Operation, Deconstructed. Nine: finish line

Truth be told, sewing up holds no magic for me, other than the fact that in some cases it's a time to breathe a sigh of relief. (A main attraction of neck surgery is that once the fun's over, closing happens in the blink of an eye.) Still, it's not a time to stop paying attention. As in all aspects of an operation, there are dangers, and there are ways to screw it up. On the other hand, keeping your eye on the ball doesn't preclude a little relaxation. With very little encouragement (most often, without any at all) I'm liable to launch into my repertoire of Gilbert and Sullivan or Rogers and Hammerstein. I can do most of the parts in "HMS Pinafore," and a truly show-stopping "Pore Jud is Daid," keeping it up until the circulator, sighing with force that could break bricks, marches over and turns up the radio.

The anesthesiologist has a tough job: ideally, the abdominal muscles are fully relaxed (paralyzed) for closure, because it keeps the patient from pushing the guts into the wound, and it makes approximation of those muscles much easier. And yet it's also nice to see the patient fully able to breathe by the time the bandage goes on. Some are better at it than others; and surgeons make it harder by being unpredictable. Not me, of course. Today, it's one of the good ones; while I sew perfectly limp muscles, he tells me about his latest attempt to electrocute squirrels. Been reading about Ben Franklin, made a model of his capacitor or some damn thing.

Closing the peritoneum -- the freeing of which on the way in I described a couple of weeks ago (has it been that long?) -- helps. Not everyone does it. In addition to holding the insides in during the rest of the closure, it allows thorough irrigation of the incision with that nice brown solution I used in the belly. I place a couple of large and tough clamps on the edge of the muscle (the fascia -- the halves of the linea alba I divided when making the initial incision), at about the mid-point of the incision. Joanie lifts them up and together with one hand, and with the other elevates a small retractor I've placed at the apex of the wound. That's hard work (although it's good for the pecs) so it helps to be fast. I run a whip-stitch down the peritoneum, and give her a break while I wash out the wound. It's at this point that I infiltrate, generously, with long-acting local anesthetic: the peritoneum, above and below the muscle on both sides, just below the skin.

Having been trained -- as were we all back then -- to close the muscle layer with interrupted (individual, one at a time) sutures, of non-dissolving material, it took overcoming many voices in my head to switch to a running suture made of stuff that goes away in a few months. But it's better in every way, starting with taking less time, passing through less pain, and ending with better healing. Studies confirm it. I strongly believe in taking large bites, well away from the edge and widely spaced. Choking off the wound with too many sutures, placed too closely, and pulled too tight means more pain and less healing. You couldn't break #1 vicryl if you tried; I use it on a big honkin' needle, grab it and the fascia with monster Russian forceps, and it comes together as it should. When the bowel is distended or when there are other reasons why it's hard to keep things inside when closing, there are various tools you can slide under the muscle while the sutures are placed. What you don't want to do is forget to remove them before you finish:



The scrub and the circulator are pointing at piles of sponges and counting them together. "Seven, eight, nine, ten.... seven, eight, nine...." They rustle around. The scrub reaches up and picks at the drapes near my belly. "You missing a sponge? What kind? I know there's nothing inside... A four-by-eight? You got all the laps? The only four-by-eights were on the sponge sticks and I gave 'em all back to you..." I start looking around as well: under the table, lift up my shoes, peek under the drapes as far as I can without contaminating the field. Shit. Am I going to have to re-open? "Here it is! It was in a lap..." Most of the time, the counts are correct. When not, invariably the missing sponge or needle gets found somewhere outside of the patient. Twice, I think, I've actually had to reopen and have dug one out. Huge thanks to the nurses, abject embarrassment. Never have I left one in and taken the patient to the recovery room. I wouldn't like that.

My skin closure consists of a few fine interrupted sutures under the skin, followed by steri-strips. It's quick, cosmetically nice, and people can shower in a day or two. The only downside is the strips sometimes look a little bloody; but any disapproval of that is more than made up by the happy realization that there're no stitches to remove. Skin staples, plainly, suck. I put on the smallest bandage possible, believing that big ones are too scary.

I hang around to help move the patient onto the gurney; in fact, I usually go into the hall to get it, grab a roller on the way past where it's leaning against the wall, slide it onto the gurney while steering. Pump the gurney up to table height, roll the patient away, slide the roller under, then glide the patient onto the gurney, roll her the other way, remove the roller. "Thanks, everybody. See you in a few minutes."

When I have a line-up of cases, I head first to pre-op to talk to the next patient. Then to the family waiting area to talk about the just-finished case; then to the recovery room to have a look at my patient, write orders, dictate the op note. I always talk to the awakening patient, giving some good vibes, even though without exception, they never remember the conversation. If it's the A-team in the OR, by the time I'm done the next patient is ready to go into the room. The layout is such that I can see when the gurney is on the go. Usually, though, it's not that efficient. Stewing and brewing in the lounge while things happen too slowly for me... In this case, I have to run down to the ER to see what's going on with that acute abdomen they called about. I let the desk know I might have an add-on. And I guess I'll check to see if Carol ever got ahold of Dr. Smith...

I walk into the spacious surgery waiting room. Groups of families and friends have staked out their spots with pillows, books, blankets; couple of kids running around, TV on too loud. Heads turn expectantly, then look away, disappointed, when they see it's not their surgeon. I look for familiar faces, the volunteer at the desk helpfully nods toward the corner. Striding over, green-clad, I'm not unaware of the drama, the reading of my face as I approach. I give a smile and a thumbs-up before I'm in earshot. "She's fine, she's in the recovery room, everything went great." Getting the important stuff out right away, watching the tension dissipate, people visibly relax. "It was just as we expected, diverticulitis; everything went fine. I think she's gonna be really happy we did this. Did some of my best work... (Wait for the laugh.) She'll be in recovery give or take an hour and a half. They usually don't let visitors in there, but they'll let you know when she's heading to her room. Anybody have any questions?..." We talk a while more and, yes, I have to say I drink in the gratitude, the relief, the optimism. The sense of accomplishment. If that weren't part of it, what would be the point?

As I get up to leave, something occurs to me: "Oh, by the way, I realize I said it'd only take an hour or so, and it's been three weeks. Hope it didn't worry you...."

"It's OK doc," her husband says. "Blogging's a bitch."

Knot Really

Of all the strongly-held beliefs imparted to me in training (and the list is long, indeed), using which suture under what circumstance may be at the top of the list. Emphasis on "strongly" as the operative criterion. That various surgeons had widely divergent views on the matter didn't diminish the near religious intensity of those beliefs. Woe be to the trainee who even questioned it: and forget about actually making up your own mind. If you were working with Doctor X, you used his/her preferred suture. At some point, it's likely you'd hear each one's reasons. Everyone had an understandable basis, I suppose. It's just that it turns out most of them were wrong. Some stuff never really made any sense; other things changed as materials improved, so I guess the old guys should get a pass.

Before getting to the meat of the matter (I could make it a pretty long and ultimately boring post if I enumerated all the examples), here's one thing I'd bet each surgeon has had etched deeply into his/her sensibility: how long the "tails" ought to be when cutting suture. As if giving the most precious of gifts, generous beyond the call, the senior surgeon would allow a new intern to cut the suture he'd just tied. In tern, the young fellow/fellowette would tremulously apply the scissor beyond the knot and snip, knowing with near-certainty that the move would be followed by the loudly-declared "That's too long!" or "That's too short!!" In fairness, too short could lead to a knot untying itself (at least if poorly tied and/or finished off with too few throws [another imprint: how many throws is just right?]). The result, over time, is a stone-carved sense of proper appearance of those two little ends, variation from which can cause a physical sense of unease. It took me many years to realize: the suture may have been placed, for example, around a munch of muscle in closing an incision such that its entire length is well over an inch, maybe two. What possible difference can it make if the ends are a couple of millimeters "too long?" And now, I can tell you, tying and cutting knots laparoscopically -- which gives a very close and magnified view -- can distort one's sense of proportion beyond repair. But enough of minutiae.

The only time I've used wire suture on my own patients was on the trauma service at the county hospital. There, our chief of service insisted on it: wire suture was strong as hell and, more importantly for traumatic and therefore typically contaminated wounds, it was highly unlikely to become a nidus for infection. Despite the fact that tying it many times a day literally rubbed the ulnar aspect of our palms raw and often bloody, and that the knots tended to be uncomfortable (even though we carefully bent them downward) under the skin of the patients and frequently required later removal, it's what we used. Period. Embedded in my brain, the need to close such incisions with wire extended briefly into my early practice days until I was convinced (didn't take much) that the new strong-as-steel but soft and comfortable dissolving materials worked just fine. To his credit, the chief (one of my heroes!) later published a paper confirming the efficacy and he abandoned wire.

At our weekly conference wherein the chief residents on all the various surgical services presented their data, including all complications, one of my friends was profoundly excoriated for brazenly flaunting the party line and closing a long midline abdominal incision with a single running suture in the muscle layer. With no exceptions -- no matter the size and material of the sutures -- no one, NO ONE, closed that layer in any way but with single interrupted stitches, placed and tied one at a time, laboriously, plentifully. Having read some papers on continuous closure, Jerry thought it made sense and gave it a go. Sadly, being at the VA hospital, he unwittingly used nylon material that had been sitting around in storage, left there by George Washington not long after he'd crossed the Delaware River. Brittle and aged, it broke, resulting in a rather dramatic (but ultimately devoid of long-term consequences) reappearance of the man's innards, not in the operating room but in his bed. Yuck. The professors, on hearing the report, went ballistic: the stupidest thing they'd ever heard of. Reckless, idiotic, no understanding of wound healing. Righteous yada yada, indignant. Poor Jerry. Now an internationally respected and universally admired and loved academic surgeon, that was a bad day for him. Suffice it to say, very shortly after finishing training I came to close nearly all of my major incisions with a running suture and never -- not once -- had a reason to regret it. Not only does it save significant time, studies have shown healing is facilitated and pain is less. Who knew?

Wounds heal between sutures. In other words, the tissue actually grasped by the stitch, being squeezed, often doesn't get adequate circulation. More so, the tighter the stitch, the smaller the bite, the more closely placed to the neighboring one. Individually placed and tied sutures, in other words, potentially provide innumerable micro-zones of ischemia. With a running suture, there's essentially no crimped zone. You can, of course, screw anything up. The important thing, in my opinion, is to take larger bites than most people take, and to cinch up the suture gently, getting the edges just together. Otherwise, if I were letting an intern do it, I'd holler "too loose," or "too tight!!"

(Only the very hip will get the photo-pun. And I'm nothing, if not hip.)