Sunday, March 5, 2017
It started about three and a half years ago: an episode of pain in my abdomen. Not terrible pain, but a gnawing pain in my upper abdomen, coupled with a queasy feeling.
Probably just my GERD acting up.
I took my Prilosec and an antacid and went on my way. The pain, however, stayed with me.
And the next day.
And the next.
This is annoying. It must be more than reflux. Maybe it’s my gallbladder?
One would think that I would have thought of gallbladder disease first. I see patients with gallstones, dysfunctional gallbladders, biliary dyskinesia and every other manifestation of biliary tract disease almost every day.
“Do you think you can do a quick sono on my gallbladder?” I asked Dr. L., a Radiologist friend. “I’ve been having epigastric pain for four days and I think it might be my gallbladder. That is, if you’re not too busy and the ultrasound is available.”
“Sure,” he answered.
“No doubt about it,” he remarked a few minutes later. “Those are gallstones. You should get an official ultrasound if you are going to have anything done.”
“Agreed,” I answered as I went on my way, still with pain, but at least with the knowledge of what was causing the problem.
The next day the pain was gone. I thought about having surgery at that time, but the pain stayed away and I didn’t think about it again until about five months ago.
Pain came back, but different than before.
It’s just my reflux. I’ll go back on my Prilosec.
The pain was a little sharper than previous, but only lasted about twenty minutes, at first.
The days went by and the pain lasted longer, still not terribly severe. It was always in my epigastrium, now lasted about an hour, almost always in the morning. And, it got better if I ate, particularly a large meal.
Definitely atypical for gallbladder.
Pain from gallstones typically is worse after eating, often occurs at night. Pain the morning, relieved by food was more consistent with peptic ulcer disease. Except, I’d had an Upper GI endoscopy only about a month before which did not reveal any ulcer.
Still, it was just an annoyance. And, I did have gallstones.
There was a change for the worse about two months ago. The pain I had was sharper, just to the right of the midline in the epigastrium and it persisted for about three hours. Then, it moved to my back for an hour before vanishing completely.
RUQ abdominal pain, lasting for hours, radiating to the back? No question. This is my gallbladder.
Still, I considered it an annoyance rather than something dire, something mandating immediate intervention. I occasionally took two Tylenol which helped, but otherwise went about my daily buisiness.
Pain, however, can wear you down. Particularly when it occurs every day and lasts for hours.
A daily cycle began.
I awoke each morning feeling well. After about an hour the pain would start in my upper abdomen, always in the middle. It would intensify for about an hour. By the time lunch rolled around it would start to diminish and disappeared by early evening.
You need to be a good patient.
I scheduled myself for an ultrasound of my gallbladder which confirmed a gallbladder packed full of stones. Then I went to see my partner, gave him the whole story and scheduled my surgery.
I guess there’s no way I can operate on myself? I’ll just have to trust my partner.
We scheduled the surgery for a Friday about ten days hence. The abdominal pain continued its daily pattern unabated. Some days the pain was sharper and lasted for 4-5 hours. It eventually moved to my back and then dissipated. Unlike so many of my patients who say the pain occurs at night, mine almost always started in the morning and disappeared completely by dinner time.
Three days before surgery the pain was less, merely a mild gnawing ache which only lasted a couple of hours. Two days before surgery I only felt a slight queasiness without real pain.
Maybe I don’t really need this surgery.
But, the day before surgery the real pain returned.
I guess it’s time.
The morning of surgery I did my usual thing: got up a little after five, fed the bird, fed the dogs, fed everybody but myself.
My wife and I parked the car at six twenty five and went into Bayshore Hospital’s Day Surgery.
“This way Dr. Gelber, we’ve got the VIP suite ready,” one of the nurses chimed.
“Room fifteen?” I answered. “Nothing very VIP about it.”
Back in the old Day surgery unit there was Room Twenty Two. It was larger and had its own bathroom. Now the only difference between room fifteen and the other rooms is that is separated from the other rooms by a hallway. I suppose it does afford a little more privacy.
I donned my hospital gown and my red, no skid socks and lay down on the stretcher to wait.
It wasn’t very long.
Two pre op nurses descended. One asked the usual questions: medical history, allergies, previous surgery, was I wanted by the FBI; you know, routine. The other started my IV. I pointed out my prominent “intern vein” which is at my right wrist and she started the IV like the pro she was.
There was another short wait until the anesthesiologist made an appearance. Unlike some other VIP’s I did not choose any particular anesthesiologist.
They all strike me as having equivalent levels of skill and I trust my patients with all of them.
Dr. M arrived and had me sign his consent. He didn’t give me a lot of explanation, rightly assuming that I was well versed in the anesthesia routine.
Dinah and JR, who would be circulating and scrubbing the case stopped in to say hello, asked if I had any questions or concerns and then left to make sure the room was ready.
Finally, the star of this endeavor, the surgeon, Dr. L., arrived, ten minutes early, a record for him. He smiled, introduced himself to Laura and said the surgery would take about an hour.
Finally time to start.
Dr. M made another appearance. He plugged an infusion of morphine into my IV, watched as the steady drip…drip…drip began and left.
Dinah reappeared and we were off. I remember being wheeled down the hall and the doors to the OR room, #8, I believe, opening and that was it.
I can only imagine being asked to move from stretcher to table. I don’t remember any of it. I suspect Dr. M said I might feel a little sting as the Propofol was injected, but I don’t know for sure. There certainly was a time out, maybe a joke or two at my expense and the ensuing surgery.
The next thing I do remember is being asked to breathe in the Recovery room. Laura was sitting at the bedside. The PACU nurse asked if I was having any pain.
A little, certainly not excruciating.
“Some,” I answered.
A half milligram of Dilaudid was pushed through the IV.
The little pain I had went away. Once again I forgot to breathe, so that every so often I would hear “take a deep breath.”
As a matter of fact the accumulated Morphine and Dilaudid worked very well.
I couldn’t stand up, couldn’t pee, couldn’t do much of anything for about four hours.
Finally, the narcotic effects started to wear off. With help, I made it to the bathroom, emptied my bladder and was deemed fit to go home, about six hours after the surgery had finished.
Of course, I still felt the effects of anesthesia and narcotics. I drank a little water and went to bed. Winston, one our dogs, a Miniature Schnauzer/Pomeranian mix made it his personal responsibility to oversee my recovery. He jumped on the bed, sniffed me all over, made sure I was breathing then lay down beside me.
No doubt he’s concerned about me, rather he’s concerned that if anything happens to me he won’t get fed.
After a couple of hours I took my first pain pill, an Ultracet which is relatively mild. After seeing how I reacted to Morphine and Dilaudid Dr. L rightly decided that 7.5 mg of hydrocodone might be too much for my delicate system and added the prescription for Ultracet.
The entire recovery was uneventful. I was able to eat without any problem. I took only two Ultracets. And I was back to work on Monday.
I looked at the photos from the surgery. The gallbladder didn’t look inflamed, my liver looked normal.
“You had a lot of little stones,” Dr. L. reported.
Makes sense, goes along with the pain I was having. Probably passed a little stone every day.
All in all it was, as best as I can tell, a boring operation. Perfectly mundane and boring. Which is the way surgery should be.
This cholecystectomy was my third experience with general anesthesia. First was a fractured fibula which required a closed reduction in seventh grade. Then shoulder surgery after my second year of medical school.
Undergoing surgery, besides the benefit of eliminating the annoying gallbladder pain, should help me empathize with my patients. I now can say to my patients that I know what you are experiencing, even if I never had to take anything stronger than Tylenol for my gallbladder pain. Same story after this surgery, except for two Ultracet.
And, it does underscore the truth that every patient, every illness is unique. We are all individuals and deserve to have our health care tailored to our personal needs. This fact is not evidence based and doesn’t fit into any standard protocol.
It does, however, lead to happy patients and good care.
Sunday, January 29, 2017
It’s that time of year again. The national day of beer, pizza, occasionally clever commercials and one over hyped game. The Super bowl is upon us again.
Super Bowl LI.
When I first read about it I wondered who or what LI was. I did know that the game will be played in Houston, which meant that LI did not stand for Long Island. Maybe LI was a new fashion designer about to make a bold statement with the Super Bowl as his or her backdrop. But, it finally dawned on me that the annual event was always couched in Roman numerals and LI stood for “51.”
Super Bowl LI: New England Patriots vs Atlanta Falcons.
On the surface it shouldn’t even be a close game. Tom Brady, Bill Belichik with all their Super Bowl experience against a team who don’t have one player I’ve ever heard of. The current line is Patriots minus 3 points. A no brainer, at first glance.
But, such an important event deserves far closer scrutiny and analysis. I will start with the Patriots.
What are Patriots, particularly those from New England?
A rag tag band of colonists trying to separate themselves from their mother country. Typically they are armed with muskets; firearms which fire large caliber “balls” with all the accuracy of Shaquille O’Neal shooting free throws. It is true that such muskets can inflict great damage should they hit their mark, a relatively rare event.
And, battling these Patriots? Falcons. Sleek birds with sharp claws and beaks, perfectly designed for hunting and killing mice, rats and other small animals. The Falcon is the fastest of all birds, able to soar at speeds of close to seventy miles per hour and dive at speeds over two hundred miles per hour.
Is this a fair matchup?
A motley crew of colonials armed with inaccurate firearms vs. a deadly, high speed hunter with claws and beaks which could peck out eyes while their hapless prey are trying to reload their worthless muskets.
Surely, dear reader, you have heard of Alfred Hitchcock’s “The Birds.”
There is no question about this year’s ritual game. The Patriots will be caught flat footed by the lightning Falcon attacks and all that will remain will be the bloodied bodies and tattered uniforms of New England’s storied team.
Falcons 27 Patriots 17
Saturday, December 3, 2016
Memo to the Medical Staff
From the CEO,
A discussion at the recent meeting of the Hospital Employee Safety and Serenity (HESS) Committee brought to light work conditions which have caused some of our employees to experience feelings of uneasiness and agitation in the hospital work environment.
Specifically, the term “Physician’s Orders” inherently creates an intimidating work atmosphere. The idea that one individual may order another individual to perform any task, even a necessary one, strikes the HESS Committee as potentially threatening and harkens back to days of master and slave; of one individual lording over another for personal gain, thus introducing charges of racism, misogyny and xenophobia into our workplace.
Several members of the nursing staff have expressed feelings of fear, anxiety and apprehension when having to carry out “orders.”
To remedy this situation and fend off possible litigation, the term “Physician’s Orders” will be modified to reflect these more enlightened and progressive times.
Several alternative phrases were proposed, including Physician’s Directions, Physician’s Mandates, Physician’s Instructions, Physician’s Advice, Physician’s Commands (immediately rejected) and Physician’s Guidelines. After much discussion and debate, however, the HESS Committee has reached a consensus. The new terminology will be “Physician’s Suggestions.”
The Committee feels, very strongly, that this phraseology will promote the greatest sense of collegiality, warmth and acceptance in the hospital workplace.
I hope this change will not cause any undue stress and the that the medical staff will agree to this adjustment and see things in the proper light of twenty first century reality.
Saturday, October 29, 2016
About four years ago Miss Daisy wandered or was abandoned into our life. It was a typical Sunday. I was at the hospital making patient rounds when a call from my wife.
“I found two dogs in the circle,” she reported. “I’m texting you their picture.”
“OK,” I answered, “I’m still making rounds, but should be done home in an about an hour.”
“I think someone dropped them off in the neighborhood,” she concluded. “One is a Basset Hound.”
The picture arrived. There was a rather frazzled looking tan and white lady, fairly tall and thin. And there was her companion, a mostly black, fine looking Basset Hound. The phone rang again.
“I put the dogs in the driveway and gave them some food,” Laura reported. “Of course, no collars or tags.”
“Maybe they’re microchipped?” I wondered, full well knowing that the odds finding their true owners was around a thousand to one.
Needless to say, the owners remained a mystery and Freckles, a Weimariner mix, and Daisy, the Basset Hound were adopted into our family, joining our other four dogs.
Daisy, or Daisy Mae, as I call her, paying homage to Lil’ Abner, had glaucoma and was already blind in her left eye. Freckles had very early heartworms which were successfully eradicated with antibiotics.
Daisy Mae started on a regimen of eye drops, the blue bottle twice a day, the beige one three times and the pink and green ones once at night.
But, this article isn’t about the life story of Daisy Mae and Freckles. No, it’s about walking poor Daisy. I wonder if poor is the proper term? Daisy Mae has since gone on to lose the vision in the right eye which required surgical enucleation, that is, it was removed.
Now she is Daisy Mae, the blind Basset hound.
“Poor Daisy,” one might say.
But is she poor?
If you are familiar with the Basset Hound,
(see “Man’s Best Friend, The Noble Basset Hound http://heardintheor.blogspot.com/2010_04_01_archive.html)
then you know that this breed of dog lives its life on its own terms. They are not mean or unruly, just independent and stubborn. Their keen sense of smell is second only to the Bloodhound among dogs, following their nose to the finest discarded garbage in the neighborhood. They instinctively find the most comfortable spot in the house to sleep, happily usurping your favorite overstuffed chair.
Should you feel the urge to relax in this chair they will give you a look of shock that you would even consider taking their spot. That is if you are able to wake them.
Now consider Miss Daisy Mae. All she has is her amazing nose.
The chore, or is it joy, of walking her often falls on me.
Call her name and she rises from her bed, sensing that it is either time for treats or a walk. She trots through the kitchen, deftly avoiding cabinets, garbage cans, chairs and other dogs, barking in her deep, loud Basset voice until she is hooked to the leash and heads to the door. Sometimes in her excitement she bumps into a couch or table leg, but she manages, always leading me to the door. Somehow her nose can smell the step off the front stoop as she jumps down and is on her way.
First order of business is emptying her bladder. With nose millimeters from the ground and ears flapping she finds the perfect spot, squats and nature’s call is answered. Now she is free to follow her nose. Literally.
And what a nose. Sniffing subtle aromas may be almost as good as, or even better, than sights. Daisy Mae walks along, gingerly sniffing, always along the edge of the sidewalk close to the grass. Her nose can “see” where the sidewalk ends as she only veers off to pursue a new and, I assume, wonderful, interesting, enticing scent. Once an odor is discovered she will stop and sniff and snuffle until she’s had her fill of whatever she has unearthed. Then, she will raise her head, give a snort, cleansing her nostrils of the scent and go on her way.
Methodical, slow and steady, and relentless she goes her way, oblivious to me, her leash and any other impediments. And, if her chosen path varies from mine we are left with a classic battle of wills. Me, pulling the leash, against Daisy’s 65 low slung, dense pounds.
“There’s an interesting scent this way,” her face says. “I’m not budging until I investigate.
Most of the time she wins.
Then there are those moments of joy, for Daisy, at least. She will come across a trail that excites her. A howl escapes from her throat, followed by three loud barks and another howl. She forgets her blindness, she forgets me, she forgets everything but this unseen, odiferous trail. Off she goes at a fast trot, nose to the ground, determined and resolute as she tracks down a particularly pungent, perhaps dangerous and nefarious quarry. The chase lasts for thirty or even sixty seconds until she stops and raises her head pretending to look into the distance before she turns back to me and we begin the trek home.
But, in that moment she could “see.”
Sunday, August 7, 2016
It was a bit exhilarating. By all accounts it should have been a mundane simple case. Tom was the patient. He had suffered with tuberculosis thirty years ago, but was pronounced cured after his treatment. Now he had a new problem, or was it a new manifestation of his old Tb?
He came to me with a mass in his neck, not really painful or tender, but draining through the skin for about a month. He was a smoker and drank a bit, but otherwise was healthy. His passion was fixing cars, a job which he began every morning at about 4:30.
The mass was a nuisance to him and his coworkers.
“Can you do it soon? Maybe tomorrow?” Tom asked.
He came with the report of a CT Scan of the neck which revealed the large mass with a low density center. Pulmonary doctor was hoping it was tuberculosis and not cancer.
The mass was three centimeters. It was inferior to the angle of the jaw, which suggested it was not from the parotid gland, and there was a sinus tract opening draining some cloudy, particulate fluid. There was no erythema and it was not tender.
What’s best? This looks more like cancer than Tb, a large node with necrotic tumor. Maybe a needle biopsy first? Still, it has ruptured through the skin which makes it unlikely to heal. It needs to be removed. Maybe I can do it this week. The schedule isn’t terribly busy.
“OK, Tom. Surgery in two days,” I answered.
I went on to explain the procedure in detail, did the necessary paperwork and sent him on his way.
The night before Tom’s operation I considered what his surgery might entail as I perused my schedule for the following day.
Inguinal hernia, venous access port, gallbladder, another inguinal hernia and Tom.
Everything straightforward and uncomplicated. What about Tom? Just a neck mass. But what if it’s more than that? Just do what you have to do.
I went to sleep.
The next morning I breezed through Mike’s inguinal hernia, Mary’s VAP, Lupe’s gallbladder and Oscar’s hernia.
Tom smiled at me as I greeted him in the pre-op area.
“Do a good job, doc. I’ve got a souped up Mustang waiting for me,” he conveyed.
“Don’t worry. We’ll take good care of you,” I gave my standard answer, the perfect words for a patient awaiting an operation, understated enough to provide a sense of calm and confidence, to the point, yet clearly stating that we will take care of everything.
Tom went to sleep and the dressing on his neck was removed, revealing the mass which was bulging against the skin. He was prepped and draped and the surgery began.
I started with an elliptical excision intended to remove the skin overlying the mass with the draining sinus. Skin flaps were raised lifting the skin and platysma off the underlying mass and the tissue surrounding it.
Find the sternomastoid muscle.
This muscle, the sternocleidomastoid is always a safe landmark when working around the neck. Important structures like the jugular vein and carotid artery run beneath it, other structures, like the parotid gland usually come down to it, but are easily separated. So the first task was accomplished quickly. The anterior border of this muscle a couple of centimeters away from the mass was exposed.
All the tissue superficial to this muscle was dissected away, the plan being to remove this normal tissue with the mass to ensure complete removal if it turned out to be cancer.
But things began to get complicated.
This mass is growing into the muscle. Where’s the jugular vein?
I identified this vein, once again, inferior to the point where the mass began, I began dissecting along the vein, isolating and ligating some side branches.
Uh-oh. This is not going to be simple.
The mass was abutting the vein.
It’s probably stuck.
Indeed, it was. As I pushed and teased the fat away from the vein, all of a sudden I was inundated with dark blood.
“5-0 Prolene, por favor,” I asked.
There was a hole in the jugular vein, but it wasn’t bleeding as much as I would expect. The blood was only coming from the thoracic side of the vein, none from the intracranial portion.
The tumor must be growing into and occluding the vein above where I’m working.
The hole was quickly repaired.
Time to reassess the situation.
It was clear that this was going to be a malignant process, but at this point I sent a piece of the mass to the pathologist to be sure.
“Squamous Cell Carcinoma,” she reported.
The mass was sitting squarely between the sternomastoid muscle and the jugular vein. It was now clear that it was going to take a neck dissection of some sort to remove it. The muscle and the vein would have to go.
I went to work above the mass.
“What’s that structure?” I pimped my assistant.
“It’s the tendon of the digastric muscle. And this nerve?”
“The hypoglossal. And that artery is the carotid.”
I don’t get to see these structures very often, although they are landmarks a surgeon always looks for in the course of any neck dissection. The digastric muscle is another safe place to dissect. I also spied the inferior edge of the parotid gland, the jugular vein above the tumor and the spinal accessory nerve and trapezius muscle soon came into view.
It was time to commit. I dissected and encircled the jugular vein inferior to the mass, ligated and divided it. I divided the sternocleidomastoid muscle with cautery.
These two structures were dissected off the underlying tissue together, once again removing the fatty lymphatic tissue with the specimen. The carotid artery and vagus nerve were preserve as they were not involved with the tumor. I reached the digastric muscle and dissected from the central tendon posteriorly, lifting the jugular vein off the muscle, followed by the sternomastoid muscle and the tumor.
A branch of the spinal accessory nerve, the one going into the sternocleidomastoid was divided while the main trunk of this nerve was preserved. Finally I was left with muscle and vein above the tumor. The vein was transected and sutured closed and the muscle was divided and the specimen was free, passed into the hands of the tech.
I took a moment to admire my handiwork. It looked like a page from Netter.
There were two ligated ends of the jugular vein. The carotid artery from the inferior neck to above the bifurcation was clearly seen as was the hypoglassal nerve crossing it. The vagus nerve ran alongside the carotid, perfectly intact. The lower end of the parotid gland stood out as did the digastric muscle. The most anterior portion of the trapezius muscle was also clearly exposed with its spinal accessory nerve. All in all it was a very neat and clean modified neck dissection.
A surgical Rembrandt? Or Picasso?
Tom’s case was a demonstration in how surgery can be so appealing to the inquisitive young mind. Tom’s was not a perfect operation and he was almost certainly not cured, but this operation demonstrated the joy of surgery.
Joy of Cooking? Of course. Joy of Sex? Certainly.
But, the Joy of Surgery?
What is this joy that can come from cooking? Or sex? Or surgery? What is joy?
It is defined as the emotion evoked by well-being, success, or good fortune or by the prospect of possessing what one desires.
Such joy is the certainty that if you follow all the proper steps, do things in a certain way you will be rewarded with a contented or blissful or exhilarating outcome. It could be a delightful meal, or a wonderful sexual encounter, or a surgery which has a perfectly successful outcome for the patient and surgeon.
This does not mean that one needs to smoke a cigarette after the operation. But, an operation which provides complete relief for a sick patient while providing a gratifying challenge, sans frustration, worry or doubt would be considered joyful. Tom’s was such a case.
I think the closest thing would be collecting the fruits of a large wager on a perfectly handicapped horse race combined with the feeling one gets when looking at a beautiful painting.
Dissecting out all those named structures, knowing that it’s safe to cut along this muscle, that an important nerve is lurking nearby or that the jugular vein may be removed or that the external carotid may be ligated, but not the internal, or that this gland is the parotid, but if the dissection is more anterior then the submaxillary (or is it submandibular?) gland will be encountered are some of the important little facts surgeons must learn if any time is spent lurking around the neck. Every operation is filled with such little facts. Be aware of the common bile duct, or recurrent laryngeal nerve, or ureter or this artery or that.
All those little things start with basic anatomy, initially taught in the first year of medical school. But, beyond Anatomy 101, and far more important, are the knowledge and wisdom to properly assess a situation and make the appropriate decisions. What operation to do, when to do it, when to alter the plan to accommodate unforeseen pathology are skills which are difficult to teach. Book knowledge certainly helps, but there is no substitute for gray hair.
Saturday, May 28, 2016
It looked like it was going to be a good day. I wasn’t on call, I would be off the weekend and all I had scheduled for the day was four elective cases, all laparoscopic cholecystectomies.
How could the day be any better?
The surgeon’s prayer popped into my head:
“Lord, please protect me from the interesting cases and don’t let me screw up today.”
Cholecystectomy is the most common operation that is performed in the United States. Gallbladder disease occurs as a consequence of diet, hormonal changes, genetics and physiologic changes involving the rest of the body. It seems that everything affects the gallbladder. Gaining weight, losing weight, pregnancy, illness, stress and probably a whole bunch of other things cause the gallbladder to form stones, stop functioning or become inflamed. Whenever the gallbladder starts to behave badly one can rest assured that a friendly general surgeon is nearby to address the problem.
It was six thirty in the morning, the dogs were fed and I was scheduled to start in an hour.
Maybe I can get rounds done before I surgery.
It was a rare day. I only had patients at one hospital, the same venue where the cases were scheduled. I arrived at six fifty five and greeted my first patient in Day surgery.
Maria was forty, about five foot one and weighed in at two hundred sixty pounds. She had multiple gallstones and had suffered through repeated episodes of right upper quadrant abdominal pain. She had gone to the ER once, but otherwise had endured multiple nights of suffering.
“I just get up and walk around or sit in the chair until the pain goes away, usually after a couple of hours. I take some Motrin, which helps a little.”
Textbook case. All Four F’s: Female, Fertile, Forty and ‘Rotund’.
I went to the hospital computer and checked on each of my in house patients, their vital signs, lab results and such. I only had five patients to see. Everyone looked good in the computer.
I guess I need to see each one in person.
I ran up to the third floor, the post surgical unit. I saw Bill and Irma and Lucille, each post op from laparotomies and each was doing well. Notes and orders were written (the good old days, before computerized everything) and then I ran down to the OR to start Maria’s surgery.
She was just going to sleep when I walked into OR five. I went out to wash my hands while she was being prepped.
“Draperies please,” I asked.
The tech handed me a towel and I began to drape Maria.
All the proper tools were passed off and connected and surgery commenced.
I infiltrated some long acting local anesthetic in Maria’s belly button area, made a small incision, elevated her abdominal wall and tried to pass the Veress needle. This needle is what I commonly use to insufflate the abdomen, that is blow it up with carbon dioxide gas. Only the needle wouldn’t pass. I put it in up the hilt, but no go.
She doesn’t look to be that large. But, women tend to have their adipose tissue in the abdominal wall, I guess Maria has a bit more than I thought.
“I need a longer Veress needle.”
In about a minute the circulator returned with the 150 cm needle which I was able to pass into the abdomen without difficulty.
I hope that’s the only glitch for the day.
And Maria’s case went off without a hitch. Inside her abdomen there wasn’t much fat. Each structure stood out. The gallbladder was hanging off the liver, the common bile duct was easily seen, and the cystic artery nearly jumped out at me. It was spread, spread, clip, clip, clip, cut, clip, clip, clip, clip, cut, then snip, snip, snip, snoop and in five minutes the gallbladder was in a pouch, pulled out through the epigastric wound and on the back table. Ten minutes later the final band aids were laid over the last of Maria’s wounds as she began to wake up. Thirty five minutes after she had gone to sleep she was in the Recovery Room.
I should have time to see my other two hospital patients.
I saw Joe and Juana on the fourth floor. Neither had a problem which would require surgery. I stopped to say “hello, how are you, you should be going home soon and then went back to the OR to operate on Michael.
Michael had been having pain for years, always in the upper abdomen, radiating to his back, occurring almost every day. He had gone through endoscopies, CT Scans, MRI’s, ultrasounds and more endoscopies. Finally, he found a GI specialist who ordered a HIDA Scan. This is an anatomic and functional test of the gallbladder. In Michael’s case the HIDA revealed his gallbladder only emptied 4% when stimulated and, maybe more important, his symptoms were reproduced, exactly. I told his there was an 85-90% chance his pain would be relieved by surgery.
He was being wheeled into the OR as I finished my rounds.
Should be straightforward. No stones, chronic symptoms, overall in excellent health.
Never make such assumptions.
Michael’s surgery started off simple enough. The gallbladder was partially intrahepatic, but that just means a little more dissection until the gallbladder is free. I began in the usual way, incising the thin layer of peritoneum over the neck of the gallbladder and dissecting this peritoneum and the some surrounding fat away from the wall of the gallbladder. I lmost always start on the inferio lateral aspect of the gallbladder, where I should be safely away from the common bile duct.
As I began Michael’s dissection I saw a bluish structure just below the cystic duct and going towards the liver.
Not the right spot for the common bile duct or any bile duct. Be careful. Maybe it will be easier on the other side of the gallbladder.
I began dissecting on the medial aspect of the gallbladder.
It looks like there is another duct on this side. Maybe the gallbladder is lying between the right and left hepatic ducts? The structure in the middle looks like the cystic duct.
I started working higher on the gallbladder, away from any ducts, I hoped.
This is becoming far too much work. This was supposed to be my easy case.
As I dissected along the medial wall of the gallbladder I was able to identify a duct running along this part of the gallbladder and then going towards the liver. Luckily, I was able to separate this duct from the gallbladder.
That must be the left hepatic duct. At least Michael is not too chunky.
I retracted the gallbladder to the right and began teasing out the cystic duct.
Better check that duct like structure on the right side of the gallbladder.
It’s a good thing I did, because what I thought was all cystic duct turned out to be what I now presumed to be the right hepatic duct almost fused to the back wall of the gallbladder. I tried to separate these two structures. No luck. I did manage to find what I presumed was the cystic artery, very short and running along the medial aspect of the gallbladder, almost tethering the gallbladder between the two hepatic ducts.
Maybe take it from the top down, like the old days.
And so I began working on the fundus of the gallbladder. I pushed the liver up and retracted the gallbladder down and was able to separate the gallbladder until it was attached buy only the cystic duct, which was still fused to the right hepatic duct.
I’ll just take where it’s safe and leave the rest behind.
I used a stapling device to divide the gallbladder at its neck, being careful not to injure the bile ducts.
Finally it’s done. This was far too much work.
Michael woke up without a hitch, oblivious to the torture I had suffered. His operation which normally would have taken about thirty minutes had lasted over two hours.
Next was Michelle, twenty one, with pain for a week and a big stone impacted in the neck of the gallbladder. Michelle was typical of most patients with cholecystitis. That is she had persistent episodes of pain, and stones which either intermittently passed from the gallbladder through the bile duct, causing “biliary colic” or had big stones which would cause obstruction of the gallbladder with either acute symptoms of severe pain and tenderness, “acute cholecystitis” or paroxysmal pain, “chronic cholecystitis.”
Michael and Michelle, good name for a duo. And now we present “Michelle and Michael” the gallbladder singers.
My first glance at Michelle’s gallbladder revealed only that is was very distended. It wasn’t very inflamed and there was only a brief moment when it seemed like there might be some difficulty grasping it. There was a big stone filling the gallbladder neck, but I was able to retract the gallbladder to the right so that I could dissect the cystic artery and duct. Fifteen minutes later the gallbladder was in the endopouch.
But, it wouldn’t come out. The pouch was half in and half out of the abdomen, pulling it out through on of the larger trocar sites. I grabbed the gallbladder and tried to deliver it out of the pouch and abdomen. I was rewarded with a tiny piece of the gallbladder wall.
Keep at it. You always win in the end.
I tried to grab the stone with the ring Forceps, a clamp which has two rings which is ideally suited to grasping gallstones and pulling them out of the Endopouch. Michelle’s stone was big, really big. With one lucky swoop I managed to get the jaws of this clamp around the stone. I pulled it up towards the small opening in the abdominal wall. It was equivalent to trying to put a camel through the eye of a needle.
Maybe I can break the stone up.
I tried to close the jaws of the clamp and break the stone into pieces. There was a “snap” and then I was able to pull the clamp out, minus one of its jaws.
That is one tough stone.
I tried a different type of clamp. No luck.
After twenty minutes of pulling, prying and hoping I did what I needed to do.
I made the incision bigger, big enough to deliver this baby. I made it bigger and bigger until it was a mini laparotomy. Finally, I pulled pouch gallbladder and stone out of Michelle’s abdomen. T
The stone was five and a half centimeters in diameter, the size of a chicken egg. I took a break for a minute, shaking my hand to relieve a cramp and stretching my fingers after this ordeal. I closed Michelle in short order and got ready for Owen.
I’m not sure they pay me enough. Maybe Owen will treat me better.
I shouldn’t think such thoughts, surely I jinxed myself. Owen. Even now the name makes me shudder.
Owen was 78 years old and had typical complaints of RUQ abdominal pain. He had been having pain almost daily for 6 weeks. His ultrasound revealed, and I quote, “Multiple mobile stones,” and the gallbladder was not visualized on HIDA scan, which suggests cystic duct obstruction and certainly explained Owen’s frequent symptoms.
“Are you ready to get this over with?” I asked.
“Sure thing, Doc. I’m planning to play eighteen holes tomorrow,” He answered.
“Well, you may want to wait until the weekend,” I countered.
Owen’s case started well enough. Pneumoperitoneum established without difficulty, all the trocars placed and then I looked in with the scope.
All I saw was a bit of omentum stuck to the spot where the gallbladder was supposed to be.
It must be underneath those adhesions.
I teased the omentum away and was rewarded with a structure which looked like it was the gallbladder. It was small to say the least, but it was where the gallbladder was supposed to sit and I was sure I could see the common bile duct.
Once the adhesions were gone I began to retract the gallbladder superiorly as is almost always done during laparoscopic gallbladder surgery. The gallbladder was not only shrunken it was very hard to grasp. Every time I tried to grab it, it would slip away. Finally, all I could do was push the liver superiorly. As I tried to dissect this diminutive little beast it tore. I did see some stones inside but I realized I was fighting a losing battle.
“Scalpel, please and get all the instruments to open,” I requested.
Better to have a big incision and a healthy, whole patient, than four small incisions and a piece of the common bile duct in the specimen jar.
Over the years I have never had a patient complain that they had to have open surgery. However, they definitely are not happy if they require multiple surgeries to fix a complication.
For the next hour and a half I wrestled with Owen’s little nubbin of a gallbladder. I managed to separate it from the liver and I thought I found his cystic duct and junction with the common bile duct. The cystic duct was very short. I stitched it closed, being careful not to narrow his CBD and I left a drain in place.
I delivered a gallbladder which was the size of a nickel and contained a couple of stones which filled its tiny lumen.
Two hours of work for that little thing?
Owen woke up without a hitch.
“No golf for a few weeks,” I informed him.
“There goes my handicap,” he answered.
At least I’m done.
My phone went off.
“Consult, ICU 21. Tad Schultz, acute cholecystitis.”
I thought I was done.
It was now 3:30 in the afternoon. My plan to be done and home by one was just a fading memory.
I guess I need to go check out Tad. I wonder why he’s in ICU if it’s just his gallbladder which is the problem?
Tad was not in the ICU just because of his gallbladder. He had undergone coronary artery bypass surgery thirty six hours ago. Now he was complaining of severe upper abdominal pain, nausea and vomiting, all of which had commenced twelve hours earlier.
“Hello, Mr. Schultz. I’m Dr. Gelber, one of the General surgeons here. They tell me you have pain in your abdomen?” I inquired.
He was sitting still in his bed, an oxygen cannula draped across his face which was flushed. The monitor to the right of his bed gave a clue to his condition. Heart rate was 112, blood pressure 100/50, Respirations 22, oxygen saturation was 100%.
Looks like something is going on; something more than just post op discomfort.
“It hurts right here,” he replied as he pointed to the right upper quadrant of his abdomen, right where his gallbladder sat.
“It hurts to move, to breath, even to smile,” he added.
I wonder if it’s more than just his gallbladder?
“Any nausea or vomiting?”
“Had a pain like this before?”
I palpated his abdomen. He winced when I lightly tapped beneath the right costal margin (below the ribs).
It feels like there’s a mass there.”
“I’ll be back in a few minutes,” I said and I went to check the results of any testing which had been done.
I sat a the computer, waiting for Tad’s data to appear.
I don’t feel like ding another surgery today, especially on someone fresh from open heart surgery.
The tests revealed that his white Blood Cell count was 23,000, H/H 10.5 and 32. Total bilirubin was 2.0, ALT 125, AST 114 and Alkaline Phosphatase 201. His other labs were more or less normal. Ultrasound revealed a very distended gallbladder with stones and a thickened wall at 10 mm.
No question, Tad is sick and the culprit is his gallbladder. Surgery would best be avoided if possible. Maybe Dr. L can help.
Dr. L was our local, friendly Interventional Radiologist.
“Percutaneous cholecystostomy, if you have the time,” I requested from Dr. L. “Mr. Schultz, ICU 21. I think it would be best if he does not have to have surgery again so soon.”
Dr. L agreed and two hours later Tad was sitting up, smiling with a tube running from his right flank to a bag which was filled with golden brown bile.
It was not definitive treatment, but the drainage procedure bought time, allowing Tad to recover from his open heart surgery without further complication. Six weeks later he had a second surgery, an uncomplicated laparoscopic cholecystectomy.
The day ended at around 6:00 pm. I had performed four cholecystectomies, tackling gallbladders of a variety of shapes and complexities. My hand was still a little sore from battling Michelle’s ostrich egg of a gallstone, but otherwise it had been a successful day.
Cholecystectomy can be one of the easiest surgeries to perform or extremely difficult. An elective gallbladder surgery in a thin patient with little inflammation and normal anatomy may take all of ten minutes. Meanwhile, at the other end of the spectrum, a case like Owen, a small contracted, fibrotic gallbladder with anatomy which is unclear will cause the best surgeon to pause and rue the day he chose to work with a scalpel, rather than sit a dark room all day and read chest X-Rays.
I thought about the surgeon’s prayer.
“Lord, please protect me from the interesting cases and don’t let me screw up today.”
Maybe it needs an addendum:
“And please make all the gallbladder surgeries easy.”