Friday, December 01, 2006

Unkindest Cut

My father asked me recently, "What's the scariest surgery you've done?" By "done" I assume he meant "assisted with" or "was in the same room with and was able to peak over someone's shoulder and see something of", because as a third-year medical student, I don't get to"do" much of anything. A third of the way through the year, I think I've actually performed three surgeries (out of the 65 or so that I've "done"): I shaved down a kneecap, I did a laparoscopic appendectomy, and I cut out a big abscess.
As far as scary surgeries go, my options are limited by the fact that, here in Yankton, South Dakota, we don't do any heart or brain surgeries. So, the scariest stuff tends to be also the most common stuff: abdominal surgeries.
We do lots of abdominal surgeries, and they're all very scary. Aside from the routine risks associated with major surgery (bleeding, infection, poverty…), abdominal surgery, especially anything having to do with manipulation of the intestine (and even if you're not dealingdirectly with the intestine, you usually have to move it out of the way), carries some fun and unique risks that always bob to the forefront of my mind during abdominal surgery: obstruction, ileus, and perforation.
By obstruction I mean any structural problem that keeps food from moving through the GI tract. The most common cause of obstruction is abdominal surgery, and usually what happens is the bowel gets irritated by being cut up, moved around, handled, or even just looked at, and gets inflamed. The inflammation activates a healing mechanism that causes the bowel to stick to whatever it's lying next to. When it gets stuck, this adhesion can keep the bowel from moving food along, the bowel gets distended, the distention cuts off the blood supply to the bowel, the bowel dies, then ruptures, and several pounds of septic material spills out into the abdominal cavity, which usually results in death.
Of course, most of the time patients go to the doctor complaining of symptoms of bowel obstruction long before things get too serious, but the wild thing about obstruction is that in order to fix it you often need to do abdominal surgery! A 1999 study in the fun-sounding journal Diseases of the Colon and Rectum found that patients undergoing abdominal surgery wind up with obstructions 15% of the time. So, 15%of the time when you do surgery to relieve an abdominal obstruction, you're going to cause another abdominal obstruction. I think about obstruction during surgery.
Ileus is even more common than obstruction. With ileus, the bowel (or stomach) is paralyzed by being irritated (again, due to being cut, handled, or looked at incorrectly by a medical student) and, just like with obstruction, food can't pass through it. The good news is thatileus is usually temporary, causing a few days of bloating, abdominal pain, and constipation. The bad news is that it's not always temporary, and can result in all the nasty complications ofobstruction. Also, often patients aren't allowed to leave the hospital until they've had a bowel movement, which can take a week or more.
During this time the patients are lying in bed, bloated and groaning, being bombarded by all the aggressive and antibiotic-resistant bacteria that live in hospital rooms, watching lots of TV thatfeatures lots of commercials of personal injury lawyers. I think about ileus during surgery.
Finally, perforation occurs when some part of the GI tract gets poked, slashed, cut, or torn. This can happen during surgery. Once, when I was "doing" a laparoscopic appendectomy, the surgeon asked for graspers (kind of like blunt pliers). The room was very dark becausethe camera we'd stuck in the patient's abdomen wasn't working very well, and the surgical tech handed the surgeon scissors instead of graspers. The surgeon tried to grasp the bowel with the scissors, and, for medicolegal reasons, I can't tell any more of this story, except to say that thepatient's okay. I do my best not to think about perforating a bowel during surgery.
So, a few months ago I was doing (and I actually did some cutting, poking, and sewing on this one) exploratory surgery on a patient with bowel obstruction and air in his abdomen. The air in the abdomen (or pneumoperitoneum) was a very bad thing, indicating that he probably had a perforation somewhere. He'd had previous abdominal surgery, so we were also looking for adhesions. What we did was pull the patient's small intestine out through a slit in their abdomen and piled as much of it was we could get out onto their belly. Then I carefully went hand-over-hand along the intestine (All the while thinking to myself "You're handling it! You're looking at it!") trying to find the perforation or obstruction. I couldn't find anything. The surgeon tried, he couldn't find anything. We covered the bowel with dampcloths to keep it from drying out. We squirted some dye down the patient's esophagus to see if it would leak out of the GI tract anywhere. It didn't. An hour passed while we stared in a puzzledfashion into the patient's abdomen. I began to feel sweaty. I had to change my mask because it kept fogging up. I would catch myself thinking about ileus, obstruction, and perforation, and my eyes would go unfocussed. I started to feel light-headed. "Great," I thought tomyself. "Let's see, the bowel is probably perforated somewhere. You've handled it, looked at it, dried it out, and now you're going to faint into the hole you've cut in the abdomen?" I flexed my legs to pump blood up into my brain. I took deep breaths. I wiggled my toes. Finally, the surgeon shrugged, and we closed up the patient. He never went home.
Posted by Joel on November 30, 2006 5:43 PM

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