Monday, February 25, 2008
You Are So Beautiful
Do you have any idea how beautiful you are? Well, okay; maybe for some it's were. Before you got a little thick in the middle, smoked, or even just breathed city air for enough years, or drank a little, or did a few drugs, there was a time -- and maybe it's still true -- when you were knock-down, take-your-breath-away gorgeous. Many times while operating inside a belly I've stopped working and just looked, and then said to the others in the room, "C'mere everyone, look at this. Look how beautiful it is." Because it's true. Really, you should see yourself.
Operating, as is our aim, on sick people, more often than not things aren't so pretty inside. Diabetic, or old, or overweight, or with concomitant diseases affecting various organs, typical surgical patients rarely retain the born-in beauty and peach-fuzz perfection with which they came into the world. But sometimes bad things happen to the well-kept or the young, and, in another of those paradoxical disconnects of the surgical mind, we are given a moment to find pleasure despite another's pain. Sometimes it's just all look-at-me laid out, not hidden in adipose, undistorted; the logic, the development, the relationships, the purity so bright as to be stupefying. Who gets to witness it, who's allowed at the window? Not many. Me, amazingly enough. Let me try to show you what I mean.
More often than not, when inside a belly what you see is this:
The grayish stuff is intestine. The yellow, of course, is fat, covering blood vessels and other structures you'd like to be able to identify. Here's another view:
If you know what you're looking at, you'd be able to tell what's underneath:
So you dissect, and scrape, and burrow through fat, and you find what you need, and deal with it. But sometimes, wonderfully, amazingly, it looks like this (the picture might not be of a human. The fact that I couldn't find a picture only underscores the rarity. But the point remains):
Imagine the joy! Not only is the operation immeasurably easier, it allows a look at the exquisite elegance of our bodies as they were meant to be. A basic principle of surgical technique is traction and counter-traction: elevating or spreading tissues and applying pressure in opposite directions to stretch things out, making dissection possible. When you pick up a loop of bowel to get that tension, most often there's much more work to do until you find the target vessels. But sometimes, like that picture above, it's all there. You can see right through it. If you like doing surgery, it's impossible not to be ecstatic. Like rounding a bend after a long climb and being able to see forever, you must stop and savor it. You can be precise and gentle; the tissues require no more, and deserve no less. There's something like sadness when the operation is over.
Down the backside of the abdominal cavity runs all the plumbing: the aorta, bigger around than your thumb, carrying blood from the heart; the vena cava, bulging and blue, bringing it back; the ureters, carrying urine from the kidneys to the bladder. More often than not, they're hidden by fat. When you can see them -- the aorta, at least, and its branches -- they're often pocked and corroded, rusted and irregular. But just often enough to be a thrilling surprise, you can see them in all their orderly complexity; shiny and pristine, they ought to sizzle like high-tension wires.
Those big blue veins are both turgid and tender, scarily so. Their thinness speaks loudly of danger. Like a powerful waterfall, they call you closer, even as your knees feel weak. And the aorta, in the young and healthy, is a wonder. Its walls are strong and thick, but they bulge with each heartbeat. Retaining their natural elasticity (before inevitably giving it up to cholesterol) they throb and push against your fingers; simultaneously static and brimming with life. Knowing the power enclosed within (poke a hole and see what happens!), it's like standing at Kilauea and feeling tremors. Smaller branches, curlicued in the mesentery, lift and uncoil, stretching out and falling back, to the music of the heart monitor. It can be mesmerizing.
Much more than simple tubes, the ureters produce sensuous muscular waves, more subtle than gut peristalsis and less frequent, and therefore more pleasing. When unsure what you're looking at, rather than wait you can pinch with a forceps or give a flick with your finger: it'll respond with a lazy roll. Sometimes, just for the pleasure, I've done it more than once.