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December 31, 2017

Written by Man Kim Phan (class of 2017-2018)

I got to Highland super early today and got myself situated in room 230 half an hour before the morning meeting. At about 7:10 am, residents started trickling in, but the attending was still not here. Everyone decided to wait 5 more minutes but the attending still hadn’t shown up. And so the meeting was cancelled as people dispersed to grab early breakfast. I gotta admit I was really disappointed as I was curious as to what the Wednesday’s lecture could be about. I went to the cafeteria and waited until the first surgery.

Once in the OR, as I was checking out the schedule of surgeries on the whiteboard, an intern, whose name I recalled was David Liu (?), was also there wondering which surgeries he should observe for the morning. He gave me a brief overview of each type of surgery listed on the board and gave me advice on which one I should watch. He said if I’m interested in seeing surgery, then a laparoscopic cholecystectomy would be ideal as there will be a camera; on the other hand, if I’m interested in learning about surgical procedures then any of the orthopedic surgeries would be extremely informative. He was personally interested in a case on unclogging the arteries of an elderly patient that might involve complications (I couldn’t catch the names of the procedures) but the patient wasn’t there yet. Since this is only my second surgery day and I hadn’t seen a lot of surgeries yet, I took his advice to catch the cholecystectomy.

The surgery already started when I got into the room. The circulation nurse kindly got me up to speed with what was going on. On the screen, I could see the gallbladder, a dark red mass of tissue covered with fat and layers of connective tissues, and the liver in the back. The surgeon was delicately “peeling” away the peritoneum (I think…) with heat! At the same time, I overheard them looking for the cystic duct and artery. After some time had passed, the surgeon encountered a thin pale white duct slightly inferior to the gallbladder as the gallbladder was flipped over. Upon close examination, I think they determined that it was the cystic artery, and the surgeon ligated it with a clip. Furthermore into the dissection, as more layers of tissues were peeled off, the surgeon located the cystic duct, slightly larger in diameter than the artery. The cystic duct was also ligated. Then, both ducts were cut. At this point, he finished up dissecting the gallbladder from its attachment to the liver. I think the tool he used was also heated as it left the surface of the liver with shiny, metallic-looking traces everywhere it touched. As the surgeon moved away, I started paying attention to the three port insertions on the patient’s abdomen and realized how incredible it was to be able to operate on the internal anatomical structures of the human body through only three small incisions. I witnessed the gallbladder completely detached from the liver and safely placed in a specimen bag- this process was still going on inside the abdomen. I couldn’t see how the specimen was sucked out, I assumed through one of those three “holes”. Then, I noticed the patient’s abdomen was unusually inflated and flaccid but did not give it more thought as to why. Later on, as I looked up written explanation of this procedure, I found that the surgeon must inflate the patient’s abdominal cavity with carbon dioxide after initial incisions to create easier access. This was the preparation step that I missed but I was in awe that a seemingly insignificant detail that the eye of an amateur, aka me, did not catch does matter in the course of the surgery. Everything all made more sense to me.

As the first surgery was over, the nurse recommended me to watch some orthopedic surgeries so I went to OR 1 where Dr. Liu was. Before entering the room, I made a quick observation of what everyone was wearing from outside the room and noticed the CT machine. I went to grab a lead vest and was told that the purple vests are the lighter ones (“small” people take note!).

This time, an Open Reduction and Internal Fixation of Distal Femur (ORIF) was in progress. This room had a completely different atmosphere than the room I was in earlier- more vibrant and almost hectic as surgeons shouted out instructions and, every now and then, words of motivation. And unlike in the previous surgery, the surgeons and med students were all operating with large tools such as long needle-looking nails, screw, metal graft, etc. I could see quite an amount of blood on the patient’s lower leg which got onto the CT machine and all over the floor. At the moment, a surgeon was pulling from the patients’ leg as others adjusting the positions of the nails and metal plate. I could see the CT scans taken at every step although I could not tell at all what the changes in positions of the bones or the instruments were. I could, however, make out the fractures around the medial epicondyle of the femur. I couldn’t tell what was going on during most of the procedure but some quick Google searches helped me understand the overall steps involved in an ORIF. Basically, this procedure is used to treat bone fractures. The broken pieces will be aligned and secured with screws, metal plates, wires, or pins. The surgeons were incredibly meticulous, making sure every pieces of metal was in the exact position. Countless CT scans were taken until the surgeons were satisfied with their work. This process took about four hours. Toward the final stretch, the patient started regaining some sensation so the nurse and Dr. Liu gave the patient some injections through the IV. I actually did not realize the patient was awake until half-way through the procedure. The patient was only given local anesthesia. The nurse and Dr. Liu continued comforting and checking in with the patient over the blue shield. I could not imagine what the patient must have felt throughout the surgery but I’m glad the staffs were really supportive and professional. Someone shouted out, “Final stretch,” as the head surgeon secured the last walkers (like some sort of screw that secures the metal plate in a position laterally along the femur). Other surgeons quickly sewed up the patient’s skin and cleaned up the blood. The surgery was being wrapped up as the head surgeon asked the CT tech to take a couple final shots of the femur where the metal plates were. At that point, the room was getting rather crowded as the staffs were working on transitioning to the next surgery so I just excused myself and headed out. There weren’t any more surgeries besides a couple of cataract removals so I decided to call it off, amused and inspired by what I have observed and learned today.