Tuesday, September 25, 2007

Pattern Recognition



A physician-seamstress and plastic surgeon emailed an idea into my head, bringing up an amusing consequence of the dawn of the laparoscopic age: docs are required to infer a patient's history from a bunch of cat-scratches on the belly.

Although it's not particularly rare that you point to a surgical scar on a patient and ask what the operation was, only to be told "I don't know," the more common situation is with a patient sick or injured enough to be unable to give a history at all. Finding surgical scars, we may need to make an educated guess about their past. Some scars tell their stories pretty well: long scar under and parallel to the right rib margin means gallbladder removal. Short one in the right lower quadrant: appendectomy. Flank scars likely mean kidney surgery. Some others that have a nearly singular signature: pyloromyotomy, umbilical hernia; splenectomy or sigmoidectomy if done in not-common ways. Others at least provide a short list: lower midline, upper midline, right paramedian -- you can narrow them down. If it looks like it might have been infected at one time, that can help: upper midline, maybe a perforated ulcer; lower, maybe diverticulitis...

Our brains are wired to recognize patterns, and to be able to add context. With laparoscopy, though, it can be confounding: bunch 'a little cuts scattered here and there, seemingly randomly. Some are counter-intuitive: to remove the appendix laparoscopically, the biggest hole is made on the left. Taking out a gallbladder, some people make an incision in the umbilicus, others avoid it; still, most have a fairly common pattern of three (or four!) additional scars. But there's a novel amount of variation, amongst surgeons, in where they like to poke their holes, and what size to use, for a given operation done laparoscopically. And if a person's had more than one laparoscopic operation, fuggedaboudit! I think surgeons can recognize the patterns pretty well, at least for the operations with which they're personally familiar. But I'm guessing we're in a transition period for ER personnel. (God knows what'll happen if an unconscious patient shows up needing tracheostomy, and who's had an axillary approach to thyroidectomy.)

Readers here may know of my mini-gallbladder operation, wherein I removed that organ through a single tiny (inch, inch-and-a-half) incision below the right ribs. I've seen ER notes from my patients' visits that refer to the fact that the patient had had a "lap chole," because no one had seen such a small incision done any other way (and suggesting the inability to note the difference between one and four -- not that it matters all that much, in that situation.) I had many patients tell me, years later, when having an exam that their doctor said, "Oh, you must have had Dr Schwab do your gallbladder surgery."

Coming full circle, plastic-surgeon-in-the-post-wise, I once two-teamed with my favorite one, starting off with my little mini-gallbladder on which he assisted, followed, in the same patient, by a tummy-tuck with which I helped him. My scar, though smaller than one from a typical appendectomy, ended up in the lady's right lower quadrant, where anyone seeing it later would properly assume it signified an absent appendix. I had to impress on the woman the difficulty she might anticipate in convincing a future physician that she
still had her appendix, and it was her gallbladder that had been removed.

11 comments:

rlbates said...

When I was gen surg resident, we had a nurse talk a gen surgeon into doing her gall bladder surgery at the same time a plastic surgeon did her tummy tuck. The skin flap was raised and then the gall bladder accessed through the muscle (no outside gall bladder scar). She was left with just the tummy tuck scar.

Or check out this "no scar" gall bladder surgery (transvaginal access)--http://drsmak.blogspot.com/2007/09/my-what-long-skinny-fingers-you-have.html

Sid Schwab said...

Don't know why we didn't think about that in our case... other than I'm not sure how the flap would have interfered with such a small hole...

As to the transvaginal thing... I wrote about that a while back, too.

make mine trauma said...

Whoa, wait a minute. Endoscopic thyroidectomy? Axillary approach? You mean through the axilla, as in arm pit? Why? I am having a very hard time picturing ths. And what is the benefit? Is it cosmetic? Aren't they going just a little too far with endo/laparo surgeries? Gallbladder through the vagina, no thank you. Gallbladder (and appendix!) out through the mouth? NOT! It's bring on the scars for me. I agree with your April post. "Holes"

http://seattletimes.nwsource.com/html/localnews/2003760506_gallbladder24.html
mmt

Greg P said...

OT, sorry.
Sid, why is it that the font size in your blog has gotten so small?

Sid Schwab said...

Greg: I don't know. Something weird going on: the "control panel" that lists fonts doesn't actually give any font options at the moment. I assume there's something screwed up with blogger or my account with it. I can individually edit posts to 125% font size, but I can't seem to change the default size, and I don't know why it changed. Annoying.

Sid Schwab said...

Actually, I think I just figured it out. Don't know why it had smallified, but I seem to have gotten it back...

Michelle said...

Lets see the gallbladder scars I have: a 1 incher at an angle an inch and a half below my sternum, then a porthole right above my bellybutton (guess I can say goodbye to piercing it)then three little random portholes around my waistline on the right side - two being a 1/4 inch, and the other which you can't even see anymore, 1/8th inch. Does it sound like they did it right? haha

jean said...

just curious...

is it safer to do a laparoscopic operation on an obese patient than to have to do probably one deep and long opening?

or doesn't it matter because it's just more complicated to operate on an obese patient anyway?

surgically challenged...

Sid Schwab said...

jean: it depends somewhat on the particular operation; but in general, for common operations it's easier done laparoscopically in the obese. However, there are differences within the category: people who are "pear-shaped," with most of their weight nearer to the hips, have a lot less internal fat -- and are therefore easier -- than those who are "apple shaped."

Bongi said...

but should one really compare apples and pears?

peter said...

It may not always be safer to do a laparoscopic procedure on an obese patient compared with an open procedure, but at least with gallbladders it's almost certainly easier. Getting the first port in can be tough, but after that it's not usually much different than the same operation in a skinny person. It certainly beats fighting a large and very deep incision.

Apples vs. pears is a good comparison. Or, as we've learned to describe it: "women are fat on the outside, men are fat on the inside." With obese women, it's always amazing how, after fighting thru a couple of inches of fat to gain access, the inside of the abdomen looks the same as in someone half as heavy. For men, though, access is easier as the subcutaneous fat isn't usually as much of a problem, but once inside you realize where we sock away all of our fat stores.