Saturday, October 20, 2012
“Will this case take very long?”
“If the surgery gods are with me we should be done in an hour”
The above brief exchange took place between me and the anesthesiologist attending to my patient on a recent surgery. The patient was a middle aged woman who was about to undergo surgery to relieve a small bowel obstruction. She had been visiting her husband in a distant city where he was working and had become ill. She was hospitalized and after several days of testing surgery was recommended. Her husband was reluctant for her to undergo a major operation in a city far away from home and their regular doctors.
He drove her home against medical advice and she was admitted to the hospital. I was called in as a consultant and it was clear she had a small bowel obstruction. Despite this obvious fact, she did not appear toxic. She had a mildly elevated white blood cell count, her vital signs were completely normal and her abdominal exam was unremarkable. Her medical history was most significant for multiple previous abdominal surgeries: Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy, Partial Colon Resection, Cholecystectomy, two Cesarean Sections, and Exploratory Laparotomy for a previous small bowel obstruction.
Thus, my reluctance to rush her into surgery. A day of watchful waiting would not harm her in the least, she’s already had eight days. The operation had the potential to be long and tedious, given her surgical history. She was as comfortable as coud be expected with a nasogastric tube decompressing her stomach. But, her obstruction persisted and surgery became necessary; thus my supplication to the surgery gods.
The operation commenced with a midline incisions. Upon opening the fascia and saw bowel adherent in this area.
Where are you gods of surgery.
The adhesions were gently lysed and I was able to enter the peritoneal cavity. I had managed to open the fascia at the only point where there were adhesions to the abdominal wall. The remainder of the abdominal wal was completely free and the incision was opened into the peritoneal cavity without further difficulty. The markedly dilated small bowel was delivered into the wound and followed distally to the point of obstruction. The adhesions in this area were divided and the obstruction was relieved. The bowel was inspected from its beginning at the ligament of Treitz all the way to the terminal ileum. It all looked healthy with no other adhesions and no holes. It was returned to its home in the peritoneal cavity and the fascia and skin closed without difficulty. Thirty minutes from start to finish cured the patient’s condition and started her on the road to recovery.
In this case the gods of surgery smiled upon me and my patient as the surgery was uncomplicated and the problem fixed with a minimum of fuss. This is not always the case, however. Small bowel obstruction is a common diagnosis. High grade obstructions that require surgery are most commonly caused by adhesions; scar tissue which arises in response to inflammation, most often after previous operations. Such adhesions may be only a single fibrous band that the bowel can wrap around or travel under or through causing a slight kink or a tight stricture or a complete obstruction.
Other times there are cases like the one presented. A few adhesions are present and the bowel manages to find a path that leads to blockage. Despite persistent attempts, the trapped bowel can’t break free and surgery becomes necessary. Often, the bowel finds a way to free itself, perhaps by breaking free from flimsy adhesions or figuring out a way to liberate itself from the entrapping web. The patient begins to feel better and surgery is avoided.
Then, there are the extreme cases; patients who have had multiple previous surgeries or previous severe intrabdominal infections. The bowels are glued together by a mass of adhesions that require painstaking dissection to carve out the many feet of bowel and find the point of obstruction. In such cases the surgery gods are definitely not smiling as the operation proceeds millimeter by millimeter, hours pass and adhesions seem to form as quickly as they are divided. Cursing the gods of surgery may make the surgeon feel a bit better, but often leads to enterotomies (holes in the bowel). Such difficult cases, when the gods are upset, call for post operative penance such as child sacrifice, self mortification or donation to the Obama campaign.
The surgery gods can be your best friend or your worst enemy. They can shine their face upon you and keep the common bile duct from sneaking away from its normal position to a vulnerable point directly behind or even lateral to the gallbladder, or, if angry, can command the ureter to adhere to the back wall of the colon, leaving it vulnerable to division by sloppy surgeons. These gods can be vindictive if not properly appeased.
And, if one chooses to ignore the gods of surgery, it is in one’s best interest to be fully knowledgeable of anatomy and pathology and how one can affect the other and vice versa. In the end, knowledge and experience will always trump these capricious gods, but it doesn’t hurt to try to appease them with a token sacrifice from time to time.
Sunday, October 14, 2012
You’ve spent much of your life alone, almost like you’ve been in solitary confinement, has this been difficult for you?
At first it was extremely hard. I was only twelve when I was first shut away in the Labyrinth. I may have appeared to be a fearsome monster to others, but I was just a scared kid, left alone with absolutely nothing. I thought I’d be dead before the week was out. My god, was I wrong.
Before I go any further discussing my life after the Labyrinth, I need to give you a little background. I was, technically, royalty, the son of Pasiphae, who was married to Minos, king of Crete, although I’m sure that Minos was not my real father. Pasiphae, my wonderful mother, did her best to protect me. What that means is she kept me from being thrown into the sea while taking it upon herself to educate me. In the beginning my life was confined to the palace, specifically, Pasiphae’s opulent quarters, which were like a prison for me. I didn’t venture outside her three rooms for the first ten years of my life.
But, you can’t keep a good bull down and shortly after my tenth birthday I was allowed to “play” with the other children in the palace. I’m not sure play is the right word, because no matter what I did or how I did it, I just didn’t fit in; those other children weren’t very friendly.
The first time I went into the courtyard the other boys squatted down and started to make mooing noises. At first I thought it was a game, but then they started to laugh and point and I just wanted to run away. I did my best not to cry, but I couldn’t bring myself to face them again and all I could do that first day was sit in the far corner by myself. In retrospect it was a glimpse into my future. Every once in a while one of those boys would run by, snort and paw the ground or put their fingers on either side of their head pretending to have horns. I thought that morning would never end.
Thankfully, it started to rain and the torture was cut short. My mother knew I was upset and I tried to tell her, but she started on about how wonderful it was that I could be like all the other children and how I was destined to be follow Minos and be the next King. I was next in line for the job of King, being the eldest living son of Minos’ many offspring. (There had been another older son, but he died shortly after birth). The fact that I wasn’t really his son shouldn’t have mattered. He never really acknowledged my illegitimacy. Anyway, I stiffened my upper lip and prepared for the next day with my “siblings”.
The following day was more of the same, only worse. There was more mooing and pawing and an occasional stone thrown my way. I went to “my” corner and sat by myself. Days, weeks and months went by without a change. I wore the grass down in my little corner while the boys and girls continued their bullying. I suppose this was my first taste of solitude, as well as giving me what I consider an accurate picture of humanity. Then things changed. Demetrius, the ring leader of my tormenters came up to me and offered to shake my hand. He apologised for their “immature” behavior and said that I could play with them the next day. I was filled with hope.
The following day things did seem to be better. None of the boys seemed to pay much attention to me at first. But, then they let me play in some of their games: the stone throw and the javelin. Even though I was only ten, I was pretty strong and I could throw both the javelin and the stone farther than any of them. But, those juvenile delinquents had more in mind than mere sport.
After the javelins and stones are tossed, it becomes the responsibility of the each participant to retrieve the apparatus for the next contestant. After I’d made my throws I dutifully went to gather up the three javelins and three sixteen pound stones. As I started back I looked up just in time to see javelins and stones flying through the air and headed straight for me. Of course, there wasn’t much I could do. I dropped my gear and prepared for what I thought was to be my end. I was frozen in place as stone and spear rained down around me, forming an almost perfect circle, but missing me completely. Needless to say I was more than a bit perturbed and I charged at the other boys, but mostly aimed for Demetrius.
He started to run as fast as he could, but I quickly caught up to him. He reached the wall at the end of the courtyard where he was trapped. I put my head down and gored him with my horn, right through his left thigh. Blood squirted out everywhere as he crumpled to the ground. My anger melted as I forgot his bullying, bent down and pressed my hand against the gaping wound, stemming the flow of blood and probably saving his leg. He eventually recovered, even though he had to walk with a cane for the rest of his life. I, however, earned a new, and as far as I’m concerned, undeserved, title: “Fearsome Beast.”
That was the end of my playing with other kids, I was kept isolated in the palace, more or less in prison and two years later I was shut away in “The Labyrinth”, a place I returned to, physically and mentally, over and over as my long life went on.
“The Labyrinth”; it was my true home off and on for the next several thousand years. When I was first locked away I did nothing for the longest time, just sat and sat, wallowing in a sea of self pity. I ate very little, drank only a little bit more, didn’t talk, didn’t howl at the moon or any other such nonsense. Mostly, I sat. An occasional tear welled up and ran down my cheek, but I still just sat. I think I was a bit of a disappointment to Minos who was using me for his political gains. He created the most dreadful lies about me: I was vicious and vindictive, devouring innocent children for my own perverse pleasures. He called me fearsome beast, using that poor boy’s playground injury to his utmost advantage. That, along with some fabricated “eyewitness” accounts of my brutality was all it took. A legend was born.
The fierce, vicious Minotaur, half man, half bull, one hundred per cent monstrous. In the beginning I was completely unaware of how I was being used. I was little more than a child and ignorant of the world and politics. Apparently there was a parade of “victims” that testified about how I’d attacked them, cutting off arms and legs and heads, consuming them to satisfy my voracious appetite for raw meat. Why, I would have been afraid of me, too, if any of it was the slightest bit true.
All the time these lies were being spread I was isolated in the Labyrinth. I planted a garden and began tending vineyards and olive trees in the heart of the Labyrinth, alone, depressed, at times almost suicidal.
Over the years I grew accustomed to solitude, but to a prepubescent half man half bull beast it was the worst form of torture. Only one thing kept me going. I believed that somewhere in this world there was something or someone that was truly good. Someone who wouldn’t care if I was a bull or a man or made of green cheese. I knew I wouldn’t spend my entire life locked away. I would find a way to make my escape and then I would find it or him or her. If you hear the story I have to tell or read my book, you will learn that, after thousands of years, I did find what I was looking for.
"Minotaur Revisited" e-book is now available on Amazon.com and Barnes and Noble online.