Category Archives: excising lymph tissue

January 29, 2015

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.