First OREX Day — October 2011 (Part 1)
By Alexis Krupp, OREXer ’11-12
I arrived to OA2 early to find a dark, empty room. I didn’t expect to be the first one there, and having a quiet moment to myself only heightened the excitement and anticipation that had been building for weeks. Today was going to be the first time I would see surgery, the first time I would see the chest from the inside, and the first time I would see the beauty of a human lung—inflating after having been deflated for the operation. Suddenly, Dr. Sasaki flew in the door and sat down at the computer to view some CT images of a patient’s chest. When another resident arrived, they began to discuss the case to prepare for the procedure. I would later learn that the patient depicted in the images was Mr. L, at 65 year-old man from Vietnam, with a thymoma (cancer of the thymus). Mr. L’s would be the first surgery I would see that day.
The topic of Dr. Harken’s morning lecture was a hypothetical 65 year-old patient with cancer of the sigmoid colon. As he questioned the residents about what they would do if this were their patient, I paid special attention to Dr. Harken’s urging that if a test was to be ordered, that something should then be done with the results. Dr. Harken put forth some additional advice for the residents who, I gathered, are preparing for their oral board exams (I’ll paraphrase here)—“take me to the fork in the road,” he said, “take me through your reasoning, tell me what the options are (for treating the patient), and then choose one.” This was his advice to the surgeons in training—weigh the options, reason through the problem, and then choose a course of action. This advice stuck with me as I observed the decisions the doctors made throughout the day.
After the morning lecture, Dr. Sasaki generously offered to usher me upstairs and show me how to get the OR scrubs out of the scrub “vending machine.” Since she had introduced herself to me and I had already heard about Mr. L’s potentially difficult surgery, during which Dr. Sasaki would be assisting, I chose to watch this thymectomy via sternotomy. The attending surgeon on the case was Dr. Victorino, the residents were Drs. Sasaki and Chang. Apparently, Mr. L had been diagnosed with a thymoma a few months earlier and had started on chemotherapy. While his tumor had responded to the chemotherapy and was smaller in size on his most recent CT from August, the surgeons still weren’t sure exactly what they’d find when they began the procedure.
The thymus is a gland that lies behind the sternum and in front of the heart, in the anterior superior mediastinum. The thymus plays an important role in the developing immune system of a child and adolescent, but has usually atrophied by adulthood. To access the thymus, the surgeons made an incision down the front of the chest and used a bone saw to cut through the sternum. A metal retractor was then placed to hold the two halves of the sternum apart so that they could gain access to the tumor. After a laborious hour dissecting away the thin membranes in the chest to gain access to the thymoma, as well as a consult from Dr. Harken, the surgeons determined that the tumor had grown into the pericardium (the membrane that surrounds the heart) and was also entwined in the great vessels. Since the surgeons could not safely remove the tumor in its entirety, they elected to leave the whole mass in situ. The surgeons closed the chest cavity by sewing metal wires through the sternum and twisting the wires to bring the two halves closer together. Apparently, the patient would always have these wires in his sternum, but should not be able to feel them.
Drs. Victorino, Sasaki, and Chang were visibly disappointed by the outcome of the surgery, but there was unfortunately nothing else that could be done at that time. Later, at the beginning of the next surgery, Dr. Victorino returned to the room after having spoken with a radiologist. According to the radiologist, the CT scan did not show the extent to which the tumor had entwined itself with the patient’s anatomy, meaning that no one could have known before surgery that the tumor would be inoperable.
The second surgery I saw was a lung surgery. Mrs. V, a woman in her early 60s, was having a lobectomy to remove the upper lobe of her right lung due to cancer. Dr. Sasaki expressed some concern about this surgery because the patient had very poor pulmonary function pre-surgery, as she had been a smoker for many years. Mrs. V was electing to have the surgery in order to cure her Stage I cancer so that she could, hopefully, spend more time with her family. When I followed Dr. Sasaki into the pre-op room to meet with Mrs. V and her two daughters, it was apparent that the family was very close.
Though it was probably one of the most difficult conversations that a family can have, I was honored to be able to listen to the manner in which Dr. Sasaki empathetically, yet pragmatically, explained the risks and likely outcome of the procedure to the patient and her family. Mrs. V seemed to understand that she may, or may not, ever be able to breathe on her own after the surgery, as well as the other risks associated with the procedure. I was struck by the gravity of the decision that the family had to make—wait for the cancer to grow and spread, risk a major operation that could result in death, face an uncertain and challenging recovery, or have a successful procedure. Dr. Sasaki explained that there was a very real risk that Mrs. V would not wake up from surgery, and when she said this, the weight of her words seemed to remind the patient’s daughters that they would have to think about saying goodbye to their mother before her surgery. While I was thrilled by the technical skill of the surgeons that I witnessed during the first surgery, this conversation reminded me that physicians must care for the whole person—physically and emotionally.
After lunch, I returned to the operating room for Mrs. V’s lobectomy. The same surgical team that had performed Mr. L’s operation would also be doing Mrs. V’s. To access the upper lobe of the right lung, the patient was placed on her left side and the head and foot of the operating table were lowered—leaving the patient in an inverted “V”-shape. Dr. Sasaki explained that this was to help spread the patient’s ribs apart so that the surgeons could access her lung through the ribs. In order to perform the operation, a special breathing tube was used when the patient was intubated. This special bifurcated tube allowed the anesthesiologist, Dr. Proctor, to clamp off the right side to deflate the right lung so that it would collapse and remain stationary during surgery.
Drs. Victorino and Sasaki were successful in removing the upper lobe of Mrs. V’s right lung. When they had removed the cancerous tissue, they needed to clamp off the bronchus that had connected to that lobe. This was done using a special stapling apparatus that simultaneously cut the bronchus while sealing it off. After the surgery was nearly complete, Dr. Sasaki filled the chest with sterile water to make sure that there were no air leaks coming from the sealed bronchus. As the clamp was taken off the right side of the breathing tube, Mrs. V’s lung filled with air, expanding to fill her chest. The lung, which had been dark and lifeless as the surgeons worked, was now beautiful and pink. It rose and fell with the compressions of the ventilator, expanding even beyond the confines of her chest wall, as the chest was still open from surgery. I found myself taking a deep breath—fascinated by the beauty of the body and the experience of witnessing surgery.