Monday, May 21, 2007

Operation, Deconstructed. Four: packing for the trip




Inside the belly, everything is slippery. The peritoneum is a glistening layer of self-moistening plastic wrap, enveloping the surfaces of all the organs, and the inner aspect of the abdominal wall. Undisturbed, the intestines coil and slither, reptilian. Watching waves of peristalsis makes me smile: there's something always entertaining about those moving contractions, following one upon another, gurgling, surprisingly tight bands of tension moving along the length of the bowel in a wonderful concert of muscle action. Like those gifted prestidigitators and their moving coins. Exposure -- providing excellent view of what you're doing at all times -- being a sine qua non of efficient and safe surgery, that slipperiness isn't necessarily your friend, amusing as it may be.

Having taken three posts to get to the peritoneum, it's now time to pass through it. In some people you can tell before opening it that things will be OK: the membrane is translucent and you can see through well enough to recognize that the omentum or bowels are sliding around underneath, unattached. Nice. So you make a little knick with a knife, taking care not to cut anything on the other side. Classically you and your assistant grab a bite of peritoneum with forceps, picking it up, allowing a cut away from underlying structure. When you can see, you can save that step. (Fast surgery is not really about fast hands: it's about an accumulation of countless little quanta of efficiency.) Having made a hole, you might grasp on either side with clamps, elevating it, then zip a scissor downhill, never moving the jaws. Or pull it open further with two fingers. Or slide your finger under it and open it with cautery, your finger protecting the bowel, and the glove protecting your finger from getting cooked. In the case of prior surgery, where you are re-entering a old incision, it's an entirely different animal: time slows down; you might have to try several different spots for entry, trying to find even a little area to which bowel is not attached. The smallest free zone can make all the difference. Finding none, dissection can be tedious, laborious, frustrating. But since this is an imaginary patient, the innards fall away as soon as we puncture the peritoneum; entry is a splashless dive. (Note to do-it-yourselfers: taking a moment, before cutting it, to sweep your finger across the peritoneum to separate it from under the muscle layer makes sewing it back up much easier.)

That slippery bowel wants to be everywhere. Like everything else for which there's not a perfect solution, many techniques exist to pack it and keep it out of the way. With a stem-to-sternum incision, as for some vascular operations, you can put it in a bag. Tethered to the back-side of the abdominal cavity, whence comes the blood supply, nearly the full length of the small intestine is free, frontward. You can slide your hands in from each side, heading under the bowel and down to the root of the mesentery; rock your hands backward, seemingly lifting all the guts right out of the belly. You can't go quite that far, but you can expose the bottom side, allowing your assistant to lay the open mouth of a large plastic bag, not unlike one that might be in the waste-basket under your sink -- complete with a tie. Releasing the bowel gloppily and gurgily into the bag, feeling it slip-slide over your hands, is one of those surprising sensual experiences that surgeons get to have. Tie the tie snugly enough to keep the bowel in but not enough to choke it off, and enjoy the show as the bowels wiggle through the whole case.

But we haven't made that sort of incision. In fact, the smaller incision is an aid in the typical packing process: using laparotomy pads ("lap-pad," "lap-sponge" or "lap," as in "gimme a moist lap" -- the saying of which in another context ((particularly with "you" in front of it)) might deserve a slap in the face but herein is a request that the scrub hands you a moistened sponge for packing) folded in whatever way you were taught or in a way you finally figured out yourself and tucked here and there, you find the integrity of the uncut abdominal wall above the incision holds those pads in place. (Every once in a while, I need to write a sentence like that.) Bowel has a way of squirting around the edges of packs, so taking a moment at the beginning to get them right saves a lot of pawing and repacking just when you don't want to have to. Another of those quanta of efficiency. So here's what I do: I reach into the pelvis with my left hand and grab a handful of small bowel while my assistant is holding onto the sigmoid colon -- our ultimate target -- and lifting it up. I may have to replace my right hand over the left, and then the left again over the right, until I have the guts up and out of the pelvis and exposed down to the root. The scrub hands me a succession of lap-pads, moistened and folded in half. With my right hand, I slide a sponge over my left, which I then withdraw, leaving the end of the pad tucked under the bowel at the root of the mesentery; the body of the pad is over the bowel, and the top end is tucked under the abdominal wall, with the blue tag-string out of the wound. (That keeps you from losing it.) Working from the right side of the pelvis to the left, it usually takes three or four pads fully to cover and tuck the bowel and keep it out of the field. A nicely-arrayed field of white has replaced the ruddy-brown bowel, leaving in view only the sigmoid colon, as if displayed on a table-cloth. Some surgeons use fully-unfolded pads: they usually don't have the turgidity to hold things steady; invariably, it seems, a loop of bowel finds its way into the field. One of my first partners used to roll pads into balls and stuff them all over the place. As I said: having lots of methods bespeaks imperfection of all. But mine worked pretty darn well.

Most surgeons use some sort of self-retaining retractor to hold the incision open; if so, it gets set up before the packs are placed. There are some pretty ingenious erector-set gadgets that can do the work of several hands. When possible, I like to omit such retractors because I think the steady pull at the wound edges makes for additional post-op pain. But more often than not, some form is necessary; for this incision, I like the old-fashioned, quick and easy Balfour retractor. Simple and nearly foolproof, it also makes a businesslike ratcheting sound when opened into place. Downside: I often manage to get my glove caught in the mechanism when I release it at the end. If I can get away with having my assistant hold a simple retractor during parts of the procedure, I'm happy. Retractor or not, I put moist pads -- usually soaked in a mixture of saline and betadine -- over the wound edges, to keep them from drying out, and to protect from contamination. And it looks very tidy, which has value if for no other reason than my own enjoyment -- the apprehension of beauty has no prohibited venues.

Positioning matters. Working in the pelvic regions, tipping the patient head-down gets gravity on your side, helping to keep the bowel away. "Can you give us a little Trendelberg?" I ask of the anesthesiologist. (The term is "Trendelenberg," but I like to save time.) Of all the things to have named after you, it seems a body position is a weird choice, particularly when all we're talking about is taking a flat table and tipping it. Most used for a patient in shock, the Trendelenberg position is a mouthful in an emergency. "Drop the head, drop the head, dropthehead goddammit!!" is more to the point. On the other hand, I suppose to have some complex position named after you..... "Honey, feel up to a Schwab tonight?" But I digress.....

So we're ready to conduct the business for which we came: getting rid of the sigmoid colon. Sigmoid means "S-shaped." Our target organ is curled on itself and it's time to uncoil it. Doing so is among the more satisfying maneuvers of colon surgery; a little magic, a little danger, couple of tricks here and there and we should be able to unlatch it from its position along the left side of the pelvis and bring it right up into the incision where it should give itself up to us gladly....

[The intercom honks: "Dr. Schwab, I have the ER on the line. Can I transfer them in?" "Do I have a choice?" "Ha ha." "Sid? This is Pete. I've got a lady here with an acute abdomen. You're on backup, right?" "Must be, or you wouldn't be calling. What's the deal?" "Just letting you know. Sending her for a CT. I'll get back to you. She seems fairly stable for now." "Great. Thanks." Deep breath. Long sigh...]

8 comments:

happyj said...

Dr. Schwab,
This helps me to understand an episode of "The Critical Hour" on The Discovery Health Channel, where the trauma surgeon handled the intestines and pancreas and stomach (I think they had all been knicked by a single stab wound) and he was amazed had how much damage a single wound did. I also wanted to tell you that though I'm not a med student, reading your posts helped encourage me and I ended up earning an A in that class that I was initially failing. I like the persistent, never-give-up, sometimes overwhelming attitude of surgery because it helps me to remember where I've been and what it took to recover.

Alexandra Lynch said...

That's interesting.

And it explains why when I've had surgeries I feel like someone's inserted a large spoon into my belly and given everything a good stir, like fruit salad. It's all still in there, it just feels messed about.

SeaSpray said...

Hi Dr. Schwab - yet another excellent post! I truly appreciate the additional insights into life in the OR.

So..these bowels...large and small - it seems they always have to be moved away in some form. Is the bag for the large intestines only for the upper Abd incisions?

When some one has had prior surgeries as in c-sections - then is it likely that they have scar tissue adhering to the bowels, etc. and what if they have had a hx of endometriosis/ How does that play out in any Abd/pelvic surgery?

Is it a given that the Trendelenberg is used in pelvic and Abd surgery? So it is used to put gravity in your favor and for shock. When it is used for gravity - is there a time limit? Just wondering if it is safe for extended periods of time?

"Honey, feel up to a Schwab tonight?" My mind is running wild with THAT one! LOL! Hmmm... a Scwab? What could that beee... :)

Sid Schwab said...

seaspray: the bag is used for the small intestines, in a full-length incision, generally when operating on the aorta.

C-section is less likely than other lower abdominal incisions to lead to adhesions, because when the incision is made, the uterus is between the cut and the bowels. Endometriosis can lead to adhesions, depending on how extensive, and if it's had surgical treatment.

Trendelenberg position is used if the surgeon prefers it; not always. There's no general limit on it. For one thing, it's not usually all that steep. It might be a concern if a person had particular circulatory problems in his/her legs.

SeaSpray said...

Thank you :)

athenivanidx said...

wow..........I'm hooked. completely hooked. As you can probably tell by the number of comments I've left in various places..........

I'm adding you to my blogroll.......

happyj: I'm a big fan of the critical hour myself............

Dr. Schwab: have you ever known a transplant surgeon who's done a complete digestive system transplant? I watched an episode of Children's Hospital on the discovery health channel once.......I heard about it there.......little girl had transplanted intestines, and whatever else the digestive system is made up of (can't remember now, I need sleep desperately)

I bet that kind of surgery requires a LOT of work........and many steps........

dang I'm tired. I fell asleep on my couch watching the results from the primaries in NC and IN.......woke up at 4:30........it's almost 6am now. time to go to bed again.

and wake up at 8:45am........

The Integral

Sid Schwab said...

Integral: I tried to leave a comment on your blog. For some reason wordpress isn't letting me do it lately. Any how, I posted here about a similar heroic operation...

athenivanidx said...

Dr. Schwab: I fixed that. For some reason, Akismet registered your comment as spam. I fished it out.......wasn't that hard as I only had that one comment registered as spam. Shouldn't happen again, wordpress learns from what people say is not spam in their filters, apparently.

thanks for your comment

and please do come back!

The Integral