Written by Lisa Jo (class of 2016-2017)
My first OREX day was Thursday, November 17. It was awesome! I saw a craniotomy, cataract removal, ankle draining, and a laparoscopic gallbladder removal.
I got to Kaiser Oakland for Grand Rounds, enjoyed a free breakfast burrito, and listened to a few residents give their presentations. The first presentation was “Does Surgery Stimulate Inflammation?” (apparently it does); he summarized the immune and endocrine response to surgery. One new term I learned is “third-spacing”, which is fluid shifting into interstitial spaces; surgery typically involves blood volume loss, so (as I will discover later) the amounts of IV going into the patient and the urine produced after are recorded to monitor fluids.
The next resident briefly talked about Ella Wheeler Wilcox, a poet who outlived her children and husband, and read her poem “Solitude”.
The final two presentations were the pros and cons of using statin and aspirin during surgery. Both presentations cited the Jupiter trial and Poise-2 paper, and mentioned Dr. Poldermans (a doctor that fabricated data for many papers). Overall, it seems that statins do not significantly harm patients during or after procedures, while aspirin marginally does.
Grand Rounds was over around 8 am.
At Highland, the first surgery I observed was a craniotomy! I walked in to see the patient already unconscious, on her side, and head in a clamp. It was unexpectedly fast; the surgeon, Dr. Patel, dictated the patient information before starting and predicted that it would take about an hour and a half (and it did). The patient had meningioma. He has able to pinpoint the tumor location by using a reflective tool to create a 3D model of the current head and compared it a recent MRI. He sliced through the iodined scalp, drilled and picked a small (~3 inch diameter) circle in the skull, removed it into a bucket, and used an ultrasound tool to cut through the brain matter. The white tumor he removed was about the size of a grape and probably benign. Dr. Patel filled with a white material then a blue liquid plug that mimics the cerebrospinal fluid. The skull flap was polished and had metal brackets attached to it so that the piece can be screwed to the rest of the skull. Then the scalp was sewn, stapled, and wrapped.
The patient’s urine was collected to measure the patient’s fluid loss during the procedure.
The cataract removal was performed by a resident. The patient was responsive and draped throughout the procedure and put under a microscope. The surgeon dropped in a liquid onto the eyeball to keep the eye dilated and injected anesthesia under the eye. He cut a few slits around the iris and injected a blue dye into the eye to stain the capsule surrounding the cloudy lens. He removed a part of the blue capsule, and the lens surfaced. He used an ultrasonic tool that also acts as a vacuum to break up the lens and suck it out; he also used another tool that filled the area with water. After he made sure the area was clean of cloudiness, the resident injected the lens implant and stitched slits in the cornea with the smallest thread and needle I’ve ever seen. The eye was covered with gauze and a hard patch. The procedure took about 2 hours.
An orthopedic surgeon and a resident did the ankle drain. The patient had a previous injury and had sutures. The resident cut the sutures, and the doctor stuck his finger into the open wound! He felt around the tissue, lifted the foot over a bucket, and washed the wound with saline solution. He injected and vacuumed the solution multiple times. He pointed out a visible nerve in the foot; it looked like an off-white, thin cord. The wound was closed with sutures and the whole leg was wrapped. The procedure took about 15 minutes.
I visited Dr. Krosin on the 7th floor. The orthopedic back office was really cramped and full of computers displaying x-rays. I shadowed him while he met and followed up with two patients, one who had hip replacement surgery a month prior and another with back pain. He was really amicable with the patients and their family, but also efficient. He addressed their concerns on the spot and explained away any confusion. The patients were visibly glad to be in his care. (Afterwards, I got another even bigger and better free burrito in their office!)
The laparoscopic gallbladder removal was performed by three doctors. They inverted the belly button and cut it into quadrants. The reason of going through the belly button is the skin there is relatively thin for all patients. This is where the camera went through. They filled the cavity with air so they had more room to see and work; with the light of the camera inside, the body looked like a red, glowing balloon. They made two other entry points near the gallbladder with their scalpels for their tools. The gallbladder was white-ish green and really distended. They cut and burned near the base of the organ to look for the cystic duct and blood vessel; the gall bladder popped during this process and black bile leaked out. They used the vacuum to suck out the bile. Once they found the vessel and duct, they clamped and cut them. After the gallbladder was free, they cut to detach it from the surrounding area, tossed it into net that passed through the belly button, and removed it from the body. The entry points were stitched. The procedure took about 2 hours.
At about 4pm, my feet were a bit sore and decided to get going. After all the excitement, I was glad I didn’t get kicked out once! Everyone was helpful and willing to answer my questions.
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.