October 31. 2014
Written by Lisa Zhang (class of 2014-2015)
I read Anna’s journal a little late and didn’t get the memo that this week all the attendings would be out of the hospital for a conference. I showed up for the (nonexistent!) lecture at around 7:00 a.m. and sat in the room with a second-year resident (John Swanson) who was just there in case other people accidently walked in. He chilled with me until around 7:10 a.m., when four new UCSF third years walked in and told us they were here for their first day and were told to come to the lecture. After John explained that we weren’t having lectures this week, the students said they’d be okay with just waiting in the room until 8, when they were supposed to be meeting someone in charge of their orientation. John told me that he had a bunch of administrative stuff to take care of in the morning so it’d be more fun if I just followed the medical students around, so I stayed with them in the conference room and got to chat with them about their lives for an hour. (Thanks for keeping me entertained, John, Kacey, Joy, and Ryan!)
At 8, someone came to give them an orientation, and when she passed out the schedule, I noticed they were not going to the OR until 1 pm. The lady was really nice and let me page John to ask if he’d be okay if I just went to the OR by myself instead of following a resident around. He said he was fine with that, so I made my way to the OR and asked the front desk for scrubs. He gave me the vendor card and showed me the changing rooms. After I changed into scrubs, another nurse showed me where to get hair-nets and shoe-covers (hint: right next to the scrubs machine). I then followed her to her first room to watch the removal of an umbilical hernia. The nurse told me that there were a couple more surgeries going on if I wanted to check them out since she said there wasn’t much happening in that room at the moment and she said I could back later if I wanted.
Surgery 1: (Dr. Patel) Spacing open C2-C6 because of spinal cord contusions
I wandered out of the room and walked into the next room that had people in it. It turns out I was in one of Dr. Patel’s rooms where he was in the process of putting in spacers in a man’s cervical vertebrae (C2-C6). The nurse told me that the man they were operating on had been in a bike accident and ran into a pole. Because there wasn’t a lot of space and cushioning for the spinal cord in the man’s cervical vertebrae, his spinal cord actually ended up hitting his bone and getting bruised around C3, causing partial paralysis (known as a spinal cord contusion). They were then going to go in surgically and force open his C2-C6 and place in spacers in order to increase the space/cushioning the spinal cord had and prevent this from happening during future trauma accidents. I actually walked in at a good time — they had were in the process of drilling open each of the bones. The doctor let me watch from the head of the bed, where the anesthesiologist was, and one of the nurses found two step stools for me to stand on to see.
Dr. Patel was drilling open each vertebrae on the left side and loosening the right side in order to forcibly shift the the top of the vertebrae a little to the right and insert spacers (little chunks of plastic connected to screws). During this time, the nurse was on the other side, constantly irrigating and suctioning the area in order to remove all the bone dust that had accumulated. He was just finishing up the drilling when I started watching and was beginning to measure spacers that were needed to be placed. They used these things that looked like screwdrivers with the sharp end replaced with a rectangular piece of metal in the shape of a spacer. It only took Dr. Patel a few tries to measure out the three spacers he was inserting. He asked his tech to pass over the actual plastic spacers (which each had small metal rings of different sizes on the side) as well as screws of certain sizes and then began drilling the screws into the man’s bones. I was standing there for about an hour (from 9 to around 10) when a resident walked in to watch and told Dr. Patel he was apparently making very good time with this surgery since it usually took a lot longer.
Once the screwing in was finished, Dr. Patel prepared to suture the man back up. The nurse told me that they first used interrupted suture to stitch up the innermost layer, and then used a continuous suture on top of that. They then used another layer of interrupted suture on the very top and used surgical staples on top of that to keep the wound closed. After they finished padding the area, they began to move him to another bed and I left the room when they began to prepare for the next surgery (which was a man who had a part of his thoracic vertebrae completely thrown off to the side because of a motorcycle accident that I kind of wanted to watch too).
Surgery 2: (Dr. Valentine and Dr. Lee) Total laparoscopic hysterectomy and bilateral salpingectomy (laparoscopic removal of the uterus and fallopian tubes) due to fibroids
I actually chose this room because it looked like they had just put the patient to sleep and not much had happened yet. I entered the room before either of the doctors had gotten there and the nurses (Tiffany and Tim) said it was fine if I watched (and that it’d be easier to watch because it was laparoscopic).
The surgery was actually listed under Dr. Lee’s name, but I remember from shadowing Dr. Valentine previously that he often worked together with Dr. Lee for surgeries. I was pleasantly surprised when I saw him walk in and got to catch up with him briefly (especially since the last time I saw him was almost half a year ago). Dr. Lee and Dr. Valentine were both more than happy to let me watch. Dr. Lee went over the purpose of the surgery and their main goals with everyone in the room to make sure they were all on the same page, including logistics such as how long it was supposed to take and who would be doing what. Then, they began.
They first made four small incisions: one in the belly button (which was a bit larger and would be where they would end up inserting the camera) and one on each side. The last one was a bit anterior to the left one. They then inserted tubes in each of the incisions to keep the holes open during the surgery. They inserted a camera through the tube at the belly button and something similar to a pincer with teeth attached to a very long stick into the other three (Dr. Valentine held onto one and Dr. Lee held onto the other two). Before they even began the surgery, Dr. Lee and Dr. Valentine showed me a couple of anatomical features inside, including the uterus, ovaries, fallopian tubes, bladder, and peritoneum. Dr. Lee then began the slow process of using one of the heated tweezer pincers to cut around the uterus. They told me they were removing the fallopian tubes because they may ultimately result in complications in the future and were of no use to the patient if she didn’t have a uterus. They were, however, keeping the ovaries in because they provided important hormonal balance functions.
During the time she was cutting, Dr. Lee showed me how close she was to the uterine artery, which was a potential source of complications, especially given how much more blood flow was entering the uterus due to fibroids. She also showed me how close they were cutting to the ureters and bladder, where were both other sources of potential complications (and they would test this later to make sure this wasn’t an issue). The whole cutting process took over an hour, and Dr. Lee finished by cutting the connection of the uterus to the vagina. She then explained that they had to temporarily plug the vagina during this process with a raytex because once the uterus was detached, the cavity would no longer be airtight and would deflate, limiting their vision. Dr. Valentine then explained that one way they could tell if their cutting was successful was that the uterus was turning white because a lack of blood flow to the area.
After Dr. Lee successfully detached the uterus from everything inside the body, they removed the organ by pulling it through the vagina and plugging the vagina shortly afterwards with a bulb used for newborn CPR (points for creativity here!). Dr. Lee actually held up the uterus for me to glance at — it was a lot smaller than the screen made it seem! — before she handed to a nurse who placed it in a bucket for Pathology to look at it.
Dr. Valentine then explained that, while Dr. Lee made laparoscopic suturing look like the easiest thing in the world, it was actually extremely difficult as she tried to stitch the vaginal opening closed from the inside. He also explained that the string they used contained very small barbs in order to make sure it didn’t come loose during the process and would prevent the need to tie a knot at the end.
After they finished suturing, Dr. Valentine and Dr. Lee performed a cystoscopy (where they visualize inside your ureters and bladder) in order to make sure they didn’t puncture anything during surgery. During the surgery, they had asked for methylene blue to be injected. At this time, they had placed another camera into the bladder to look at the two intersections where the bladder met the ureters for a squirt of the methylene blue (meaning they were intact and undamaged). Dr. Valentine spotted the first one on the right quickly, but we waited for almost two minutes, staring at a very small dot on the screen, to see the second one (when we finally did, people cheered).
I unfortunately had to leave at that time — this was around 1:30 PM — but both the doctors assured me that most of the surgery was finished and they were just going to finish with the suturing. My legs were also killing me, and Dr. Valentine told me that if I ever wanted to be a surgeon, I’d need to be on my feet for hours at a time. I guess I’ll start building my tolerance now.
Overall, the day was super interesting since I got to see a lot of different types of surgeries. I was really excited to see Dr. Valentine actually operating, especially since all of my experience working with him as a chaperone had involved just clinical visits and I only got to hear about the surgical process through numerous pre-op/post-op appointments he had with patients. All the rooms I entered had nurses and doctors who were super welcoming, and all of them were inviting me to get closer to get a better view of what they were actually doing. I was also really grateful for their explanations (and all the answers to my questions) they gave and just how willing they were to teach me about what they did. I look forward to the next month!
Posted on January 6, 2015, in Uncategorized and tagged bilateral salpingectomy, cystoscopy, fibroids, inserting spacers (C2-C6), laparoscopic hysterectomy, removal of uterus and fallopian tubes, spinal cord contusion. Bookmark the permalink. Leave a comment.