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.

Operation, Deconstructed. Five: getting to the nitty-gritty

There's a reason for the cliche' -- surgeon barks out the name of an instrument, scrub nurse whacks it into the hand. The reason is this: when you are focused on a particular area -- especially if it's one in which danger lies -- you don't want to look away. If you need to change instruments you lay down the one you're using, open your hand toward the scrub while keeping your eyes on the object of your effort, and want that new tool placed quickly and firmly. So you know where it is without having to fumble. So you can feel it through your glove which, when your palm is open, makes a little trampoline between the bases of your thumb and pinkie. Mobilizing the sigmoid colon from its attachments along the left side of the pelvis is one of those areas. Behind the sigmoid colon passes the left ureter (the tube carrying urine from the kidney to the bladder); causing it harm while working on the colon is a major transgression. Unless the area is distorted by infection or tumor, avoiding the ureter usually isn't difficult.

I'm standing to the patient's right, turned slightly footward, affording me better access to the left side of the abdomen. With my left hand I grasp the mid-portion of the sigmoid colon and pull it gently but firmly toward me, exposing the lateral mesentery. "Long Metz," I say (it's more of a request than a bark), and feel a smart snap into my hand. I love it. Some scrubs seem a bit reluctant really to whack it in, but I don't know any surgeon who doesn't appreciate that crackle, the absence of which means fumbling around to figure where the business parts are. "Nice," I acknowledge with a masked smile. "Old school. I want you on all my cases." Worse is bringing the instrument into view ready to cut, and finding it's been handed backwards, with the curve of the blades opposite to the curve of my fingers. (Most surgical instruments are curved, making them an extension of the hand, conferring versatility. The default direction is that the tip continues the curve of one's hand. Sometimes I want it backwards; but only if I say so.)

It's as if the body was designed with surgeons in mind. Things come apart just where they ought. In some places, there's even a dotted line. Along the outer edge of the ascending and descending colon, where the peritoneum covering the abdominal wall joins that covering the bowel, truth be toldt, there's a white line (see, that's a little in-joke: it's called the white line of Toldt.) The pull I'm providing is such that when I incise along that line, the area underneath falls away, exposing one of those little secret spots the body keeps: airy like cotton candy, areolar tissues behind the sigmoid colon open easily (welcoming because I said the secret word announcing my worthiness) with nary a blood vessel to worry or obscure the view. "Stick sponge." I take a ring forceps with a sponge in its jaws and sweep it through the area I've opened, pushing down and away. What few vessels there are slide back. The ureter shows itself and, happy to be noticed, it does the wave: peristalsis isn't limited to bowel. "Metz." I continue the incision of the white line north and south: having cleared a portion of the space behind the colon, now I can easily see where I need to go. Leaving my ring finger in the handle of the scissor, I release my thumb and rotate the instrument 180 degrees, so the shaft is resting on my wrist and inside my forearm while I do a little finger work, further opening the space behind the colon. In a quick move, I spin the scissor back into my hand, cut a little more, use the closed blades as a dissecting tool. Flip it back to my wrist. All surgeons do that move: keeping an instrument in half a hand while doing something else, then regaining full use of it. Still, mundane as it is, that "third eye" part of my brain notices and likes that I can do it. It's part of that little voice that constantly reminds me, whispers in amazement, that I'm here doing this stuff.

I'm moving my left hand up or down the colon as I dissect with my right, providing my own counter-traction as my assistant holds the anterior abdominal wall up and away. My left index finger is working at the edge of the cut I'm making in the peritoneum, exploring and exposing. It all takes only a minute or two and the entire left side of the sigmoid colon is opened up, and I can elevate the bowel a couple of inches further than when I started. Now I can begin to decide where I'll be dividing it, having converted the S-shape into a C. It means the whole loop can be removed, and the ends will be very near each other; which is one of the reasons I like sigmoid resection. It just falls into place...