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...

Operation, Deconstructed. Four: packing for the trip

Inside the belly, everything is slippery. The peritoneum is a glistening layer of self-moistening plastic wrap, enveloping the surfaces of all the organs, and the inner aspect of the abdominal wall. Undisturbed, the intestines coil and slither, reptilian. Watching waves of peristalsis makes me smile: there's something always entertaining about those moving contractions, following one upon another, gurgling, surprisingly tight bands of tension moving along the length of the bowel in a wonderful concert of muscle action. Like those gifted prestidigitators and their moving coins. Exposure -- providing excellent view of what you're doing at all times -- being a sine qua non of efficient and safe surgery, that slipperiness isn't necessarily your friend, amusing as it may be.

Having taken three posts to get to the peritoneum, it's now time to pass through it. In some people you can tell before opening it that things will be OK: the membrane is translucent and you can see through well enough to recognize that the omentum or bowels are sliding around underneath, unattached. Nice. So you make a little knick with a knife, taking care not to cut anything on the other side. Classically you and your assistant grab a bite of peritoneum with forceps, picking it up, allowing a cut away from underlying structure. When you can see, you can save that step. (Fast surgery is not really about fast hands: it's about an accumulation of countless little quanta of efficiency.)

Having made a hole, you might grasp on either side with clamps, elevating it, then zip a scissor downhill, never moving the jaws. Or pull it open further with two fingers. Or slide your finger under it and open it with cautery, your finger protecting the bowel, and the glove protecting your finger from getting cooked.

In the case of prior surgery, where you are re-entering a old incision, it's an entirely different animal: time slows down; you might have to try several different spots for entry, trying to find even a little area to which bowel is not attached. The smallest free zone can make all the difference. Finding none, dissection can be tedious, laborious, frustrating. But since this is an imaginary patient, the innards fall away as soon as we puncture the peritoneum; entry is a splashless dive. (Note to do-it-yourselfers: taking a moment, before cutting it, to sweep your finger across the peritoneum to separate it from under the muscle layer makes sewing it back up much easier.)

That slippery bowel wants to be everywhere. Like everything else for which there's not a perfect solution, many techniques exist to pack it and keep it out of the way. With a stem-to-sternum incision, as for some vascular operations, you can put it in a bag. Tethered to the back-side of the abdominal cavity, whence comes the blood supply, nearly the full length of the small intestine is free, frontward. You can slide your hands in from each side, heading under the bowel and down to the root of the mesentery; rock your hands backward, seemingly lifting all the guts right out of the belly.

You can't go quite that far, but you can expose the bottom side, allowing your assistant to lay the open mouth of a large plastic bag, not unlike one that might be in the waste-basket under your sink -- complete with a tie. Releasing the bowel gloppily and gurgily into the bag, feeling it slip-slide over your hands, is one of those surprising sensual experiences that surgeons get to have. Tie the tie snugly enough to keep the bowel in but not enough to choke it off, and enjoy the show as the bowels wiggle through the whole case.

But we haven't made that sort of incision. In fact, the smaller incision is an aid in the typical packing process: using laparotomy pads ("lap-pad," "lap-sponge" or "lap," as in "gimme a moist lap" -- the saying of which in another context ((particularly with "you" in front of it)) might deserve a slap in the face but herein is a request that the scrub hands you a moistened sponge for packing) folded in whatever way you were taught or in a way you finally figured out yourself and tucked here and there, you find the integrity of the uncut abdominal wall above the incision holds those pads in place. (Every once in a while, I need to write a sentence like that.)

Bowel has a way of squirting around the edges of packs, so taking a moment at the beginning to get them right saves a lot of pawing and repacking just when you don't want to have to. Another of those quanta of efficiency. So here's what I do: I reach into the pelvis with my left hand and grab a handful of small bowel while my assistant is holding onto the sigmoid colon -- our ultimate target -- and lifting it up. I may have to replace my right hand over the left, and then the left again over the right, until I have the guts up and out of the pelvis and exposed down to the root.

The scrub hands me a succession of lap-pads, moistened and folded in half. With my right hand, I slide a sponge over my left, which I then withdraw, leaving the end of the pad tucked under the bowel at the root of the mesentery; the body of the pad is over the bowel, and the top end is tucked under the abdominal wall, with the blue tag-string out of the wound. (That keeps you from losing it.) Working from the right side of the pelvis to the left, it usually takes three or four pads fully to cover and tuck the bowel and keep it out of the field.

A nicely-arrayed field of white has replaced the ruddy-brown bowel, leaving in view only the sigmoid colon, as if displayed on a table-cloth. Some surgeons use fully-unfolded pads: they usually don't have the turgidity to hold things steady; invariably, it seems, a loop of bowel finds its way into the field. One of my first partners used to roll pads into balls and stuff them all over the place. As I said: having lots of methods bespeaks imperfection of all. But mine worked pretty darn well.

Most surgeons use some sort of self-retaining retractor to hold the incision open; if so, it gets set up before the packs are placed. There are some pretty ingenious erector-set gadgets that can do the work of several hands. When possible, I like to omit such retractors because I think the steady pull at the wound edges makes for additional post-op pain. But more often than not, some form is necessary; for this incision, I like the old-fashioned, quick and easy Balfour retractor. Simple and nearly foolproof, it also makes a businesslike ratcheting sound when opened into place. Downside: I often manage to get my glove caught in the mechanism when I release it at the end.

If I can get away with having my assistant hold a simple retractor during parts of the procedure, I'm happy. Retractor or not, I put moist pads -- usually soaked in a mixture of saline and betadine -- over the wound edges, to keep them from drying out, and to protect from contamination. And it looks very tidy, which has value if for no other reason than my own enjoyment -- the apprehension of beauty has no prohibited venues.

Positioning matters. Working in the pelvic regions, tipping the patient head-down gets gravity on your side, helping to keep the bowel away. "Can you give us a little Trendelberg?" I ask of the anesthesiologist. (The term is "Trendelenberg," but I like to save time.) Of all the things to have named after you, it seems a body position is a weird choice, particularly when all we're talking about is taking a flat table and tipping it. Most used for a patient in shock, the Trendelenberg position is a mouthful in an emergency. "Drop the head, drop the head, dropthehead goddammit!!" is more to the point. On the other hand, I suppose to have some complex position named after you..... "Honey, feel up to a Schwab tonight?" But I digress.....

So we're ready to conduct the business for which we came: getting rid of the sigmoid colon. Sigmoid means "S-shaped." Our target organ is curled on itself and it's time to uncoil it. Doing so is among the more satisfying maneuvers of colon surgery; a little magic, a little danger, couple of tricks here and there and we should be able to unlatch it from its position along the left side of the pelvis and bring it right up into the incision where it should give itself up to us gladly....

[The intercom honks: "Dr. Schwab, I have the ER on the line. Can I transfer them in?" "Do I have a choice?" "Ha ha." "Sid? This is Pete. I've got a lady here with an acute abdomen. You're on backup, right?" "Must be, or you wouldn't be calling. What's the deal?" "Just letting you know. Sending her for a CT. I'll get back to you. She seems fairly stable for now." "Great. Thanks." Deep breath. Long sigh...]