November 4, 2015
Written by Antony Gout (class of 2015-2016)
The name of the day was laparoscopic Cholecystectomy, or in common parlance, gallbladder removal. I saw three such procedures, and one hernia repair with a mesh. But let me start at the beginning.
I got to the conference room early, and sat nervously in the dark because I didn’t want to turn on the light and draw any attention to myself. Residents started filling in at around 6:55, and I exchanged pleasantries with one of them, Jessica, while waiting for the lecture to start. It was a discussion on lower GI bleeds, which mostly involved the discussion leader (whose name I forgot to note), quizzing the residents about their reading. Evidently lower GI bleeds are rarely surgical and have many possible causes (including hemorrhoids, ulcerative colitis, bacterial infections, etc…). As the discussion wound to a close, I paid less and less attention, as I got more and more nervous. Not wanting to have the same experience as Sarah-Jane, as soon as the discussion ended, I got up my courage and rushed to introduce myself to Dr. Harkin. He immediately paired me up with a Chief Resident, Abhishek Parmar (who I will call AP, in case I misspelled his name), who I followed around for the rest of the day.
I followed him up to the surgery floor, although I didn’t really get a chance to talk to him, because 3 other residents were crowding around him most of the way talking about plans for specific patients, which I couldn’t really follow. He showed me to the dressing room where I fumbled into my scrubs. A few minutes later, I follow AP into the surgery room.
Surgery #1: Laparoscopic gallbladder removal
The patient, a middle aged female, was already sleeping and the abdomen had been cleaned when I entered. I picked a spot that seemed out of the way, and crossed my arms so as to not touch anything. Dr. Cushman, the attending, must have thought I was cold, and draped a warm blanket around me. He also offered me a seat near where I could see one of the two screens, which I thought was very sweet. The resident performing every surgery I saw was a second year resident, Michelle (M). The patient was covered with seemingly unending layers of blue surgery sheet things, and the surgery started.
First, AP or M punched a hole in the abdomen, I believe the navel (I’m not entirely sure, because I couldn’t see very well), inflated it with CO2, and placed the camera. Then M illuminated from the inside the other spots where they want the other holes to go. AP injected some lidocaine at each site, scored the skin with a scalpel, and jammed in a laparoscopic channel (And when I say jam, I mean it. When I saw it on the screen I was shocked by how physical and almost crude the process was). Once all the tools were inside, they looked for the gallbladder (which apparently looked so generic it could have been from an anatomy textbook). Once found, they have to free it from the tough peritoneum around it by using the cauterized tool (Figure A). I looked up how that tool works, and it uses a small electric current to heat itself up and burn the tissue you place it on. M started out by hooking the cauterizing tool in between the peritoneum and the gallbladder and twisting the tool to free up some space. AP told her that it is instead preferable to move it up and down (Figure B), after which you can pull away from important tissue and
cauterize. Then she dissected out the artery and the duct, by using the Maryland tool (Figure C) with which she was told to columnize the fascia (Figure D). She also used the “peanut” to twist away some fascia. She then clipped three times the duct and artery and cut in between the second and third clip (Figure E). After this, they carefully cauterized the gallbladder out, plopped it in a plastic bag, and popped the bag out of the body. They popped in some gauze to sop clean up the area, and then deflated the patient (it sounded like letting the air out of ball, it was weird). Finally, they cauterized the wounds (also sometimes touching the cauterizing tool to the tweezers, which I assume heated those up and allowed AP to cauterize with more precision, which was very cool), and sewed her up layer by layer. Phew! What a trip. We grabbed a small bite to eat, and got back down to business.
Surgery #2: Laparoscopic gallbladder removal
The second surgery was extremely similar to the one before it, so I won’t bore you with another long-winded description. There were some differences though! First, the artery seemed to branch, so Dr. Cushman asked M to dissect it out to make sure one branch didn’t go to the liver, which it turns out it didn’t. The first clipping tool was faulty and M accidentally launched a clip into the abdominal cavity, which AP quickly grabbed. After another few more close calls, they switched out the tool. Once the surgery was done, I followed M who had to get a consent form filled by a patient to have her gallbladder removed later that day. Then, we went back to the OR for the next operation.
Surgery #3: Inguinal hernia repair with mesh placement
This patient was a 29 year old male. I didn’t get to see nearly as much as the previous two surgeries, because it was not laparoscopic and thus there was no screen to watch. Nevertheless, I gave my calves a really good workout in order to make myself as tall as possible. AP made one slice into the lower abdomen and they went at it. They dug in with their fingers (again, it seems so crude), pulled out a slightly white tube out of the way which I thought was a portion of intestine, but actually I later learned was a spermatic cord (I was quite shocked that those things went up so high! They also mentioned the “vas” a lot during the surgery, which again, I didn’t think was the vas deferens because I didn’t know it went up so high). They pulled out some stuff (like I said, I couldn’t see that well), cut out the ilioinguinal nerve (which apparently can get tangled up in the mesh which caused a lot of pain. Sacrificing it means losing some sensation on the skin if the thigh, a relatively low price to pay for not being in pain), pushed the mesh cone in, then sutured the flat part of the mesh in around the spermatic tube. They shoved everything back to where it belonged, and sutured the patient up layer by layer. I make it sound like it all happened in five minutes, but it really took quite some time to find the hernia, isolate it, cut it out, and suture the mesh in place. M’s final suturing was quite beautiful, because you couldn’t see the stitches when she was done. She then applied pressure to the wound for a while. I had time to quickly eat before coming back to the OR.
Surgery #4: Laparoscopic gallbladder removal
My last surgery was on the 26 year-old woman from which we had just obtained consent. Again, I won’t bore you, but instead I will highlight differences I saw in this surgery. Her gallbladder
was again, normal looking, even though it was supposed to look inflamed (AP joked that I was their lucky charm, as my presence clearly caused these wonderful gallbladders and smooth operations, and that I should maybe come again next week. I think so too, AP. I think so too.) This gallbladder was a little less eager to leave the abdominal cavity, because it ruptured while they were cauterizing it out. M had to quickly cauterize it to stem the flow of bile, and then quickly cut it out. They had to irrigate the area (with saline I believe) to wash away the bile. Lastly, there was some bleeding that they had to stop so they cauterized a whole big area until they were satisfied. Once they closed her up, I followed AP out of the room, and thanked him and said goodbye.
I think it was because I was so tired, but I forgot to thank M and the rest of the surgical team for letting me watch them before I took off my scrubs, and once I had changed, I couldn’t go back in to the OR and speak to them, so I’m really annoyed at myself because of that. I hope I see them again to tell them so! Thus ended my first OREX day, at 4:05 PM.
For those of you who have followed me this far, I have a few remaining comments. I was incredibly thankful for being able to see three of the same procedures by the same surgery team. I saw M learn throughout the day and integrate her learning. As AP said, it is a rare thing to have three of the same procedures lined up like that, which really will help her get comfortable with the operation. I spent the rest of the day in awe of the skill and care the entire surgery team displayed.
The images of the surgeries have kept playing in my head; as I fell asleep that night, my mind was filled with images of Maryland tools, spreading fascia, again, and again, and again.
Thanks for reading! I have the figures below (some of them from the stryker website source: Stryker website, and some of them drawn with my great artistic skills).
Figure A: Some cauterizing tools from Stryker. I’m not sure if AP and M used any of these, because they don’t look all that familiar.
Posted on January 9, 2016, in Uncategorized and tagged ilioinguinal nerve, Inguinal hernia repair with mesh placement, laparoscopic cholecystectomy, Laparoscopic gallbladder removal. Bookmark the permalink. Leave a comment.