March 20, 2018

Written by Tommy Ivey (class of 2017-2018)

Hello again Team, here is my review for my most recent OREX date on Tuesday, March 20, 2018. Due to the last time getting there right at 6:55 am and missing the last Resident meeting by a few minutes, I made sure to get to Highland a lot earlier in the morning this time. I arrived at Highland around 6:20am and started looking for coffee but remembered the cafeteria didn’t open until 7am so I headed over to Resident City around 6:40am and took a seat and waited for the meeting to start.  I noticed there were a lot of residents and Doctors I never saw before walking into the meeting.

One of the first topics that came up in the meeting was Short & Long-Term outcomes after a Reconstituting & Fenestrating Subtotal Cholecystectomy.  In discussing Cholecystitis, the team was addressing the cause, treatment, how long the patient has had it, the location, the patient’s medical history,  any previous surgeries, and any other relevant info pertaining to the patient’s health. One of the Doctors addressed a question to the group asking what types of negative health issues going on with the patient would make the Chief “nervous” while in the middle of the surgery process.  Some of the answers included too thick of a wall between the gall bladder and the liver, larger than usual size stones in the patient fundus, excess fluid, or possibly the cystic duct would change in length and shape making it more difficult to function properly or gain proper access.

The next question addressed to the group that was asked was what does ERCV stand for? I looked this up and saw that it stands for Emergency Response Containment Vessel, which could also stand for Emergency Response Communications Vehicle. There was also the mention of the Critical View of Safety referring to Calot’s Triangle. This area connects the Duodenum, Stomach and Liver which also includes the Cystic Duct, Common Hepatic, and a small corner of the Gall Bladder. The significance or importance of this area is where the Cholecystectomy is usually performed.  Following that, there was a list of steps for the Culture of Safety that included:

Culture of Safety Steps:

 

  • Use Critical view of Safety
  • Time out before clipping
  • Consider aberrant anatomy
  • Low threshold for IOC (Intraoperative Cholangiography)
  • Recognize the risk & utilize a safe bailout
  • Ask for help

 

Following the discussion of these steps, the team was asked which gall bladders were bad ones?

Here’s some determining factors:

  • Patient factors
  • Elderly
  • Morbid Obesity
  • Thick walled
  • Girizzi’s Syndrome
  • Cirrhosis
  • Cholecystoenteric

One important key factor to remember is not to dissect below the Rouviere’s  Sulcus. In

discussing Subtotal Cholecystectomy, there was the comparison between  Fenestrating (Opening the first part of the gall bladder)  vs. Reconstituting (Opening gall bladder, clearing stones, and hand sewing incision back up).  In this comparison, there was supportive evidence to show that with the Reconstituting procedure, only 18% had bile leaks, which was comparative, as well as substantially lower than the Fenestrating procedure. At this time, the  meeting was pretty much coming to a close so I grabbed my things and left and headed up to the OR.

I scrubbed in and picked a Laproscopic Cholecystectomy procedure in OR #3 figuring since we had just come from hearing all about this, I figured it would be interesting to see it firsthand and to hopefully gain a little bit of an understanding of all that it entailed.  I walked in just after 8am and waited until everyone was free from their duties pertaining to setting up so I could introduce myself to them one by one. After everything was ready to go, the team timed out right at 8:30am and I thanked them for allowing me to observe the procedure.  From what I saw, it looked like they made 3 small incisions on the right side of the stomach area. One was medially just below the right chest area, the second one was just slightly inferior and a little laterally from there, followed by the third one which was also inferior and lateral from the second one.  So the procedure was to eradicate the stones and the gall bladder as well.Screen Shot 2018-03-31 at 9.53.05 AM(Pic similar to the procedure with the incisions all on upper Right Abdomen area with 1st one being superificial to the other two and medial to the spine, the 2nd one slightly inferior and lateral, and 3rd slightly inferior and lateral to the previous one)

The incisions were made in the upper abdomen area of the patient, followed by suction-type devices that were attached to the patient so the surgeons can enter through those incisions with tools, cameras, and to be able to pull the gall bladder out once it’s ready for removal.  I watched as the surgeon and resident started burning through the layers of fat to reach the designated area and once in the area of the gall bladder, two long cameras with sharp surgical scalpels on the end were inserted into the circular suction-like areas covering the incisions.

The team and staff were very friendly to me which put me a little more at ease, while taking the time to explain all what they were doing, who they were, and to feel free to ask any questions I may have.  This was the first time that I was able to see the procedure on two different screens which were on each side of the bed. Seeing the stones on the screen made me realize that they actually resembled pellets from a pellet gun. There was quite a bit of stones in this patient’s affected area and they had quite a bit of layers of skin and fat to cut through to remove the gall bladder so it took a fair amount of time to get to nearing the gall bladder. One surgeon used a tool to pull layers up, while the other resident surgeon would burn through the layers one by one. Once all the areas that needed to be removed were done and the area was cleared, the team started the removal of the gall bladder.   Once the gall bladder was free to be removed, they placed it into a small plastic bag, which would later be put in a glass jar and taken by the nurse.

This was a much more in-depth experience being able to see the whole procedure every step of the way by watching it on the two screens so I was pretty grateful about that.  I was planning on seeing a second procedure shortly after that but realized I had an appointment that day so I left around 11:10am and headed home. For me, it seems each time I get more intrigued and fascinated by the different procedures and the whole overall experience.  I left there feeling pretty excited and am honestly really looking forward to the next one I signed up for in a couple of weeks.

Thank you very much everyone for reading my OREX journal entry and I hope you enjoyed it.

 

 

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Posted on March 31, 2018, in Uncategorized and tagged , , , , , , . Bookmark the permalink. Leave a comment.

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