Sunday, June 24, 2007

A narrative from OR 3

I will be spending my seven weeks with Dr. Spigland from the department of pediatric surgery as well as with two residents, Dr. Nandankumar and Dr. Afaneh, a 3rd year resident and a 1st year resident respectively. I found myself scrubbed-in the operating room on most days with rounds and consults between cases.

After obtaining a clearance badge on Monday 9am, I was greeted by a crash course in invasive surgery when my doctor told me to scrub-in during our first minute of interaction. The case involved a one month old baby boy with rare genetic disorder; his small and large intestines didn’t connect and protruded out of his abdomen. Dr. Spigland started out by using an electric scalpel to cut around the end of the large intestine freeing the intestine from the abdomen. The electric scalpel is able to minimize bleeding as it burns any contacted blood vessels. The smell of burning flesh started to make me queasy and I remember Dr. Nandankumar advising me to step back and sit down if I couldn’t handle it. Of course I had to suck it up as I know this will be the only time I’ll ever get to see this rare procedure –so I observe the doctor’s next step. Dr. Spigland then separated the small intestine from the abdomen and made a transverse cut exposing the subsurface intestine. The procedure was then to connect the large and small intestine back together and cut out any strictures (abnormal narrowing of a vessel) and abnormal intestine tissue. We found a few centimeters of dilated intestine and a few centimeters of strictures in both the small and large intestine. She proceeded to tie off the blood vessels leading to the small and large intestine using thread and staples. With blood flow eliminated, the abnormal tissue was then cut away. The intestines were then sewn together and the abdomen closed.

A few days later I was able to scrub-in with a transplant doctor who happened to be performing a kidney transplant. The patient had two failing kidneys and was in desperate need of a functional one. Luckily, she was able to obtain a kidney from her daughter. During the surgery the doctor opened the patient’s abdomen and exposed the iliac artery and vein. The kidney’s input vessels were attached to the iliac vessels by conventional thread and needle. Both the attendee and resident were painstakingly careful and precise but were able to connect the input valves in less than 40 minutes. The doctor finishes by spreading a gelatinous matrix solution with thrombin called floseal, preventing any leakage that may take place through the stitches. Blood began perfusing the kidney as the clamps were loosened, allowing the normal red color and beating of the kidney to return. The kidney’s output valve must now be attached to the bladder. Doctors have mistakenly attached the output valve to the colon as the colon and bladder are next to each other and appear similar. To prevent complications, the doctor filled the bladder intravenously, giving it a firm feel when touch. The kidney vessel is then attached to a random point on the bladder, again threaded and flosealed. The abdomen is then stitched up; the first being the fascia which directly closes the body cavity. The next layer of stitches is a mixture of loose fascia and adipose tissue, ending with the external skin.

Throughout the week, I was able to scrub into multiple other surgeries such as hernia and neuroblastoma (the most common extracranial solid cancer in infancy and childhood. It is a neuroendocrine tumor, arising from any neural crest element of the sympathetic nervous system) surgeries. All surgeries I’ve observed had no complications partly due to precise and cautious work. The doctors were very careful not to tear or break any unwanted vessels or tissue and spent most of their time painstakingly tying off vessels as failure to do so would lead to imminent excessive bleeding. These doctors are clearly good at what they do and as one resident told me they are expected to scrub in to 1000 cases before they graduate.

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