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.

Pleasin' Squeezin'

From my prior comments about my love for bowel surgery and for the old-fashion method of hooking the ends together, one might draw the erroneous conclusion that I eschew all forms of operative shortcuts. Untrue. While not the top priority, speed is an issue, and I've written about that, too. My reasons for preferring hand-sewing over staples -- aesthetics, cost savings, connection to the history of surgery -- don't apply when it comes to clamping and tying blood vessels. Surgical clips, particularly the old-style individually loaded ones (as opposed to the fancy disposable multi-fire guns) are cheap as dirt, simple as hell, and save lots of time.

For the first thousand years or so, surgical clips were made of stainless steel. More recently, and mainly because of concerns about clips being pulled off by MRI machines, they come in titanium or, most lately, are made of absorbable material. Whatever the composition, the idea is straightforward: shaped like the marriage-bed issue of a V and a U and grasped in the jaws of whatever instrument, the open part is slid across a vessel or duct, the holder-handles are squeezed, and the clip flattens into two legs tightly pressing the tubular structure in question and rendering it closed. Depending on size, pressure, and tightness of one's own sphincter, more than one clip might be closed onto the business end before cutting. Either way, it saves several seconds over clamping and tying; over a long operation with need for many ligatures, it adds up.

Blessedly uncommon, one teensy problem can occur: if the jaws of the applier are out of alignment, instead of bringing the "legs" of the clip properly together, they may overlap in such a way as to turn it into a scissor, cutting when the intent had been the opposite. Depending on where and what, it can fall anywhere along that line which connects "nuisance" with "disaster."

Practically every patient who's had his/her gallbladder out in recent years will have had two little clips placed, one on the artery to the gallbladder, and one on the duct that drains from it into the main bile duct. By the pattern and location, you can tell a person has had the operation just looking at a plain belly Xray. Consequently, I've had many patients return to me upset because their chiropracter took one of their infamous whole-body Xrays and told them that those clips near their spine are causing all sorts of problems, likely requiring monthly manipulations for the rest of their life. I'm guessing the regular reader will not have to wonder what I think of that. It did, however, lead me to be sure to inform everyone in advance, pointing out that we leave chunks of steel the size of doorknobs in hip sockets, and pacemakers aplenty, big as a pocket watch and housed happily.

Mother of all general surgical operations, the Whipple procedure (about which I've written here and in my book) affords many opportunities for applying clips, and I've always done so liberally. One such patient brought me an amazing story, which I'd never heard before and haven't since.

Other than being the color of a daffodil, when I met him he was a very healthy and vigorous man, in his sixties and in need of a Whipple, which I did promptly, slick and quick. His recovery was rapid (much more so than indicated in the preceding link) and he returned in short order to his major pleasure, golf. One day, several weeks after the operation, golfing as usual and on a dog-leg left, long par four, he explained, he felt a strange tickling sensation on his belly. Lifting his shirt and looking down, he noticed some activity at the small and previously healed scar from where I'd placed, and left for a few days, a drainage tube. He got his hand to the area in time to catch a whole series -- fourteen, to be exact -- of steel clips exiting out the former hole in single file like little tin soldiers, blip, blip, plop, plop. He brought them to me in a baggie.

ZAP

Not many surgeons nowadays would want t0 operate without an electrosurgery unit, but it wasn't all that many years ago that everyone did. In fact, when dinosaurs roamed the earth and I was still in training, a couple of my teachers refused to use it at all. So I learned both ways. Cutting only with a knife, and controlling bleeding only with clamps and ties and sutures has a certain elegance; grace, even, as tying a small vessel requires gentleness and coordination of the fingers so as not to avulse the knot from the bleeder. But it can also be tedious. I wear size 8 1/2 or 9 gloves.

An electrician or physicist I'm not, so I can only say that electrosurgery refers to any of several devices that provide the surgeon with a pencil-like hand unit, connected to some sort of magic box which sends little electrons or something to that hand unit, which then arc to the patient in at least two different modes: one that's best suited for cutting, and one that serves to cauterize; ie, cook tissue to make it stop bleeding ("dead meat don't bleed," a colleague liked to say). I guess the first such devices, widely available only in the last fifty years or so, were those invented by a guy named Bovie. That name has become like Kleenex to facial tissue -- pretty much used generally and generically to refer to any unit, which I assume must annoy the other manufacturers. "Bovie," the surgeon says, and he or she receives a hand-unit most likely made by someone else.

In those days of yore (or mine) the Bovie looked like something from a B-grade science fiction movie, with knobs and buttons and dials; having a fat handle and foot pedals to operate it. "Turn the coag to sixty," the orthopedist would say when encountering bleeding, and the dial would be rotated far to the right, the surgeon would step on the left-hand pedal (there was one each, for cutting current and for coagulating current). Spzzziiiiit the arc sounded, while the floor unit emitted a low-pitched and disquieting hum. Now, we have tidy little boxes with digital readouts, buttons marked ">" and "<" and spiffy hand units with a rocker switch to go from cut to coag, with no need for a pedal. (Most surgeons, I think, like to dance their index finger on that switch -- or buttons, which some "pencils" have -- but I preferred the side of my thumb, which I could rock back and forth without changing my grip.)

I didn't much use electro surgery for cutting, except for going through muscle, preferring the lesser tissue-trauma and greater speed of a knife, cauterizing as needed. You can scald directly, by touching the bleeder with the tip of the unit and firing away. More precise is to clasp the vessel with fine forceps, then touch the blade of the pencil to the metal of the forcep. "Buzz me," is what I'd say after forceptualizing the bleeding point; my assistant would touch the bovie to my instrument and activate it, and I could let go of the tissue at the instant I was happy. Excellent control. Cautery is great for (some kinds of) bleeding from the liver. The old units had a ball-ended option: turn the phaser to stun or kill, press the ball into the wetness, and blast away. It would, of course, smell exactly like grilling liver, and smoke would rise, white, profuse, acrid. (Concerns have been raised and remain, regarding health hazards to the team inhaling that stuff.) "Turn up the coag," I'd request, "and get us some sterile onions."

Sometimes, when it's cranked way up, you can see little lightning bolts running away from the point, for a few millimeters, within the tissues. Spidery sparks, singeing. A charcoal-like coagulum of tissue and baked black blood forms; depending on the nature of the bleeding, blood may continue to ooze from underneath and around, making the field look like an evil-staring eye. Pulling away the cautery unit, stuck like a grill on steak, sometimes also pulls away the char, and you have to start again.

Since sliced bread, the greatest invention is "spray mode" cautery. Using some electromagical manipulations, these new units can be adjusted to provide a white and sizzling rivulet which leaps as if from a Van de Graaf generator, lighting the space between tissue and tip, covering a relatively broad field of fire, cooking without the need for touching. Excellent! No avulsion of clot. Perfect on liver or spleen, where suturing is tricky.

Gathering dust in many an OR are uber-expensive laser units, once sold to hospitals as the next wave, the future of surgical cutting. Better than electric current, and what the public is demanding, they were told. Half-right. For most operations with which I'm familiar, laser offers absolutely no advantage other than marketing. (It has a rightful place in eye surgery, various skin procedures...) In laparoscopic surgery (where laser was predicted to be the ne plus ultra and isn't), there are cleverly conceived devices that combine in one wand, cautery, suction, and irrigation. In the early years of laparoscopy, that was precisely what I thought was needed, and, by golly, here it is. When scissors are added, a lot of annoying motion (taking one instrument out, inserting another, back and forth) will be eliminated. Surgeons nowadays are deeply beholden to engineers.

Smooth Move

On a Nobel Prize website, in reference to Theodor Kocher, recipient of the Prize in Medicine in 1909, it says, among other things, "The influence of a devoted mother and later the loving care of a selfsacrificing wife enabled him to pass without interruption through the continuous strait of secondary school and University, and he obtained his doctorate in 1865." Some things, I guess, don't change all that much; in others, he was unique.

In surgical lore, Emil Theodor Kocher is known for many things, as is the case with all those greats of old: innovation, invention, vision. Clarity. Viewers, they were, of the empty spaces between knowledge and action, and seers of ways to fill them. Despite my cognizance of the breadth of his influence, when I think of Kocher three main things come to mind: a big honkin' surgical clamp (curved or straight), the classical gallbladder incision, and his discovery of how to mobilize the duodenum; another of those simple and anatomically-correct tricks that gives the surgeon entry into secret places, and makes a hard job easier. The Kocher Maneuver. What a great thing to have named after oneself. A maneuver.

It's as if the duodenum is the command module of the belly: riding high and hanging back, daunting (one might assume) to the lesser organs, it receives input from the stomach, the liver, the pancreas and distributes it all downstream.

With many life-sustaining tubes draining into it, and with as many big and scary blood vessels passing behind, beside, and around it, surgery of the duodenum is tricky, and requires most of the skills a surgeon must have acquired. The simple snip Dr Kocher invented makes the work a little cleaner, and is essential to working on that part of the intestine, on the pancreas, and for much of the surgery of the stomach.

In one sense, it's no big deal at all: just a few seconds of scissoring along an imaginary line. In another, it's amazing that there's one person to whom the move is attributed, since it seems anyone working there would see the need to do it. Which makes it all the more noteworthy: when the Kochmeister was poking around in bellies, many of even the most basic concepts were yet to be deduced.

I can barely imagine what it must have been like to be a surgeon in those times. Scary, exhilarating, deflating, rewarding. Those guys must have lain awake many nights as their brains buzzed and glowed with ideas. ("Teddy," his wife might have sighed, "Can you stuff a cork in your ear? The light is keeping me awake.") Would they have been barely able to keep from getting up and running to the lab to enflesh their latest inspiration?

I guess you could say there was no downside to what those trailblazers attempted: the conditions against which they were struggling had, until then, only bad outcomes. Either they found new ways, or the patients died as usual. Depending on how you look at it: either unbearably pressure-filled, or completely liberating.

The duodenum is plastic-wrapped to the backside of the abdominal cavity, covered as it is by the posterior parietal peritoneum for most of its length. Looking at the picture above, you can see that after connecting to the stomach, it descends downward and then curves hard to its owner's left. That curve is called the C-loop (or the "second portion," or the "descending duodenum.") The Kocher Maneuver is the process of cutting the C-loop loose, by incising the peritoneum covering its lateral edge. Made a verb, the term is "Kocherize," as in dictating "the duodenum was Kocherized..."

Doing so gives just enough mobility to be able to tug the duodenum upward to join the stomach if you happen to have cut part of it (the stomach) away (only so far: the duodenum is, ultimately, tightly tethered by the aforementioned tubes and vessels); or more easily to open the duodenum across the pylorus for any of several reasons. And, most exquisitely, to gain access for your finger to nooger behind the duodenum and pancreas together, all the way to the superior mesenteric vein, after which, among other things, you can extend the Kocher Maneuver downward and to the left. Then you really have the meat of the belly in your hand. Awesome.

On the other hand, maybe you have to be there...

Word!

[Credit to Judy for suggesting this picture.]


I think it might be about 8,000. Or is it 12,000? Anyway, somewhere I've seen the number of new words people learn in medical school, and whatever the correct amount, it's impressive. Here and there in this blog, I've mentioned some words I really enjoy just for the saying: bezoar, inspissated. How about radiculopathy? (Sounds like a word that could be applied to most politicians, whether you pronounce it "rih-diculo... or "raa-diculo...) Neovascularization. Tachyarrythmia. Pancreaticoduodenectomy. Intussusception. Bezoar.

Bee-zore. Say it like the taunting "air-ball" at a basketball game. (Digression: It's been shown that at every venue, whenever the chant is chunt, it's always in the same pitch, the same notes on the scale. F - D, matter of fact.)

OK. The point I want to make is that in addition to the neo-vocabulary we learn, there is also a more esoteric lexicon: words or terms that bubbled into the vernacular and have become universally understood, at least within certain sub-cultures: gomer; O-sign; Q-sign; flail. Let me tell you one of my favorites. It has it all: nice sound, excellent meaning, and, in my case, a connection to one of my favorite people. The word is

NOOGER.

In my book, I described learning how to dissect through distorted, inflamed, difficult anatomy. I called the method "delicate brutality." (Too late, it occurs to me that that would have been a great title for the book.) Central to the technique is the ability to nooger; namely, to ootz a finger into a sticky place and wiggle it, pinch it, insinuate it until you find a way through without poking a hole into something important. Noogering can be done with other blunt instruments: a sucker, a round-ended clamp, closed scissors, often along with the finger. Indeed it requires a combination of delicacy and brutality, plus some sort of either learned or innate (or both) sense of touch; of tissue turgor (there's another good word: turgor, turgid) and confidence of anatomy. If you can't tell where a thing is, you need to be fairly confident of where it isn't.

Not all surgeons need to nooger. Orthopods and neurosurgeons don't. Bone isn't noogerable, and brain, well, God help us... But a non-noogerescent general surgeon is bound for trouble. Important as it is, I can't think, exactly, how I learned it; or how properly to teach it. But I did, both. In a situation requiring one to nooger -- precarious as it usually is -- I'd rather do it myself than try to tell someone else how.

Among my favorite characters from training was the chief cardiac resident, a gangly, good-humored, soft-spoken, slow-walking but fast-thinking southern boy, Joe (full name: Joe) Utley. (The picture is from much later, in his evidently post-gangly years. Like mine.) In stark contrast to the other men populating that department -- who were volatile, egomaniacal, bad surgeons, crazy, nasty, or pretty much any combination of those characteristics -- Joe was laid-back, engaging, and highly talented. He told dumb jokes, quoted lines from movies, played the fluglehorn while wearing a sombrero, and treated me -- his over-worked intern -- with respect and caring (although, it could be argued, having an intern and his girlfriend [now wife] over and subjecting them to the horn and the hat was anything but respectful). I loved the guy. (Joe died a couple of years ago. I sent a copy of my book, in which he played a prominent role, to his wife; she wrote back that she knew he'd have loved it, and she could imagine him laughing out loud while reading it. That made me feel good.)

In hooking a person up to the heart-lung machine, it's necessary to control blood returning to the heart via the venae cavae. That requires (did then, anyway) slinging the veins with ties; to do so necessitates dissecting within the pericardium, behind those delicate structures, completely encircling them. Joe had a favorite instrument for the job, a very large clamp with a curved and bluntly-rounded tip. This he referred to as a "Giant Noogerer." Open heart surgery has a certain drama, and, in those relatively early days on the time-line, tension compounded by lengthiness. But as an intern on the service, because there was always lots to do, stretching into sleeplessness, time in the cardiac room was -- depending on who was in charge -- rarely pleasant. With no opportunity to do anything but stand there and answer questions, the hours dragged me down, while pushing the day's work further into the night. Except with Joe. I found myself looking forward each time, as the moment approached, to hearing him ask for the tool. "Giant noogerer," he'd say, hand out, and it always arrived with no need for clarification. With his gentle accent, it sounded like "jahnt nurgrer." I wanted to link here to a picture of one. But I have no idea what the real name is.

Sleeve (Up)

[This is another post that's been sitting around in draft form for a while. It might be obvious why I hadn't posted it. More cleaning of the attic -- or in this case, maybe the basement. It's conceivable that some day one person might find one thing useful.]




In no particular order, and for no special reason, here's a few surgical "tricks." Most are amalgams of observations, teachings, and trial and error. Surgeons will shrug, non-medical types (and non-surgical medical types) will say "who cares." Credulous and ingenuous students might make note and tuck them away, against the possibility -- remote as it might be -- that they'd prove useful in a future life. Whatever.

1: In thyroidectomy, "walking" to the outer parts of the poles by sequentially placing suture-ligatures provides excellent traction for exposure -- much more wieldy than Leahy clamps, the sutures can be pulled any which-way as you work.

2: The same technique facilitates the removal of a breast fibroadenoma.

3: The biggest mistake people make in open appendectomy is placing the incision too far medial. Go lateral to the rectus muscle, come down on the cecum, and you won't have to wave your finger all over the place to find the appendix.

4: At the base of the appendix there's almost always a clear window through the mesoappendix. Poke a clamp through, pull back a tie, have your assistant tie it while you snip the mesoappendix.

5: Developing flaps in thyroidectomy doesn't accomplish much more than increasing post-op swelling.

6: Use marcaine in all incisions: generously, up to 1 cc/kilo of 1/4%. Get the peritoneum. Use it all around the pectoralis muscles for mastectomy. Use lidocaine when infiltrating the sac in inguinal hernia, in case you flood the femoral nerve.

7: Sweeping a finger circumferentially around the surface of the peritoneum and behind the fascia in open appy, before entering it, greatly facilitates closure later.

8: In the proper plane, sweeping a finger in front and behind a thyroid lobe allows it to be flipped forward and out of the wound.

9: There are two ways to handle the laryngeal nerve: be sure you see it, or be sure you don't. I prefer the latter.

10: Squirting marcaine into the gallbladder fossa reduces the chance of "phantom" biliary pain in the recovery room.

11: Nearly any umbilical hernia can be repaired using a curved incision within the umbilicus.

12: Nearly any adult umbilical hernia is best repaired with mesh.

13: To make a nice mastectomy scar, draw one side of the elliptical incision, then "measure" it with a tie, placing it in the jaw of a clamp at one end of the incision, laying it onto the marked arc, and clamping it at the other end. Then use it to lay out the other arc: each will be the exact same length, eliminating bunching on closure.

14: Use curved Mayo scissors to develop the flaps in mastectomy; grab bleeders with a Debakey forceps and cauterize them.

15: For tracheotomy, place 2-0 silk sutures vertically on either side of the first tracheal ring before dividing it vertically. Use them for traction when inserting the tube, leave them for several days in case the tube needs replacing before the tract is firm.

16: Non-inflamed/infected sebaceous cysts can be removed through a tiny hole by poking them with a 15 blade, squeezing the gunk out, and continuing the squeeze to expel the sac.

17: Don't shave around a scalp cyst. Tape the hair apart with paper tape.

18: When draining an abscess under local, keep injecting with one hand and make the incision with the other, into the blanched area.

19: When operating on the chronically ill, if not giving TPN, add multivitamins to the IV; and use post-op nasal oxygen for healing.

20: Make rounds at least twice a day. Sit down in the patient's room (on the bed is OK.) Read the nurses' notes, preferably before seeing the patient.

20a: Sit down when seeing a patient in your exam room, too.

20a, i: Don't make the patient undress any more than absolutely necessary.

21: If, after many years in practice, you can only come up with this many items, you probably should have kept your mouth shut (hands in your pockets). I think there were more, but it's been a long time...

Operation, Deconstructed. Seven: resection, finally

Would you know what I mean if I describe whistling without whistling? Barely pursing the lips, making little quasi-audible windy sounds while inhaling and exhaling, in tune yet nearly silent? Unless there's music playing, that's what I do when I operate. And for reasons about which I have absolutely no clue, I nearly always "whistle" The Caisson Song. I've always wondered if anyone in the room noticed. Joanie? I suppose if anyone did, they'd eventually recognize it as a sign of contentment. "Over hill, over dale, looks like things are going well...." So it's "hi hi hee" to cut the colon free. I grasp the sigmoid again, and pull it upward then downward, looking to see where the bottoms of the loop fall, determining how much looser I need to make it before removing the damaged portion. Having mobility not unlike that of the sigmoid, the rectum can be made to stand up and out of the pelvis with a few judicious snips of its surrounding peritoneum. No matter how extensive the diverticula, they always spare the rectum. (The anatomic definition of the rectum is a little loose, not unlike the actual organ. I consider it to be the part of the colon that starts below the pelvic brim, and continues to the anus.) And since I'm doing the writing, in our patient the diverticula trail off markedly at the upper end of the sigmoid, as is typical, so the resection is less extensive. I unzip the white line a little higher, maybe up to above the left kidney, and achieve enough mobility to get point A to point B after the sigmoid is in a pan. And now, what used to be the most annoying part of the operation: clearing the chosen spots for division, and making them ready for the placing of clamps. The blood supply to the colon comes, more or less, from the center of the abdomen and radiates out like the hands on a clock. Taking the clock analogy beyond its limits, if you want to remove -- as in this case -- a section of colon from three to five o'clock, to get to the blood supply you make a pie-shaped pair of cuts from those numbers to the center of the dial. The difficulty is in direct relation to the amount of fat within the mesentery. Once in a while -- rare enough that it makes you want to be able to record it in your brain and replay it in your dreams -- you can hold the bowel up and see right through the mesentery. It takes a very skinny person. More beautiful than the wings of a mayfly, it's spectacular calligraphy on wetted rice paper, the vessels visible in their spidery and laddered connections; clamping them off -- individually, precisely -- is exhilarating and easy, as if there were no choice but to do it. Most often, though, it's hardly that beautiful. In my early years of training, the process frustrated me. Turns out, there's a trick: the fat in the mesentery nearly always thins out right at its border with the colon. Grasping the colon over the top, I can usually feel the lower edge of the bowel; pushing toward myself from the opposite side, feeling my way to that edge with my middle finger, I come at it from my side with the tip of a curved clamp. Judging the resistance to be sure I'm not punching through bowel, looking over to the other side to confirm, I push the tip onto my middle finger, and wiggle it through. "Two-oh tie." (It's a thread without a needle on it.). I push the clamp further through, spreading my fingers to let it pass between them on the other side, and then I open the clamp. Joanie directs the end of the tie between the jaws of the clamp, and I pull it back through, bringing my end to the top so it's around the bowel, and I click it into the clamp. Point A.

I repeat the process at my selection of point B. Now I literally have a handle at each end of the bowel where I'll divide it. And having made that little hole, I've opened the peritoneum on each side of the mesentery and can insert the tip of a scissor. The fat recedes. I can easily move it off the bowel surface and, turning the scissor centrally while pulling backward on my suture-handle, incise the tensed peritoneal layer with a push of the blades all the way to the root of the mesentery, from which the vessels fan out. This unroofs the underlying fat, and I can scrape at it with the closed scissors, pulling it away from the vessels hidden underneath. And there they are. To make ready for clamps, I punch through the mesentery above and below each vessel that I see. And here's a situation that distinguishes elegant surgery from the brutal: it takes only a moment to clear each vessel separately. Some surgeons do, some don't. Having gotten to the base of the mesentery, you can just "walk" back up to the edge of the bowel with a series of clamps, not really seeing any of the vessels you're dividing, grabbing them by inference, along with globs of fat. It works, as long as you don't take an enormous bite (if you do, when you release the clamp as you tie a tie, the glob may fall away and bleed.) But in my view, it means choking off a wad of fat which will die and inflame and generally add to the work of healing. Plus, it looks bad. And when you see each vessel, you can save some time by applying clips instead of clamps and ties. Which is what I do. It's like jazz (the Caisonnity-sonitty song?): winging it with regard to when I squeeze on a clip, and when I feel like using clamps and ties. (I never leave a clip near the bowel surface: it'd be in the way of the anastomosis.) Given the same curtain of blood vessels on two different days, the music might sound different, who knows? "Clip... Clip... 'Nother one... Clamp... Clip... Clamp." Get a feel. Go with the flow, the size and the nearness of the vessels. And, after all the upstream ends of the vessels have been controlled, I may or may not clamp the back-leak ends before I divide them. Depends on the size of the resection, how much I can control with my left hand. Sometimes I click a clamp ex post facto. If so, I never waste time tying them off, since it's all coming out -- unless the resection is so big that we've run out of clamps.

For a total colectomy, I might use the LDS stapler, which clips both sides of a vessel and divides it all in one beautiful gas-powered "k'chzzz," delivered from a very satisfying pistol-grip. I don't trust it for big vessels; I add another clip on the business end before pulling the trigger. One way or another, I scissor through the vessel after controlling it, usually whisking the instrument to my wrist (as previously described) when receiving the next clip or clamp. So now we're ready for the coup de grace. The sigmoid colon is free of its attachments. Holding it up, the mesentery hangs off it like a bib, maybe dangling a clamp or two. "Couple'a betadine laps." For beauty, and for infection protection, I drape the field around and under the bowel with lap pads soaked in povidone/iodine: luscious chocolate brown drapery covering the entire field, with only the bowel loop visible above it. A presentation fit for royalty. Museum quality, it ought to be in a lighted display case. With two OR lights aimed right at it, it is. It takes four long intestinal clamps: two delicate ones that stay (for now) with the patient, and two who-cares ones that go away with the specimen. The former I place with the handles aiming at my assistant, the latter toward me. Picking the first pair, she holds hers, I hold mine and I slice between them with a #10 scalpel, the one I used for the initial incision. I wipe the cut end of the bowel with a betadine-soaked sponge. Ditto for the second pair. Then I hand off the bowel, hanging like an abandoned hammock between the two clamps, drop it into a pan, along with the now-contaminated knife. I like the heft of it in my hands, the rattle and clang of the clamps and knife in the metal pan. With a total colectomy, the weight of the specimen is such that the receptacle dips in the outstretched hands of the nurse. Now that's surgery! "What should I call it?" the circulator asks. (She wants to know what to write for the pathologist.) "How about 'Dave?' " I say, as usual... Squawk... "Dr. Schwab?" "Whaawttt?" (Said in the way of a fishwife -- I think they know it's a joke. On the other hand, it's not always Dee on the intercom...) "I have Carol from 6-A on the line." "OK, transfer her in..." ".... Dr. Schwab, this is Carol from 6-A. I'm calling about Mr. Jones. He has a temp of 102..." "Who's Mr. Jones?" "He's a patient of Dr. Smith." "....Have you called Dr. Smith?" "The answering service says you're on call." ".... (cleansing breath)...I am. But, uh, we take call on our own patients during the day... (Unsaid: as we have for the last fifteen frickin' years. Frickin' answering service drives me crazy.)" "OK, I'll call him." "Great! Let me know if you can't find him." (!!!)

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...]

Operation, Deconstructed. Two: cutting in

The preliminaries are over. Sponges, needles, and instruments have been counted and checked, their number recorded on a whiteboard on the wall, as well as a clipboard. The checkoff is a comforting hum of words; the tuned machinery of the workplace. As the bottle of local is opened and poured into a sterile bowl on the back table, the expiration date is read aloud. "January, Two Thousand Ten." "We'll be done by then," I say, as usual. I look over the ether screen and ask the anesthesiologist, "OK to start?" "Dig in," he says.

Scalpel blades come in myriad sizes and shapes. #15 for a delicate cut, needing controlled curvature, like around the edge of an areola. With those little pokes for insertion of laparoscopy tools, it's #11. This being the real deal, I use a #10 blade, for its deep and long belly; a serious cutting device, but wieldy. There are bigger knives.

The act of incising human flesh is one of moment, never light, never routine no matter how familiar. Having thought about the exact location and length -- not always standard for a "standard" operation -- and having spoken to this person only minutes before; having made and accepted an awful commitment, asking for and taking trust; still, to take a knife in hand and with it to open a wound is a startling event. I never feel as focused, as intent, as responsible as when I make that first cut. I'm aware of transgressing, of forced entry, of crossing barriers, physical and ethereal.

It's like passing through an arbor draped with not entirely familiar vines, ominous and appealing simultaneously, not quite seeing to the other side until they're pushed away, with resistance. It's OK. I've been given the key, evidently I'm allowed here. But is such a thing possible? It remains a mystery. My breaths are shorter and harsher than normal; my pulse perhaps a few beats quicker; it never fails to excite me. Yet (almost) always my hands are steady. At this moment, there's nothing else. Later, as it goes, the air gets lighter.

How the knife is held is dictated by the task at hand: sometimes, in the finger-tips; others, like a pen, pinkie down on the patient as a steadying unipod. For a full-fledged incision, my last three fingers curl around the handle, thumb alongside the blade, index finger on top, right over the belly of the blade. As I make the cut, depth is controlled by that index finger, sensing the resistance and the ease with which the knife penetrates. Not everyone is the same: some skin is thick and leathery, some nearly translucent and feathery, like a summer roll. One has to adjust, on the fly, eyes bright and shiny, central also to the feedback loop.

I push hard, aiming to swipe through the skin and fat and to the muscle, even through it, in a single motion. A perfect incision, to me, is one that exposes the peritoneum with the first sweep. It's not always possible (only in the slender), or safe, and safety is paramount. But time spent doodling in an incision is time wasted and probably deleterious. (I've mentioned it elsewhere: few things surgical bug me as much as the tendency of many surgeons to incise partly through the dermis, to finish it off with electrocautery, and then to cook their way through the fat layer as well. It takes a ridiculous amount of time, fills the air with stinky smoke, and leaves behind a thin layer of dead tissue which, theoretically at least, interferes with healing. When everything else important has been studied, I'd guess a comparison of that skin technique with straight-through sharpness would show a cosmetic disadvantage as well.)

The best surgery is the most efficient: wasting the least amount of time, leaving behind the smallest possible areas of damaged tissues. The first cut sets the tone; it signifies where you stand. That brisk and controlled savagery is exactly what's called for; a promise fulfilled, senses keen. Cautery is one step removed; it's a barrier between you and your patient; shorthand, cheating. (As you'll see, I use it all the time, and extensively, when it's the most efficient option. For the initial incision, it's wrong logically, physiologically, economically, historically, metaphorically, artistically, poetically.)

I think if you watched an incision being made in super slow-motion, you'd see the skin indent under the knife and, as it is drawn forward, a wake of skin rise slightly in front of the keel of the blade. If there were sound, it would be a shishhhh; if it were music, it would be strings, not brass. Laying the scalpel nearly horizontal at the outset, as soon as the skin is penetrated the handle is elevated a wisp, bringing the blade's belly more fully frontward to the pull. The thickness of the skin is revealed as it falls slightly away. (In a belly bloated by ballooned bowel, the skin springs away from itself, as if to run from the explosion to follow.) Interesting, isn't it: seeing skin in cross-section? Bleeding -- especially in the midline -- is most often minimal, easily controlled with a little pressure, the placing of gauze along the edges. In some, time must be taken.

Classically, little clamps were placed, their noses snipped just to the open end of the bleeder, to be followed with a fine tie. Delicacy required: the purchase on the tiny amount of tissue was tenuous; tying the knot after the clamp was gone, if done too artlessly, saw the whole thing pull away and the bleeding resume. "Off!" the surgeon would say to the assistant, signaling the release of the clamp just as the index finger met the knot. Then holding each end and throwing more knots with such grace as to cause not a waver of the held tissue, increasing tension equally on each end as the knot is tightened -- too much in either direction and it pulls off -- laying down a couple of loops until secure. If you can do it, you might be a surgeon. (The time-honored practicum: tying a knot around a single match in a matchbox, never lifting it out nor bringing it to the edge.) But having proved it long ago to my satisfaction, I use cautery now, like everyone else. Still, there are a few right ways and lots of wrong ones.

If you fire off the cautery in a pool-let of skin-blood, the blood will eventually boil and blacken, and maybe the coagulum will plug the leak. Some will keep up that untidy turmoil for a disturbingly long time, to their own "goddammit"s, red continuing to seep around the edges of the black. Some move the tip around nearly randomly, waving it a little, like shaking a dick at the end of a piss. If that works, it probably didn't need it in the first place. Or they paw at the bleeder with a sponge, then zap, then paw some more. Whack, buzz; whack, buzz. If it's brisk, it doesn't work: by the time you take the gauze away there's enough blood to obscure the exact spot. But if you place a gauze and roll it away, you can hit the bleeder right as it appears. Or you have your assistant lift the edge of the skin with fine forceps, then grab the bleeder with a forceps of your own, and touch the cautery to the metal. A spot-weld. Precision.

The six-pack muscle, the rectus abdominus, is separated vertically in the midline by a fibrous band, the linea alba ("d" in the illustration). In the healthy, it's broad and thick, and the much-loved target of a vertical midline incision, because it's nearly bloodless, tough enough to hold a good stitch, and affords entry into the abdominal cavity without cutting muscle. By "broad," I mean a few millimeters. It's possible to miss it when cutting down to it; in fact, it seems I always did as a junior resident.

The first time I cut into it, I was attempting a paramedian incision (rarely done: ordered for the experience by my attending), aiming NOT to be at the midline. In time, I got the hang. The only incision that has a chance of being that "perfect" one, cutting down to (but not through!) the peritoneum in a single heraldic swath, is through the upper midline, in a person not much overweight. In the lower abdomen, the place chosen in our imaginary patient here, the white line (which is what "linea alba" means) becomes less distinct, a little more narrow, and pastier, because the rectus muscle loses its posterior fibrous covering. Cutting into the lower midline is gooier somehow: less sturdy. But do it we must.

And since we've digressed from the particular cut of our aim, let's also take a moment to get real: surgeons may or may not be crazy, but there is a form of schizophrenia at work. Those things I said up there? Totally true. The ever-present awe, the sense of responsibility and privilege and focus, the third-person look at myself in perpetual disbelief: all true, all the time.

And yet the mind allows room, simultaneously and up front, for the mundane. Along with the tonal beeps and the tubular hisses, as I pick up the knife and make the cut, there's this sound: "So Joanie, how was your weekend?" Omnipresent OR humor: usually crude, often -- when the audience is known -- sexual. Despite being taught to do otherwise, irrelevant conversation is the norm. Just so you know. And music. Personally, I'm neutral about it: I usually enjoy it, with an omnivorous taste. But I can live without it. And when things get gritty, I ask for the music to go off, and for an end to extraneous talking, for as long as it takes to smooth things up. Speaking of talking, I seem to have blabbed all the way through the incision. Let's get more detailed, and back on point...

Stones and Knives

No chemist I, unable to explain solubility constants or crystal formation, I can only note and admire: gallstones come in all sizes, shapes, and textures. Hard and shiny like agates, faceted like emeralds, crumbly like clay. Mulberry-shaped, round, uniform or uneven; surfaces determined by their neighbor, or identically shaped as if manufactured. Green, black, bright yellow, fecaloid. They can occur by the hundreds in a single gallbladder, or fill up an entire bag in the form of one gigantic rock. Feeling like a magician, I liked to save a few from the lab and present them to their owners, more amazed than if I'd pulled a quarter from behind their ear. I always enjoyed looking at gallstones. Unless they were oozing out of a gooey gallbladder in the middle of an operation, like cockroaches from a garbage bin.

Learning surgical technique is an incremental process. The student may be allowed to cut some sutures, maybe even tie a few. Simple as that is, it allows a sense of tissue tension, unlearns the old way of holding scissors, teaches the new. Taking up a knife and cutting through the skin requires overcoming practically everything you ever knew. I was eventually allowed to "do" a hernia as a student (a rarity indeed), although I really had no idea what was happening, anatomically speaking. The resident held something in such a way that I had no question of what I was to do, and I did it. As an intern, I did more of them, getting better at maneuvering instruments, placing sutures where I aimed them, cutting without shaking so hard it was visible across the room. Taking out a gallbladder was, where I trained, too big a deal for an intern. It was real surgery, inside the abdomen, close enough to structures of significance, demanding enough of dissecting skills that we waited a year before getting the chance. So it always held special significance: like passing through a portal, like being taught the secret handshake. Tourists in fancy eateries are shown to the main dining area; locals get invited to the wood-paneled special rooms upstairs.

You can do some operations without knowing how to operate. In my book I wrote "with enough bananas, you could teach a monkey to take out an ovary." Some gallbladders are so easy to remove, hanging loosely under the liver like a pluckable plum, that I refer to them as "gynecologic gallbladders." If your first couple of gallbladders are like that, you can get lulled into thinking you know what you're doing. (Way back in my early practice days, when our community allowed more or less unfettered surgery privileges, more than once I was urgently invited in to bail out a family doc who discovered dramatically the mysteries held in the right upper quadrant, and who'd been epiphanized into the realization that knowing how to hold a scissors in one's hand does not a surgeon make.) In those same ancient times, it was believed that operating when the gallbladder was actively inflamed was to be avoided at almost all costs. Whereas it's true that most attacks of acute cholecystitis simmer down without the need for emergency intervention, they don't always. Gallbladders can get severely infected and can rupture (especially in diabetics); acute attacks can flare up again during a cooling off period. More recent studies tend to show that early intervention isn't associated with more problems than waiting. But it sure as hell requires knowing how to operate.

While serving in Vietnam, I "flew" EC-47s. The pilot would arrange power settings and trim, giving over to me the stick and rudder. I "did" takeoffs and landings, accomplished some cool maneuvers over the China Sea. Shit hot, as we pilots liked to say. On final approach, if the crosswinds were a little too harsh and I was coming in crabwise, at the last minute he'd say "I got it" and keep us alive. Under tight tutelage I removed a few gallbladders early in training, and came to feel I could do it. When I first encountered the real thing while helping a young 'un -- a red, swollen, pus-filled gallbladder, speckled with the black spots of gangrene and stuck tightly to the colon and liver -- I squealed for help like a kid who'd wandered out of the shallow end. Throughout my career, when I'd be working my way through such a mess with confidence, at some point I'd always remind myself of that first really scary one, and allow myself a smile. Behind the mask.


In the illustration above, you can see how the colon makes a sharp left turn (the "hepatic flexure" -- "left," by the way, orients vis a vis the patient). In life, it's immediately below the gallbladder, very often touching it. Same with the duodenum, which isn't marked but is the C-shaped tube at the bottom of the stomach. Uninflamed, those structures easily peel away from the gallbladder. There's a thin covering of the gallbladder which holds it to the undersurface of the liver, filmy, as if it were sprayed on, easy to navigate, buzzing a few small bleeders on the way. Down at the business end, the tube that connects the gallbladder to the main bile duct, and the artery that feeds the gallbladder (cystic duct and cystic artery) are usually not to hard to identify and divide: in most cases it takes a little dissection through a layer of fat to find them, typically not a great challenge. Ironically, though, some studies show that it's when things are "easy" that injury is most likely to occur: when your guard is down, you feel relaxed and floaty, recreational, and you might not attend as intently to the anatomy. So they say. Subtle anatomic variations occur here, and they can fool you. Still, with care, it's fun and safe.

Oh man! Not when the gallbladder is acutely inflamed or infected or both. That sprayed-on film is now thick as a the peel of a grapefruit. The colon -- duodenum, also, maybe -- is plastered to the mess and has become inflamed, too, such that where one ends and the other begins is anyone's guess. The adjacent surface of the liver, caught up in the raging redness, is gooified and extra bloody. And the little duct and artery? Good luck! Encased in dense edematous tissue and often indecipherable. This is where everything you've ever learned about handling tissues, every trick you were taught and every wrinkle you've come up with yourself needs to come front and center. When nothing is normal, no move has a predictable outcome.

How can I describe a combination of caution and boldness, of confidence and trepidation? What does it take to enter such a zone recognizing the danger but believing you can do it? (Not as much as entering a burning building or a free-fire zone.) In "Cutting Remarks," I came up with the term "delicate brutality." I like it (in fact, I've since thought that would have been a better title for the book.) You can't blunder into the foray swinging sledgehammers like an orthopedist. But if you diddle around forever, nibbling at the edges, afraid of the water, you'll drag the operation out too long: the sicker you are, the less you need a long anesthetic. So you resort to techniques that can move along briskly but respectfully. Blunt baby steps. A careful cudgel. Delicate brutality.