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.

On the Other Hand...

The thing about laparoscopy is that it's so impersonal. If open surgery is intimate, as I tried to convey in my previous post, laparoscopy is insulated, stripped of sensation; performed, in essence, outside of and separate from the patient. I like it. Don't love it.

I'm no Luddite; not a troglodyte. I'm enlivened by the innovations that are a part of surgery, and I think it'd make an interesting post at some point to enumerate the ways in which things are different now in the care of the surgical patient, compared to the ice age in which I trained. Unlike some of my fellow elders -- unschooled in video games -- I found the transition to laparoscopy technically easy: the ability to do three-dimensional things while looking up at a two-dimensional screen is not intuitive for everyone. From the outset, for the most part, I could get a skinny instrument to where I aimed, and make it do what I Nintended. It isn't hard to see that certain operations done laparoscopically are better in all ways for the patient. And yet.

In that previous post, I tried to describe what it's like to stand before a person and cut deeply; to reach in and hold and touch. I suppose there's no reason why a procedure has to encompass that kind of drama, nor why a surgeon ought to or needs to have that sense of awe. Still, it's my reality. And it's entirely missing in laparoscopy, which happens to be all I do nowadays, in the OR.

To begin an open operation, you step to the patient's side, receive the scalpel, and go to work. WIth laparoscopy, you screw around with half a dozen hoses and cables -- these go here, those go there. Hook things up, white-balance the camera, adjust the screens. Make sure the settings are correct; there's gas in the tank. Then finally, pick up a pathetic toad-stabber of a knife, and make a little poke. A silly, baby-step of a puncture; like you ought to say "s'cuse me." Then, as enough time has passed already to be half-way through some operations, you fffffffffffill the belly with gassssssssssss, and wait some more, watching as the abdominal wall -- rather than submitting and opening itself to you -- distends like yesterday's roadkill.

Sorry. It's not that bad, really. But there's surely something missing. If you do what you do by watching on a TV, you're almost not there. The patient can't be sensed; it's remote and cold. And it's not just rhetorical: you get information from the feel, the warmth, the tissue resistance, the smell when you are open. Via the scope and its tools, it's transmitted; just pixels. You are in a real sense divorced from it. As with a jigsaw puzzle, or putting together the Christmas toys, it's engaging in another sense. It's the delivery of a skill, the application of rapidly evolving technology, using beautifully engineered tools. As I said, I like it, but in a way very different from open surgery. And whereas it's being used for a number of operations where it really is no better than well-managed open surgery (no safer, more expensive, no shorter recovery), it is a very positive innovation and a huge step forward in many important ways. Nissen fundoplication (to cure esophageal reflux) is clearly one of them.There's something fun about it, in a laboratorical way: placing a suture, cutting and tying it while observing your actions on a screen (despite the annoying time-wasting of constantly sliding instruments in and out of trochar ) is a rewarding challenge, the development of the skill for which is quite satisfying. Still, it would never happen in open surgery, as it does occasionally in laparoscopy, that when you and your assistant are manipulating the same sort of instruments, staring at the TV screen, you ask "Is that me, or you?"

Isn't there something to be said for intimacy? Is there no way in which a meeting is better than a video conference? Will we not have a more important bond if I've really touched you? Truth is, I don't know. Without doubt, the surgeon's relationship is different, in some ways, with laparoscopy. In the long run: probably doesn't matter. Even if it does, we ain't going back. If it did matter, I suppose there'd be surgeons and their patients wandering aimlessly around surgical wards like duckings that failed to imprint on their mothers. And I admit it: other than writing about it with the afterglow of my previous post still warm in my mind, I think laparoscopy is, in fact, a very good thing. Mostly. Much of the time. Usually. If well-chosen.