really is an art.

My dad passed away years ago. He was a thoracic surgeon. I feel like I've gotten a better idea of what his work was like and the psychology behind it from reading your blog.

Good stuff! Thank you! :)

Sid Schwab said...

thingmaker: I love comments like that. Thanks!

Silk said...

I drank in every word - as a medical transcriptionist whose favourite is the surgical report, this was a delight to read and follow carefully. I'll be back for another round...

Sid Schwab said...

Thanks, Silk, glad you liked it.