Sunday, August 7, 2016

The Joy of Surgery


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.
No surprise..
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.