Monthly Archives: February 2015
Written by Marty Susskind (class of 2014-2015)
Cranioplasty and Radius Fracture Repair
Today could easily be summed up with one powerful word; Brain! Sure I have seen them on T.V, movies, and textbooks but there is absolutely nothing like the real thing in this case. A human brain exposed commands the same kind of zoned-in visual awe that a campfire or the ocean waves do. For a neuro-nerd like myself this was a truly unforgettable day.
First, some advise to all OREXers, when you see “cranioplasty” written on the white board, choose it. In this case, the patient was a 35-year-old man who had suffered a traumatic brain injury in a car accident on New Years. The patient underwent a number of surgeries right after the accident including the removal of a large portion of his right skull (called a bone flap in surgical terms) in order to relieve pressure on his swollen brain. Significant brain hemorrhaging was detected by a CT-scan but the doctors decided not to go through with any lobotomy procedure. The hope was that the patient would instead regain some cognitive activity over a two-month span without his right skull putting pressure on his brain. Unfortunately the patient’s status had not improved significantly and the surgeons were pessimistic about his chances of recovery after this cranioplasty procedure.
The patient’s head had what could only be described as a huge chunk missing from it as he was brought into the room and prepped by the nurses. His hair was buzzed off with clippers and the site on his skull was carefully prepped with iodine. The nurse described the surgery site as “soft” because it was essentially just brain and muscle left under his skin. The “skull flap” was brought into the surgery room in a box sent from a tissue bank the night before. The surgeon told me that in most cases they would have put the piece of skull into the patient’s abdominal cavity for storage until this second surgery but they couldn’t in this case because the patient had also had his spleen removed after the accident and couldn’t handle the temporary implant. The sample was stored in a sort of anti-biotic solution on ice and so the surgeon (Dr. Castro-Manre) had to thaw it for roughly an hour and a half in saline before beginning the surgery. The patient was under anesthesia during this time and I took the opportunity to see another surgery (compound radius fracture) in the mean time.
This surgery was only about 1 hour long. A metal plate was drilled into the patient’s re-set radius with 8 screws to repair the fracture but the coolest part was the anatomy lesson I got from the doc. He tugged on all of the individual tendons in the open surgical site to show me how they moved their corresponding fingers! It was one of the coolest things I have ever seen; pull the string, watch the finger curl! We Orexers are pretty spoiled by the amazing surgeons/teachers in the O.R.
When the wrist surgery was finished and the patient was stitched back up, I went back into O.R. 1 for the cranioplasty and sure enough the bone flap had thawed and the operation was underway. The skin had already been opened by the time I walked in and a huge portion of brain was entirely exposed! The surgeons let me get right up against the surgical bed to see the entire operation. The peeled back skin and the skin around the exposed brain were lined with plastic clips, which were attached to the sterile covering so that only the operation site was exposed. The thick membrane above the brain called the dura mater (Latin for “tough mother”) was peeled back so new protective layers could be added to the patient’s brain. First a white Duragen implant like a lattice mesh was layered onto the brain like patches on a quilt. Then, a blue gel epoxy was squirted onto the patches. The gel instantly polymerized on the brain to mimic the fluid like layer that naturally blankets the human brain. At this point, the surgical site was an explosion of red, white, and blue. A patriotic mess. The next step was to put the two pieces of the patient’s skull flap back together into one. The surgeons used butterfly clips to bridge the breaks in the skull pieces and then screwed them together. They used 6 screws in three clips to re-assemble one continuous chunk of skull. They then screwed the fully assembled skull flap back into the open site in the patient’s head again using these butterfly clips and screws to connect it to the surrounding skull. The temporal muscle was then sewn back to the skull using the butterfly clips as a kind of scaffolding (crazy innovative!). Finally the plastic clips were removed from the surrounding skin and the flap was sewn back to the head. Roughly 30 staples were also used to close the patient back up.
In the end, one piece of skull right at the temple was left without repair so that any remaining pressure from swelling could be relieved during his hopeful rehabilitation. If he does indeed make a miracle comeback, he can always have that last piece of skull patched up in cosmetic surgery. Here’s hoping! Some tubing was also left through his skull so that it could be hooked up to an aspirator in the I.C.U. and relieve fluid pressure for the next few days.
The surgeon told me that the biggest concern was that the patient had been hypoxic for a long time after (maybe a half hour) the accident and his brain would probably never recover from hat. Apparently it is common for the heart to slow down drastically right after a traumatic brain injury. Another new thing learned in OREX…
Today was the first time I ever saw a human brain and the entire operation was one of the most intense things I have ever witnessed but it was also the first time I saw a surgery on a patient that will probably never recover. Today was a real reminder and eye opener that these bodies on these gurneys are patients, they are people, with families, and surgery is sometimes just as much about hope as technique. Again… here’s hoping!
Written by Chuck Chan (class of 2014-2015)
After a two month hiatus, I was excited to be back in the OR. I arrived at Highland at 7:15AM and listened in on a medical ethics talk by Dr. Harken. Though I had heard a similar talk by Dr. Harken a few months back, something really stood out to me this time around. Dr. Harken took out a pocketbook of the U.S. Bill of Rights from the inside of his coat and read the first amendment aloud. He made a point that people have the right to practice religion, but some beliefs can compromise the ability to deliver healthcare. The residents had some great input in this discussion. At what point can we breach the first amendment to ensure the safety of others? This is a topic that deserves thorough elaboration especially when it comes to vaccination. Doctors are trained for medical intervention, but the extent of intervention that doctors are entitled to is seldom clearly defined. It was great food for thought before getting my day started. Dr. Francesca Maertens was my resident guide for the day and I was happy to follow her into the OR.
CASE 1 – Fistula
Dr. Harken & Dr. Maertens
Entered OR @ 8:10AM
I asked Dr. Maertens about how she decided between surgery and medicine because I had heard that it was a major fork in the road before becoming a doctor. Dr. Maertens described how surgeons have a distinctive personality and an innate ability to be calm under even the worst circumstances. She compared the competitive personality of a surgeon to that of an athlete. The live surgery was essentially a performance, similar to a game for an athlete. My experiences so far in the OR were absolutely consistent with what Dr. Maertens had to say.
The first case of the day was a cimino fistula. I had heard the term fistula before, but I really didn’t know what its purpose was. Dr. Maertens told me to look up the procedure a few minutes before the surgery started, which was really helpful in getting myself to ask the right questions when the procedure actually began. For the large majority of cases, a fistula is a surgical manipulation to connect an artery to a vein for access to the bloodstream for dialysis patients. An ultrasound was used along the patients left arm to locate a nerve for anesthetic injection. A large needle with an electrode was used to determine where the nerve was. When a voltage was applied near the nerve, the entire arm would twitch in a pulsatile, rhythmic fashion. Dr. Harken pointed out the deep veins and arteries that looked like large circles on the ultrasound screen. Veins collapsed much more easily upon applied pressure than arteries so it was easy to differentiate veins and arteries. Once the anesthesia was in place, it was time to start cutting.
Dr. Maertens made a cut parallel to the length of the arm that was about 4 ½ inches long. The cut exposed a large artery, a large vein, and a nerve. A yellow loop was tied around each tissue type. Dr. Maertens used a black marker to mark the vein in black. The vein was cut and injected with a clear, anti-clotting agent. A separate incision was made parallel to the first cut to locate an artery to attach the vein to. Once the artery was identified, a yellow loop was tied around it. The artery was carefully cut and suspended so that the vein can be threaded into the artery. Dr. Maertens knotted the artery-vein attachment and felt around the attachment to ensure that there was proper blood flow. The skin was sutured and the procedure was finished in a little over two and half hours. The patient was awake for the entire procedure and I only noticed once the surgery was completed.
CASE 2 – AV Graft
Dr. Harken and Dr. Maertens
Entered OR 10:31AM
The subsequent case was an AV graft. Despite the lack of similarity in name between an AV graft and fistula, the procedures are nearly identical. The one major difference between the two procedures was that in an AV graft, the artery and vein are joined by a white tube. The major advantage in using another material to join the artery and vein is that the white tube has a large diameter, which ensures great blood flow between the artery and the vein. This makes complete sense according to Poiseuille’s Law on blood flow. Who knew physics was important in medicine after all.
Dr. Maertens started by making two parallel incisions along the elbow bend. The median nerve was exposed and it looked like a flat elastic band. Prongs were used to hold the medial incision open. Plastic yellow ropes were tied around the nerve, artery, and vein just as had been done for the fistula case. A third perpendicular incision was made distal to the first two incisions. The vein was marked and cut. Anti-clotting agent was added to the vein and the white tube was attached to the vein. Dr. Harken explained that the white tube was made of the same material used in North Face outerwear jackets. Once the white tube was attached to the vein, it was pulled through the perpendicular incision and back inside to reach the second parallel incision. The artery was carefully cut and knotted to prevent bleeding. Dr. Maertens used a syringe to inject saline through to make sure that the passageway was not obstructed. The artery was then attached to the white tube. The three incisions were promptly sutured and the procedure was finished by 1pm. I thanked Dr. Harken and Dr. Maertens for the great opportunity and I was on my way out of the OR just in time for my afternoon class. It was an awesome day of surgery to say the least.
Written by Stephanie Nguyen (class of 2014-2015)
Yet again, Dr. Harken strutted (more like, I imagine he did because he’s awesome) into the meeting room dressed again in a suit. He jumped very quickly into the topic of scientific data—something I wouldn’t think would be discussed as a complete topic in and of itself. He focused very specifically on data gathered on patients with sepsis, describing the rating system for research and the reasons for why it is actually very difficult to collect complete data based on this system. It was an interesting lecture, to say the least. Something notable that Dr. Harken said was that he was “startled yesterday about how little [the students] knew about ebola”. That didn’t sound too good…
I had no guidance whatsoever in the OR this time, which made me feel a little more lost than I have been since starting with OREX. However, I figured that wherever Dr. Krosin was, I would be in good shape because of how outgoing and receptive he is toward his students. I ended up in a Right Knee Ligament Debridement with the resident Dr. Dickinson. There was a shuffle of attendings because of Dr. Billing’s sickness, and I did not end up seeing Dr. Krosin at all. The nurses reported that Dr. Billings was actually incredibly sick and needed to go home, but that he was still around trying to tend to one last surgery—I guess there are no sick days for surgeons.
Getting right to the surgery was a very quick intubation, because of the anesthesiologist’s technique that she claimed was “new” and more effective. They set up the patient’s legs, one off to the side and the other held up by the patient’s big toe and bound by a tourniquet. A computer screen was set at the end of the bed and shocked me when it very clearly said “SDC vein, visual capture initializing”. I didn’t realize this surgery was going to be laparoscopic and it was the first time I was seeing it. The surgeons did not immediately place the camera into the patient’s knee and instead spent a long time discussing the case. There was a definite need for meniscal debridement, which is more or less clearing out tissue at the meniscus, but there was also a possibility of an ACL repair that was difficult to actually diagnose because of contradictions in different tests and an MRI. What was a 1-hour surgery could become a 3-hour one with the addition of an ACL repair. It was decided that 5 minutes into the surgery, they would determine if it was necessary.
(Side note: this surgery is so much more relevant to me now that my sister recently twisted her knee in a lacrosse match. Her primary care doctor said that she may have a tear in her meniscus, just the way this patient did. It made so much more sense now to understand her condition and the necessary steps to fix this problem. I love when things like this become so applicable to my own life!)
Dr. Dickinson drew a star at the point of incision at the patient’s kneecap and stuck in a rod deep into her leg. The screen registered a lot of white and fibrous structures, with some yellow and red things floating around. I wasn’t able to grab anyone at the table to explain to me what everything was, but I watched as Dr. Dickinson moved the camera around to expose a great variety of images on the computer screen. Occasionally, Dr. Dickinson would pull the camera rod out of the knee to readjust, and fluid would pour out of the point of incision. I later pieced together that this camera rod has the function of ejecting fluid, possibly to flush things when needed. At the 5-10 minute mark, Dr. Dickinson announces to the team that the ACL is intact, although it is not in great shape. He informs Dr. Shah that he will not operate on the ACL, but will notify the patient and discuss with her the possibility of returning and performing surgery if she deemed it necessary.
Once the camera was finally set up in a way that Dr. Dickinson thought appropriate, he handed off the camera to another resident, Dr. Jackie. She took the camera in her left hand and inserted a pincer-like rod into the other side of the patient’s knee. The pincer came into view once she aligned the two rods together in the knee. The next hour or so involved the pincer rotating and trimming down the white meniscus particles, while another probe was used to pull out these fibers. Dr. Dickinson takes over at some point and he very obviously has more experience, trimming faster and more steadily. It all looks fairly easy, if not also reasonably tedious, but it is clear that it is extremely precise work—they do say that surgeons need to have steady hands. When the surgery is finally over in about an hour and a half, the patient’s knee is sewed up at the small holes where the rods went in and wrapped up at those same spots. Everything was so small and precise, it was amazing!
My next surgery was a left inaugural hernia repair with resident Dr. Arturo Garcia. As I pass a surgeon to go into the room, he informs me that Dr. Garcia is the “chief”, as they call him. I have observed a surgery with him before, but I never knew that he was so high-ranking and important (if not humorously so). Dr. Garcia creates an incision from the groin up and uses clamps to hold his incision open. It is rather small although the nurse positions me at the head of the patient and with a step-stool so I am able to see at least the movement of the tools and whatever is pulled up from the site. At this point, I wrote down in my notebook, “How can you tell?! Everything looks red and orange and squishy and lumpy”, which represents my awe about what I didn’t know and what these doctors clearly knew very well. Dr. Garcia and the other resident surgeon stick their fingers inside their incision, feeling for the hernia and pulling out more structures. Occasionally, the medical student dabs and rinses the area. The most interesting part of this surgery is when the surgeons insert an A-shaped mesh that is sutured in. It looked so foreign in a body full of tissue. And then went the numerous sutures and ties that seem inevitable in a hernia repair. Toward the end, there is light-hearted conversation about Dr. Garcia’s new baby girl and the funny events of his wife’s pregnancy and delivery. Who would have known this tall, outgoing doctor is considered the head honcho of the OR?
That ended my 4-hour shift with OREX for January. Until next time!
Written by Vickie Nguyen (class of 2014-2015)
Since today was a Thursday, I entered the OR just a little bit after 11am as suggested by those who do attend their OREX days on Thursday. By then a lot of the surgeries looked like they were just starting or just being finished up, I ended up choosing Dr. Patel’s laminectomy, T3/T4 decompressive transpedicular tumor resection. It was a particularly long surgery, though I spent about 5 hours in the OR, a bulk of it was spent in Dr. Patel’s surgery.
His patient was diagnosed with colon cancer, and unfortunately the cancer spread to his bones. The proper term for this is mestastic colorectoral cancer. His backbone, in the T3/T4 region, was affected by tumor growth, and if left alone would eventually leave him paralyzed. A soft white membrane called the dura covers the spinal cord; the spinal cord sits inside of the dura and is surrounded by cerebrospinal fluid. The tumor was in fact squeezing the spinal cord, and began affecting his motor functions. To avoid his eventual paralysis, Dr. Patel, accompanied by another doctor who introduced herself to me as Jennifer (I never got a chance to see her last name, though I really wished I had), worked together to remove the tumor.
Before beginning the surgery, a radiology team came in to perform some x-rays. The entire time, Dr. Patel was the conductor, asking for many different positions in which to examine her spine. Every now and then, Dr. Patel would point to certain parts of the spine using something similar to a peon (like scissors) but with a long and curved end. After about an hour of taking x-rays, the surgery began. An interesting thing to note about this surgeon is that he brought in his own set of CDs and a speaker system to play music throughout this surgery. I didn’t know you could do that!
I got a pretty awesome view during this surgery. Jennifer as well as Lydia, the student nurse-anesthetist, suggested I stand at the front of the operating table, where her head was! At first I got to see the top of the spine, it looked a lot smaller than I had imagined, but nonetheless I thought it was quite cool to see it in real life. Next thing you know, Dr. Patel takes a tool, which looks similar to small pliers, and completely removes the top of the spine! It was mind-boggling! I thought to myself “Woah man, this can’t be right, don’t we need that?”
Later, Jennifer told me that he was suffering from spinal stenosis because of the tumor and this would help relieve his symptoms. With some research, I also found out that the top of the spine that was removed is called a lamina, hence the surgery name ‘laminectomy.’ A lot of bone was removed, and eventually Jennifer pointed out the dura, it was this off-white looking piece that ran vertically up and down his back. She told me that the spinal cord is supposed to be even in width, but for him this wasn’t the case, it looked similar to that of an hour glass, pinched right in the middle and equal in size everywhere else. Their job that day was to remove all the cancerous bone they could, and all that they could not would be removed via chemotherapy.
Standing at the front of the operating table, I was much closer to the anesthetists and was able to see a lot of the tasks that they had to perform. Normally, I always see a lot of tubing everywhere, and they’re mostly clear. One of the tubes was red, and I then realized it was blood. A few times, I saw Lydia move towards some of the patient’s tubes, and she squeezed in some calcium chloride. Curious, I asked Lydia what the calcium chloride was used for. She said that since he is a very sick patient, he had a low blood count and needed extra blood for this surgery, something that they don’t normally like to give patients. The blood that he was given was mixed with something else, and this causes the blood to bind to calcium. Because of the lower concentrations of calcium in his body, they had to supplement it with more calcium. It’s a pretty awesome thing to learn outside of a classroom.
After the surgery ended, Jennifer showed me to the PACU to see him. They were still trying to wake him up after the surgery, and with the one that he underwent it was crucial to see if he still had function in his arms and legs. Someone at his bed asked if anyone could speak Chinese, as he could not speak or understand English well. Jennifer asked me if I could, and I told her I spoke Cantonese. It worked out well because his Chinese dialect is Cantonese! She asked me to talk to him and get him to wiggle his toes. I said “Uncle! Uncle! Can you hear me? Do you understand me? Uncle, could you move your feet for me?” I tried my best to get through to him, but he was still too groggy and was not compliant. Jennifer thanked me for trying and asked me to follow her into the waiting room. There, we encountered his wife. I helped translate between her and Jennifer. I’m definitely not a professional translator, and I think I often have difficulty interpreting for people mainly because it feels like I’m having a one-on-one conversation with two people at the same time. I think a huge tip for my fellow bilingual/trilingual/multilingual OREXers is to take a lot of pauses in between the conversation so that both parties are included. This is something that Jennifer expressed to me, and I think it was really great advice. It’s a lot easier to talk to someone directly, though having a translator helps with people who speak two different languages, it’s still a highly difficult task.
This was quite an interactive OREX day for me. I’m really glad Jennifer was around to show me things inside the OR as well as outside. I give her 5 stars for the stupendous learning experience, and I’m really thankful to have had her guidance that day. I’m kind of falling in love with OREX, is that a weird thing to say?
Written by Anna Grace (class of 2014-2015)
Last Thursday I walked into the conference room at 7:00AM and it was dark and deserted. I then remembered Grand Rounds are on Thursday! Whoops. My school schedule in the fall kept me busy on Thursdays so I guess it slipped my mind. I checked the OR board and saw a couple interesting things happening at 8:30 so I killed time until then.
I chose a laparoscopic hysterectomy with Drs. Edraki and Tukenmez and an MS-3 named Veronica. Dr. Edraki was a bit late arriving as he is not based at Highland and had to drive in for the procedure against some traffic. After a digital pelvic exam, the surgeons spent some time positioning the patient optimally on the table. She was obese, so it took some effort from the team. There was also a big problem with the holstering of the patient for the procedure. The positioning required for the laparoscopic nature of the procedure required the patient to be tilted head down, legs up and apart, arms at her side. The apparatus used was an inflatable “bean bag” that gripped the patient. The problem was that no one in the OR had used it before, and couldn’t get it quite stabilized. The patient was showing signs of slipping in position. It was clear that no one was able to remove the bag from under her to try and figure out the best way to attach it to the operating table, especially since at this point, the patient was already attached to IVs, anesthetized, etc.
Dr. Edraki made the call to operate traditionally, as there was no strange positioning necessary, and over half an hour had been wasted deliberating on the positioning of the patient. It was a bit tense in the room–clearly a frustrating situation for everyone on the team–right down to the surgical tech, who had to change up all her tools at the last minute!
I was looking forward to finally seeing a uterus. Our female cadaver in anatomy class was missing her uterus due to cancer (unfortunately, just like the patient I was observing now) and I wanted to see a uterus in person. (That sounds strange to say, but if anyone understands that, it’s you guys, right?) The patient was adjusted to lay flat, and sterilization began. I really couldn’t get a great vantage point for this surgery even though I did get a step at one point. I did see Dr. Edraki start with quite a long incision that seemed to span from the pubic bone to near the belly button. He made quick work of getting down past the fat and muscle, and they set up an apparatus around the incision as a framework for tools to hold the intestines out of the way. I couldn’t actually see anything beyond this, but could see Dr. Edraki placing several laps in the cavity, I think to isolate the uterus. He began tying suture lines in various places, and doing lots of work involving scalpel, bovie and suction. He spoke to the medical student occasionally, pointing out landmarks and asking her questions. I had no idea the open hysterectomy was so invasive in terms of the open access to the thoracic cavity. It sounded like an incredible anatomy lesson and I wished for a GoGo Gadget Neck to crane over and watch more closely. Finally I saw them lift up the uterus and hand it to the surgical tech. They had to page a pathologist to come and test some of the tissues to confirm cancer. I am not sure quite what the situation was, but obviously the patient was getting the uterus removed regardless so perhaps there were masses felt during palpation prior to surgery that were not confirmed cancer. At any rate, pathology needed to report back during the surgery, because if they did detect cancerous cells in the tissue, Dr. Edraki explained he would be taking tissue from the pelvic and aortic lymph nodes. I couldn’t tell if this was to remove the nodes completely due to cancerous growth, or to simply test samples from each node to monitor the spread of the cancer.
Pathology came and took the uterus and then everyone basically just waited around for 20 minutes over the open cavity. Dr. Tukenmez and Dr. Edraki chit chatted a bit, and Dr. Tukenmez asked Dr. Edraki’s opinion on a situation she had with another patient. Dr. Edraki gave more awesome anatomy lessons to Veronica. Gentle hold music played in my head.
The pathologist came back and reported that he did see “grade 1” (I think) tissue abnormalities, and some other things that I didn’t catch, but the upshot was that it indeed was cancer, and the patient’s lymph nodes needed to be sampled/removed. Dr. Edraki lengthened the incision significantly up the thoracic area. It looked like he added several inches onto the incision. This gave him access all the way up to the patient’s aortic lymph nodes. He worked carefully, gathering several tissue samples from the left and right pelvic lymph nodes, pointing out more anatomy to Veronica, and rejiggering the resecting tools as he switched sides. Interestingly, he had to ask the CRNA to relax the patient at a few different points during this stage of the operation, as she was pushing back against his tools with her abdominal muscles. It’s so crazy to think how “dynamic” anesthesia is. I don’t even know if that’s the right word, but there are so many levels to consciousness and to sub-consciousness. Prior to OREX, if someone told me that people starting to wake up during surgery is not uncommon, I would have not believed them. But it’s true! There are so many levels to “waking up” and the maintenance of anesthesia is such an active part of surgery. After quite a while excising lymph tissue from the left and right pelvic nodes, the surgeons moved on to the aortic nodes. First Dr. Edraki reached pretty far in and palpated the area around the aortic lymph nodes. He instructed Veronica to reach in and feel where his hands were and she murmured in amazement. I think he was instructing her to feel the heart or lungs. He took tissue from the right side, and then had to take greater care on the left side due to proximity to parts of the heart.
After the tissue samples were all collected, it was time to close up. The surgery ended up taking a few hours all told, and it ended up not being too bad that they couldn’t go in laparoscopically given the need to take the extensive tissue sampling. They possibly would have had to open up anyway during that portion.
Written by Xiteng Yan (class of 2014-2015)
Dr. Harken’s lecture focused on the treatment of venous thromboembolism and the problems with blood coagulation. The lecture was complex and fast-paced, and I found it challenging to keep up and understand the overall picture. First, Dr. Harken discussed the diagnosis of an illness named BPT. The symptoms include pain, swelling, and skin changes. Diagnosis can be further verified by an ultrasound, which has an accuracy of 70%, and a venogram measurement, which has an accuracy of ~100%. Dr. Harken then went on to discuss the differences between patient groups (e.g. medical patient vs. ICU medical patient vs. general surgery patient) and the unique risks they each face. For instance, stasis, hypercoagulability and tissue damage are some problems that afflict general surgery patients. From this topic, Dr. Harken segued into a quick overview of the coagulation cascade and the two pathways that define it: that resulting from damaged surfaces and that resulting from trauma. Heparin, a blood thinner, was reintroduced. Dr. Harken posed a question to the residents: “what happens when someone starts bleeding from Heparin?” The answer was to simply wait and give the patient blood since Heparin has a short half-life. The alternative is to give protamine, a drug that binds to heparin to reverse the anti-coagulating effect, with calcium, which counteracts the hypotensive affect of giving too much protamine. To conclude the lecture, Dr. Harken discussed two papers that focused on anti-coagulation drugs (for one of the papers, he notes that more than half of the writers were employees of the company that manufactured the tested drugs, suggesting the pressure for positive results and thus the presence of bias)
The first surgery I observed was a bilateral laparoscopic tubal ligation. The attending was Dr. Valentine, and Dr. Lee assisted him. The patient was a middle-aged, Hispanic woman. To prepare her legs were slightly elevated – almost as if she were giving birth – and her arms were placed near perpendicular to her sides. During this time, Dr. Valentine introduced himself to me and explained that the patient was getting “her tubes tied.” When Dr. Lee arrived at around 8:30AM, the surgery began. First, the patient was fitted with a catheter. When this was completed, Dr. Lee and Dr. Valentino made incisions on the belly button to create an opening for the laparoscopic portals, or trocars. Two additional trocars were inserted on the lower left and right abdomen. The insertion of these devices was quick, and soon enough, the laparoscopic camera and instruments were inserted. Using the laparoscopic instruments, which appeared to burn through and then seal the tissue, Dr. Valentine and Dr. Lee removed both of the fallopian tubes. To my surprise, the phrase “getting one’s tubes tied” was a misnomer – the fallopian tubes were not constricted but removed completely.
Once the procedure was completed, Dr. Lee told me that there was an alternative called Essure. For the Essure procedure, the patient is often left awake. The doctor would go through the vagina to place implants into the two fallopian tubes. These implant cause scarring and will ultimately seal the tubes if everything goes as plan. According to Dr. Lee, Essure is safer than bilateral tubal ligation because no incisions are made and general anesthesia is avoided. The downside to Essure is that the process is lengthy and not foolproof as complete removal of the tubes (if the implants do not seal the tubes fully, then the procedure fails).
Following the tubal ligation, I stayed to watch the next scheduled operation, which was a laparoscopic abdominal hysterectomy (the removal of the uterus). For this case, Dr. Lee was the main attending, with Dr. Valentine assisting her. The patient was a middle-aged, African American woman. The set-up and patient preparation was more or less the same as the previous operation: the positioning of the patient, the location of the incisions, the positioning of the laparoscopic instruments, etc. The first structure to be removed was a T-fibroid, or a mass of muscle, on the abdomen. The fibroid was like a golf ball in terms of size, shape, and color. Once this structure was removed, Dr. Lee and Dr. Valentine turned their attention to the connective tissue linking the uterus to the abdomen wall. Using the laparoscopic instruments, they slowly worked their way through the connective tissue. After reaching a certain depth, the amount of blood flowing into the abdomen increased. The problem of blood proliferation became a concern, and a suction tube (as well as new laparoscopic instruments) was brought in. However, neither of the doctors was truly alarmed, so I don’t think that it was an emergency. After Dr. Lee and Dr. Valentine worked their way through half of the uterus’ base on the abdomen, I excused myself for the day.
Written by Nichollette Minix (class of 2014-2015)
OR7 Tracheostomy/Percutaneous Endoscopic Gastrostomy (PEG)
This double procedure was performed by Dr. Liu and Dr. Menen on January 13. The tracheostomy was the first procedure, which was creating a surgical airway in the trachea. The PEG was the second half which, the doctors created an opening in the stomach to insert a feeding tube.
The patient is a young male, appeared to be in his early twenties. He was born with a neurological disorder, making swallowing and breathing very difficult. He also has a severe lung infection. As a result, the patient lacks the ability to receive adequate amounts of nutrition and oxygen to maintain his weight, which was clearly visible when he was transferred onto the operating table. His body looked thin and fragile.
After the patient was placed on the operating table, the anesthesiologist began intravenous sedating the patient. A shoulder roll was used to lift the shoulder, extended the neck and prepped the patient’s neck to make the area sterile. Dr. Menen runs two fingers up and down his neck feeling his Adam’s apple and palpating the thyroid cartilage and cricothyroid cartilage. Then, Dr. Mene made a vertical incision to the suprasternal notch. She flips the scalpel over and uses the handle to open the incision. Blood began to slowly profuse from the opening. Dr. Menen inserted her index finger in the opening to palpate the thyroid. A second incision was made, which allowed the doctors to identify the cartilage rings. Some form of solution was injected into the trachea; the syringe was removed while the needle portion remained in the trachea. A wire was inserted into the needle along with a dilator. At this point, the sedation was wearing off and the patient rose up from the table twice. More sedation was delivered to the patient by the anesthesiologist, the staff waited for a couple of minutes before proceeding on. Finally, the tracheostomy tube is inserted.
Dr. Menen and the medical student used an endoscope through the mouth to examine the upper region of the esophagus ensuring the location for the correct tube. A small incision was made into the abdomen and the PEG tube was placed through the incision into the stomach. This procedure took about 20 minutes.
OR2 Avfistula Revision
The patient has renal disease and is on dialysis. An Arteriovenous fistula (AV fistula) Revision was performed by Dr. Harken and Dr. Lee. This procedure consists of connecting an artery to the vein of the left forearm so the blood can flow directly into the vein. The patient was prepped and sedated. Dr. Harken requested that the operating table be placeed in a diagonal position. A Doppler ultrasound was passed over his arm to evaluate the blood flow. A small incision was made to join together the cephalic vein and the radial artery. The Doppler ultrasound made a loud high pitch sound, which was an indication to Dr. Harken, blood was not flowing accurately. After making some adjustment to the radiocephalic fistula, the blood flowed smoothly based on the low tone sound, which is an indication that blood is flowing accurately. This procedure took the doctors only twenty-two minutes to do.