“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.
