Operation, Deconstructed. Six: sticky stuff

Let's make it easy on ourselves. I haven't yet established why -- other than liking the particular operation -- we're removing this nice person's colon. So since our patient has agreed to remain exposed and to do so for all to see, I declare s/he has diverticulitis. (I'm planning a post about that entity in the near future, so for now I'll ignore the details.) (Were it cancer, the operation would be largely the same, taking a bit more out.) Most likely there have been a few prior episodes of infection which resolved with antibiotics, but we've agreed the time has come to do a little preventative work. There's unlikely to be even the slightest adverse consequence of losing this portion of the colon; and it should ensure that the attacks will end. So let's backtrack a few steps. Because of the prior infections, it's likely that there are some adhesions with which to deal: that means that a few loops of small intestine are stuck to the sigmoid colon; and the colon might be plastered to the bladder or to the pelvic sidewall. So the reality is that, before that beautiful packing job I described, I needed to address those areas; unstick the bowel so I can pack it away, not to mention freeing the colon to work on it. Early in my training, I concluded that adhesions were the bane of the surgeon's existence. Dividing them can be arduous, time-consuming, even dangerous. Turns out I was sort of wrong: given that adhesions are pretty commonly encountered, either you learn to love (too strong. Accept. Find ways to enjoy.) them or you'll hate your job. There's pleasure to be gained from working through adhesions artfully and without creating havoc. In part, it's about timing. Which is about judgment. About which I've previously written. It's been at least six weeks -- ideally considerably longer -- since our patient's last attack of diverticulitis. Operating in the midst of such an attack means things will be densely stuck, and bloody. Dissection planes will be difficult, if not impossible, to delineate. Allowing time for the acute inflammatory process to subside, and for adhesions to mature makes all the difference. Given enough time, areas of adherence will become nearly bloodless; applying a little tension makes a little white fuzz appear between the stuck organs (the fine, avascular scar tissue that remains), and the dissection through it is quick and easy. But not always. Today, the small intestine is looped on itself and tightly stuck to the sigmoid colon, and the colon is thick and woody where the infection has occurred. "Shit. This'll take a while... Sucker." I'm asking for the suction device. There are several kinds; seems like most people use plastic disposable ones, but I like a particular metal one, because the outer sheath comes off, allowing use of a thinner (five millimeters?) straight tube for the purpose of blunt dissection. Cutting into a densely stuck area means you are making the plane, and you might be wrong. Bluntly probing it allows for the (possible) opening up of natural, if swollen and distorted, ones. Plus, suction keeps the field clean while you are working through it. Here, I'm only using it between the colon and the pelvic wall, because the only possible damage is to the part of the colon that'll be coming out. Where small and large bowel are stuck together, that sort of blunt dissection needs very sparing use.

"Aha!" The sucker finds a nice plane lateral to the sigmoid, into which I can now insert my finger which, although blunter than the tube, is sensitive to when I can force things and when I need to gentlify. Probing with my left middle finger I keep the sucker in the field with my right hand, still working it in such a way as to help open the plane. With the thumb on the outside, I give a series of pinches -- one of the greatest and best-of-all maneuvers in distorted tissues: it's nearly impossible to pinch your way through something that should have stayed intact."OK, it's free. Metz."

Cutting small bowel off the colon is a little trickier, in that on either side of the dissection is the inside of bowel. It's better, since it's coming out, to leave a little colon on the small bowel than small on the colon. When planes aren't obvious, that's often what you have to do. So I'm nibbling with the teeth of the scissors, and once in a while sweeping them, with jaws shut, across the plane in which I'm working, trying that blunt dissection when it seems safe. Grasping the loop of small bowel with my left hand, pulling it this way and that to expose a new view, I'm snipping carefully and slowly where the adherence is dense, and more quickly when I can produce that nice white fuzzy plane. (That's another dictum: when going is tough, find another direction.)

Inevitably, there's a little damage to the outer wall of one or the other of the two kinds of bowel stuck together. "Have a 4-0 vicryl G.I. ready." The small bowel finally comes loose, looking a little battered, but without obvious holes. I have the legs of the loop in my hand and give it a little squeeze (like folding a sausage-shaped balloon in your hand with the loop sticking up), making the dissected area bulge out. No leak. But I put a little stitch in it anyway. Lets me sleep. Grossly, the difference between chronically inflamed tissues and cancer isn't always obvious. Both are knobby-hard; each can stick itself to surrounding areas. Scar tissue can have the same sort of pallor that cancer often does. Hmm, I'm thinking. I'm certain this is diverticulitis, but this stuff is a little hard. "I'm gonna give you something for frozen. ("Frozen section" is a quick way for the pathologist to examine something immediately, while the operation is going on: they freeze it, slice it thin, stain it, and have a look.) Label it 'pelvic sidewall...' Fifteen blade on a long handle." The scrub scrambles to load the blade, since I usually don't use that size in this operation. (When Joanie was scrubbing, she'd have had it ready, just in case.)

I slice a thin bit of the hardened tissue I've left in the pelvis. Carefully. There are big veins down there. Holding the sample in a forcep, I lay it on a moistened non-stick pad the scrub holds out to me; then she drops it into a cup, to be sent to the pathology department. A little clock starts ticking inside my head: after twenty minutes or so, I'll ask how long it's been, how come we haven't heard from the lab, did they get the specimen, what the hell are they doing down there? The biopsy site bleeds a little, and I touch the area with the suction device I've been using. "Buzz me." My assistant touches the cautery to the metal of the tube and hits the switch. Another reason I like using that metal sucker. A little spark jumps from the tip of the tube to the bleeding area, and it chars in a puff of smoke, which disappears into the tube. Once in a great while, with that move you find out very painfully that somewhere along the line you've gotten a little hole in your glove. It's a shock and a burn and it hurts like hell. Sometimes it'll make your hand twitch, and it always leaves a pinhead-sized bit of charcoal on your finger that stays for a few days. "FUCK!!!" (Startled, my assistant jerks back and drops the cautery pencil.) "Yikes. Sorry... Guess I need a new right glove."

Like a flag of defeat, I wave my hand toward the circulator (the non-sterile person), pawing at the glove with my thumb to loosen it, making it easier: the circulator grabs the cuff of my glove and of the underlying sleeve and pulls, removing the glove and sliding the sleeve over my hand. Having received a fresh pair of gloves (the circulator opens the package, peels back the wrapper like leaves, simultaneously flipping it all forward while holding the outer package in the heels of her palms, and the inner glove-pack arcs onto the back table. Some do it with more force: a line-drive), the scrub proffers a new one, and I slide in, pull the sleeve back until it's cuff to cuff, and soldier on...

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...