October 28, 2014
Written by Anna Grace (class of 2014-2015)
Hi fellow OREXers! I just came back from my first day, and it was a really exciting experience. I arrived at 7:00AM to OA-2 and took a seat in the back corner of a room full of what looked like residents and some interns. After several minutes it became clear that there would be no lecture (bummer) and everyone began to disperse in search of breakfast. Luckily, a couple of residents took pity on me and let me tag along to the cafeteria with them. Sitting near the table they were at with several other residents, I felt like an awkward lurker! But they asked if I wanted to stick with them in elective surgery. I said I would love to, and the most senior resident, Dr. Leah Candell, shephard-ed me up to the OR and showed me how to get the scrubs and where to put my things. She warned me that her cases that day were mostly hernias and not that exciting. I replied that everything is pretty exciting to me at this point! The first surgery was a hemorrhoid with possible anal fistulotomy.
Dr. Candell asked if I wanted to scrub in. She showed me how to wash my hands and arms, and I learned how tough it is to get used to keeping a sterile environment. I tapped my arm against the edge of the sink! This would normally require starting over, but given the nature of the surgery and its location on the terminus of the GI tract, it is not considered a 100% sterile environment anyway (and of course the fact that I wouldn’t be doing anything!). So, she said it was ok not to. We proceeded into the room where the patient was being put under by the very focused nurse anesthetist, Amy. The other two residents with Dr. Candell (they introduced themselves as Rob and Alicia, and I can’t remember their last names) introduced me to the surgical tech, Gilbert, and showed me how to dry off with a sterile towel and slip into the gown and two layers of gloves that he held out. I’m not gonna lie, it was pretty fun. The rules and order of the OR are quite a sight to behold, and I felt really lucky to not only be in the room, but get to experience the preparations.
The patient’s legs were hoisted into stirrups and he was maneuvered a bit on the table to expose the area. He was obese, and I was about to get a firsthand look at one of the complications and dangers that can befall patients carrying excessive amounts of weight…
Dr. Candell got the ok from Amy to begin, and she palpated the perineum, opened the anus with a speculum, and located the external opening of the fistula. Dr. Candell explained that fistulas are tracts that run from inside, near the anal sphincter, opening up outside the anus. The can fill up internally as an abscess, and need time to drain before they can be closed up. The objective of this surgery was to install a sort of rubber band that would run the length of the tract and be tied up outside to allow for open drainage of the abscess. Here’s a link for an image search that clarifies the fistulotomy mechanism, don’t click unless you want to see some sphincters: (http://bit.ly/1wCfPNP).
It took some effort to position the speculum in such a way that would open the area for Dr. Candell to see what was going on. The patient’s perineal area was crowded due to his excessive weight. As she and Dr. Rob angled for some workspace, we began to hear groans and noise from the patient. Woah. Amy (the nurse anesthetist) explained that she didn’t want to give him any more anesthetic (I think it was Propofol), but due to his size, it was hard to keep him knocked out enough.
That’s when he started moving his legs. Dr. Alicia and a nurse known as the circulator (because she did not scrub in so she was free to make notes and get items needed by the surgical tech and surgeons) held his legs steady as Amy decided that he needed to be intubated to keep his oxygen levels up high enough to sustain the amount of anesthesia he was being given. She requested that the procedure be paused while she worked to stabilize him. She attempted intubation unsuccessfully, and had to alternate her attempts with holding an oxygen mask over his mouth, clamping it tightly with her hands. I watched the patient’s heart rate and blood oxygen saturation level fluctuate as she worked. His heart rate was up in the 110s as he “bucked,” and back down in the 90s when stabilized. Amy paged the anesthesiologist on duty, it was his first day at Highland and I didn’t catch his name amidst the intensity of the moment. He was a tall, very kind man, and came in and conferred with Amy about the best course of action. He suggested administering a muscle relaxer, but Amy was concerned that that would make intubation more difficult. I couldn’t tell if they ended up administering it or not. It seemed that the anesthesiologist was trying to respect Amy’s work and only act as an oversight, but it soon became clear that the patient needed a quick intervention. The two worked together, trying various types and sizes of instruments to intubate, always alternating with administering oxygen by a mask. The physicality of surgery really was a sight to see. Amy’s knuckles were white as she formed a seal over the patient’s nose and mouth with the mask, holding it against his jaw. They hoisted his head and shoulders to try and open his airway as best they could. They paged a man that brought in some type of endoscopy machine to aid intubation. Still no luck. Each unsuccessful tube they pulled out was covered with red sputum on the far end. As Dr. Rob explained after the surgery, the airway was so small and compressed due to the man’s weight. Things were getting tense and the patient was still making occasional noises and moving his limbs a bit, but I was so impressed with the calm focus that they had. Finally the anesthesiologist successfully intubated, and relief filled the room. By my count they were trying to intubate for around half an hour. “Thanks to whomever said the prayer,” he said aloud. He thanked the surgeons for their patience and the procedure continued. (He later mentioned that was the hardest intubation he can remember doing in recent history.)
Dr. Candell irrigated the external opening of the fistula with hydrogen peroxide to locate the internal opening. She then placed the rubber piece along the tract and looped it through. It was quickly trimmed to size (so as to not dangle out so far) and stitched closed in a loop. At that point, the procedure was over, the area wiped clean, and soon the patient was wheeled out of the room.
I stayed with Dr. Candell and the other residents for the next surgery, and this meant staying in the same OR with the same team. This patient was a smaller woman that had an epigastric hernia and an umbilical hernia. She was a little nervous before surgery, but everyone reassured her that she was in great hands. This time I got to see more of what Amy does to bring the patient under, and it involved two different syringes stuck into a line of some kind. She would squeeze out part of one, then the other, then pause, look at some readouts, give more of each. It was all really interesting, mysterious, and it made me very curious as to how anesthesia works. And then just like that, the patient was out. It felt like she went from alert to anesthetized in a minute.
Dr. Candell let me scrub in again and stand next to her on one side of the patient, with Drs. Rob and Alicia on the other side. Dr. Rob performed most of the surgery under Dr. Candell’s guidance. He made the initial slices to open the skin, and then they began to open up the subdermal/fatty layer. Dr. Candell would stab some forceps under a piece and spread them out. Dr. Rob would run a cauterizing wand over the area and so on. The umbilical hernia was quite small and required a couple sutures to seal. The epigastric hernia was on the border between something that can be sutured up, or something needing some mesh to hold it together. The patient’s CT scan was brought up and measured and they palpated around the incision, thinking it over. They also checked digitally for any surrounding fascial irregularities. Dr. Candell’s attending physician, Dr. Burell (I think I am getting her name wrong…) came in and offered advice. She asked if she could scrub in and feel around. She looked at the CT carefully and measured the hernia with the on screen size reference. She felt a mesh would be more successful, even though the patient had subpar fascia. I wanted to ask what that means, to have poor fascia, but I forgot to ask after the surgery. The mesh was measured, cut, and stitched in. I didn’t see a ton of details at this point because I preemptively moved further away when the attending scrubbed in.
When they were done, Drs. Rob and Alicia sutured up the external openings. Dr. Rob had to start over at one point, I guess something wasn’t sitting well. It was a privilege to see someone in the learning process of a very complex skill. He was very patient and careful and pulled out the stitches and began again, finishing successfully. I ended the day at 12:30. I wanted to stay for the last two patients of the day for the residents but I had a midterm I was dreading and needed to go study. All in all, it was a great day in the OR. 🙂
Posted on January 6, 2015, in Uncategorized and tagged anal fistulotomy, challenges with anesthesia, endoscopy machine, epigastric hernia, hemorrhoid, intubation, umbilical hernia. Bookmark the permalink. Leave a comment.