Tuesday, September 25, 2007
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.