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November 30, 2016

Written by Bianca Salaverry (class of 2016-2017)

The day of my first OREX shift, I got up at 5:15 hoping to shower and get ready without disturbing my family, but no dice. My 6-year-old woke up loud and full of energy, ready to turn on all the lights and welcome the day. Luckily I had kid-interruption time built into my morning schedule, so I still made it out the door in time to reach my favorite coffee place before they opened at 6:30. I bought a quick coffee and forced myself to have a bite to eat before heading to Highland. I got to OA2 a few minutes before 7 and grabbed a seat at the table, determined to get the most out of the experience. Dr. Harken arrived a few minutes later and started his lecture with a broad question: Why do we treat the same symptoms or presentation differently in different patients? He gave a few hypothetical scenarios where the patients differed in age, health history, and reasons for coming to the hospital. The lecture was interesting, but for the most part over my head. I was able to follow a little of it by reaching back into the depths of my memory from my time working as an EMT in college…pneumothorax, I know what that is!

After the lecture, I introduced myself to Dr. Harken who looked for a resident to walk me up to the OR. The only person going up was an intern who seemed like he was in a rush and not particularly thrilled to have me in his charge. We walked up to K5 together, and he left in a hurry after showing me where the card was to get my scrubs. It was exciting to suit up in official hospital scrubs for the first time. I looked at myself in the mirror and felt giddy just looking like a doctor. I wondered if the surgeons I would be observing felt any of that excitement still, or if it had become totally rote to them.

With my scrubs on, I made my way to the board to pick out my first surgery. It was a little daunting, but I picked a procedure that sounded promising…only to find that the assigned OR was empty. Not wanting to attract attention by walking back to the board, I went into the first room I could find where a surgery was getting set up. The patient had fallen and gotten a compression fracture in their thoracic spine, so the doctors were going to fuse the vertebrae — the exact procedure my grandmother had just a week or two ago! I was stoked to watch and tell my grandmother about the experience, but unfortunately, the circulating nurse told me they wouldn’t be getting started for half an hour and recommended I come back then.

Although I really wanted to see that surgery, I didn’t want to stand around for half an hour arousing suspicion, so I ducked into another room where a different surgery was being prepped. This operation was a proctectomy (removal of the rectum), ileal pouch anal anastomosis, and diverting ileostomy. I didn’t get a full run-down of the patient’s history, but my understanding was that he had had an ileostomy placed previously because he suffered from diverticulitis. In recent months another doctor prescribed high dose ibuprofen for the patient’s back pain, which led to the development of a perforation in his bowel. From what I could tell, the gist of the surgery was to reverse the ileostomy, remove the rectum, and reconnect the remaining tissue to his anus to restore gastrointestinal continuity.

There were four doctors on the floor from the beginning of the surgery and a few others who came in and out at various points. Dr. Miraflor seemed to be in charge of everything. I didn’t catch  the other doctors’ names, but there was a senior resident who led the surgery with Dr. Miraflor instructing and advising him, as well as a junior resident and an intern. An OR tech assisted the surgeons at the table, handing them tools, helping them with their gowns and gloves, keeping track of supplies, and coordinating with the circulating nurse. We chatted a bit and she shared an interesting fact about the blue loops on the lap pads. I had assumed they were there just to visually detect the laps, but she explained that they’re actually radiopaque, which means if one is missing and the docs can’t find it, it will show up on an x-ray. Crazy!

The surgery began with the doctors detaching the ileum from where it had fused to the patient’s abdomen. This was a long and meticulous job; Dr. Miraflor described and modeled every move for the senior resident. She mentioned repeatedly how critical it was that they avoid accidentally cutting through the intestinal tissue. It took about 90 minutes and was done almost entirely by the senior resident.

Screen Shot 2017-01-14 at 7.48.13 PM.pngOnce the intestine was completely free from the abdominal wall, the doctors used the device shown here called a proximate linear cutter. It clamped around the end of the intestine, simultaneously sealing it and cutting the excess tissue off. It looked vaguely similar to the end of a tube of toothpaste when it was finished. They pushed the sealed ileum through the hole in the abdominal wall and moved on to the next part of the procedure.

The doctors started by making a midline incision from the patient’s sternum down to his pelvic floor, curving around the umbilicus. Once they had the patient open, Dr. Miraflor was dismayed to find that his intestines and mesentery were “all tangled up.” He had a lot of adhesions and so instead of the intestines being one long loopy piece, sections of it were held together in a jumble by thin membranes that all had to be carefully cut with the bovie. Apparently adhesions are a fairly common result of abdominal surgery, so these likely formed when the patient had his ileostomy put in.

At this point, it became a little hard for me to see because most of the work was being done deep in the patient’s abdomen. There were five or six people around the table, so I couldn’t visualize much and had to go by what they were saying. After removing all of the adhesions, the doctors carefully dissected out the rectum, removing a piece that was roughly 8 inches long. As they were completing this stage of the procedure, the senior resident stepped away from the table for a moment and began quizzing me about rectal anatomy. I tried to stammer out some answers, but Dr. Miraflor told him I wasn’t a med student and had no reason to know anything he was asking. I have to admit I was a little disappointed — I don’t know much anatomy, but I was happy to make some educated guesses and be wrong.

Although there was a lot I couldn’t see or make much sense of, I read a little about the procedure at home afterward and learned that after removing the rectum, reversal of the ileostomy involves using a section of the small intestine to create a pouch that will serve as a reservoir for stool — essentially recreating the function of the rectum. I couldn’t see this happening at all, but several hours in, the docs announced that it was done. With the ileal pouch made, they were ready to move forward with the anal anastomosis.

In order to attach the anus to the ileal pouch, Dr. Miraflor planned to use an end-to-end anastomosis (EEA) stapler shown here.

Screen Shot 2017-01-14 at 7.48.21 PM.pngThe doctors were getting ready to do that when they found that the staples closing the end of the anus had come out (or hadn’t fully set in the first place). Things immediately got very tense. The surgery had been going on for several hours with no break, and everyone had assumed they would be wrapping up in about an hour. Now it seemed clear that was an unrealistic expectation, but in the absence of any idea about what went wrong, the timeline became muddy. The only explanation anyone could think of was that one of the staplers had malfunctioned and they hadn’t noticed for some reason. Dr. Miraflor called Dr. Victorino, one of the attendings, and they had a hushed and somewhat anxious conversation about what to do. She decided to try to sew a purse string around the section where the staples had come out for fear that if they tried the stapler again, they would risk ripping apart the tissue. Despite her best attempts, the purse string didn’t work, and everyone’s anxiety levels continued to rise. As they tried to come up with another solution, Dr. Miraflor kept updating the anesthesiologist, “Okay, it’s going to be at least another two hours,” and he kept assuring her everything was fine.

Finally, Dr. Victorino decided to scrub in and assist with the surgery. Initially he sat between the patient’s legs (which were in stirrups) and physically pushed on his perineum to give the doctors working in the abdomen a little more access to the internal end of the anus. After the purse string failed, they decided to try a contour stapler, but it wouldn’t fit around the Allis clamps holding the end in place.

Screen Shot 2017-01-14 at 7.48.34 PM.pngThis led to another meticulous (but creative!) task where they individually placed ~25 loops of prolene thru the end of the tissue, each with a clamp hanging off of it. Once they were all in, which took about half an hour, one of the attendings pulled all the threads taut and Dr. Victorino was able to get the contour stapler into place. It seemed successful and everyone started to breathe a little easier.

As they prepared again to do the anastomosis, Dr. Victorino went down to the patient’s anus and reached inside to determine if the staples were holding. Dr. Miraflor reached down to the stapled area from inside the abdomen, and all of a sudden they realized they could feel each other’s fingers. There was a lot of cursing then, and Dr. Miraflor resigned herself to the fact that she would have to be there for another several hours. At this point I had to leave to go to class so I didn’t get to see how it all resolved. As I was leaving, Dr. Victorino called in Dr. Bui, another attending, to fill him in and hear his opinion. Dr. Miraflor spoke to Marisal, the circulating nurse, to give her a list of the tools and equipment she needed for the ensuing procedure. Everyone was upset and exhausted, so it seemed like a good time to call it a day.

UPDATE: Apparently the surgery continued until around 7 pm, a full four hours past when I left. See Cici’s Day 1 notes for the end of the story!