Operation, Deconstructed. Nine: finish line

Truth be told, sewing up holds no magic for me, other than the fact that in some cases it's a time to breathe a sigh of relief. (A main attraction of neck surgery is that once the fun's over, closing happens in the blink of an eye.) Still, it's not a time to stop paying attention. As in all aspects of an operation, there are dangers, and there are ways to screw it up. On the other hand, keeping your eye on the ball doesn't preclude a little relaxation. With very little encouragement (most often, without any at all) I'm liable to launch into my repertoire of Gilbert and Sullivan or Rogers and Hammerstein. I can do most of the parts in "HMS Pinafore," and a truly show-stopping "Pore Jud is Daid," keeping it up until the circulator, sighing with force that could break bricks, marches over and turns up the radio.

The anesthesiologist has a tough job: ideally, the abdominal muscles are fully relaxed (paralyzed) for closure, because it keeps the patient from pushing the guts into the wound, and it makes approximation of those muscles much easier. And yet it's also nice to see the patient fully able to breathe by the time the bandage goes on. Some are better at it than others; and surgeons make it harder by being unpredictable. Not me, of course. Today, it's one of the good ones; while I sew perfectly limp muscles, he tells me about his latest attempt to electrocute squirrels. Been reading about Ben Franklin, made a model of his capacitor or some damn thing.

Closing the peritoneum -- the freeing of which on the way in I described a couple of weeks ago (has it been that long?) -- helps. Not everyone does it. In addition to holding the insides in during the rest of the closure, it allows thorough irrigation of the incision with that nice brown solution I used in the belly. I place a couple of large and tough clamps on the edge of the muscle (the fascia -- the halves of the linea alba I divided when making the initial incision), at about the mid-point of the incision. Joanie lifts them up and together with one hand, and with the other elevates a small retractor I've placed at the apex of the wound. That's hard work (although it's good for the pecs) so it helps to be fast. I run a whip-stitch down the peritoneum, and give her a break while I wash out the wound. It's at this point that I infiltrate, generously, with long-acting local anesthetic: the peritoneum, above and below the muscle on both sides, just below the skin.

Having been trained -- as were we all back then -- to close the muscle layer with interrupted (individual, one at a time) sutures, of non-dissolving material, it took overcoming many voices in my head to switch to a running suture made of stuff that goes away in a few months. But it's better in every way, starting with taking less time, passing through less pain, and ending with better healing. Studies confirm it. I strongly believe in taking large bites, well away from the edge and widely spaced. Choking off the wound with too many sutures, placed too closely, and pulled too tight means more pain and less healing. You couldn't break #1 vicryl if you tried; I use it on a big honkin' needle, grab it and the fascia with monster Russian forceps, and it comes together as it should. When the bowel is distended or when there are other reasons why it's hard to keep things inside when closing, there are various tools you can slide under the muscle while the sutures are placed. What you don't want to do is forget to remove them before you finish:



The scrub and the circulator are pointing at piles of sponges and counting them together. "Seven, eight, nine, ten.... seven, eight, nine...." They rustle around. The scrub reaches up and picks at the drapes near my belly. "You missing a sponge? What kind? I know there's nothing inside... A four-by-eight? You got all the laps? The only four-by-eights were on the sponge sticks and I gave 'em all back to you..." I start looking around as well: under the table, lift up my shoes, peek under the drapes as far as I can without contaminating the field. Shit. Am I going to have to re-open? "Here it is! It was in a lap..." Most of the time, the counts are correct. When not, invariably the missing sponge or needle gets found somewhere outside of the patient. Twice, I think, I've actually had to reopen and have dug one out. Huge thanks to the nurses, abject embarrassment. Never have I left one in and taken the patient to the recovery room. I wouldn't like that.

My skin closure consists of a few fine interrupted sutures under the skin, followed by steri-strips. It's quick, cosmetically nice, and people can shower in a day or two. The only downside is the strips sometimes look a little bloody; but any disapproval of that is more than made up by the happy realization that there're no stitches to remove. Skin staples, plainly, suck. I put on the smallest bandage possible, believing that big ones are too scary.

I hang around to help move the patient onto the gurney; in fact, I usually go into the hall to get it, grab a roller on the way past where it's leaning against the wall, slide it onto the gurney while steering. Pump the gurney up to table height, roll the patient away, slide the roller under, then glide the patient onto the gurney, roll her the other way, remove the roller. "Thanks, everybody. See you in a few minutes."

When I have a line-up of cases, I head first to pre-op to talk to the next patient. Then to the family waiting area to talk about the just-finished case; then to the recovery room to have a look at my patient, write orders, dictate the op note. I always talk to the awakening patient, giving some good vibes, even though without exception, they never remember the conversation. If it's the A-team in the OR, by the time I'm done the next patient is ready to go into the room. The layout is such that I can see when the gurney is on the go. Usually, though, it's not that efficient. Stewing and brewing in the lounge while things happen too slowly for me... In this case, I have to run down to the ER to see what's going on with that acute abdomen they called about. I let the desk know I might have an add-on. And I guess I'll check to see if Carol ever got ahold of Dr. Smith...

I walk into the spacious surgery waiting room. Groups of families and friends have staked out their spots with pillows, books, blankets; couple of kids running around, TV on too loud. Heads turn expectantly, then look away, disappointed, when they see it's not their surgeon. I look for familiar faces, the volunteer at the desk helpfully nods toward the corner. Striding over, green-clad, I'm not unaware of the drama, the reading of my face as I approach. I give a smile and a thumbs-up before I'm in earshot. "She's fine, she's in the recovery room, everything went great." Getting the important stuff out right away, watching the tension dissipate, people visibly relax. "It was just as we expected, diverticulitis; everything went fine. I think she's gonna be really happy we did this. Did some of my best work... (Wait for the laugh.) She'll be in recovery give or take an hour and a half. They usually don't let visitors in there, but they'll let you know when she's heading to her room. Anybody have any questions?..." We talk a while more and, yes, I have to say I drink in the gratitude, the relief, the optimism. The sense of accomplishment. If that weren't part of it, what would be the point?

As I get up to leave, something occurs to me: "Oh, by the way, I realize I said it'd only take an hour or so, and it's been three weeks. Hope it didn't worry you...."

"It's OK doc," her husband says. "Blogging's a bitch."

Operation, Deconstructed. Eight: coming together

Scenario one: "Hi Sid, this is Dave, calling about Patient Blahblah, pelvic sidewall. Is it OK to talk?" (Wondering if the patient is awake.) "Fire away." "Can you send me any more tissue?" "If I had to. Why, what's up?" "Well, I think it's just inflammation. Probably nothing, but I don't want to commit....yak yak yak..." "OK, OK, OK. I'll send you some more..." (Useless sonofabitch. I'da known he was there, I'da never sent a frozen...) Scenario two: "Room two? Dr. Schwab?" "Speaking." "Hi Sid. It's Ernie. Can I talk?... Patient Blahblah, date of birth yadayada, sigmoid resection, specimen pelvic sidewall?" "Right." "Nothing here but inflammatory cells. Histiocytes, neutrophils, fibroblasts, few eosinophils. Were you worried about something?" "Not really. Little more indurated than usual. I'm sure she has diverticulitis. Just giving you something to do." (Got some bloggers looking over my shoulder, making it real for them.) "Will you be sending anything else? You'll be orienting the sigmoid for me?" "Anything for you, Ernie. Nothing more coming. Thank you." "OK. Have a nice day." "Same to you... (click)... I love Ernie." Joanie brings the bowel clamps to within a couple of inches of each other and rotates them a few degrees in opposite directions to expose the backside of the colon ends. Using the classic 4-0 silk sutures, I place a stitch through the bowel that's at the very end of the clamp, and carry it through the same place on the other piece of bowel. Then I pop the needle off, grasp both ends of the suture in a roach clip and lay it down. Repeat at the other end of the jaws of the clamp: now I have the ends of the anastomosis controlled and marked. Next I place a series of individual silk stitches, filling in the space between the two ends, a few millimeters apart, in the backside of each bowel end. These I lay down as I place them, ends stretched out and unclamped. There's something about a needle-holder that's very pleasing, particularly the ones with gold handles. Receiving it from the scrub nurse with the needle perfectly placed, the middle of the curve right at the tip of the jaws, suture held back so it doesn't drape across my palm (if it does, it can get pulled out when I re-grab it after the first pass), I slide my index finger down the shaft of the instrument for precise control, and it fits just right in my hand. I leave my fingers out of the finger-holes, preferring to latch and unlatch by pressing them against my palm with my fourth and fifth fingers. The tip of the needle starts perpendicular to the bowel wall, and as I drive it in (just right: not too deep -- the idea is to penetrate the muscular layer but not all the way into the lumen) I rotate my hand, shooting for a perfectly circular motion. As it emerges, I grab the tip of the needle with the forceps in my left hand and pull it the rest of the way out. My left hand is steadied by resting it on the edge of the wound, which allows me briskly and accurately to present the needle to the needle-holder back end first, re-grab it in the jaws in a burst of crunchy clicks, and stitch the other end of the bowel, symmetrically with respect to the placement of the first bite.

As the needle reappears, I let go with the needle-holder, re-grasp it on the other side of the bowel, and draw it out, grabbing the string with my forceps (or keeping the forceps in my hand and using my fingers) and then pulling on the needle-holder. The needle pops off (an innovation that occurred in my surgical lifetime: time was we threaded our own needles, and the first "swaged on" ones didn't pop off) and I hand the instrument back to the scrub, needle in its jaws. She gives me another. (Among the great ((yet small)) frustrations is getting handed a needle-holder of a size differing from the first one. The motions of laying down that series of sutures is repetitive, and the muscle-memory likes it to be consistent: having to adjust to a long instrument then a short one feels like walking with one foot on the curb and the other in the street.) Sewing bowel is a circus of sensory feedback: the clicks, the pops, the vibrations in my hand as the instruments ratchet open or closed. The steely and dry hardness of the clamps against the living and wet softness of the bowel; the ever-present musty odor of an open belly, above which the air is noticeably humid. The small arteries in the mesentery -- confirming I've left the edges alive -- dancing in time to the heartbeat monitor, their steps delayed a split second from the sound. I can't help but drink it in, always, no matter what else might be going on. Not many people get to do this: I savor it while I can. Up to a point (maybe five or ten in a row), tying knots is fun. It's one exercise wherein speed and flash are useful -- if not indispensable. 

Since early in med school, prospective physicians test their worthiness by learning various tying techniques, the acquiring of which is, in some measure, a palpable sign of progress, a talisman against ever-present self-doubt. If a cowboy validates his claim on the title by twirling a rope, a surgeon does the same in a blur of flying fingers. Surely the scrub, my assistant, even the anesthesiologist have expressions of admiration hidden behind their masks as they witness my underhand, overhand, left hand, right hand, my double-handed single-motion surgeon's knot. Admittedly knot the fastest, I can hold up my ends of a suture. 

Having placed this entire back row of silk sutures, I pick them all up and hand them to my assistant. If it's Joanie, she knows how to select each proper pair by sliding a deBakey forceps across the bottom of the pair and bringing it up to present them to me (if it's a less skillful assistant, I use the forceps myself and keep it in my hand while I tie. More clumsy, but quicker than laying it down and picking it back up each time): I grab an end in each hand and work my magic, pulling the ends perpendicular to the bowel so the knot lies down in the groove between the ends of bowel, making the tension just right. ("Just right" is completely subjective, but I think it's another area of divergence among surgeons: if too tight you risk affecting circulation and therefore healing. Too loose, leaks are possible. I suppose we need the equivalent of a torque-wrench; as it is, we hope for having developed the right feel.)

The reason I keep using silk for this layer is that it ties so, well, silkily; and having imbued the knot with that just-right tension, it holds it perfectly while awaiting the next loop. If surgery is, at times, art, it's like having a favorite brush. Once all the knots are tied (three throws for silk, four for vicryl, hundred fifty for nylon), it's time to remove the bowel clamps. For colon surgery, for which there's usually been some sort of prep to empty the bowel, and which is unlikely to spill anything when unclamped, I don't place any upstream clamps. I do for small bowel surgery. Still, when opening the clamp, I have the suction ready; I give the opening a swipe with a betadine-soaked sponge. 

Theoretically dirty, the clamps go off the field. Now I tie the corner stitches, having waited until the clamps were off to avoid too much tension while tying. At this point, it's as if we have two hoses lying side-by-side, like a double-barreled shotgun, with only the touching edges attached. In placing an inner row of continuous sutures, we bring the hoses end-to-end, sealed. It's the most fun stitching, because it's the trickiest; rounding the "corners," switching from inside the bowel to outside, and from a simple right to left through and through, to left to right, inside/outside, outside/inside. [I know I'm not giving you a perfect picture. And believe me, I searched for some diagrams.

But the point is there's some technique involved, the doing properly of which ends up with a very happy sense of satisfaction, perfectly inverted bowel edges around the whole circumference.] "Is that pretty, or what?" I say when it's done. "Yes, Dr. Schwab, you're a goddamn genius," says the nurse, mentally twirling her finger and saying whoop de frickin' do.

There's a final row of interrupted silk sutures to place on the anterior surface of the anastomosis. Finished, I cut them one at a time, aiming for equal length, Goldilocksianlly not too long, not too short. With thumb on one side, middle finger on the other, I pinch across the anastomosis to confirm patency. "Drive a damn truck through it..." My thumb and finger squish against each other, padded by the spongy walls of bowel, gliding between the rubbery ring of the anastomosis. "Be closing in a couple of minutes," I add, to the anesthesiologist, so he can begin his chemical resurrection. If you don't close the mesentery, small bowel could slip through the hole and cause an obstruction. "Three-oh vicryl on a long needle-holder." Whap.

Reaching in with my left hand and bringing the edges together with my fingers, I place a stitch at the apex of the rent with my right. Joanie ties the knot since my hands are engaged; I'm re-grabbing the needle with the needle holder, having pushed it through as far as possible, twirling the instrument over in my hand to re-align it for the next stitch. I run the suture line out to the edge of the bowel, while Joanie "follows" (grabbing the suture after I've placed a stitch, applying a little tension, barely tenting it up to ease the next placement.)

Nailing a blood vessel at this point is hazardous, in that the need to clamp it off could jeopardize circulation to the anastomosis; so I pass the needle just under the peritoneal surface with each bite. Breaking a cardinal rule of safety, sometimes I grab the needle with my left fingers, steading my hand against the bowel, and hold it while I re-click it into the needle holder. "Here's your sponges," I say as I hand them all back to the scrub. Or, if she prefers, I arc them one at a time into a pan next to the table, letting the ones that hit the target speak for themselves; saying "somebody moved it" when I miss.

I remove the retractor, lift the wound edges to let the small bowel slush into the pelvis. "Irrigation." A critical intervention: I use sterile water, not saline, because it osmotically explodes single cells, like bugs or loose cancer cells. Mixed with betadine, light brown and heated, it floats some of the bowel. The final internal sensation is my hand in the warm water, gently stirring the gutty soup, then inserting the sucker over my hand and vacuuming it all out. And now, boys and girls who've waded through this with me, we're ready to close...

Operation, Deconstructed. Seven: resection, finally

Would you know what I mean if I describe whistling without whistling? Barely pursing the lips, making little quasi-audible windy sounds while inhaling and exhaling, in tune yet nearly silent? Unless there's music playing, that's what I do when I operate. And for reasons about which I have absolutely no clue, I nearly always "whistle" The Caisson Song. I've always wondered if anyone in the room noticed. Joanie? I suppose if anyone did, they'd eventually recognize it as a sign of contentment. "Over hill, over dale, looks like things are going well...." So it's "hi hi hee" to cut the colon free. I grasp the sigmoid again, and pull it upward then downward, looking to see where the bottoms of the loop fall, determining how much looser I need to make it before removing the damaged portion. Having mobility not unlike that of the sigmoid, the rectum can be made to stand up and out of the pelvis with a few judicious snips of its surrounding peritoneum. No matter how extensive the diverticula, they always spare the rectum. (The anatomic definition of the rectum is a little loose, not unlike the actual organ. I consider it to be the part of the colon that starts below the pelvic brim, and continues to the anus.) And since I'm doing the writing, in our patient the diverticula trail off markedly at the upper end of the sigmoid, as is typical, so the resection is less extensive. I unzip the white line a little higher, maybe up to above the left kidney, and achieve enough mobility to get point A to point B after the sigmoid is in a pan. And now, what used to be the most annoying part of the operation: clearing the chosen spots for division, and making them ready for the placing of clamps. The blood supply to the colon comes, more or less, from the center of the abdomen and radiates out like the hands on a clock. Taking the clock analogy beyond its limits, if you want to remove -- as in this case -- a section of colon from three to five o'clock, to get to the blood supply you make a pie-shaped pair of cuts from those numbers to the center of the dial. The difficulty is in direct relation to the amount of fat within the mesentery. Once in a while -- rare enough that it makes you want to be able to record it in your brain and replay it in your dreams -- you can hold the bowel up and see right through the mesentery. It takes a very skinny person. More beautiful than the wings of a mayfly, it's spectacular calligraphy on wetted rice paper, the vessels visible in their spidery and laddered connections; clamping them off -- individually, precisely -- is exhilarating and easy, as if there were no choice but to do it. Most often, though, it's hardly that beautiful. In my early years of training, the process frustrated me. Turns out, there's a trick: the fat in the mesentery nearly always thins out right at its border with the colon. Grasping the colon over the top, I can usually feel the lower edge of the bowel; pushing toward myself from the opposite side, feeling my way to that edge with my middle finger, I come at it from my side with the tip of a curved clamp. Judging the resistance to be sure I'm not punching through bowel, looking over to the other side to confirm, I push the tip onto my middle finger, and wiggle it through. "Two-oh tie." (It's a thread without a needle on it.). I push the clamp further through, spreading my fingers to let it pass between them on the other side, and then I open the clamp. Joanie directs the end of the tie between the jaws of the clamp, and I pull it back through, bringing my end to the top so it's around the bowel, and I click it into the clamp. Point A.

I repeat the process at my selection of point B. Now I literally have a handle at each end of the bowel where I'll divide it. And having made that little hole, I've opened the peritoneum on each side of the mesentery and can insert the tip of a scissor. The fat recedes. I can easily move it off the bowel surface and, turning the scissor centrally while pulling backward on my suture-handle, incise the tensed peritoneal layer with a push of the blades all the way to the root of the mesentery, from which the vessels fan out. This unroofs the underlying fat, and I can scrape at it with the closed scissors, pulling it away from the vessels hidden underneath. And there they are. To make ready for clamps, I punch through the mesentery above and below each vessel that I see. And here's a situation that distinguishes elegant surgery from the brutal: it takes only a moment to clear each vessel separately. Some surgeons do, some don't. Having gotten to the base of the mesentery, you can just "walk" back up to the edge of the bowel with a series of clamps, not really seeing any of the vessels you're dividing, grabbing them by inference, along with globs of fat. It works, as long as you don't take an enormous bite (if you do, when you release the clamp as you tie a tie, the glob may fall away and bleed.) But in my view, it means choking off a wad of fat which will die and inflame and generally add to the work of healing. Plus, it looks bad. And when you see each vessel, you can save some time by applying clips instead of clamps and ties. Which is what I do. It's like jazz (the Caisonnity-sonitty song?): winging it with regard to when I squeeze on a clip, and when I feel like using clamps and ties. (I never leave a clip near the bowel surface: it'd be in the way of the anastomosis.) Given the same curtain of blood vessels on two different days, the music might sound different, who knows? "Clip... Clip... 'Nother one... Clamp... Clip... Clamp." Get a feel. Go with the flow, the size and the nearness of the vessels. And, after all the upstream ends of the vessels have been controlled, I may or may not clamp the back-leak ends before I divide them. Depends on the size of the resection, how much I can control with my left hand. Sometimes I click a clamp ex post facto. If so, I never waste time tying them off, since it's all coming out -- unless the resection is so big that we've run out of clamps.

For a total colectomy, I might use the LDS stapler, which clips both sides of a vessel and divides it all in one beautiful gas-powered "k'chzzz," delivered from a very satisfying pistol-grip. I don't trust it for big vessels; I add another clip on the business end before pulling the trigger. One way or another, I scissor through the vessel after controlling it, usually whisking the instrument to my wrist (as previously described) when receiving the next clip or clamp. So now we're ready for the coup de grace. The sigmoid colon is free of its attachments. Holding it up, the mesentery hangs off it like a bib, maybe dangling a clamp or two. "Couple'a betadine laps." For beauty, and for infection protection, I drape the field around and under the bowel with lap pads soaked in povidone/iodine: luscious chocolate brown drapery covering the entire field, with only the bowel loop visible above it. A presentation fit for royalty. Museum quality, it ought to be in a lighted display case. With two OR lights aimed right at it, it is. It takes four long intestinal clamps: two delicate ones that stay (for now) with the patient, and two who-cares ones that go away with the specimen. The former I place with the handles aiming at my assistant, the latter toward me. Picking the first pair, she holds hers, I hold mine and I slice between them with a #10 scalpel, the one I used for the initial incision. I wipe the cut end of the bowel with a betadine-soaked sponge. Ditto for the second pair. Then I hand off the bowel, hanging like an abandoned hammock between the two clamps, drop it into a pan, along with the now-contaminated knife. I like the heft of it in my hands, the rattle and clang of the clamps and knife in the metal pan. With a total colectomy, the weight of the specimen is such that the receptacle dips in the outstretched hands of the nurse. Now that's surgery! "What should I call it?" the circulator asks. (She wants to know what to write for the pathologist.) "How about 'Dave?' " I say, as usual... Squawk... "Dr. Schwab?" "Whaawttt?" (Said in the way of a fishwife -- I think they know it's a joke. On the other hand, it's not always Dee on the intercom...) "I have Carol from 6-A on the line." "OK, transfer her in..." ".... Dr. Schwab, this is Carol from 6-A. I'm calling about Mr. Jones. He has a temp of 102..." "Who's Mr. Jones?" "He's a patient of Dr. Smith." "....Have you called Dr. Smith?" "The answering service says you're on call." ".... (cleansing breath)...I am. But, uh, we take call on our own patients during the day... (Unsaid: as we have for the last fifteen frickin' years. Frickin' answering service drives me crazy.)" "OK, I'll call him." "Great! Let me know if you can't find him." (!!!)

Operation, Deconstructed. Six: sticky stuff

Let's make it easy on ourselves. I haven't yet established why -- other than liking the particular operation -- we're removing this nice person's colon. So since our patient has agreed to remain exposed and to do so for all to see, I declare s/he has diverticulitis. (I'm planning a post about that entity in the near future, so for now I'll ignore the details.) (Were it cancer, the operation would be largely the same, taking a bit more out.) Most likely there have been a few prior episodes of infection which resolved with antibiotics, but we've agreed the time has come to do a little preventative work. There's unlikely to be even the slightest adverse consequence of losing this portion of the colon; and it should ensure that the attacks will end. So let's backtrack a few steps. Because of the prior infections, it's likely that there are some adhesions with which to deal: that means that a few loops of small intestine are stuck to the sigmoid colon; and the colon might be plastered to the bladder or to the pelvic sidewall. So the reality is that, before that beautiful packing job I described, I needed to address those areas; unstick the bowel so I can pack it away, not to mention freeing the colon to work on it. Early in my training, I concluded that adhesions were the bane of the surgeon's existence. Dividing them can be arduous, time-consuming, even dangerous. Turns out I was sort of wrong: given that adhesions are pretty commonly encountered, either you learn to love (too strong. Accept. Find ways to enjoy.) them or you'll hate your job. There's pleasure to be gained from working through adhesions artfully and without creating havoc. In part, it's about timing. Which is about judgment. About which I've previously written. It's been at least six weeks -- ideally considerably longer -- since our patient's last attack of diverticulitis. Operating in the midst of such an attack means things will be densely stuck, and bloody. Dissection planes will be difficult, if not impossible, to delineate. Allowing time for the acute inflammatory process to subside, and for adhesions to mature makes all the difference. Given enough time, areas of adherence will become nearly bloodless; applying a little tension makes a little white fuzz appear between the stuck organs (the fine, avascular scar tissue that remains), and the dissection through it is quick and easy. But not always. Today, the small intestine is looped on itself and tightly stuck to the sigmoid colon, and the colon is thick and woody where the infection has occurred. "Shit. This'll take a while... Sucker." I'm asking for the suction device. There are several kinds; seems like most people use plastic disposable ones, but I like a particular metal one, because the outer sheath comes off, allowing use of a thinner (five millimeters?) straight tube for the purpose of blunt dissection. Cutting into a densely stuck area means you are making the plane, and you might be wrong. Bluntly probing it allows for the (possible) opening up of natural, if swollen and distorted, ones. Plus, suction keeps the field clean while you are working through it. Here, I'm only using it between the colon and the pelvic wall, because the only possible damage is to the part of the colon that'll be coming out. Where small and large bowel are stuck together, that sort of blunt dissection needs very sparing use.

"Aha!" The sucker finds a nice plane lateral to the sigmoid, into which I can now insert my finger which, although blunter than the tube, is sensitive to when I can force things and when I need to gentlify. Probing with my left middle finger I keep the sucker in the field with my right hand, still working it in such a way as to help open the plane. With the thumb on the outside, I give a series of pinches -- one of the greatest and best-of-all maneuvers in distorted tissues: it's nearly impossible to pinch your way through something that should have stayed intact."OK, it's free. Metz."

Cutting small bowel off the colon is a little trickier, in that on either side of the dissection is the inside of bowel. It's better, since it's coming out, to leave a little colon on the small bowel than small on the colon. When planes aren't obvious, that's often what you have to do. So I'm nibbling with the teeth of the scissors, and once in a while sweeping them, with jaws shut, across the plane in which I'm working, trying that blunt dissection when it seems safe. Grasping the loop of small bowel with my left hand, pulling it this way and that to expose a new view, I'm snipping carefully and slowly where the adherence is dense, and more quickly when I can produce that nice white fuzzy plane. (That's another dictum: when going is tough, find another direction.)

Inevitably, there's a little damage to the outer wall of one or the other of the two kinds of bowel stuck together. "Have a 4-0 vicryl G.I. ready." The small bowel finally comes loose, looking a little battered, but without obvious holes. I have the legs of the loop in my hand and give it a little squeeze (like folding a sausage-shaped balloon in your hand with the loop sticking up), making the dissected area bulge out. No leak. But I put a little stitch in it anyway. Lets me sleep. Grossly, the difference between chronically inflamed tissues and cancer isn't always obvious. Both are knobby-hard; each can stick itself to surrounding areas. Scar tissue can have the same sort of pallor that cancer often does. Hmm, I'm thinking. I'm certain this is diverticulitis, but this stuff is a little hard. "I'm gonna give you something for frozen. ("Frozen section" is a quick way for the pathologist to examine something immediately, while the operation is going on: they freeze it, slice it thin, stain it, and have a look.) Label it 'pelvic sidewall...' Fifteen blade on a long handle." The scrub scrambles to load the blade, since I usually don't use that size in this operation. (When Joanie was scrubbing, she'd have had it ready, just in case.)

I slice a thin bit of the hardened tissue I've left in the pelvis. Carefully. There are big veins down there. Holding the sample in a forcep, I lay it on a moistened non-stick pad the scrub holds out to me; then she drops it into a cup, to be sent to the pathology department. A little clock starts ticking inside my head: after twenty minutes or so, I'll ask how long it's been, how come we haven't heard from the lab, did they get the specimen, what the hell are they doing down there? The biopsy site bleeds a little, and I touch the area with the suction device I've been using. "Buzz me." My assistant touches the cautery to the metal of the tube and hits the switch. Another reason I like using that metal sucker. A little spark jumps from the tip of the tube to the bleeding area, and it chars in a puff of smoke, which disappears into the tube. Once in a great while, with that move you find out very painfully that somewhere along the line you've gotten a little hole in your glove. It's a shock and a burn and it hurts like hell. Sometimes it'll make your hand twitch, and it always leaves a pinhead-sized bit of charcoal on your finger that stays for a few days. "FUCK!!!" (Startled, my assistant jerks back and drops the cautery pencil.) "Yikes. Sorry... Guess I need a new right glove."

Like a flag of defeat, I wave my hand toward the circulator (the non-sterile person), pawing at the glove with my thumb to loosen it, making it easier: the circulator grabs the cuff of my glove and of the underlying sleeve and pulls, removing the glove and sliding the sleeve over my hand. Having received a fresh pair of gloves (the circulator opens the package, peels back the wrapper like leaves, simultaneously flipping it all forward while holding the outer package in the heels of her palms, and the inner glove-pack arcs onto the back table. Some do it with more force: a line-drive), the scrub proffers a new one, and I slide in, pull the sleeve back until it's cuff to cuff, and soldier on...

Operation, Deconstructed. Five: getting to the nitty-gritty

There's a reason for the cliche' -- surgeon barks out the name of an instrument, scrub nurse whacks it into the hand. The reason is this: when you are focused on a particular area -- especially if it's one in which danger lies -- you don't want to look away. If you need to change instruments you lay down the one you're using, open your hand toward the scrub while keeping your eyes on the object of your effort, and want that new tool placed quickly and firmly. So you know where it is without having to fumble. So you can feel it through your glove which, when your palm is open, makes a little trampoline between the bases of your thumb and pinkie. Mobilizing the sigmoid colon from its attachments along the left side of the pelvis is one of those areas. Behind the sigmoid colon passes the left ureter (the tube carrying urine from the kidney to the bladder); causing it harm while working on the colon is a major transgression. Unless the area is distorted by infection or tumor, avoiding the ureter usually isn't difficult.

I'm standing to the patient's right, turned slightly footward, affording me better access to the left side of the abdomen. With my left hand I grasp the mid-portion of the sigmoid colon and pull it gently but firmly toward me, exposing the lateral mesentery. "Long Metz," I say (it's more of a request than a bark), and feel a smart snap into my hand. I love it. Some scrubs seem a bit reluctant really to whack it in, but I don't know any surgeon who doesn't appreciate that crackle, the absence of which means fumbling around to figure where the business parts are. "Nice," I acknowledge with a masked smile. "Old school. I want you on all my cases." Worse is bringing the instrument into view ready to cut, and finding it's been handed backwards, with the curve of the blades opposite to the curve of my fingers. (Most surgical instruments are curved, making them an extension of the hand, conferring versatility. The default direction is that the tip continues the curve of one's hand. Sometimes I want it backwards; but only if I say so.)

It's as if the body was designed with surgeons in mind. Things come apart just where they ought. In some places, there's even a dotted line. Along the outer edge of the ascending and descending colon, where the peritoneum covering the abdominal wall joins that covering the bowel, truth be toldt, there's a white line (see, that's a little in-joke: it's called the white line of Toldt.) The pull I'm providing is such that when I incise along that line, the area underneath falls away, exposing one of those little secret spots the body keeps: airy like cotton candy, areolar tissues behind the sigmoid colon open easily (welcoming because I said the secret word announcing my worthiness) with nary a blood vessel to worry or obscure the view. "Stick sponge." I take a ring forceps with a sponge in its jaws and sweep it through the area I've opened, pushing down and away. What few vessels there are slide back. The ureter shows itself and, happy to be noticed, it does the wave: peristalsis isn't limited to bowel. "Metz." I continue the incision of the white line north and south: having cleared a portion of the space behind the colon, now I can easily see where I need to go. Leaving my ring finger in the handle of the scissor, I release my thumb and rotate the instrument 180 degrees, so the shaft is resting on my wrist and inside my forearm while I do a little finger work, further opening the space behind the colon. In a quick move, I spin the scissor back into my hand, cut a little more, use the closed blades as a dissecting tool. Flip it back to my wrist. All surgeons do that move: keeping an instrument in half a hand while doing something else, then regaining full use of it. Still, mundane as it is, that "third eye" part of my brain notices and likes that I can do it. It's part of that little voice that constantly reminds me, whispers in amazement, that I'm here doing this stuff.

I'm moving my left hand up or down the colon as I dissect with my right, providing my own counter-traction as my assistant holds the anterior abdominal wall up and away. My left index finger is working at the edge of the cut I'm making in the peritoneum, exploring and exposing. It all takes only a minute or two and the entire left side of the sigmoid colon is opened up, and I can elevate the bowel a couple of inches further than when I started. Now I can begin to decide where I'll be dividing it, having converted the S-shape into a C. It means the whole loop can be removed, and the ends will be very near each other; which is one of the reasons I like sigmoid resection. It just falls into place...

Operation, Deconstructed. Four: packing for the trip

Inside the belly, everything is slippery. The peritoneum is a glistening layer of self-moistening plastic wrap, enveloping the surfaces of all the organs, and the inner aspect of the abdominal wall. Undisturbed, the intestines coil and slither, reptilian. Watching waves of peristalsis makes me smile: there's something always entertaining about those moving contractions, following one upon another, gurgling, surprisingly tight bands of tension moving along the length of the bowel in a wonderful concert of muscle action. Like those gifted prestidigitators and their moving coins. Exposure -- providing excellent view of what you're doing at all times -- being a sine qua non of efficient and safe surgery, that slipperiness isn't necessarily your friend, amusing as it may be.

Having taken three posts to get to the peritoneum, it's now time to pass through it. In some people you can tell before opening it that things will be OK: the membrane is translucent and you can see through well enough to recognize that the omentum or bowels are sliding around underneath, unattached. Nice. So you make a little knick with a knife, taking care not to cut anything on the other side. Classically you and your assistant grab a bite of peritoneum with forceps, picking it up, allowing a cut away from underlying structure. When you can see, you can save that step. (Fast surgery is not really about fast hands: it's about an accumulation of countless little quanta of efficiency.)

Having made a hole, you might grasp on either side with clamps, elevating it, then zip a scissor downhill, never moving the jaws. Or pull it open further with two fingers. Or slide your finger under it and open it with cautery, your finger protecting the bowel, and the glove protecting your finger from getting cooked.

In the case of prior surgery, where you are re-entering a old incision, it's an entirely different animal: time slows down; you might have to try several different spots for entry, trying to find even a little area to which bowel is not attached. The smallest free zone can make all the difference. Finding none, dissection can be tedious, laborious, frustrating. But since this is an imaginary patient, the innards fall away as soon as we puncture the peritoneum; entry is a splashless dive. (Note to do-it-yourselfers: taking a moment, before cutting it, to sweep your finger across the peritoneum to separate it from under the muscle layer makes sewing it back up much easier.)

That slippery bowel wants to be everywhere. Like everything else for which there's not a perfect solution, many techniques exist to pack it and keep it out of the way. With a stem-to-sternum incision, as for some vascular operations, you can put it in a bag. Tethered to the back-side of the abdominal cavity, whence comes the blood supply, nearly the full length of the small intestine is free, frontward. You can slide your hands in from each side, heading under the bowel and down to the root of the mesentery; rock your hands backward, seemingly lifting all the guts right out of the belly.

You can't go quite that far, but you can expose the bottom side, allowing your assistant to lay the open mouth of a large plastic bag, not unlike one that might be in the waste-basket under your sink -- complete with a tie. Releasing the bowel gloppily and gurgily into the bag, feeling it slip-slide over your hands, is one of those surprising sensual experiences that surgeons get to have. Tie the tie snugly enough to keep the bowel in but not enough to choke it off, and enjoy the show as the bowels wiggle through the whole case.

But we haven't made that sort of incision. In fact, the smaller incision is an aid in the typical packing process: using laparotomy pads ("lap-pad," "lap-sponge" or "lap," as in "gimme a moist lap" -- the saying of which in another context ((particularly with "you" in front of it)) might deserve a slap in the face but herein is a request that the scrub hands you a moistened sponge for packing) folded in whatever way you were taught or in a way you finally figured out yourself and tucked here and there, you find the integrity of the uncut abdominal wall above the incision holds those pads in place. (Every once in a while, I need to write a sentence like that.)

Bowel has a way of squirting around the edges of packs, so taking a moment at the beginning to get them right saves a lot of pawing and repacking just when you don't want to have to. Another of those quanta of efficiency. So here's what I do: I reach into the pelvis with my left hand and grab a handful of small bowel while my assistant is holding onto the sigmoid colon -- our ultimate target -- and lifting it up. I may have to replace my right hand over the left, and then the left again over the right, until I have the guts up and out of the pelvis and exposed down to the root.

The scrub hands me a succession of lap-pads, moistened and folded in half. With my right hand, I slide a sponge over my left, which I then withdraw, leaving the end of the pad tucked under the bowel at the root of the mesentery; the body of the pad is over the bowel, and the top end is tucked under the abdominal wall, with the blue tag-string out of the wound. (That keeps you from losing it.) Working from the right side of the pelvis to the left, it usually takes three or four pads fully to cover and tuck the bowel and keep it out of the field.

A nicely-arrayed field of white has replaced the ruddy-brown bowel, leaving in view only the sigmoid colon, as if displayed on a table-cloth. Some surgeons use fully-unfolded pads: they usually don't have the turgidity to hold things steady; invariably, it seems, a loop of bowel finds its way into the field. One of my first partners used to roll pads into balls and stuff them all over the place. As I said: having lots of methods bespeaks imperfection of all. But mine worked pretty darn well.

Most surgeons use some sort of self-retaining retractor to hold the incision open; if so, it gets set up before the packs are placed. There are some pretty ingenious erector-set gadgets that can do the work of several hands. When possible, I like to omit such retractors because I think the steady pull at the wound edges makes for additional post-op pain. But more often than not, some form is necessary; for this incision, I like the old-fashioned, quick and easy Balfour retractor. Simple and nearly foolproof, it also makes a businesslike ratcheting sound when opened into place. Downside: I often manage to get my glove caught in the mechanism when I release it at the end.

If I can get away with having my assistant hold a simple retractor during parts of the procedure, I'm happy. Retractor or not, I put moist pads -- usually soaked in a mixture of saline and betadine -- over the wound edges, to keep them from drying out, and to protect from contamination. And it looks very tidy, which has value if for no other reason than my own enjoyment -- the apprehension of beauty has no prohibited venues.

Positioning matters. Working in the pelvic regions, tipping the patient head-down gets gravity on your side, helping to keep the bowel away. "Can you give us a little Trendelberg?" I ask of the anesthesiologist. (The term is "Trendelenberg," but I like to save time.) Of all the things to have named after you, it seems a body position is a weird choice, particularly when all we're talking about is taking a flat table and tipping it. Most used for a patient in shock, the Trendelenberg position is a mouthful in an emergency. "Drop the head, drop the head, dropthehead goddammit!!" is more to the point. On the other hand, I suppose to have some complex position named after you..... "Honey, feel up to a Schwab tonight?" But I digress.....

So we're ready to conduct the business for which we came: getting rid of the sigmoid colon. Sigmoid means "S-shaped." Our target organ is curled on itself and it's time to uncoil it. Doing so is among the more satisfying maneuvers of colon surgery; a little magic, a little danger, couple of tricks here and there and we should be able to unlatch it from its position along the left side of the pelvis and bring it right up into the incision where it should give itself up to us gladly....

[The intercom honks: "Dr. Schwab, I have the ER on the line. Can I transfer them in?" "Do I have a choice?" "Ha ha." "Sid? This is Pete. I've got a lady here with an acute abdomen. You're on backup, right?" "Must be, or you wouldn't be calling. What's the deal?" "Just letting you know. Sending her for a CT. I'll get back to you. She seems fairly stable for now." "Great. Thanks." Deep breath. Long sigh...]

Operation, Deconstructed. Three: parting the curtain

Traction and counter-traction: along with maintaining excellent exposure, that is one of the fundamental principles of operating. It's Newtonian: equal and opposite. In nearly all forms of surgical dissection, there's a need for some pull in the opposing direction: tissues that are a little stretched-out, that are under some tension, fall open more easily when dissected. Plus, it's a form of stabilization, another obligatory component of safe and precise work. One of the great pleasures of operating is having an assistant who understands, so that actions are coordinated and balanced. Constantly in motion, it's an ever-changing dance, as if we were tethered together by a silk cord, leaning slightly away, each move I initiate perfectly mirrored, keeping the cord perfectly taut, no matter where I choose to go. Ideally, it happens in a constant flow, with no words needed, part of the music of surgery well-done. In fact, when the orchestra is at full throat, my assistant knows where I'm headed and presents the field before I've finished moving. "Beautiful," I say in appreciation.

In making the initial incision, I provide my own counter-traction; left hand pulling backward as I draw the knife forward in my right. In a very long incision, I move my left hand to another point, thumb and fingers arching astride the fresh gap, simultaneously pulling backward and spreading outward: three-dimensional traction. In deepening the wound, my assistant and I pull across from each other, often against a moistened sponge I've placed on either side of the incision just before starting, left hands pulling in exact balance (else you might miss the midline); the knife is in my right hand, a forceps might be in hers. When there's an especially thick layer of fat, we put down our instruments, dig both hands over the edge of the wound, and pull hard against each other -- sometimes gruntingly hard. Magically, the fat parts like the Yellow Sea (or was it...?), right and exactly to that desirable middle stripe.

I wish I were more ambidextrous: in a pinch, I can cut or sew with my left, but I'm much better with my right. Still, there's a lot of subtle stuff to be done with the left, whether it's holding a forceps to grab something I'm cutting, or doing some fine noodling: moving the fingers as if on a keyboard, to expose and apply tension to an area that I'm working with the other. Imagine being tasked to find a pea hidden within a bowl of pasta, given a tweezer in one hand and using the other to explore. You'd move your fingers this way and that, stroking and spreading, using your medial or ulnar fingers (remember the anatomic position?) to hold stuff away as you work your way around with your thumb and index fingers. Wouldn't you? Can you imagine doing that in a fellow human-being? Let me assure you: it's stupefying! As is the recognition, while doing it, that I've acquired (and am allowed!) the touch, the ability to do it; to reach inside someone and with delicate motions of my fingers, to expose, to analyze by touch, to forge a way for my eyes to follow. Nor are these entirely unfamiliar acts: you've arranged flowers, sewn cloth, kneaded bread. You've twisted a screw, coiled a hose. You've bathed your baby, touched a lover. Your hands and your fingers are sensitive as mine, you've been guided by feel, you've closed your eyes and still known where you are; breathed in odors, heard intimate sounds of the body. The wonder is in the context.

The skin falls asunder from each side of my knife like red-robed palace guards, bowing and backing away, sweeping their arms in a curlicue of grace: "You may enter." [Joanie says, "I had a nice weekend, kids came over for a picnic........]

Operation, Deconstructed. Two: cutting in

The preliminaries are over. Sponges, needles, and instruments have been counted and checked, their number recorded on a whiteboard on the wall, as well as a clipboard. The checkoff is a comforting hum of words; the tuned machinery of the workplace. As the bottle of local is opened and poured into a sterile bowl on the back table, the expiration date is read aloud. "January, Two Thousand Ten." "We'll be done by then," I say, as usual. I look over the ether screen and ask the anesthesiologist, "OK to start?" "Dig in," he says.

Scalpel blades come in myriad sizes and shapes. #15 for a delicate cut, needing controlled curvature, like around the edge of an areola. With those little pokes for insertion of laparoscopy tools, it's #11. This being the real deal, I use a #10 blade, for its deep and long belly; a serious cutting device, but wieldy. There are bigger knives.

The act of incising human flesh is one of moment, never light, never routine no matter how familiar. Having thought about the exact location and length -- not always standard for a "standard" operation -- and having spoken to this person only minutes before; having made and accepted an awful commitment, asking for and taking trust; still, to take a knife in hand and with it to open a wound is a startling event. I never feel as focused, as intent, as responsible as when I make that first cut. I'm aware of transgressing, of forced entry, of crossing barriers, physical and ethereal.

It's like passing through an arbor draped with not entirely familiar vines, ominous and appealing simultaneously, not quite seeing to the other side until they're pushed away, with resistance. It's OK. I've been given the key, evidently I'm allowed here. But is such a thing possible? It remains a mystery. My breaths are shorter and harsher than normal; my pulse perhaps a few beats quicker; it never fails to excite me. Yet (almost) always my hands are steady. At this moment, there's nothing else. Later, as it goes, the air gets lighter.

How the knife is held is dictated by the task at hand: sometimes, in the finger-tips; others, like a pen, pinkie down on the patient as a steadying unipod. For a full-fledged incision, my last three fingers curl around the handle, thumb alongside the blade, index finger on top, right over the belly of the blade. As I make the cut, depth is controlled by that index finger, sensing the resistance and the ease with which the knife penetrates. Not everyone is the same: some skin is thick and leathery, some nearly translucent and feathery, like a summer roll. One has to adjust, on the fly, eyes bright and shiny, central also to the feedback loop.

I push hard, aiming to swipe through the skin and fat and to the muscle, even through it, in a single motion. A perfect incision, to me, is one that exposes the peritoneum with the first sweep. It's not always possible (only in the slender), or safe, and safety is paramount. But time spent doodling in an incision is time wasted and probably deleterious. (I've mentioned it elsewhere: few things surgical bug me as much as the tendency of many surgeons to incise partly through the dermis, to finish it off with electrocautery, and then to cook their way through the fat layer as well. It takes a ridiculous amount of time, fills the air with stinky smoke, and leaves behind a thin layer of dead tissue which, theoretically at least, interferes with healing. When everything else important has been studied, I'd guess a comparison of that skin technique with straight-through sharpness would show a cosmetic disadvantage as well.)

The best surgery is the most efficient: wasting the least amount of time, leaving behind the smallest possible areas of damaged tissues. The first cut sets the tone; it signifies where you stand. That brisk and controlled savagery is exactly what's called for; a promise fulfilled, senses keen. Cautery is one step removed; it's a barrier between you and your patient; shorthand, cheating. (As you'll see, I use it all the time, and extensively, when it's the most efficient option. For the initial incision, it's wrong logically, physiologically, economically, historically, metaphorically, artistically, poetically.)

I think if you watched an incision being made in super slow-motion, you'd see the skin indent under the knife and, as it is drawn forward, a wake of skin rise slightly in front of the keel of the blade. If there were sound, it would be a shishhhh; if it were music, it would be strings, not brass. Laying the scalpel nearly horizontal at the outset, as soon as the skin is penetrated the handle is elevated a wisp, bringing the blade's belly more fully frontward to the pull. The thickness of the skin is revealed as it falls slightly away. (In a belly bloated by ballooned bowel, the skin springs away from itself, as if to run from the explosion to follow.) Interesting, isn't it: seeing skin in cross-section? Bleeding -- especially in the midline -- is most often minimal, easily controlled with a little pressure, the placing of gauze along the edges. In some, time must be taken.

Classically, little clamps were placed, their noses snipped just to the open end of the bleeder, to be followed with a fine tie. Delicacy required: the purchase on the tiny amount of tissue was tenuous; tying the knot after the clamp was gone, if done too artlessly, saw the whole thing pull away and the bleeding resume. "Off!" the surgeon would say to the assistant, signaling the release of the clamp just as the index finger met the knot. Then holding each end and throwing more knots with such grace as to cause not a waver of the held tissue, increasing tension equally on each end as the knot is tightened -- too much in either direction and it pulls off -- laying down a couple of loops until secure. If you can do it, you might be a surgeon. (The time-honored practicum: tying a knot around a single match in a matchbox, never lifting it out nor bringing it to the edge.) But having proved it long ago to my satisfaction, I use cautery now, like everyone else. Still, there are a few right ways and lots of wrong ones.

If you fire off the cautery in a pool-let of skin-blood, the blood will eventually boil and blacken, and maybe the coagulum will plug the leak. Some will keep up that untidy turmoil for a disturbingly long time, to their own "goddammit"s, red continuing to seep around the edges of the black. Some move the tip around nearly randomly, waving it a little, like shaking a dick at the end of a piss. If that works, it probably didn't need it in the first place. Or they paw at the bleeder with a sponge, then zap, then paw some more. Whack, buzz; whack, buzz. If it's brisk, it doesn't work: by the time you take the gauze away there's enough blood to obscure the exact spot. But if you place a gauze and roll it away, you can hit the bleeder right as it appears. Or you have your assistant lift the edge of the skin with fine forceps, then grab the bleeder with a forceps of your own, and touch the cautery to the metal. A spot-weld. Precision.

The six-pack muscle, the rectus abdominus, is separated vertically in the midline by a fibrous band, the linea alba ("d" in the illustration). In the healthy, it's broad and thick, and the much-loved target of a vertical midline incision, because it's nearly bloodless, tough enough to hold a good stitch, and affords entry into the abdominal cavity without cutting muscle. By "broad," I mean a few millimeters. It's possible to miss it when cutting down to it; in fact, it seems I always did as a junior resident.

The first time I cut into it, I was attempting a paramedian incision (rarely done: ordered for the experience by my attending), aiming NOT to be at the midline. In time, I got the hang. The only incision that has a chance of being that "perfect" one, cutting down to (but not through!) the peritoneum in a single heraldic swath, is through the upper midline, in a person not much overweight. In the lower abdomen, the place chosen in our imaginary patient here, the white line (which is what "linea alba" means) becomes less distinct, a little more narrow, and pastier, because the rectus muscle loses its posterior fibrous covering. Cutting into the lower midline is gooier somehow: less sturdy. But do it we must.

And since we've digressed from the particular cut of our aim, let's also take a moment to get real: surgeons may or may not be crazy, but there is a form of schizophrenia at work. Those things I said up there? Totally true. The ever-present awe, the sense of responsibility and privilege and focus, the third-person look at myself in perpetual disbelief: all true, all the time.

And yet the mind allows room, simultaneously and up front, for the mundane. Along with the tonal beeps and the tubular hisses, as I pick up the knife and make the cut, there's this sound: "So Joanie, how was your weekend?" Omnipresent OR humor: usually crude, often -- when the audience is known -- sexual. Despite being taught to do otherwise, irrelevant conversation is the norm. Just so you know. And music. Personally, I'm neutral about it: I usually enjoy it, with an omnivorous taste. But I can live without it. And when things get gritty, I ask for the music to go off, and for an end to extraneous talking, for as long as it takes to smooth things up. Speaking of talking, I seem to have blabbed all the way through the incision. Let's get more detailed, and back on point...

Judging Judgment

I remember a party my folks had when I was in high school. A couple of their doctor friends were talking -- a general surgeon and an orthopedist -- and the subject was whether, given the choice, they'd like to have more brains or more brawn. At the time, their answers impressed me: surgery was such a physical enterprise, they both agreed, that they'd want more strength, more endurance. Back then, I think I thought "wow, what a tough job." Now, I think "wow, what bullshit!" What makes a good surgeon is judgment. A strong back? Useful, no doubt. Deft hands? Sure. But -- stereotype to the contrary -- surgery is a thinking person's sport, one where thoughts have immediate and profound consequences. In retrospect, maybe those guys were kidding or otherwise off-point. My dad made a mean gin and tonic.

Since I've been writing I've been thinking a lot about the concept of judgment -- surgical in particular, but also medical in general. From where does it derive? Can it be taught? Why do some doctors seem to have good judgment in greater quantities than others? Do bad experiences build judgment more than good ones? If so, do you have to be bad before you can be good? (I'm not real serious about that one, although it brings to mind a study I once read, showing that people who have surgery for colon cancer, and who have post-op infections from leaks ((and who survive!)) have a higher chance of cure than those who don't have such problems; the theory being that somehow infection activates immune response. It made me worry that by being a careful surgeon who didn't have bowel leaks I was doing my patients harm. Where do you go from there?)

Dino and I seem to have developed a friendly (I think it's friendly) tweak-fest on occasion. I imply family docs know a little about a lot, and he suggests surgeons sit around waiting to be handed a diagnosis on a silver-plated (it would be sterling, were it the other way around) platter, then operating thoughtlessly and collecting bigger bucks than deserved. (I'll admit one of his "rules" suggests he may believe otherwise.) Still, there's a perception out there -- not wholly undeserved nor free of self-propagation) that surgery is just about cutting, and then running. I've seen a few for whom that's a fair description. But I think they're very much the exception, at least in the worlds I've inhabited.

As I think about it, one interesting aspect of the process of acquiring judgment (it's always seemed to me that there should be an "e" between the "g" and the "m" in that word, and I really wish there were) is that having a bad experience can adversely affect the process. You know the saying, "once bitten, twice shy." You hear it a lot in operating rooms. During my training I saw a couple of patients who'd been transferred to us after undergoing surgery elsewhere for acute diverticulitis and who'd had horrendous complications. I concluded the decision-making involved in that disease -- when to operate and which operation to do -- must be among the most difficult and danger-laden there is. And, really, sometimes that's true. But in looking back, I think I can make out among the foggy forgotten a couple of times when I dragged my feet unnecessarily, and operations when I may have committed my patient to a temporary colostomy -- taking an unarguably safe route -- when I could have avoided it. Had I not seen those catastrophes during training, my perspective would have been different.

The fact is I never repeated the mistakes of those other surgeons. But did I react too strongly in the other direction? As time went on I came to re-think many of the attitudes I learned in residency -- sometimes because of data presented by others, sometimes after considering my own experience. Still, when it comes down to making a decision, for example looking at an inflamed section of colon and deciding what length to remove, gauging the safety of sewing the ends together instead of bringing them temporarily to the skin, one calls upon all sorts of tangible and intangible things that mysteriously coalesce into what we call judgment. It tended to work out well for me and my patients, yet I'm not sure I understand why. I'll have to write more about it before I do. If ever.

Guts. Glory.

I've said it before: I love sewing bowel. Nothing, it seems to me, represents what the general surgeon does more than that. It makes me feel connected to and a part of the chain of daring and innovative people who braved the terrain and blazed the path for us all, a century and a half ago; done right, it can be beautiful. Yes, guts: beautiful. Done wrong, it can kill.

Even unopened, intestine has a faintly unpleasant odor. Not repellant; certainly easy to ignore. In fact, the smell is like a musty greeting, of sorts: here we are now, in the belly, what's next? In a virgin abdomen, where they are free to slither and slide unbound by scars of previous surgery or from disease, grabbed by a hand gloved in latex, the bowels are slippery and smooth, and the sensation of holding them is like warm pudding flowing. When you need to push them out of the way, to expose a particular area, they stream around either side of your hand, slurpily wanting back in.

The classic method of sewing together two open ends of bowel demands everything of a surgeon: delicacy, accuracy, knowledge of anatomy; boldness, caution. Meticulous technique. To apprehend beauty where not all might see it, while admittedly dispensable, is to elevate the process to the level of art. Hidden, transitory, and unseen except by a few -- particularly not including the beneficiary; even unappreciated. But art, nonetheless. Like Andy Goldsworthy's.




And here's the thing: the newest crop of surgeons may never have the pleasure. Substituting staplers for sutures -- except when staples allow a hookup that's otherwise impossible or unnecessarily difficult -- is like handing Michaelangelo an eight-inch brush and asking him to whitewash your fence. Damn near criminal. But that's what they prefer, every time. In fact, they're barely taught the old way.

Any sort of stapled anastomosis uses at least a couple of machines, tossed away at the end, costing a couple hundred bucks a pop. If they save time (depends) and are easier to do, less exacting, they add cost, distort the anatomy (not functionally significant, but ugly) and deprive the operator of quite specific satisfaction. Whap, whap. K'chunk. Squeeze the stapler, leave the bowel not end-to-end but overlapping, like broken bones. Even kinked backwards on itself, like a frightened U-turn. How different from a hand-wrought creation! Properly sutured, as the ends are made lovingly to appose, the cut edges will roll inward, making a smooth juxtaposition held in place by perfectly spaced stitches. (That's no distortion of nature: like a perfectly laid-out vineyard, it's an honor to the land.) It's that rolling, precipitated by pulling just right on the suture as it's tied, that looks so beautiful, like two waves flowing into one, like something meant to be exactly as it is. Leaving it looking as if, in time, no one will be able to tell you were there. I've had GI docs say they can always tell my patients when they scope them in followup: they can't find the anastomosis. Surgery. As it used to be.

[Lest I be considered a Luddite, let me state for the record: I admire and use staplers. They've allowed me to avoid colostomy by hooking colon back up deep in the pelvis; they work great for certain esophageal anastomoses. Cleverly designed and steadily improving, they are fun to use, and I like doing so. It's just that in the situations where they offer no advantage, gimme the old fashioned way every time: I love everything about it.]

You Tube, I Tube, No Tube

We experimented on each other in medical school. Practiced drawing blood, poked arteries, even did rectal exams. In one memorable event, we were blindly divided into three groups to take either iodine, potassium, or placebo prior to doing various thyroid investigations. Rumor spread that in the previous year the pharmacy had mistakenly prepared ten times the proper dose of the iodine prep, causing inflamed salivary glands. In our year, one student claimed pain in his parotid gland, and the entire group of which he was a member stopped taking their pills, screwing up the whole experiment, as student after student fell ill with pain and nausea. No surprise: when the code was broken, it was the placebo group. I still wonder if that was the intended lesson.

In the laboratory, we were regaled with samples of stool from people suffering many malodorous maladies; and noted the look of pride on the face of the prof as he displayed the "normal" specimen. On another day, we were to study gastric juices as influenced by various chemicals. This required the passing of NG tubes (nasogastric tubes; stomach tubes), providing, in addition to interesting data, the first experience most of us had had with inserting or wearing such devices. It broke down along these lines: about one third were unable to accept the NG tube at all; another third were able to receive it but couldn't tolerate it long enough to produce the required results; and the final third had no problems with it at all. What's interesting about this is that in my practice, having inserted countless tubes myself, and having ordered them inserted countless more times, it was exceedingly rare (happened a couple of times, max) that in an actual patient it was impossible to pass a tube. I'd guess it reflects, in some mix of the factors, the difference between having a tube passed by someone who knows how to do it; and the impact of being sick, ie, acknowledging a need for having a tube.

I was in the second group. My student partner was unable to negotiate and I was unable to receive the tube without hopeless retching. Finally a lab doc crammed it into me. Over the next hour (it was supposed to remain for four), by some mystery of physics as yet inexplicable, the diameter of the tube grew -- I'll swear it's true -- to that of a garden hose. Before it split my face wide open, I yanked it out, to the consternation of the instructors, but to the everlasting gratitude of my self, my sinuses, my pharynx, and the top of my head. I learned what I needed to know about gastric physiology from a book or two. And I developed an abiding respect for the misery one of those tubes can cause.

Certain dicta were accepted without question in the misty times of my training. Among the most hallowed were those regarding the need for NG tubes in virtually any patient who underwent abdominal surgery. In stony decalogic, it was decreed that the tube went in during the operation and was removed, in the example of gallbladder surgery and most intestinal surgery, on postop day three. Regardless. Data were neither provided nor requested; it's just the way it was. It was not without rationale: manipulation (whether due to surgery or various illnesses) within the abdominal cavity is often followed by a period of reflexive shut-down of peristalsis, the muscular milking action that moves food through the gut. That reflexive shut-down is called ileus, and at its worst it can be quite serious, with backup of intestinal content into the stomach, leading to vomiting and/or aspiration. There's a certain logic to keeping the stomach deflated after surgery until ileus would have resolved. But there was also arbitrariness: three days for a gallbladder, dammit. Not two, not four. Three. And I dutifully ordered them for all of my patients. It wasn't until laparoscopy came around that people started looking askance. Instead of having large and painful incisions, requiring narcotics, limiting ambulation, these patients were up and around and raring to go. Tubes came out in a day or less, and what happened was nothing. Nothing bad. Something was different, people said, about laparoscopy: less trauma, less ileus. Soon, there were no tubes in those patients.

Meanwhile, I and others had been making gallbladder incisions smaller and smaller without scopes. I'd gotten it down to an inch or two, and saw people ready to rumble in hours, as with laparoscopy. No magical mystery of wind in the abdomen: maybe the tubes just weren't necessary. Eventually, after several generations of credulity, studies were actually done: do a given operation with and without NG tubes, see what happens. And it turns out not only that omitting them caused no problems: saving patients the misery of NG tubes actually speeds recovery. Those tubes, used on gazillions of patients for a hundred years were actually causing more harm than good. Being miserable, it turns out, is miserable. Having a tube sucking on stomachs actually invites ileus. Having been criticized in the remote past for removing tubes too soon out of sympathy for my patients, I found myself using them less and less. Strongly held beliefs (to wit: failure to use a tube when sewing bowel together meant ruptured suture lines) fell away like loosed chains. In the latter years of my practice, I stopped using them altogether in elective surgery: even gastric surgery patients awoke hose-less. About the only situation where they remained a part of my practice was bowel obstruction, in which the patients presented with vomiting and distended guts.

The list is long: keep patients in bed for several days after major abdominal surgery; no food until passing gas; nobody goes home till they have a bowel movement (that's a lot of thousand-dollar turds, don't you think?); jello for the first meal after an operation. We surgeons, while wanting the best for our patients, perseverated in untested interventions that made things worse, for no reason other than having been taught wrongly. It may be that the bed rest thing evolved from the days of crappy sutures: getting up and watching your guts spill out has a suppressive impact on recovery. Pneumonia and blood clots in the legs, highly related to immobility, were just part of the risk and were common. They've receded into rarity of late, in large measure because of mobilizing patients immediately: an incision well closed and numbed with local anesthetic means patients are up walking around within hours of the most major surgery. The single most important part of post op management, in my opinion.

It's a welcome trend: looking at things we do with a freshly-peeled eye; dredging up old axioms and considering them anew. "Best practice" is the buzz word du jour, denoting a worthy goal. I'm no historian, no great student of human nature. But I think it all began with those infernal NG tubes. Maybe enough docs, themselves made miserable by them, were willing -- anxious! -- to flush them into the mucoid medical morass; and the ripples washed away much more in the process.

Silence is Bronze

My chief of surgery during training, Dr Dunphy, had a few rules for the OR. Worried about little hairs falling in the wound, he told us never to get a haircut the day before doing surgery. 'Course, he'd never be caught dead wearing a nurse's bouffant net hat, which is what I wear nowadays, which is why I don't think it's a problem. Perhaps he only showered on Saturdays, being old school, but I doubt it. Anyway, it's a rule that I've not seen followed currently. (Parenthetically [which is why it's in parentheses], I've cut my own hair since I was in college, saving enough money to buy a car, I'm thinking. Maybe working in a mirror for all those years is why I caught on to laparoscopy so easily: depending on where the camera is, your moves look backwards.)

Likewise the silence thing. Dunphy eschewed any extraneous talk in the OR. The reason -- a good one, really -- was the unnecessary spewing of talk-droplets. Problem is, he broke the rule all the time. A garrulous Irishman who liked little better than telling a good joke, he couldn't resist it anywhere, anytime, followed invariably by the hearty laughing at his own proffering. No sycophants, we; our chiming in with laughter was genuine. He was a natural story-teller, and knew a good joke when he heard one. (As opposed to..... oh heck, I promised myself to stay away from politics for now.) And of course there were times in the teaching institution when lots of necessary operative talk ensued: explaining a difficult procedure, demonstrating or correcting technique. It could be quite extensive; and I was never convinced that saying words such as "retropertioneum" or "white line of Toldt" or "Jesus Christ, man, what are you doing!! Stop!! Let ME do it" conveyed fewer bugs than "what did you do this weekend" or "you can handle my instrument any time you want." (This would seem a good time to mention that loose talk in the OR is often loose, indeed; thick skin, sense of humor, and disinclination to see sexual harassment in the telling of lewd jokes are all useful traits for surgery personnel.)

Dr Dunphy also thought music in the OR was a distraction, and unprofessional. Given that the breaking of that rule required active and directed effort and, in the days before iPods, the lugging around of equipment, it didn't happen. Since professors' preferences (to describe them softly) were generally inculcated with (quoting my book, now) a blowtorch, or in ways that could induce self-soilage, there were many beliefs and behaviors that I took away from training that were hard to revise, even when there was ample evidence that they could or should be tossed out. I'll save the more interesting and amazing examples for another post: today we're just talking about the sounds of surgery. OK, I'm gonna go on a slight tangent here, at the risk of negating the kind words #1 dino said about me: I do have a favorite OR sound, and it has nothing to do with the thrust of this post. It comes from an ingenious device called an LDS stapler (no relation). When you pull the trigger on the device, which is gas-powered, it makes a k'chzzz sound that is deeply satisfying. (On the other side of the surgical sound spectrum is the descending tone of the oxygen monitor, as a patient's O2 level drops. Bad sound.)

Back on point: for a while after I entered the private practice of the surgical science, my operations were conducted in relative silence. I'm not sure what changed. For one thing, my partner -- with whom I operated nearly always -- talked up a storm and it didn't seem to cause infections. In training, where there were usually at least two more people scrubbed in than needed (some of whom -- no offense to my med student readers, whom I revere and admire and of whose enthusiasm I'm envious and nostalgic -- probably contaminated themselves five times in the process), and operations took twice as long as they do in real life (now I'm REALLY losing the dino), wound infections were as commonplace as moss in the Pacific Northwest. In practice, they are astoundingly rare. So what the heck: yak away. And I've come really to like music in the OR as well. In fact, studies have been done that have confirmed benefit in terms of reducing tension.

Used to be that the anesthesiologist was the designated disc jockey. They can put away the journals or business magazines they read long enough to spin some tunes, and they do. Some bring their own music, playing in the way of their choosing come hell or high water (sometimes water of the red kind.) Others are willing simply to be the mechanic, playing what's requested. Some surgeons insist on their own genre, giving no thought to the idea that others may not like it. Others -- and I put myself in this camp -- are pretty omnivorous musically and are happy to let others choose. I'd often ask patients if there was a type of music they'd like to have played: while awake, the reasons are obvious. And I'm not beyond thinking that at a subconscious level it might have benefits while asleep. If I may humbly say it, my iPod playlists have become objects of desire of many of the nurses (the only part of my gestalt of which such a thing can be said), and when for whatever reason I haven't brought it, disappointment prevails. I tend to favor a mix of new and old rock 'n roll, or blues, or jazz. Jazz, it turns out, is less generally favored, in my experience, so I'm selective. Can't explain it; but I go with it. Many ORs now have computers online, so streaming audio is supplanting the iPod. Might be just as well: I've left my iPod in the OR a couple of times.

Many surgeons seem to like the music no matter what. For me, there are still times that call for silence. Maybe it reflects poor powers of concentration; but if things get dicey, when I find myself working in a critical area where anatomy is distorted, where things threaten to go south at any moment, I ask everyone to stop talking, want the music shut down, and I go into a world of my own: focused, eyes boring in, tunneling into the job at hand with complete purpose of mind. No distractions, no fun. It still works for me.