November 19, 2017
Written by Jonathon Taylor (class of 2017-2018)
“Cause it’s a bittersweet symphony this life.
Trying to make ends meet, trying to find some money then you die.”
Among the many things I learned during my first OREX day is that Dr. Ito, the urologist performing the cytoreductive radical nephrectomy, has excellent taste in pop music. Nary a repeated tune as his phone played the likes of Beyonce, the Verve, and Prince. Several hours into the process, and despite my best attempts at professionally representing both the Highland Volunteer program, and OREX, I admit that I quietly sang along to Raspberry Beret while standing on a step stool to get a better view into the dissection as Dr. Ito and Dr. Yamaguchi worked to remove the football-sized kidney from their patient.
I arrived at the O.R. after Grand Rounds in time to watch as the patient, a man in his mid 40s, was being prepared for surgery. I stood at the back of the room, facing the foot of the bed and observed as William, an OR tech, carefully set out the sterile tools. I took notice of a corrections officer in the back corner, and then turned my attention to the center of the room, where the patient sat on the edge of the bed, fully tattooed, back exposed, in preparation for an epidural. A CRNA named Rebecca was seated in front of him, quietly and very gently guiding him through the severe pain he appeared to be in while holding both of his hands in what struck me as an extremely empathetic gesture. A CRNA resident was administering an epidural using a glass syringe, but this man’s pain was profound, he could barely bend forward enough to expose the spaces in his vertebra. His right kidney was all tumor, compressing his spine, making every movement a painful chore.
The atmosphere of the room was sensitive and respectful of the patient throughout the procedure, but shifted into an animated, positive and professional tone once the patient was under anesthesia. Wendy, the circulating nurse, generously provided me with a running commentary during the preparation and initial dissection. Before the first cut, there was a palpable pause in the action, Wendy explained that this is the timeout period, part of “Universal Protocol” designed to help avoid wrong-patient and wrong-site surgery. Also, she said, it allows time for the alcohol used to prepare the incision site time to dry, otherwise the electrocauter used to cut through tissue might light the patient on fire…
With the assistance of resident Sidney Le, a bilateral subcostal incision was made through the epidermis as part of the anterior transperitoneal approach to renal tumor excision. After cutting through the dermis, adipose tissue, muscle and finally the peritoneal lining, the surgeons were able to see the kidney. William explained that The Verve were sued by the Rolling Stones for the melody of “Bitter Sweet Symphony”; Mick Jagger and Keith Richards now share a songwriting credit for that catchy tune.
A large ring, to which various soft tissue retractors were attached, was placed above the patient’s abdomen to keep the cavity open. My rudimentary understanding of the excision is that the renal artery and vein, which run medially to the kidney were clamped, as well as the ureter which runs medially and distally. The surgeons used color-coded bands to identify the anatomy to be cut. At some point each surgeon took a turn reaching around the posterior side of the kidney to help free it for the final part of the removal. Meanwhile a discussion ensued about the state of Mariah Carey’s voice, apparently her technique has had a detrimental effect on her singing voice in the opinion of some.
Doctors Yamaguchi and Ito explained that the massive posterior tumor had already metastasized. Current theory posits that removing the kidney allows the immune system to concentrate on the metastasis. Perhaps more importantly in this case, the surgery provides symptom reduction which will hopefully allow this man to live in less pain for the statistical one to two years he has left to live. The Spanish word ‘profudo’ entered my mind as I first peered into the dissection – the term is used to describe both the physical depth of an opening and also the effect that something has on the soul. This was the first surgery I’ve ever witnessed and it was the first time that I’ve simultaneously felt enthusiasm, fascination, and ultimately sorrow. I do not know what this man did, nor do I know if he will spend the rest of his life incarcerated. What I know is what I observed, that every person in that room did all they could to provide another human being with some level of comfort and relief, and treated him with dignity and compassion.
- Cytoreductive surgery: surgical procedure used to remove tumors. Cyto (greek) = cell
- Nephrectomy: kidney removal. Nephr (greek) = The kidney, -ectomy (greek) = cut out